Maurizio Bifulco, M.D.,a Emmanuele A. Jannini, M.D.,b Vieri Boncinelli, M.D.,c and Simona Pisanti, Ph.D.d
aDepartment of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II,” Naples; bDepartment of Systems Medicine, University of Rome Tor Vergata, Rome; cCentro Studi Terapia Disturbi Affettivi Sessuali, Firenze; dDepartment of Medicine, Surgery and Dentistry ‘Scuola Medica Salernitana’ (SP), University of Salerno, Salerno, Italy
In the history of sexuality and sexual medicine, the Middle Ages has erroneously been considered by most to be the Dark Ages. In actuality, for medicine it was a period characterized by valid innovations and improvements as well as a surprisingly modern attitude. In the 10th to 13th centuries, the Scuola Medica Salernitana (Medical School of Salerno) in southern Italy was a brilliant example of medieval medicine modernity. By diffusing knowledge via abundant scientific literature, it became the most famous medical institution in the Western world. Here we report on the modern sensibilities of medieval sexual medicine through an in-depth analysis of one of the Medical School of Salerno’s works, the Liber Minor de Coitu (The Handbook of Intercourse). This work’s medical concepts, methods, recipes, pharmacological natural products, and useful dietary, hygienic, and behavioral advice remain interesting and relevant up to the present day.
Contrary to the misconception of many hold of the “Dark Ages,” the medieval period (the 5th to 15th centuries) witnessed great discoveries and advancements, even in the field of medicine. Retracing the history of sexuality and sexual medicine will reveal that many modern day attitudes toward sex and sexuality, especially from a medical point of view, originated in the Middle Ages (1). The Scuola Medica Salernitana, or Medical School of Salerno (MSS), which flourished from the 5th to 13th centuries in the Italian harbor city of Salerno, was a shining example of medieval medical modernity.
Thanks to its privileged location on the Mediterranean Sea in the south of the country, the MSS gained an international reputation for medical innovation and oversaw the birth of the first hospital units inside monasteries. The higher education that developed there to train doctors in the practice of medicine opened the field to other medical cultures, combining traditional Greek and Roman (Hippocratic-Galenic) medical knowledge with new information gleaned from the Arabic, Byzantine, and Jewish traditions. The MSS thus generated a unique, new, multifaceted, modern medical method that was grounded in empirical, extremely practical approaches, giving its students a comprehensive overview of the best characteristics of all these different cultures (2–4).
Medieval sexual medicine in MSS texts
The Liber Minor de Coitu
Particularly from the 12th to 13th centuries, the literature on sexual medicine directly or indirectly encompassed Arabic traditions of drugs and plants considered to be either aphrodisiac or antisexual. Constantinus Africanus, a famous physician who studied at the MSS, contributed to the spread in Western countries of Arabic medical knowledge through the translation of numerous Arabic medical works into Latin. One of his well-known works was a text on sexual medicine, the Liber de Coitu (Textbook on Intercourse) (5, 6). This work (which was not solely limited to that topic in scope) was representative of the great interest the MSS took in the field of sexual medicine.
Another essay on this topic with a similar title, the Liber Minor de Coitu (freely translated as The Handbook of Intercourse), was written by an anonymous author who also belonged to the illustrious MSS (7). This work, which perfectly reflects the unique multicultural milieu of the MSS, became popular in the context of medieval scientific literature dealing with sexuality and reproduction. Although scholars erroneously attributed both the Liber de Coitu and the Liber Minor de Coitu to the same author, Constantinus Africanus, philological analyses have clarified that the Liber Minor de Coitu was written after the death of Constantinus Africanus in 1078. It is most likely that it was written around 1250, most certainly before the end of the 13th century.
The author of the Liber Minor de Coitu, an anonymous physician who matured in the MSS milieu, was clearly influenced both by previous works in Arabic and by the works of Constantinus. This is suggested by the extensive use in the handbook of ingredients listed by their Arabic names in both the text and the pharmacological glossary (ambra, asa, been, berberis, camphora, carvi, citrangulum, fisticus, galanga, musa, penith, sambacus, sumac). It also is interesting that the Liber Minor de Coitu adopts more a more original, far more practical approach to the topic than the older textbook by Costantinus (7).
The Liber Minor de Coitu is divided into two distinct parts. The first part deals with the harms that coitus may cause: “Que mala venerios subsequntur usus”—“diseases due to sexual excesses.” The second part focuses on its benefits: “Nunc vero de utilitate dicemus”—“Now we discuss how [sex] is beneficial.” T[VW3] [SP4] hat is, the first part explains how sexual activity can be detrimental for individuals (men) who have certain conditions or temperaments (an idea also found in Eastern cultures, such as in traditional Chinese medicine) (8), and the second part highlights how sexual activity can improve general health (9).
The theoretical basis of the Liber Minor de Coitu follows the medieval medical precepts of Hippocrates and Galen, though they are richly blended with ideas drawn from Arabic medicine (mainly from Avicenna). On the basis of the Hippocratic theory of the four humors or temperaments, the secret to good health depends on a proper balance of humors, which can be attained through nutrition, rest, exercise, and sexual activity (10). To this end, men must ejaculate semen regularly to avoid both physical and mental pathologies, an argument that could be easily inserted in the current debate on the role of frequent ejaculation in prostate cancer prevention (11).
The emphasis on the problems of male sexual health and their remedies, with solutions in line with both Latin and Arabic medicine, is similar to the older textbook by Constantinus and other Arabic manuscripts dealing with sexual issues. However, the Liber Minor de Coitu also contains original references to female sexual health, which may seem surprising given the dilatory state of scientific knowledge of female sexual behavior and female sexual dysfunction that persists even in contemporary sexual medicine. Thus, even as we currently debate the possibility of improving female sexuality with drugs (12), the Liber Minor de Coitu was already offering several recipes for aphrodisiacs for women alongside those for men.
This work’s breadth was in line with the precepts of the MSS, where particular attention was devoted to women’s health. The school not only analyzed gynecologic issues and female pathologies in depth, but trained women as students and medical practitioners (the so-called mulieres salernitanae, the Dames of Salerno). The essays of Trotula De Ruggiero, the school’s most famous female physician who is regarded as the first Western female gynecologist, considered issues of sexual medicine and fertility from both male and female perspectives (2, 13).
Recipes from the Liber Minor de Coitu
The predominant approach of the Liber Minor de Coitu was practical: original recipes for increasing or restraining the libido with instructions on how to prepare them and when to employ them, under which physiological or pathological conditions. Although it is difficult to ascertain whether the utility of such medieval recipes was based on clinical, empiric, or statistically consistent evidence, we must take into account that Constantinus Africanus described aphrodisiacs in his own work that he claimed he had successfully tested in clinical practice.
Similarly, the short, anonymous Liber Minor de Coitu contains abundant useful dietary advice about which foods and spices are good for increasing sexual desire (anise, ginger, black pepper, cardamom, cinnamon, flax or nettle seeds, onions, chickpeas, beans, asparagus, almonds, nuts, pine nuts, pistachio nuts, Saracen cardoon, citrons, bananas, figs, melons, grapes, partridge or ostrich eggs, bovine or rooster testes, and others) or reducing it (rue, dill, cumin, marjoram, barley, vinegar, pomegranate, blackberries, green quinces, apples and plums, lettuce, pumpkin, chard, chicory, endive, cucumber, etc), as tailored to the individual’s condition and personal temperament. This nutraceutical approach to sexuality obviously contains numerous mistakes but also many insights (14).
The author describes in detail the recipes for these remedies, reporting the amounts of the ingredients and the exact procedure to make oral formulations, enemas, and unguents to be rubbed on the penis, testes, or lumbar region. For example, “sparagi elixi et post in vaccino lacte frixi et ovi medium commisces; pigmenta ut zinziber, galangam, cinnamomum, piper eciam appones”—stir cooked asparagus fried in bovine milk and egg yolk; add spices such as ginger, cinnamon, black pepper. The handbook also describes an intraurethral formulation: “asam ut filo producere queat et musceleo perunges et virge inmittes, neque longum, ne intus aliquid ledat, inesse permittes”—make a little thread with asafoetida, grease it with muscelino oil, and insert it in the penis, without leaving it inside for a long time in order to avoid internal lesions. This procedure surprisingly anticipates the transurethral delivery of proerectile drugs (15).
Several of the unguents and preparations are specific for women. For example, “ulieribus: carvi, zinziber, piretrum, cinnamomum equaliter tempera cum vino stiptico odorato et inungatur”—for women: stir cumin, ginger, cinnamon, pyrethrum in equal amounts with astringent and sweet-smelling wine and grease.
Beyond the herbal, edible, or mineral ingredients in the formulation of such unguents we can find also atypical ingredients such as worms (porcellos), live ants, and pigeon bile. Great attention also is devoted to hygienic precepts, once again anticipating the current emphasis on the role of lifestyle choices in general as well as in sexual health of both sexes (16).
Although the medieval period had limited scientific knowledge, was deeply influenced by religious and philosophical issues, and was repressed and censorious about sexuality in general and sexual pleasure in particular, the modernity of the Liber Minor de Coitu is evident, as some of its medical concepts, methods, and recipes remain valid today. When analyzed from a scientific point of view, the therapeutic effectiveness of the remedies proposed in this treatise are noteworthy. Some of the herbs and natural products described in these recipes are still today used to address male sexual dysfunction. Their peculiar chemical constituents, such as saponins, flavonoids, alkanes, and terpenes, have proven biological activity and clinical efficacy. Indeed, some herbal products available in contemporary stores contain ginseng, black pepper, pumpkin, cinnamon, valerian, and other herbs or foods recommended in this medieval treatise (17).
Links to modern sexology
The author of the Liber Minor de Coitu proposes an interesting taxonomy of sexual issues—including erectile and ejaculatory dysfunction, and hypoactive sexual desire disorder in both men and women—and provides several pharmacological treatments that go beyond practical dietary, hygienic, and behavioral advice. The handbook also suggests that the benefits of sexual activity include the reduction of aggressiveness, melancholy, and depression, all ideas that are still debated today (18), and it surprisingly anticipates a very recent finding that sexual activity contributes to increased memory function: “[coitus] memoriam illustrari, ira extinguitur et ideo melancholia minuitur”—coitus increases memory, extinguishes anger, and decreases depressive habitus (19).
Pertaining to the complexions classified according to the Hippocratic theory of the four humors (hot/dry, hot/wet, cold/dry, cold/wet), the modern reader can find correlations with a neurovegetative basis. In fact, numerous patients affected by sexual dysfunction or problems display sympathetic and parasympathetic manifestations (20). For instance, during his first sexual experiences a young, sexually naïve, anxious man may experience low salivation, cold sweat, and fear of losing his erection (21–23). In parallel, women in the arousal phase may experience intestinal peristalsis and flushed skin (24).
As part of the heritage of Hippocratic medicine, the remedies described in the Liber Minor de Coitu based on balancing opposite humors are still valid and used in the modern popular practice. Indeed, the practical advice to take cold showers to lessen sexual excitement or to take a warm bath with essential oils or foam, or receive relaxing massages to heighten sexual desire in both women and men is well known in the sexology field. Moreover, the concept that sexual activity can be detrimental in the presence of certain physical and psychophysical illnesses seems in keeping with the Darwinian, adaptive mechanisms that reduce reproductive and sexual ability in presence of internal or external troubles (25).
The limited scientific knowledge of the medieval era was what likely led to the author confusing the cause–effect relationship. For example, the author stated that interrupting the frequent sexual activity that is necessary to maintain a healthy, rubicund complexion can cause genital ulcers and adenopathies. These conditions are more probably a consequence of sexually transmitted infections caused by sexual promiscuity. Similarly, the statement that women affected by mental pathologies need to avoid sexual activity confuses cause for consequence.
The Liber Minor de Coitu is a transcultural sexual medicine text relatively free of ideological and religious biases. Its genuine interest in male and female sexual health seems modern. Its psychological and pharmacological approaches to sexual dysfunction in both sexes make it a true manifesto against the persisting psychoreductionism and urological mechanisms that form the two faces of modern therapy for sexual dysfunction. The Liber Minor de Coitu, one of the first handbooks of sexual medicine in the Western culture, testifies to the modernity of the medieval approach to sexual medicine.
1. Jannini EA. SM = SM: the interface of systems medicine and sexual medicine for facing non-communicable diseases in a gender-dependent manner. Sex Med Rev 2017;5:349–64.
2. Bifulco M, Capunzo M, Marasco M, Pisanti S. The basis of the modern medical hygiene in the medieval Medical School of Salerno. J Matern Fetal Neonatal Med 2015;28:1691–3.
3. Bifulco M, Marasco M, Pisanti S. Dietary recommendations in the medieval Medical School of Salerno: a lesson from the past. Am J Prev Med 2008;35:602–3.
4. Bifulco M, Amato M, Gangemi G, Marasco M, Caggiano M, Amato A, Pisanti S. Dental care and dentistry practice in the Medieval Medical School of Salerno. Br Dent J 2016;221:87–9.
5. Delany P. Constantinus Africanus’ “De Coitu”: a translation. Chaucer Rev 1969;4:55–65.
6. Constantini Liber de coitu. In E. Montero Cartelle, ed., Eltratadomenor de andrología de Constantinoel Africano. Santiago de Compostela, Spain: Universidad, 1983.
7. Liber minor de coitu. In E. Montero Cartelle, ed., Tratadomenor de andrología, Anónimo salernitano. Valladolid, Spain: Universidad, 1987.
8. Chen HF. Between passion and repression: medical views of demon dreams, demonic fetuses, and female sexual madness in Late Imperial China. Late Imperail China 2011;32:51–82.
9. Jannini EA, Fisher WA, Bitzer J, McMahon CG.Is sex just fun? How sexual activity improves health. J Sex Med 2009;6:2640–8.
10. Laios K, Tsoucalas G, Kontaxaki ΜΙ, Karamanou Μ, Sgantzos Μ, Androutsos G. Mental health and sexual activity according to ancient Greek physicians. Psychiatriki 2015;26:198–203.
11. Aboul-Enein BH, Bernstein J, Ross MW. Evidence for masturbation and prostate cancer risk: do we have a verdict? Sex Med Rev 2016;4:229–34.
12. Tiefer L. Female sexual dysfunction: a case study of disease mongering and activist resistance. PLoS Med 2006;3:e178.
13. Bifulco M, Ciaglia E, Marasco M, Gangemi G. A focus on Trotuladé Ruggiero: a pioneer in women’s and children’s health in history of medicine. J Matern Fetal Neonatal Med 2014;27:204–5.
14. Kamenov Z, Fileva S, Kalinov K, Jannini EA. Evaluation of the efficacy and safety of Tribulus terrestris in male sexual dysfunction—a prospective, randomized, double-blind, placebo-controlled clinical trial. Maturitas2017;99:20–6.
15. Williams G, Abbou CC, Amar ET, Desvaux P, Flam TA, Lycklama à Nijeholt GA, et al. The effect of transurethral alprostadil on the quality of life of men with erectile dysfunction, and their partners. MUSE Study Group. Br J Urol 1998;82:847–54.
16. Jannini EA, Nappi R. Couplepause: a new paradigm in treating sexual dysfunction during menopause and andropause. Sex Med Rev;6:384–95.
17. Kotta S, Ansari SH, Ali J. Exploring scientifically proven herbal aphrodisiacs. Pharmacogn Rev 2013;7:1–10.
18. Collazzoni A, Ciocca G, Limoncin E, Marucci C, Mollaioli D, Di Sante S, et al. Mating strategies and sexual functioning in personality disorders: a comprehensive review of literature. Sex Med Rev 2017;5:414–428.
19. Maunder L, Schoemaker D, Pruessner JC. Frequency of penile-vaginal intercourse is associated with verbal recognition performance in adult women. Arch Sex Behav 2017;46:441–53.
20. Nugent AC, Bain EE, Thayer JF, Sollers JJ, Drevets WC. Sex differences in the neural correlates of autonomic arousal: a pilot PET study. Int J Psychophysiol 2011;80:182–91.
21. Jannini EA, Lenzi A, Isidori A, Fabbri A. Subclinical erectile dysfunction: proposal for a novel taxonomic category in sexual medicine. J Sex Med. 2006;3:787–94.
22. Corona G, Ricca V, Bandini E, Rastrelli G, Casale H, Jannini EA, et al. SIEDY Scale 3, a new instrument to detect psychological component in subjects with erectile dysfunction. J Sex Med 2012;9:2017–26.
23. Barata BC. Affective disorders and sexual function: from neuroscience to clinic. Curr Opin Psychiatry 2017;30:396–401.
24. Levin RJ. The physiology of sexual arousal in the human female: a recreational and procreational synthesis. Arch Sex Behav 2002;31:405–11.
25. Cellerino A, Jannini EA. Male reproductive physiology as a sexually selected handicap? Erectile dysfunction is correlated with general health and health prognosis and may have evolved as a marker of poor phenotypic quality. Med Hypotheses 2005;65:179–84.