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I'm out of sorts, but Symmachus is here,
After the fall of the Roman Empire we find the teaching of medicine conducted like the apprenticeship of a trade. A youth who wanted to become a physician would attach himself to a friendly practitioner, much as in the preceptorial system. This arrangement in a modified form lasted until about twenty-five years ago.
With the spread of Christianity and the establishment of hospitals by the ecclesiastical orders, medical practice, to a large extent fell again into the hands of the priests, particularly the Benedictines who according to Puccinotti were the first in the Middle Ages to give clinical and didactic instruction. It seems also that in the time of Charlemagne, 764-814, the teaching of medicine received some attention at his court; few data, however, have come down to us regarding this school.
When celibacy became a law among ecclesiastics, priests were forbidden to practice surgery and to treat diseases of women.1
Among the Arabs at this time, medicine was at a very high level. They had hospitals with vast numbers of students, who were instructed both practically and theoretically. There were hospitals at Damascus, Bagdad, Cairo, and probably elsewhere in Europe and Northern Africa, wherever the Saracens had gained a strong foothold. Yet progress under the Arabs was not so great as it might have been, despite clinical teaching in the hospitals, for the reason that dissection was indirectly forbidden by the tenets of the Koran, a corpse being “unclean.'
The first real progress in medical teaching after this time is coincident with the rise of the great University of Salerno, the origin of which is shrouded in obscurity, although, according to some of the Italian historians (as for example, Puccinotti: “Storia della medicina,” vol. II, part 1, p. 247, “La Scuola detta Salernitane é benedettina e Cassinense di origine”), it is the offspring of the Benedictine monastery of Monte Cassino.? Since Charlemagne is known to have been interested in it (Ravon: “La France médicale,” 1902, p. 409), its origin certainly dates back to the eighth century. Its medical faculty was composed of Greek, Italian, Jewish, and Arabic physicians, so that almost anyone could there study medicine in his own language. It was unusually free from ecclesiastical influence; the professors were married. Strange as it may seem, some of the lectureships were held by women, usually the wives or daughters of professors. Abella wrote: “De atro bilo et de natura seminis humani”; another, the famous Trotula, published a work on diseases of women entitled, “De mulierum passionibus ante, in et post partum”; and Rebecca, one on fevers, urines and the embryo.
The school received a great impetus through the Crusades, and many a wounded and sick Crusader as, for example, Robert of Normandy, son of William the Conqueror, was treated there. Clinical instruction must have been carried out at Salerno, although details are meagre. We do know, however, that special attention was paid to dietetics. Under the great emperor Frederick II, in versatility and in ruthlessness not unlike the last of the Hohenzollerns and like him of Swabian blood, the medical school at Salerno in 1213 grew into a complete university. It is a fact
1 It appears that for a time celibacy was enforced among physicians also. At any rate, in 1452, Cardinal d'Estouteville, charged by Pope Nicholas V. with the reorganization of the University of Paris, obtained the suppression of celibacy "as an impious and unreasonable thing for a doctor.” (Supoy, “Le moyen âge médicale,” p. 27).
· Daremberg (“Histoire des Sciences Médicales," Tome I, p. 259) denies that the medical school of Salerno originated from the Benedictines, the Arabs, or the Jews, and holds that it is Neo-Latin or GrecoLatin in origin.
worthy of note that the two great Continental universities of the Middle Ages, Salerno and Montpellier, arose out of medical schools. Frederick also gave to the Salernitan school an excellent code of laws and a curriculum. Three years had to be devoted to philosophy, and five to medicine, with examinations at the end. Just as in Pennsylvania at the present time, this university examination did not per se confer the right to practice; the young physician had to associate himself for one year with an older practitioner-a custom similar to our hospital year.
I have just spoken of Montpellier, which is of particular interest to us, as the great Sydenham studied there. Montpellier was founded under the influence of the Saracens, who came from neighboring Spain. In 1137, the medical school had its own building. Its fame really begins with the advent of Solomon Matthæus from Salerno in the twelfth century. In 1220, Cardinal Conrad, a German, demanded that everyone who intended to teach there must pass an examination. Pope Clement V, in 1308, established the rule that medical students must hear lectures for five years and during eight months, or two summers must attend a physician in medical practice. An intense rivalry existed between the University of Montpellier and the University of Paris. This rivalry was probably good for medical teaching; its bitterness is well illustrated in some of the Latin verses of Gilles de Corbeil,
the great medical teacher of Paris in the thirteenth century. (Vieillard: La France médicale, 1902, p. 397.)
Under the corroding taint of scholasticism, both the University of Salerno and that of Montpellier rapidly deteriorated; the latter suffering eclipse through the growing fame of the University of Paris. In the seventeenth century, Montpellier experienced a temporary revival through the fame of Charles Barbeyrac (1629–1699), called the Hippocrates of Languedoc, who is remembered as one of Sydenham's teachers.
It seems that after the decline of the schools of Salerno and Montpellier, and at a time when learning in general was beginning to reanimate the world, in preparation for the coming of the Renaissance, medical teaching ebbed to almost the lowest possible point. Instruction degenerated into dialectical discussions and hairsplitting arguments based chiefly on the writings of Hippocrates and Galen. Even the great Rabelais was roused to wrath by the medical teaching of his day, which was “toute livresque.” (Ledouble: La France médicale, 1907, p. 207.) There is extant a program of lectures in medicine at the University of Heidelberg for the year 1569. Professor Curio lectured on “De generibus morborum” of Galen, and explained “De morborum signis” of Hippocrates. Professor Erastus did not lecture, because he had gone to the fair in Frankfort. Professor Melancthon, a nephew of the great Protestant reformer, delivered lectures in medicine on the basis of Galen. Would not Hippocrates, who had taken his pupils to the bedside of his patients and had taught them physical signs and keen observation, have marveled at the fact that, twenty centuries after his time, such inane discourses should constitute the sole instruction in medicine? Another hindrance to progress was the interdiction by the Church of dissection of the human body; and even after that was lifted, the obtaining of
3 It may not be without interest to quote a statute of this Cardinal dated 1220 regarding the University of Montpellier. It is a medieval example of the black list: “If a professor is in litigation with one of his pupils with respect to his salary or for any other reason, no other professor shall knowingly receive this pupil until he has given or promised satisfaction to his former master.” The same statute forbids sordid competition among the professors: “No teacher shall attract to himself the disciple of another teacher, in order to take him away, by solicitation, present or any other means whatsoever.”
bodies for dissection
a difficult examinations. When his studies were finally matter.
completed, the new doctor had expended It is interesting to learn through the about sixteen thousand francs though after researches of Sudhoff (“Studien zur Ge- the year 1550 the cost was reduced to eightyschichte der Medizin,” Heft. 8) how medical one hundred and fifty francs, still a formidstudents were taught in the University of able sum (Paul Delmas, Bull. mensuel de Leipzig during the first hundred
l'Académie des sciences et lettres de Montits foundation in 1409. The lectures were pellier, March, 1913, No. 3). given from six to seven o'clock in the morn- Although hospitals were springing up all ing during the summer and from seven to over Europe (in Germany, for instance, the eight during the winter. During the first Order of the Holy Ghost founded not less and second semesters, the first canon of than 154), clinical instruction was not given Avicenna, during the third and fourth the in
of them. Not even in the great Hotel liber tegni of Galen, and during the fifth and Dieu of Paris, founded in the eighth censixth the aphorisms of Hippocrates, with tury, was any use made of its wealth of commentaries by Galen, were explained. clinical material for nearly a thousand The course in “practical medicine," so- years. What practical experience the stucalled, took place in the afternoon. The dent got was obtained by his attaching holder of the chair explained a book of himself to some obliging physician outside Rhazes, the first chapter of the fourth book of the university, who acted as an extraof Avicenna, and the fourth chapter of the mural teacher and took him along on his first canon by the same author. The lec- rounds. This custom eventually led to the tures were given in the church of St. Nicho- establishment of policlinics, apparently first las. As for surgery and anatomy, they were at Montpellier. By "policlinic" is meant completely neglected at Leipzig during the something quite different from that which first century of this school's existence. the word polyclinic now connotes, namely,
At the University of Montpellier, which an organization for visiting patients in their was already ancient when the University of homes in various parts of the city. Hence, Leipzig was established, teaching was car- the word poli-clinic (todus, city); the ried out as follows: The lectures began at present term, "poly-clinic” (tolus, many), six o'clock in the morning and lasted one being really a misnomer. One of the Monthour. They consisted of dictation or reading pellier
pellier physicians, Theophrastus Renauof Latin texts and making comments upon dot, migrated to Paris, established a polithem. Dissections, inaugurated in 1376, did clinic there, and became a protégé of not take place more than once or twice a Richelieu and physician to Louis XIII. year and then the entire public was per- In the Rue de Calandre at the Sign of the mitted to attend on paying an admission Golden Cock he established a sort of disfee. There was absolutely no clinical teach- pensary for the poor. He incurred, however, ing. The whole course occupied a total of the enmity of the faculty of the University about six months. At the end of this time of Paris-particularly of its brilliant but the student in order to obtain his license vindictive leader, Guy Patin (1601-1672), had to practice six months outside of the whose motto, “Saigner et senner" (Bleedcity. If then he passed his examinations as ing and senna) helped to make him famous. a bachelor, the beadle clothed him with a
*Guy Patin anathematized William Harvey and red robe, while his comrades one by one
spoke of Harvey's discovery of the circulation of administered a good blow with the fist. To
the blood as "paradoxical, unintelligible, absurd, obtain the doctorate he had to pass sixteen and harmful to human life.”
In consequence the dispensary did not last long; and yet it was practically the only attempt at clinical teaching in Paris for several centuries. It is almost inconceivable that the material of the Hotel Dieu, which at this time had a capacity of two thousand beds, was not used for medical instruction. The conditions in this famous hospital were very remarkable as we know from a graphic account written by a Saxon tailor, Christoph Rink. This man entered the hospital as a patient and was received by an old barber, who touched him in various places to determine the nature of his disease. A priest recorded his name in a book, and two assistants conducted him to his quarters, where he was placed in a large bed between two other patients, in such a way that his head lay between the feet of his bed-fellows. This sort of community of living was quite the rule in those days; and even in the eighteenth century, three, four and even five patients were often placed in a single bed. Frequently as many as four puerperal women were put together. Both of Rink's bedfellows died. The first treatment our Saxon tailor received was psychic, an attempt being made to persuade him to believe the right religious doctrine; but he was a staunch Lutheran and resisted. The following day the doctor came, with the apothecary and the barber; and the traditional bleeding began. Rink was bled not less than twenty times, and yet lived to tell his tale. For the nuns, who conducted the nursing in the hospital and of whom there were three hundred, he had only the highest praise.
Molière, in his inimitable comedy, “Le malade imaginaire,” has drawn a true picture of the time. The son, Thomas of Diafoirus, comes up for his baccalaureate degree in medicine; and in his behalf the following statements are made: "He is firm in dispute, and strong like a Turk in his principles; and he never recedes from his
opinion, but presses the argument to the last vantage point of logic; but, above everything else, that which pleases me,” says his father, “and in which he follows my example, is that he is attached blindly to the opinions of the ancients, and that he will not comprehend nor hear the reasons and the experiences of the pretended discoverers of our times touching the circulation of the blood or any other opinion of equal stripe.” To all questions as to the remedies to be used in the various diseases, Thomas invariably answers:
Et reclysterisare to which the chorus makes the following response:
Bene, bene, bene,
In nostro corpore. In Rome, as late as the sixteenth century, in order to become a physician the medical student had to pass an examination on the physics of Aristotle and the doctrines of Galen. This was followed by a question in which one of the examiners described the symptoms of a disease and then asked the name and treatment. Having passed this test, the final act of initiation was the giving of a banquet to the examiners.
About the middle of the sixteenth century, near the close of the Renaissance, Professor Dal Monte, a friend of Vesalius,
• Dal Monte took an active part in the battle raging between the two camps into which the profession was divided in his time on the matter of bleeding. The one upheld the Arabic method, according to which the bleeding was to be done at the point farthest removed from the disease focus; at the foot, for example, in pneumonia; the other practiced the Hippocratic method, according to which the patient was to be bled from the arm corresponding to the side affected. Dal Monte and Vesalius were Hippocraticists.
made the first modern attempt at clinical of the pulse and the urine. As most of the teaching, in the hospital of St. Francis at diseases were believed to have their seat in Padua. Little resulted from Dal Monte's the blood, and as the urine was looked upon efforts, but under his successors, Oddi and as a percolate of the blood, it seemed logical Bottoni, in about 1578, real bedside teaching to determine the chemical composition of began. Until quite recently I accepted it as the latter by a study of the former. This a fact, having seen it in a number of works, rendered diagnosis extremely easy. As an that the first clinical teacher was Boerhaave; illustration, I might cite what the monk but Renaudot, Petersen, Puschmann and Mercurius taught (at a somewhat earlier other reliable authors have clearly demon- period, it is true) regarding the pulse: “If strated that the credit for inaugurating clini- one lays four fingers of the right hand on cal teaching belongs to these two otherwise the pulse of the right arm of the patient, unknown Italians, Oddi and Bottoni. Oddi one can conclude that the disease is in the gave his clinical lectures in the women's head if the pulse is felt mainly by the ward and Bottoni in the men's ward of index finger; that the disease is in the thorax St. Francis' Hospital. They illustrated their if the middle finger feels it; and that it is lectures with autopsy material. Autopsies in the abdomen if the fourth finger perwere, however, still forbidden by the eccle- ceives the chief impact.” One of the notasiastical authorities. Not long after Oddi ble Byzantine physicians, John Actuarius, and Bottoni, a blight struck the University distinguished fourteen colors of the urine, of Padua, so that when the Dane, Thomas each one having a definite diagnostic meanBartolin, visited the city, he found only a ing. "scola de pulsibus et urinis.” Nevertheless, In the days of Van Heurne, enemas were short as the period of clinical teaching was
and much time was spent at Padua, it bore great fruit. The new in instructing the students in their prepaidea was transplanted first to Holland, ration. where Jan Van Heurne, who had studied at Under the stimulus of the invention of Padua, introduced it. His own success was the thermometer, the magnifying lens, the slight; far greater was that of his son, Otto microscope, and above everything else, Van Heurne, who followed him in 1601. through the epoch-making discovery by Somewhat later, in 1636, Wilhem Van Den William Harvey, of the circulation of the Straten (1593–1681) established a remark- blood a spirit of rebellion arose against the able clinic at Utrecht. He examined patients authority of the ancients that had held mediin the presence of a class of students, and cine in bondage for so long. When a man discussed the diagnosis, prognosis and treat- appeared upon the scene who taught mediment with them. Following this, there was cine at the bedside, students flocked to a public debate concerning the nature of
6 A famous enema of Van Heurne's had seventeen the disease.
ingredients, for the mixing of which the most minute Under Otto Van Heurne the students in
directions were given. I might also mention anLeyden visited the clinic two days a week,
other famous preparation—the mystical theriacumfour students acting as clinical clerks, as which had no less than seventy-two constituents, we know from an extant letter of Thomas and was looked upon as the apothecary's masterBartolin. The authorities, however, in their
piece. It is recorded that in 1754, in Nuremberg,
the completion of this drug, which had required two wisdom, decided that this sort of teaching
months' labor under the supervision of the Senate, was not of much use and commanded the
was celebrated with many civic festivities. Both professors to instruct their students in the
Boerhaave and Van Swieten used theriacum, alknowledge that can be gained from a study though the former's motto was simplex sigillum veri.