Education: How Old The New

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 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 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 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.

Lanfranc had been invited to Paris to take the chair of surgery, because the authorities of the university wanted to add prestige to the medical school, which was not as well known as the school of philosophy. The fame of William of Salicet had spread throughout academic Europe, and so Lanfranc was offered the chair at the University of Paris in order to carry his master's message there. The next in the succession of great teachers at Paris was Mondeville, who found less to do in an original way than his master Lanfranc and his protomaster William, but who accomplished much for surgery. All that he did was thrown into the shade by what was accomplished for succeeding generations by the next in the series, Guy de Chauliac, who studied for a time in Paris under Mondeville, though his early medical education was obtained at Montpellier, but had also had the advantage of spending a year in Italy at the various medical schools which were famous at that time. These two incidents, Lanfranc's invitation to Paris to be a teacher there from Italy more than a thousand miles away, and Guy de Chauliac's studies in all the important universities of Europe of the time before he took up his own work, illustrate better than any words of ours can the ardent enthusiasm for study, the thoroughgoing anticipation of our most modern methods in education. Mondeville, like Chauliac, had made very nearly the same round of the universities. It is a custom, not a chance incident, that we have to deal with here.

Guy de Chauliac has been given the name of the father of modern surgery. Any one who wants to see why should read the text-book on surgery that Chauliac wrote and which for two centuries after his time (he died about the middle of the fourteenth century) continued to be the most used text-book of surgery in the medical schools of Europe. Chauliac, for instance, describes the treatment of conditions within all three of the important cavities of the body, the skull, the thorax and the abdomen. Pagel has three closely-printed pages in small type of titles alone of subjects in surgery which Chauliac treated with distinction. His description of instruments and methods of operation is especially full and suggestive. He describes the passage of a catheter, for instance, with the accuracy and complete technique of a man who knew the difficulties of it in complicated cases from practical experience. He even recognizes the dangers for the patient from the presence of anatomical anomalies of various kinds and describes certain of the more important of them. He has very exact indications for trephining. For empyema he advises opening of the chest and indicates where and how. He says very frankly that in wounds of the abdomen the patient will die if the intestines have been perforated and left untreated, and he describes a method of suturing wounds of the intestines in order to save the patient's life.

His treatment of bone surgery and of fractures and dislocations is especially interesting and shows how far these very practical men had reached conclusions resembling those of our time. It was in hernia particularly that Chauliac's surgical genius manifested itself. He operated for hernia and its radical cure, placing the patient in an exaggerated Trendelenberg position, head down, feet fastened to a slanting board. For such work anatomy had to be known very well, and Chauliac had made special studies at Bologna under Bertruccio, the successor of Mondino. Chauliac once declared that the surgeon ignorant of anatomy carves the human body as a blind man would carve wood. Of ulcers of all kinds Chauliac writes from a knowledge evidently derived from experience. Of ulcers due to cancer he has much to say. He considers them hopeless unless they can be excised at a very early stage and the incision followed by caustics. For carcinomatous ulcers there is not much that we can do beyond this, even in our day. It is no wonder that the great historians of medicine have been unanimous in praise of this wonderful scientific genius. For my lecture on "Old-Time Medical Education," before the Johns Hopkins Historical Club, last year, I quoted some of those opinions. Portal, for instance, says of him, "It may be averred that Guy de Chauliac said nearly everything that modern surgeons say and that his work is of infinite price, but unfortunately too little pondered." Malgaigne declares Chauliac's "Chirurgia Magna," "A masterpiece of learned and luminous writing." Pagel says, "Chauliac represents the summit of attainment in mediaeval surgery, and he laid the foundation of that primacy in surgery which the French maintained down to the nineteenth century." Professor Clifford Allbutt says of Chauliac's treatise, "This great work I have studied carefully and not without prejudice; yet I cannot wonder that Fallopius compared the author with Hippocrates or that John Freind calls him the prince of surgeons. The book is rich, aphoristic, orderly and precise." In a word it has all the qualities that are usually said to be lacking in the work of mediaeval scientists, and it is a standing reproach to those who ignorantly have made so little of the work of these wonderful men of the olden time, who anticipated so many of the features of our modern medicine and surgery that we are prone to think of as representing climaxes in human progress, indications of a wonderful human evolution.

Two other names of great professors of surgery deserve to be mentioned because they make it very clear that this wonderful development of surgery was not confined to France and Italy, but made itself felt all over Europe. One of these is John Ypermann, a surgeon of the early fourteenth century, of whom almost nothing was known until about twenty-five years ago, when the Belgian historian, Broeck, brought to light his works and gathered some details of his life. He was a pupil of Lanfranc, and at the end of the thirteenth century studied at Paris on a scholarship voted by his native town of Ypres, which provided maintenance and tuition fees for him at the great French university expressly in order that he might become expert in surgery. We are likely to think of Ypres as an unimportant town, but it was one of the great industrial centres of Europe and one of the most populous, busy towns of Flanders in the Middle Ages, noted for its manufacture of linens and fine laces. The famous Cloth Hall, erected in the thirteenth century, one of the most beautiful architectural monuments in Europe, and one of the finest buildings of its kind in the world, was the result of the same spirit that sent Ypermann to Paris.

After his return Ypermann settled down in his native town and obtained great renown not only at home, so that in that part of the country an expert surgeon is still spoken of as an Ypermann, but he became famous throughout all the Teutonic countries. He is the author of two books in Flemish. One of these is on medicine. Pagel calls it an unimportant compilation. The terms that occur in it, however, are enough to show us how much more than we are likely to think, these old masters in medicine discussed problems that are still puzzling us. He treats of dropsy, rheumatism, under which occur the terms coryza and catarrh, icterus, phthisis (he calls the tuberculous tysiken), apoplexy, epilepsy, frenzy, lethargy, fallen palate, cough, shortness of breath, lung abscess, hemorrhage, blood-spitting, liver abscess, hardening of the spleen, affections of the kidney, bloody urine, diabetes, incontinence of urine, dysuria, strangury, gonorrhea and involuntary seminal emissions–all these terms are quoted directly from Pagel.

His work in medicine, however, is as nothing compared to his writings on surgery. A special feature of his book is the presence of seventy illustrations of instruments of the most various kinds, together with a plate showing the anatomical features of the stitching of a wound in the head. Even Pagel's brief account of its contents will be a source of never-ending surprise for those who think that surgery has developed entirely in our time. Even in this work on surgery, however, there are many things that we now treat under medicine. As this gives us an opportunity to show how much more of medicine was known at this time than is usually thought, I venture to quote some of Pagel's brief resume of the contents of a single chapter. This is a chapter devoted to intoxications, which includes the effect of cantharides as well as alcohol, and treats of the bites of snakes, scorpions and of the fatal effects of wounds due to the bite of mad dogs.

The other great surgeon and surgical writer of the time, for there must have been many distinguished surgeons and only a few writers, if we can trust to common experience in that matter, was John Ardern, an English surgeon. He was educated in Montpellier, practised for a time in France, then settled for some years in the small town of Newark in Nottinghamshire, and then for nearly thirty years in London. His "Practice of Surgery," as yet existing only in manuscript, is another one of these wonderful contributions to the applied sciences of anatomy and medicine at a time when such applications are often supposed to have been absent. He was an expert operator and had a wide reputation for his success in the treatment of diseases of the rectum. He was the inventor of a new clyster apparatus. Daremberg, the medical historian, who saw a copy of Ardern's manuscript in St. John's College, Oxford, says that it contained numerous illustrations of instruments and operations. We fortunately possess an excellent manuscript copy in the Surgeon General's Library at Washington, and sometime it is hoped this will be edited and published.

The most interesting feature of the work of all of these men is their dependence on personal observation and not on authority. Guy de Chauliac's position in this matter can be very well appreciated from his criticism of John of Gaddesden's book in which he bewails the blind following of those who had gone before. His bitterest reproach for many of his predecessors was that, "They followed one another like cranes, whether for fear or love he would not say." Pagel praises Ypermann for the well-marked striving which he has noted in him to free himself from the bondage of authority, and because most of his therapeutic descriptions rest upon his own experience. William of Salicet, at the beginning of this great period of surgery, had insisted that notes of cases were the most valuable sources of wisdom in medicine and surgery. The last of them, Ardern, gave statistics of his cases and was quite as proud as any modern surgeon of the large number that he had operated on. He gives these carefully and accurately.

I have dwelt on the medical side of these universities mainly, of course, because this is more familiar to me as a historian of medicine than their work in other scientific departments, but also to a great extent because the medical schools gathered unto themselves nearly all the scientific knowledge of the time. Botany, mineralogy, climatology, meteorology were all studied for the sake of what could be learned from them for the benefit of medicine. Even astronomy which was then the old astrology, was cultivated seriously, because of the supposed effect of the stars on human constitutions. For this we surely cannot blame these mediaeval students of science since four centuries later Galileo and even Kepler were still making horoscopes for their patrons and laying down laws from astronomy that were supposed to be applicable to medicine. Even Copernicus studied astronomy and medicine side by side and this combination of studies was not at all infrequent.

The medical schools, then, are the real index of the serious interest of the mediaeval universities in science. Our scientific departments in modern universities have developed other interests, because of various applications that these have to life and its concerns. Always in scientific universities applied science is sure to encroach upon the domain of pure science, and no one knows that better than we do, for we have been bewailing the presence of machine shops and boiler factories on the university grounds. The old universities did not teach applied mechanics or engineering, but that does not mean that these subjects were not taught. There were special technical schools conducted by the gilds by means of apprenticeship and the journeyman training, which enabled them to teach those who cared to have it all the knowledge necessary for construction work of various kinds. The wonderful architectural engineering exhibited in the cathedrals, university buildings, town halls and castles of this time, and the magnificent bridges, some of which are still in existence, show us that the technical subjects were by no means neglected.9 Our mediaeval forefathers in education had the wisdom not to let the technical subjects interfere with pure science too much, as they inevitably do whenever the two are brought too closely together. Culture is always overshadowed by the practical, but not to the ultimate benefit of the race.

The proof for us here in America, close at hand, that these universities of the Middle Ages were thoroughly scientific in spirit and not only capable of, but actually active and successful in scientific investigation, is to be found in our earliest American universities. We are prone to think, because of the curiously defective way in which our histories of education have been written, that the only things worth while talking about in the origins of education here in America are to be found in English America. Recent investigations have shown how utterly deceived we were by foolish self-conceit in this matter. Long before the English-American universities were founded, and still longer before they began to do any serious work in education, there were important universities having literally thousands of students in attendance in the Spanish-American countries. The University of Mexico and the University of Lima in Peru were both founded about the middle of the sixteenth century. Harvard came nearly a century later, Yale a full century and a half, Princeton more than two centuries. The contrast between our English-American institutions of learning, however, and their Spanish-American rivals in accomplishment and numbers in attendance is still more striking than the mere dates of foundation.

Of course there were chairs of many sciences, strange as that may seem to us with our ridiculous traditions with regard to the history of education. These Spanish-American universities were the direct descendants of the old mediaeval universities. They were in close relationship with Salamanca, Valladolid and Alcala. They were the progeny of scientific universities and they were, of course, occupied mainly with science. In spite of the fact that already the influence of the Renaissance, with its classical studies as the basis of education, had begun to make itself felt, these Spanish-American universities retained, to a great extent, the scientific curriculum. Nor must it be thought that they were shilly-shally institutions of learning, doing nothing in reality, but making a great pretence of studying many things. To know the very opposite we turn to Bourne, himself at the time a professor at Yale, and writing one of the volumes of a series edited by Professor Albert Bushnell Hart, who holds the chair of history at Harvard, to be told in very definite emphatic terms how successfully investigations in science and scientific education were carried on in Mexico. Professor Bourne says:

"Not all the institutions of learning founded in Mexico in the sixteenth century can be enumerated here, but it is not too much to say that in number, range of studies and standard of attainments by the officers they surpassed anything existing in English America until the nineteenth century. Mexican scholars made distinguished achievements in some branches of science, particularly medicine and surgery, but pre-eminently linguistics, history and anthropology. Dictionaries and grammars of the native languages and histories of the Mexican institutions are an imposing proof of their scholarly devotion and intellectual activity. Conspicuous are Toribio de Motolinia's 'Historia de las Indias de Nueva España,' Duran's 'Historia de las Indias de Nueva España,' but most important of all Sahagun's great work on Mexican life and religion."

The scientific products of these universities in America are interesting because almost as a rule we know absolutely nothing about them in English America, and, therefore, conclude there must have been none. The first book written on a medical topic in America was the "Secretos de Chirurgia," written by Dr. Pedrarias de Benavides, which was published at Valladolid in Spain in 1567. The first book on medicine actually published in this country was "Opera Medicinalia," by Francisco Bravo.10 On Columbus' second expedition, however, a Dr. Chança who had been physician-in-ordinary to the King and Queen of Spain, was sent with the expedition as what we would now call a scientific attaché. On his return he wrote a volume of scientific observations that he had made in America. Some of these were doubtless written while he was over here, though the book was published in Spain. Dr. Ybarra of New York recently published a résumé of this in the Smithsonian Publications and an article on it in the Journal of the American Medical Association. It shows very well how wide were the scientific interests of the physicians of the time and how ardent their investigation of science, for there is scarcely a phase of modern science that would be touched on by the corps of scientists now attached to such an expedition which does not receive some serious treatment in Dr. Chança's book. Thus early did the Spanish-Americans take up scientific investigation seriously.