CHAPTER V.

THE SCHOOL OF SALERNO. The Monks of Monte Cassino.—Clerical Influence at Salerno.—Charlemagne.—Arabian Medicine gradually supplanted the Græco-Latin Science.—Constantine the Carthaginian.—Archimatthæus.—Trotula.—Anatomy of the Pig.—Pharmacopœias.—The Four Masters.—Roger and Rolando.—The Emperor Frederick. The connecting link between the ancient and the modern medicine was the school of Salerno. It is true that Hippocrates and Galen in Arabian costume re-entered Europe after a long absence in the East, when the Moors occupied a great part of Spain; but great as was this Saracenic influence on medical science, it was not to be compared with the powerful and permanent influence secured by the native growth of medical science which sprung up on Italian soil. The origin of this celebrated mediæval institution is involved in obscurity; it has been generally understood to have sprung from the monastery of Monte Cassino, founded by St. Benedict in the sixth century. St. Benedict probably possessed some medical knowledge, and it is certain that many of his order did. The Benedictines had houses in La Cava and Salerno. The legends of the wonderful cures wrought by St. Benedict would naturally attract crowds of sufferers to the doors of the learned and charitable monks. There would consequently be abundant opportunities for the study of diseases and their remedies; and though there was probably little enough of what could strictly be called scientific medical practice, there was doubtless as much effort to cure or mitigate suffering as was consistent with the rule of a learned religious order. Some writers think that the famous school of Salerno existed as early as the seventh century, that Greek thought and traditions lingered there long after they had ceased to exist in other parts of Italy; and they argue that as it was, as is now clearly shown, a purely secular institution, it was independent in origin and constitution of any monastic connection. Others maintain that it was founded by the Arabs; but, as Daremberg points out,[743] the first invasions of the Saracens in Sicily and Italy, dating from the middle of the ninth century, had for their objects simply pillage and slaughter; and there is nothing whatever to show in the whole course of their devastations the slightest desire to found literary or scientific institutions. The Saracens never sojourned at Salerno, and before the end of the eleventh century there is no trace of Arabian medicine in the works written by the great teachers of Salerno. It is as unnecessary as it is unjust to seek any other origin for the Salernian school than that of the Benedictines of Monte Cassino.[744] Bede, Cuthbert, Auperth, and Paul were brought up at that monastery, and we know that medicine was always cultivated to a certain extent in those ancient abodes of learning and religion. As Balmez says concerning Monte Cassino,[745] “the sons of the most illustrious families of the empire are seen to come from all parts to that monastery; some with the intention of remaining there for ever, others to receive a good education, and some to carry back to the world a recollection of the serious inspirations which the holy founder had received at Subiaco.” It seems, therefore, that the origin of the medical school of Salerno was somewhat on this wise: a lay spirit of science was developed, and many young men having no aptitude for the monastic life, but desirous to devote themselves entirely to the healing art as an honourable and lucrative profession, doubtless desired to form themselves into a society or school for this end; they would receive encouragement from their more liberal and enlightened monastic teachers to settle in a beautiful and healthy resort of invalids such as Salerno had long been considered, and to pursue their medical studies under the supervision of the men most competent to instruct them. Dr. Puschmann, quoting from S. de Renzi,[746] states that in documents of the years 848 and 855, JOSEPH and JOSHUA are named as doctors practising there. The Lombard REGENIFRID lived there in the year 900; he was physician to Prince WAIMAR of Salerno. Fifty years later the doctor PETRUS was raised to the bishopric of Salerno. Many doctors of this time were clerics, but there were also many who were Jews.[747] This ancient people, hated and persecuted in every other relation of life, were popular as physicians in the Middle Ages. The books studied and expounded were Hippocrates and Galen, which were translated into Latin before A.D. 560.[748] Its cosmopolitan sentiments probably gave rise to the story that is told in an ancient Salernian chronicle, rediscovered by S. de Renzi, to the effect that the school was founded by four doctors; namely, the Jewish Rabbi ELINUS, the Greek PONTUS, the Saracen ADALA, and a native of Salerno, who each lectured in his native tongue.[749] It is said that Charlemagne in 802 A.D. greatly encouraged this Salerno school by ordering Greek works of medicine to be translated from the Arabic into Latin. Salernum, in consequence of the medical and public instructions given by the monks in the neighbouring monastery, became known as a _civitas Hippocratica_.[750] BERTHARIUS, abbot from 856, was a very learned man; and it is stated that there are still in existence two manuscripts of his which contain a collection of hygienic and medicinal rules and prescriptions.[751] ALPHANUS (SECUNDUS) (flourished about 1050), a distinguished monastic philosopher and theologian, wrote a treatise on _The Union of the Soul and Body_, and another on _The Four Humours_. He carried with him, when he removed to Florence, many manuscripts and a great quantity of medicines. During the eleventh century Salerno rose to great importance, not only from its situation as a port from which the Crusaders departed to the wars, but from the daily widening influence of its medical school. PETROCELLUS wrote on the practice of medicine about 1035; he was the author of the _Compendium of Medicine_. GARIOPONTUS (died before 1056) wrote a work entitled _Passionarius Galeni_. These are the two most ancient works of this school which have reached our times, says Daremberg. The medicine of Salerno before the year 1050 was a combination of methodism in its doctrines and of Galenisms in its prescriptions.[752] We find, says Baas,[753] in Gariopontus the first intimation of the inhalation of narcotic vapours in medicine, while the ancients could only produce anæsthesia by compression and the internal use of such drugs as mandragora and belladonna. Herodotus says[754] that the Scythians used the vapour of hemp seed to intoxicate themselves by inhaling it, but this was not for medicinal purposes. DESIDERIUS was abbot of Salerno, and afterwards became Pope Victor III. in 1085. He is said to have been _medicinæ peritissimus_.[755] About this time flourished _Constantine_, the Carthaginian Christian, whose fame was European, and who finally placed Salerno in the front as a great and specialized public school of medicine. He travelled far in the East, and is said to have learned mathematics, necromancy, and the sciences in Babylon. He visited India and Egypt, and when he returned to Carthage he was the most learned man of his time in all that related to medical science. Naturally he was suspected of witchcraft, and he fled for refuge to Salerno. Robert Guiscard the Norman held him in the highest favour, and under his protection he published many works of medicine of his own, and made many translations of medical books from the Arabic. He ultimately retired to the monastery of Monte Cassino, where he died in 1087. We may safely date the establishment of the splendid reputation of the Salerno school from the time of his settlement there.[756] Daremberg does not allow that the influence of Constantine was so great as is generally supposed. He points out that it was not in the middle of the eleventh but at the end of the twelfth century that Arabian medicine was substituted in the school of Salerno, as in the West generally, for the Græco-Latin. And it is perfectly true that if we examine the medical writings of this period we find very little progress from the times of the ancients, except in pharmacy and the knowledge of drugs and their properties. Daremberg’s researches go to prove that many of Constantine’s works, previously supposed to have been original, were but cunningly disguised translations from the Arabic. By altering the phraseology, and suppressing such proper names as would have led to suspicion of the origin of his treatises, he obtained credit for a great mass of literary work which had really another source.[757] JEAN AFFLACIUS, a disciple of Constantine, wrote _The Golden Book on the Treatment of Diseases_, and another work _On the Treatment of Fevers_.[758] Daremberg says that these works of Afflacius show no more traces of Arabian influence than the works of his contemporaries. He advised that the air of the sick-room should be kept cool by the evaporation of water, and he administered iron in enlargement of the spleen. ARCHIMATTHÆUS lived soon after Constantine; his name occurs about the year 1100 as the author of two important books on medicine, _The Instruction of the Physician_ and _The Practice_. The former work is occupied with advice, sometimes exaggerated, on the dignity of the healing art; and though it appears childish enough to our more sophisticated age, it is not without evidence of a desire to instruct the doctor in all that relates to the welfare of the patient and the dangers incurred by any deviation from the strictest code of professional rectitude. It is unfortunately, however, blended with so much that is crafty and sly that it approaches in some directions very closely to charlatanism. Archimatthæus very minutely instructs the doctor how to comport himself when called to visit a patient.[759] He should place himself under the protection of God and under the care of the angel who accompanied Tobias. On the way to the patient’s home he should take care to learn from the messenger sent for him the state of the patient, so that he may be, on reaching the bedside, well posted in all that concerns the case; then if, after he has examined the urine and the state of the pulse, he is not able to make an accurate diagnosis, he will at least be able, thanks to his previous information, to impress the patient with the conviction that he completely understands his case, and so will gain his confidence. The author considers it very important that the sick person, before the arrival of the physician, should send for a priest to hear his confession, or at least promise to do so; for if the doctor were to see reason to suggest this himself, it would give the patient cause to suppose that his case was hopeless. “Upon entering the house of his patient, the physician should salute all with a grave and modest air, not exhibiting any eagerness, but seating himself to take breath; he should praise the beauty of the situation,[760] the good arrangements of the house, the generosity of the family; by this means he wins the good opinion of the household, and gives the sick person time to recover himself a little.” After the most careful directions as to the examination of the patient, the author takes the doctor from the house with as much artfulness as he has brought him hither. He is to promise the patient a good recovery, but privately to the friends he is to explain that the illness is a very serious one: “if he recovers, your reputation is increased; if he succumbs, people will not fail to remember that you foresaw the fatal termination of the disease.” If he is asked to dine, “as is the custom,” he is to show himself neither indiscreet nor over-nice. If the table is delicate, he is not to become absorbed in its pleasures, but to leave the table every now and then to see how the patient progresses, so as to show that he has not been forgotten while the doctor was feasting. He is honestly to demand his fee, and then go in peace, his heart content and his purse full. In the _Practice_ of the same author, we have, says Daremberg, a true _Clinic_, the first work of the kind since the _Epidemics_ of Hippocrates; it exhibits a skilful practitioner, a good observer, and a bold therapeutist. The doctrines and methods are those of Hippocrates and Galen, but not of the Arabs. It is also interesting as proving that at this period the distinction was established between the true physicians and the common physicians, or the specialists and the general practitioners or physician-apothecaries. A remarkable and interesting feature in the history of the school of Salerno is the fact that some of its most famous professors of medicine were ladies. About the year 1059, TROTULA, a female physician, wrote a well-known book on the diseases of women, and their treatment before, during, and after labour. She discusses all branches of pathology, even of the male sexual organs.[761] It was supposed that she was the wife of John Platearius the elder, and that she belonged to the noble family of Roger. Her person and name were at one time considered legend and myth, but M. Renzi’s investigations have proved her to be sufficiently historical. Trotula lived at Salerno, as is shown by the _Compendium Salernitanum_, and she practised in that city, as is clear from her work on the diseases of women. Her name occurs variously as Trotula, Trotta, and Trocta.[762] ABELLA wrote a treatise _De Natura Seminis Humani_; she was a colleague of Trotula’s. COSTANZA CALENDA was the daughter of the principal of the medical school, and was distinguished both for her beauty and her talents; she left no writings. MERCURIADIS and REBECCA GUARNA were doctresses of the fifteenth century. They wrote chiefly on midwifery and diseases of women.[763] COPHO, in the early part of the twelfth century, was an anatomist, and probably a Jew; he wrote the _Anatomy of the Pig_. Students were instructed in dissections by operating on dead animals when, as in those days, human bodies were not accessible. The pig was killed by severing the vessels of the neck, and was then hung up by the hind legs, and when the blood had escaped the body was used for teaching purposes; it was not dissected in the modern sense at all, the examination consisting merely in observation of the great cavities and the vital organs, according to the suggestions of Galen and the old anatomists.[764] NICHOLAS PRÆPOSITUS, about 1140, was the president of the school, and wrote a famous book called the _Antidotarium_—a Pharmacopœia as we should call it. This book of recipes was compiled from the works of the Arabian doctors Mesues, Avicenna, Actuarius, Nicolaus Myrepsus, as well as from Galen. It is interesting as giving the forms which the compounders of the prescriptions were sworn on their oath to observe; they promised to make up all their potions, syrups, etc., “_secundum prædictam formam_,” and they further promised that their drugs should be fresh and sufficient. It shows also that there was a habit of writing a prescription when a patient was visited; this, it seems, was a custom which originated with the Arabian physicians.[765] Nicholas was also the author, says Dr. Baas,[766] of a work called “_Quid pro Quo_,” which was a list of drugs which were equivalent to other drugs, and might be used as substitutes for each other in case of either running short. Dr. Baas says our expression “Quid pro Quo” originated from this. The writings of Bartholomæus and of Copho the Younger (between 1100 and 1120), says Daremberg, are of great interest in the history of medicine; they show how great was the freedom of spirit which existed at Salerno at this time. Copho described certain diseases which were not referred to in the works of other writers of Salerno; for example, ulceration of the palate and trachea, polypi, scrofulous tumours of the throat, condylomata, etc. Bartholomæus and Copho also held certain original ideas as to the classification of fevers. Copho distinguished between medicine for the rich and for the poor: the rich are delicate, and must be cured agreeably; the poor wish only to be cured at as little cost as possible. Thus the nobles must be purged with finely powdered rhubarb, the poor, with a decoction of mirobalanum, sweetened or not. Naturally the more precious drugs would be used for the wealthy, and probably the poor, who could not afford the complicated and terrible confections of mediæval pharmacy, might have congratulated themselves on being treated with a few simples instead of the precious messes which the wealthy had to swallow. JOHANNES PLATEARIUS deserves notice as having been the inventor of the term “Cataracta,” in place of the ancient Egyptian “ascent” and the Greek “hypochosis,” in classical Latin “suffusio humorum” (Hirsch).[767] MATTHÆUS PLATEARIUS was the son of the above; he composed a _Practica Brevis_ and other books on medicine; it is not certain at what precise date they flourished. ÆGIDIUS “CORBOLENSIS,” canon of Paris, physician to Philip Augustus, king of France (1165-1213), wrote a poem on the decline of Salerno as a medical school; he describes the doctors as caring nothing for books which were not full of recipes, and the professors as merely beardless boys. The famous but somewhat mysterious “Four Masters” were commentators on the surgery of Roger and Roland. MUSANDINUS wrote on the diet of the sick; bleeding was recommended for the want of appetite in convalescents, and patients were rather to be purged to death than permitted to die constipated. BERNARD THE PROVINCIAL recommends wine for the delicate stomachs of bishops; he said they could not bear emetics unless they were administered on a full stomach. His treatise was written between the years 1150 and 1160. He did much to simplify the materia medica of his time, advising the poor not to waste their means on costly foreign drugs, but to gather simples from the fields. It is interesting to find in the thirteenth century police regulations which required in many cities of Italy that physicians should inspect druggists’ shops and see that their medicines were pure and fresh. Pharmacy, it seems, was already becoming divorced from medical practice.[768] In the middle of the twelfth century there appeared a didactic poem called _Schola Salernitana, Flos Medicinæ_, or _Regimen Sanitatis_, or _Regimen Virile_. This celebrated work went through hundreds of editions.[769] Dr. Handerson, in his translation of Baas’ _History of Medicine_, says it had other titles than those given above, as _Medicina Salernitana_, _De Conservanda Bona Valetudine_, _Lilium Sanitatis_, _Compendium Salernitanum_, etc. The work was for centuries the physician’s _vade mecum_. It is not known who was the author; originally it was put forth as emanating from “the whole school of Salerno to the king of England,” namely, Robert, son of William the Conqueror, who was cured of a wound at Salerno in 1101. The poem consisted of some two thousand lines. Dr. Handerson gives the following translation of a few lines of this curious work:— “Salerno’s school in conclave high unites, To counsel England’s king, and thus indites: If thou to health and vigour would’st attain, Shun mighty 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 slumbers, nor delay The urgent calls of nature to obey: These rules if thou wilt follow to the end, Thy life to greater length thou may’st extend.” It has been translated into English by Thomas Paynell in 1530, by John Harrington in 1607, and by Alexander Croke in 1830. The poem is a composite work, and its form was doubtless adopted for facility of committing to memory an important text-book of health rules. ROGER, or RUGGIERO, known as Roger of Parma or of Palermo, lived about 1210, was a student, and for a long time a professor in Salerno. He was a celebrated surgeon, who practised trepanning of the sternum and stitching of the intestine. He was the first to describe a case of hernia pulmonis, to use the term seton, and to prescribe the internal use of sea-sponge for the removal of bronchocele.[770] He knew how to arrest hæmorrhage by styptics, sutures, and ligatures. He was the earliest special writer on surgery in Italy.[771] His later editor ROLANDO exhibits an acquaintance with surgery, which shows that, although the art had not been previously written upon in Italy, it was very well understood at Salerno. De Renzi says that some of the operations described are trephining, the removal of polypi from the nose, resection of the lower jaw, the operation for hernia and lithotomy. Malignant tumours of the rectum and uterus are referred to.[772] Salerno was the first school in Europe in which regular diplomas in medicine were granted to students who had been duly instructed and had passed an examination in accordance with the requirements of the legal authorities. The great patron of Salerno, Frederick II., in the year 1240 confirmed the law of King Roger, passed in the year 1137, or as some say in 1140, with reference to licences to practise medicine. That ancient enactment was that, “Whoever from this time forth desires to practise medicine must present himself before our officials and judges, and be subject to their decision. Any one 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 practitioners.”[773] Frederick’s law was: “Since it is possible for a man to understand medical science, only if he has previously learnt something of logic, we ordain that no one shall be permitted to study medicine until he has given his attention to logic for three years. After these three years he may, if he wishes, proceed to the study of medicine. In this study he must spend five years, during which period he must also acquire a knowledge of surgery, for this forms a part of medicine. After this, but not before, permission may be given him to practise, provided that he passes the examination prescribed by the authorities and at the same time produces a certificate showing that he has studied for the period required by the law.” “The teachers must, during this period of five years, expound in their lectures the genuine writings of Hippocrates and Galen on the theory and practice of medicine.” “But even when the prescribed five years of medical study are passed, the doctor should not forthwith practise on his own account, but, for a full year more he should habitually consult an older experienced practitioner in the exercise of his profession.” “We decree that in future no one is to assume the title of doctor, to proceed to practise or to take medical charge, unless he has previously been found competent in the judgment of teachers at a public meeting in Salerno, has moreover by the testimony in writing of his teachers and of our officials approved himself before us or our representatives in respect of his worthiness and scientific maturity, and in pursuance of this course has received the state-licence to practise. Whoever transgresses this law, and ventures to practise without a licence, is subject to punishment by confiscation of property and imprisonment for a year.” “No surgeon shall be allowed to practise until he has submitted certificates in writing of the teachers of the faculty of medicine, that he has spent at least one year in the study of that part of medical science which gives skill in the practice of surgery, that in the colleges he has diligently and especially studied the anatomy of the human body, and is also thoroughly experienced in the way in which operations are successfully performed and healing is brought about afterwards.”[774] For centuries after this barbers in other countries practised surgery without let or hindrance. The doctor was bound to give advice to the poor gratis, and to inform against apothecaries who did not make up his prescriptions in accordance with the law. The doctor’s fee in the daytime within the town was half a gold tarenus; outside the city he could demand from three to four tareni, exclusive of his travelling expenses.[775] Doctors were not permitted to keep drug-shops. Apothecaries were obliged to compound the medicines in conformity with the doctor’s prescriptions, and the price they charged was regulated by law. Inspectors of drug-shops were appointed to visit and report. The punishment of death was imposed on the officials who neglected their duties.[776] These laws have served as the pattern for succeeding enactments for the regulation of medical education and practice. In 1252 King Conrad created the school of Salerno a university, but King Manfred in 1258 by his restoration of Naples University left Salerno only its medical school. On the 29th of November, 1811, a decree of the French Government put an end to the oldest school of medicine in Europe. Daremberg concludes his admirable treatise on the school of Salerno with a pathetic account of a visit which he made to that city in 1849; he tells how he wandered through its streets, once so active with the movements of the students and professors of the medical sciences, and he laments that not a single remembrance of its illustrious masters remains to remind the visitor of its ancient glories. Not a stone of the edifices, not an echo of its traditions, not even a manuscript in any library remains to remind us of the learned and venerable men and women who did so much for medicine in those dark ages. A few years back I visited Salerno myself, and I found not even a decent hotel in which to remain a night or two. I rested at the best hostelry I could find, and after dinner proposed to the friend who accompanied me, that on the following day we should visit Pæstum and see its noble ruined temples. As we chatted and turned over the pages of the visitors’ book, we came across a long and doleful account of an Englishman who some few years previously had visited Pæstum from Salerno, and was captured by brigands; he was detained their prisoner for many weeks, and only at last liberated, after threats of mutilation, by the payment of a heavy ransom. We did not go to Pæstum; we left Salerno early the following morning and went to Amalfi. The hotel was gloomy and crumbling into decay, the rooms were all empty, the landlord was suggestive of the host in some of the old stories of our boyish days. Thus has Salerno fallen. Most travellers now make La Cava their headquarters, and do not stay at Salerno at all.