Vol.

XIX, No 1
June, 2013
 Surgical Pain Management at The Medical School of Salerno, Vesalius, XIX , 1, 31-36, 2013

Surgical Pain Management at

The Medical School of Salerno
(11th-13th Centuries)
Valentina Giuffra

Summary

Before the advent of general anesthesia, only poorly effective remedies were known to relieve pain. Although classical medical
authorities describe a number of elaborate surgical techniques, no references about some forms of anesthesia are reported.
Only the authors of pharmaceutical or botanical texts mention the use of substances, especially mandrake, to induce sleep in
the patient. The first and most detailed evidences of general anesthesia described in medical texts of the western world can be
found at the Medical School of Salerno. However, the use of substances aimed to relieve pain or to induce sleep during surgery
is mentioned only by the authors of pharmaceutical or botanical texts and not by surgeons. Furthermore, the efficacy of these
preparations to produce a profound and lasting sleep is doubtful. The general impression is that surgeons knew how to relieve
pain, but considered it a necessary appendix of surgery and therefore an incisive effort to eliminate it was not pursued.

Résumé

Avant l’avènement de l’anesthésie générale, n’étaient connus que de petits remèdes efficiaci pour soulager la douleur.
Bien que les autorités médicales classique décrivent de nombreuses techniques chirurgicales élaboré, pas de références
sur quelque formes d’anesthésie sont signalés. Seuls les auteurs des textes pharmaceutiques ou botaniques mentionnent
l’utilisation de substances, en particulier mandragore, pour induire le sommeil chez le patient. La première et la plus
détaillée des preuves de l’anesthésie générale décrite dans les textes médicaux du monde occidental peuvent être
trouvées à l’école de médecine de Salerne. Cependant, l’utilisation de substances visant à soulager la douleur ou pour
induire le sommeil pendant la chirurgie n’est mentionné que par les auteurs de textes pharmaceutiques ou botaniques
et non par des chirurgiens. En outre, l’efficacité de ces préparations pour produire un sommeil profond et durable est
douteuse. L’impression générale est que les chirurgiens savaient comment soulager la douleur, mais ils la considéraient
comme un appendice nécessaire de la chirurgie et donc un effort pour éliminer incisive il n’était pas poursuivi.

Introduction obtained not as a deliberate anesthetic effect, but only

Pain has always accompanied mankind and, starting from
the most ancient civilizations, several attempts have been
made by physicians to relieve pain. However, before the
advent of general anesthesia, nothing but poorly effective
remedies were known. Several herbs were used as
narcotics or analgesics, but these anodynes were not
sufficient against the acute pain of surgery.
Although classic medical authorities describe a number
of elaborate surgical techniques, no references have
been made as to forms of anesthesia affording surgical
interventions. Hippocrates (ca 460-380 BC) advises on
the peril derived from intense pain in amputation, which
in certain cases caused sudden death. 1 Similarly, Celsus
(first half of 1st century AD) mentions only the great
risk that can occur as a consequence of hemorrhage or
fainting in the amputation of a limb. 2 All the writings of
Archigenes (1st-2nd centuries AD) were devoted to the
risk of blood loss, which was prevented by ‘bending’
the vessels or the entire limb, and his contemporary
Heliodorus recommended to tie up the part to be sawn.3
The insensitivity derived from bending was therefore
as a remedy against hemorrhage. In this respect, Galen
(129-200 or 216 AD) claimed that no danger could derive
from cutting the gangrenous flesh, which is insensitive.4
None of these authors mention some anesthetic or
analgesic substance to relieve pain even with the most
painful operations, such as amputations. The only remedy
to the problem of pain was considered the rapidity of
the surgeon and the compression made to prevent
hemorrhage. Until the Modern age young surgeons were
advised with the words of Celsus that the “surgeon
should be filled with pity, so that he wishes to cure his
patient, yet is not moved by his cries to go too fast, or cut
less than is necessary; but he does everything just as if the
cries of pain cause him no emotion”. 5
Only the authors of pharmaceutical or herbal texts
mention the use of substances, mostly mandrake,
to relieve pain or to induce sleep in the patient. 6
Dioscorides reports on the use of mandrake as an
anaesthetic in surgery (Fig. 1): the patient would fall in
a deep sleep so that the surgeon could painlessly cut or
cauterize. 7 Dioscorides (ca 40-ca 90 AD) used the Greek
word anesthesia for insensitivity, a term reintroduced

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 Surgical Pain Management at The Medical School of Salerno, Vesalius, XIX , 1, 31-36, 2013
Figure 1: Mandrake in an early seventh century Greek herbarium
based on the De Materia Medica of Dioscorides. Codex
neapolitanus Ms. Ex Vindob. Gr. 1. National Library, Neaples
later in the 19th century. Pliny the Elder (23-79 AD)
refers that mandrake was administered before incisions
and punctures in order to ensure insensitivity to pain. 8
In the Herbarium of Pseudo-Apuleius (4th century)
it is affirmed that mandrake macerated in wine was
administered to patients undergoing amputation,
mutilation or cauterization: the patient fell asleep without
perceiving pain. 9 The same concept is found in the Ex
herbis feminis of Pseudo-Dioscorides (5-6th centuries):
the wine of mandrake is given to those whose treatment
demands an operation; the sleep prevents the sensation
of pain. 10 The use of mandrake as anesthetic entered
Medieval practice thanks to Isidore of Seville, who
describes the drinking of mandrake before surgery. 11
Popular surgery, entrusted to itinerant practitioners and
barbers with no solid preparation, who performed minor
surgical interventions, is likely to have used narcotic drugs,
but no references in written documents have attained to
us.
The most consistent and detailed evidence of a form
of general anesthesia described in medical texts in the
western world can be found within the Medical School
of Salerno.
32
The Medical School of Salerno
The early Middle Ages are considered a time of diffuse
ignorance, during which most of the ancient knowledge
went lost. Medicine and surgery were no exception
and, after Galen, little else was produced in those times
but mere compilations, chiefly of the nature of herbals
or domestic recipe-books. The handbook available in
the Latin West between the 6th and the 11th centuries
included only simple surgery, essentially represented by
phlebotomy and cauterisation. Greek surgery remains
mainly inaccessible to the direct knowledge of the
western world until the 15th century, with the exception
of some Hippocratic treatises. 12
However, starting from the 9th century, a reawakening
of medicine in Western Europe took place in the city
of Salerno. This cultural revival was certainly linked
to Benedictine monasticism, with its main center at
Montecassino, where ancient knowledge was jealously
conserved and transcribed in the silence of the scriptoria.
Furthermore, as suggested by Sudhoff 13 a small enclave
of Greek surgery persisted uninterruptedly from the
Antiquity in the Calabria region, close enough to influence
Salerno. As early as in the 9th century the physicians
practicing in Salerno gained wide reputation, attracting
students from all Europe, and teaching was carried out in
a school with a lay organization.
Constantine the African (1020-1087), who translated
many classical texts from Arabic into Latin in the 12th
century, greatly broadened the medical knowledge
available at the school of Salerno. Following these stimuli,
the Salernitan physicians began to produce a number of
works which covered all the aspects of medicine. 14 The
most productive period of the Salerno masters was in
the 11th-13th centuries. The importance of the school is
witnessed in 1231 by the decree of Frederic II (1194-
1250), who attributed to the School of Salerno the
sole right to approve for the practice of physicians and
surgeons.
General anesthesia at the Medical school of
Salerno: the spongia somnifera
The most ancient written Medieval document reporting
the use of a hypnotic remedy to be administered before
surgical practices is conserved in a codex of Montecassino
dated back to the 9-10th centuries. Sedative and soporific
ingredients, such as opium, mandrake, hemlock and
henbane, were macerated in water, in which a sponge
 Surgical Pain Management at The Medical School of Salerno, Vesalius, XIX , 1, 31-36, 2013

was soaked; the latter was then dried in the sun. When Farmacopea Universalis of Lemery at the end of the 18th
a surgeon had to perform an intervention, he soaked the century.
sponge in hot water and applied it to the nostrils of the
patients, who lost consciousness. Another sponge soaked In the Circa Instans, a pharmacological text by the Salerno
in hot vinegar was used to wake the patient. 15 Medical School probably written between 1150 and 1170,
and traditionally attributed to Matteo Plateario (Fig. 2),
The spongia somnifera is likely to have been introduced in another formula is reported; this time blackberry, lettuce,
the West from the Arabic world, through the translation and ivy are added to the formula of the Bamberg surgery:
work carried out by Constantinus Africanus. The sponge
of Arabian physicians contained a mixture of hashish,
opium, C-hyoscine and a wheat infusion; this last
preparation was used as a carrier of other ingredients
after water evaporation. 16

Basically, the same recipe of the Montecassino codex is

reported by “Bamberg surgery”, the earliest book dealing
with surgery produced within the School of Salerno. The
contents of this anonymous work derive partly from the
writings of Constantinus and partly from pre-Salernitan
sources. 17 The Bamberg surgery reports:

“Helpful hypnotic, that is soporific, compound for he who

is going to undergo surgery. Sleeping patients will not feel
the pain. Take: one ounce of opium, eight ounces of juice
from the leaves of mandrake, hemlock green juice, three
ounces of henbane. Put everything in a sufficient amount
of water to make a potion. The potion is to be put on
a dry sponge which will then be allowed to dry. When
needed the same sponge is put for an hour in warm
water, then under the nostrils of the patient. He will fall
asleep as it were to steal his spirit. When one wants to
wake him up, another sponge soaked in warm vinegar is
put under his nostrils”. 18

A third copy of this recipe is reported in a manuscript

probably originated in southern Italy and now in
Copenhagen. 19

Another similar composition is described in the
Antidotarium of Niccolò Salernitano, author of the first
book on compound drugs of the medieval West around
the half of the 12th century; this text is a collection of
pre-Constantinian recipes from antiquity and early
medieval authors, and became one of the most influential
pharmaceutical handbooks of the period. In fact this recipe
closely follows the formula of Bamberg surgery, both for
its main ingredients and mode of administration, but adds
some other substances, such as mulberry, blackberry,
lettuce and ivy. 20 The recipe of the soporific sponge of the
Antidotarium had a wide fortune in the following centuries,
and can be retraced, with some modifications,  also in the
Figure 2: Miniature of an apothecary from the Circa Instans of
Matteo Plateario (Ms. Sloane 1977, f. 49v.). By courtesy of the
British Library, London
“take three ounces of thebaic opium, one of
henbane juice, one of juice of green blackberries,
one of lettuce seeds, one of hemlock that is
poppy, juice of mandrake, juice of climbing ivy
three ounces. Put all these things together in a
vase and embed in it a sea sponge, just fished and
not touched by fresh water, and put it under the
sun in the dog days, so that it is totally consumed.

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 Surgical Pain Management at The Medical School of Salerno, Vesalius, XIX , 1, 31-36, 2013

When necessary, embed again this sponge in hot
water and put it on the nostril of the patient, who
will suddenly fall asleep.When you want to awake
him, put juice of fennel roots on the nostril and
the patient will wake up”. 21
other passages in the text it can be inferred that the
patient remained conscious during the treatment and had
to tolerate the pain, although this could compromise the
intervention. 26

The composition of the spongia somnifera varied from

recipe to recipe, but it was widely believed that it was
effective.The four main ingredients were opium, hemlock,
mandrake and henbane, substances whose properties had
been known since ancient times, although they were not
administered by inhalation. Opium has an antalgic and
soporific action thanks to morphine; hemlock contains
conicine, which produces paralysis and loss of sensation;
mandrake has weak local anesthetic effects, due to
mandragorine and it potentiates the narcotic action of the
general anesthetic substances; finally, henbane contains
alkaloids, such as hyoscine, scopolamine and hyoscyamine,
which produces effects similar to mandrake. Therefore,
the plants used in the spongia somnifera have analgesic and
anesthetic properties.

Nevertheless, modern experiments on guinea pigs 22 and

rats 23 demonstrated that these preparations could not
have produced a sleep profound enough to be considered
as general anesthesia. Inhalation was probably preferred
to administration by ingestion, as the collateral effects of
the latter could lead to coma and death. On the other
hand, the lack of precision in the dosage and mode of
administration through inhalation, which quite prevented
the absorption of the active ingredients, probably
produced a scarce analgesic effect but a high risk of severe
complications. 24 Some Authors 25 hypothesized that the
soporific sponges were in some measure effective enough
to perform short-duration interventions.
As already highlighted for classical authors, even in the
school of Salerno the use of substances to relieve pain
or to induce sleep during surgery is mentioned only by
the authors of pharmaceutical or herbal texts and not by
surgeons, with the exception of Bamberg surgery. In this
respect, it is noteworthy that in the Practica chirurgiae by
Roger Frugard (12th century), the first medieval work in
the field of surgery, several hardiness surgical procedures
are described, such as the treatment of skull fractures
or of abdominal wounds with evisceration, which implied
the opening of the abdominal wall and manipulations
of viscera, but no mention to any form of anesthesia
is reported. The author declares that every time the
surgeon intervened, he used to tie the patient to the
table and to hold him tight before operating (Fig. 3). From
Figure 3: Miniature of a patient treated for a wound in the torso
from the Chirurgia of Roger Frugard; an assistant holds him down
(Ms. Sloane 1977, f. 7). By courtesy of the British Library, London
Therefore, the masters of Salerno had pain relieving
drugs at their disposal, although of limited efficacy. The
general impression is that surgeons knew how to relieve
pain, but considered it a necessary appendix of medicine
and surgery and therefore an incisive effort to eliminate
it was not pursued. The delay in the introduction of pain
allaying drugs can partly be attributed to the old western
belief that pain and suffering were the price that humans
had to pay for their sins. Medieval medicine accepted
pain and tried to relieve it only if it was dangerous to the
patient. 27
Other remedies against pain
Within the School of Salerno, the same ingredients of the
spongia somnifera administered through inhalation could
be employed in other forms of surgical practice. Magister

34
 Surgical Pain Management at The Medical School of Salerno, Vesalius, XIX , 1, 31-36, 2013
Salernus, author of several texts of general therapy, active
between 1140 and 1166, prescribes the use of a cataplasm
to eliminate pain in surgical operations: “it is noteworthy
that opium, henbane and mandrake produce a deep
somnolence in consequence of their great humidity. If you
prepare a cataplasm and pose it where the incision or an
operation have to be made they will completely eliminate
the sensitivity, so that the pain of whatever nature will
not perceived”. 28 In addition to inhalatory and local
remedies Cofone, who flourished between the 11th and
12th centuries, refers to another way of administrating
a soporific remedy: “Prepare a soporific enemy with
opium, henbane, white and black poppy, seeds of lettuce,
of purslane, pumpkin and barberry”. 29
In the texts of authors belonging to the Medical School
of Salerno soporific compositions were prescribed not
only in surgery, but also to manage the pain derived from
different pathologies. Cofone suggests the use of a sponge
embedded with several narcotic substances that has to be
applied to the head in case of high fever. Besides opium,
mandrake and henbane, he cites poppy, lettuce, goldmoss
stonecrop, common houseleek, crassula, common mallow,
prickly wild lettuce and purslane. 30
In addition to these soporific compositions, several
remedies based on the use of vegetal substances in
accordance to the popular and classical tradition of the
material medica are documented in the texts of the
magisters of Salerno.
The Antidotarium Nicolai includes 142 prescriptions, of
which 41 have mainly analgesic properties. The recipes
prescribed for different illnesses causing pain, in particular
headache, stomach-ache and tooth-ache, include several
ingredients, but the most recurrent for pain relief are
opium, henbane and mandrake. 31
In the Regimen sanitatis Salernitanum, an anonymous poem
concerning domestic medical practices such as daily
hygienic procedures and diet, which gained enormous
popularity and became the most important medical text
coming to us from Salerno, several plants are mentioned
for analgesic purposes. For example, chervil melted in
wine is considered as an analgesic drug; nettle provides
relief for articular pain; cooked black nightshade and viola
purpurea are used as analgesics for head-ache; pennyroyal
relieves the pain of gout. 32
The only analgesic remedies cited by Roger Frugard in his
Chirurgia are prescribed for the treatment of tooth-ache
35
and ear-ache.  For the former he recommends: “burn
the soft spot behind the lobe of the ear… for the same
purpose, take the seeds of the white henbane and leek
in equal parts and put them on the coals; put a funnel on
the coals and let the patient direct the smoke coming out
of it on the tooth”. 33 Similarly, a local application of oil,
boiled onions, boiled egg white, rue and other remedies
is prescribed for ear-ache (I, xliv). 34
Conclusions
Although the physicians of the school of Salerno were
acquainted with some recipes having soporific and
anesthetic properties, in particular the spongia somnifera,
it is probable that these remedies had limited efficacy
and that they were not employed in surgical procedures,
but only in the treatment of less severe pathologies. This
hypothesis is supported by the complete absence of
references to anesthetic practices in the surgical texts
of the Salerno masters, in particular in the Chirurgia by
Roger Frugard, which instead describes audacious and
complex surgical interventions. The Salerno surgeons
probably adopted the methods reported by classical
authors, the rapidity and ability during operation.
Valentina Giuffra, Post-Doctoral position, Department of
Translational Research on New Technologies in Medicine and
Surgery, Division of Paleopathology and History of Medicine,
University of Pisa,Via Roma 57, 56126 Pisa, Italy
Acknowledgements
This work was supported by a grant from the ARPA
Foundation (www.fondazionearpa.it).
Notes and References
1 HIPPOCRATES. De articulis, III, 247.
2 CELSUS. De medicina,VII, 33.
3 A. COCCHI. (1754) Graecorum chirurgici libri
Sorani vnus de fracturarum signis Oribasii duo
de fractis et de luxatis e collectione Nicetae
ab antiquissimo et optimo codice florentino
descripti conversi atque editi ab Antonio Cocchio.
Ex typographio Imperiali, Florentiae, p.156 and p. 159.
 Surgical Pain Management at The Medical School of Salerno, Vesalius, XIX , 1, 31-36, 2013

4 GALEN. De articulis, commentarius IV. 20 D. GOLTZ. (1976) Dargestellt an Geschichte und

5 CELSUS. De medicina VII, prooemium. Inhalt des Antidotarium Nicolai.
6 E.J. CHIDIAC, R.N. KADDOUM, S.F. FULEIHAN. Wissenschaftliche Verlagsgesellschaft MBH,
(2012) Mandragora: anesthetic of the ancients. Stuttgart. Here the translation of the recipe:
Anesthesia & Analgesia 115: 1437-1441. “Soporific sponge. Take one ounce of opium from
7 DIOSCORIDES. De materia medica, 76. Thebes, then one ounce each of juice of henbane,
8 PLINY. Naturalis Historia, XXV, 150. unripe mulberry, blackberry, seed of lattuce,
9 PSEUDO-APULEIUS. Herbarium, 131. hemlock, of poppy, mandrake and arboreal ivy. Put
10 PSEUDO-DIOSCORIDES. Ex herbis feminis, 15. all these in a vessel, together with a sponge just
11 ISIDORE OF SEVILLE. Etymologies, XVII.ix.30. taken from the sea so that it has never been in
12 N.G. SIRAISI. (1990)  Medieval & early Renaissance contact with fresh water. Expose (the vessel) to
medicine: an introduction to knowledge and the sun during the dog days until everything is
practice. University of Chicago Press, Chicago consumed. When you want to use it, moisten the
– London. sponge lightly with hot water and apply to the
13 K. SUDHOFF. (1921) Zu den Schlafschwammen patient’s nostrils, who will quickly fall asleep”.
des Borgognoni. Archiv für Geschichte der Medizin 21 B. OLIVIERI. (1968) Questioni intorno alla spongia
13: 127-8. soporifera. Salerno: civitas hippocratica 2: 43-54.
14 S. DE RENZI. (1852-1859) Collectio salernitana, 22 M.L. BAUR. (1927) Recherches sur l’histoire de
ossia Documenti inediti e trattati di medicina l’anesthésie avant 1846. E.J. Brill, Leiden.
appartenenti alla Scuola medica salernitana. 23 M. INFUSINO,Y.V. O’NEILL, S. CALMES. (1989)
5 voll. Sebezio, Napoli. Hog beans, poppies and mandrake leaves: a test
15 SUDHOFF, op. cit., pp.127-128; L. STROPPIANA. of the efficacy of the Medieval soporific sponge.
(1959) Sul ritrovamento di una spongia sonnifera In R.S. ATKINSON, T.B. BOULTON (editors), The
del IX secolo. Rivista di Storia della Medicina 1: history of anaesthesia. The Royal Society of
47–56.  The recipe is clearly provided: “Hypnotic Medicine Services and the Parthenon Publishing
remedy: it is a soporific useful to those who cure Group, London, p 29-33.
themselves with surgery, so that once fallen asleep 24 P. PRIORESCHI. (2003) Medieval anesthesia – the
they do not feel the pain of the cut. Take these spongia somnifera. Medical Hypotheses 61:
things: half an ounce of thebaic opium, eight ounces 213-219; G. LAURIELLO. (2011) Post mundi
of the juice of the green herb of black nightshade, fabricam: manuale di chirurgia. Magister Ruggiero di
three ounces of green juice of henbane, of juice Frugardo. Editrice Gaia, Salerno.
of mandrake squeezed from half an ounce of 25 P. JUVIN, J.M. DESMONTS. (2000) The ancestors
minced leaves. Collect in a sponge and leave to dry of inhalational anesthesia: the soporific
diligently. When you want to use this sponge, sponges (XIth-XVIIth centuries): how a universally
embed it for one hour in hot water and bring it recommended medical technique was abruptly
near the nostrils of the patient, taking care that discarded. Anesthesiology 93: 256-9.
the sick person inhales it in order to sleep for 26 LAURIELLO, op. cit.

long. When you want to awake him, you will apply 27 E. COHEN. (1995) Towards a history of European
to the nostrils another sponge embed with physical sensibility: pain in the later Middle Ages.
hot vinegar and in this manner you will get rid of Science in Context 8: 47-74.
the sleep”. 28 DE RENZI. op. cit., vol.V, p. 227.
16 M. AL-FALLOUJI. (1997) Arabs were skilled in 29 DE RENZI. op. cit., vol. IV, p. 463.
anaesthesia. British Medical Journal 314: 1128. 30 Ibidem.
17 G.W. CORNER. (1937) On early Salernitan surgery 31 GOLTZ, op. cit.

and especially the “Bamberg surgery”. Bulletin of 32 F. GHERLI. (1993) Regola sanitaria salernitana.
the History of Medicine V: 1-28. Tascabili economici Newton, Roma.
18 H. SIGERIST. (1923) Studien und texte zur 33 ROGER FRUGARD. Chirurgia, I, xxxix.
frümittelaltherlichen Rezeptliteratur. Johann 34 ROGER FRUGARD. op. cit., I, xliv.
Ambrosius Barth, Leipzig.
19 W.F. DAEMS. (1970) Spongia somnifera:
philologische und pharmakologische Probleme.
Beiträge zur Geschichte der Pharmazie 22: 25-26.

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