Treatment of Particular Ailments

Gynecology

Trotula (eleventh century)

Translated by Elizabeth Mason-Hohl¹

Annotated by Michael McVaugh

PROLOGUE

SINCE God, the author of the universe, in the first establishment of the world, distinguished the individual natures of things each according to its own kind, He differentiated the human race above the other creatures by means of extraordinary dignity. To it, beyond the condition of other animals, He gave freedom of reason and of intellect. Moreover, desiring its generation to subsist perpetually, He created it male and female in different sexes that by means of their fertile propagation future offspring may never cease to come forth. Blending their embraces with a pleasing mixture, He made the nature of the male hot and dry and that of the female cold and wet so that the excess of each other’s embrace might be restrained by the mutual opposition of contrary qualities. The man’s constitution being hot and dry might assuage the woman’s coldness and wetness and on the contrary her nature being cold and wet might soothe his hot and dry embrace. Likewise that the male having the stronger quality might pour seed into the woman as into a field and the woman endowed with a weaker quality, subject as it were to the function of the man, might naturally take unto her bosom the poured out seed. Since then women are by nature weaker than men it is reasonable that sicknesses more often abound in them especially around the organs involved in the work of nature. Since these organs happen to be in a retired location, women on account of modesty and the fragility and delicacy of the state of these parts dare not reveal the difficulties of their sicknesses to a male doctor. Wherefore I, pitying their misfortunes and at the instigation of a certain matron, began to study carefully the sicknesses which most frequently trouble the female sex. Since in women not so much heat abounds that it suffices to use up the moistures which daily collect in them, their weaknesses cannot endure so much exertion as to be able to put forth that moisture to the outside air as in the case of men. Nature herself, on account of this deficiency of heat, has assigned for them a certain specific purgation namely the menses, commonly called flowers. For just as trees do not produce fruit without flowers so women without menses are deprived of the function of conception. This purgation occurs in women just as ’pollutio’ occurs in men. Nature always, burdened by certain moistures, whether in man or in woman, strives to lay off its yoke and diminish its exertion. Now a purgation of this sort usually befalls women about the 13th or 14th year or a little earlier or later according to whether heat or cold abounds in them more. It lasts up to about the 50th year if she is lean; sometimes up to the 60th or 65th if she is moist; in the moderately fat up to about the 45th. If such purgations have been of normal time and regularity, Nature sufficiently unloads women of superfluous moisture. If the menstruation has taken place too copiously various sicknesses arise from it. The appetite for food and drink is diminished, sometimes vomiting occurs, and often they have an appetite for earth, coals, chalk, and the like. At times from the same cause they feel pain around the neck, the back, and around the head. There may be acute fever, sharp pains in the heart, dropsy, and dysentery. These conditions appear either because the menstrual periods are missing for a long time or because they do not have them at all. For this latter reason not only dropsy, dysentery, and heart attacks but also other more serious illnesses occur. Diarrhoea occurs too on account of excessive coldness in the womb, either because the veins are very slender as in thin women since in this case thick and excessive fluids do not have free channels through which they can break forth, or because the liquids are thick and viscous and because of clotting their egress is hindered. Sometimes it is because the women eat too luxuriously or because from some exertion they sweat profusely. Galen says: "A woman who does not exercise much must necessarily be abundant in many menstrual periods in order that in this respect she may be in good health." Sometimes a woman’s periods are lacking because the blood is clotted in the body or it is emitted through other parts as through the mouth in the spit, through the nostrils, or through hemorrhoids.

Sometimes the periods fail because of excessive grief or anger or excitement or fear. If they have ceased for a long time there is a suspicion of serious future illness. Often the urine is changed into a red color or into a color like the washings from fresh meat; sometimes the woman’s appearance is changed into a gray or leaden color, or into the color of grass.

CHAPTER 1

ON THE RETENTION OF THE MENSES

If the menses are lacking and the woman is thin in body, the vein that is under the inner arch of her foot, the internal saphenous, should be lanced. On the first day from one foot, on the following day from the other foot—the blood to be drawn as the case demands. In every sickness general care must be taken and regard must be shown that the patient be not too much weakened. Galen reports the case of a woman whose menses had been lacking for nine months and her body had been tense and thin and her appetite had failed completely; he himself drew out her blood from the aforesaid vein for three consecutive days. He took from one foot on the first day one pint, on the second day one pint from the other foot, on the third day eight ounces from the first foot again and in a short interval her color and lively warmth returned with improved condition of the whole body. Moreover since the bowels are constipated as often happens in suppressed menses, one should make small pills of a certain efficacious medicine and sharpen them to the extent that she will be able to support their sharpness and give them to her. Then let blood be drawn from the internal saphenous vein. Let her be bathed and after the bath let her drink calamento, or catnip, or mint cooked with honey in such proportion that there be seven parts of water and nine of honey. Let her bathe often and after the bath let her drink a diatesseron with the decoction of honey and water. Diuretics are helpful also—fennel, wheathead, parsley, ciminum, ameos, carui, rock parsley, and the like. All these herbs or each separately cooked in wine and drunk are a help. Galen’s prescription is "wormwood rubbed in wine or cooked in it, if drunk, helps greatly." It is some help too if in the bath catnip is drunk, or if it be cooked in the bath; or let a trodden green plant be tied over the abdomen either below or above the navel. Or let it be cooked in a pot covered with a perforated gall bladder and let the woman sit over it covered in all directions or let the steam go out through a reed or a tube so that the steam being received within may penetrate to the womb. Wormwood also is efficacious mixed with thapsia, skirwort, salvia, wild marjoram, ciminum, ameos, nettle, honey, pennyroyal, dill, betonica, anise, savory, and privet. Let all of these or any of them be cooked in water, then take a little wool shredded so fine that it is like powder, dip it in that water, and while hot apply it all to the abdomen. Do this frequently. The best remedy for producing the menses is to take an equal quantity of flammula, hemlock, castorei, myrrh, century, and salvia; let a powder be made and let one dram be given in water in which nettle and myrrh have been cooked. Let her drink this in her bath, one scruple to be taken at a time. If however the womb has hardened so much that by these means the menses cannot be produced take the gallbladder of a bull or some other gallbladder and powdered soda and let them be mixed with juice of parsley or of hyssop. Let it be soaked into shredded wool and pressed so that it is firm and long and of a size to be inserted into the vulva, and let it be inserted. Or let a hollow pessary be made in the shape of a man’s penis and in it let the medicine be placed so that it can be injected.

CHAPTER 2

CONCERNING SCANTINESS OF MENSES

There are women who, when they come to the time of the menses, have none or a very slight amount. These patients we help in this way: take the red roots of willow, the kind of which baskets are woven and crush them after cleaning them well of their outer bark. When crushed blend them by cooking with wine or water and the next day give a warm draught of the decoction for drinking. If she is suffering very severely you will give her food prepared in the following way: grate a rather large carrot and a mallow, mix with barley flour and whites of eggs, and of all this make small curls or noodles. Herbs of this sort are also efficacious when suffumigated for producing menstruation, or add to the same mixture verbena and rue crushing them vigorously, or cook them with bacon fat and give to the patient for food. Also grate the root of a delicate willow and a rather large carrot and give the juice with wine to the patient. If women have scanty menses and emit them with pain, take one dram each of betonica, pennyroyal, centonica, and wormwood; let them be cooked down to one-half in wine or water. Strain this through a cloth and let it be drunk steaming hot. If the menses have been absent for a long time, make a powder of two drams of rhubarb and one dram each of wormwood and pepper; let her take this morning and evening for three days and let her cover herself so that she sweats. Also take one dram each of mint, pennyroyal, and rue, four drams of grain salt, five drams of red caulis, and three heads of leek. Cook all of these together in a clean pot and let her drink it in her bath. Another remedy is this: take a root of iris, catnip, rue, coloquintidam, and fennel; clean them well, cook them in wine, and give the wine to the woman to drink. Or cook the following in wine: juniper, parsley, fennel, rock parsley, lovage, and catnip, and let it be drunk. Also take tansy, clover, and wormwood cooked with butter and place over the navel. A certain doctor in the region of Francia did this: he took leaves of laurel and ginger and ground them together in a clean pot; he put this mixture over live coals under a perforated seat and over this he let the woman sit. She took in the smoke from below and thus made the menses begin. It may be necessary to do this thrice or more times. However let the woman who habitually practices fumigations of this sort anoint her vulva inside with cold ointments lest she be irritated. For the aforementioned fumigation the following are also efficacious: ciminum, fennel, dill, calmento, mint, and nettle either all mixed together or one alone. For bringing on the menses massage is helpful, and likewise coitus. However, bloodletting is injurious. Let her eat, if she be without fever, leeks, onions, pepper, garlic, ciminum, and scaly fish. Let her drink strong wine, if she be without pain in the head and without weakness of muscles and without fever, because in all fever wine is injurious.

. . . . . . .

CHAPTER 11

ON THE HINDRANCES TO CONCEPTION AND OF THE THINGS WHICH MAKE FOR IMPREGNATION

Certain women are useless for conceiving either because they are too thin and lean or because they are too fat. In these latter the flesh folded around the opening of the womb binds it and does not permit the seed of the man to enter it. Some have a womb so soft and slippery that the seed having been received cannot be retained in it. Sometimes this happens through a defect of the male who has seed so thin that when it is poured into the vagina it slips out because of its own liquidness. Some men also have testicles cold and dry; these men rarely or never beget, because their seed is useless for procreation. It is evident therefore that conception is hindered as often by a defect of the man as of the woman. If it is by a defect of the woman it happens either from excessive warmth or from excessive moistures of the womb. Sometimes on account of its natural softness the womb cannot retain the seed injected into it, and often because of its excessive moisture it suffocates the seed. Often because of its excessive heat the womb burns the seed up and she cannot conceive. If for these reasons she cannot conceive these will be the signs: The lips of the vulva appear ulcerated and as if chapped by the north wind. There will be red spots, continuous thirst, and falling out of the hair. When we have observed these symptoms and the woman has passed thirty years we judge her incurable. If she is very young and the ailment not of long standing you may help her thus: Take mallow and mugwort cooked in water and douche the patient three or four times with this decoction. Between these douchings you will use suppositories and also pessaries for the vulva with oil of weasel and a small quantity of moss that the womb may be relieved. On the seventh day after the purgation or douching take from a great plant which bears thrice a year a fruit in the shape of an acorn and wrap it in silk. Make it into a suppository for the vulva that by its beneficient action and by the many douches she may receive some relief, assuagement, and softness. On the following day you will arrange that she have intercourse with her husband. It will be expedient to employ the same procedure the following week—the douchings and the other pleasant things we have mentioned. Do this until symptoms are relieved and tell her to have intercourse two or three times a week because thus she will be able to become pregnant more quickly. If she cannot conceive because of excessive moisture of the womb these will be the signs: Her eyes will be continuously tearful for since the womb is frequently tied up with the sinews it is necessary that the brain suffer with the womb. If the womb is too moist the brain is filled with water and the moisture running over to the eyes compels them involuntarily to shed tears. Since the brain suffers with the womb, the estrangement of the womb is indicated by the retention of the menses. Therefore purge her first with broken doses of Theodorics, or have Paulinius’ made and wrapped in silk so that they may not dissolve. Insert as carefully as possible through the private parts. If the womb has not been well purged you should the next day make a pessary from a thrice bearing plant and add a small quantity of musk. Continue this until you know that the excess moisture has been evacuated. Later take a little musk with oil of weasel or some other strong smelling oil and insert it through the vulva. If she has been well purged she will taste the odor and if one kissed her he would think she were holding musk in her mouth. She will know it too because she will feel thirsty. When she is thus well purged let her have intercourse frequently and she will conceive.

If conception be hindered because of a defect of the male it would be from a lack of force impelling the sperm, a defect of the organ, or a defect of heat. If it be from a defect of heat, the sign is that he is not eager for copulation. Hence he ought to anoint his loins with arrogon or take seed of colewort and euphorbia and reduce them to a fine powder. Then mix them with the oils of fleabane and of weasel and with this anoint his loins. If it happens through a defect of the spirit the sign will be that he has desire but the penis is not erected. We aid him with an ointment that generates spirit. If it happens through a defect of the sperm the sign is that when he copulates he emits either none or too little seed. We aid him with things that increase sperm such as orris, domestic parsnips, and the like.

If the woman or the man be sterile you will ascertain it by this method: take two jars and into each put bran. Into one of them put the urine of the man and into the other put the urine of the woman and let the jars be left for nine or ten days. If the barrenness be from a defect of the woman you will find many worms and the bran foul in her jar. On the other hand you will have similar evidence from the other urine if the barrenness be through a defect of the man. But if you have observed such signs in neither urine neither will be the cause of the barrenness and it is possible to help them to conceive by the use of medicines. If they wish to have a male child let the man take the womb and vulva of a hare and have it dried and pulverized; blend it with wine and let him drink it. Let the woman do the same with the testicles of the hare and let her be with her husband at the end of her menstrual period and she will conceive a male. Another remedy is this: Take the livers and testicles of a little pig—one which the sow bore alone—and let them be dried; make a powder of this and give it in a drink to the man and woman who cannot conceive and they will procreate. Also if the woman wishes to become pregnant let her take the dried testicles of a boar pig or wild boar reduced to powder. Mix this with wine and let the woman drink it at the end of her menstrual period and when she copulates with her husband she will conceive.

"Note," says Galen, "that women who have narrow vulvas and tight wombs ought not to have husbands lest they die if they conceive." But since they cannot all abstain they need our help. If one of them for fear of death dare not conceive let her carry on her naked flesh the womb of a she-goat which has never had offspring. A certain stone is found called Galgates which, worn on the neck or even tasted, prevents conception. Also remove the testicles from a weasel and let it be left alive. Let the woman carry these testicles with her on her bosom tied in the skin of a goose or in some other skin and she will not conceive. If she has been injured in childbirth and for fear of death does not wish to conceive again, let her lay on the last afterbirth as many grains of cataputia or of barley as the years which she desires to remain sterile. If she wishes to remain barren forever let her lay on a handful.

CHAPTER 12

ON THE FORMATION OF THE SEED WHEN CONCEIVED

In the first month occurs a small clot of blood. In the second occurs the formation of the blood and of the body; in the third the nails and hair are produced. In the fourth motion and therefore women are nauseated. In the fifth the foetus receives the likeness of father or mother. In the sixth, the binding together of the sinews. In the seventh, the bones and sinews are strengthened; in the eighth nature helps and the child puts on flesh. In the ninth, it proceeds from darkness into light.

CHAPTER 13

ON THE POSITION OF THE FOETUS IN THE MOTHER’S WOMB

Galen gives the report that the foetus is fastened in the womb just as the fruit is on the tree, which when it comes forth from the blossom is very tender and falls from any occasion whatsoever. When it has become full grown, riper, and established, it clings to the tree and will not fall on slight occasion. When it has become completely ripe it will fall of itself and not of any other occasion. Thus when a child is first produced from a conceived seed the ligaments by which it is fastened to the womb are tender and unfirm and therefore it is easily let fall by abortion. On account of a cough, diarrhoea, dysentery, excessive activity or anger, or loss of blood, a woman can lose her foetus. But when a soul or life has been infused into the child it clings a little more firmly and does not slip quickly. When the child has ripened it is quickly let out by the office of nature. Hippocrates says that if a woman requires bleeding or purgation, you should not do these things before the fourth month. In the fifth or sixth months she can be bled or purged cautiously, if there be necessity, with a mild cholagogue or decoction according as the strength of the patient shall be able to tolerate. Beyond and before this time an evacuation will be dangerous. When the time for parturition has arrived the child moves more violently and struggles toward the exit. Nature in its own time causes the vulva to be opened, the foetus finds its own exit and thus it is expelled by the force of nature from its own resting place, the afterbirth.

CHAPTER 14

ON SIGNS OF PREGNANCY

For knowing whether a woman is carrying a male or female child take water from a spring and let the woman draw out two or three drops of blood or of milk from the right breast. Let them be poured into the water and if they seek the bottom she is bearing a male; if they float on top she is bearing a female. Hippocrates said that the woman who is bearing a male is well colored and has the right breast larger; if she is pale she is bearing a female and has the left breast larger.

CHAPTER 15

ON REGULATIONS FOR PREGNANT WOMEN

When a woman is first pregnant care must be taken that nothing be named in her presence which cannot be had because if she shall ask for it and it not be given to her she has occasion for miscarrying. But if she should seek to have potter’s earth or chalk or coals, let beans cooked with sugar be given to her. When the time for parturition is imminent the woman should be bathed often; anoint her abdomen with olive oil or oil of violets and let her eat light and digestible foods. If her feet have swollen, let them be anointed with oil of roses and with vinegar. Instead of heavy foods let her eat quickly digested things like citrons and pomegranates. If her abdomen is distended with flatulence take three drams each of parsley seed, ameos, mint, mastic, garyophyllous, cardamon, roots of carrots, coffee, galangale, iris, and five drams of sugar; make a very fine powder and cook it all with honey; give three scruples to her with wine for this substance removes flatulence and prevents abortion if properly taken.

CHAPTER 16

ON THE REGULATIONS FOR THE WOMAN ABOUT TO GIVE BIRTH

When the time for giving birth is imminent, let the woman prepare herself as the custom is, and the midwife likewise. Let sneezing be done with great caution, holding tightly the nostrils and the mouth, in order that the greatest part of the strength and spirits may tend toward the womb. Give her a decoction of chick peas, a paste of flax and psyllium as an antidote, or another remedy is a mixture of four ingredients with a decoction of mugwort in wine. Likewise make troches of galbanum with asafoetida and myrrh or rue; from this make a fumigation for the nostrils. Above all things let her guard herself from cold. Let an aromatic fumigation be made below the nostrils; it can also safely be applied at the mouth of the womb because then a fragrant womb follows and an ill smelling one is avoided. For this purpose fragrant kinds of substances avail as musk, amber, wood of aloe and the like for rich patients, and fragrant herbs as mint, pennyroyal, calamentum, wild marjoram and the like for the poor. It is to be noted that there are certain physical remedies whose virtues are obscure to us, but which are advanced as done by midwives. They let the patient hold a magnet in her right hand and find it helpful. Likewise they let her drink a powder of ivory or they find that coral suspended on the neck is helpful. In similar fashion that white substance which is found in the dung of an eagle, when given in drinks is advantageous. Likewise give the dung of babybirds which is found in the swallow’s nest. Washings of this are serviceable for this and for many other purposes.

CHAPTER 17

ON DIFFICULTY OF PARTURITION

There are, however, certain women so narrow in the function of childbearing that scarcely ever or never do they succeed. This is wont to happen for various reasons. Sometimes external heat comes up around the internal organs and they are straightened in the act of giving birth. Sometimes the exit from the womb is too small, the woman is too fat, or the foetus is dead, not helping nature by its own movements. This often happens to a woman giving birth in winter. If she has by nature a tight opening of the womb, the coldness of the season constricts the womb still more. Sometimes the heat all goes out of the woman herself and she is left without strength to help herself in childbearing.

In the first place and above all things when there is difficulty in childbirth one must have recourse in God. Descending then to lower means, it is helpful to the woman in difficult labor to be bathed in water in which has been cooked mallow, chick peas, flaxseed, and barley. Let her sides, abdomen, hips, and flanks be rubbed with oil of roses or oil of violets. Let her be rubbed vigorously and let vinegar and sugar be given her as a drink, and powdered mint and a dram of absinth. Let sneezing be provoked by placing dust of incense in the nostrils, or powder of candisium, or pepper or euphorbia. Let the woman be led with slow pace through the house. Do not let those who are present look in her face because women are wont to be bashful in childbearing and after the birth. If the child does not come forth in the order in which it should, that is, if the legs or arms should come out first, let the midwife with her small and gentle hand moistened with a decoction of flaxseed and chick peas, put the child back in its place in the proper position. If the child be dead take rue, mug-wort, absinth, and black pepper and give this pulverized in wine or in water in which lupins have been cooked. Or let savory be mashed and bound over the abdomen and the foetus, whether dead or alive, will come forth. Verbena drunk with wine, water, or vinegar does the same thing. Or let sea water or rose water be drunk with an equal quantity of ass’s milk. Or let butter be mixed with honey or wine and given to her to drink. If the birth is still delayed or if the foetus is dead in her and is not released, take rue, mugwort, opoponacum, and absinth with a little oil and let a small quantity of sugar be mixed with it. Place it over the loins and above the navel and it will be very efficacious. Likewise let the woman be girt with the skin of a snake—one which a snake has cast off. The stone "Aetiteo," tied to the thigh, produces the same effect. Or let the root of agourd be tied to her kidneys and have the foetus be taken away as soon as it comes out lest the womb come out after the emergence of the child. Also those who are in difficult labor must be aided in the following manner: Let a bath be prepared and the woman put in it; after she has come out let a fumigation be made of wheat and similar aromatics for comforting and relaxing. Let sneezes be produced with white hellebore well reduced to powder. Colphon says to let the limbs be shaken to break the bag of water and in this way the foetus will come forth. Thus also those may be aided who are laboring much to bring forth a dead foetus: Let the patient be placed in a linen cloth stretched by four men at the four corners with the patient’s head somewhat elevated. Let the four corners be strongly drawn this way and that by the opposite corners and she will give birth immediately, God favoring her. If the afterbirth has remained within there is need of haste that it shall come out. Let sneezing be provoked with mouth and nostrils shut. Or take lye made from ash tree ashes and mix it with one dram of powdered mallow seed. Give this to the woman to drink and she will immediately vomit. Or give mallow seed powder alone in a drink of hot water and if she vomits it will be a good thing. Also let her be fumigated below with bones of salted fish or with horses hoofs, or with the dung of a cat or lamb. These things bring out the afterbirth. Also let those things be done which have been mentioned before for bringing forth menstruation. If difficulty in childbirth should result from tightness of the mouth of the womb, the cure of this is more difficult than anything else, therefore we subjoin this advice: let the woman take care the last three months in her diet that she so use light and digestible foods that through them the limbs may be opened. Such foods are egg yolks, the meat and juice of chickens and small birds—partridges and pheasants, and scaly fish of good flavor. Let her often take a bath in fresh water to which has been added herbs of softening character such as matura and the like. Let her avoid a bath tinctured with copper and calcium. When she comes out of the bath, let her be anointed with hot ointment such as oil of laurel, oil of flaxseed, or the grease of goose, duck, or hen. Let this anointing be done from the navel down.

^1. Reprinted by permission of Elizabeth Mason-Hohl, M. D., from Trotula of Salerno, The Diseases of Women, translated by Elizabeth Mason-Hohl, M.D. (Los Angeles: Ward Ritchie Press, 1940), pp. 1–3, 5–8, 16–25.

The "Trotula" to whom this work is ascribed was already spoken of in the twelfth century as a woman who had practiced medicine at Salerno perhaps a hundred years before. The present text does, in its original form, go back to eleventh-century Salerno, and we have undoubtable evidence that there were women practicing there by the fourteenth century at the latest. But the historical existence of Trotula herself (traditionally supposed to be the wife of the Salernitan physician Johannes Platearius) and her authorship of this work remains moot: For a balanced judgment, see H. P. Bayon, "Trotula and the Ladies of Salerno," Proceedings of the Royal Society of Medicine, XXXIII (1939–1940), 471–474. Whoever the author, the treatise "taught the professional handling of gynaecological and obstetrical conditions in a manner . . . more enlightened than was usual at that time" (compare the little work of Constantine the African in the following selection); nor was it superseded in the later Middle Ages. Yet The Diseases of Women remains quite revealing of the first stage in the developing medieval medical tradition: Heavily practical, it preserves disorganized scraps of classical knowledge (attributed to Galen or Hippocrates) but is largely ignorant of and unconcerned with theoretical explanations.