CHAPTER XXI. Medical Instruction At Salerno, Italy, in the Middle Ages

MEDICAL INSTRUCTION AT SALERNO, ITALY, IN THE MIDDLE AGES

The date of origin of the Medical School at Salerno is not known, but such evidence as we possess shows without a doubt that already in the earliest part of the Middle Ages some sort of facilities for studying medicine were provided in that little town--the Civitas Hippocratica, as it was called at a later period. It seems to be the general impression, says Daremberg, that during those early centuries only ignorance and superstition prevailed in Italy and Gaul; in other words, that all desire for scientific research had vanished, and that there no longer existed such a thing as the regular practice of medicine. This impression, he adds, is erroneous. History shows that schools modeled after those established by the Merovingian and Carlovingian kings (448–639 A. D.), existed up to as recent a date as the middle of the seventh century, and that subsequently the bishops organized the teaching in such a manner that it should be entirely under their control. As time went on, however, the schools assumed a more public character, although the actual teaching was still carried on in the cloisters and church edifices. It is well known, furthermore, that the chief of the Ostrogoths, Visigoths and Lombards--the so-called Barbarians, who at that time occupied these parts of Europe as conquerors--showed themselves on many an occasion to be the enlightened protectors of public instruction and the enthusiastic admirers of classical literature and science.

At Milan there is preserved a manuscript which furnishes satisfactory proof that the writings of Hippocrates and Galen were made the subject of public teaching at Ravenna toward the end of the eighth century of the present era.... And the transcribing of medical manuscripts was known to be carried on at the Monastery of St. Gall, in Switzerland, during the eighth century.... It is plain, therefore, that throughout those extensive regions which previously had formed a part of the Roman Empire, but which during the Middle Ages were under the dominion of Barbarian kings, there was never an entire lack of physicians, or of medical knowledge, or of facilities for teaching medicine. (Daremberg.)

In the light of these statements it is easy to believe that the original development of the Medical School at Salerno was a perfectly natural event like that of the founding of any of the medical schools of a more recent date. The remarkably healthy and singularly attractive character of the spot where the town of Salerno is located; the proximity of mineral springs; the comparatively short distance which separated it from such important centres of population as Naples and the cities of the Island of Sicily, and from the famous Benedictine Monasteries at La Cava, Beneventum and Monte Cassino; and the circumstance that a Ducal Court was established there--all these are facts which amply explain both why a medical school was founded here rather than at some other spot, and why physicians of exceptional ability were easily induced to make the place their home. At no time in the history of the school, it is important to state, do the church authorities appear to have been in control of its affairs. At most, one or two of the monks seem to have taken part in the teaching for limited periods of time; but in its main characteristics the school may truthfully be described as an institution created and managed by physicians for the advancement of medical science and the best interests of the profession as a whole.

The organization of hospitals and their utilization for purposes of clinical instruction must have been the most important events which followed next in order. It is only upon this assumption that we can satisfactorily explain why, for many years in succession, physicians traveled all the way from France, Germany and England to Salerno. They were eager to gain additional knowledge of medicine, and clinical instruction afforded the only sure way of obtaining it; but instruction of this kind was nowhere else to be obtained at that remote period, and consequently men of this earnest and ambitious stamp were compelled to make the long journey and to incur the expense and the risk incident to such a trip. As a further evidence of the value which the physicians of the later Middle Ages set upon the writings of the teachers at Salerno, the fact deserves to be mentioned that, toward the end of the twelfth century and all through the thirteenth and fourteenth centuries, these works were frequently quoted.

But the ability and learning of the Salerno physicians were highly appreciated by the public at large as well as by their confrères in other lands; for many people of wealth and of high social standing visited Salerno for the purpose of consulting them. Among the number were Adalberon, Bishop of Verdun, France, who journeyed thither in 984 A. D., but failed to obtain the relief which he required; Desiderius, the Abbot of Monte Cassino; Bohemund, the son of Duke Robert Guiscard; and William the Conqueror, afterward King of England. The two last named remained for some time in Salerno, in order to secure needed treatment for the wounds which they had received in battle.

Toward the end of the tenth, or at the beginning of the eleventh, century the teaching of medicine at Salerno began to assume the character of regularly organized work. The names of the men and women who conducted it--for there were women as well as men in the corps of teachers--are mentioned in various contemporaneous documents which have come down to our time. They are as follows: Petroncellus, Gariopuntus, Alphanus, Bartholomaeus, Cophon, Trotula, John and Matthew Platearius, Abella, Mercuriade, Costanza Calenda, Rebecca Guarna, Afflacius, Maurus, Musandinus and many others. According to Puschmann, the list of physicians who, during the existence of the Medical School at Salerno,--a period of nearly one thousand years,--acted as teachers in the institution, comprised no less than 340 names. The presence of several women among the instructors of this school, and the great esteem in which they were held by the men of that time, both for their ability as practitioners and for the excellence of the treatises which they wrote, furnish strong confirmation of the statement which Plato makes in his work entitled “The Republic,” and which I have already quoted in one of the earlier chapters, viz.: “For women have as pronounced an aptitude as men for the profession of medicine.” And, if further evidence of the correctness of Plato’s opinion were needed, the success attained by women physicians during the past thirty or forty years in the United States of America might be cited.

To the general statement made above I may with advantage add a few details regarding both the individual physicians at Salerno and the books which they wrote. During recent years, thanks to the researches of Henschel, de Renzi and Piero Giacosa, our knowledge of these matters has been greatly enlarged. In 1837 Henschel found, in the library at Breslau, Germany, a manuscript collection of Salerno medical treatises (“Compendium Salernitanum”) dating back as far as the latter part of the twelfth century of the present era. De Renzi, working in association with Daremberg and Baudry de Balzac, succeeded in collecting from the different libraries of Italy quite a large number of additional Salerno treatises, all of which have since been published under the title “Collectio Salernitana, ossia documenti inediti e trattati di medicina appartenenti alla scuola medica Salernitana” (5 vols., Naples, 1852–1859). Finally, Piero Giacosa has added to this stock of Salerno writings by the publication (Turin, 1901) of a work which bears the title “Magistri Salernitani nondum editi etc.” Beside the treatises to be found in these three collections there is one other which, according to Neuburger, contributed more than all the others combined to the fame of the Medical School of Salerno. The title of this extraordinary work is: “Regimen sanitatis Salernitanum.”

The Salernian writings, it appears, may readily be divided into two groups--those of the earlier and those of the later epoch of this famous school. The treatises which belong to the older epoch are written in the degraded Latin of the Middle Ages, and seem to have been composed entirely for didactic purposes. In the main they are compilations of still earlier Graeco-Latin works, but here and there, especially in the parts which relate to therapeutics, evidences of a certain measure of originality are discoverable. The pathology adopted shows a hodge-podge of the humoral doctrine and that of the Methodists.

The chief representative of this early epoch is Gariopontus (first half of the eleventh century), whose treatise on special pathology and therapeutics--entitled “Passionarius”--was very popular for a long period of years. Next in order comes Petroncellus, whose “Practica” calls for no special comment. Of the works of Alphanus, John Platearius (the elder) and Cophon (the elder), we possess only fragments. Trotula, who lived about 1059 A. D. and was believed to be the wife of John Platearius I., attained greater celebrity than any of those just mentioned. She was related to Roger I., Count of Sicily, and was therefore probably of Norman extraction, and she was considered by her contemporaries to be very learned (“sapiens matrona”). Her writings, which are quite numerous, are frequently quoted by later authors, this being especially true of her work on diseases of women. The four other women who took an active and creditable part in the work of the Salerno Medical School also wrote treatises on various subjects: Abella, on “Black Bile”, (written in verse); Mercuriade, on “Pestilential Fever,” and also on “The Treatment of Wounds”; and Rebecca Guarna, on “Fevers.” In the case of Costanza Calenda, the daughter of the Dean of the medical school and a woman remarkable for her wisdom as well as for her great beauty, no record of the treatises which she wrote appears to have been preserved.

The later epoch of the literature created by the Medical School of Salerno begins about the year 1100 of the present era, after the Latin translations and compilations made by Constantinus the African had taught the physicians who were then at the head of affairs something about the medicine of the Arabs, and had, at the same time, through the latter medium, brought to their attention afresh the teachings and practice of the ancient Greeks. Among the works of the latter character--works which in their Latin dress proved most valuable to the Salerno physicians--are the following: “The Aphorisms of Hippocrates”; “Galen’s Ars Parva” (Mikrotechne); and the same author’s “Commentaries on the Hippocratic Writings.”

John Afflacius, a monk who lived during the latter half of the eleventh century of the present era, was one of the pupils of Constantinus. His treatise “On Fevers,” according to Neuburger, contains ample evidence of the author’s ability as a clinical observer.

Something still remains to be said concerning Bartholomaeus, Cophon the Younger, John Platearius the Younger and Archimathaeus. They have already been mentioned in the list of authors whose writings contributed materially to the celebrity of the Medical School of Salerno, and it is now only necessary to furnish a few particulars with regard to their lives and the nature of the work which they accomplished.

Bartholomaeus wrote a treatise (entitled “Practica”) on the practice of medicine as taught by Hippocrates, Galen, Constantinus and the Greek physicians. Its enduring popularity is evidenced by the facts that it was translated at an early period into several languages and that portions of its text are often quoted by later authors. The book contains ample evidence that its author was a very close observer and a physician who strove to make accurate diagnoses.

Cophon the Younger (about 1100 A. D.) was the author of two works: a treatise on anatomy which bore the title “Anatomia Porci,” and one on the practice of medicine (“Practica”). The ancients, it is stated, selected a pig for purposes of anatomical study “because its internal organs present a very close resemblance to those of the human being.” Both books are written in a clear and simple style.

John Platearius the Younger was the author of a work on internal medicine (“Practica Brevis”) and also of one on the subject of urine (“Regulae Urinarum”).

Archimathaeus wrote and published three treatises: one on “Urines,” another on practical medicine (“Practica”), and the third on “The Demeanor which a Physician should Observe when he Visits a Sick Person” (“De Aventu Medici”). The latter treatise, says Neuburger, is “a mixture of piety, artlessness, and slyness; but it furnishes a capital picture of the carefully regulated behavior of the mediaeval physician at the patient’s bedside, of the manner in which he conducted his examination of the case, and of his intercourse with the household as well as with the sick person.”

In addition to the treatises referred to above,--treatises which are known to have been written by the authors to whom I have credited them,--the Collectio Salernitana contains several of which the authorship is not known. One of these, which bears the title “De Aegritudinum Curatione,” is reputed to furnish a better account of the special pathology and therapeutics taught at the Medical School of Salerno during the height of its celebrity than is to be found in any of the other treatises. In one part of the book--that, namely, in which local affections are discussed--the anonymous author gives in succession the opinions held by the seven leading teachers of the school (Platearius II., Cophon II., Petronius, Afflacius, Bartholomaeus, Ferrarius and Trotula) with regard to each one of a certain number of local diseases; thus enabling the reader to obtain a very fair idea of what was the condition of medical science at Salerno during the twelfth century of the present era.

The famous didactic poem known as the “School of Salerno” (Schola Salernitana) and also as the “Code of Health of the School of Salerno” (Regimen Sanitatis Salernitanum), was composed originally about 1100 A. D. It was clearly intended in the first instance for the guidance of laymen in matters relating to diet, the conservation of health and the prevention of disease; but from time to time, as the years rolled on, there were added to it several sections which changed materially the character of the poem. From a mere code of health it became eventually a fairly complete cyclopaedia of medicine in versified form; the number of the verses having increased fully tenfold during this long period. The poem, in its latest state, is arranged in ten principal sections, as follows: Hygiene (8 chapters); materia medica (4 chapters); anatomy (4 chapters); physiology (9 chapters); etiology (3 chapters); significance of different signs (24 chapters); pathology (8 chapters); therapeutics (22 chapters); nosology (20 chapters); and the practice of medicine as actually experienced (5 chapters).

The work has been translated into nearly every modern language, and, according to an estimate which was made in 1857, there are in existence no fewer than 240 different editions. The most recent of these is the French translation made by Meaux Saint-Marc and published by him (2d edition) in Paris in 1880. There are two English versions--that by A. Croke (Oxford, 1830), and the more recent one by John Ordronaux (Philadelphia, 1871).

Some authorities make the statement that the poem was written originally for the guidance of Robert, the son of William the Conqueror; but Neuburger says that the dedication of the work to this prince is lacking in many of the original manuscript copies and that in some instances the word “Francorum” is to be found in the place of “Anglorum”; for which reason he believes that the introduction of a dedication was made long after the poem had been written. It will probably appear strange to most readers that the author of the “Regimen Sanitatis” (or “Flos Medicinae,” as it was sometimes called) should have written his text in the form of verse rather than in that of prose. He himself states briefly, at the end of the poem, some of the reasons why he preferred to adopt this course. Rhythm, he maintains, makes it easy to say a great deal in a few words; besides which, it facilitates by its novelty the memorizing of new facts, and also enables one quickly to recall to mind those which have been learned at some previous time. His judgment seems to have been entirely correct, for the book proved to be immensely popular, and retained its popularity throughout an extraordinarily long period of time. Furthermore, as already stated, it accomplished a great deal toward enhancing the reputation of the Salerno School of Medicine. When we consider how difficult it must have been in those days for students of medicine to memorize facts which were stored in books that were very costly and oftentimes not obtainable at any price, we cease to wonder at the great popularity of this miniature cyclopaedia in leonine verse. Here were to be found, at one-fourth or one-tenth the price of any similar book written in prose, all the essentials (anatomy, physiology, pathology, etc.) required by the candidate for medical honors; and if, perchance, he possessed a good memory, he might, without a very great mental effort, transfer the entire poem to his own private storehouse of facts.

A few extracts from this remarkable piece of medical literature are given below, in the belief that many of our readers will find them of interest.

ORIGINAL TEXT DR. JOHN ORDRONAUX’S TRANSLATION

Si vis incolumen, si vis te If thou to health and vigor wouldst vivere sanum, attain, Curas tolle graves, irasci Shun weighty cares--all anger deem crede profanum, profane, Parce mero, coenato parum; From heavy suppers and much sit non tibi vanum wine abstain. Surgere post epulas; somnum Nor trivial count it, after pompous fuge meridianum; fare, Ne mictum retine, ne comprime To rise from table and to take the fortiter anum. air. Haec bene si serves, tu longo Shun idle, noonday slumber, nor tempore vives. delay The urgent calls of Nature to obey.

Conditiones Necessariae Medico. Demeanor Necessary For the Physician.

Clemens accedat medicus cum Let doctors call in clothing fine vesta polita; arrayed, Luceat in digitis splendida With sparkling jewels on their gemma suis. hands displayed; Si fieri valeat, quadrupes And, if their means allow, let sibi sit pretiosus; there be had, Ejus et ornatus splendidus To ride, a showy, rich-attired pad. atque decens. Ornatu nitido conabere carior For when well dressed and looking esse, over-nice, Splendidus ornatus plurima You may presume to charge a higher dona dabit price, Viliter inductus munus sibi Since patients always pay those vile parabit, doctors best, Nam pauper medicus vilia Who make their calls in finest dona capit. clothing dressed, While such as go about in simple frieze, Must put up with the meanest grade of fees; For thus it is, poor doctors everywhere Get but the smallest pittance for their share.

At Salerno the anatomical demonstration made, apparently only once a year, for the benefit of the students, consisted in exposing to view the abdominal viscera of the pig and commenting upon the features which distinguish them from the same organs in the human body. In the “Regimen Sanitatis” only eight lines of text are devoted to anatomy.

In section IV., which relates to physiology, the text is more instructive and entertaining, but still--as compared with the splendid work accomplished by Galen--extremely incomplete and superficial.

In the early part of the twelfth century, Nicolaus Praepositus composed, at the request of his colleagues in the school of Salerno, an “Antidotarium”--that is, a collection of formulae for combining together, in a single pharmaceutical preparation, various drugs, both those commonly employed in that part of Europe and others which were then known only to the Arabian physicians. This book of formulae, containing as it did descriptions of the effects which might be expected from the different preparations, and furnishing instructions with regard to the proper mode of employing them, served its purpose admirably, not only in Salerno but throughout Europe, at least during the Middle Ages. All the pharmacopoeias of a later date were based upon his “Antidotarium,” and indirectly upon the still earlier celebrated treatises written by Matthew Platearius and bearing the titles “Glossae” and “Circa instans” (also that of “De simplici medicina”). The most remarkable item, however, which is to be found in the Antidotarium is that in which mention is made of the use of soporific sponges (“spongia soporifera”), for anaesthetizing purposes by means of inhalations, in certain surgical procedures. (Neuburger.) They were made by impregnating the sponges thoroughly with the juices of narcotic plants (opium, hyoscyamus, mandragora, lactuca, cicuta, etc.), drying them, and putting them aside until they were actually needed. Then the sponge was saturated for about an hour with hot water or steamed, after which it was applied over the patient’s nostrils and held there until the inhalation of the fumes had induced sleep.

Another Salernian treatise worth mentioning is that written by Peter Musandinus, under the title “On Foods and Beverages suitable for Persons affected with a Fever.” This writer, who was one of the teachers at the school of Salerno about the middle of the twelfth century, says that great attention was paid in his time to the preparation of foods in such a manner as to tempt the appetite of people who were ill. He speaks of a meat extract which is prepared from the flesh of the chicken, and also recommends that a soup made by boiling a fowl in rose water be given to patients who are affected with diarrhoea. He even goes so far as to lay stress upon the importance of serving food to a sick person in dishes which are pleasing to the eye. Apropos of the subject of foods that are easily digestible and therefore suitable for invalids I may mention how Meaux Saint-Marc translates or interprets the line in the “Regimen Sanitatis Salernitanum” which reads O fluvialis anas, quanta dulcedine manas! His version may be rendered into English thus:

“Oh wood-duck, how gently doth thy soft flesh glide over the internal surface of the stomach!”

Toward the end of the twelfth century (1180 A. D.) there was published at Salerno a work on surgery--the oldest treatise on this subject that is known to have been written in Italy during the Middle Ages. It is now called “Roger’s Practice of Surgery,” but originally it was spoken of (in accordance with a custom quite common in those days) as “Post mundi fabricam,” which are the first three words of the text. This book is of a very practical character and is written in a simple, straightforward style. While it contains the usual amount of traditional knowledge about surgical matters, it gives at the same time the results of the personal experience of Roger, of his teachers, and of his associates. As published in the “Collectio Salernitana” the work represents, not the treatise as it was originally written, but a revision made by Rolando of Parma. It is divided into four parts or books, the topics treated in which comprise most of those usually discussed in works on surgery. Under the heading “Wounds of the Intestine,” in Book III., there occurs this most remarkable piece of advice, viz., “to insert into the intestinal canal a small tubular piece of elder and then to stitch the raw edges of the bowel together over it.”

Another treatise on surgery, entitled “Chirurgia Jamati,” was published at Salerno before the end of the twelfth century. Its authorship is attributed to Jamerius, and in many respects it resembles closely the treatise of Roger.

The “Regimen Sanitatis” was not, it appears, the only treatise on medicine which was published at that period in the form of a poem. Gilles de Corbeil (Petrus Aegidius Corboliensis), who had received his professional training at the school of Salerno and was afterward appointed the personal physician of King Philip Augustus in Paris (1180–1223 A. D.), wrote versified treatises on these two groups of topics--“The pulse, the urine, and the beneficial characteristics of composite remedies,” and “The signs and symptoms of the different maladies.” Both of these treatises were received everywhere throughout Europe with great favor and they maintained their popularity for a period of over four centuries. A French translation (by C. Vieillard) of the treatise on urology was published in Paris in 1903. An edition of the “De signis et symptomatibus aegritudinum” was printed in Leipzig in 1907. The following five lines are quoted by Neuburger; and they certainly display the remarkable gift possessed by Aegidius for condensing a large amount of information into a very small space:--

DE CONDITIONIBUS URINAE

Quale, quid, aut quid in hoc, quantum, quotiens, ubi, quando, Aetas, natura, sexus, labor, ira, diaeta, Cura, fames, motus, lavacrum, cibus, unctio, potus, Debent artifici certa ratione notari, Si cupit urinae judex consultus haberi.

To translate this into easily comprehensible English prose would certainly require the employment of at least five times as many words.

Another physician who received a part of his training at Salerno and who is mentioned by Neuburger as “The greatest eye surgeon of the Middle Ages,” is Benevenutus Grapheus (twelfth century), a native of Jerusalem, and probably of Jewish parentage. He wrote a practical treatise (“Practica oculorum”) which had a wide circulation, and which has been translated into Provençal, French and English.

Toward the end of the thirteenth century the famous Medical School of Salerno began to show signs of decadence. Various circumstances were responsible for this change. In the first place, its career of great usefulness had already covered a period of about seven hundred years, and--according to the law affecting all things human--its time of decrepitude was already more than due. Then, in the next place, vigorous rivals were beginning to appear in different parts of Europe,--at Bologna, at Montpellier and at Paris,--and these new schools must have attracted large numbers of students who otherwise would have frequented the University of Salerno for the educational facilities which they required. Commercialism--if such a term may be employed to characterize the action of those who were not willing to undergo the entire course of training required for obtaining the full privileges belonging to a physician--may perhaps also be named as one of the influences which contributed to the slow breaking up of the school. That this force had already begun to exert some effect upon the management of the institution may be inferred from the fact that in 1140 A. D., Roger, King of Sicily and Naples, promulgated the law that nobody would be permitted to practice medicine in his kingdom until he should have satisfied the royal authorities that he was properly qualified to undertake such practice. The establishment of such a law surely indicated that the number of those who were incompetent to assume the responsibilities of a practitioner of medicine was alarmingly on the increase; and, after it had gone into effect, many must have been deterred from choosing a medical career, and perhaps others have been diverted to schools which were located in countries where the laws were more lax. In 1240 A. D. the Roman Emperor Frederic II., who was also King of Sicily, made it a law that the course of medical studies at Salerno should cover a period of five years. All these factors taken together would seem to have been sufficient slowly to diminish the popularity of this celebrated school. But to these there were added, in the latter half of the thirteenth century,--if we may believe Puschmann,--two new factors, which exerted a powerful influence in destroying all hope of further regeneration, viz., the establishment of a university at Naples, in 1258 A. D., by Manfred, King of Sicily, and the narrow and illiberal spirit in which the Church, by this time in almost full control of the education at Salerno, managed the medical school.

During the following four centuries the University of Salerno--for during the thirteenth century it became a university in fact, if not in name--retrograded steadily, until finally the French Government, on November 29, 1811, officially put an end to its existence. The traveler who to-day visits Salerno, in the hope of seeing some remains of the oldest medical school in Europe, will find there only a collection of squalid buildings which serve as dwellings for the poorer classes, a dirty and uncomfortable inn, and shops of nearly the same dimensions as those which once lined the narrow streets of Pompeii. As he gazes, however, at the superb view presented by the Gulf of Salerno he may readily, by an effort of the imagination, reconstruct the picture of the famous “Hippocratic City” as it was when William the Conqueror and other distinguished persons visited it nearly a thousand years ago.

Neuburger, in his review of the career of the Salerno Medical School, sums up its contributions to the science of medicine in about these terms: Those who taught at Salerno were the first physicians in the Christian part of Western Europe who procured for medicine a home in which scientific considerations alone prevailed, where the Church exercised no control whatever, and where all the different branches of the science were favored to an equal degree. They devoted their best energies, by oral teaching and by their writings, to the single object of communicating practical knowledge of the healing art to all who desired to obtain it; and, by the admirable example of their own lives, they furnished a high standard for the guidance of those who wished to reflect honor upon the name of physician.