13th and 14th Century Medical Training and Texts

Texts:

Prior to the eleventh century, medical texts were limited to imperfect translations of Greek fragments. Charlemagne's extensive library contained only one medical text, "De Curandis Morbis" of Serenus Sammonicus. Portions of the Hippocratic corpus, of Celsus, Galen, Soranus, Aetius, Paulos Egineta were extent in a limited number of copies. Later, in the time of Constantine the African, Arab works and additional Greek texts became available via the Arab translations.

In the 14th century, the roster of texts at the University of Paris (?) mentioned: "Isogogue" of Johannitius, "Liber urinarum" of Theophilus, the "Liber de pulsibus" of Philaretus, the "Aphorisms" and "Prognostics" of Hippocrates with Galen's commentaires, the "Ars parva" of Galen with Haly's commentary, the "De regimine acutarum aegritudium" of Hippocrates with Galen's commentaries. Other works in the medival medical course were Theophilus "Anatom" based on Galen, Gilles de Corbeil's treatise on urine and the pulse, and the works of Soranus, Isaac, Alexander of Tralles, Dioscorides, and "Macer."

At Oxford, the curriculum included Galen's "Tegni," Isaac Judaeus' "Liber Febris," the "Antidotarium" of Nichoals of Salerno, and the aphorisms of Hippocrates. Others may have been included under the "Ars Medicineae." The "Antidotarium" of Nicholas was the standard for apothecaries. (One Nicholas lived and taught at Salerno in the 12th century and another was French, of Lyon and Tours, called Nicholas Praepositi, according to Wickersheimer.)

The most used texts were Hippocrates, the "Canon" of Avicenna, Celsus, Galen, Dioscorides, and also the "Pantegni" of Haly Abbas. The Canon was the most important until well into the 17th cent, and was challenged only by Galen.

Many more texts were added to the curricula and libraries in the late 14th century and onward. Pages 351 to354 give the list of the "Corpus of Medieval Scientific Literature" that was arranged by Lynn Thorndike in his "Prospectus." The context would indicate that they date to the early days of the printing press, but many are copies of tests that are old enough to have been extant in the 13th and 14th centuries.

The Compedium medicinae of Gilbertus Anglicus dates from the 13th century and achieved such fame that Chaucer referred to it as a text studies by his doctor of physik. His training seems to have derived more from Salerno and Montpellier than from Paris.

John of Toledo, Cardinalis Albus from 1243, wrote several works of which De regimine sanitatis was the most popular, being full of sensible advice.

Schools:

Salerno was the first "modern" medical school, Almum et Hippocraticum Medicorum Collegium, founded in the 9th century in southern Italy, formally organized in the 10th century and reached its peak at the end of the 12th century. According to De Renzi in his "Storia della Medicina in Italia," it took 3 years of college work, then 4 years of medical study, followed by a year of practice with a physician, and possibly another year of anatomy for surgery, to earn licensure, with a doctoral degree and teaching priviledges granted after the 4 years of medical study.

The most famous teacher at Salerno was Constantine Africanus, from Carthage, who lived in the 11th century and had studied Arab medicine. After his time, the principal texts of the school were, according to De Renzi, Hippocrates, Galen and Avicenna, plus also the Antidotarium of Mesue, various compendiums such as the Articella, and for surgery the works of the Four Masters of Salerno (putative founders).

The Regimen Sanitatis Salernitanum, the Code of Health of the School of Salernum, gives a good idea of the medical teaching of the school and was translated into English several times. The Regimen was popular for many centuries and contains no specific remedies, only charming rules for diet, air, exercise, etc. for good health and "simples:" A Salernitan influence cannot be shown to have penetrate England until perhaps the early 12th century.

Montpellier in the south of France is the next great medical school. It, like Salerno, started as a health resort, with the gathering of physicians leading to a gathering of students. The school goes back to the 10th century, was famous by the 11th and attracted students from all over Europe in the 12th century. Montpellier and Salerno thus came to be known as the twin pillars of medical education, THE places to study medicine. Montpellier was associated with the founding of the hospitals that were required by Pope Innocent III to be established in every diocese. Famous alumni of the 12th and 13th centuries include Mondeville who later taught surgery at Paris, and Guy de Chauliac who was Papal Physician at Avignon.

A distinguished professor, Arnold de Villanova, was famous by 1285 as he was called to treat Peter III, King of Aragon. His writings appeared in many editions up to 1586, and many of his practical aphorisms survive. Gilbertus Anglicus is best known for his "Compendium Medicinae," which contains material derived from Roger of Parma, Theodoric of Lucca, and quotations of Arab work.

John of Gaddesden, Joannes Anglicus, also studied there following his career at Oxford and treated the son of Edward II for small pox. His book, Rosa Anglica, is a compilation, and was criticized by Guy de Chauliac for lack of originality. John of Gaddesdon synthesized the ideas of his predecessors at the beginning of the 14th century.

Bernard Gordon, or Gourdon, taught at Montpellier in the late 13th and early 14th centuries.

Montpellier became the equal of Salerno in the 12-13th centuries but with a stronger Arab influence. Many English physicians studied there. One, Ricardus Anglicus, shows the influence of both Salerno and Montpellier in his 12th or 13th century work Micrologus, which was intended to be a brief manual of all available medical knowledge.

The Paris schools were based on the old basis of the attraction of famous individual masters, even as they came to prominence in the 12th century. William of Champeaux and his pupil, Abelard, attracted students from far away. But in the early 13th century, medicine was still conspicuously absent as a full, separate branch of study. As it developed, it adopted the same teaching philosophy as the law and liberal arts branches, with verbal commentary, argument, definition, deference to authoritative texts, etc. with no room for clinical observation or experimentation. (Contrast with 9th cent Walafrid Strabo's attitude about the importance of experience and practical application.)

The curriculum began with 20 lectures on the Isagoge of Johannitius, a brief systematic survey dealing with elements, humors, powers, spirits, exercise, food, baths, fevers, classes of sickness, causes and treatments. Next was 50 lectures on the Aphorisms of Hyppocrates, 26 on the Prognostics and 38 on De regimine acutorum. A lecture a week for a year on urines by Theophilus and Isaac Judaeus and on pulses by Philaretus and Theophilus, and then Isaac's work on fevers and diets, the Viaticum of Constantine was added. Later, the curriculum also included Rhases, Avicenna and Galen. The course was spread over several years. Disputations were held between October and Easter on subjects with no definite answer, called Quodlibets, thus debating skill was evaluated, not factual information. 13th century statutes required 4 years study of medicine to receive the degree of bachelor (term first appears in 1231) and this was later made more precise. The periods of study lengthened in the 14th century and for transfer students, the times were doubled.

After completing the studies, students underwent 2 examinations - one before the regents of the Medical Faculty and the other before 4 masters before receiving the Bachelor, giving him a position between scholar and master, when he could give lectures while continuing to pursue a higher degree. The next step, the licentiate, was conferred by the Chancellor of Notre Dame after proving medical study for 6 years (of 5.5 if a Master of Arts). This time was also lengthened in the 14th century. Six months later, the licentiate could receive the degree of Master, when he had to undergo two more examinations. After this, the candidate was appropriately robed and took his place among the Regent Masters, required to give lectures for two years.

It wasn't until the mid-14th century that there was a requirement for practical experience to become a Master, and it took another century to extend this to the Bachelors.

The remarks about Paris also apply to Oxford, which modelled itself after Paris. Medicine did not seem to achieve it's own faculty until the late 13th century. The earliest mention of the medical faculty is from 1303. The faculty remained small and undistinguished (only one doctor of medicine available for teaching in 1414) throughout the Middle Ages. This was also true of Cambridge, and thus the English universities produced no physicians of international reputation. There was a medical faculty at Cambridge at least by the mid-14th century, but it was even smaller than at Oxford. Prior to 1350 the Oxford requirement for incepting into medicine had been established as first reading in the Arts, attending lectures on medicine for 6 years, giving a couse of lectures on one pratcial treatise (the Regimen acutorum of Hippocrates or the Liber febrium of Isaac), and on one theoretical text (Liber Tegni of Galen, or the Aphorisms of Hippocrates). They must also have defended certain theses publicly and opposed others defending theses. Those without the M.A. degree had to have been previously admitted to practice and given lectures for two years. All in all, therefore, a mastership or doctorate in medicine required at least 13-15 years at the university, followed by two years of lecturing. From accounts of what was involved in evaluating disputations, it is clear that logical reasoning and clever argument was more important than practical application. Exceptions to this course were made, generally in cases where the university studies were interupted by going into practice. Despite all of the above, Oxford medical alumni seem to have had a good reputation, which was meant to be protected by 14th century statues following the same lines as the above.

Surgical Developments:

Surgical developments of the Middle Ages began in Salerno, not surprisingly, with the 1180 textbook written by Roger of Parma or Salerno. His student, Rolando, commented on the text, and this work was annotated by the Four Masters. Surgical cleanliness called for clean hands, avoiding coitus and food that may corrupt the air such as onion, avoid mentruating women and otherwise maintain absolute cleanliness.

Other leading figures: Bruno da Longoburgo, Theodoric and his father Hugh of Lucca, William of Saliceto, Lanfranc (a disciple of William who taught at Paris), and Mondino, author of the first dissection manual - used for centuries. These men largely worked between 1250 and 1300.

Union by first intention (?) and the use of anesthesia were known in the work of the northern Italian surgeons of the later Middle Ages. They replaced ointments by wine, evidently realizing its cleansing (antiseptic) qualities. The old traditional treatment of wounds by pouring wine and oil into them was actually reasonable if not ideal - wine inhibiting germs, oil soothing and keeping out dirt. According to Clifford Allbutt, (guided by the work of Theodoric?)

Hugh of Lucca was called to Bologna in 1214 as City Physician and seems to have been intent on chemical experiments, especially anodyne and anesthetic drugs. He left no writings, being known through the work of his son, Theodoric. Mandragora was the base of most anesthetics.

Lanfranc came to France around 1290, after being banished from Milan, and ended up a professor of surgery at the University of Paris attracting hundreds of students at the peak of the University's glory. Lanfranc completed his "Chirurgia Magna" in 1296. Lanfranc was particularly cognizant of the importance of nerves and their treatment, even though many confused them with tendons. He believed separated nerve ends should be stitched together, although Theodoric and others disagreed.

Guy de Chauliac describes the use of inhalation as it was applied in his time. France was the first in Western Europe to follow the Italian example in surgery, but England, Flanders, Spain and Germany record their own surgical advances.

Albert the Great, Thomas Aquina, Roger Bacon, and Duns Scotus were all involved with the University of Paris.

Henri de Mondeville was born in the north of France, studied under Theodoric in Italy, then studied in Montpellier and Paris. He gives the lie to the notion that 14th cent. surgery was conducted by ignorant barber-surgeons who were despised by their physician colleagues.

Guy de Chauliac was the other great French surgeon of the fourteenth century - "the father of modern surgery." His postgraduate work was in Italy, the home of higher education in all fields. (Many French, German and English followed his example, esp. to study medicine.) Guy insisted on the value of experience over authority.

While medicine all but stagnated in the 13th century, surgery advanced by leaps and bounds - Roger of Salerno's book was extant by 1170 and was full of practical experience, although based largely on Constantine.

In 1187, Gerard of Cremona translated Rhases, works by Albucasis and the Canon of Avicenna, which enlarge the scope of the development of surgery. Roland's work was written after 1230 or 1240, and while it shows no originality, it is a good source for surgical instruments available at the time: trephine, scalpels, razors, spatulae, curved and straight pincers, various needles, dilators, wound-draining implements and cauterization implements.

William de Congenis worked in the early 13th century and spoke without disdain of itinerant surgeons who were noted for their practical expertise and specialization.

William's pupil, who studied also at Paris, Bologna and Montpellier, wrote an excellent text in 1250 Germany, strongly influenced by Roger's text, which also had influence up into Iceland and Denmark.

William of Saliceto was contemporary with Theodoric and wrote a complete, detailed and original work meant for both surgeons and physicians (no dichotomy in Italy) in 1275 while city surgeon of Verona. His Summa conservationis et curationis also had a lasting influence, not just in Italy, but in France and England as well. There are many others who influenced surgery in this time period.

Women in Medieval Medicine

Women were given opportunity for higher education at nearly all the Italian universities and even became professors from the 12th century on. The later Middle Ages was particularly active for women in education. The application of women to medical studies was actually encouraged in the 12th to 14th centuries, many studying and teaching and writing on medicine.

The best known female physician was Trotula, at Salerno, and many texts were attributed to her, though most probably by disciples of hers. Other female professors at Salerno included Mercuriade "On Crises in Pestilent Fever" and "The Cure of Wounds," Rebecca Guarna "On Fevers" and "On the Urine" and "On the Embryo," Abella gained a reputation with "On Black Bile" and "The Nature of Seminal Fluid" all of which show that the women's studies were not limited to female ailments.

Licenses for women to practice medicine that are preserved in the Archive of Naples make no limitations on their practice, but do emphasize the propriety and suitability of women treating women's diseases.

The Benedictine convents for women, inspired by St. Benedict's sister Scholastica, pursued the intellectual life as well as the spiritual, just as the male orders and like other monastic establishments were active in providing medical care. They gathered simples, treated ordinary ailments and encouraged healing states of mind.

St. Hildegarde, a Benedictine Abbess, wrote perhaps the most important book on medicine that survives from the 12th century and had a wide correspondence with leading lights of the period. Her works include "Liber Simplicis Medicinae" and "Liber Compositae Medicinae." From Salerno, medical education for women spread to Bologna at the beginning of the 13th century, including Alessandra Giliani who assisted Mondino's dissection instruction.

Women were evidently also practicing medicine and surgery in France on the evidence of a 1311 edict, and later edicts, that forbade women to practice medicine without being examined by a standard board of appointed masters. Guy de Chauliac also speaks of female surgeons. It was not until the 16th cent that the practice of medicine by women all but disappeared. However, women in France weren't encouraged as they were in Italy, perhaps because of an incident early in the history of the University of Paris. (Heloise-Abelard incident).

The Ordinary Medieval Practitioner:

Most doctors worked in small towns, and we know even less of them than the university professors and the royal physicians. Texts that tell us something of the typical practice are tables of various kinds, with calendars, eclipses of the sun and moon, tables of planets, rules for phlebotomy and analysis of urine - meant for use in rapid calculations, diagnosis, treatment and prognosis. These consisted of several pieces of parchment, folded across the middle and then into three sections to form narrow strips about 7 inches long and 2 inches wide. Each strip was dedicated to an aspect of diagnosis - the actual date the illness began, the position of sun and moon for its continuance, the planet ruling the afflicted body part, the vein to be cut, the 24 kinds of urine and their significance. Some also included things like the Sphere of Apuleius that used the numerology of the patient's name to predict whether they would live or die, tables for predicting the future - foretelling weather, finding stolen property, capturing the thief. These hung form the belt or girdle and were similar to texts worn by monks and friars that had lists of virtues and vices, scriptures, etc. Besides the tables, the manuscripts also had illustrations of the phases of eclipses, the zodiac man, the venous man and a colored (lemon to red) roundel of urinals. These seem to have been produced in large quantities by stationers in Oxford from the 12th century on and reveal the limits and stagnation of common medical practice, despite the theorization done in the universities.

Extracts from the vade-mecum: Instructions for the use of the table of planets, surgical ramifications of the planets, bloodletting contraindications, cure for cut veins, rules about urine. Many of the ideas date from the 9th century, the text on urines is from Isaac Judaeus available after the 11th cent. via Constantine, but these little manuscripts were still current in the 15th cent and were the stock-in-trade of most physicians who had studied many years at the universities and this says a lot about the state of medicine.

Astrology was scientific compared to the amulets and superstitions also to be found in vernacular medical practice. It was based on ideas of macrocosm/microcosm, the 4 elements and the 4 qualities, the 4 temperamants and humors, etc. The complex art of determining the safe and proper time and place for bloodletting reached its peak of precision in the late 14th and early 15th centuries. Urinalysis was less dangerous and was the most common form of diagnosis, so much that the urine flask was a symbol of the medical profession.

Aries, the Ram Taurus, the Bull Gemini, the Twins Cancer, the Crab Leo, the Lion Virgo, the Virgin Libra, the Balance Scorpio, the Scorpion Sagittarius, the Archer Capricornus, the Goat Aquarius, Water Carrier Pisces, the Fishes

Head Neck and shoulders Arms and Hands Chest and adjacent parts Heart, and mouth of the stomach Intestines, base of stomach, umbilical region Kidneys Genitals Hips Legs Knees Feet