The Emergence of University Education
The Emergence of University Education
Medical education did not always take place in universities. Until the tenth century, medicine was practiced by individuals and taught to apprentices, or passed down from father to son. Those who practiced medicine were more like tradespeople but they had a higher status than "lowly" midwives, herbalists, stone-cutters, bone-setters, cataract-couchers, or tooth-pullers. The latter traveled from town to town to ply their specialty because there were no cities large enough to support them. Itinerant healers had varying degrees of knowledge, experience, and education but some were charlatans and magicians who preyed on a patient's gullibility.
Barber-surgeons, apothecaries, and surgeons were organized into guilds that had rules for membership, training, practice, and fees. These individuals had more status than herbalists but less than physicians. In fact surgeons were suspect individuals, granted little respect.
The school of Salerno, Italy was created by a group of students who studied with a group of physicians composing a faculty. The word universitas, meant an aggregate of persons at first but later came to designate learned people or scholars, not a place to study. The city of Salerno had been an ancient Greek colony which came to be known as civitas hippocratica because a mix of clerics, lay people, natives, and foreigners joined forces to practice medicine. It was near a monastery, Monte Cassino, which had a reputation for healing by miracles performed by saints and the use of magic herbs.
Geographically, it was an ideal place for healing. The Bay of Naples was an attractive respite for noblemen injured in the crusades. All trade routes pointed to Salerno. With Normans from the west, Sicilians from the south, Greeks, Benedictine monks, Jewish physicians, and Arabs, it was an ideal learning environment. This city is the oldest center of lay medical instruction and the first school to confer diplomas and the title of doctor.
There were female physicians for female patients and female physicians to train them. The most famous female physician in the twelfth century was Trotula but her name survives more than factual information about her. Other women physicians at Salerno were Constanza, Calendula, Abella, Mercuriade, Rebecca Guarna, and Louise Trencapilli.
However, few facts are known about Salerno until 1071 when the African slave, Constantine (Constantinus Africanus; c. 1020-1087), who spoke Greek and Babylonian came to study at Monte Cassino. Through his travels through Syria, India, Egypt, and Ethiopia, he accumulated many medical manuscripts. After converting to Christianity from Islam, he translated Arabic, Greek, and Indian medical documents for the university, making new knowledge available.
The Pantegni is the treatise for which he is best known. It contains mostly Galenic medical information and if one were to "blame" anyone for the perpetuation of Galen's misinformation, it would be Constantine. Soon that information became available to the medical people in Salerno.
Prior to the development of the medical school at Salerno, the Arabs excelled in medical knowledge. They had translated Greek texts. Their rich tradition boasted of Rhazes (c. 865- c. 923), who wrote more than 200 medical and philosophical treatises and Abu Ali al-Husayn ibn Abd-Allah ibn Sina (Avicenna; 980-1037), a genius whose acute observations led him to discover how mental phenomena affected physiology as when a quickened pulse betrays one's feelings. Al-Zahrawi (Albucasis; 936-1013) wrote On Surgery and Instruments, an early comprehensive book on cautery. The Arabs had expertise in pharmacology, ophthalmology, and cardiology. Interestingly, the mystery of pulmonary circulation was known to Ibn an-Nafis long before Miguel Serveto (Michael Servetus; 1511-1553) or William Harvey (1578-1657) expounded on their discoveries. One of the most famous people who lived among the Arabs was Abu Imran Musa ibn Maymun ibn Ubayd Allah (Maimonides, or Moses ben Maimon, 1135-1204), a Jewish-Spanish scholar and physician. Born in Córdoba, he had fled that city to avoid persecution and lived in Morrocco and Cairo. He wrote in Arabic, his best known works being Poisons & Antidotes, Regimen Sanitatis, and Medical Aphorisms. Interestingly, Jewish scholars had the skills to translate Arab manuscripts into Latin which aided the spread of Arabic science and medicine to Salerno and other European centers of learning.
The theoretical basis of medical training was Socratic and depended on the student being able to answer questions such as "What is medicine? Is it an art or not? If so, what other disciplines are important?" just as the method used in religious institutions in the past. Through these questions, the student would come to understand comprehensively rather than by rote, although memorization played a large part in knowing the answers to these questions. Galenic knowledge was extremely important as were inductive reasoning and logic. The logical syllogism was the method used in teaching physicians. A syllogism is a structure of language where a fact or truth can be arrived at in a simple three-part sequence using deductive reasoning. This is not to say that logic was more important than authority. Galen was the authority, and although the modern student may wonder why there were so many errors if medical education was logical and inductive, it is because no one dared to question discrepancies. This was a time when the senses and observation were not trusted.
Philosophically, to depend on human perception was a fearful practice, irreligious and definitely discouraged. Thus, a five-lobed liver, a two-horned uterus with seven chambers, and the "rete mirable" were repeated for many years. Also, even though a syllogism was supposed to be a way to organize information, teaching in certain cases consisted of taking a sentence, breaking it down into words and then analyzing each word that made the subject difficult to identify. For example, in talking about a symptom such as ringing in the ears, the professor would talk about sound, the theoretical aspect related to hearing. One can see that this was a less focused and more circumferential way of presenting knowledge.
As medical knowledge became institutionalized, it could be transmitted more effectively. It was now group knowledge rather than individual thus its distribution was greater and a tradition had begun. Standards of competency were set for physicians. Students had to finish three years in the humanities and then four years of medical school. After that, they were required to work with a physician for a year. When the "internship" was completed, only then could the graduate practice medicine alone. By 1140 examinations were required for those who wished to practice medicine.
Students attended four lectures a day. In the morning they were taught theory, in the afternoon, practice. Year one depended on the preliminary book of Avicenna and anatomy, although there was more anatomy taught at Bologna than Salerno. The first two lectures included diseases, children's ailments, dietetics, and regimen. The next about fevers and Galen. But as the reader now knows, Galen's information about anatomy was based on his dissection and vivisection of the pig, the dog, and the Barbary ape. And Galen had the endorsement of the church which meant that his authority was not to be questioned.
In the second, third, and fourth years, there was a great deal of review. The tradition spread from Salerno to Bologna, Montpellier, Paris, and Padua. Hippocrates' Aphorisms, Galen's De diebus criticus, Averroës' Colliget, Avicenna's Canon, and Gilbertus Angelicus' (1180-1250; he worked in Montpellier) Compendium medicinae, a seven volume work, were texts known to have been taught during the time of developing university medical education. Later, on the practical side, Arnau de Villanova (c. 1235-1311), also called Arnaldus Villanovanus, wrote De regimine sanitatis, a poem that recommended common sense preventive treatment. It can be considered a folk epic guidebook. For example the translation of one line reads, "If thou to health and vigor woudst attain, Shun weight cares, all anger deem profane, From heavy suppers and much wine abstain." He later taught at Montpellier.
To the Greek theory of humors, the Salernitan doctors attributed personality types to go with each imbalance of an element. Bloodletting, a practice which rid the body of sanguinous humor, was said to "soothe rage, bring joy to the sad, and save all lovesick swains from going mad." Although physicians developed the theory of phlebotomy (bloodletting), barbers performed it. The red stripes on white poles outside barber shops are reminders that long ago barber-surgeons bled people who suffered from an excess of sanguinous humor.
At Bologna, Anathomia, the first manual of dissection was written by Mondino dei Liucci (c. 1270-c. 1326). For over 500 years this book was the only guide to human anatomy. From Salerno came Taddeo Alderotti (c. 1223-1295), who developed a new tradition of collecting and reporting on clinical cases.
Also at Bologna was Hugh de Lucca, the surgeon who taught that "laudable pus" was not necessary for healing. In the thirteenth century, wound infection was so common that it was mistakenly believed that healing had to go through a pus-producing stage. We know now that pus is a sign of infection rather than health. It is laudable that de Lucca recognized that wounds could heal without becoming infected.
The center for university medical education in France was Montpellier. There, students required three and a half years of arts education, and six months of practical experience in order to obtain a bachelor of medicine. The most famous person associated with Montpellier was Guy de Chauliac (1300-1368), a surgeon whose Chirurgia magna and writings on dentistry were translated many times. He employed anesthesia and noted that loss of brain tissue was not necessarily fatal.
The medical school at Paris was influenced by both Salerno and Montpellier. Its requirements were complex and ongoing. First the study, then examinations, votes by faculty, then back to lectures, practical experience, and more exams. Paris is said to have been less innovative than Bologna but more important as far as developing the role of medicine as a profession.
The school at Padua, Italy (famous for both Galileo and Vesalius) was philosophically influenced more by Aristotle than theology. It is reasonable that natural science and scientific methodology (albeit early science) was a better foundation for the study of medicine than religion. Jacopo da Forli and Hugo of Siena both taught at this university, later to be the epitome of intellectual achievement during the Renaissance.
Thus medical education started as a small group of lay teachers and students who eventually standardized a curriculum and created examinations of competency to insure that those who practiced medicine would first "do no harm." The qualifications and examinations became more stringent as medicine became part of a university setting starting in Italy and spreading throughout Europe by the end of the fourteenth century.
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