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May 27th, 2021 
Awake Goy The Trotula is a very well-known 12 th century text, originally written for male medical practitioners treating gynecological or obstetrical issues, which reveals a great deal about how people perceived sickness, health, and the circle of life during the medieval era. The modern perception of medieval medicine is generally that it was crude and barbaric, and there was very little or no knowledge of “real” medical science at all in the Middle Ages. But, to what extent is this actually true?
If we take a closer look at medieval medicine, we can see that while some of the ideas about illness and treatment regimens may have been misguided, they were nonetheless based on very extensively researched pseudo-scientific theories dating back to the Classic Age. Some of these theories were so predominant in medical science as to define Western medicine for over one and a half millennia.
Most interestingly though, is how medieval people thought about and practiced women’s medicine, meaning obstetrics and gynecology. Up until the High Middle Ages, this field of medicine had been solely the province of midwives and other female practitioners, but around the 12th century things began to change and male doctors took over responsibility for treating so-called “women’s conditions.”
The Trotula on display at the Bibliothèque Nationale de France in Paris. Source: Public domain
The Trotula: A Medieval Textbook on Women’s Medicine
Perhaps the most famous medieval textbook on women’s medicine is the Trotula, which was written in the 12th century in the southern Italian town of Salerno. It consists of three books and was most likely composed not by one person, but by a group of masters in medicine known as the School of Salerno. The first book however, entitled On the Conditions of Women , states in the preface that it’s author was impelled to write by “the influence of a certain woman stirring my heart,” implying that it was composed by a single author.
Medical doctors in the Middle Ages were always male and received formal education in their field. Surgeons however were uneducated laypeople who often had no formal training whatsoever and were little better than butchers. A surgeon would usually only be called to see a patient as a last resort, as most of their patients did not survive surgery. Medical doctors would sometimes be priests or members of the clergy as well, men of religion were very well-educated in the Middle Ages, but clerics and priests could not practice as surgeons because they were forbidden by the Church to participate in any blood-shedding activity.
Spirituality was an important part of medical practice, so it was expedient to have a practitioner who was knowledgeable in both areas. Medieval people did not perceive a difference between illness of the mind or spirit and illness of the body. One was intimately connected to the other and if the mind suffered so would the body, and vice versa. A certain level of “magical thinking” was involved in the way medieval people perceived sickness and health, such as believing that certain ailments could be caused by demons or that illness could be cured by divine intervention procured by praying to God or to a particular saint. For example, women having difficulty conceiving would pray to St. Anne or the Virgin Mary , both patrons of fertility.
There was however somewhat of a divide between the way the Church perceived sickness and health, and the way that “scientific” practitioners of medicine thought about them, and this divide is perhaps most evident in the field of women’s medicine. The perceptions of the general population were more heavily influenced by the ideas preached by the Church, but that is not to say the art of medicine was completely unaffected by Christian teachings either.
Image of woman giving birth from the 1500s. ( Public domain )
Medieval Women’s Medicine: Impurity of Body, Impurity of Spirit
One of the issues of greatest consternation to the medieval Church was that of menstruation. While most people in the Middle Ages would have recognized to some degree that menstruation was a natural bodily function and necessary for childbearing, the general view of menstruation was that it had a polluting effect and therefore women during their menses should be shunned or avoided.
It was for this reason that women were often discouraged, or openly prohibited, from entering a church while menstruating. Many female saints were also said to not menstruate at all, as a sign of their spiritual purity, and much debate went on between theologians as to whether the Virgin Mary menstruated or not, seeing as she had been able to conceive and bear the Christ child.
Medical textbooks however, such as the Trotula, describe menstruation as being a very normal, necessary physical process. Women were inherently accepted as being the “weaker sex” and therefore more prone to fragility and sickness, particularly ailments of the organs involved in reproduction and childbearing. Women were also not given to undertake hard physical labor in the medieval period, as it was thought that they were too weak to tolerate it. While men were able to “purge” their bodies of ill humors through sweat, women must purge their bodies by menstruating.
The Trotula recognizes several causes for paucity or excess of menstruation that agree with modern medical diagnoses. If a woman is dangerously underweight, her menses may be deficient or cease altogether, and excessive bleeding during menstruation may be caused by vascular disorders of hemorrhaging. But the similarities with modern medical science ends here. The main causes of menstrual disorders, according to medieval thought, was an imbalance of humors.
Female healer with a urine flask from the Trotula. (Wellcome Collection / CC BY 4.0 )
Hippocrates and Humorism Underlying the Trotula
The underlying theory that influenced every aspect of medical practice during the Middle Ages was that of humorism. Hippocrates, the famous classical Greek physician who was born in the 5th century BC, invented the idea of the four humors: blood, phlegm, yellow bile and black bile. These correspond to the four elements – earth being represented by black bile, fire by yellow bile, and water by phlegm, while blood is a mixture of all four elements.
Hippocrates’ theory was expanded on by a Roman physician, Claudius Galen , whose theories on humorism would go on to define Western medicine for over 1,500 years. Born in Pergamum in 129 AD to a wealthy family, Galen studied philosophy in his 20s and then went on to become a scholar of medicine, being appointed to the prestigious position of physician to the emperors Commodus and Septimius Severus. Galen created the theory of the four temperaments, which remained the predominant theory behind Western medicine until the 17th century. The four temperaments were sanguine, choleric, melancholic, and phlegmatic.
Hippocrates’ four humors were thought to be related to heat and moisture, so a predominance of certain humors made one’s temperament hot or cold and moist or dry, and not only defined their personality traits but also their physical robustness or fragility. Men, as the stronger sex, were thought to be hot and dry (choleric), while women were considered more cold and wet (phlegmatic).
Almost every diagnostic method, and many treatments, outlined in the Trotula are based upon the theories of Hippocrates and Galen. For example, excessive menses can be caused by “excessive heating of the blood caused by bile pouring out from the gall bladder” and so the treatment would be to draw blood from the hand or arm so as to provoke the corrupt humors upwards and away from the womb. Conversely, “suffocation” of the womb caused by “frigidity of the heart” or abundance of cold fumosity from buildup of semen can be treated by applying hot ointments to the vagina, such as iris, chamomile, and musk, or by applying heated cupping glasses to the pubic area.
In the 12th century, the field of women’s medicine was still fairly new to male physicians, as it had been the province of female practitioners such as midwives for hundreds of years. Many of the treatments recommended in the Trotulaare not based on the “science” of humorism and are instead more superstitious in nature, having been handed down through generations of female practitioners. For example, to treat an excess of menses: “take two wide slabs of salted bacon, and let powder of coriander together with its seed be sprinkled on top, and powder of wormwood. And let one slab of bacon be tied upon the navel and the other upon the loins.” The author confesses that some of these midwives’ remedies “whose power is obscure to us” are nonetheless helpful, such as drinking ivory shavings, wearing coral around the neck, or holding a magnet in the right hand to assist in difficult childbirth.
A medieval birthing scroll with Christian prayers on both sides, used to protect women during pregnancy and childbirth. (Wellcome Collection / CC BY 4.0 )
The Trotula and Infertility
Other than menstruation, the Trotula is largely concerned with is pregnancy and childbirth. The primary role of women in medieval European society was to bear and raise children, but it was also the most difficult and dangerous activity most women ever undertook. Mortality rates for both women and babies were extremely high during pregnancy and childbirth, and if the unfortunate choice had to be made between saving the life of the mother or the child, the mother’s life was seen as the priority so that she could go on to bear more children in the future.
Of course, fertility is a delicate thing and not every woman was capable of conceiving a child and carrying it to term. The medieval Church taught that infertility was a punishment from God for sin, such as adultery or fornication, or the work of demons or witchcraft, which drove the societal perception that if a couple could not conceive then the woman was to blame.
As such, treatments often included the use of talismans or remedies to repel evil or appeal to the supernatural, such as the use of birthing girdles. Birthing girdles were made from different materials, such as silk, iron, or parchment roll, and could be inscribed with prayers or religious symbols which would then be wrapped around the belly and groin of the pregnant woman.
Medical practitioners however, took a more rational approach to infertility and saw it as a medical condition to be treated. From a medical perspective, infertility could be a condition of either men or women, and was usually caused by a humors imbalance or by physical impediments, such as a woman being over or underweight, having a “slippery” womb unable to retain seed, or a man having excessively thin semen that slips out of the womb.
To determine the source of the problem when a couple could not conceive, one had to fill two pots with wheat bran and put the man’s urine in one and the woman’s urine in the other, then leave them sit for 9 or 10 days and at the end of this time, if one pot has worms in it and stinks then it will indicate which of the couple is infertile. However, if neither pot is found with worms, then there is no defect and the couple can be aided in conception with medicine.
Contraception and Conception in the Trotula
Most books on medieval medicine are hesitant to discuss methods of contraception, as it contradicts the teachings of Christianity and God’s command to “be fruitful and multiply.” Some textbooks spoke of “methods to ensure conception” by not doing certain things, thereby implying possible methods of contraception. The Trotula is more forthright in suggesting how conception might be avoided, acknowledging that childbearing might be dangerous, even deadly, for some women who have “narrow vaginas and constricted wombs.”
In such cases, the medieval text recommended these women avoid having sex with men. However, in the case of those unable to abstain, the Trotula claimed that conception could be prevented by carrying “against her nude flesh the womb of a goat which has never had offspring,” or tasting a gagates stone, a black mineraloid from the estuary of the river Gages in Anatolia, in modern-day Turkey. These were therefore methods of contraception in the medieval era.
Methods for promoting conception were outlined in far greater detail, including remedies to ensure conception of a male child (no such remedies are given for a female child) such as a woman drinking powdered testicles of a male hare before intercourse with her husband. Interestingly, medieval people thought that the sex of the child would be determined by where in the uterus the embryo became implanted.
If the fetus implanted on the right side, the child would be male and this would be visible by outward signs in the pregnant woman, such as high color and a bigger right breast. Likewise, if the fetus implanted on the left, the child would be a girl and the pregnant woman would be pale with the left breast bigger than the right. Hermaphrodites were thought to be born when the fetus implanted in the center of the womb, and thus were seen as a natural occurrence by medical practitioners, rather than an abomination.
While a 21st-century reader may find some of these concepts of medieval medicine humorous or ridiculous, it is worth noting that many of the theories upon which these ideas were based remained dominant in Western medicine until as recently as the 19th century, and were thought to be the pinnacle of medical science. Some of these medieval superstitions, particularly those regarding fertility and childbirth, are still around today, lingering in our cultural sub-conscious as old wives’ tales. While it is certainly fascinating to discover how medieval people understood sickness and medical treatment, we can simultaneously be thankful that medical science has advanced to a much more sophisticated level in the modern era.
Top image: The diagnostic methods and treatments in the Trotula are based on the theories of Claudius Galen and Hippocrates, shown in this 12 th century mural from Anagni in Italy. Source: Nina-no / CC BY-SA 2.5
By Meagan Dickerson
References
Fiddyment, S., Goodison, N. J., Brenner, E., Signorello, S., Price, K. and Collins, M. J.. 2021. “Girding the loins? Direct evidence of the use of a medieval English parchment birthing girdle from biomolecular analysis.” Royal Society Open Science, 8.
Fullerton, J. B., and Silverman, M. E.. 2009. “Claudius Galen of Pergamum: authority of medieval medicine.” Clinical Cardiology, 32.
Green, Monica H., ed. 2001. The Trotula: a medieval compendium of women’s medicine . University of Pennsylvania Press.
Nam, J. K. 2016. “Social Perception of Infertility and Its Treatment in Late Medieval Italy: Margherita Datini, an Italian Merchant’s Wife.” Korean Journal of Medical History 25.
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