Ann Thorac Surg 1997;64:1855-1857
© 1997 The Society of Thoracic Surgeons
Our Surgical Heritage
The Women of Salerno: Contribution to the Origins of Surgery From Medieval Italy
Zoë Alaina Ferraris, BA,
Victor A. Ferraris, MD, PhD
Cardiovascular and Thoracic Surgery, Huntington, West Virginia
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Abstract
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Medicine in medieval Europe benefited from Greek, Arabic, Hebrew, and Latin influences. Because of geographic and other favorable conditions, many of these cultural contributions synergized to form the Medical School at Salerno around 900 AD. somewhat uncharacteristically, women physicians played a part in the advances that came from this school. among the contributions associated with the school of salerno were (1) textbooks of anatomy, obtained mainly from porcine dissections, (2) insistence on certification and training for physicians, (3) application of investigative thinking and deduction that led to important advances such as the use of healing by secondary intention, (4) the first textbook about women's medicine, and (5) the first recorded female medical school faculty member named trotula de ruggiero or trocta salernitana. the women physicians of salerno contributed to a textbook that gained wide acceptance and distribution throughout europe. the textbook, called De Passionibus Mulierium, was first published about 1100 AD and was a prominent text until a significant revision by Ambrose Paré's assistant in the early 1600s. Paré was the preeminent anatomist of his time, and many of his important anatomic and surgical considerations were directly and indirectly derived from the work of the women of Salerno. The advances first recorded, taught, and implemented by the women of Salerno are an interesting and important part of our surgical heritage.
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Introduction
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Salerno is a small port town near Naples in southern Italy that was a hub of Mediterranean commerce from the fifth century onward. Originally settled by the Greeks, Salerno was renowned for its spa and health resort, which included natural mineral springs. What was for the Europeans a "dark ages" was for the Arabic and Middle Eastern peoples a time of great learning and scientific advance. From the seventh century until the beginning of the Renaissance, Salerno benefited from its proximity to the Eastern world and became an important European center of commerce, industry, and education. The cultural influences of Arabs, Jews, Greeks, and Romans all coalesced to support intellectual and academic achievements, most notably in the field of medicine.
The origin of the school of Salerno is swathed in a veil of legend and obscurity. It seems to have arisen around 900 to 1000 AD. Benedictine monks at the nearby monastery of Monte Cassino presumably founded the school itself and helped shape its intellectual developments by providing valuable translations of both Arabic and Greek medical writings. A monk named Constantinus Africanus supplied the school with one of its central documents: al-Majusi's Pantegni, a medical treatise whose subjects ranged from anatomy and the humors to descriptions of diseases and cures [1]. Physicians trained at Salerno gained considerable prestige and notoriety throughout southern Europe in the 10th and 11th centuries.
The 12th century found the school at its apogee, and it was during this time that Salerno made its most notable contributions to the shaping of a medical curriculum at medieval universities. The school produced original anatomic texts, huge collections of drug remedies based largely on a well-known Arabic pharmacopoeia, and one of the preeminent medical school faculties of its time. The school's body of texts served most of Europe well into the Renaissance. Perhaps their most striking feature was their tendency, adopted from the Arabic model, to approach medicine scientifically rather than from a theologic or ethical standpoint [1].
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The Women of Salerno
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The climate of tolerance extended itself to women practitioners as well as Jews and Arabs, and during most of its lifetime, Salerno was the only medical school in Europe that opened its doors to women. Multiple references to an independent team of women physicians, teachers, and medical scholars attest to the vital role they played in surgical and scientific achievements [2–7]. Perhaps the most famous female physician was named Trotula (also Trotta, Trocta, and Dame Trot) [7]. Trotula, who was a Magistra of Medicine at the School of Salerno, ran a prolific clinical practice. She taught her students about three types of diseases: inherited, contagious, and self-generated. Her instruction focused on diagnosing various illnesses, using tools such as urine analysis, pulse rate, and skin tone evaluation. Her students were able to differentiate between typhoid and malaria, they could calculate fever temperatures and estimate recovery times, and they could treat complex wounds with some chance of success [8].
Early medieval surgery was most concerned with the lack of sufficient methods for managing serious pain, bleeding, and infection. Hence, medieval surgeons can best be attributed with innovation in the area of wound management and pain control. In this field, the women of Salerno played a vital role. The frequency with which a midwife encounters common wounds, like perineal tearing and uterine ruptures, lent Trotula and her students ample occasion for the development of new techniques and remedies for wound management. She developed and documented a wide variety of herbal and animal remedies for the prevention and care of infectious wounds. For labor pains, she also developed a variety of opiates, which were extended to deal with general postoperative pain as well [8].
Being a literate woman in the 11th century, Trotula benefited from the studies of Galen and Hippocrates, whom she quotes in her texts, as well as the numerous Arabic authors, such as Avicenna and al-Majusi, who were translated into Latin during her lifetime. She and her husband, also a physician at the school, collaborated in the creation of the Regimen Sanitatis Salernitanum, an encyclopedia of medicine that was among the most popular and accepted medical works of its time.
Trotula is credited as the author of a text called De Passionibus Mulierum Curandorum (also called Trotula Major) that was revised and copied extensively and that served as the primary manuscript on women's health in Europe for more than 400 years [8]. Its contents ranged from discussions of general surgical ailments to elements of wound healing, as well as problems in pregnancy and childbirth. Another work, De Ornatu Mulierum, (also called Trotula Minor) dealt with cosmetic issues and the care of the complexion. More than 19 less-comprehensive Trotula manuscripts can be found in European libraries today [8].
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Medical Certification in Southern Italy
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Given that only a small minority of medieval medical practitioners were university educated, the princes who ruled the provinces of Southern Italy in the 12th century became concerned with unsafe medical practices. In 1140, Prince Roger II of Sicily issued an edict forbidding anyone to practice medicine without proper examination [1]. This was followed in 1224 by a similar edict from Roger's grandson, Emperor Frederick II of Naples. Frederick's edict required that candidates for license to practice medicine must be examined in public by the masters of Salerno [1, 4]. Examinations were based on the writings of Hippocrates, Galen, and Avicenna. Each candidate had to give evidence that he or she had finished a course of study that included 3 years of general university work (emphasizing mathematics and philosophy), 4 years of the study of medicine, a year of practice with a physician, and an additional year of anatomy study for those who would perform surgery. These were unbelievably high standards for medieval doctors, standards that eventually loosened and that Western medical practice has returned to only in the past 100 years [5].
After finishing his or her exams, the physician was given the title of "doctor" and was required to treat the poor pro bono, to visit patients twice a day and at night as necessary, and to avoid collusion with apothecaries—good standards for our times as well. The concepts of medical qualification developed parallel to the concept of specialized medical education. Thus, given the blossoming scholarship at Salerno, one of the important contributions of Salernitan medicine was the ability to provide a coherent curriculum that allowed for medical qualification and certification.
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Anatomic Dissections at the School of Salerno
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The decree of Frederick II stated that candidates for the practice of medicine must study human anatomy [1, 3]. The Salernitan physicians had access to Galen's graphic manuals—based on dissections of monkeys—as well as the copious and detailed written descriptions of human anatomy given by al-Majusi [1]. Because Islamic law forbade pictorial representations of the human body, written description of human anatomy translated from the Arabic formed a basis for the texts developed at Salerno. The faculty of the Medical School realized that their knowledge of the human body was incomplete, and they initiated the practice of porcine dissection for the first time since antiquity [1]. They developed graphic anatomic manuals of the pigs they dissected, and projected many porcine traits onto the human body.
The anatomy of the reproductive organs was only known from animal dissections and written descriptions (without pictures) of Islamic texts. It was to the study of the female reproductive system that the women physicians of Salerno made vital contributions, because women doctors had greater access to female patients than did their male counterparts. In her book, Trotula writes that she was called to the practice of medicine because she had too often seen the suffering of women who were ashamed to share their maladies with a male doctor [8]. A good number of the 63 chapters of Trotula Major are devoted to the problems of conception, pregnancy, embryonic development, and childbirth.
With the practice of porcine dissections, the school of Salerno provided one of the first European anatomic texts, which were a great stimulus to the advancement of surgery as it was practiced in medieval times. Shortly after the decree of Frederick II in 1241, the practice of dissecting human cadavers was begun at the medical school in Bologna [1].
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Surgical Contributions
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Until the 12th century, the treatment of wounds had involved medication with plasters, powders, ointments, or in the case of ulcers, corrosive substances. A measure of suppuration was accepted as a normal stage in the healing of wounds. Wounds contained either pure white pus, often indicative of an infection that would either heal or form a local abscess, or a watery, fetid pus indicative of a type of infection likely to be followed by gangrene and death. The term "laudable pus" implied white pus and a good prognosis. Various ancient practitioners including Arabic physicians recognized the importance of "laudable pus." Consequently, physicians at Salerno developed the accepted practice of applying unguents to induce "laudable pus" and to keep the wound open until its healing by secondary intention—from the depth of the wound to the surface. Although not originated, but refined, in Salerno, this concept appeared in the textbooks that came from the Salernitan school and these principles provided the framework for the understanding of wound healing as well as the development of surgery as a specialty.
One of the first Western authors to show an interest in surgical procedure was Constantinus Africanus [1], but the texts he translated for the school of Salerno were difficult to use, given their obscure terminologies and absence of graphics. Practitioners in Salerno, therefore, produced voluminous interpretations and criticisms of the Greek and Arabic texts that were available to them. These were the first European writers to show a special interest in surgical writing. They were not necessarily surgical specialists, but the existence of a body of specialized knowledge about anatomy and wound intervention (with graphic texts) created the idea of literate surgery as a distinct discipline.
It is interesting to observe that a major impetus for innovation in the handling of wounds is the upsurge of violent war. The rise of the Medical School of Salerno coincides with the First Crusade, which was begun at the end of the 11th century. Salerno, an important trade center in the Mediterranean, was also a primary arrival point for returning Crusaders during the 11th and 12th centuries. It is quite possible that the high influx of wounded Christians to Salerno demanded innovation in surgical care from the Salernitan practitioners.
Similarly, Trotula's De Passionibus served as Europe's primary text on women's health until the 17th century, when better weapons of war like artillery and gunpowder prompted advances in the technology of wound management. It was not until the early 1600s that Louise Bourgoise, a midwife whose husband worked under Ambrose Parè, wrote an updated manuscript on women's health that contained many of the principles of Trotula of Salerno, particularly her emphasis on the anatomic origins of disease.
Many of the concepts explored by the Salernitan school, evolved and refined by the passage of time and the infusion of creativity from surgical predecessors, have shaped the modern practice of surgery. The women of Salerno played a part in this evolutionary process.
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Footnotes
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Address reprint requests to Dr Ferraris, 341 12th Ave, Huntington, WV 25701 (e-mail: ferraris{at}earthlink.net).
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References
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- Siraisi NG. Medieval and early Renaissance medicine: an introduction to knowledge and practice. Chicago: University of Chicago Press, 1990:13–5, 84–90, 162, 169.
- Jacquart D. Aristotelian thought in Salerno. In: Dronke P, ed. A history of twelfth-century western philosophy. Cambridge: Cambridge University Press, 1988:407–28.
- Garrison FH. An introduction to the history of medicine. Philadelphia: Saunders, 1929:138–73.
- Rashdall H. The universities of Europe in the Middle Ages. Oxford: Clarendon Press, 1895:75–86.
- Walsh JJ. Medieval medicine. London: A & C Black, 1920:37–60.
- Anderson BS, Zinsser JP. A history of their own: women in Europe from prehistory to the present. New York: Harper & Row, 1988:412–24.
- Campbell Hurd-Mead K. Trotula. Isis 1930;14:349–66.
- Brooke E. Women healers: portraits of herbalists, physicians, and midwives. Rochester, VT: Healing Arts Press, 1995:28–39.
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Abstract
Introduction
