"Ideo Medico id in primis curandum, ut ab aegro circ.u.mstantias omnes accurate intelligat, intellectas consideret, ut inter curandum media illa adhibeat, quae tollendo morbo apta sunt, ne ex medicina noc.u.mentum proveniat."
--Basil Valentine, _Triumphal Chariot of Antimony_.
[The physician must therefore especially take care that he understand all the circ.u.mstances of his patient very clearly, and after understanding them weigh them well, so that during his treatment he may use those means which are especially suited to control the disease, lest any harm should come from his medicine.]
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UNIVERSITY MEDICAL SCHOOLS [Footnote 25]
[Footnote 25: Address to the graduates of St. Louis University Medical and Dental Schools, May 31, 1910, at the Odeon, St. Louis.]
It affords me great pleasure to accept the invitation of your Faculty to address the graduates of a university medical school here in the Middle West. I wondered, of course, what I should talk to you about, and have come to the conclusion that as an historian of medicine any message I may have for you is likely to come from my own subject. It so happens that we are just beginning to realize that the history of medicine may have much greater significance for us than we have usually been accustomed to think, and, above all, that it may mean much in furnishing incentive for the maintaining and raising of standards in medical education. In recent years there has come a very decided improvement in medical education in the United States. It is not hard to understand that the foreigner lifts his eyebrows in surprise when he is told that most of our medical schools a generation ago required but two terms of four months each, and that there was then just beginning to be a demand for a little more complete course and better facilities. There was a large number of medical schools, turning out graduates every year with the degree {378} of doctor of medicine, which was a license to practise in every state in the Union, for there were no state or federal laws regulating the practice of medicine. As for preliminary requirements the less said the better. If a man could write his name and, indeed, he did not have to write it very plainly, he found it easy to matriculate in a medical school and to be graduated at the end of two scant terms of four months each. He might come from the mines, or from the farm, or from before the mast, or from the smithy, or the carpenter shop; he need know nothing of chemistry, nor physics, nor of botany, nor of English and, above all, of English grammar, and he was at once admitted to what was called a professional school and graduated when he had served his time.
Practically no one was plucked. The desire of the faculty for numbers of students forbade that in most cases. The two terms in medicine were not even successive courses. The second-year student listened, as a rule, to the same lectures that he might have heard the preceding year.
We all know the reason now for this extremely low standard of medical education. Proprietary medical schools made it their one business in life to make just as much out of medical education as possible and the historic septennate of professors, or sometimes the Dean, pocketed the fees (I came near saying spoils) every year, and robbed medical American education of {379} whatever possibilities it might have for the real training of young men in the science and art and practice of medicine. Perhaps the most interesting feature of this maintenance of extremely low standards in medical education, however, is the fact that in spite of it, men, or at least some of them, succeeded in obtaining a good foundation in medicine and then by personal work afterwards came to be excellent pract.i.tioners of medicine. Professor Welch said not long since: "One can decry the system of those days, the inadequate preliminary requirements, the short courses, the dominance of the didactic lecture, the meagre appliances for demonstrative and practical instruction, but the results were better than the system. Our teachers were men of fine character devoted to their duties; they inspired us with enthusiasm, interest in our studies and hard work, and they imparted to us sound traditions of our profession."
Nothing that I know is a better compliment to American enterprise and power of overcoming the difficulties of the situation than the life stories of some of the men who came from these completely inadequate schools. If with the maimed training and incomplete education given a generation ago American medicine not only succeeded in maintaining the dignity of the profession to a noteworthy degree, but also developed many men who made distinct contributions to world medicine, what will we not do now that {380} our medical education is gradually being lifted up out of the slough of despond in which it was and the preliminary education for medical studies set at a standard where real work of thoroughly scientific character can be looked for, from the very beginning of the medical course?
Is it any wonder, then, that those of us who have the best interests of American medicine at heart are watching with careful solicitude the movement that is now reforming medical education in this country? The one hope of medical education is, and always has been, organic connection with a university. Real University Medical Schools, that is medical schools as the genuine Post-Graduate Departments of Universities with the fine training that they give, have opened our eyes to what is needed in medical education in this country. Some of the old-time medical schools here in the United States had been connected by name with universities but this was more apparent than real, and the medical faculty ruled absolutely in its own department and throttled medical education and divided the income of the college among themselves, devoting as little as possible to equipment, to laboratories, to all that was needed for medical education.
Now has come the epoch of university medical schools in this country.
I came near saying America, but we must not forget that the Spanish-American countries, having adopted their educational systems from the mother Latin country, {381} have always maintained the organic connection of the medical school with their universities, and as a consequence a good preliminary education, the equivalent of three years of college work with us, is required and has always been, and then some four years in the medical school and, indeed, in most of the countries five or six years and in one at least seven years of medical study required. I have thought, however, that this story of medical education in connection with universities and real university work will be especially interesting to the graduates of this thorough Western university, whose work in medicine is acknowledged as up to some of the best standards of professional attainment and whose organic connection with a great university a.s.sures not only the continuance, but the future development of medical education here along lines that shall place this among the serious progressive medical schools of the world.
The first university medical school that well deserves that name is the one that came into existence in connection with the University of Alexandria. I have been at some pains, because it is so delightfully amusing, to point out how closely the University of Alexandria resembles our modern universities in most particulars. It was founded by a great conqueror, who had gone forth to conquer the world, and having attained almost universal dominion sighed for more worlds to conquer. Then he set about the foundation of {382} a great city that was to be the capital of his empire, and endowed a great inst.i.tution of learning in that capital that was to attract students from all over the world. When he died prematurely the Ptolemys, who inherited the African portion of his vast dominions, carried out his wishes. Money was no object at Alexandria: they put up magnificent buildings, founded a great library, bought a lot of first editions of books in the shape of author"s original ma.n.u.scripts, stole the archives at Athens, used Alexander"s collection (made for Aristotle) as the foundation of what we would call a museum, paid professors better salaries than they received at that time anywhere else and housed them in palaces. What a strangely familiar sound all this has! Then Alexandria proceeded to do scientific work.
Euclid wrote his geometry, and, unchanged, it has come down to us and we still use it as a text-book in our colleges. Archimedes, following up Euclid"s work, laid the foundation, of mechanics in his study of the lever and the screw, and of hydrostatics and of optics in his studies of specific gravity and burning mirrors and lenses. He made a series of marvellous inventions showing that he was a practical as well as a theoretic genius, who would be gladly welcomed, nay, eagerly sought for, as a member of the faculty even of a university of the highest rank or largest income in our modern times. Ptolemy elaborated the system of astronomy that had been so ably {383} developed by teachers at Alexandria before his time, and Heron invented his engines, which we have had as toys in our laboratories for centuries.
We realized the true significance of one of them only when the turbine engine was invented and we found that the principle of it was in the toy engine of this old natural philosopher of Alexandria. They even did their literature scientifically at the University of Alexandria.
We have no great original works from them in literature, but they invented comparative literature; for this making the Septuagint translation of the Holy Scriptures and doing the same for many other religious doc.u.ments of the surrounding nations for comparative study.
It is rather easy to understand, then, that a medical school arose in connection with this scientific university, and that it did excellent work. The collections of Aristotle contained many ill.u.s.trations which served as the basis for zoology, botany, comparative anatomy and probably even comparative physiology. The Ptolemys were very liberal and allowed dissection of the human body, so that human anatomy developed from a definite scientific standpoint better then ever before. The number of strangers in the town and the rather unhealthy climate of Egypt left many unclaimed bodies. It has always been the difficulty of obtaining bodies much more than prejudice against the violation of the human body on any general principle, that has been the reason {384} for the absence of human dissection in many periods of the world"s history. We object to having the bodies of friends cut up, but we do not mind much if the bodies of those who are unknown to us are treated in that way. So long as men did not travel much there were few unclaimed bodies. With the advent of travel came abundant material for dissection and the Ptolemys allowed the medical school to use it.
Two great anatomists built up the structure of scientific human anatomy on the rather good foundation that had been laid on animal anatomy in the foretime. After all, the anatomy of the animal resembles that of man so much that very precious knowledge had been gained from zootomies in the previous ages. These two anatomists were Erasistratos and Herophilos. Both of them studied the brain especially, as might have been expected. For just as soon as the opportunity for dissecting man was provided, this, his most complex structure, attracted instant attention. Herophilos has named after him the _torcular herophili_, and the name he gave the curious appearance in the floor of the fourth ventricle--the _calamus scriptorius_--is still retained. He describes the membranes of the brain, the various sinuses, the choroid plexuses, the cerbral ventricles and traced the origin of the nerves from the brain and the spinal cord, recognizing, according to well-grounded tradition, the distinction between nerves of sensation and motion. {385} He described the eye and especially the vitreous body, the choroid and the retina. He did not neglect other portions of anatomy, however, and his power of exact observation, as well as his detailed study, may be judged from his remark that the left spermatic vein in certain cases joins the renal.
Erasistratos, his colleague, was perhaps even a more successful investigator than Herophilos. He represented the best tradition of Greek medicine of the time. He had two distinguished teachers, one of them Metrodoros, the son-in-law of Aristotle. It was probably through this influence that Erasistratos received his invitation from the first Ptolemy to come to Alexandria. The scientific work of Alexandria was founded on Aristotle"s collections, on his books, for his library was brought to Alexandria as the foundation of the great University Library, and then best of all on the direct tradition of his scientific teaching through this pupil of his son-in-law.
Erasistratos" other great teacher was the well-known Chrysippos of Cnidos. Cnidos was the great rival medical school to that of Cos.
Owing to the reputation of Hippocrates we know of Cos, but we must not ignore Cnidos.
Erasistratos" discoveries were more in connection with the heart than anything else. He came very near discovering the circulation. His description of the valves and of their function is very clear. He looked for large-sized {386} anastomoses between veins and arteries and, of course, did not discover the minute capillaries which required Malpighi"s microscope to reveal them nearly 2,000 years after. Like Herophilos, Erasistratos also studied the brain very faithfully.
One story that we have of Erasistratos deserves to be in the minds of young graduates in medicine, because it ill.u.s.trates the practical character of the man and also how much more important at times it may be in the practice of medicine to know men well rather than to know medical science alone. Erasistratos was summoned on a consultation to Antioch to see the son of King Seleucus. Seleucus was one of the four of Alexander"s generals who, like Ptolemy, had divided the world among them after the young conqueror"s death. His portion of the Eastern world, with its capital at Antioch, was probably the richest region of that time. There had been no happiness, however, in the royal household for months because the scion of the Seleucidae, the heir to the throne, was ill and no physician had been able to tell what was the matter with him, and, above all, no one had been able to do anything to awaken him from a lethargy that was stealing over him, making him quite incapable of the ordinary occupations of men, or to dispel an apathy which was causing him to lose all interest in affairs around him. He was losing in weight, he looked miserable, he seemed really to have been stricken by one of {387} the serious diseases as yet undifferentiated at that time which were expressed by the word phthisis, which referred to any wasting disease.
As a last hope then almost, Erasistratos was summoned from distant Alexandria as a consultant in the case of young Seleucus. The proceeding, after all, is very similar to what happens in our own time. The head of an important department in medicine at a university is asked to go a long distance to see the son of a reigning monarch, or of a millionaire prince in industry, or perhaps a coal baron, or a railroad king, and a special train is supplied for him and every convenience consulted. A caravan was sent to bring Erasistratos over the desert to Antioch. It is such consultations that count in a physician"s life. I hope sincerely that you shall have many of them and that you shall conduct them as successfully as Erasistratos this one.
The young prince"s case proved as puzzling to Erasistratos for a time as it had to so many other physicians before him. Like the experienced pract.i.tioner he was, he did not make his diagnosis at once, however.
Will you remember that when you, too, have a puzzling case? It is when we do not take time to make our diagnosis that it often proves erroneous. Not ignorance, but failure to investigate properly, is responsible for most of our errors. He asked to see the patient a number of times, and saw him under varying conditions. Finally, one day, while he was {388} examining the young man"s pulse--and I may tell you that Erasistratos made a special study of the pulse and knew many things about it that it is unfortunate that the moderns neglect--his patient"s pulse gave a sudden leap and then continued to go much faster than it had gone before. At the same time there came a rising color to the young man"s cheek. Erasistratos looked up to see what was the cause of this striking change, and found that the young wife of the King Seleucus, the prince"s stepmother, had just come into the room. Seleucus, as an old man, had married a very handsome young woman, and it was evident that the young man"s heart was touched in her regard, and that here was the cause of the trouble. Erasistratos did not proclaim his discovery at once. He did announce that now he knew the cause of the trouble, that it was an affection of the heart that would be cured by travel, and he proposed to take young Seleucus back with him to Alexandria. In private, very probably, he told his young patient that he had discovered his secret, and then persuaded him that absence would be the thing for him. Very probably the young man considered that cure was impossible, and with many misgivings he consented to go to Alexandria, and as has happened many times before and since, in spite of the patient"s a.s.surance to the contrary, the travel cure proved effective even for the heart affection.
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I hope sincerely that you shall have as much tact, as much knowledge of men and women and as much success as this great teacher at the first of our modern university medical schools, when the great consultations do come your way, for it is easy to understand that when the young man recovered under the kindly ministrations of Erasistratos and the good effect of absence from the disturbing heart factor, Erasistratos was loaded with the wealth of the East and acquired a reputation that made him known throughout all the world of that time.
There is a curious commentary on this story that I think you should also know. It is Galen who has preserved the incident for us. He does so in the book on the pulse, mainly in order to show, as he thinks, the fatuity of such observations. After giving the details he says, "Of course, there is no special pulse of love." Poor Galen, how his wits must have been wool-gathering, or how forgetful he must have been of his own youth writing in the serenity of age, or how lacking in ordinary human experience if that is his serious meaning. The older man was by far the better observer, and I hope that you shall not forget in the time to come that there are many things that affect men and women besides bacteria and auto-intoxications of various kinds and metabolic disturbances and nutritional changes. Erasistratos seems to have known very well how much the mind, or as they called it in the older terminology, and we {390} still cling to the phrase, the heart, meant for many a phenomenon of existence supposed to be physically pathologic and yet really only representing psychologic influences apart from the physical side of the being. I may say to you that the more you know about these old teachers of medicine the more you will appreciate and value their largeness of view, their breadth of knowledge of humanity and their practical ways.
It is no wonder that students from all over the world were attracted to Alexandria for the next three centuries because of the opportunities, for the study of medicine afforded them there. After the first century of its existence not as much was accomplished as at the beginning, because what always happens in the history of medicine after a period of successful investigation, happened also there. Men concluded that nearly everything that could be, had been discovered and began to theorize. They were sure that their theories explained things. Men have persisted in spinning theories in medicine. Theories have almost never helped us and they always have wasted our time.
_Observation! Observation_ is the one thing that counts, Alexandria continued to have her reputation, however, and in the first century of the Christian era was the centre of medical interest. It was probably here that St. Luke was educated, and as we know now from the careful examination of the {391} Third Gospel and of the Acts, he knew his Greek medical terms very well. Harnack has shown us recently once more how thoroughly Luke converted the ordinary popular terms of the other Evangelists into the Greek medical terms of his time. Luke must have known medicine very well. His testimony to the miracles of Christ is therefore all the more valuable, and so the Alexandrian medical school has its special place in the order of Providence.
We are p.r.o.ne to think because of the curious way in which not only the histories of medical education, but of all education, have been written, that while there were some medical schools in the interval from the days of Alexandria and Rome down to the modern time, these were so hampered by unfortunate conditions that men practically did nothing in education and, above all, scientific and medical education until comparatively recent times. Nothing could well be more absurd than such an opinion. The great universities founded during the thirteenth and fourteenth centuries attracted more students to the population of the countries of the time than go to our universities to the number of our population in the present time. These universities are the model of our universities of the present time and, indeed, the history of many of the old European universities is continuous for seven centuries. They had an undergraduate department in which students were trained in grammar, rhetoric, logic, {392} arithmetic, astronomy, music and gymnastics, and graduate departments of law, theology and medicine. Professor Huxley, reviewing mediaeval education, once said that the undergraduate education of the mediaeval universities was better than our own. He doubted "that the curriculum of any modern university shows so clear and generous a comprehension of what is meant by culture as this old trivium and quadrivium did."
Their post-graduate work was just as fine as their undergraduate work.
They made the law of the world in the thirteenth century, and laid the foundations on which the philosophy and theology of the after-time have been built up. Strange as it may seem to many accustomed to give credence to far different traditions, they did the same thing in medicine. Take as a single example what they did for the regulation of medical education and practice. A law of the Emperor Frederick II, issued in 1241 for the Two Sicilies (Southern Italy and Sicily proper), required three years of preliminary training in the ordinary undergraduate course at the university before a man was allowed to take up medicine, and four years at medicine before he got his degree.
But even this was not all; after graduation, a year of practice with a physician was required before he was allowed to practise for himself.
If he were going to practise surgery an extra year of the study of anatomy was required. But it may {393} be said by those who cannot persuade themselves that the Middle Ages so far antic.i.p.ated us: since they knew almost nothing of medicine and surgery, what did they spend their time at during these four years? The more we know about the details of that early teaching, the more we respect them and the more we admire the magnificent work of the old-time professors and their schools.
Probably the most surprising feature of their teaching was surgery. We are rather likely to think that the development of surgery was reserved for our day. Nothing could be more untrue. The greatest period in the history of surgery, with the possible exception of our own time, is the century and a half from 1250 to 1400. What they taught in surgery we know not from tradition, but from the text-books of the great teachers which have been preserved for us, and which have been recently republished. Three men stand out pre-eminent: William of Salicet; Lanfranc, who taught at Paris, having been invited there from Italy, where he had been a pupil of William of Salicet, and Guy de Chauliac, to whom has been given by universal accord the t.i.tle of Father of Modern Surgery.
There is practically nothing in modern surgery that these men did not touch in their text-books. Perhaps the most surprising thing is to find that William of Salicet, in discussing his {394} cases, suggested that sometimes he succeeded in obtaining union by first intention by keeping his wounds clean. Alas for the surgery of succeeding centuries, Guy de Chauliac, a greater mechanical genius than William, insisted that union by first intention was an illusion and that it could only come through pus formation. Laudable pus became the shibboleth of surgery for centuries, imposed upon it by the genius of a great man. Most men think that they think, they really follow leaders, and so we followed blindly after Guy until Lister came and showed us our mistake.
Guy was the professor of surgery down at Montpellier, and also the physician to the Popes, who for the time were at Avignon. His text-book of surgery is full of expressions that reveal the man and the teacher. He said the surgeon who cuts the human body without a knowledge of anatomy is like a blind carpenter carving wood. He insisted that men should make observations for themselves and not blindly follow others. He discussed operations on the head, the thorax and the abdomen. He said that wounds of the intestines would surely be fatal unless sewed up, and he described the technique of suture for them. His specialty was operation for hernia. There are pictures still extant of operations for hernia done about this time in an exaggerated Trendelenberg position. The patient is fastened to a board by the legs, head down, the board at an angle of {395} forty-five degrees against the wall. The intestines dropped back from the site of operation and allowed the surgeon to proceed without danger. Guy said that more patients were operated on for the sake of the doctor"s pocket in hernia cases than for their own benefit. His instructions to his students, his high standard of professional advice, all show us one of the great physicians of all time and historians of medicine are unanimous in their praise of him.
The next great development in medicine came at the time of the Renaissance with the reorganization of the universities. In the sixteenth century Italy particularly did magnificent work in the universities, stimulated by close touch with old Greek medicine. At Padua, at Bologna, above all, at Rome, the great foundations of the modern medical sciences were laid. I need only mention the names of Vesalius, Varolius, Eustachius, Fallopius, Columbus (who discovered the circulation of the blood in the lungs), Caesalpinus, to whom and rightly the Italians attribute the discovery of the systemic circulation nearly half a century before Harvey. These men all of them did fine work, everywhere in Italy. They were doing original investigation of the greatest value. Whenever anybody anywhere in Europe at this time wanted to do good work in science of any kind,--astronomy, mathematics, physics and, above all, in any of the medical sciences,--he went down to Italy; Italy was and continued for five {396} centuries after the thirteenth to be what France was for a scant half a century in the nineteenth, and Germany for a corresponding period just before our own time. How curiously the history of science and of medicine was written when it seems to contradict this.
Above all, what ridiculous nonsense has been talked about Papal opposition to science. The great universities of Italy in the thirteenth and fourteenth centuries had charters from the Popes. They were immediately under ecclesiastical influence, yet they did fine work in anatomy and surgery. The Father of Modern Surgery was a Papal physician. The Papal physicians for seven centuries have been the greatest contributors to medicine. The Popes deliberately selected as their physicians the greatest investigators of the time. Besides Guy de Chauliac such men as Eustachius, Varolius, Columbus, Caesalpinus, Lancisi, Malpighi were Papal physicians. We have even a more striking testimony to the Papal patronage and encouragement of medicine and to the Church"s fostering care of medical education, here in America. The first university medical school in America was not, as has so often been said, the medical school of the University of Pennsylvania founded in 1767, but the medical school of the University of Mexico, where medical lectures were first delivered in 1578. Our medical schools in this country have only become genuine university medical schools in the sense {397} of being organic portions of the university in the last twenty-five years. Before that their courses were brief and unworthy and no preliminary education was required.
The universities of Spanish America from the very beginning required three years of preliminary training in the university before medicine could be taken up, and then four years of medical studies. These four years became five and six years in certain countries, and at no time during the nineteenth century did the medical education of Spanish America sink to the low level unfortunately reached in the United States. The lesson of it is clear. When medical education is seriously undertaken as a university department, all is well. When it is not, the results are disastrous.
In our day and country another great awakening of university life has come and with it a drawing together in intimate union of universities and their graduate departments. Above all, the medical schools have profited by this closer connection with university work, and the prospects for medical education in the United States and a new period of wonderful progress in it are very bright. You have my hearty congratulations, then, on your graduation from a great university medical school here in the West, and I hope sincerely that you shall prove worthy of Alma Mater. You have had the privileges of university education and these involve duties. {398} This is ever true, though unfortunately it is somewhat seldom realized. _n.o.blesse oblige_. We hear much in these days of the stewardship of wealth, and do not let us forget that there is a stewardship of talent and education. Much more will be demanded of you because of your opportunities, and we look for an accomplishment on your part far above the ordinary in medical work and maintenance and uplift of professional dignity, that shall mean much for your fellows.
Remember that you are doing only half your duty if you but make your living or even make money. You are bound besides to make medicine. For all that the forefathers have done for us we in this generation must make return by a broadening of their medical views for the benefit of posterity. If you were graduates of some fourth-rate proprietary medical school, perhaps it would be sufficient if you succeeded in making your living out of your profession. Perhaps even your teachers would then be quite satisfied with you. No such meagre accomplishment can possibly satisfy those who are sending you out to-day. Above all, you must remember that your education is not for yourself, but for the benefit of others as well. If, somehow, its influence becomes narrowed so as only to affect yourself and your intimate friends then it is essentially a failure. You must not only live your lives for yourselves, but so that at the end of them the community shall have been benefited and medicine {399} and its beneficent mission to mankind shall be broader and more significant because you have lived.
With this message, then, I welcome you as brother physicians and bid you G.o.d-speed in your professional work.
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THE COLLEGE MAN IN LIFE
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"Non scholae sed vitae discimus."
--Seneca, _Epist._, 106.
[We learn for life not for school.]
"Nec si non obstatur, propterea etiam permitt.i.tur."
--Cicero, _Philip_., xiii, 6.