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J Matern Fetal Neonatal Med, Early Online: 1–3

! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.964681

EDUCATION AND DEBATE

The basis of the modern medical hygiene in the medieval Medical

School of Salerno
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Maurizio Bifulco, Mario Capunzo, Magda Marasco, and Simona Pisanti

Department of Medicine and Surgery, University of Salerno, Baronissi, Italy

Abstract Keywords
The link between hygiene and the concept of transmission of infective diseases was established Hand hygiene, hygiene, Medical School of
earlier than the birth of microbiology, thanks to the studies of two neglected physicians of Salerno, prevention, trotula
maternity clinic, Ignác Fülöp Semmelweis and Oliver Holmes, in the mid-1800s. Surprisingly,
centuries earlier, a medieval women physician, Trotula de Ruggiero, introduced for the first time History
the notion of diseases’ prevention, highlighting the importance of the association of personal
hygiene, balanced nutrition and physical activity for better health. Moreover, she was Received 10 July 2014
particularly concerned of hands hygiene for the midwives during child birth, to preserve the Revised 5 September 2014
good health of both the mother and the baby. She practiced inside the medieval Medical Accepted 9 September 2014
School of Salerno, whose main text, the ‘‘Regimen Sanitatis Salerni’’ has an entire part Published online 30 September 2014
dedicated to hygiene, providing hygienic precepts that anticipate the concepts derived from
the revolutionary discoveries in medical science only centuries later.
For personal use only.

It is out of doubt that the improvement of hygiene procedures
is a key strategy, strongly encouraged by national and
international authorities (e.g. WHO), to reduce the transmis-
sion of pathogens and hence to promote good health. In this
perspective, the WHO guidelines on hand hygiene treat the
important and still neglected issue of hand-washing to prevent
the spread and incidence of infective diseases, in particular,
of health care-associated infections that concern 5–15% of
hospitalized patients and are dangerously increasing, with
a negative impact on patient’s health but also on health
expenditure and on the development of increased resistance
of microorganisms to antimicrobials [1–3].
The issue has to be treated also from an anthropologic and
historical point of view, since personal hygiene is not only a
factor that contributes to human health, but also a part of
religious and cultural habits that characterize the behavior of
specific populations. Looking at the past, the link between
hygiene, in particular hands’ hygiene, and the concept of
transmission of infective diseases was surprisingly established
earlier than the discoveries of Pasteur and Lister, milestone of
the medical sciences, gave rise to the bacteriology and
subsequent evidence that infectious diseases are caused by
pathogenic germs [4,5]. Indeed, in the mid-1800s in Vienna,
Address for correspondence: Maurizio Bifulco, Simona Pisanti,
Department of Medicine and Surgery, University of Salerno, Baronissi,
Italy. Tel: +39 089969742 (M.B.); +39 089968119 (S.P.). E-mail:
maubiful@unisa.it (M.B.); spisanti@unisa.it (S.P.)
the Hungarian physician Ignác Fülöp Semmelweis, particu-
larly concerned of the high mortality due to puerperal fever,
had a brilliant deduction following the death of his colleague
Jacob Kolletschka, who died of a febrile illness very similar to
puerperal fever, after a scalpel injury during an autopsy.
Semmelweis experimented that the high incidence of
puerperal fever could be drastically reduced if doctors and
students washed their hands in a chlorinate solution before
every contact with the patients, particularly after the
autopsies. This practice, even if at that time was accepted
with difficulty, led to a dramatic reduction of the mortality
rate in the obstetric clinic due to puerperal fever [6,7]. Several
years before, in Boston, Oliver Wendell Holmes in the essay
‘‘The contagiousness of puerperal fever’’ resolved, following
a deductive pathway similar to Semmelweis, that the cause of
the high incidence of puerperal fever was indeed due to the
patient–patient indirect contact through their common
physicians [8]. Both these physicians applied successfully
antiseptic procedures in the clinical setting, even if their
innovative ideas were obstructed and derided by the medical
community and opposed by eminent professors of obstetrics,
who drastically rejected the heretical notion that puerperal
fever was transmitted by medical personnel through direct
physical contact. Less known is that eight centuries earlier
than Semmelweis in Vienna and Holmes in Boston, there was
in Italy, in the medieval city of Salerno, a famous women
physician and obstetrician, maybe the first in the history and
surely the most famous among the ‘‘mulieres salernitanae’’,
whose name was Trotula De Ruggiero, who applied hygiene
precepts and good clinical practice in her work exerted inside
 2 M. Bifulco et al.
the Medical School of Salerno (about 900–1200 AD), the
most ancient institution in the western world for medical
knowledge and progenitor of the modern Medical School
[9,10]. In the major of her scriptures ‘‘De passionibus
mulierum ante, in et post-partum’’ the first systematic treatise
of gynecology and obstetrics, she described the anatomical
basis of the reproductive apparatus and its patho-physiology,
and the herbs to cure almost all women’s diseases such as
menstrual and uterus-related bleeding, birth injuries, infec-
tious diseases and hysteria [11–13]. Trotula introduced for the
first time the notion of diseases’ prevention, highlighting the
importance of the association of personal hygiene, balanced
nutrition and physical activity to preserve good health. She
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was particularly concerned with the relevance of hygiene in
medical practice and in particular of hands hygiene for the
obstetricians during the child birth, to preserve the good
health of both the mother and the baby, a concept really
revolutionary for those times, that preceded of eight hundred
years the studies of Semmelweis and Holmes. The treatises
written by Trotula were translated throughout Europe in
Spanish, French, English and German and were used as
medical texts in all universities for a long time [14].
Also the main text of the Medical School of Salerno, the
‘‘Regimen Sanitatis Salerni’’ has a part dedicated to hygiene,
providing very innovative precepts in the light of the limited
knowledge of the medieval time that would have found their
scientific basis only centuries later. Far being a theoretic
For personal use only.
medical treatise for practitioners, the Regimen was an
innovative healthy life style program, result of the experience
of the school’s doctors, written in a poem of 362 Leonine
verses, easy to keep in mind and to put into practice by
common people [15]. As regard to hygiene’s advices, the
Regimen says ‘‘De aeris usu et qualitate: aer sit purus, sit
lucidus et bene clarus. Infectus per se, nec olens foetore
cloacae’’ (Pars Prima, CAP I, Art. II, p. 446, lines 37–39) (Let
air be clear and light, and free from infectious or malodorous).
Particular attention is given also to personal hygiene that
contributes to good health. Indeed, ‘‘Lumina mane manus
surgens frigid lavet aqua . . . crines pectat, dentes fricet, ista
confortant cerebrum, confortant coetera membra. Si fore vis
sanus ablue saepe manus’’ (Pars Prima, CAP III, p. 448, lines
116;118–119) (Remember to wash your hands and eyes with
cold water . . . both comb your head and rub your teeth, to
refresh your brain and every member. If you want to be in
health remember to wash often your hands). The frequent
hand-washing is therefore considered by the School as a
fundamental condition to preserve health: this is particularly
innovative, since in a time in which the origin of contagious
diseases was in the ‘‘miasma theory’’ of bad air or due to the
balance of the four humors (black bile, yellow bile, phlegm
and blood) within a patient’s body, particular attention was
given to the hands, a real means of pathogens transmission.
The issue is still of extraordinary actuality, since the doctors
of the School with their aphorisms on hygiene meant to
stimulate in the people a common consciousness to preserve
health, exactly the same that national and international
authorities still do with their campaigns on the importance
of hand-washing to prevent infectious diseases dissemination.
In the ‘‘Pathologia’’ chapter of the Regimen Sanitatis
Salerni it is claimed another aspect that makes the School of
J Matern Fetal Neonatal Med, Early Online: 1–3
Salerno very active in the hygiene and prophylaxis field.
Indeed, through the Regimen the School recommends the
useful technique of variolation of infants to minimize the
severity of smallpox infection and the mortality rate
(‘‘Ne pariant teneris variolae fanera natis/Illorum venis
variolas mitte salubres’’) (Pars Nona, CAP X, p. 508, lines
1920–1921), being the first to introduce in Italy and in the
entire Europe the method of variolation, centuries earlier than
Lady Mary Wortley Montagu, wife of the British ambassador
in Turkey, known to have imported in Europe in 1722 the
Turkish medical procedure of smallpox inoculation [16]. It is
worthy of note that, as the legend says, the Medical School of
Salerno was founded by a Latin, a Greek, an Arab and a Jew,
supporting its international inspiration and its links with the
Arab medical traditions. Moreover the Regimen recognizes as
causes of infection the sick person, its breath, the bed-clothes
and all the things came in contact with the patient,
anticipating the practices of modern medical sciences (‘‘Seu
potius morbi contagia tangere vitent: aegrum, aegrique
halitus, velamina, lintea, vestes ipseque quae tetigit male
pura corpora dextra’’) (Pars Nona, CAP X, p. 508, lines
1922–1924).
In conclusion, in the cradle of the medieval Medical
School of Salerno, centuries earlier that the revolutionary
discoveries in medical science helped us to understand the
origin and dissemination of infectious diseases were gener-
ated several simple, wise and universal principles on the basis
of the modern medical hygiene.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of this article.
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