Old-Time Makers of Medicine Part 6

Altogether there are some thirty-three works of Averroes on philosophy and science. Only three of these are concerned with medicine. One is the "Colliget," so-called, containing seven books, on anatomy, physiology, pathology, diagnostics, materia medica, hygiene, and therapy. Then there is a commentary on the "Cantica of Avicenna," and a tractate on the "Theriac." Averroes' idea in writing about medicine was to apply his particular system of philosophy to medical science. His intimate relations with other great physicians of the time, and in particular his close friends.h.i.+p with Avenzoar, enabled him to get abundant medical information in faultless order so far as knowledge then went, but his theoretic speculations, instead of helping medicine, as he thought they would, and as philosophers have always been inclined to think as regards their theoretic contributions, were not only not of value, but to some extent at least hindered human progress by diverting men from the field of observation to that of speculation. It is interesting to realize that Averroes did in his time what Descartes did many centuries later, and many another brilliant thinker has done before and since.

ARABIAN INFLUENCE

The fame of these great thinkers and writers in philosophy and in medicine came to be known not only through the distribution of their books long after their death, but during their lifetime, and in immediately subsequent generations, ardent seekers after knowledge, who were themselves afterwards to become famous by their teaching and writing, found their way into the Arabian dominions in order to take advantage of the educational opportunities afforded. These were better than they could secure at home in Christian countries, because the process of bringing culture and devotion to literature and science into the minds of the Northern nations, who had replaced the old Romans in Europe, was not yet completed. Bagdad and Cordova were the two favorite places of educational pilgrimage. The names that are most familiar among the scholars in the Middle Ages in Europe are those of whom it is recorded that they made long journeys in order to get in touch with what the Arabs had preserved of the old Greek civilization and culture. Among them are such men as Michael Scot or Scotus, Matthew Platearius, who was afterwards a great teacher at Salerno; Daniel Morley, Adelard of Bath, Egidius, otherwise known as Gilles de Corbeil; Romoaldus, Gerbert of Auvergne, who later became Pope under the name of Sylvester II; Gerard of Cremona, and the best known of them all, at least in medicine, Constantine Africa.n.u.s, whose wanderings, however, were probably not limited to Arabian lands, but who seems also to have been in Hindustan.

We are rather p.r.o.ne to think that this great spirit of going far afield for knowledge's sake is recent, or, at least, quite modern. As a matter of fact, one finds it everywhere in history. Long before Herodotus did his wanderings there were many visitors who went to Egypt, and many more later who went to Crete, and many more a few centuries later who went to the sh.o.r.es of Asia Minor seeking for the precious pearl of knowledge, and sometimes finding it without finding the even more precious pearl of wisdom, "whose worth is from the farthest coasts."

To the Arabs we owe the foundation of a series of inst.i.tutions for the higher learning, like those which had existed around them in Asia Minor and in Egypt at the time they made their conquests. Alexandria, Pergamos, Cos, Cnidos, Tarsus, and many other Eastern cities had had what we would call at least academies, and many of them deserved the name of universities. The Arabs continued the tradition in education that they found, and established educational inst.i.tutions which attracted wide attention. As we have said, the two most famous of these were at Bagdad and at Cordova. Mostanser, the predecessor of the last Caliph of the family of the Abba.s.sides, built a handsome palace, in which the academy of Bagdad was housed. It is still in existence, and gives an excellent idea of the beneficent interest of this monarch and of other of the Abba.s.side rulers in education. Its fate at the present time is typical of the att.i.tude of the Mohammedans towards education.

Though the building is still standing, the inst.i.tution of learning is no longer there. As Hyrtl remarks, it is not ideas that are exchanged in it now, but articles of commerce. It has become the chief office of the Turkish customs department in Bagdad.

These inst.i.tutions of the higher learning, founded by the Arabs, at first as rather strict imitations of the museums or academies of Egypt and Asia Minor, gradually changed their character under the Arabs. Their courses became much more formal, examinations became much more important. Scholars.h.i.+p was sought not so much for its own sake, as because it led to positions in the civil service, to the favor of princes, and, in general, to reputation and pecuniary reward. Formal testimonials proclaiming education, signed by the academic authorities, were introduced and came to mean much. Lawyers could not practise without a license, physicians also required a license. These formalities were adopted by the Western medieval universities to a considerable degree and have been perpetuated in the modern time. Undoubtedly they did much to hamper real education among the Arabs by setting in place of the satisfaction of learning for its own sake and the commendation of teachers the formal recognition of a certain amount of work done as recognized by the educational authorities. There was always a tendency among the Arabs to formulate and formalize, to over-systematize what they were at; to think that new knowledge could be obtained simply by speculating over what was already acquired, and developing it. There are a number of comparisons between this and later periods of education that might be suggested if comparisons were not odious.

The influence of Arabian medicine on modern medicine can, perhaps, best be judged from the number of words in our modern nomenclature, which, though bearing Latin forms, often with suggestion of Greek origins, still are not derived from the old Latin or Greek authors, but represent Arabic terms translated into Latin during the Renaissance period. Hyrtl, without pretence of quoting them all, gives a list of these which is surprising in its comprehensiveness. For instance, the mediastinum, the sutura sagittalis, the scrobiculus cordis, the marsupium cordis, the chambers of the heart, the velum palati, the trochanter, the rima glottidis, the fontanelles, the alae of the nose, all have their present names, not from original Latin expressions, but from the translation of Arabic terms. For all such words the Greeks and Romans have quite other expressions, in which the sense of our modern terms is not contained.

This has given rise to many misunderstandings, and to many attempts in the modern times to return to the cla.s.sic terminology rather than preserve what in many cases are the barbarisms introduced through the Arabic, but it is doubtful whether any comprehensive reform in the matter can be effected, so strongly entrenched in medical usage have these terms now become.

Freind, in his "History of Medicine," already cited, calls attention to the fact that the Arabs had an unfortunate tendency to change by addition or subtraction of their own views the authors that they studied, and wished to translate to others. This seems to have been true even of some of the most distinguished of them. Of course, the idea of preserving an author's text untouched, and making it clear just where note and commentary came in, had not yet come to men's view, but quite apart from this the Arabs apparently often tried to gain acceptance for their own ideas by having them masquerade as the supposed ideas of favorite cla.s.sic authors.

Another unfortunate tendency among the Arabs was their liking for the discussion of many trivial questions. Hyrtl, in his volume on "Arabian and Hebrew Words in Anatomy,"[6] declares that it is almost incredible how earnestly some trivial questions in anatomy and physiology were discussed by the Arabs. He gives some examples. Why does no hair grow on the nose of men? Why does the stomach not lie behind the mouth? Why does the windpipe not lie behind the esophagus? Why are the b.r.e.a.s.t.s not on the abdomen? Why are not the calves on the anterior portion of the legs?

Even such men as Rhazes and Avicenna discuss such questions.

It was this tendency of the Arabs that pa.s.sed over to the Western Europeans with Arabian commentaries on philosophy and science, and brought so many similar discussions in the scholastic period. These trivialities have usually been supposed to originate with the scholastics themselves, for they are not to be found in the Greek authors on whom the scholastics were writing commentaries, but they are typically Oriental in character, and it must be remembered that during the twelfth and early thirteenth centuries, at least, Greek philosophy found its way largely into Europe in Arab versions, and these characteristically Arabian additions of the discussion of curious trivial questions came with them and produced an imitative tendency among the Europeans.

As a rule the more careful has been the study of Arabian writers in the modern time, particularly by specialists, the clearer has it become that they lacked nearly all originality. Especially were they faulty in their observations; besides, they had a definite tendency to replace observation by theory, a fatal defect in medicine. The fine development of surgery that came at the end of the Arabian period of medicine in Europe could never have come from the Arabs themselves. Gurlt has brought this out particularly, but it will not be difficult to cite many other good authorities in support of this opinion.

Hyrtl, in his "Thesis on the Rarer Old Anatomists,"[7] says that "the Arabs paid very little attention to anatomy, and, of course, because of the prohibition in the Koran, added nothing to it. Whatever they knew they took from the Greeks, and especially Galen. Not only did they not add anything new to this, but they even lost sight of much that was important in the older authors. The Arabs were much more interested in physiology; they could study this by giving thought to it without soiling their hands. They delighted in theory, rather than in observation."

While we thus discuss the lack of originality and the tendency to over-refinement among the Arabian medical writers, it must not be thought that we would make little of what they accomplished. They not only preserved the old medical writers for us, but they kept alive practical medicine with the principles of the great Greek thinkers as its basis. There are a large number of writers of Arabian medicine whose names have secured deservedly a high place in medical history. If this were a formal history of Arabian medicine, their careers and works would require discussion. For our purpose, however, it seems better to confine attention to a few of the most prominent Arabian writers on medicine, because they will serve to ill.u.s.trate how thoroughly practical were the Arabian physicians and how many medical problems that we are p.r.o.ne to think of as modern they occupied themselves with, solving them not infrequently nearly as we do in the modern time.

VI

THE MEDICAL SCHOOL AT SALERNO

The Medical School at Salerno, probably organized early in the tenth century, often spoken of as the darkest of the centuries, and reaching its highest point of influence at the end of the twelfth century, is of great interest in modern times for a number of reasons. First it brought about in the course of its development an organization of medical education, and an establishment of standards that were to be maintained whenever and wherever there was a true professional spirit down to our own time. They insisted on a preliminary education of three years of college work, on at least four years of medical training, on special study for specialist's work, as in surgery, and on practical training with a physician or in a hospital before the student was allowed to practise for himself. At Salerno, too, the department of women's diseases was given over to women professors, and we have the text-books of some of these women medical teachers. The license to practise given to women, however, seems to have been general and did not confine them merely to the care of women and children. We have records of a number of these licenses issued to women in the neighborhood of Salerno. This subject of feminine medical education at Salerno, because of its special interest in our time, will have a chapter by itself.

These are the special features of medical education in our own time that we are rather p.r.o.ne to think of as originating with ourselves and as being indices of that evolution of humanity and progress in mankind which are culminating in our era. It is rather interesting, then, to study just how these developments came about and what the genesis of this great school was. The books of its professors were widely read, not only in their own generation but for centuries afterwards. With the invention of printing at the time of the Renaissance most of them were printed and exerted profound influence over the revival of medicine which took place at that time. Salerno became the first of the universities in the modern sense of the word. Here there gathered round the medical school, first a preparatory department representing modern college work, and then departments of theology and law, though this latter department particularly was never quite successful. The fact that the first university, that of Salerno, should have been organized round a medical school, the second, that of Bologna, around a law school, and the third, that of Paris, around a school of theology and philosophy, would seem to represent the ordinary natural process of development in human interests. First man is interested in himself and in his health, then in his property, and finally in his relations to his fellow-man and to G.o.d.

Though much work has been done on the subject in recent years, it is not easy to trace the origin of the medical school at Salerno. The difficulty is emphasized by the fact that even the earliest chroniclers whose accounts we have were not sure as to its origin, and even had some doubt about the age of the school. Alpha.n.u.s, usually designated Alpha.n.u.s I because there are several of the name, who is one of the earliest professors whose name and fame have come down to us, gives us the only definite detail as to the age of the school. He was a Benedictine monk, distinguished as a literary man, known both as poet and physician, who was afterwards raised to the Bishopric of Salerno. As a bishop he was one of the beneficent patrons, to whom the school owed much. He lived in the tenth century, and states that medicine flourished in the town before the time of Guimarus II, who reigned in the ninth century. In the ancient chronicle of Salerno, re-discovered by De Renzi and published in his "Collectio Salernitana," it is definitely recorded that the medical school was founded by four doctors,--a Jewish Rabbi Elinus, a Greek Pontus, a Saracen Adala, an Arab, and a native of Salerno, each of whom lectured in his native language. There are many elements in this tradition, however, that would seem to indicate its mythical origin and that it was probably invented after the event to account for the presence of teachers in all these languages and the coming of students from all over the world. The names, for instance, are apparently corruptions of real names, as can be readily recognized.

Elinus, the Jew, is probably Elias or Eliseus, Adala is a corruption of Abdallah, and Pontus, as pointed out by Puschmann in his "History of Medical Education," should probably be Gario-Pontus.

While we do not know exactly when the medical school at Salerno was founded, we know that a hospital was established there as early as 820.

It was founded by the Archdeacon Adelmus, and was placed under the control of the Benedictines after it was realized that a religious order, by its organization, was best fitted for carrying on such charitable work continuously. Other infirmaries and charitable inst.i.tutions, mainly under control of the religious, sprang up in Salerno. It was the presence of these hospitals in a salubrious climate that seems first to have attracted the attention of patients and then of physicians from all over Europe and even adjacent Africa and Asia.

Puschmann says that it is uncertain whether clinical instruction was imparted in these inst.i.tutions or not, but the whole tenor of what we know about the practical character of the teaching at Salerno and of the fine development of professional medicine there, would seem to argue that probably those who came to study medicine here were brought directly in contact with patients.

As early as the ninth century Salerno was famous for its great physicians. We know the names of at least two physicians, Joseph and Joshua, who practised there about the middle of the ninth century.

Ragenifrid, a Lombard by his name, was private physician to Prince Wyamar of Salerno in the year 900. The fact that he was from North Italy indicates that already foreigners were being attracted, but more than this that they were obtaining opportunities unhampered by any Chauvinism. From early in the tenth century physicians from Salerno were frequently brought to foreign courts to become the attending physicians to rulers. Patients of the highest distinction from all over Europe began to flock to Salerno, and we have the names of many of them. In the tenth century Bishop Adalberon, when ailing, went there, though he found no cure for his ills. Abbot Desiderius, however, the great Benedictine scholar of the time, who afterwards became Pope Victor III, regained his health at Salerno under the care of the great Constantine Africa.n.u.s, who was so much impressed by the gentle kindness and deep learning and the example of the saintly life of his patient that not long after he went to Monte Ca.s.sino to become a Benedictine under Desiderius, who was abbot there. Duke Guiscard sent his son Bohemund to Salerno for the cure of a wound received in battle, which had refused to heal under the ordinary surgical treatment of the time. William the Conqueror, early in the eleventh century and while still only the Duke of Normandy, is said to have pa.s.sed some time at Salerno for a similar reason.

The most interesting feature of the medical life at Salerno at this time is the relations between the clergy and the physicians. In the sketch of the life of Constantine Africa.n.u.s, which follows this chapter, there is some account of the friends.h.i.+p between Abbot Desiderius of Monte Ca.s.sino and Constantine Africa.n.u.s, and the latter's withdrawal from his professors.h.i.+p to become a Benedictine. One of the physicians of the early tenth century who stood high in favor with Prince Gisulf was raised to the Bishopric of Salerno. This was Alpha.n.u.s, whom we have already mentioned as a chronicler, a monk, a poet, a physician, and finally the Bishop of Salerno.

The best proof of how thorough was the medical education at Salerno and how much influence it exerted even over public opinion is to be found in the regulation of the practice of medicine, which soon began, and the insistence upon proper training before permission to practise medicine was granted. The medical school at Salerno early came to be a recognized inst.i.tution in the kingdom of the Two Sicilies, representing a definite standard of medical training. It is easy to understand that the attraction which Salerno possessed for patients soon also brought to the neighborhood a number of irregular physicians, travelling quacks, and charlatans. Wealthy patients were coming from all over the world to be treated at Salerno. Many of them doubtless were sufferers from incurable diseases and nothing could be done for them. Often they would be quite unable to return to their homes and would be surely unwilling to give up all hope if anybody promised them anything of relief. There was a rich field for the irregular, and of course, as always, he came. Salerno had already shown what a good standard of medical education should be, and it is not surprising, then, that the legal authorities in this part of the country proceeded to the enforcement of legal regulations demanding the attainment of this standard, in order that unfit and unworthy physicians might not practise medicine to their own benefit but to the detriment of the patients.

Accordingly, as early as the year 1140, King Ruggiero (Roger) of the Two Sicilies promulgated the law: "Whoever from this time forth desires to practise medicine must present himself before our officials and judges, and be subject to their decision. Anyone audacious enough to neglect this shall be punished by imprisonment and confiscation of goods. This decree has for its object the protection of the subjects of our kingdom from the dangers arising from the ignorance of pract.i.tioners."

Just about a century later the Emperor Frederick II, the Hohenstaufen, in the year 1240, extended this law, emphasized it, and brought it particularly into connection with the great medical school of the Two Sicilies, of which territory he was the ruler. This law has often been proclaimed as due to his personality rather than to his times,--as representing his very modern spirit and his progressive way of looking at things. There is no doubt that certain personal elements for which he should be given due credit are contained in the law. To understand it properly, however, one must know the law of King Roger of the preceding century; and then it is easy to appreciate that Frederick's regulation is only such a development of the governmental att.i.tude toward medical practice as might have been expected during the century since Roger's time. It has sometimes been suggested that this law made by the Emperor Frederick, who was so constantly in bitter opposition to the Papacy, was issued in despite of the Church authorities and represents a policy very different from any which they would have encouraged. The early history of Salerno, even briefly as we have given it, completely contradicts any such idea. The history of medical regulation at the beginning of the next century down at Montpellier moreover, where the civil authorities being weak the legal ordering of the practice of medicine was effectively taken up by the Church, and the authority for the issuance of licenses to practise was in the hands of the bishops of the neighborhood, shows clearly that it is not because of any knowledge of the real medical history of the times that such remarks are made, but from a set purpose to discredit the Church.

The Emperor Frederick's law deserves profound respect and consideration because of the place that it holds in the legal regulation of the practice of medicine. Anyone who thinks that evolution must have brought us in seven centuries much farther in this matter than were the people of the later Middle Ages should read this law attentively. Everyone who is interested in medical education should have a copy of it near him, because it will have a chastening effect in demonstrating not only how little we have done in the modern time rather than how much, but above all how much of decadence there was during many periods of the interval.

The law may be found in the original in "The Popes and Science" (Fordham University Press, N.Y., 1908). Three years of preliminary university education before the study of medicine might be taken up, four years of medical studies proper before a degree was given, a year of practice with a regularly licensed physician before a license to practise could be obtained, a special course in anatomy if surgery were to be practised; all this represents an ideal we are striving after at the present time in medical education. Besides this, Frederick's law also regulates medical fees, requires gratuitous attendance on the poor for the privilege of practice accorded by the license, though the general fees are of a thoroughly professional character and represent for each visit of the physician about the amount of daily wage that the ordinary laborer of that time earned. Curiously enough, this same ratio of emolument has maintained itself. This law was also a pure drug law, regulating the practice of pharmacy, and the price as well as the purity of drugs, and the relations of physicians, druggists, and the royal drug inspectors whose business it was to see that only proper drugs were prepared and sold.

All this is so much more advanced than we could possibly have imagined, only that the actual doc.u.ments are in our possession, that most people refuse to let themselves be persuaded in spite of the law that it could have meant very much. Especially as regards medical education are they dubious as to conditions at this time. To them it seems that it can make very little difference how much time was required for medical study or for studies preliminary to medicine, since there was so little to be learned. The age was ignorant, men knew but little, and so very little could be imparted no matter how much time was taken.

This is, I fear, a common impression, but an utterly false one. The preliminary training that is the undergraduate work at the universities consisted of the Seven Liberal Arts--the trivium and quadrivium, which embraced logic, rhetoric, grammar, metaphysics, under which was included not a little of physics, cosmology in which some biology was studied, as well as psychology and mathematics, astronomy, and music. This was a thoroughly rounded course in intellectual training. No wonder that Professor Huxley said in his Inaugural Address as Rector of Aberdeen, "I doubt if the curriculum of any modern university shows so clear and generous a comprehension of what is meant by culture as this old trivium and quadrivium does." There is no doubt at all about the value of the undergraduate training, nor of the scholars.h.i.+p of the men who were turned out under the system, nor of their ability to concentrate their minds on difficult subjects--a faculty that we strive to cultivate in our time and do not always congratulate ourselves on securing to the degree, at least, that we would like.

As to the medical teaching, aegidius, often called Gilles of Corbeil, who 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 s.e.xual 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 Africa.n.u.s, 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.

Ma.s.sage 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 s.p.a.ce 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 quant.i.ty 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 princ.i.p.al 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 t.i.tle 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 princ.i.p.al 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 t.i.tle, "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 doc.u.ment, 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 circ.u.mstances 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, ill.u.s.trates 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 acc.u.mulation 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 inst.i.tutions 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.