Education: How Old The New

One of them was our greatest pathologist, the other a great teacher of clinical medicine, who came into medicine through chemistry and therefore had a right to opinions with regard to the chemical side of medicine. We had been discussing the question of how much serious medical education there was in the Middle Ages and how, in spite of the magnificent work done, so many superstitions in medicine continued to maintain themselves. I remarked that it seemed impossible to teach truths to large bodies of men without having them accept certain doctrines which they thought truths but which were only theories and which they insisted on holding after the reasons for them had passed away. I even ventured to say that I thought that there were as many superstitions now, and such as there were, were of as great significance as those that maintained themselves in the Middle Ages. My chemical clinician brother on the right side said, "Let us not forget in this regard the hold the uric acid diathesis has on the English-speaking medical profession." And the brother pathologist on the left side: "Well, and what shall we say of intestinal auto-intoxication?"

Perhaps you will not realize all the force of these expressions at the present time, but after you have been five years in the practice of medicine and have been flooded by the literature of the advertising manufacturing pharmacist and by the samples of the detail man and his advice and suggestion of principles of practice, if you will listen to them, perhaps you will appreciate how much such frank expressions mean as portraying the medical superstitions of our time.

Surely we who have for years been much occupied with the superstition, for such it now turns out to be, of heredity in medicine, will not be supercilious toward older generations and their superstitions. Until a few years ago we were perfectly sure that a number of diseases were inherited directly. Tuberculosis, rheumatism, gout, various nutritional disturbances all were supposed to pass from father to son and from mother to daughter, or sometimes to cross the sex line. For a time cancer was deemed to be surely hereditary to some degree at least. Now most of us know that probably no disease is directly inherited, that acquired characters are almost surely not transmitted, and that while defects may be the subject of heredity, disease never is. Not only this, biological investigations have served to show that what is the subject of inheritance is just the opposite,–resistance to disease. A person whose father and mother had suffered from tuberculosis used to think it almost inevitable that he too should suffer from it. If they had died that he too would die. Our experts in tuberculosis declare now, that if tuberculosis has existed in the preceding generation there is a much better chance of the patient recovering from it, or at least resisting it for a long time, than if there had been no tuberculosis in the family. We had been harboring the superstition of heredity, the surviver opinion from a preceding generation, until we learned better by observation.

Let us turn from such discussion to the beginnings of the story of our medical profession as it has been revealed to us in recent years.

The first picture that we have of a physician in history is, indeed, one to make us proud of our profession. The first physician was I-em-Hetep, whose name means "the bringer of peace." He had two other titles according to tradition, one of which was "the master of secrets," evidently in reference to the fact that more or less necessarily many secrets must be entrusted to the physician, but also, doubtless, in connection with the knowledge of the secrets of therapeutics which he was supposed to possess. Another of his titles was that of "the scribe of numbers," by which, perhaps, reference is made to his prescriptions, which may have been lengthy, for there are many "calendar" prescriptions in the early days, but may only refer to the necessity of his knowing weights and measures and numbers very exactly for professional purposes. I-em-Hetep lived in the reign of King Tchser, a monarch of the third dynasty in Egypt, the date of which is somewhat uncertain, but is about 4500 B.C. How distinguished this first physician was in his time may be gathered from the fact that the well-known step pyramid at Sakkara, the old cemetery near Memphis, is attributed to him. So great was the honor paid to him that, after his death he was worshipped as a god, and so we have statues of him as a placid-looking man with a certain divine expression, seated with a scroll on his knees and an air of benignant knowledge well suited to his profession.

I called attention in 190721 to the fact that the earliest pictures of surgical operations extant had recently been uncovered in the cemetery of Sakkara near Memphis in Egypt. These pictures show that surgery was probably an organized branch of medicine thus early, and the fact that they are found in a very important tomb shows how prominent a place in the community the surgeon held at that time. The oldest document after that which we have with regard to medicine is the "Ebers Papyrus," the writing of which was done probably about 1600 B.C. This, however, is only a copy of an older manuscript or series of manuscripts, and there seems to be no doubt that the text, which contains idioms of a much older period, or, indeed, several periods, probably represents accumulations of information made during 2,000 or even 3,000 years before the date of our manuscript. Indeed, it is not improbable that the oldest portions of the "Ebers Papyrus" owe their origin to men of the first Egyptian dynasties, nearly 5,000 years B.C. To be members of a profession that can thus trace its earliest written documents to a time nearly some 7,000 years ago, is an honor that may be readily appreciated and that may allow of some complacency.

There is a well-grounded tradition which shows us that an Egyptian monarch with whose name even we are familiar, though we may not be able to pronounce it very well–he was Athothis, the son of Menes–wrote a work on anatomy. The exact date of this monarch's death is sometimes said to be 4157 b.c. We have traces of hospitals in existence at this time and something of the nature of a medical school. Indeed, one may fairly infer that medical education, which had been developing for some time, probably for some centuries, took a definite form at this time in connection with the temples of Saturn. Priests and physicians were the same, or at least physicians formed one of the orders of the clergy and the teachers of medicine particularly were clergymen. This tradition of close affiliation between religion and medicine continued down to the fifteenth century. How few of us there are who realize that until the fourteenth century the professors of medicine at the great universities were not married men, because members of the faculty, as is true at the present time of many members of the faculty in the English universities, were not allowed to marry. The old clerical tradition was still maintaining itself even with regard to the medical teachers.

Perhaps the most interesting thing about this early history of medicine in Egypt is that, with the very earliest dawn of medical history, we have traces of highly developed specialism in medicine. There were thirty-six departments of medicine, or at least there were thirty-six medical divinities who presided over the particular parts of the human body. In the larger temples, at least, there was a special corps of priest physicians for each one of these departments. Herodotus, the Father of History, is particularly full in his details of Egyptian history, and though he wrote about 400 B.C., nearly 2,300 years ago, his attention was attracted by this highly developed specialism among the Egyptians. He tells us in quaint fashion, "Physicke is so studied and practised with the Egyptians that every disease hath his several physician, who striveth to excell in healing that one disease and not to be expert in curing many. Whereof it cometh that every corner of that country is full of physicians. Some for the eyes, others for the head, many for the teeth, not a few for the stomach and the inwards."

It is interesting to realize that the same state of affairs upon which you young graduates will come now that you are going out to find an opportunity to practise for yourselves at the end of the first decade of the twentieth century, is not very different from that which the great Father of History chronicles as the state of affairs among the Egyptians between 600 and 1,000 before Christ,–let us say about 3,000 years ago. You, too, will find that every corner is full of physicians, some for the eyes, others for the head, many for the teeth, not a few for the stomach and everything else under the sun quite as in ancient Egypt. After a time you will probably find that some little corner has been left for you, and you will work hard enough to get into it first, and then to fill it afterward. The story of how young physicians have got on in their first few years has probably been interesting at all times in the world's history. I think that I know about it at five different periods, and in every one of these there seemed to be no possible room, and yet somehow room was eventually found, though only after there had been a struggle, in the midst of which a certain number of the young physicians found another sphere of activity besides medicine.

Of course it is easy to think that these specialties did not amount to much, but any such thought is the merest assumption. A single instance will show you how completely at fault this assumption is. Dentistry is presumed to be a very modern profession. As a matter of fact mummies were found in the cemetery of Thebes whose bodies probably come from before 3000 B.C., who have in their teeth the remains of gold fillings that were well put in, and show good workmanship, nearly 5,000 years ago.22 After dentistry, the specialty that we would be sure could not have had any significant existence so long ago would be that of ophthalmology. As a matter of fact, it is with regard to the knowledge of eye diseases displayed by these early teachers of medicine that the "Ebers Papyrus" is most startling. It is especially full in diagnosis and contained many valuable hints for treatment. As for laryngology and rhinology, one of the earliest medical records that we have, is the rewarding by one of the kings of Egypt of an early dynasty (nearly 4000 B.C.), of a physician who had cured him of a trouble of the nose of long standing, that seems to have interfered with his breathing.

It is easy to think in spite of all this, that the Egyptians did not know much medicine; but only one who knows nothing about it thinks so. According to Dr. Carl von Klein, who discussed the "Medical Features of the Ebers Papyrus" in the Journal of the American Medical Association about five years ago, over 700 different substances are mentioned as of remedial value in this old-time medical work. There is scarcely a disease of any important organ with which we are familiar in the modern time that is not mentioned here. While the significance of diseases of such organs as the spleen, the ductless glands, and the appendix was, of course, missed, nearly every other pathological condition was either expressly named or at least hinted at. The papyrus insists very much on the value of history-taking in medicine, and hints that the reason why physicians fail to cure is often because they have not studied their cases sufficiently. While the treatment was mainly symptomatic, it was not more so than is a great deal of therapeutics at the present time, even in the regular school of medicine. The number and variety of their remedies and of their modes of administering them is so marvellous, that I prefer to quote Dr. von Klein's enumeration of them for you:

"In this papyrus are mentioned over 700 different substances from the animal, vegetable and mineral kingdoms which act as stimulants, sedatives, motor excitants, motor depressants, narcotics, hypnotics, analgesics, anodynes, antispasmodics, mydriatics, myotics, expectorants, tonics, dentifrices, sialogogues, antisialics, refrigerants, emetics, antiemetics, carminatives, cathartics, purgatives, astringents, cholagogues, anthelmintics, restoratives, haematics, alteratives, antipyretics, antiphlogistics, antiperiodics, diuretics, diluents, diaphoretics, sudorifics, anhydrotics, emmenagogues, oxytocics, caustics, ecbolics, galactagogues, irritants, escharotics, caustics, styptics, haemostatics, emollients, demulcents, protectives, antizymotics, disinfectants, deodorants, parasiticides, antidotes and antagonists."

Scarcely less interesting than the variety of remedies were their methods of administration:

"Medicines are directed to be administered internally in the form of decoctions, infusions, injections, pills, tablets, troches, capsules, powders, potions and inhalations; and externally, as lotions, ointments, plasters, etc. They are to be eaten, drunk, masticated or swallowed, to be taken often once only–often for many days–and the time is occasionally designated–to be taken mornings, evenings or at bedtime. Formulas to disguise bad tasting medicaments are also given." We have no advantage over the early Egyptians even in elegant prescribing.

With all this activity in Egypt, it is easy to understand that the other great nations of antiquity also have important chapters in the history of medicine. The earliest accounts would seem to indicate that the Chaldeans, the Assyrians and the Babylonians all made significant advances in medicine. It seems clear that a work on anatomy was written in China about the year 2000 B.C. Some of the other Eastern nations made great progress. The Hindoos in particular have in recent years been shown to have accomplished very good work in medicine itself. Charaka, a Hindu surgeon, who lived not later than 300 B.C., made some fine contributions to the medical literature in Hindostani. There were hospitals in all these countries, and these provided opportunities for the practice of surgery. Laparotomy was very commonly done by Hindu surgeons, and one of the rules enjoined by Hindu students was the constant habit of visiting the sick and seeing them treated by experienced physicians. Clinical teaching is often spoken of as a modern invention, but it is as old as hospital systems, and they go back to the dawn of history.

It is among the Greeks, however, that the most important advances in medicine, so far as we are concerned, were made. This is, however, not so much because of what they did as from the fact that they were more given to writing, and then their writings have been better preserved for us than those of other nations. The first great physician among the Greeks was AEsculapius, of whom, however, we have only traditions. He is fabled to have been the son of Apollo, the god of music and the arts, and therefore to have been a near relative of the Muses. The connection is rather interesting, because sometimes people try to remove medicine from among the arts that minister to the happiness of man, and place it among the sciences whose application is for his profit. Medicine still remains an art, however. The temples of AEsculapius were the first hospitals, though the priests were not the only ones who practised medicine, for there were laymen who, after having served for some time in the hospitals, wandered through the country under the name of Asclepiads, treating people who were not able to go to the hospitals or shrines. These evidently, then, were the first medical schools in Greece as well as the first hospitals.

Six hundred years after AEsculapius came Hippocrates, of Cos, the Father of Medicine. He undoubtedly had the advantage of many Egyptian medical traditions and other Oriental medical sources, as well as the observations made in the hospitals and shrines of AEsculapius. He wrote some great works in medicine that have never grown old, Young men do not read them, old men who are over-persuaded of how much progress is being made by their own generation in medicine neglect them. The busy practitioner has no time for them. The great teachers of medicine whom all the professors look up to and who think for us in each generation turn fondly back to Hippocrates, and marvel at his acumen of observation and his wonderful knowledge of men and disease. Sydenham thought that no one had ever written like him, and in our turn we honor Sydenham by calling him the English Hippocrates. Boerhaave, Van Swieten, Liancisi, the great fathers of modern clinical medicine, turned with as much reverence to Hippocrates as does Osler, the Regius Professor of Medicine at Oxford, in our twentieth century. Hippocrates wrote 2,500 years ago, but his writing is eternal in interest and value.

The famous oath of Hippocrates, which used to be read to all the graduates of medicine, well deserved that honor, for it represents the highest expression of professional dignity and obligation. There is a lofty sense of professional honor expressed in it that cannot be excelled at any period in the world's history. Among other things that Hippocrates required his adepts in medicine, his medical students when they graduated into physicians, to swear to was the following: "I will follow the system of regimen which according to my ability and judgment I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to man, woman, or child born or unborn. With purity and with holiness I will pass my life and practise my art, Whatever in connection with my professional practice, or not in connection with it, I see or hear in the life of men which ought not to be spoken of abroad, I shall not divulge, as reckoning that all such should be kept secret. While I continue to keep this oath inviolate may it be granted to me to enjoy life and the practice of my art respected by all men in all times; but should I trespass and violate this oath may the reverse be my lot."

It is sometimes thought that after the Roman medicine, which was an imitation of the Greek (though Galen well deserves a place by himself, and Galen is usually thought of as a Roman though he wrote in Greek and had obtained his education at Pergamos in Asia Minor), there was an interregnum in medicine until our own time. This is, however, quite as much of an assumption as to suppose that the Egyptians had no medicine–as we used to until we knew more about them–or that old-time medicine is quite negligible because we were ignorant of its value, The Middle Ages had much more of medicine than we are likely to think, and just as soon as the great universities arose at the end of the twelfth and the beginning of the thirteenth centuries, medicine gained a new impetus and flourished marvellously. These university medical schools of the later Middle Ages are models in their way, and put us to shame in many things. According to a law of the Emperor Frederick II issued for the Two Sicilies in 1241,23 three years of preliminary study were required at the university before a student might take up the medical course, and then he had to spend four years at medicine, and practise for a year under the supervision of a physician of experience before he was allowed to practise for himself. The story of the medicine of this time is all the more wonderful because subsequent generations forgot about it until recent years, and supposed that all of this period was shrouded in darkness. It was probably one of the most brilliant periods in medical history. Some of the men who worked and taught in medicine at this time will never be forgotten.

Probably the greatest of them was Guy de Chauliac, a Papal chamberlain, whom succeeding generations have honored with the title of Father of Surgery. His great text-book, the "Chirurgia Magna," was in common use for several centuries after his death, and is full of surgical teaching that we are prone to think much more modern. He trephined the skull, opened the thorax, operated within the abdomen, declared that patients suffering from wounds of the intestines would die unless these were sewed up, operated often for hernia in an exaggerated Trendelenberg position, with the patient's head down on a board, but said that many more patients were operated upon for hernia "for the benefit of the surgeon's purse than for the good of the patient." His directions for the treatment of fractures and for taxis in hernia were followed for full four centuries after his time. No wonder that Pagel, the great German historian, declared that "Chauliac laid the foundation of that primacy in surgery which the French maintained down to the nineteenth century." Portal, in his "History of Surgery," declares that "Guy de Chauliac said nearly everything which modern surgeons say, and his work is of infinite price, but unfortunately too little read, too little pondered." Malgaigne declared "the 'Chirurgia Magna' a masterpiece of learned and luminous writing."

Chauliac's24 personal character, however, is even more admirable than his surgical knowledge. He was at Avignon when the black death occurred and carried away one-half the population. He was one of the few physicians who had the courage to stay. He tells us very simply that he did stay not because he had no fear, for he was dreadfully afraid, but he thought it his duty to stay. Toward the end of the epidemic, he caught the fever but survived it and has written a fine description of it. He was looked upon as the leader of surgery in his time, and this is his advice as to what the surgeon should be as given in the introductory chapter of his "Chirurgia Magna": "The surgeon should be learned, skilled, ingenious and of good morals; be bold in things that are sure, cautious in dangers; avoid evil cures and practices; be gracious to the sick, obliging to his colleagues, wise in his predictions; be chaste, sober, pitiful and merciful; not covetous nor extortionate of money; but let the recompense be moderate, according to the work, the means of the sick, the character of the issue or event and its dignity." No wonder that Malgaigne says of him: "Never since Hippocrates has medicine heard such language filled with so much nobility and so full of matter in so few words."

The old-time medical traditions of education which in the mediaeval universities produced such men as William of Salicet and Lanfranc and Mondeville and Guy de Chauliac, persisted during the next two centuries in the southern countries of Europe, and then were transferred to America through Spain. The first American medical school was not, as has so often been said, at my own Alma Mater, the University of Pennsylvania, which had its first lectures in 1767, while the Physicians and Surgeons of New York did not come for some ten years later and Harvard only in the following decade, but in the medical school of the University of Mexico, where the first lectures were held in 1578, and where a full medical school was organized before the end of the sixteenth century. In this medical school, which during the seventeenth century came to have several hundred students, the university tradition of the olden time was well preserved. Three years of preliminary study at the university were required before a student could take up the course in medicine, and four years of medical study were required before graduation. We have some of the text-books, and know much about the curriculum of this old medical school, and in every way it is worthy of the old university traditions.

Unfortunately our universities in what is now the United States developed very slowly. King's College (Columbia) did not become a university in the sense of having law and medical schools as well as an undergraduate department until the nineteenth century had almost begun. Harvard did not have a law school affiliated with it until the first quarter of the nineteenth century had almost run its course. The affiliations between the medical schools and the universities in these cases was only very slight, and the medical schools were entirely in the hands of the medical faculty, whose main purpose during a great part of the nineteenth century was to make medical studies as short as possible and as inexpensive as they could possibly be made for the faculty, because that left so much more of the fees to be absorbed by the historic septennate of professors who ruled and managed the university. The consequence was that during most of the nineteenth century two terms of four months each were all that was required for the diploma in medicine in most American medical schools. Three schools maintained a very high standard by requiring twenty weeks in each of two calendar years. The medical school that was considered one of the best in the country, and whose graduates obtained the highest marks in the army and navy examinations, that of the University of Virginia, required but two terms of four and one-half months each which might be taken in the same calendar year, and then gave the doctor's degree.