Bologna

     Greetings from Bologna, an ancient city, dating back to the Etruscans if not earlier. Its University is among the oldest in Europe, said to have been founded in 1088, a place where early pioneers in medicine are to be found.  It consisted originally of a law school – both canon law and civil law (Copernicus studied canon law here), followed by the School of Philosophy, each unit known as a Studium. Medicine is thought to have entered the curriculum in the early 13^th century, and was incorporated into the Philosophy Division (typical of other Italian universities). The Studium included the study of Aristotle, medicine, astrology, mathematics, rhetoric, and what we would call the “arts”. Aristotle in northern Europe was taught as speculative philosophy, while in northern Italy it was taught as a basis of medicine. The above arts, including disputation and dialectic, were considered necessary in medicine.

     It was a time when works by Aristotle, Galen, Hippocrates, and Arab physicians, through translations from Arabic and Greek, were entering Europe. Only limited works by these authors had been available before. Shaping these works into an organized medical curriculum was accomplished by Taddeo Alderotti. Nephew of a surgeon, he studied in Bologna, and by the 1260s he was teaching medicine at the University.  His consolidated curriculum became a standardized body of works serving as a basis for examination and licensing, and leading to the first formal “College of Physicians”. (Others followed, and served as a template when Thomas Linacre secured a charter from Henry VIII in 1518 to form the Royal College of Physicians.) The reading included the Aphorisms of Hippocrates, the Canon of Avicenna, and works by Galen and Arab physicians, along with a work of his own: the Consilia, a collection of clinical cases with advice on how to treat them. Taddeo was known for his high fees (nothing new!). Pope Honorious IV was a patient of his.    

     One of Alderotti’s students, Mondino di Luzzi, an anatomy professor, was the first to dissect human cadavers, with permission from a Church that now considered anatomy part of “natural philosophy” – a study of God’s creation.(1) Most important, Mondino published an anatomy text in 1316 (based almost entirely on Galen) that was a standard text for the next 200+ years. Unfortunately it contained little that was new but it stimulated further dissection and emphasized anatomy’s importance in medicine (as Galen had emphasized). It was really a manual, the first of its kind, designed to be read aloud while the cadaver, an executed criminal or a body stolen from a grave (11), was dissected over three or more days by a surgeon, proceeding from the abdomen and reproductive organs upward (to minimize putrefaction). In line with Aristotle’s idea of “final cause” and man’s body as God’s perfect creation, every structure had a function.

     Surgery was part of the curriculum, unlike in northern Europe. The Dominican Friar Theodoric Borgognoni, a contemporary with Alderotti, studied medicine in Bologna and was a surgeon as well, probably learning much of it from his surgeon father. His works are known for the advice that pus in wounds is not desirable, the use of wine on wound dressings, and the use of sponges soaked in opiates and placed over the nose to induce some narcosis.

Image of brain from Isagogae breves

     Roughly 200 years later Berengario da Carpi, professor of surgery at Bologna, wrote an update on Mondinus’ text (called a “Commentary”), followed in 1522 (the year after Pope Leo X excommunicated Martin Luther) by a masterful anatomy manual of his own, entitled Isagogae breves, or “Short Introduction” (to anatomy). The latter is said to be the first illustrated anatomy book, and reflects the author’s attention to human dissections rather than ancient texts (Galen dissected apes and other animals) in that he described new structures including the brain’s ventricles, the foramen ovale, the appendix, and several other structures absent from Galen and Mondinus. It was a major advance and laid the groundwork for Vesalius’ masterpiece in 1543 (Vesalius did not credit Berengario). Several of the poses in Vesalius’ work are thought to be modeled on those seen in Berengario’s manual.

     Several years later Giulio Cesare Aranzio, professor of surgery and anatomy at Bologna, established anatomy as a separate department, retaining himself as chief of both. He described several structures including the hippocampus. He also wrote a book on the human fetus, which included good descriptions of the fetus and gravid uterus.  Aranzio, as a surgeon, was unusual for performing rhinoplasties, an operation known in ancient India which resurfaced in southern Italy and, in improved form, was made famous by the Viraneo family in the small Calabrian town of Tropea. Knowledge of the procedure made its way to Bologna, where Aranzio took it up. Aranzio’s pupil, Gaasparo Tagliacozzi, adopted and improved the technique and wrote a book on it, though failing to give any credit to his professor, Aranzio. In spite of what appears to have been favorable acceptance of the operation, it died out shortly after Tagliacozzi’s death in 1599. In the procedure, a skin flap was taken from the upper arm to the nasal area, the arm held near the face with an awkward contraption (see figure) until the flap appeared viable, then the flap was severed from the arm, all without anesthesia. Tycho Brahe, the astronomer, who lost his nose in a sword fight in 1566 and had a metal replacement made, was a contemporary. Whether he was aware of this procedure is unclear.

Gasparo Tagliacozzi

Apparatus for nose replacement

     Of particular interest in the 16^th and 17^th centuries in Bologna medicine is the creation of a tribunal to regulate and supervise the practice of medicine – the Protomedicato. Comprised of rotating members of the College of Physicians, it assumed the civic functions of inspecting pharmacies for improper drugs, licensing lower-level practitioners (the College licensed full physicians, surgeons, etc), prohibiting treatments thought to be harmful, and pursuing other “public safety” activities. It was particularly careful in supervising the production of theriac, a remedy for almost anything, including poisoning. Viper meat was theriac’s main ingredient, and its manufacture was so hallowed and expensive that it was part of a public ceremony.

      The Protomedicato also decided on lawsuits between patients and healers. Before this body a doctor could sue to recover an unpaid fee or a patient could allege that his treatment was substandard. Particularly curious, as described by Gianna Pomata in her book, Contracting a Cure, is the custom of patient and doctor entering into either verbal contracts with witnesses present or written contracts, stipulating the medical complaint, the treatment (including its duration), the expected (or promised) outcome, the fee, and various do’s and don’ts for the patient. Often the fee would be placed with a third party and paid in installments as the treatment proceeded. Suits arose if the patient did not recover as promised, in which case the plaintiff wanted his money back. Over time, however, the College of Physicians drifted into demanding fees for their services, regardless of outcome.

     Perhaps the most unusual professor and physician in Bologna was Gerolamo Cardano (1501-1576), a genius and polymath, whose interest in medicine was one of many. He received his medical education at Pavia and was later professor of medicine there, but after his son (also a physician) was executed for poisoning his wife, he lost his position at Pavia and, through connections, obtained a professorship in Bologna. By then he was famous for other works, such as a pioneering work on algebra (which included a solution to cubic equations and adumbrated imaginary numbers), 2 encyclopedias, works on astrology (he once created a horoscope for Jesus), and works on medicine. Astrology and the occult heavily infused his ideas on medicine and disease. He was also a sharp gambler, supplemented his income through it, and was one of the first to formulate rules of probability. Cardano’s horoscope of Christ eventually got him into trouble with the Inquisition. He spent time in prison, lost his professorship in Bologna, and finally retired to Rome where he wrote his autobiography.

     Moving to the next century, we should mention Marcello Malpighi. Born in 1628, he received his medical training in Bologna, learned to use the microscope (a Galileo model) in Pisa, worked productively at the university in Messina, and became Professor of Practical Medicine at Bologna in 1666. By this time he had found, using the microscope, the capillary circulation and the alveolar structure of the lungs as well as (using injections into renal arteries) the capillary connections to the renal glomeruli. With these and further discoveries he is considered the founder of microscopic anatomy. He was a contemporary of Robert Hooke and Anton van Leeuwenhoek, but outstripped them both with his facility in microscopic anatomy. Other discoveries include taste buds, sensory organs in the skin, respiratory tubules in insects, and more. He also practiced medicine continuously, trying to base his therapies on anatomic findings. Much of his practice was carried on by correspondence, not uncommon at the time. Since physical examinations were almost nonexistent, a history by mail was almost as good as one in the office, and treatments were advised by return mail. This correspondence, and that with his scientific colleagues, were part of a larger endeavor, the “Republic of Letters”, through which new ideas and knowledge were disseminated before journals took over. Malpighi was made a member of the Royal Society and his contributions published regularly. In 1691 he left Bologna for Rome where he was personal physician to Pope Innocenzo XII, and a Professor of Medicine. He died in 1694. He is buried in Bologna.

     There is a fascinating web site that lists medical historical items in cities all over the world. For more on Bologna, go there: http://himetop.wikidot.com/start.

Some works consulted for this essay:

1. Cunningham, A: The Anatomical Renaissance.  1997

2. Pomata, Gianna: Contracting a Cure: Patients, Healers, and the Law in Early Modern 

          Bologna. 1998

3. Siraisi, Nancy: Taddeo Alderotti and His Pupils. 1981

4. Gnudi, MT and Webster, JP: The Life and Times of Gaspare Tagliacozzi. 1950

5. Berengorio da Carpi: Isagogae Brevis, trans by LR Lind, 1959

6. Mondino, Alderotti, Cardano, Malpighi: In Dictionary of Scientific Biography.

7. Bresadola, M: A Physician and a Man of Science: Malpighi’s Medical Practice. Bull

         Hist Med 2011. 85: 193-221

8. Ioli,A, et al: Marcello Malpighi. Am J Nephrology 1993. 13: 223-8

9. Bresadola,M: “A Physician and a Man of Science: Patients, Physicians, and Diseases

         in Marcello Malpighi’s Medical Practice”. Bull Hist Med, 85: 193-221. 2011

10. Castiglione, A. A History of Medicine, 2^nd edit. 1958.

11. Mettler, C C. History of Medicine.1947, p.36.

12. Mezzogiorno, A and P. “Marcello Malpighi”. Amer J Nephrol. 1997. 17: 269.