It was as a consequence of their direct attachment to these old mediaeval medical schools that the medical schools founded here in America in the sixteenth century at once began with high standards. Three years of preliminary work was required and four years of medicine. In the United States no preliminary requirements were demanded; and for a full century only two years of medical study, which really consisted of but two terms of four months each, was the requirement. The old mediaeval medical schools were originally attached to the universities, and it is a well-known rule in the history of education that whenever the medical schools are independent then standards are sure to be low. Whenever the university controls the medical school and it is a real graduate department, then standards of admission and of graduation are properly maintained. It is surprising to think that the old mediaeval universities should be able to give us lessons in this matter and should put us to shame for our slip-shod nineteenth-century medical education in the United States, but this is a simple fact. Contrast [{126}] the South American countries where the mediaeval traditions with which they were founded constrained them to give four, five and even six years to medicine before granting a degree. Go a step further and see how devoted to science were the Universities of Lima (Peru) and Mexico, centuries before we did any serious scientific work in the United States, and all because they were direct descendants of the old mediaeval universities.
The feeling of certain modern educators would be that it did not matter how much time these mediaeval universities gave to medicine since, after all, they had nothing of any value to teach in medicine. Even educated people have been led to believe that there was nothing in medicine and, above all, in the surgery of those times to be of any value. Probably no opinion is more foolishly ignorant or more ridiculously absurd than this, though it is a commonplace among people who are sure they know something about history, and, above all, among those who consider themselves authorities in the history of education, and of the development of science. In surgery a magnificent development was made at this time of which I shall have something to say later. In medicine there was much less anticipation of our modern progress, but even here there was much that demands our respect. One of the university men, Simon of Genoa, worked out the dosage of opium and indicated its uses. Anodyne drugs were [{127}] employed much more generally and successfully than we are apt to think; various methods of anaesthesia, one of them by inhalation, of which I shall say more when talking of surgery, were invented and a large number of drugs and simples were experimented with. Down at Montpellier Bernard Gordon suggested red light for smallpox.
This is not much of a record, perhaps, but we must not forget what Professor Richet, the Director of the Physiological Laboratory of the University of Paris, said not long since in an article on "Physicians and Medicine" in La Revue de Deux Mondes. It is startling but chasteningly true. "The therapeutics of any generation has always been quite absurd to the second succeeding generation." Indeed it is one of the almost disheartening things in the history of medicine to see how treatments come in, are widely accepted and hailed as great advances in therapeutics and then gradually disappear. They bled a great deal and they purged not a little, in accordance with the teaching in the medical schools of the universities of the thirteenth and fourteenth centuries, but then they bled a great deal and purged a great deal more, according to the teaching of the medical schools of the beginning of the nineteenth century. There have been many periods in the interval when purging and bleeding were, and very properly, not nearly so popular.
It was in preventive medicine particularly that [{128}] these progressive medical men of the early university days secured their triumphs. They made separate hospitals for the lepers all over Europe, and by segregation succeeded in wiping out that disease, though it was as widely spread as tuberculosis in our day and presented just as serious a problem. Indeed the most encouraging incentive for our present tuberculosis campaign is drawn by many authorities from the experience with leprosy, which was eventually obliterated as an endemic popular disease, by strict segregation methods. These same generations created special hospitals for erysipelas and thus prevented the spread of this disease in the ordinary hospitals, where it used to be so serious a factor for morbidity if not for mortality. Men forgot this later and the disease became a serious problem once more in all the hospitals of even a generation ago. The hospital organization worked out by these university men is the finest jewel in the crown of their accomplishment as applied scientists. Pope Innocent III, himself a University of Paris man, founded the Santo Spirito Hospital in Rome, summoning for that purpose the best authority on hospitals in Europe, Guy of Montpellier, and then required the bishops of the world to erect similar hospitals in their dioceses. This was done, and it is Virchow, whose sympathies were anything but favorable to the Popes, who has been most loud in his praise of the wonderful hospital organization of these centuries. Every town in [{129}] Europe of 5,000 inhabitants or more had a hospital, and there were hospitals in many of the smaller towns.
It would be easy to think that these hospitals were rudely built, were badly ventilated, were ill-arranged and, above all, were likely to be houses for the perpetuation of disease rather than for the regaining of health. We are prone to think that we are the first generation to solve the problem of hospital construction. We know what poorly-constructed, badly-planned institutions were the hospitals of three generations ago. What, then, must have been the hospital buildings of centuries ago? This argument has no place in history; the worst hospitals in the world and in history were erected at the end of the eighteenth and the beginning of the nineteenth century. Some of the best hospitals ever constructed date from the thirteenth, fourteenth and fifteenth centuries. This was a time when great architects were successfully solving the construction problems for cathedrals, municipal buildings, colleges and the like, and they solved them quite as successfully for hospitals. Some of these hospitals were models in their way. One of them, built toward the end of the thirteenth century, by the sister of St. Louis, Marguerite of Bourgogne, with its large windows high in the walls, in single-story buildings, with arrangements for the segregation of patients, with the kitchens in a separate building, with beautiful [{130}] frescoes on the walls so that patients' minds might be occupied and not left to their own often disturbing devices as with our bare wall, with a stream of running water divided so as to pass on both sides of the hospital, is a model of construction for all time.
It was in surgery rather than medicine, however, that these great mediaeval university medical schools left their impress upon the history of medicine. During the thirteenth, fourteenth and fifteenth centuries we have a series of wonderful teachers of surgery, whose achievements we know not by tradition nor by fragments of their writings, but by the text-books which they wrote and which constituted the teaching for generations and sometimes for centuries after their time. Gurlt, the great German historian of surgery, devotes some 300 pages of the first volume of his "History of Surgery" to the surgical accomplishments of the Middle Ages. He even protests that space compels him to abbreviate the story of what these old-time masters of surgery did to lay the foundation of modern surgical practices. It is a commonplace in the American writing of history that there was no surgery at this time. President White says that, "for over a thousand years surgery was considered dishonorable until the German Emperor Wenceslas, in 1403, ordered that it should be held in honor again." The two centuries immediately preceding this date represent the [{131}] greatest period in the history of surgery down to our own time, and because of its originality probably greater in real achievement than even our vaunted age.
It is sometimes the custom to say that this surgery was derived from the Arabs. This is supposed to rob the mediaeval universities of any prestige that may come to them for this marvellous progress. Gurlt, however, in his "History of Surgery," in his sketch of Roger (Ruggiero), who was the first of the great surgeons of the thirteenth century, who taught at the Italian universities, says: "Though Arabian writings on surgery had been brought over to Italy by Constantine Africanus 100 years before Roger's time, these exercised no influence over Italian surgery in the next century, and there is not a trace of the influence of the Arabs to be found in Roger's work." When Gurlt says this it is because he has deliberately studied the question, and we can be absolutely sure, therefore, that whatever we find in surgery at this time comes to us from these great mediaeval universities themselves, and is not imported from abroad.
After Roger, who was at Bologna for a time after having been in Paris, and who then became a Papal physician, there are a series of great names that deserve to be mentioned. Four names are connected together by association as master and pupil for what may be termed four generations of surgical progress. From the birth [{132}] of the first to the death of the last represents about 100 years. That 100 years is a gloriously fruitful century in the history of surgery. The first of the group is William of Salicet, of whom Professor Clifford Allbutt, the Regius Professor of Physic at the University of Cambridge, in his address on the "Historical Relations of Medicine and Surgery to the End of the Sixteenth Century," delivered by special invitation at the Congress of Arts and Sciences at the World's Fair in St. Louis in 1904, has the highest praise. Allbutt says: "Like Lanfranc and the other great surgeons of the Italian tradition, and unlike Franco and Paré, William had the advantage of the liberal university education of Italy; but like Paré and Wurtz, he had a large practical experience in hospitals and on the battlefield and fully recognized that surgery cannot be learned from books only." Allbutt praises him and rightly for his careful notes of cases and then tells us something of his accomplishments in surgery. He says: "William discovered that dropsy may be due to a durities renum six centuries before Bright; he substituted the knife for the Arabist abuse of the cautery; he investigated the causes of the failure of healing by first intention (Italics ours), he described the danger of wounds of the neck; he sutured divided nerves; he forwarded the diagnosis of suppurative diseases of the hip; and he referred chancre and phagedaena to their proper causes."
His pupil Lanfranc equalled his master in devotion to practical surgery and surpassed him in his development of the great science of medicine. Pagel, the well-known German historian of medicine, says that, in his text-book Lanfranc has excellent chapters on the affections of the eyes, the ears and mouth, the nose, even the teeth, and treats of hernia in a very practical common-sense way. He warns against the radical operation and says, in words that come home to us with strange familiarity at the present time, that many surgeons decide on operations too easily, not for the sake of the patient but for the sake of the money that is in them. Lanfranc's discussion of cystotomy, Pagel characterizes as prudent but rational, for he considers that the operations should not be feared too much but not delayed too long. In patients suffering from the inconvenience which comes from large quantities of fluid in the abdomen he advises paracentesis abdominis, but warns against putting the patient in danger from such an operation without due consideration. Pagel says that Lanfranc must be considered as one of the greatest surgeons of the Middle Ages and the real establisher of the prestige of the French school of surgery which maintained its prominence down to the nineteenth century.