SALERNO AND THE BEGINNINGS OF MODERN MEDICAL EDUCATION
The first medical school of modern history, and the institution which more
than any other has helped us to understand the Middle Ages, is that of
Salerno. Indeed, the accumulation of information with regard to this
medical school, formally organized in the tenth century but founded a
century earlier, and reaching a magnificent climax of development at the
end of the twelfth century, has done more than anything else to
revolutionize our ideas with regard to medieval education and the
scientific interests of the Middle Ages. We owe this development of
knowledge to De Renzi, whose researches with regard to matters Salernitan,
and medical education generally in Italy in the Middle Ages, are well
deserving of the prestige that has been at length accorded them.
In his "Storia della Medicina in Italia," published so modestly at Naples,
the patient Italian student of medical history made an epoch-making
contribution to the history of medicine. Unless one has actually read his
book, it is difficult to understand how deep our obligations to him are.
Anyone who might be tempted to think that medicine was not taken
seriously, or that careful clinical observations and serious experiments
for the cure of disease were not made at Salerno, will be amply undeceived
by a reading of De Renzi. Above all, he makes it very clear that medical
education was taken up with rigorous attention to details and high
standards maintained. Three years of college work were demanded in
preparation for medical studies, and then four years at medicine, followed
by a year of practice with a physician, and even an additional year of
special study in anatomy, had to be taken, if surgery were to be
practised. All this before the licence to practise medicine was given;
though the degree of doctor, granting the privilege of teaching as the
word indicates, was conferred apparently after the completion of the four
years at the medical school. We have had to climb back to these medieval
standards of medical education in many countries in recent years, after a
period of deterioration in which often the requirements for the
physician's training for practice were ever so much lower.
It may seem surprising that the first medical school should have arisen in
the southern part of Italy, but for those who know the historical
conditions it will seem the most natural thing in the world that this
development should have come in this region. As we have said, touch with
Greek has always been the most important factor for modern educational and
intellectual development. Salerno was situated in the heart of that Greek
colony in the southern part of Italy which came to be known as Magna
Græcia. Apparently at no time during the Middle Ages was Greek entirely a
dead language in this part of Italy, and there were Greek travellers,
Greek sailors, and many other wanderers, who made their way along the
shores of the Mediterranean at this time, and carried with them everywhere
the stimulus that always came from association with the Greeks of Asia
Minor and of the Grecian Islands and peninsula.
There were two other factors that made for the development of the medical
school at Salerno. The first of these seems undoubtedly to have been the
presence of the Benedictines, who had a rather important school at
Salerno, and who were closely in touch with their great mother-house at
Monte Cassino not far away. It was they who imparted the academic
atmosphere to the town, and made it possible to gather together the
elements for the university which gradually came into existence around the
medical school, after that began to attract European attention.
The actual foundation of the medical school, however, seems to have been
due to the fortunate accident that Salerno became a health resort, a place
to which invalids were attracted from many parts of Europe because the
climate was salubrious, and opportunities for obtaining the medical advice
of men of many different schools of thought from all over the
Mediterranean, and securing the Oriental drugs which were so much
valued--as drugs from a distance always are--were there afforded. It is
easy to understand that, especially in the winter-time, better-class
patients from all over Europe would be glad to go down to the mild
temperate climate of Salerno and spend their time there.
It has been pointed out that the first modern university, that of Salerno,
had for a nucleus a medical school, representing man's interest in his
body as his primary intellectual purpose in modern history. The second
modern university, that of Bologna, gathered around a law school
representing man's interest in his property--his second formal purpose in
life. And the third, that of Paris, developed around a school of theology
and philosophy, demonstrating that man's intellectual interests rise
finally to the consideration of his relations to his fellow-man and to
God.
The first that we know definitely about the medical school of Salerno,
the origin of which is difficult to trace, is concerned with Alphanus,
usually designated "the First," because there are several of the name. He
was a Benedictine monk, distinguished as a literary man and known by his
contemporaries as both poet and physician, who was afterwards raised to
the Bishopric of Salerno. He had taught at Salerno in the Benedictine
school there before becoming Bishop, and when exercising the highest
ecclesiastical authority did much to encourage the development of Salerno.
He states that medicine flourished in the town even in the ninth century,
and there is an old chronicle published by De Renzi in his "Collectio
Salernitana" in which it is said that the medical school was founded by
four doctors--a Jewish Rabbi, Elinus; a Greek, Pontus; a Saracen, Adale;
and the fourth a native of Salerno--each of whom lectured in his native
language. This reads like a mythical legend that has formed around some
real tradition of the coming of physicians from many countries. Puschmann
in his "History of Medical Education" has suggested that the names are
probably as much varied as the absolute truth of the facts. Elinus, the
Jew, is probably Elias or Eliseus, Adale is probably a corruption of
Abdallah, and Pontus should be probably Gariopontus.
There was a hospital at Salerno that was somewhat famous as early as the
first quarter of the ninth century. This was placed under the control of
the Benedictines; and other infirmaries and charitable institutions,
similarly under the care of religious orders, sprang up in Salerno to
accommodate the patients that came. The practical character of the
teaching at Salerno, as preserved for us in the writings of the school,
would seem to argue that probably those who came to study medicine here
were brought directly in contact with the patients, though we have no
definite evidence of that fact.
The most interesting feature of the medical school at Salerno is
undoubtedly the development of legal standards of medical education in
connection with the school. Before the middle of the twelfth century
Roger, King of the Two Sicilies, issued a decree according to which
preliminary studies at the University were required as a preparation for
the medical school, and four years of medical studies were made the
minimum requirement for the degree of doctor in medicine, which was,
however, as we have said, not a licence to practise, but only a
certificate authorizing teaching. There seemed to have been, even thus
early, some further state regulations with regard to practice. About the
middle of the next century, however, there came, through a law of the
Emperor Frederick II., a still further evolution of legal standards for
medical education and medical practice in the Two Sicilies. This law
required that the student of medicine should have spent some years,
probably the equivalent of our undergraduate training, in the university
before studying medicine, and that he should then devote four years to
medicine, after which, on proper examination, he might be given the degree
of doctor--that is, teacher of medicine; but he must spend a further year
of practice with a physician before he would be allowed to practise for
himself.
This is such a high standard that, only that we have the actual wording of
the law, it would seem almost impossible that it could have been evolved
at this period in medical history. It actually represents the standard
that we have climbed back to generally only during the past generation or
two, and in the interval there have been many rather serious derogations
from it. This law of the Emperor Frederick is, moreover, a pure drug law,
regulating the sale of drugs and their purity, and inflicting condign
punishment for substitution; in this regard also anticipating our most
recent well-considered legislation. The penalty by which the druggist was
fined all his movable goods for substitution, while the government
inspector who permitted such substitution was put to death, would seem to
us in the modern time to make the punishment eminently fit the crime.
Almost needless to say, then, the law (see Appendix for full text)
represents one of the most important documents in the history of medicine,
particularly of medical education. The fee regulation included in it shows
that medicine was looked upon as a profession, and was paid accordingly.
From Salerno come many of the traditions of the conferring of degrees
which are still used in a large number of modern medical schools. Before
receiving his degree, the candidate had to take an oath, of which the
following were the principal tenets: "Not to contradict the teaching of
his college, not to teach what was false or lying, and not to receive fees
from the poor even though they were offered; to commend the sacrament of
penance to his patients, to make no dishonest agreement with the
druggists, to administer no abortifacient drug to the pregnant, and to
prescribe no medicament that was poisonous to human bodies."
It has sometimes been said that youths of tender age were admitted to the
study of medicine at Salerno, and that many of them were given their
degrees at the age of twenty-one. De Renzi's discussion would seem to show
that the usual age of receiving the degree was twenty-five to
twenty-seven. As medical students had to have three years of preparatory
studies in literature and philosophy, it would seem that they must have
been rather mature on their admission to the medical schools.
De Renzi tells us that the medical school of Salerno was of great
importance not only for medical education, but it acquired sufficient
means to extend its benefits over the entire city. Gifts were made of
statues to the churches, and especially to the shrine of St. Matthew the
Apostle, situated here; monuments were set up, inscriptions placed and
ample donations made to the various institutions of the city. The formal
name of the medical school was _Almum et Hippocraticum Medicorum
Collegium_. This is the first use that I know of the word _almum_ in
connection with a college, and may very well be the distant source of our
term _alma mater_. The medical school was situated in the midst of an
elevated valley which opened up on the mountain that dominates Salerno,
and while enjoying very pure air must have been scarcely disturbed at all
by the winds which can be blustery enough from the gulf. De Renzi says
that in his time some of the remains could still be seen, though visitors
to Salerno now come away very much disappointed because nothing of
interest is left.
The most famous of the teachers at Salerno was Constantine Africanus, so
called because he was born near Carthage. His life runs from the early
part of the eleventh century to near its close, and he lived probably well
beyond eighty years of age. Having studied medicine in his native town, he
wandered through the East, became familiar with a number of Oriental
languages, and studied the Arabian literature of science, and above all of
medicine, very diligently. The Arabs, owing to their intimate contact with
the Greeks in Asia Minor, had the Greek authors constantly before them,
and Hippocrates and Galen have always roused men to do good work in
medicine. Constantine seems not to have learned Greek, finding enough to
satisfy him in the Arabic commentaries on the Greek authors, and probably
confident, as all young men have ever been, that what his own time was
doing must represent an advance over the Greek. He brought back with him
Arabian books and a thorough knowledge of Arabian medicine. When he
settled down in Carthage he was accused of magical practices, his medical
colleagues being apparently jealous of his success--at least, there is a
tradition to that effect to account for his removal to Salerno, though the
immediate reason seems to have been that his reputation attracted the
attention of Duke Robert of Salerno, who invited him to become his
physician.
After Constantine's time the principal textbooks of the school became,
according to De Renzi, Hippocrates, Galen, and Avicenna. To these were
added the _Antidotarium_ of Mesue, and there were various compendiums of
medical knowledge, quite as in our own time--one well known under the name
of _Articella_. In surgery the principal textbook was the surgical works
of the Four Masters of Salerno, which interestingly enough was the sort of
combination work gathered from a series of masters that we are accustomed
to see so frequently at the present day. De Renzi insists that there was
much less Arabic influence at Salerno than is usually thought; and Gurlt
more recently has emphasized, as we have said, the fact that the great
textbooks of surgery which we have from Salerno contain not Arabisms, as
might be expected from the traditions of Arabic influence that we hear so
much of, but Græcisms, which show that here at Salerno there was a very
early Renaissance, and the influence of Greek writers was felt even in the
twelfth century.
Probably the best way to convey in brief form a good idea of the teaching
in medicine at Salerno is to quote the _Regimen Sanitatis Salernitanum_,
the Code of Health of the School of Salernum, which for many centuries was
popular in Europe, and was issued in many editions even after the
invention of printing. Professor Ordronaux, Professor of Medical
Jurisprudence in the law school of Columbia College (now Columbia
University, New York), issued a translation of it in verse,[3] which gives
a very good notion of the contents and the spirit and the mode of
expression of the little volume.
The _Regimen_ was written in the rhymed verses which were so familiar at
this time. Many writers on the history of medicine have marvelled at this
use of verse, but anyone who knows how many verse-makers there were in the
twelfth and thirteenth centuries all over Europe will not be surprised. It
used to be the custom to make little of these rhymed Latin verses of the
Middle Ages, but it may be well to recall that in recent years a great
change has come over the appreciation of the world of literature in their
regard. The rhymed Latin hymns of the Church, especially the _Dies Iræ_,
the _Stabat Mater_, and others, are now looked upon as representing some
of the greatest poetry that ever was written. Professor Saintsbury of the
University of Edinburgh has declared them the most wondrous wedding of
sense and sound that the world has ever known. The _Regimen Sanitatis_ of
Salerno is of course no such poetry, mainly because its subject was
commonplace and it could not rise to poetic heights. A good deal of the
deprecation of its Latinity might well be spared, for most of the mistakes
are undoubtedly due to copyists and interpolation. The verses not only
rhyme at the end, but often there are internal sub-rhymes. This too was a
very common custom among the hymn-writers, as the great sequence of
Bernard of Morlaix, so well known through its translations in our time, as
"Jerusalem the Golden" attests.
The _Regimen_ was not written for physicians, but for popular information.
It seems to have been a compilation of maxims of health from various
professors of the Salernitan School. Nothing that I know shows more
clearly the genuine knowledge of medicine, and the careful following of
the first rule of medical practice _non nocere_ to which Salerno had
reached at this time, than the fact that this popular volume contained
no recommendation of specific remedies, but only health rules for
diet, air, exercise, and the like, many of which are as valuable in our
time as they were in that, and very few of which have been entirely
superseded--together with some general information as to simples, and a
few details of medical knowledge that would give a convincing air to the
compilation.
The book was dedicated to the King of the English, _Anglorum regi scribit
schola tota Salerni_, and in the translation made by Professor Ordonaux
begins as follows:
If thou to health and vigour wouldst attain,
Shun weighty cares--all anger deem profane,
From heavy suppers and much wine abstain.
Nor trivial count it, after pompous fare,
To rise from table and to take the air.
Shun idle, noonday slumber, nor delay
The urgent calls of Nature to obey.
These rules if thou wilt follow to the end,
Thy life to greater length thou mayst extend.[4]
Evidently it was rather easy to commit such rhymes to memory, and this
accounts for the fact that we have many different versions of the
_Regimen_ and disputed readings of all kinds. These medieval hygienists
believed very much in early rising, cold water, thorough cleansing,
exercise in the open air, yet without sudden cooling afterwards. The lines
on morning hygiene seem worth while giving in Ordonaux's translation.
At early dawn, when first from bed you rise,
Wash, in cold water, both your hands and eyes.
With brush and comb then cleanse your teeth and hair,
And thus refreshed, your limbs outstretch with care.
Such things restore the weary, o'ertasked brain;
And to all parts ensure a wholesome gain.
Fresh from the bath, get warm. Rest after food,
Or walk, as seems most suited to your mood.
But in whate'er engaged, or sport, or feat,
Cool not too soon the body when in heat.
The Salernitan writers were not believers in noonday sleep, though one
might have expected that the tradition of the _siesta_ in Italy had been
already established. They insist that it makes one feel worse rather than
better to break the day by a sleep at noonday.
Let noontide sleep be brief, or none at all;
Else stupor, headache, fever, rheums, will fall
On him who yields to noontide's drowsy call.
They believed in light suppers--
Great suppers will the stomach's peace impair;
Wouldst lightly rest, curtail thine evening fare.
With regard to the interval between meals, the Salernitan rule was, wait
until your stomach is surely empty:
Eat not again till thou dost certain feel
Thy stomach freed of all its previous meal.
This mayst thou know from hunger's teasing call,
Or mouth that waters--surest sign of all.
Pure air and sunlight were favourite tonics at Salerno--
Let air you breathe be sunny, clear, and light,
Free from disease or cess-pool's fetted blight.
Taking "a hair of the dog that bit you" was, however, a maxim with
Salernitans for the cure of potation headaches.
Art sick from vinous surfeiting at night?
Repeat the dose at morn, 'twill set thee right.
The tradition with regard to the difficulty of the digestion of pork,
which we are trying to combat in the modern time, had already been
established at Salerno. The digestibility of pork could, however, be
improved by good wine.
Inferior far to lamb is flesh of swine,
Unqualified by gen'rous draughts of wine;
But add the wine, and lo! you'll quickly find
In them both food and medicine combined.
Milk for consumptives was a favourite recommendation. The tradition had
come down from very old times, and Galen insisted that fresh air and milk
and eggs was the best possible treatment for consumption. The Salernitan
physicians recommended various kinds of milk, goat's, camel's, ass's, and
sheep's milk as well as cow's. It is probable, as I pointed out in my
"Psychotherapy," that the mental influence of taking some one of the
unusual forms of milk did a good deal to produce a favourable reaction in
consumptives, who are so prone to be affected favourably by unusual
remedies. The _Regimen_ warned, however, that milk will not be good if it
produces headache or if there is fever. Apparently some patients had been
seen with the idiosyncrasy for milk, and the tendency to constipation and
disturbance after it which have been noted also in the modern time.
Goat's milk and camel's, as by all is known,
Relieve poor mortals in consumption thrown;
While ass's milk is deemed far more nutritious,
And e'en beyond all cow's or sheep's, officious.
But should a fever in the system riot,
Or headache, let the patient shun this diet.
Salerno's common sense with regard to diet is very well illustrated by a
number of maxims. Diet tinkering was not much in favour.
We hold that men on no account should vary
Their daily diet until necessary:
For, as Hippocrates doth truly show,
Diseases sad from all such changes flow.
A stated diet, as it is well known,
Of physic is the strongest cornerstone--
By means of which, if you can nought impart,
Relief or cure, vain is your Healing Art.
They believed firmly that many of the conditions of eating were quite as
important as the diet itself, and said:
Doctors should thus their patients' food revise--
_What_ is it? _When_ the meal? And what its _size_?
How _often_? _Where?_ lest, by some sad mistake,
Ill-sorted things should meet and trouble make.
They recommended the various simples, mallow, mint, sage, rue, the violet
for headache and catarrh, the nettle, mustard, hyssop, elecampane,
pennyroyal, cresses, celandine, saffron, leeks--a sovereign remedy for
sterility--pepper, fennel, vervaine, henbane, and others. There were
certain special affections, as hoarseness, catarrh, headaches, fistula,
for which specific directions for cure were given. Here for instance are
the directions to be given a patient suffering from rheum or catarrh. The
verses conveyed interesting information with nice long names for the
various affections, as well as the directions for its management.
Fast well and watch. Eat hot your daily fare,
Work some, and breathe a warm and humid air;
Of drink be spare; your breath at time suspend;
These things observe if you your cold would end.
A cold whose ill-effects extend as far
As in the chest, is known as a catarrh;
Bronchitis, if into the throat it flows;
Coryza, if it reach alone the nose.
The _Regimen_ conveyed a deal of information in compact form. It gives the
number of bones in the body as 219 with 32 teeth, and the number of veins
as 365, this number being chosen doubtless because of some supposed
relation to the number of days in the year. It contains also a good brief
account of the four humours in the human body--black bile, blood, phlegm,
and yellow bile; and of the four temperaments--the sanguine, the bilious,
the phlegmatic, and the melancholy. These four temperaments were
discussed at considerable length by all the psychologists and most of the
writers on religious life for centuries afterwards, largely on the basis
of the information conveyed by the Salernitan handbook. There are
descriptions of the symptoms of plethora or excess of blood, of excess of
bile, of excess of phlegm, and excess of black bile. The little volume
finally contains discussions as to bleeding, its indications,
contraindications, as in youth--"Ere seventeen years we scarce need
drawing blood"--and in old age; and then of the mode of practising it, and
the place whence the blood should be drawn to relieve different
symptoms.[5]
Salerno impressed itself much more deeply on surgery than on medicine, for
the magnificent development of medieval surgery, the knowledge of which
has proved so surprising in our day, began down at Salerno. Some of the
details of this phase of Salernitan accomplishment are given in the
chapter on Medieval Surgeons of Italy. Roger and Roland and the Four
Masters were great original founders in a phase of medical science that
proved extremely important for the next three or four centuries.
Undoubtedly the presence of a hospital at Salerno, where there were
gathered a number of the chronic cases from all over Europe, most of them
of the better-to-do classes looking for ease from their ills, gave the
incentive to this development. When the natural means of cure, tried for a
considerable time, failed, recourse was had to surgery for relief, and
often with excellent results. This chapter on Salerno's history shows how
thoroughgoing was the effort of the members of the faculty of the medical
school to develop every possible means of aid for their patients, even
when that required pioneer work.
Pagel's appreciation of Salerno's place in the history of medicine, in his
chapter on Medicine in the Middle Ages in Puschmann's "Handbuch Der
Geschichte der Medicin," Berlin, 1902, gives in very brief space a summary
of what was accomplished at Salerno that emphasizes what has been said
here, and his authority will confirm those who might possibly continue to
doubt of any institution of the Middle Ages having achieved so much. 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, easy-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 literary standpoint, as well as
from practical applications, came from ardent devotees."
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." It illustrates very well the
practical nature of the teaching of Salerno, and gives a rather vivid
picture of the medical customs of the time. The instruction as to the
conduct of the physician when he first comes into the house and is brought
to the 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
demeanour 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 neighbourhood, 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 of 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 rest of the advice smacks rather more of sophistication than we care
to think of in a professional man, but its display of a profound knowledge
of human nature makes it interesting.
"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."
Salerno taught as well as it could the science of medicine, and initiated
great advances in surgery; but it also emphasized the art of medicine,
and recognized very clearly that the personality of the physician counted
for a great deal, and that his influence upon his patients must be
fostered quite as sedulously as his knowledge of the resources of medicine
for their ills.