University-Trained Physicians and Others Who Learned from Books

The creation of medical training programs in a university setting
was one of the most important developments in medicine
during the Middle Ages, and the men who trained at universities
became the elite of the medical profession. The university movement
began in the 12th century with the founding of universities
in Paris (1150), Bologna (1158), Oxford (1167), Montpellier (1181),
and Padua (1222). In Oxford and Paris, medical instruction was
informal at first. By the 15th century (1436), Padua had become
the most highly respected of the medical schools, with fifteen medical
professors.

Universities were originally founded as places to study
Christian theology, and women were barred from becoming
clergy in medieval times, so women were not admitted. The
exception was in Salerno where women were permitted to teach
and practice medicine. Though these women excelled and were
well known for their medical skills, their numbers dwindled
by the end of the 12th century and the profession came to be
dominated by men.
In addition to excluding women, men of the Jewish religion
were mostly kept out as well. (A few universities admitted Jews if they were willing to pay higher fees.) Despite this discriminatory
practice, Jewish men found ways to become educated, and they
often had the finest reputations, which meant they were in high
demand by royal and other noble households.
In all universities, a working knowledge of Latin was a prerequisite
for admission since the texts and lectures were in
Latin. Incoming students also needed basic knowledge of logic
and philosophy in preparation for medical courses. This limited
those who qualified. Members of the clergy or those who
were training to be clergy had the right background because
they learned Latin in order to read and understand theology.
In addition, a few laymen from relatively wealthy families also
had the opportunity to gain an education that prepared them
for studying medicine.
The original curriculum in medical schools at that time was
based on The Articella and Avicenna. (See the sidebar “The Articella
as a Basis for University Teaching” on page 26.) During the
13th century, the Italian religious leader (later to achieve sainthood)
Thomas Aquinas (1225–74) introduced an emphasis on the
naturalism of Aristotle in the university curriculum, integrating
it with Aquinas’s own primary interests in scientific rationalism
and theology.
As the educational system evolved and favored the training
of clerics for the medical profession, it set up an interesting
dynamic: Most physicians were clerics but later on, the clergy
in many jurisdictions were forbidden from practicing medicine.
While caring for the sick was viewed as a Christian duty, the
church became concerned about two issues involving the practice
of medicine: The first was that blood was never to be shed
by clergy, so clerics had to abstain from any sort of surgical
treatment including any form of study that resulted in bleeding.
The second issue had to do with financial success. Practicing
medicine became lucrative, and the church worried that the
clergy would neglect their religious responsibilities for personal
gain. To qualify as a doctor of medicine, a student underwent a full 10
years of training. After this formal education, there was a period
of supervised practice that was like an internship, followed by an
examination that was conducted by other physicians. If all went
well, the physician was licensed to practice on his own. Only a few
men successfully completed the course of study each year. Because
there were so few graduates, the number of university-
trained
physicians was exceedingly small, meaning that only nobility or
the very wealthy might have had access to these specially trained
individuals.
The medicine practiced at this time was a blend of Galen’s
theories as influenced by Hippocrates. Diagnoses were made by
checking the pulse and studying the urine (uroscopy). Astrological
charts were consulted and “critical days” were noted. The prime
remedies were dietary changes to rebalance the humors, and the
use of herbal drugs. The physicians who served the nobility were
known as court physicians, and their role was actually a broad
one. Records show that a court physician to Henry III of England
was expected to counsel the steward about the choice of meat and
drink served to the king. He was also to be on watch for signs of
pestilence or the arrival at court of anyone who might have leprosy,
and the king was to be warned of signs of either of these threats.
The ratio of physicians to townspeople in Florence, Italy, in
1338 provides an interesting picture of the time. Florence had
the highest physician per capita rate with about 60 licensed physicians
for a population of about 120,000. After the Black Death,
the ratio improved because of the precipitous drop in population:
There were then 56 physicians for only 42,000 people. A few
towns paid for physicians to oversee the care of the public and
treat the poor, but for the most part, physicians treated those
who could afford to pay. By 1211, the town of Reggio, Italy, not
only paid a public physician, called a medici condotti, to help care
for the poor, but they expanded the physician’s duties to include
helping with inquests, treating the sufferers of plague, and tending
to injuries inflicted on prisoners.