Kitabı oku: «Medieval Medicine», sayfa 10

They had no large asylums such as we have now, but neither did they have any poor-houses; yet we have come to recognize how readily they solved the social evils of poverty. The almshouses at Stratford, with their accommodations for an old man and his wife living together, are a typical, still extant example of this. Each small community cared for its own sufferers. They did not solve their social problems in the mass fashion which we have learned is so liable to abuse, but each little town cared to a great extent for its own mentally ailing. They were able to do this mainly because hospitals were rather frequent; and psychic cases were, at the beginning, cared for in hospitals, and when in milder state their near relatives were willing to take more bother in caring for them than in our time. Delirious states due to fever had not yet been definitely differentiated from the acute insanities, and all these cases then were taken in by the hospitals. This was an excellent thing for patients, because they came under hospital care early; and one of the developments that must come in our modern hospitals is a psychopathic ward in every one of them, for patients will be saved the worst developments of their affection.

The better-to-do classes found refuges for their non-violent insane in certain monasteries and convents, or in parts of monastic establishments particularly set aside for this purpose. When the patient was of the higher nobility, he was often put in charge of a monk or of several religious, and confined in a portion of his own or a kinsman’s castle and cared for for years. There are traditions of similar care for the peasantry who were connected with monastic establishments, and sometimes small houses were set apart for their use on the monastery grounds. As cities grew in extent, certain hospitals received mental patients as well as the physically ailing, keeping them segregated. After a time some of these hospitals were entirely set aside for this purpose. Bedlam in England, which had been the old Royal Bethlehem Hospital for the care of all forms of illness, came to be just before the end of the thirteenth century exclusively for the care of the insane. In Spain particularly the asylums for the insane were well managed, and came to be models for other countries. This development in Spain is sometimes attributed to the Moors, but there is absolutely no reason for this attribution, except the desire to minimize Christianity’s influence, even though this effort should attempt the impossible feat of demonstrating Mohammedanism as an organizer of charity and social service.

Some of the developments of their care for the insane in the Middle Ages are very interesting. Before this period closed, there was a custom established at Bedlam by which those who had been insane but had become much better were allowed to leave the institution. This was true, even though apparently there might be no friends to care for them particularly, or to guarantee their conduct or their return, in case of redevelopment of their symptoms. This amounted practically to the open-door system. The authorities of the hospital, however, made one requirement. Those who had been insane and were allowed to leave Bedlam were required to wear a badge or plate on the arm, indicating that they had been for some time in this hospital for the insane. These people came to be known as Bedlamites, or Bedlams, or Bedlamers, and attracted so much sympathy from the community generally that some of the ne’er-do-wells, the tramps and sturdy vagrants who have always been with the world as a problem quite as well as the insane, obtained possession of these insignia by fraud or stealth, and imposed on the charity of the people of the time.

It is easy to understand that wherever these patients were recognized by their badges as having been for a time in an asylum for the insane, they were treated quite differently from ordinary people. Though allowed to leave the asylum, and left, as it were, without surveillance, they were really committed to the care of the community generally. No one who knows the history is likely to irritate a person who has been insane, nor are such people treated in the same spirit as those who are supposed to have been always normal, but out of pity and sympathy they are particularly cared for. They are not expected to live the same workaday existence as mentally healthy individuals, but their pathway in life is smoothed as much as possible. Many an unfortunate incident in modern times is due to the fact that a previous inmate of an asylum is irritated beyond his power to control himself in the ordinary affairs of life by those who know nothing of his previous mental weakness. It is not unlikely that our open-door system will have to be supplemented by some such arrangement as this medieval requirement of a badge, and that we can actually get suggestions from the medieval people with regard to the care of the insane that will be valuable for us.

Another very interesting development of care for the mentally afflicted was the organization of institutions like the village of Gheel in Belgium, in which particularly children who were of low-grade mentality were cared for. This was practically the origin of what has come in our time to be called the colony system of caring for defectives. We now have colonies for imbeciles of various grades, and village systems of caring for them. At Gheel the system developed, it might be said, more or less accidentally, but really quite naturally. St. Dympna was an Irish girl-martyr whose shrine, said to be on the site of her martyrdom, existed in the village of Gheel. Her intercession was said to be very valuable in helping children of low-grade mentality. These were brought to the shrine, sometimes from a long distance, and when the prayers of relatives were not answered immediately the children were often left near the shrine in the care of some of the villagers, to have the benefit of the martyr’s intercession for a prolonged period. As a consequence of this custom, many of the houses of the village came to harbour one or more of these mentally defectives, who were cared for by the family as members of it.

The religious feelings, and particularly the impression that the defectives were under the special patronage of the patron saint of the village, not only kept them from being abused or taken advantage of in any way, but made them an object of special care. They were given various simple tasks to perform, and the public spirit of the community cared for them. It was only with the development of modern sophistication that the tendency to take advantage of social defectives came and special government regulations had to be made and inspectors appointed. This system of caring for these defective children, however, was eminently satisfactory. Other villages took up the work, especially in the Low Countries and in France. The village and colony system of caring for the insane, which we are now developing with so much satisfaction, was entirely anticipated under the most favourable circumstances, and with religious sanctions, during the Middle Ages. Not a few of the defectives, when they grew up, came to be attached in various humble occupations to monastic establishments. Here they were out of the current of the busy life around them, and were cared for particularly. They were not overworked but asked to do what they could, and given their board and clothes and the sympathetic attention of the religious. There are many more of such cases at the present time than are at all appreciated. They emphasize how much of this fraternal care there must have been in the Middle Ages.

Between the village system of caring for defectives, and the germ of the colony idea in their recognition of the value of the country or small town as a dwelling-place for those suffering from backwardness of mind or chronic bodily ills that disturb mentality, and the “open-door system” for the insane, as practised at Bedlam and other places, the Middle Ages anticipated some of the best features of what is most modern in our care for mental patients. Their use of severe pain as a corrective for the psychoneuroses, even when they thought of them in connection with diabolic possession, is another striking instance of their very practical way of dealing with these patients in a manner likely to do them most good. We have had to make our own developments in these matters, however, before we could appreciate the true value of what they were doing in the Middle Ages.

APPENDIX I

Law of the Emperor Frederick II. (1194-1250) regulating the practice of Medicine.¹⁸

“While we are bent on making regulations for the common weal of our loyal subjects we keep ever under our observation the health of the individual. In consideration of the serious damage and the irreparable suffering which may occur as a consequence of the inexperience of physicians, we decree that in future no one who claims the title of physician shall exercise the art of healing or dare to treat the ailing, except such as have beforehand in our University of Salerno passed a public examination under a regular teacher of medicine and been given a certificate, not only by the professor of medicine, but also by one of our civil officials, which declares his trustworthiness of character and sufficiency of knowledge. This document must be presented to us, or in our absence from the kingdom, to the person who remains behind in our stead in the kingdom, and must be followed by the obtaining of a licence to practise medicine either from us or from our representative aforesaid. Violation of this law is to be punished by confiscation of goods and a year in prison for all those who in future dare to practise medicine without such permission from our authority.

“Since the students cannot be expected to learn medical science unless they have previously been grounded in logic, we further decree that no one be permitted to take up the study of medical science without beforehand having devoted at least three full years to the study of logic.¹⁹ After three years devoted to these studies he (the student) may, if he will, proceed to the study of medicine, provided always that during the prescribed time he devotes himself also to surgery, which is a part of medicine. After this, and not before, will he be given the licence to practise, provided he has passed an examination, in legal form, as well as obtained a certificate from his teacher as to his studies in the preceding time. After having spent five years in study he shall not practise medicine until he has during a full year devoted himself to medical practice with advice and under the direction of an experienced physician. In the medical schools the professors shall during these five years devote themselves to the recognized books, both those of Hippocrates as well as those of Galen, and shall teach not only theoretic but also practical medicine.

“We also decree as a measure intended for the furtherance of public health that no surgeon shall be allowed to practise, unless he has a written certificate, which he must present to the professor in the medical faculty, stating that he has spent at least a year at that part of medicine which is necessary as a guide to the practice of surgery, and that, above all, he has learned the anatomy of the human body at the medical school, and is fully equipped in this department of medicine, without which neither operations of any kind can be undertaken with success nor fractures be properly treated.

“In every province of our kingdom which is under our legal authority, we decree that two prudent and trustworthy men, whose names must be sent to our court, shall be appointed and bound by formal oath, under whose inspection electuaries and syrups and other medicines be prepared according to law and be sold only after such inspection. In Salerno in particular we decree that this inspectorship shall be limited to those who have taken their degree as masters in physic.

“We also decree by the present law that no one in the kingdom except in Salerno or in Naples [in which were the two universities of the kingdom] shall undertake to give lectures on medicine or surgery, or presume to assume the name of teacher, unless he shall have been very thoroughly examined in the presence of a government official and of a professor in the art of medicine. [No setting up of medical schools without the proper authority.]

“Every physician given a licence to practise must take an oath that he shall faithfully fulfil all the requirements of the law, and in addition that whenever it comes to his knowledge that any apothecary has for sale drugs that are of less than normal strength, he shall report him to the court, and besides that he shall give his advice to the poor without asking for any compensation. A physician shall visit his patient at least twice a day and at the wish of his patient once also at night, and shall charge him, in case the visit does not require him to go out of the village or beyond the walls of the city, not more than one-half tarrene in gold for each day’s service.²⁰ From a patient whom he visits outside of the village or the wall of the town, he has a right to demand for a day’s service not more than three tarrenes, to which may be added, however, his expenses, provided that he does not demand more than four tarrenes altogether.

“He (the regularly licensed physician) must not enter into any business relations with the apothecary nor must he take any of them under his protection nor incur any money obligations in their regard. Nor must any licensed physician keep an apothecary’s shop himself. Apothecaries must conduct their business with a certificate from a physician according to the regulations and on their own credit and responsibility, and they shall not be permitted to sell their products without having taken an oath that all their drugs have been prepared in the prescribed form, without any fraud. The apothecary may derive the following profits from his sales: Such extracts and simples as he need not keep in stock for more than a year, before they may be employed, may be charged for at the rate of three tarrenes an ounce. Other medicines, however, which in consequence of the special conditions required for their preparation or for any other reason, the apothecary has to have in stock for more than a year, he may charge for at the rate of six tarrenes an ounce. Stations for the preparation of medicines may not be located anywhere but only in certain communities in the kingdom as we prescribe below.

“We decree also that the growers of plants meant for medical purpose shall be bound by a solemn oath that they shall prepare their medicines conscientiously according to the rules of their art, and so far as it is humanly possible that they shall prepare them in the presence of the inspectors. Violations of this law shall be punished by the confiscation of their movable goods. If the inspectors, however, to whose fidelity to duty the keeping of the regulations is committed, should allow any fraud in the matters that are entrusted to them, they shall be condemned to punishment by death.”

APPENDIX II

Bull of Pope John XXII., issued February 18, 1321, as a charter for the Medical Department of the University of Perugia.²¹

“While with deep feelings of solicitous consideration we mentally revolve how precious the gift of science is and how desirable and glorious is its possession, since through it the darkness of ignorance is put to flight and the clouds of error completely done away with so that the trained intelligence of students disposes and orders their acts and modes of life in the light of truth, we are moved by a very great desire that the study of letters in which the priceless pearl of knowledge is found should everywhere make praiseworthy progress, and should especially flourish more abundantly in such places as are considered to be more suitable and fitting for the multiplication of the seeds and salutary germs of right teaching. Whereas some time ago, Pope Clement of pious memory, our predecessor, considering the purity of faith and the excelling devotion which the city of Perugia, belonging to our Papal states, is recognized to have maintained for a long period towards the Church, wishing that these might increase from good to better in the course of time, deemed it fitting and equitable that this same city, which had been endowed by Divine Grace with the prerogatives of many special favours, should be distinguished by the granting of university powers, in order that by the goodness of God men might be raised up in the city itself pre-eminent for their learning, decreed by the Apostolic authority that a university should be situated in the city and that it should flourish there for all future time with all those faculties that may be found more fully set forth in the letter of that same predecessor aforesaid. And, whereas, we subsequently, though unworthy, having been raised to the dignity of the Apostolic primacy, are desirous to reward with a still richer gift the same city of Perugia for the proofs of its devotion by which it has proven itself worthy of the favour of the Apostolic See, by our Apostolic authority and in accordance with the council of our brother bishops, we grant to our venerable brother, the Bishop of Perugia, and to those who may be his successors in that diocese, the right of conferring on persons who are worthy of it the licence to teach (the Doctorate) in canon and civil law, according to that fixed method which is more fully described and regulated more at length in this our letter.

“Considering, therefore, that this same city, because of its convenience and its many favouring conditions, is altogether suitable for students and wishing on that account to amplify the educational concessions hitherto made because of the public benefits which we hope will flow from them, we decree by Apostolic authority that if there are any who in the course of time shall in that same university attain the goal of knowledge in medical science and the liberal arts and should ask for licence to teach in order that they may be able to train others with more freedom, that they may be examined in that university in the aforesaid medical sciences and in the arts and be decorated with the title of Master in these same faculties. We further decree that as often as any are to receive the decree of Doctor in medicine and arts, as aforesaid, they must be presented to the Bishop of Perugia, who rules the diocese at the time, or to him whom the bishop shall have appointed for this purpose, who having selected teachers of the same faculty in which the examinations are to be made, who are at that time present in the university to the number of at least four, they shall come together without any charge to the candidate and, every difficulty being removed, should diligently endeavour that the candidate be examined in science, in eloquence, in his mode of lecturing, and anything else which is required for promotion to the degree of doctor or master. With regard to those who are found worthy, their teachers should be further consulted privately, and any revelation of information obtained at such consultations as might redound to the disadvantage or injury of the consultors is strictly forbidden. If all is satisfactory the candidates should be approved and admitted and the licence to teach granted. Those who are found unfit must not be admitted to the degree of doctor, all leniency or prejudice or favour being set aside.

“In order that the said university may in the aforesaid studies of medicine and the arts so much more fully grow in strength, according as the professors who actually begin the work and teaching there are more skilful, we have decided that until four or five years have passed some professors, two at least, who have secured their degree in the medical sciences at the University of Paris, under the auspices of the Cathedral of Paris, and who shall have taught or acted as masters in the before-mentioned University of Paris, shall be selected for the duties of the masterships and the professorial chairs in the said department in the University of Perugia, and that they shall continue their work in this last-mentioned university until noteworthy progress in the formation of good students shall have been made.

“With regard to those who are to receive the degree of doctor in medical science, it must be especially observed that all those seeking the degree shall have heard lectures in all the books of this same science which are usually required to be heard by similar students at the University of Bologna or of Paris, and that this shall continue for seven years. Those, however, who have elsewhere received sufficient instruction in logic or philosophy having applied themselves to these studies for five years in the aforesaid universities, with the provision, however, that at least three years of the aforesaid five or seven year term shall have been devoted to hearing lectures in medical science in some university and according to custom, shall have been examined under duly authorized teachers and shall have, besides, read such books outside the regular course as may be required, may, with due observation of all the regulations which are demanded for the taking of degrees in Paris or Bologna, also be allowed to take the examination at Perugia.”