 Chapter 6 of Old Time Makers of Medicine, this is a LibriVox recording. All LibriVox recordings are in the public domain. For more information or to volunteer, please visit LibriVox.org. Recording by Adam Marsatich, September 2009, Alexandria, Virginia. Old Time Makers of Medicine by James Joseph. Chapter 6 The Medical School at Salerno The medical school at Salerno, probably organized early in the 10th century, often spoken of as the darkest of the centuries, and reaching its highest point of influence at the end of the 12th 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 time. They insisted on a preliminary education of three years of college work, on at least four years of medical training, a special study for specialist work, as in surgery, and on practical training with a physician or in a hospital before the student was allowed to practice for himself. At Salerno, too, the Department of Women's Diseases was given over to women professors, and we have the textbooks of some of these women medical teachers. The license to practice 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. The 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 prone 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 the time. Salerno became the first of the universities in the modern sense of the word. Here they are gathered around 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 around a medical school, the second, that of Bologna, around a law school, and the third, that of Paris, around the 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 prosperity, and finally, in his relations to his fellow man and to God. 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. Alphanus, usually designated Alphanus 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 10th century, and states that medicine flourished in the town before the time of Guimaris II, who reigned in the 9th century. In the ancient chronicle of Salerno, rediscovered by De Renzi, and published in his colectio 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 Eleus, or Elsius. Adala is a corruption of Abdala, and Pontus, as pointed out by Pushman in his history of medical education, should probably be Garriopontus. 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 institutions, 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. Pushman says that it is uncertain whether clinical instruction was imparted in these institutions 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 9th century, Salerno was famous for its great physicians. We know the names of at least two physicians, Joseph and Joshua, who practiced there about the middle of the 9th century. Regenefrid, a lombard by his name, was private physician to Prince Weimar 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 10th century, physicians from Salerno were frequently brought to foreign courts to become the attending physicians to rulers. Patience of the highest distinction from all over Europe began to flock to Salerno, and we have the names of many of them. In the 10th century, Bishop Ado Baron, 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 Africanus, 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 Cassino 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 11th century, and while still only the Duke of Normandy, is said to have passed 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 Africanus, which follows this chapter, there is some account of the friendship between Abbot Desiderius of Monte Cassino and Constantine Africanus, and the latter's withdrawal from his professorship to become a Benedictine. One of the physicians of the early 10th century, who stood high in favor with Prince Giesulf, was raised to the bishopric of Salerno. This was Alphanus, 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 practice medicine was granted. The medical school at Salerno early came to be a recognized institution 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, traveling 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 practice 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, quote, 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 attitude towards 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 Montpelier, 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 practice 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 have we 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, New York 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 practice could be obtained, a special course in anatomy if surgery were to be practiced. 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 according 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 emulgament has maintained itself. The 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, drugists, 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 documents 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 Quad Trivium, 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, quote, 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 Quad Trivium does, end quote. There is no doubt at all about the value of the undergraduate training, nor of the scholarship 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, Agedius, often called Giles of Corbile, 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. Pushman says, quote, the accounts given of intermittent fever, pneumonia, thysis, psoriasis, lupus, which they call the malmortem, of ulcers of the sexual organs, among which it is easy to recognize cancer, and of the disturbances of the mental faculties, especially deserve mention, end quote. They seem to have been quite expert in their knowledge of thethysis. In the treatment of it, they laid great stress upon the giving up of a strenuous life, though 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 supervented 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 equitable temperature, though the custom was almost unheard of in the Salerno of that time, and indeed at the present time there is very little heating during the winter in southern Italy. They insisted that patients who were liable to pulmonary affections should have their rooms heated. On the other hand, they suggested the cooling of the air of the sick room, as we have noted in the chapter on Constantine Africanus, and Ephlaceus 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 symbols, 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 goiter by reducing its size. Iodine has been used so much ever since in this affection, even down to our own day, that this employment of one of its compounds is rather striking. Massage of the goiter was also recommended, and this mode of treatment was commonly employed for a number of ailments. Probably the best idea that can be obtained in brief space of the achievements of the University of Celerno is to be found in Pagel's appreciation of Celerno's place in the history of medicine, in his chapters on medicine in the Middle Ages. In Pushman's Handbuch der Geursteiched der Medicine, Berlin 1902, he said, quote, If we take up now the accomplishments of the School of Celerno in the different departments, there is one thing that is very remarkable. It is the rich independent productivity with which Celerno advanced the banners of medical science for hundreds of years, almost as the only autonomous center of medical influence in the whole West. One might almost say that it was like a versprentin chime, a displaced embryonic element which, as it unfolded, rescued from destruction the ruined remains of Greek and Roman medicine. The productivity of Celerno, which may well be compared in quality and quantity with that of the best periods of our science, and in which no department of medicine was left without some advance, is one of the striking phenomena of the history of medicine. While positive progress was not made, there are many noteworthy original observations to be chronicled. It must be acknowledged that pupils and scholars set themselves faithfully to their tasks to further as far as their strength allowed the science and art of healing. In the medical writers of the older period of Celerno, 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 pharmaceutical formulas and an avoidance of medical mental polyprag Mesia. 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 Celerno. 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 Celerno, surgery occupied an inferior position. It is true that we have less record of it in the earlier years of Celerno 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 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 Celerno upon the pig. The principal portion of the teaching in anatomy consisted of the demonstration of the organs in the great cavities of the body and their relations with some investigations of their form and the presumed functions of the corresponding organs in man. Kofo's well-known Anatomy of the Pig was a textbook written for the students of Celerno. 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 has been cultivated by the Celernitan faculty. We have a textbook 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 Belona than that of Celerno, though there is no doubt that at least Roger and Rolando received their education at Celerno 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 conditions to their specialty under the head of the great surgeons of the medical 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 Celerno. There are many interesting features of the old teaching that they have embodied in their books. For instance, at Celerno, both sutures and ligatures were employed in order to prevent bleeding. We are rather accustomed to think that 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. 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 Celerno 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 Grigia. Greek medicine, then, had more influence here than anywhere else. As a matter of fact, the beginnings of Celernoton teaching are all Greek and not at all Arabian. This is as true in surgery as in medicine. I have quoted GERLT in the chapter on Great Surgeons of the Medical Universities insisting that the Celernoton School owed nothing at all to Arabian surgery. Celernoton medicine was, during the 12th century, just as free from Arabian influence. When Arabian medicine makes itself felt, as pointed out by Pagel in his Geschaite der Hegelande in Mitellator, far from exerting a beneficial influence, it had a rather unfortunate effect. It led especially to an over-sophistication of medicine from the standpoint of drug therapeutics. The Arabian physicians trusted nature very little. In this, they were like our forefathers of medicine 100 years ago, of whom Rush was the typical representative, so history repeats itself. Before the introduction of Arabian medicine, the Celernoton 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, quote, as the literature of the times shows very well, that rule of the apothecary in therapeutics 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. Celerno, at the end of the 12th century, had already reached its highest point of advance in medicine and was beginning to decline. Decadence was evident insofar as all the medical works that we have from that time are either borrowings or imitations from Arabian medicine with which eventually Celernoton medical literature became confounded. Only a few independent authors are found after this time, end quote. 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 worthwhile noting it particularly. Celerno 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 textbook of the Celernoton School of Medicine rather than of any particular professor. This represents a development of cooperation 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 Celerno 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 Celernoton medical poem on hygiene. The title of the original Latin was Regimen Sanatasis Celernotonum. It was probably written about the beginning of the 12th 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 Floss Miniscinae down at Montpellier and this became the Floss Miniscinae of Celerno. Pegel calls it the quintessence of Celernoton 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 Celernoton School enjoyed and the influence that it wielded better than anything else. The poem is divided into ten principal parts containing all together about 3500 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 30 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 contraindications and whatever the physician of the medical 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 Celerno bears the title the coming of a physician to his patient or an instruction for the physician himself. We have had a number of such works published in recent years but it is a little surprising to have the subject taken up thus early in the history of modern professional life. It is an extremely valuable document as demonstrating how practical was the teaching at Celerno. The work is usually ascribed to Archimethias 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 except the drink which is offered him 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 that taking advantage of every possible source of information so as to seem to know all about the case. Quote, on the way to see the sick person, he, the physician, should question the messenger who has summoned him upon the circumstances and the conditions of the illness of the patient. Then, if not able to make any positive diagnosis after examining the pulse and the urine, he will at least excite the patient's astonishment by his accurate knowledge of the symptoms of the disease and thus win his confidence. End quote. 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, quote, when the doctor quits the patient, he should promise him that he will get quite well again, but if he should inform his friends that he is very ill, in this way, 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. End quote. The story of the medical school of Salerno, even thus briefly and fragmentarily told, illustrates how very well 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 Salerno activities. As it is, as a consequence of his work, we are able to see this first of modern medical schools developing very much as do our most modern medical schools. There has been an accumulation of medical information in the thousand years, but the ways and modes of facing problems and many of the solutions of them do not differ from what they were in the distant past. The more we know about any particular period, the more is this brought home to us. It is for this that study of particular periods and institutions of the olden time, as of Salerno, grows increasingly interesting, because each new detail helps to fill in sympathetically the new old picture of human activity as it may be seen at all times. End of Chapter 6 Chapter 7 of Old Time Makers of Medicine This is a LibriVox recording. All LibriVox recordings are in the public domain. For more information or to volunteer, please visit LibriVox.org. Recording by Adam Marsatich, September 2009, Alexandria, Virginia. Old Time Makers of Medicine by James Joseph. Chapter 7. Constantine Africanus Probably the most important representative of the medical school at Salerno, certainly the most significant member of its faculty, if we consider the wide influence for centuries after his time that his writings had, was Constantine Africanus. He is interesting too, for many other reasons, for he is the first representative in modern times, that is, who, after the incentive of antiquity had passed, devoted himself to creating a medical literature by translations, by additions, and by the correlation of his own and others observations on medical subjects. He is the connecting link between Arabian medicine and western medical studies. The fact that he was first a traveler over most of the educational world of his time, then a professor at the University of Salerno, who attracted many students, and finally a Benedictine monk in the great Abbey at Monte Cassino, shows how his life ran the gamut of the various phases of interest in the intellectual world of his time. It was his retirement to the famous monastery that gave him the opportunity, the leisure, the reference library for consultation that a writer feels he must have near him, and probably also the means necessary for the publication of his works. Not only did the monks of Monte Cassino itself devote themselves to the copying of his many books, but other Benedictine monasteries in various parts of the world made it a point to give wide diffusion to his writings. As a study in successful publication, that is, in the securing of wide attention to writings within a short time, the career of Constantine and the story of his books would be extremely interesting. Medieval distribution of books is usually thought to have been rather halting, but here was an exception. It was largely because Benedictines all over the world were deeply interested in what this brother Benedictine was writing, that wide distribution was secured for his work within a very short time. His superiors among the Benedictines had a profound interest in what he was doing. The great Benedictine abbot Desiderius of Monte Cassino, who afterwards became Pope, used all of his extensive influence in both positions to secure an audience for the books, hence the many manuscript copies of his writings that we have. It is probable that Constantine established a school of writers at Monte Cassino, for he could scarcely have accomplished so much by himself as has been attributed to him. Besides, his works attracted so much attention that writers of immediately succeeding generations who wanted to secure attention for their works sometimes attributed them to him in order to take advantage of his popularity. It is rather difficult, then, to determine with absolute assurance which are Constantine's genuine works. Some of those attributed to him are undoubtedly spurious. What we know with certainty, however, is that his authentic works meant much for his own and after generations. Constantine was born in the early part of the 11th century, and he died near its close, having lived probably well beyond 80 years of age, his years running nearly parallel with his century. His surname, Africanus, is derived from his having been born in Africa, his birthplace being Carthage. Early in life, he seems to have taken up with Arter the study of medicine in his native town, devoting himself, however, at the same time to whatever physical science was available. Like many another young man, since his time, not satisfied with the knowledge he could secure at home, he made distant journeys gathering medical and scientific information of all kinds wherever he went. According to a tradition that seems to be well grounded, some of these journeys took him even into the Far East. During his travels, he became familiar with a number of Oriental languages, and especially studied the Arabian literature of science very diligently. At this time, the Arabs, having the advantage of more intimate contact with the Greek medical traditions in Asia Minor, were farther advanced in their knowledge of the medical sciences than the scholars in the West. They had better facilities for obtaining the books that were the classics of medicine, and, with any desire for knowledge, could scarcely fail to secure it. What was best in Arabian medicine was brought to Salerno by Constantine, and, above all, his translation of many well-known Arabian medical authors proved eminently suggestive to seriously investigating physicians all over the world in his time. Before he was to be allowed to settle down to his literary work, however, Constantine was to have a very varied experience. Some of this, doubtless, was to be valuable in enabling him to set the old Arabian teachers of medicine properly before his generation. After his Oriental travels, he returned to his native Carthage in order to practice medicine. It was not long, however, before his superior medical knowledge, or, at least, the many novelties of medical practice that he had derived from his contact with the East, drew upon him the professional jealousy of his colleagues. It is very probable that the reputation of his extensive travels and wide knowledge soon attracted a large clientele. This was followed quite naturally by the envy, at least, of his professional brethren, feeling became so bitter that even the possibility of serious personal consequences for him because of false accusations was not out of the question. Whenever novelties are introduced into medical science or medical practice, their authors are likely to meet with this opposition on the part of colleagues, and history is full of examples of it. Galvani was laughed at and called the frog's dancing master. Auenbrugger was made fun of for drumming on people. Harvey is said to have lost half of his consulting practice, all because they were advancing ideas that their contemporaries were not ready to accept. We are rather likely to think that this intolerant attitude of mind belongs to the older times, but it is rather easy to trace it in our own. In Constantine's day, men had ready to hand a very serious weapon that might be used against innovators. By craftily circulated rumors, the populace was brought to accuse him of magical practices, that is, of producing his cures by association with the devil. We are rather prone to think little of a generation that could take such nonsense seriously, but it would not be hard to find analogous false notions prevalent at the present time, which sometimes make life difficult, if not dangerous, for well-meaning individuals. Life seems to have been made very uncomfortable for Constantine in Carthage. Just the extent to which persecution went, however, we do not know. About this time, Constantine's work attracted the attention of Duke Robert of Salerno. He invited him to become his physician. After he had filled the position for a time, a personal friendship developed, and, as has often happened to the physicians of kings, he became a royal counselor and private secretary. When the post of professor of medicine at Salerno fell vacant, it is not surprising, then, that Constantine should have been made professor, and from here his teaching soon attracted the attention of all the men of his time. Constantine seems to have greatly enhanced the reputation of the medical school and added to the medical prestige of Salerno. After teaching for some ten years there, however, he gave up his professorship, the highest position in the medical world of the time, apparently with certain plans in mind. He wanted leisure for writing, the many things in medicine that he had learned in his travels in the east, so as to pass his precious treasure of knowledge on to succeeding generations, and then, too, he seems to have longed for that peace that would enable him not only to do his writing undisturbed, but to live his life quietly far away from the strife of men and the strenuous existence of a court and of a great school. There is probably another and more intimate personal reason for his retirement, Abbott Desiderius of the Benedictine Abbey of Monte Cassino, not far away, had become a close and valued friend. Before having been made Abbott, Desiderius and Constantine probably were fellow professors at Salerno, for we know that Desiderius himself and many of his fellow Benedictines taught in the undergraduate department there. Desiderius enjoyed the reputation of being one of the most learned men of the time when his election to the Abbey at Monte Cassino took him away from Salerno. His departure was a blow to Constantine, who had learned by years of friendship that to be near his intimate friend, the pious scholar we Benedictine, was a solace in life and a never-failing incentive to his own intellectual work. Desiderius seems, indeed, to have been a large factor in influencing the great physician to write his books rather than devote himself to oral teaching, since the circulation of his writing would confer so much more of a benefit on a greater number of people. Perhaps another element in the situation was that Desiderius was desirous of having the learned physician, the traveled scholar, at Monte Cassino for the sake of his influence on the scholarship of the Abbey and for the incentive that he would be to the younger monks to apply themselves to the varied field of knowledge which the Benedictines had chosen for themselves at this time. Whatever hopes of mutual solace and helpfulness and of the joys of intimate close friendship may have been in the minds of these two most learned men of their time, they were destined to be grievously disappointed. Only a few years after Constantine's entrance into the monastery at Monte Cassino, Desiderius was elected pope. The humble Benedictine did not want to take the exalted position, but it was plainly shown to him that it was his duty and that he must not shirk it. Accordingly, under the name of Pope Victor III, he became one of the great popes of the 11th century. One might think that he could have summoned Constantine to Rome, but perhaps he knew that his friend would prefer the quietude of the cloister and then, too, probably he wanted to allow him the opportunity to accomplish that writing for which Constantine and himself had planned when the great physician entered the monastery. All that we know for sure is that some 20 years of Constantine's life were spent as a monk in Monte Cassino, where he devoted his time mainly to the writing of his books. One bond of union there was. Each of the works, as soon as completed, was sent off to the pope as long as he lived. On the other hand, though busy with his papal duties, Pope Victor constantly stimulated Constantine, even from distant Rome, to go on with his work. There were messages of brotherly interest and solicitude, just as in the old days. The great African physician's best known work, the so-called Lieber Pontegny, which is really a translation of the Kitab el Maliki of Ali Ben el Abbas, is dedicated to Desiderius. Constantine wrote a number of other books, most of them original, but it is difficult now to decide just which of those that pass under his name are genuine. Many were subsequently attributed to him that are surely not his. These translators of the Middle Ages proved to be not only the channels through which information came to their generations, but they were also incentives to study and investigation. It is when men can get a certain amount of information rather easily that they are tempted to seek further in order to solve the problems that present themselves. There are three great translators whose work meant much for the Middle Ages at this time. They were, besides Constantine in the 11th century, Gerard of Cremona in the 12th and the Jewish Farage Ben Salim at Naples in the 13th. Gerard did in Spain for the greater Arabian writers what Constantine had accomplished for those of lesser import. Under the patronage of the Emperor Frederick Barbarossa, he published translations of Rosses, Isaac Judeus, Serapion, Abul Cases, and Avicenna. His work was done in Toledo, the city in which, during the 12th and 13th centuries, so many translators were at work making books for the western world. Constantine did much more than merely bring out his translations of Arabian works. He gave a zest to the study of the Old Masters, issued editions of certain, at least, of the works of Hippocrates, aphorisms, and Galen, microtechnics, and, in general, called attention to the precious treasure of medical lore that must be used to advantage if men were to teach the rising generation out of the accumulated knowledge of the past. Pagel, in Pushman's handbook, does not hesitate to say that, quote, a farther merit of Constantine must be recognized in as much as that not long after his career, the second epoch of the School of Salerno begins, marked not only by a wealth of writers and writings on medicine, but, above all, because from this time on, the study of Greek medicine received renewed encouragement through the Latin versions of the Arabian literature. We may think, as we will, of the worth of these works, but this much is sure that, in many ways, they brought about a broadening and an improvement of Greek knowledge, especially from the Pharmacopia standpoint, end quote. Probably the best evidence that we have for Constantine's influence on his generation is to be found in what was accomplished by men who acknowledged with pride that he was their master, and who thought it a mark of distinction to be reckoned as his disciples. Among these especially noteworthy is Johann Aphlaceus, or Saracenus, whose surname of the Saracen probably means that he, too, came from Africa, as his master did. He was the author of two treatises on fevers and urines, and the so-called cures of Aphlaceus. Some of these cures he directly attributed to Constantine. Then there is a Bartholomewl who wrote a Practica, or Manual of Practice of Medicine, with the subtitle, Introductions to and Experiments in the Medical Practice of Hippocrates, Constantine, and the Greek Physicians. Bartholomewl represents himself as a disciple of Constantine. This Practica of Bartholomewl was one of the most commonly used books of the 12th and 13th centuries throughout Europe. There are manuscript commentaries and translations, and abstracts from it, not only in the Latin tongues, but especially in the Teutonic languages. Pegel refers to manuscripts in high and low Dutch, and even in Danish. The Middle High Dutch manuscripts of this Practica of Bartholomewl came mainly from the 13th century, and have not only a special interest because of their value in the history of philology, but because they are the main sources of all the latter books on drugs, which appeared in very large numbers in German. They have a very great historical literary interest, especially for pharmacology. To Euclaceus, we owe a description of a method of reducing fever that is not only ingenious, but, in the light of our recently introduced bathing methods for fever, is a little startling. In his book on fevers and urines, Euclaceus suggests that when the patient's fever makes him very restless, and especially if it is warm weather, a sort of shower bath should be given to him. He thought that rainwater was the best for this purpose, and he describes its best application as, in rainy fashion, modo pluviali. The water should be allowed to flow down over the patient from a vessel with a number of minute perforations in the bottom. A number of the practical hints for treatment, given by Euclaceus, have been attributed to Constantine. Constantine's reputation has, in the opinion of some writers, been hurt by two features of his published works, as they have come to the conclusion that we find it difficult to understand. One of these is that his translations from the Arabic were made mainly not of the books of the great leaders of Arabian medicine, but from certain of the less important writers. The other is that it does not seem always to have been made clear in the manuscripts that have come down to us, whether these writings were translations or original writings. Some have even gone so far as to suggest that Constantine himself would have been quite willing to receive the credit for these writings. As to the first of these objections, it may be said that, very probably Constantine, in his travels, had come to realize that the books of the great Arabian physicians, Razi's, Abul Qasas, Abisun's, and others, already received so much attention that the best outlook for medicine was to call a particular notice to the writings of such lesser whites as Ali Abbas, Isaac Judeus, Abu D'Shafer, and others of even less note. Certainly, we cannot but feel that his judgment in the matter must have been directed by reasons that have been in the matter must have been directed by reasons that we may not be able to understand at present, but that must have existed. For all that we know of the man proves his character as a practical, farsighted scholar. Besides, it seems not unlikely that, but for his interest in them, we would not at the present time possess the translations of these minor Arabian writers, and that would be an unfortunate gap in medical history. The other misunderstanding with regard to Constantine refers to the fact that it is now almost impossible to decide which are his own, and which are the writings of others. It has been said that he even tried to palm off some of the writings of others as his own. This seems extremely unlikely, however, knowing all that we do about his life, and the suspicion is founded entirely on manuscripts as we have them at the present time about a thousand years after he lived. What mutilations these manuscripts underwent in the course of various copyings is hard now to estimate. Monastic copyists might very well have left out Arabian names because they were mainly interested in the fact that they were providing for their readers the works that had received the approval of Constantine and the translation of which, at least, had been made under his direction. It is quite clear that he did not do all the translating himself and that he probably must have organized a school of medical translators at Monte Cassino. Then just how the various works would be looked at is very dubious. Undoubtedly, many of the translations were done or certainly finished after his time and at least attributed to him because he was the moving spirit and had probably selected the books that should be translated and made suggestions with regard to them. For all his monks, he was, as masters have ever been for disciples, much more important and rightly so than those writers to whom he referred them. The whole question of plagiarism in these medieval times as I have pointed out elsewhere is entirely different from that of the present time. Now a writer may consciously or unconsciously claim another writing as his own. We have come to a time when men think much of their individual reputations. It was no uncommon thing, however, in the Middle Ages and even later in the Renaissance for a writer to attribute what he had written to some distinguished literary man of the preceding time and sign that writer's name to his own work. The idea of the later author was to secure an audience for his thoughts. He seemed to be quite indifferent whether people ever knew just who the writer was but he wanted to influence humanity by his writings. He thought much more of this than any possible reputation that might come to him. Of course, there was no question of money. There never has been any question of money making whenever the things written have been really worthwhile. Literature that has deeply influenced mankind has never paid. Publications that have paid are insignificant works that have touched superficially a whole lot of people. To think of Constantine as a plagiarist in our modern sense of the word as trying to take the credit for someone else's writings is to misunderstand entirely the times in which he lived and to ignore the real problem of plagiarism at that time. With the accumulation of information with regard to the history of medicine in his time Constantine's reputation has been constantly enhanced. It is not so long since he was considered scarcely more than a monkish chronicler who happened to have taken medicine rather than history for his field of work. Gradually we have come to appreciate all that he did for the medicine of his time. Undoubtedly his extensive travels, his wide knowledge, and then his years of effort to make oriental medicine available for the western civilization that was springing up again among the peoples who had come to replace the Romans set him among the great intellectual forces of the Middle Ages. Salerno owed much to him and it must not be forgotten that Salerno was the first university of modern times and above all the first medical school that raised the dignity of medical profession established standards of medical education educated the public mind and the rulers of the time to the realization of the necessity for the regulation of the practice of medicine and in many ways anticipated our modern professional life that the better part of his life work should have been done as a benedictine only serves to emphasize the place that the religious had in the preservation and the development of culture and of educating during the Middle Ages. End of Chapter 7