was a graduate of Salerno and afterward became the physician-in-ordinary
to Philip Augustus, King of France, thought that he could not say too
much for the training in medicine that was given at this first of the
medical schools. One thing is sure, the professors were eminently
serious, the work taken up was in many ways thoroughly scientific, and
some of the results of the medical investigations of that early day are
interesting even now. The descriptions of diseases that we have from the
Salernitan school are true to nature and are replete with many original
observations. Puschmann says: "The accounts given of intermittent fever,
pneumonia, phthisis, psoriasis, lupus, which they called the malum
mortuum, of ulcers on the sexual organs, among which it is easy to
recognize chancre, and of the disturbances of the mental faculties,
especially deserve mention." They seem to have been quite expert in
their knowledge of phthisis. In the treatment of it they laid great
stress upon the giving up of a strenuous life, the living a rather easy
existence in the open air, and a suitable diet. When the commencement of
consumption was suspected, the first prescription was a good course of
strengthening nourishment for the patient. On the other hand, they
declared that the cases in which diarrhea supervened during consumption
soon proved fatal. In general, with regard to people who were liable to
respiratory diseases, they insisted upon life in an atmosphere of
equable temperature. Though the custom was almost unheard of in the
Salerno of that time, and indeed at the present time there is very
little heating during the winter in southern Italy, they insisted that
patients who were liable to pulmonary affections should have their rooms
heated.
On the other hand, they suggested the cooling of the air of the
sick-room, as we have noted in the chapter on Constantine Africanus, and
Afflacius recommended the employment of an apparatus from which water
trickled continuously in drops to the ground and then evaporated. Baths
and bleeding were employed according to definite indications and diet
was always a special feature. They had a number of drugs and simples,
and the employment of some of them is interesting. Iron was prescribed
for enlargement of the spleen. The internal use of sea sponge, in which
of course there is a noteworthy proportion of iodine, was recommended
for relief from the symptoms of goitre by reducing its size. Iodine has
been used so much ever since in this affection, even down to our own
day, that this employment of one of its compounds is rather striking.
Massage of the goitre was also recommended, and this mode of treatment
was commonly employed for a number of ailments.
Probably the best idea that can be obtained in brief space of the
achievements of the University of Salerno is to be found in Pagel's
appreciation of Salerno's place in the history of medicine in his
chapters on "Medicine in the Middle Ages" in Puschmann's "Handbuch der
Geschichte der Medizin" (Berlin, 1902). He said: "If we take up now the
accomplishments of the school of Salerno in the different departments
there is one thing that is very remarkable. It is the rich independent
productivity with which Salerno advanced the banners of medical science
for hundreds of years almost as the only autochthonous centre of medical
influence in the whole West. One might almost say that it was like a
_versprengten Keim_--a displaced embryonic element--which, as it
unfolded, rescued from destruction the ruined remains of Greek and Roman
medicine. This productivity of Salerno, which may well be compared in
quality and quantity with that of the best periods of our science, and
in which no department of medicine was left without some advance, is one
of the striking phenomena of the history of medicine. While positive
progress was not made, there are many noteworthy original observations
to be chronicled. It must be acknowledged that pupils and scholars set
themselves faithfully to their tasks to further as far as their strength
allowed the science and art of healing. In the medical writers of the
older period of Salerno who had not yet been disturbed by Arabian
culture or scholasticism, we cannot but admire the clear, charmingly
smooth, light-flowing diction, the delicate and honest setting forth of
cases, the simplicity of their method of treatment, which was to a great
extent dietetic and expectant, and while we admire the carefulness and
yet the copiousness of their therapy, we cannot but envy them a certain
austerity in their pharmaceutic formulas and an avoidance of
medicamental polypragmasia. The work in internal medicine was especially
developed. The contributions to it from a theoretic and a literary
standpoint, as well as from practical applications, found ardent
devotees."
Less than this could scarcely have been expected from the medical school
which brought such an uplift of professional dignity and advance in the
standards of medical education that are to be noticed in connection with
Salerno. Registration, licensure, preliminary education, adequate
professional studies, clinical experience under expert guidance, even
special training for surgical work, all came in connection with this
great medical school. Such practical progress in medical education could
not have been made but by men who faced the problems of the practice of
medicine without self-deception and solved them as far as possible by
common-sense, natural, and rational methods.
It is usually said that at Salerno surgery occupied an inferior
position. It is true that we have less record of it in the earlier years
of Salerno than we would like to see. It was somewhat handicapped by the
absence of human dissection. This very important defect was not due to
any Church opposition to anatomy, as has often been said, but to the
objection that people have to seeing the bodies of their friends or
acquaintances used for anatomical purposes. In the comparatively small
towns of the Middle Ages there were few strangers, and therefore very
seldom were there unclaimed bodies. The difficulty was in the obtaining
of dissecting material. We had the same difficulty in this country until
about two generations ago, and the only way that bodies could be
obtained regularly was by "resurrecting" them, as it was called, from
graveyards. In the absence of human subjects, anatomy was taught at
Salerno upon the pig. The principal portion of the teaching in anatomy
consisted of the demonstration of the organs in the great cavities of
the body and their relations, with some investigations of their form and
the presumed functions of the corresponding organs in man. Copho's
well-known "Anatomy of the Pig" was a text-book written for the students
of Salerno. In spite of its limitations, it shows the beginnings of
rather searching original inquiry and even some observations in
pathological anatomy. It is simple and straightforward and does not
profess to be other than it is, though it must be set down as the first
reasonably complete contribution to comparative anatomy.
When their surgery came to be written down, however, it gave abundant
evidence of the thoroughness with which this department of medicine had
been cultivated by the Salernitan faculty. We have the text-book of
Roger, with the commentary of Rolando, and then the so-called commentary
of the Four Masters. These writings were probably made rather for the
medical school at Bologna than that of Salerno, though there is no
doubt that at least Roger and Rolando received their education at
Salerno and embodied in their writings the surgical traditions of that
school. While I have preferred, in order to have a connected story of
surgical development, to treat of their contributions to their specialty
under the head of the "Great Surgeons of the Medieval Universities," it
seems well to point out here that they must be considered as
representing especially the surgical teaching of the older medical
school of Salerno. There are many interesting features of the old
teaching that they have embodied in their books. For instance, at
Salerno both sutures and ligatures were employed in order to prevent
bleeding. We are rather accustomed to think of such uses of thread, and
especially the ligature, as being much later inventions. The fact of the
matter is, however, that ligatures and sutures were reinvented over and
over again and then allowed to go out of use until someone who had no
idea of their dangers came to reinvent them once more.[8]
Much is often said about the place of Arabian surgery and medicine at
this time, and the influence that they had over the medical teaching and
thinking of the period. To trust many of the shorter histories of
medicine the Arabs must be given credit for more of the medical thought
of this time than any other medical writers or thinkers. It is
forgotten, however, apparently, that in the southern part of Italy,
where Salerno was situated, Greek influence never died out. This had
been a Greek colony in the olden time and continued to be known for many
centuries after the Christian era as Magna Graecia. Greek medicine, then,
had more influence here than anywhere else. As a matter of fact, the
beginnings of Salernitan teaching are all Greek and not at all Arabian.
This is as true in surgery as in medicine. I have quoted Gurlt in the
chapter on "Great Surgeons of the Medieval Universities," insisting that
the Salernitan school owed nothing at all to Arabian surgery. Salernitan
medicine was, during the twelfth century, just as free from Arabian
influence. When Arabian medicine makes itself felt, as pointed out by
Pagel in his "Geschichte der Heilkunde im Mittelalter,"[9] far from
exerting a beneficial influence, it had a rather unfortunate effect. It
led especially to an oversophistication of medicine from the standpoint
of drug therapeutics. The Arabian physicians trusted nature very little.
In this they were like our forefathers of medicine one hundred years
ago, of whom Rush was the typical representative--so history repeats
itself.
Before the introduction of Arabian medicine the Salernitan school of
medicine was noted for its common-sense methods and its devotion to all
the natural modes of healing. It looked quite as much to the prevention
of disease as its treatment. Diet and air and water were always looked
upon as significant therapeutic aids. With the coming of Arabian
influence there began, says Pagel, "as the literature of the times shows
very well, that rule of the apothecary in therapeutics which was an
unfortunate exaggeration. Now all the above-mentioned complicated
prescriptions came to be the order of the day. Apparently the more
complicated a prescription the better. Dietetics especially was
relegated to the background. Salerno, at the end of the twelfth century,
had already reached its highest point of advance in medicine and was
beginning to decline. Decadence was evident in so far as all the medical
works that we have from that time are either borrowings or imitations
from Arabian medicine with which eventually Salernitan medical
literature became confounded. Only a few independent authors are found
after this time." This is so very different from what is ordinarily
presumed to have been the case and openly proclaimed by many historians
of medicine because apparently they would prefer to attribute
scientific advance to the Arabs than to the Christian scholars of the
time, that it is worth while noting it particularly.
Salerno was particularly rich in its medical literary products. Very
often we have not the names of the writers. Apparently there is good
reason to think that a number of the professors consulted together in
writing a book, and when it was issued it was considered to be a
text-book of the Salernitan school of medicine rather than of any
particular professor. This represents a development of co-operation on
the part of colleagues in medical teaching that we are likely to think
of as reserved for much later times.
The most important medical writing that comes to us from Salerno, in the
sense at least of the work that has had most effect on succeeding
generations, has been most frequently transcribed, most often translated
and committed to memory by many generations of physicians, is the
celebrated Salernitan medical poem on hygiene. The title of the original
Latin was "Regimen Sanitatis Salernitanum." It was probably written
about the beginning of the twelfth century. A century or so later it
came to be the custom to call medical books after flowers, and so we had
the "Lilium Medicinae" and the "Flos Medicinae" down at Montpellier, and
this became the "Flos Medicinae" of Salerno. Pagel calls it the
quintessence of Salernitan therapeutics.
For many centuries portions at least of this Latin medical poem were as
common in the mouths of physicians all over Europe as the aphorisms of
Hippocrates or the sayings of Galen. Probably this enables us to
understand the great reputation that the Salernitan school enjoyed and
the influence that it wielded better than anything else. The poem is
divided into ten principal parts, containing altogether about 3,500
lines. The first part on hygiene has 855 lines in eight chapters. The
second part on _materia medica_, though containing only four chapters,
has also about 800 lines. Anatomy and physiology are crowded into about
200 lines, etiology has something over 200, semiotics has about 250,
pathology has but thirty lines more or less, and therapeutics about 400;
nosology has about 600 more, and finally there is something about the
physician himself, and an epilogue. As Latin verses go, when written for
such purposes, these are not so bad, though some of them would grate on
a literary ear. The whole work makes a rather interesting compendium of
medicine, with therapeutic indications and contra-indications, and
whatever the physician of the medieval period needed to have ready to
memory. Some of its prescriptions, both in the sense of formulae and of
directions to the patient, have quite a modern air.
One very interesting contribution to medical literature that comes to us
from Salerno bears the title, "The Coming of a Physician to His Patient,
or An Instruction for the Physician Himself." We have had a number of
such works published in recent years, but it is a little surprising to
have the subject taken up thus early in the history of modern
professional life. It is an extremely valuable document, as
demonstrating how practical was the teaching at Salerno. The work is
usually ascribed to Archimattheas, and it certainly gives a vivid
picture of the medical customs of the time. The instruction for the
immediate coming of the physician to his patient runs as follows: "When
the doctor enters the dwelling of his patient, he should not appear
haughty, nor covetous, but should greet with kindly, modest demeanor
those who are present, and then seating himself near the sick man accept
the drink which is offered him (_sic_) and praise in a few words the
beauty of the neighborhood, the situation of the house, and the
well-known generosity of the family,--if it should seem to him suitable
to do so. The patient should be put at his ease before the examination
begins and the pulse should be felt deliberately and carefully. The
fingers should be kept on the pulse at least until the hundredth beat in
order to judge its kind and character; the friends standing round will
be all the more impressed because of the delay and the physician's words
will be received with just that much more attention."
The old physician evidently realized very well how much influence on the
patient's mind meant for the course of the disease. For instance, he
recommends that the patient should be asked to confess and receive the
sacraments of the Church before the doctor sees him, for if mention is
afterwards made of this the patient may believe that it is because the
doctor thinks that there is no hope for him. For the purpose of
producing an effect upon the patient's mind, the old physician does not
hesitate even to suggest the taking advantage of every possible source
of information, so as to seem to know all about the case. "On the way to
see the sick person he [the physician] should question the messenger
who has summoned him upon the circumstances and the conditions of the
illness of the patient; then, if not able to make any positive diagnosis
after examining the pulse and the urine, he will at least excite the
patient's astonishment by his accurate knowledge of the symptoms of the
disease and thus win his confidence."
At the end of these preliminary instructions there is a rather
diplomatic--to say the least--bit of advice that might perhaps to a
puritanic conscience seem more politic than truthful. Since the old
professor insists so much on not disturbing the patient's mind by a bad
prognosis or any hint of it, and since even some exaggeration of what he
might think to be the serious outlook of the case to friends would only
lead to greater care of the patient, there is probably much more
justification for his suggestion than might be thought at first glance.
He says, "When the doctor quits the patient he should promise him that
he will get quite well again, but he should inform his friends that he
is very ill; in this way, if a cure is affected, the fame of the doctor
will be so much the greater, but if the patient dies people will say
that the doctor had foreseen the fatal issue."
The story of the medical school of Salerno, even thus briefly and
fragmentarily told, illustrates very well how old is the new in
education,--even in medical education. There is scarcely a phase of
modern interest in medical education that may not be traced very clearly
at Salerno though the school began its career a thousand years ago, and
ceased to attract much attention over six hundred years ago. We owe
most of our knowledge of the details of its organization and teaching to
De Renzi. Without the devotion of so ardent a scholar it would have been
almost impossible for us to have attained so complete a picture of
Salernitan activities. As it is, as a consequence of his work we are
able to see this first of modern medical schools developing very much as
do our most modern medical schools. There has been an accumulation of
medical information in the thousand years, but the ways and modes of
facing problems and many of the solutions of them do not differ from
what they were in the distant past. The more we know about any
particular period, the more is this brought home to us. It is for this
that study of particular periods and institutions of the olden time, as
of Salerno, grows increasingly interesting, because each new detail
helps to fill in sympathetically the new-old picture of human activity
as it may be seen at all times.
VII
CONSTANTINE AFRICANUS
Probably the most important representative of the medical school at
Salerno, certainly the most significant member of its faculty, if we
consider the wide influence for centuries after his time that his
writings had, was Constantine Africanus. He is interesting, too, for
many other reasons, for he is the first representative, in modern times,
that is, who, after the incentive of antiquity had passed, devoted
himself to creating a medical literature by translations, by editions,
and by the collation of his own and others' observations on medical
subjects. He is the connecting link between Arabian medicine and Western
medical studies. The fact that he was first a traveller over most of the
educational world of his time, then a professor at the University of
Salerno who attracted many students, and finally a Benedictine monk in
the great abbey at Monte Cassino, shows how his life ran the gamut of
the various phases of interest in the intellectual world of his time. It
was his retirement to the famous monastery that gave him the
opportunity, the leisure, the reference library for consultation that a
writer feels he must have near him, and probably also the means
necessary for the publication of his works. Not only did the monks of
Monte Cassino itself devote themselves to the copying of his many
books, but other Benedictine monasteries in various parts of the world
made it a point to give wide diffusion to his writings.
As a study in successful publication, that is, in the securing of wide
attention to writings within a short time, the career of Constantine and
the story of his books would be extremely interesting. Medieval
distribution of books is usually thought to have been rather halting,
but here was an exception. It was largely because Benedictines all over
the world were deeply interested in what this brother Benedictine was
writing that wide distribution was secured for his work within a very
short time. His superiors among the Benedictines had a profound interest
in what he was doing. The great Benedictine Abbot Desiderius of Monte
Cassino, who afterwards became Pope, used all of his extensive influence
in both positions to secure an audience for the books--hence the many
manuscript copies of his writings that we have. It is probable that
Constantine established a school of writers at Monte Cassino, for he
could scarcely have accomplished so much by himself as has been
attributed to him. Besides, his works attracted so much attention that
writers of immediately succeeding generations who wanted to secure
attention for their works sometimes attributed them to him in order to
take advantage of his popularity. It is rather difficult, then, to
determine with absolute assurance which are Constantine's genuine works.
Some of those attributed to him are undoubtedly spurious. What we know
with certainty, however, is that his authentic works meant much for his
own and after generations.
Constantine was born in the early part of the eleventh century, and died
near its close, having lived probably well beyond eighty years of age,
his years running nearly parallel with his century. His surname,
Africanus, is derived from his having been born in Africa, his
birthplace being Carthage. Early in life he seems to have taken up with
ardor the study of medicine in his native town, devoting himself,
however, at the same time to whatever of physical science was available.
Like many another young man since his time, not satisfied with the
knowledge he could secure at home, he made distant journeys, gathering
medical and scientific information of all kinds wherever he went.
According to a tradition that seems to be well grounded, some of these
journeys took him even into the far East. During his travels he became
familiar with a number of Oriental languages, and especially studied the
Arabian literature of science very diligently.
At this time the Arabs, having the advantage of more intimate contact
with the Greek medical traditions in Asia Minor, were farther advanced
in their knowledge of the medical sciences than the scholars in the
West. They had better facilities for obtaining the books that were the
classics of medicine, and, with any desire for knowledge, could scarcely
fail to secure it.