Medical education was truly established in neither the monastic communities of orders such as the Benedictines nor the cathedral schools of the renascent Holy Roman Empire but in the newly established universities, among which Salerno in southern Italy was the most prominent. Although the legend of the school's founding in the ninth century by four physicians, one Greek, one Latin, one Hebrew, and one Arab, is certainly apocryphal, it does convey much of the innovative spirit of the new school.
By the second century B.C., Salerno, on the Gulf of Paestum, near Naples, was already a popular health spa and remained so during the Roman Empire. After the Fall of Rome to the Goths in 476, southern Italy and Sicily were initially part of the Eastern Empire, and for a time Sicily was even under Arab rule. As Islam spread westward in the eighth century, Christian descendants of the Hellenistic world of Egypt and Syria, especially the intellectuals and monastics, found themselves second-class citizens, and many chose to emigrate to the Greek West of southern Italy and Sicily.
Salerno
Upon this palimpsest of Greek, Latin, and Islamic civilizations, the medical school of Salerno had its beginnings. Although the Benedictine monastery of Monte Cassino was nearby, Salernitan physicians remained remarkably free of clerical control. The school of Salerno was also open to female practitioners, and the most famous was the legendary Trotula, presumed author of a treatise on obstetrics. Throughout the early medieval period in Europe, midwifery was generally the province of women while other medical concerns save nursing care were mostly forbidden to them.
By the year 904, the school was so highly regarded that a Salernitan physician was welcomed at the royal court of France, and, in 984, Alberone, bishop of Verdun, went to Salerno seeking medical advice. Twelfth- and thirteenth-century manuscript copies of much earlier texts used in the school (entitled Antrorarium and Antidotarium) reveal a concern for the practical and a disdain for the philosophical, which were to be characteristic of Salerno's empiricism.
In the eleventh century, Garipontus of Salerno composed his Passionarius, which drew heavily on the ancients, especially Galen. Modified by generations of later writers, this work remained extremely popular throughout the medieval period. Another compilation of ancient texts, the Practica of Petroncellus, was also influential in reestablishing a practical bent to the study of medicine.
Constantinus Africanus (c. 1010-87) was crucial to the establishment of the spirit of Hippocrates and Galen in Salerno and, like Cassiodorus and St. Isidore of Seville before him, maintained a continuity with the ancient world. Born in Carthage about the year 1010, Constantinus traveled for four decades in Syria, India, Egypt, and Ethiopia accumulating medical manuscripts. Knowing Greek, Arabic, and Latin, he was uniquely qualified to study and translate the medicine of the Eastern (Islamic) world. Accused of practicing magic upon his return to Carthage, he fled to Salerno and then to Monte Cassino in 1076, where he died in 1087. Constantinus was most important for his translations into Latin of ancient Greek medical texts (often done from their Arabic renderings), but also of Arabic works such as the Liber Regalis of Haly Abbas.
A beautiful manuscript found at Breslau contains thirty-five treatises from Salerno written in the eleventh and twelfth centuries. The most famous, De aegritudiorum curatione, has two parts: the first, probably the work of a single author, deals with fevers; the second deals with all diseases ab capite ad calcem. In contrast to the mystical medicine being taught throughout Europe at the time, here even epilepsy and psychoses were given somatic causes and treatments. However, Salernitan anatomy derived almost exclusively from Galen, and physicians dissected animals, especially pigs whose internal anatomy was thought most to resemble humans'.
The most famous work of the Salernitan school, a Latin poem of rational dietetic and hygienic precepts called Regimen Sanitatis Salernitanum (at times Flor Medicinae), derives from the last half of the thirteenth century. Its many versions, the earliest with as few as 362 verses and others with as many as 3,520, were certainly the result of many authors. More than three hundred editions, following the initial printing at Pisa in 1480, were made throughout Europe, and the work was a standard accompaniment of practicing physicians throughout the sixteenth and seventeenth centuries.
Roger II of Sicily in 1140 forbade anyone from practicing medicine without passing an examination. In 1224 his grandson the Hohenstaufen Emperor Frederich II specified that all candidates for medical licensure be publicly examined by the masters at Salerno after studying logic for three years, medicine and surgery for five years, and after practicing under the direction of an experienced physician for one year. The Salernitan school not only influenced the practice of medicine in the Kingdom of the Two Sicilies but also the development of the universities of Bologna, Padua, and Naples in Italy and of Montpellier in southern France.
Montpellier
The university at Montpellier rivaled Salerno not only in its return to Western medicine based on Greek concepts but also in its contributions to the development of medical education. Like Salerno, Montpellier existed on the border between the Islamic and Latin worlds. Founded in the eighth or ninth century, Montpellier soon possessed a rabbinical school of Spanish origin which taught grammar and later medicine. By 1137 the school was called in official documents a stadium generale with a universitas scholarium et magistrorum, and authorization in 1180 to admit Jews and Arabs was evidence of greater freedom from episcopal control than was generally found in other French schools. Although fifteen universities were to be established in France in the medieval period, the study of medicine was restricted to the Douze medecins of Montpellier and, later, to the University of Paris. In 1220, Cardinal Conrad, the papal legate, in concert with the bishops of France issued precise statutes for the university, continuing the somewhat remarkable acceptance of non-Christian teachers and students.
The Catalan Arnold of Villanova (c. 1235-1316), a doctor of medicine, theology, law, and philosophy at Montpellier, translated Avicenna on the heart and Avenzoar on diet and wrote one of the best of the medieval handbooks on medical practice.
University of Paris and Others
The University of Paris, as might be expected, was more directly supervised by the French kings and the Church. In contrast, the inferior College de St. Come (Cosmas), which concentrated on surgery, retained greater independence from Church and State, perhaps as a direct result of its less-academic pretensions. During the period from 1100 to 1400, many universities developed in France, England, Germany, and even in the Lowlands and Scandinavia. Two influences were almost universally found in the developing medical schools of these universities: the assignment of greater status to the practice of medicine over surgery, and a mandatory supremacy of Christian theology and philosophy over natural science.
Surgery
During the so-called Dark Ages, many of the technical advances of Greco-Roman surgery had been entirely lost because of increasing ignorance of them through disuse. The Christian belief in the mediation of the Holy Ghost as the only possibility for cure led to the gradual abandonment of all save the simplest surgical procedures, such as bloodletting, amputation, and tooth extraction. The Muslim schools (with a few notable exceptions—for example, followers of Albucasis) also abandoned many surgical procedures, except the setting of fractures and the favored use of the cautery. As a consequence, only a limited knowledge of anatomy was needed, and even the grossly distorted translators' versions of Galenic porcine anatomy provided sufficient guidance.
Europe again had to look to the Mediterranean schools for guidance, since surgery had long been thought a worthy discipline by the physicians of Salerno, who maintained a greater interest in practical matters (to the point of empiricism) than in philosophical explanations or a teleology derived from religion.
Typical of the best surgeons of the thirteenth century was Guglielmo Salicetti, or Salicet (c. 1210-77), who was professor at Bologna, city physician at Verona, and author of works on internal medicine and surgery. Salicetti preferred to use the knife rather than the cautery in most procedures, and he wrote the first known treatise on regional surgical anatomy, which quite graphically presented remedies by surgery for numerous traumatic and spontaneous conditions. His pupil Guido Lanfranchi of Milan was forced out of his native city for political reasons and journeyed to France, first to Lyons and later, in 1295, to Paris, where he did much to establish surgical practice on French soil. In his Cyrurgia magna, finished in 1296, he attempted a reconciliation between internal medicine and surgery. Henri de Mondeville (1260-1320) was surgeon to Philip the Fair and later professor of anatomy at Montpellier. Consistent with the teachings of Hippocrates, he advocated simple cleanliness in the treatment of wounds and the avoidance of pus, laudable or otherwise. Guy de Chauliac (1300-68) studied in France at Toulouse, Montpellier, and Paris and in Italy at Bologna. He was without doubt the best-educated surgeon of his time and encouraged a strong foundation in anatomy.
Anatomy and Dissection
Along with the development of surgery in the medieval period there was increased attention paid to anatomy. Whereas the Salernitans had earlier confined their studies to animal dissection and the Arabists had relied on anatomy lessons compiled from ancient works, especially of Galen, there was a revival of dissecting human cadavers in the fourteenth century. Although a desire for greater knowledge of anatomy was responsible for the revival of human dissection, rather different forces led to social sanction since the earliest dissections in the Middle Ages appear to have had an entirely medicolegal purpose, such as determining the cause of death in suspicious cases or attempting to learn about the nature of diseases, especially contagious, from pathological findings. The best of medieval dissectors was Mondino de Luzzi of the university at Bologna whose Anathomia was completed in 1316. However, his treatise was more an instruction book in dissecting techniques than a study of gross anatomy. First published in Padua in 1487, it went through nearly forty editions and remained the standard text (in spite of numerous Galenical errors) until the time of Vesalius.