Nor did she have any scruples about showing him every part of her body as freely as she would have displayed it to a woman, provided that the nature of her infirmity required her to do so.1
Boccaccio’s description of the ravages of the Black Death in Florence in 1348 is one of the most memorable we have, precisely because of his acuity in depicting the collapse of social order. One casualty of the chaos of this first great wave of the plague was sexual propriety: a patrician woman would now deign to show her body to a male servant, ‘provided that the nature of her infirmity required her to do so’. Given Boccaccio’s succinct (and I believe accurate) insight into the problem of sexual shame in medical practice, we may find it surprising that well before the onslaught of the Black Death in the mid fourteenth century, men had successfully expanded their gynaecological care of women beyond the levels we witnessed in twelfth-century Salerno. The Salernitan texts on women’s medicine—now combined into a single ensemble called the Trotula and owned (as we shall see) by the same elite Latinate physicians, surgeons, clerics, and other litterati who read and used Latin medical texts in general—played a key role in establishing this competence.2 Granted, thirteenth- and fourteenth-century physicians’ and surgeons’ interests in women’s health could be described as timid, with little innovation ‘outside of the box’ of the nosological categories or therapeutic traditions they had inherited from their Arabic sources. The fact that no new specialized gynaecological texts were composed for over one hundred years after the Trotula is itself testimony to the lack of intellectual energy invested in this field. Nevertheless, we find tentative signs of a growing confidence.
Looking for ‘innovation’ in medieval medicine may seem a modernist and anachronous endeavour when dealing with an intellectual system that valued authority and considered successful synthesis and emulation of one’s predecessors to be a laudable goal. Yet, as I will argue, there are two areas of engagement with women’s health where we can see the growing expertise of male practitioners. Here, the distinction between internal medicine (the province of the physician) and surgery (which took as its task care of the surface of the body and the rectification of lesions, growths, and fractures) becomes important. Control of diet and prescription of drugs, on the one hand, involved a very different kind of interaction with the patient than the hands-on work of surgery, on the other. Among physicians, male involvement with women’s health rarely moved much beyond intervening in cases of menstrual difficulties, certain uterine conditions, and fertility problems and, to a far lesser extent, offering recommendations for difficult birth. This was all a ‘hands off’ kind of gynaecology similar to the Salernitans. Yet suddenly, in the early fourteenth century, physicians connected to the medical school of Montpellier (which, along with Bologna and Paris, had long since superseded Salerno as the chief centre of medical teaching in Europe) began to make expanded claims to be able to diagnose and treat infertility. This would in fact be the major focus of male physicians’ gynaecological concerns right into the fifteenth century and would serve as the opening wedge for their expanded competence in women’s healthcare. For surgeons, we find a slow progression rather than a sudden leap, a gradual adding on by a series of writers who (with one exception) do not seem to have systematically problematized women’s medicine per se. In the twelfth century, surgical involvement with women’s particular conditions was limited to the breasts; late in the following century, surgeons’ attention turned to the female genitalia, and then only as a delayed reaction to the influence of their Arabic authorities. Obstetrical intervention developed somewhat differently: although not explicitly incorporated into surgical writing until after the mid fourteenth century, already c. 1300 there are signs that males were turned to for aid in obstetrical emergencies. Despite these different trajectories of physicians’ and surgeons’ involvement with women’s health, both areas show an increased confidence among male medical practitioners in claiming expertise in women’s health.
That said, Boccaccio’s passing remark is revealing because it captures the key, though usually unarticulated, barrier to the expansion of male practice of women’s medicine: the problem of sexual shame. As at Salerno, so throughout the rest of Europe social conventions about female honour and male–female relations, while never excluding men from either speculating about or actually practising medicine on female patients, did significantly complicate the practice of women’s medicine by men. We have no lack of evidence that men were involved in women’s healthcare on a general level throughout the high and late medieval periods. From the Salernitan Peter Borda who was identified in 1086 as the personal physician of Sichelgaita, widow of the Norman lord Robert Guiscard, all the way up to the end of the medieval period, male practitioners can be readily identified who treated and served as personal physicians to queens, duchesses, and other noblewomen. Indeed, from the fourteenth century on, it would probably be difficult to find a high-ranking woman who was not attended by a male practitioner at some point in her life. Nor was it just aristocratic women who employed men. Throughout southern Europe, we find heads of households as well as religious institutions entering into contracts with physicians or surgeons to provide them with regular medical care. These would often specify that care was to be provided for the women and children of the family, and we have numerous documentary cases where female patients, both adults and children, were indeed cared for by male practitioners. Iconographically, this normativeness of male medical practice is seen in such unexpected contexts as a beguine’s psalter from Belgium c.1300, which has a set of month-by-month health rules, and, in the lower margin of the same page, two women shown taking their urine to a male physician for examination (Fig. 2.1).3 An early fourteenth-century Viennese beguine, Agnes Blannbekin, describes as quite normative how one might go to the marketplace to seek out an apothecary for medicaments, just as one would go to a victualler for food or a merchant’s shop for various goods. She also describes as quite routine her experience of being phlebotomized by a male bloodletter.4 A collection of medical texts from early fourteenth-century Germany made, apparently, as a page_personal manual of practice for one Gotefridus, includes a handsome depiction of a male physician taking a female patient’s pulse (Fig. 2.2).5 This richly clothed, obviously well-off woman shows how male medical ministrations could be delivered without any compromising unveiling or undressing.
FIG. 2.1 Set of month-by-month health rules in a beguine’s psalter; in the lower margin, two women take their urine to a male physician for examination.
FIG. 2.2 Male physician taking female patient’s pulse.
Even this image, however, with patient and practitioner locked in direct eye contact, is suggestive of the dangers. If taking a woman’s pulse was problematic, how much the more complicated must any kind of gynaecological examination have been? The seeming irreconcilability of the problem of shame and any cross-sex practice of gynaecology has sustained the modern myth that medieval gynaecology was an exclusively female preserve. Yet the problem of shame in the practice of gynaecology was an issue not only for women but for men as well. Male practitioners both clerical and lay were cautioned about the dangers of involvement with women and, on occasion, men might express more discomfort about cross-sex practice than women. For the sake of both men and women, therefore, the problem of sexual shame in cross-sex medical practice was solved by employing female intermediaries to perform the visual and manual tasks that the male physician or surgeon could not or would not do.
It is a reflection of the Salernitan achievement that the gendering of twelfth-century literate medicine was to persist, for it was out of Salerno that a scholastic, text-based, learned medical tradition was born, a tradition that from its very inception was gendered masculine. It was at Salerno that the commentary traditions began on, first, a mid eleventh-century medical compendium, Gariopontus’s Passionarius, and soon after on the Articella, a collection of introductory texts that served as the foundation for medical curricula in universities all over Europe. It was also at Salerno that basic texts on materia medica, diagnosis, and even medical ethics were composed, many of which (such as the pharmaceutical treatises Circa instans and the Antidotary of Nicholus, or the text on urines by the Salerno-trained Giles of Corbeil) would prove the standard manuals in their fields for over two centuries. It was also in the southern Italian Kingdom of Sicily that the formal learning that the Salernitans had honed would first be made the standard by which medical licensing was judged.6 In other words, all the features that had most characterized the work of male medical practitioners in Salerno—their literacy, their grounding in grammar, rhetoric and logic, their engagement with philosophical principles, and the social confirmation of their stature by licensing procedures—would define the learned medicine of the later medieval universities. And these, of course, were the exclusive preserve of males.7
The Trotula never became ‘school’ texts: while we can associate them with various university masters and college libraries, it cannot be claimed that women’s medicine ever became a formal element of learned medical instruction. But then neither did many other elements of practical medicine. Rather, it was on the day-to-day level of medical practice, the actual encounters with real patients, that the practising physician or surgeon needed some guidance about how to diagnose, prognose, and then treat women’s diseases. While medical writers continued the Salernitans’ practice of incorporating gynaecological and some obstetrical chapters into their general medical textbooks, the Trotula functioned for many practitioners as their chief guide to a more detailed understanding of the conditions that particularly afflicted women.
We can never know, of course, the full number of copies that once existed. But whatever their representativeness, the seventy-six extant Latin manuscripts of the gynaecological Trotula texts that date from before 1400 (including a unique Latin verse adaptation) together with sixteen witnesses of manuscripts that are no longer extant, present an imposing body of evidence.8 Of this total, about one-fifth bear witness to at least one individual or institution that owned them up through the fourteenth century (see Appendix 1). In so far as we can name the owners, the Latin Trotula were owned exclusively by men. The monk Walter of Saint George (fl. c.1286) donated two copies of the Trotula to the Benedictine Abbey of St Augustine’s at Canterbury, and at least four of his brethren followed suit in the next century. University men similarly favoured institutions with which they were associated. William Rede (c.1315–85), Bishop of Chichester and a noted astronomer, distributed some 250 books among six different Oxford colleges, giving a collection of mostly Salernitan texts including the Trotula to New College where we know medicine was actively being studied at least from the fifteenth century and possibly before.9 Simon Bredon (d. 1372), also an astronomer and sometime physician to Elizabeth de Burgh, Lady of Clare, donated his copy to Merton College.10 Henry Whitfield, who held degrees in arts, medicine, and theology, and was an ordained priest and fellow of Queen’s College, gave his copy to Stapledon Hall (later Exeter College) in 1383 or 1387. In Paris, both Gerard of Utrecht (d. betw. 1326 and 1338), a theologian, and Jacques de Padua, master of arts, medicine, and doctor of theology (fl. 1342–53), bequeathed their copies of the Trotula to the Sorbonne. Although from the fourteenth century on surgeons were more likely to use the texts in vernacular translation,11 we can find copies of the Latin Trotula in the hands of such men as a late thirteenth-century Florentine surgeon named Sinibaldus and Bernat Serra (d. 1338), surgeon to Kings Jaume II and Alfons III of the Crown of Aragon. Ecclesiastical institutions and university and college libraries also owned copies, many of them acquired as testamentary bequests. We find a copy at the hospital of Rothenburg ob der Tauber in Bavaria and one in the hands of the canons of the cathedral of Laon in Picardy, who had a long tradition of medical practice at the local hospital of Notre-Dame. And as we have already seen, even a medical layman like Charles V of France had a copy of the Latin Trotula on his library’s shelves. In fact, the only notable group who show no interest in the Trotula are those northern Italian physicians most thoroughly wedded to the Arabic authorities that began to infiltrate the university curricula in the latter half of the thirteenth century; their non-interest in the Trotula was due not to their dismissal of female physiology and pathology as an important area of knowledge, but rather to their sense that the work of Salerno had been superseded by the richer theoretical and empirical works of Rhazes, Avicenna, and others. In their own writings, they show just as much interest in offering care to their female clientele as physicians elsewhere.12 The Trotula texts, therefore, or other works that covered comparable subject matter, were owned by every sector of literate society that we usually associate with Latinate medicine in the Middle Ages.
For manuscripts of the Trotula having no ownership information, we can reasonably speculate about owners’ identities and the intent with which they would have used a treatise on women’s medicine by examining the patterns of content and form of the codices as a whole. Although in two, possibly three cases such codicological analysis raises the possibility of female use (see Chapter 3 below), the majority of Latin codices look very similar to the volumes of known male ownership—not, of course, because the same litany of texts was being copied over and over again (in only two cases can it be shown that one manuscript is a direct, text-for-text copy of another),13 but because similarly motivated readers throughout western Europe wanted to incorporate these unique texts on women’s medicine into their own handbooks.14
Most frequently, the Trotula texts are placed squarely within the mundane, pedestrian world of daily medical practice: they are surrounded by texts on urines, pulses, materia medica, medical ethics, pharmaceutical weights and measures, prognostics, some medical astrology, and, overwhelmingly, simple general therapeutics. Oxford, Pembroke College, MS 21 can be taken as an example. Written in England towards the end of the thirteenth century, it begins with Constantine the African’s treatise on stomach ailments, and then moves on to John of Saint Paul’s work on uncompounded medicines (‘simples’) and Richard the Englishman’s Anatomy. A brief excerpt from the medical poem Schola Salernitana follows, then Richard’s rules for interpreting urines (especially those of women), a regimen for maintaining health, then a tract on the nature of the semen (male as well as female). Next come works on preparation of medicinal foods and drinks, the preparation of plasters, prognostic signs, the Salernitan Conditions of Women, and then the short tract attributed to the Salernitan Archimattheus that instructed the physician how he should behave when entering the patient’s household. The volume concludes with works on urines and the proper doses of medicines, another regimen, a study of laxative medicines, and a tract on diet. Pembroke 21 is clearly a practising physician’s handbook, comprising all the principal features of medieval medical practice: diagnosis (particularly by urines), prognosis, and therapy (particularly by controlled diet and medicines). The addition of more short texts and recipes in the fourteenth and fifteenth centuries shows that the book continued to serve its role as a much-used reference. The impression codices such as this give, therefore, is that the Trotula was used predominantly by professional medical practitioners in the course of their day-to-day practice of diagnosing, prognosing, and prescribing therapies.
A second category of reader was surgeons or individuals with a particular interest in surgical learning. Twelve of the seventy-six extant codices from the late twelfth through the fourteenth century, plus one lost manuscript that was held at Titchfield Abbey by around 1400, have a distinctly surgical character or are known to have been owned by surgeons. The earliest extant copy of any of the Trotula texts, a late twelfth-century manuscript made in southern France contains, in addition to the proto-ensemble of the Trotula, a text on phlebotomy and cupping, one on cautery, and Copho’s anatomy of the pig.15 In the mid thirteenth century, a Latin versifier in England rendered the whole Trotula ensemble, together with the surgical works of Roger Frugardi (c. 1170) and Roland of Parma (c.1230), and a general text on methods of healing into a long poem on medical practice.16 The Trotula is also paired with the surgical works of Roger, Roland, and Bruno of Longobucco (writing in 1253) in a late thirteenth- or early fourteenth-century pamphlet from northern Europe.17 An Italian manuscript from the latter part of the thirteenth century includes, after the intermediate version of the Trotula ensemble (the most expansive form of the compendium), an anonymous compilation drawn from Galen and Avicenna of remedies of particular utility in surgical practice; this is then followed by further medicines and unguents excerpted from various authors including the probable scribe and owner of the manuscript, a Florentine surgeon named Sinibaldus.18 A manuscript from the first half of the fourteenth century now in Basel has as its three main texts a tract on eye diseases by the Arabic authority ‘Al
ibn ‘Isa, the standardized Trotula ensemble, and Lanfranc’s Larger Surgery, rounded out by smaller texts on medicines, weights and measures, and various recipes and disease regimens. That the compiler (or commissioner) of this manuscript may have been a cleric is suggested by the presence of Secundus’s apophthegms and by the Franciscan Herman the Friar’s historical chronicle.19 One fourteenth-century German manuscript shows the compiler’s particular interest in urogenital disorders, with its several tracts on kidney and bladder stones.20 A fourteenth-century English manuscript demonstrates equal interest in human surgery and the care of dogs and horses.21 A late thirteenth-century male surgeon (cyrurgicus) owned a copy of the standardized ensemble alongside Isaac Israeli’s work on diets and Richardus Anglicus’s anatomy; the manuscript then passed to the cathedral of Laon in the early fourteenth century where it continued to be annotated for several decades.22 Perhaps the largest surgical and gynaecological compendium produced in the Middle Ages was a volume commissioned by a cleric, Richard de Fournival (d. before 1260), a poet, physician, and high church official of Amiens.23
A third, very different codicological context can be found in a manuscript of early fourteenth-century composition, a collection of preacher’s texts and minor medical works. It situates the first two-thirds of the Trotula ensemble amid excerpts from Thomas of Cantimpré’s mid thirteenth-century encyclopedia of learning for preachers, On the Nature of Things, some texts on poetic metrics, several short treatises on urines and prognostics, Petrus Alfonsi’s Clerical Discipline (an early twelfth-century text that was often culled for anecdotes and folk tales that could be incorporated into sermons), and finally, added gradually over time, a series of short sermons. The original owners are unknown, but two monks, Heinrich and Friedrich, both of them rectors, jointly owned the manuscript in the later fourteenth century and, around 1400, they donated it to the Premonstratensian monastery of Mildenfurth in Thuringia.24
Finally, there are what could be called ‘scientific’ codices, which place the Trotula next to texts of natural philosophy: works on the elements, the heavens, astronomy, mathematics, and other aspects of science. Most of these volumes combine natural philosophical and medical texts in a way which suggests that, in addition to their need for astrological materials to aid in regular medical prognostications, owners of the Trotula texts occasionally considered themselves adept in the ways of science in general, not simply medicine. Some of the natural-philosophical associations of the gynaecological treatises came out of rather different concerns than a strict interest in women’s health; I will have more to say about these in Chapter 5.
Just as the codicological context of the Trotula was always changing, so too did the substance of the texts themselves. The Trotula were subject to a whole variety of editorial interventions that produced a total of fifteen distinct versions between the twelfth and late thirteenth centuries. The manipulations, in form and in content, that the Trotula texts underwent are too numerous to survey here, but examination of a few subtle changes can help us better understand how male practitioners addressed (or studiously avoided) the challenge of cross-sex practice of women’s medicine.25
Two aspects of the Salernitan gynaecological treatises would, one would think, have been problematic for the dozens (perhaps hundreds) of male readers of these texts: first, Trota’s Treatments for Women, written as if by a female teacher speaking to a female audience of practitioners, had assumed that its audience could engage in the same ‘hands-on’ medical practice that its author(s) freely engaged in. How did male readers ‘read themselves’ into the ‘we’ that touched, massaged, sewed and in other ways manipulated the female body? Second, vague though it was, the Conditions of Women preface raised the troubling prospect that because women’s shame prevented them from speaking freely to male physicians, the latter might be poorly qualified to serve women’s health needs. As we shall see, neither issue was openly addressed.
The problems raised by Trota’s Treatments for Women were ignored in two ways: either by reading the text and ignoring the problematic scenarios of ‘hands-on’ practice, or by ignoring the text altogether. As noted in the previous chapter, male writers normally employed passive forms or jussive subjunctives (‘let this be done’) when referring to ‘hands-on’ aspects of gynaecological diagnosis or treatment. Although one would think that the text of Treatments for Women would need to be modified to shift all the active verbs (‘we do’, ‘we mix’, ‘we apply’) into passive forms, no such systematic editing ever took place, either when the text circulated independently or when it was combined into the larger ensemble. Apparently, male readers (assuming they read these passages closely) were able to do ‘simultaneous translation’, taking themselves out of the communal ‘we’s’ of the text and instead reading these instructions as if they were posed as injunctions for an attendant—‘let this be done’. In a few cases, the ‘we’ did in fact disappear: for example, in ¶ 149 on ano-vaginal fistula and prolapse, where the author had originally referred to ‘the other things which we are accustomed to do’ as part of the general toileting the patient should perform in bed, by the time we reach later versions of the ensemble the ‘we’ has disappeared, having undergone significant deformation as the text matured.26 Perhaps more revealingly, in that same chapter the original author had admitted that the condition was caused by the inadequacies of the women assisting. But she asks that this should not be mentioned publicly, presumably so as not to air this dirty laundry outside the community of women. Already by the time we get to the second version of the text, however, the sentence reads: ‘But this thing, you know, is kept secret among women [Sed istud nosti quod cum mulieribus sit secretum]’. As revised, the statement seems to be spoken from outside the community of women, in effect exposing women’s secret to men.
For the most part, I suspect that the Treatment for Women’s ‘we’s’ were never systematically revised because there was never any systematic rethinking of how this ‘women’s medicine’ might be employed by men. Indeed, I suspect that more often readers ignored the whole text. Take, for example, a large volume, British Library, MS Sloane 1610, the bulk of which was written early in the fourteenth century. It contains the group of introductory theoretical tracts known as the Articella, plus Giles of Corbeil’s poems on pulses and urines, an anatomical work attributed to Galen, Isaac Israeli’s works on diets, fevers, and urines, and Ibn al-Jazzār’s medical encyclopedia, the Viaticum. In other words, this has the full curriculum for the study of medicine as it was structured at Paris.27 Later in the century, another hand added, into a blank space left by the original scribe, the full text of Conditions of Women followed by the chapter on impediments to conception from Archimattheus’s Practica, both of which he seems to have copied out of an early thirteenth-century copy from England that also had a complete copy of the second version of Treatments for Women.28 Yet the scribe of these addenda in Sloane 1610 (who was probably also the owner of the manuscript) copied only a single chapter from Trota’s work: the one describing how widows, nuns and vowesses suffered from their sexual continence and how they should be treated (¶141). Why copy just this one chapter and omit such sections of Treatments for Women (which likewise had no parallel in Conditions of Women) as treatments for perineal tear or uterine prolapse? It seems likely that for this scribe/owner, who added copious notes elsewhere in the manuscript on urines and fevers, the hands-on aspects of women’s medicine were simply irrelevant. As a physician, he was primarily interested in material that would aid him in his tasks of diagnosis and prescription of regimen or drugs to control health. Actually touching the female body was not part of his job. When push came to shove, it was the ‘hands-on’ material of Treatments for Women that most often was left on the wayside of transmission.
In fact, only one medical compiler in this period, the thirteenth-century author Gilbertus Anglicus (Gilbert the Englishman, fl. 1230–40), systematically incorporated any of Treatments for Women’s unique obstetrical or ‘hands-on’ gynaecological material into his own work.29 Gilbert’s large Compendium of Medicine culled material from several twelfth and early thirteenth century writers.30 He drew heavily on Trota’s Treatments for Women for his chapters on vaginal constrictives, uterine prolapse, various obstetrical conditions, and cosmetics. His failure to credit these borrowings to Trota conforms to his omission of the names of his other sources (most importantly, the Montpellierain writer Roger de Barone and the Italian surgeon, Roger Frugardi). Gilbert’s appropriation of Trota’s Treatments for Women nevertheless shows a keen eye for the originality of her therapies.
As was his wont throughout the Compendium, Gilbert used the relevant chapters of Roger de Barone’s Practical Medicine for the basic structure of his gynaecological chapters. He begins to deploy Trota’s material when he comes to the topic of ‘wind in the womb’ (ventositas matricis). He opens with the material from Roger de Barone, but then incorporates ¶ 151 from Trota’s Treatments for Women. Gilbert suppresses Trota’s name from the anecdote of her cure and recasts the account as a straightforward prescription of what any (male) practitioner should do. Intriguingly, Gilbert readily appropriates Trota’s hands-on bathing and massaging of the female patient as part of her cure by recasting them into passive forms: ‘Let a bath be made from a decoction of mallow…’, ‘Let the limbs and soles of the feet be frequently rubbed.’ And he says nothing about the practice of taking the patient into his own home to perform this cure.31 Gilbert appropriates other elements of the ‘hands-on’ therapies from Treatments for Women, though rather amazingly, he becomes quite cavalier (or perhaps simply inattentive) about not recasting some instructions into more cautious passive forms. Thus, in the chapter on ano-vaginal fistula (¶ 149), he tells his reader that you should sew the rupture with red thread and that you should then apply a fine linen cloth, smeared with pitch, onto the reconstructed perineum.32 He expands upon the several remedies in Treatments for pain after birth, inserting a long digression on how the uterus delights in holding and retaining the foetus, mourning when it looses it, and also why, based on its anatomy, the uterus is so desirous of intercourse.
There is much in Treatments for Women that Gilbert does not exploit: he skips over the chapter on treating nuns, widows, and vowesses for the consequences of their celibacy (a topic which, as we have seen, interested other users of the text); he omits the instructions for slimming down fat women or plumping up thin ones to aid conception; and he makes no use of Trota’s material on diseased fluxes from the womb. Yet given how little attention the hands-on treatments of Trota’s text would receive from other medical compilers and copyists, it is striking how thoroughly Gilbert exploits the unique cures to be found in Treatments for Women. In fact, Gilbert seems to have readily colluded with the more subversive aspects of Treatments for Women. He not simply adopts but expounds upon the patriarchally questionable instructions for ‘restoring’ virginity, adding an unapologetic justification for their presence: ‘Sometimes virgins are corrupted, whence their ‘door’ is widened as plainly happens in sexually experienced women, and they suffer repudiation and perpetual disgrace, or they are fated for divorce, in which there is danger both to men and to women’.33 He incorporates the instructions for shrinking and deodorizing an overstretched, foul-smelling vagina from Women’s Cosmetics and then incorporates all the vaginal ‘restoratives’ from Treatments for Women, even the one that Trota had rejected as an inefficient practice of ‘unclean’ prostitutes. Finally, apparently drawing on the Salernitan writer John of Saint Paul, he recommends surgical intervention if the vagina is too tight (though like John he does not clarify who is to do this surgery).34
Gilbert’s retention of so much that was unique about Trota’s interpretation of women’s medicine is thus itself unique. Given how widely disseminated the Trotula ensemble as a whole would be, it is striking how poorly the independent Treatments for Women circulated. There is only one complete extant copy of what seems to have been the original version of the text (not surprisingly, it is an English manuscript that may have partly been written in Italy), and Gilbert’s Compendium itself constitutes one of the two other fragmentary witnesses. Gilbert’s English origins may well account for his familiarity with the independent Treatments for Women and, ironically, his text did more to disseminate Trota’s teachings than her original work itself.35 But the poor circulation of Treatments for Women cannot account for the failure of other thirteenth- or fourteenth-century writers to recognize the originality of Trota’s text since, as we have seen, the Trotula ensemble—which had incorporated Treatments for Women at its core—was fully formed by 1200 and was circulating widely. Even when they had the full (if somewhat modified) text of Treatments for Women right in front of them, most male practitioners seem to have ignored its original features.
It is perhaps not surprising, therefore, that no editorial adjustment or elaboration was made to the preface of Conditions of Women—the opening text of the Trotula ensemble—where, as we have seen, the author used women’s shame as a central element of his justification for writing the text: women are ashamed to bare their ills to a physician, therefore there was need for him to compile a handbook describing women’s diseases and their cures. This statement could have readily backfired to serve as an argument for women’s shunning male physicians altogether and taking control of the text. Indeed, a French translator would make precisely that argument sometime in the early or mid thirteenth century.36 Yet remarkably, male readers seem to have been oblivious to the suggestion, however oblique, that their gender ill-suited them for gynaecological practice: the passage was never rewritten by a single scribe, it was never deleted, and it was never commented upon by a single annotator of the Latin texts. Indeed, when vernacularizing the text for male audiences, most translators just as unproblematically rendered the passage about women’s shame and the problem with physicians with no alteration. Only a sole Italian translator omitted the reference to male physicians, thereby implying that ‘the problem’ was women’s only, and even this may be due to unclear phrasing in his Latin original.37
Thus, neither editors, scribes, nor readers ever disqualify themselves from the practice of women’s gynaecological care yet neither do they elaborate on what the physician’s or surgeon’s role should be vis-à-vis the midwife or other female attendant in the actual treatment of female patients. Indeed, despite the Trotula’s wide circulation, very few medical writers in their own work acknowledge the texts’ existence or turn to them for learned opinion.38 Gerard de Berry, an early author of a formal commentary on Ibn al-Jazzār’s Viaticum, referred to ‘Trotula’ as an authority on cosmetics, not gynaecology, as did Abbé Poutrel, the alleged author of a French surgical text from c.1300.39 The other thirteenth-century user of ‘Trotula’ was Petrus Hispanus, who made use of Conditions of Women and clearly credited ‘Trotula’ with its views. Yet ‘she’ is only one among a dozen different authorities he employs for his gynaecological section. The authentic work of Trota makes no appearance at all.
In short, then, although thirteenth- and fourteenth-century physicians readily incorporated the Trotula into their medical handbooks, most of them apparently being quite comfortable accepting a female as its author (there are, at any rate, no contestations of her authorship in this period), almost no acknowledgement was made that the embedded author Trota brought something different to women’s medicine than the dialectical reasonings and ‘hands-off’ therapeutics normally found in male-authored medical compendia (and, of course, in the male-authored Conditions of Women). The Trotula could be absorbed into the regular medical practice of learned men so easily because those elements of the texts that raised complicated questions about how gynaecological care was actually to be delivered to female patients were simply ignored.
In the margin of a large fifteenth-century French compendium of fertility texts there is a note describing what may have been a not unusual situation:
Master Odo told me that there was once a priest in Montpellier who made marvelous things for conception from the following two substances [a compound medicine called trifera magna and the juice of santio], and he had a great reputation and even greater fame than the physicians of Montpellier. And innumerable women came to him and they became pregnant by using these two remedies.40
Just who this priest (or even ‘Master Odo’) was is not clear, but it hardly matters.41 The priest’s success in alleviating the fertility problems of ‘innumerable women’ is simply one among many instances of a striking upsurge in the high and later medieval period of medical concern to enhance fertility. Richard the Englishman, writing in the late twelfth or early thirteenth century, describes in his Practica how all the medical powers of the Salernitan physicians were called on to treat the sterility of the Queen of Sicily. He was no doubt referring to King William II’s English bride Joanna (1165–99), who had married at age eleven or twelve and then had to suffer the ignominy of twelve years of sterility until her husband’s death in 1189.42 Richard considered medical treatment of infertility futile, but his pessimism was apparently not shared. From the humble women who sought out the advice of the priest in Montpellier all the way up to queens, noblewomen and urban elites of Europe, both women and their male kin often aggressively sought assistance in reproduction from a variety of sources. A fourteenth-century practitioner in the southern French town of Manosque, a certain Antoni Imbert, was convicted of having promised (but failed) to cure women’s infertility by magical means.43 His crime, of course, was not in being a man treating women, but in being a fraud and a dabbler in magic. It is a measure of the success of more learned male practitioners that a man like Antoni did not cause more scandal than he did. When called upon to bring their skills to bear on fertility problems, the physicians of Salerno and Montpellier, and elsewhere in Europe, readily complied and, when they were successful, were dearly prized.
Late antique and early medieval gynaecological texts had always had one or more brief chapters on aids to conception, but aside from Muscio’s rather general statements that infertility could be caused by either structural defects of the genitals or general disease conditions, these consisted only of a few remedies, with no theorizing of causation. It is to the Salernitans that credit goes for giving infertility a permanent place in the nosological canon of western medicine. Separate chapters on infertility can be found in the writings of all the Salernitan masters—from Trota to Copho, Bartholomeus, Salernus, and Petrus Musandinus—while one anonymous writer late in the twelfth century wrote a short tract specifically devoted to the topic.44 Several Montpellier masters of the fourteenth century would then pick up the topic, elaborating on it considerably.
A wonderful story involves the most famous of Montpellier’s medical masters, the great Catalan physician Arnau of Vilanova (d. 1311). Around 1304 or 1307, while visiting Marseille (apparently to denounce some heretics before a papal commission), he was asked by the families of Elzéar of Sabran (1285–1323) and Delphine de Puimichel (1282–1360) to diagnose the fertility problems of this noble couple who lived in the nearby town of Apt. They had been married since 1300 but, having secretly taken a joint vow of chastity, they were not, unsurprisingly, producing heirs. They let Arnau in on their secret and he complied by pretending to treat them for two weeks, when in fact he used the time to discuss spiritual matters with them. There was a great assembly of physicians in Marseille at this time, and Arnau presented the couple’s case before them, claiming that Elzéar had three different impediments to conception while Delphine was afflicted with four. By cleverly diagnosing both of them, he ensured that their marriage could not be annulled and they could continue in their chaste ways.45 This tale (which in the form we have it was probably not written down until the mid 1390s) might be dismissed as typical hagiographic exaggeration were it not for the fact that there are no fewer than seven fertility texts that begin to circulate from Montpellier in the fourteenth century, five of which would come to bear Arnau’s name. Most of the attributions are clearly spurious, but as the story of Delphine and Elzéar shows, they are not entirely fantastic in depicting Montpellier as the most important centre for the diagnosis of infertility.
The work most likely to be an authentic composition of Arnau is little more than a table laying out, in a dialectical form, a whole host of impediments to conception. Despite its brevity, it makes clear why sterility should be a proper object of diagnosis by a learned physician. It opens with a statement very characteristic of Arnau’s epistemological view that the actual composition of any given individual’s humoural temperament could only be known by experience, not by reason. In this case, Arnau offers nothing by way of therapy, but his successors would soon fill that gap.46
The relative chronology of the other Montpellierain fertility texts is not entirely clear, but comparison of four of them can give some sense of the development of the field over the course of the fourteenth century as well as the increasing sense that the conditions of the female body were indeed amenable to rational examination.47 Perhaps the earliest was the Treatise on the Sterility of Women which, although attributed to Bernard of Gordon (d. 1308), is probably the work of one of his students. Offering no theory of the causes of sterility nor citing any authorities, the Treatise follows closely the schemes employed by the Salernitans; it categorizes female sterility according to the predominant complexional characteristics: too much heat, cold, humidity, or dryness. The most extended regimen found here is said to have been prepared specifically for the countess of nearby Rodez, ‘who was as if numbed and sterile due to [both] frigidity and humidity’.48 For the countess’s condition as well as all the others, this author enumerates in close detail various therapies involving baths, unguents, fumigations, controlled diet, etc.
A second treatise, also simply called a Treatise on Sterility and variously attributed to Arnau and other Montpellierain physicians, was certainly in circulation by the middle of the century.49 Adopting an Aristotelian perspective, this author attempts to reframe the problem of infertility as more than a simple disease category; instead, it is a failure of the very function for which the reproductive organs were created: generation. Thus, all diseases of the genitalia become the concern of the expert on infertility and, in fact, we find here most of the standard gynaecological and andrological topics that were addressed in the Arabic encyclopedias and their Latin descendants. This approach makes for rather bizarre results as, for example, when uterine suffocation is seen as a cause of sterility, even though the author explicitly acknowledges that what often causes the suffocation is the fact that the woman is a virgin or widow—and therefore is not having sexual relations at all! The poorly developed logic of the text seems to have been unapparent to the author, for he closes the text with proud assertions of the efficacy of his remedies: for the past six or seven years, he says, he has proved the value of his treatments, among others on a noble woman in Lomagne who, though she had been sterile for thirteen years, was able to conceive within two months with the aid of his regimen.
The third text, the Treatise on Conception, has no personal anecdotes or attestations of efficacy, though the author does open his text with the assertion that the remedies here ‘were experienced [that is, observed to be efficacious] by me many times’. The text also shows, in its intensely formalized rationalism, how the topic of infertility has now become a suitable area for the dialectical inquiry of scholasticism; the attributions to, once again, Arnau and also to Jean Jacme (d. 1384), a chancellor of the medical school of Montpellier, and (most plausibly) Pierre Nadilz (fl. 1369–74), personal physician to Charles II, king of Navarre, are certainly appropriate.50 Despite an egalitarian admission that either the male and the female can be the cause of infertility, the author immediately claims that most of the impediments come from the woman and it is only these that he will address. He moves beyond the anonymous author of the Treatise on Sterility, however, in looking more closely at anatomical or physiological defects of the uterus and its adnexa. He also goes much further into the bedroom, prescribing not simply a precoital laxative, but also the employment of specific sexual techniques to be used by the male to promote simultaneous climax and hence conception.
All these three texts, together with Arnau’s Compilation on Conception, readily show how a kind of gynaecology could be developed without any direct examination of the female genitalia, either in the living patient or in postmortem autopsy.51 The author of the pseudo-Bernard Treatise on the Sterility of Women mentions diagnosis by, among other signs, the pulse, urine, the colour of the menses, and ‘a notable colour around the genitalia, both in front and behind’. His listing of the latter two factors in the same breadth as the pulse and urine—which were archetypically the diagnostic preserve of the physician—might imply an expectation of direct observation, yet he also includes level of sexual desire and ‘quick emission of seed’, information which could only have come from the patient’s report.52 Aside from this, none of the authors mentions examination of the genitalia, either internal or external.53 The author of the Treatise on Conception attributed to Pierre de Nadilz can readily recommend recourse to a surgeon if a wound or aposteme or other lesion is impeding conception, but he feels no need to explain in detail what such lesions might be or how they occur. When direct applications on the female genitalia are required, ‘the midwife’ (obstetrix) suddenly appears to serve as the necessary eyes and hands.54 Yet all three authors are equally confident that they have developed a real science of infertility, and that the proof of their correct understanding lies in their effective treatments.
Where did they get such confidence? It was not, I believe, simply from musing on the opinions of their written authorities, nor from speculative abstraction of the ‘principles of science’ that characterized their medical learning. A treatise called Interrogations on the Treatment of Sterility, apparently of later fourteenth-century origin, itemizes forty-one points on which the physician needs to acquire information in order to determine the cause of sterility and pinpoint some method of intervention.55 It is clear from the phrasing of the forty-one points that this is an interrogation of the woman: is she too fat? is she old or young? has she been for a long time with her husband? has she ever been pregnant before? has she ever miscarried? Importantly, the physician asks for the woman’s own perceptions of her body: does she feel herself to be hot or cold? does she menstruate at the proper time? does she feel that her uterus has descended below its neck? does she feel in intercourse that the male’s semen is hot or cold? Only a few of the questions solicit information about the male partner, and all of these (e.g. ‘Is his penis too long or too short?’) could be answered by the woman herself. This text, therefore, is neither a theoretical disquisition about what might be the cause of infertility nor a series of abstract therapies. It is literally a guide for conducting a patient interview.
It would be interesting to think that the case of Delphine and Elzéar really was the principal stimulus for the development of Montpellierain speculations on infertility, making it all the more unfortunate that we do not have a better chronology for the composition of these texts. But whether there was some particular provoking historical event or not, the Montpellier masters chose an unwittingly fortuitous moment to develop this expertise. European population levels had been growing at unprecedented rates in the previous three centuries, a demographic phenomenon that has been attributed to multiple factors. While academic interest in population was spurred by the adoption of Aristotelian science in the mid thirteenth century (and so was primarily a strictly intellectual debate),56 fertility became a major social concern after the depopulation caused by the famines of the second decade of the fourteenth century and, all the more so, after the continuing devastations of the Black Death from the middle of the century on.57 Increased attention to infertility—one might even say disproportionate attention to it—would characterize gynaecological writings through the end of the Middle Ages. The Englishman John of Gaddesden’s medical summa, the English Rose (Rosa anglica), for example, which may have been written right around the time of the great famines of 1315–17, treated infertility as the chief disease of women, under which all others were subsumed.58 By the fifteenth century, whole codices were being filled with texts on fertility, while newly composed works, usually addressed to powerful patrons, portrayed knowledge of fertility as one of the highest achievements of medical science.59 Master Odo’s claim that an anonymous priest, with his simple fertility remedy, could outperform even the physicians of Montpellier was thus no small boast.
While male physicians looked after women’s menstrual regularity, examined their urine, assessed their pulse, and intervened medicinally in their fertility problems, surgeons were primarily concerned to treat conditions of the surface of the body and the repair of wounds, dislocations, fractures, and fistulae. They did not engage in ‘exploratory’ procedures of the thoracic or abdominal cavities, and most of what we now think of as the mainstay of gynaecological or obstetrical surgery (ovariectomies, myomectomies, and abdominal hysterectomies) would have been impossible, indeed inconceivable, for them. That said, there was still considerable potential room for the development of gynaecological and obstetrical surgical interventions. That these did not develop, or did so only slowly, confirms what we have already suspected from the Salernitan evidence: while the male medical gaze or even the male medical touch was not universally forbidden, neither was it completely free.
The female breast was, surprisingly given its later history as a focus of erotic concern, unproblematically included in the definition of what constituted the male surgeon’s territory. This is apparent already in the earliest Latin surgical writings of the twelfth century when, after nearly a thousand-year hiatus, surgical writing was revived in western Europe. Although we find no discussion of breast diseases in the writings of male Salernitan masters until we reach John of Saint Paul near the end of the century, a surgeon perhaps of Salernitan origin, Roger Frugardi, composed a comprehensive Latin surgery around the year 1170 that included three chapters on diseases of the breasts. These addressed abscesses, cancer, and inverted nipples (which particularly afflicted primaparae, preventing them from nursing). Roger’s work is important because it seems to come out of his own surgical practice, owing almost nothing to any text that had gone before it. An illustrated French translation from the middle of the thirteenth century demonstrates clearly how Roger’s precepts were to be put into practice: amid ninety-six quite lavish illustrations of various therapies described in the Surgery, two women show lesions of their breasts to a male surgeon (Fig. 2.3).60
FIG. 2.3 Male surgeon treating women for diseases of the breasts, as depicted in a thirteenth-century French translation of Roger Frugardi’s Surgery; note also the unproblematic representation of the male genitalia in the other four scenes.
Conditions of the female breast would remain a standard feature of surgical writing for the rest of the Middle Ages (see Table 2.1). The exception is Bruno of Longobucco (d. 1286), who came from Calabria in southern Italy but emigrated to Bologna where he apprenticed under the famed practitioner and teacher, Ugo Borgognoni of Lucca (fl. 1205–40). In 1253, Bruno wrote his Surgery, in which he included nothing at all on women’s breasts; on the contrary, all he had was an updating of Albucasis’s chapter (similar to Constantine’s) on fatty male breasts, when they grew large ‘like women’s … which nature abhors’.61 Bruno’s peculiarity in omitting the female breasts can be seen by contrasting him with Theodoric of Lucca (c.1210–98), who was Ugo Borgognoni’s own son. Theodoric drafted his Surgery in several stages between 1243 and 1266, initially adhering closely to the teachings of his father, but gradually adding other material including much of Bruno’s text. Theodoric added some discussion of cancer of the female breast in his general chapter on cancer, plus a brief note about apostemes in the female breast which were caused by, among other things, coagulation of the milk. William of Saliceto (1210–76/80), who also studied with Ugo in Bologna, went into even further therapeutic detail, for example by specifying the exact size and firmness of certain tumours and the specific veins to be incised in treatment.62
By the time we reach Lanfranc of Milan (d. before 1306)—who, as a student of William, completed the Bolognese dynasty of surgical writers—knowledge of the character and proper treatment of the various diseases of the breast could be something about which a practitioner boasted in order to differentiate himself from the ignorant rabble. Lanfranc, in discussing the special treatment needed for bloody apostemes of the breasts (caused when the menstrual blood that should be converted into milk fails to do so), describes a remedy with which he himself has cured such apostemes in a single day. But then he warns against the dangers of a different kind of medicine:
I saw a noble woman who had an aposteme of blood and I instructed her to apply the remedy described above. A certain lay [unlettered] surgeon rejected this and he applied upon [the aposteme] a maturative which, however much he applied, so much the more did the [bloody] matter multiply. Nor did this surgeon wish to listen to my counsel. And the friends of the sick woman preferred to listen to the counsel of that lay surgeon than to mine. Seeing this, I withdrew, and I predicted that the woman would become manic. And on the third day after my withdrawal she did become manic and, with the frenzy firmly established, she died.63
Table 2.1. Gynaecological and Obstetrical Contents of Medieval Surgical Textsa
The normativeness of such practice can also be seen in William of Brescia’s (fl. 1274–1326) two separate consilia (personalized diagnoses and prescriptions, often conducted via correspondence) on the treatment of breast diseases in the female relatives of his elite male clients. In one case, he diagnosed (apparently for a fellow physician) a case of breast cancer, characterized by the heat, pain, throbbing pulse of the veins, and blackened or yellowish colour of the breast. In another, both the sister and the niece of one correspondent were suffering from hardness that remained in their breasts after treatment for an aposteme.64 William went on to serve as personal physician to a series of four different popes in the late thirteenth and early fourteenth century, which shows that expertise in breast diseases, if hardly the centre of one’s practice, in no way impeded a male physician’s successful career. The only negative sentiment connected to treatment of breast conditions that I have found is the worry that the surgeon might incur infamy from too interventionist a therapy: cancer in particular was thought to yield rarely to the needed treatment (complete excision) and Guy de Chauliac, writing in 1363, explicitly recommended that the surgeon avoid the threat to his reputation that involvement with such hopeless cases would bring.65 Although the breasts rarely became the subject of specialized examination by medical writers (the only specialized treatise is a fifteenth-century Italian text, which is probably largely derived from a Latin source),66 the later thirteenth- and early fourteenth-century northern Italian surgeons seem not to have followed in the textual footsteps of their Arabic sources but charted new territory—a development that would have been impossible had they not actually been regularly treating breast conditions (and so female patients) in their clinical practices.
The genitalia, on the other hand, the conditions of the labia, clitoris, vagina, and uterus, were more problematic for the surgeon’s inspection and touch. Although, as we have seen, the Salernitan physician John of Saint Paul had alluded to surgical incisions to open up an obstructed vagina,67 his contemporary Roger Frugardi never mentioned the female genitalia at all, and neither of Roger’s commentators—Roland of Parma (writing c.1230), or the so-called ‘Four Masters Gloss’ (written soon after Roland)—expanded into this area. Although Bruno of Longobucco and Theodoric began to exploit some elements of Abulcasis’s surgery in the mid thirteenth century, neither paid any attention whatsoever to his chapters on an enlarged clitoris or vaginal obstruction and apostemes.68 Bruno did, it is true, include ‘Al ibn al-’Abbas’s discussion of hermaphroditism, noting that both the male hermaphrodite and the female one (their ‘primary sex’ being determined by where they urinated) needed to be treated by cutting off whatever parts were ‘in excess’. The fact that such individuals were already of ambiguous sex apparently made surgical intervention on a ‘female’ acceptable.69 Elsewhere, however, Bruno signalled the problematic nature of dealing with the normal female genitalia: when he came to discuss the problem of bladder stones in the female patient, he retained Albucasis’s instructions that one should employ a female assistant to perform the necessary examination and incision if treatment involved touching the vagina.70
By the time we come to William of Saliceto and his student Lanfranc of Milan (writing in 1268–75 and 1296, respectively), the Arabic authorities began to have a more pronounced effect. What distinguishes William and Lanfranc (who later practised in Paris) was that they both attempted to bring surgery more tightly into conformity with the precepts of internal medicine. William did so by authoring complementary texts on both internal medicine (a general practica) and surgery, making it all the more intriguing why he put some material into one text rather than the other. In the Surgery, which he wrote first, besides the material on the breasts mentioned above, he presents nothing specific to the female genitalia: a chapter headed ‘On [anal] polyps, condylomas, and haemorrhoids in the anus and vagina’ in fact says nothing whatsoever about the latter organ.71 William seems to have no more experience with surgical treatment of the female genitalia than his predecessors. Yet in his general practica, we find the now normal array of gynaecological headings (including a chapter on infertility almost four times longer than any other section) as well as a category hitherto unseen in Latin surgeries: ‘On sores [ragadie] in the uterus and the opening of the penis and the thing which is called furfur, that is, excess flesh growing in the mouth of the uterus which sometimes is prolonged and sometimes shortened, and it is not prolonged except in the summer and it shortens in the winter.’72 William was clearly using Avicenna as a source here, yet in several respects William has moved far beyond his Arabic authority. Not simply has he combined what had been three separate topics in Avicenna (ragadie or vaginal tears, furfus or a penis-like growth of excess flesh, and bothor or genital warts or pustules), but whereas Avicenna had simply said that a mirror, placed against the outside of the vagina, could be used to check for internal tears, William adds that a cuffa (a type of cupping glass) can be used to better view into the vagina.73 Likewise, when he comes to treating these vaginal sores, he says explicitly that ‘the vagina should often be inverted with a large cuffa so that it is made manifest to the physician [medico] by sight how much and in what way he needs to operate on the afflicted place’.74 Treatment involves, among other things, use of a heated iron to cauterize the lesions.
Now, it has been recognized by several scholars how unusual William is in his emphasis on testing ‘the ancients’ against his own experience.75 He is in no way challenging Avicenna’s observations here, but his very specific instructions about using a cuffa do indeed suggest that he has gone well beyond a mere re-mouthing of his authoritative text to a clinical practice directly on the genitalia of female patients. Clearly, William has not single-handedly overturned traditional views on the impropriety of male touch of the genitalia. In his chapters on uterine suffocation (where he mentions masturbation of the afflicted woman), on testing for virginity, and on several aspects of childbirth, the midwife is still the necessary intermediary who touches the female patient’s body. But William now suggests that an important boundary has been crossed: it is acceptable for the male practitioner—even one as well situated as William was in northern Italian society—to inspect and treat the female genitalia as long as he touches her not with his own hands but with instruments.
In Lanfranc’s case, his medical training induced him to think more speculatively than anyone before him about female physiology as it related to surgical conditions. Thus, for example, after going into a surprising amount of detail near the beginning of his Surgery on the generation of the embryo, taking pains to differentiate (following Aristotle) between male semen and the female contribution of menstrual blood, he then clarifies why this is relevant to surgery: if a limb is amputated, bone (which comes from male seed) never grows back, but flesh (which comes from blood and regenerates daily) does. Similarly, he explains in more detail than any prior surgeon how there are certain arteries and veins that carry the menstrual blood up to the breasts, where it is converted into milk.76 When this process fails, either because of the excessive quantity or the poor quality of the blood, breast abscesses are generated.
Even more strikingly, Lanfranc’s thorough reading of his Arabic authorities (and, no doubt, the example of his teacher, William of Saliceto) emboldened him to reincorporate aspects of Albucasis’s and Avicenna’s gynaecological surgery. Although he doesn’t provide separate headings, he does include the anatomy of the uterus (it is like a penis inverted) and he addresses wounds of the uterus (those caused by a spear or sword are always fatal, while those caused by ‘something hard’ entering the vagina are usually amenable to cure if they are still recent). In his therapeutic section, Lanfranc includes a chapter on removing any skin-like growths that obstruct the vagina or cervix; ‘correcting’ the superfluous growths of hermaphrodites; and excising excessive growths ‘that hang from the vagina’ with which some women are accustomed to play the part of men with other women. Surprisingly, virtually none of this new material is coming verbatim from Albucasis or Avicenna; even though they had both addressed these topics, Lanfranc seems to be describing procedures and tools that he has employed himself. In other words, although neither William nor Lanfranc has uttered a word about how their surgical practices seem to have taken a radical new step beyond the territory carved out by their predecessors Roger, Roland, Bruno and Theodoric, they have in fact added certain aspects of gynaecological surgery permanently to the learned male surgeon’s repertoire.
Henri de Mondeville, who placed great emphasis on the surgeon’s need to know anatomy, included a detailed description of the uterus and adnexa in his Surgery, on which he was working in Paris c.1310 but left incomplete. In the planned Third Doctrine of his Third Treatise, Mondeville had dedicated chapter 21 to the diseases of the uterus and the adnexa. His list of diseases of the female genitalia is truly breathtaking, for far beyond his Latin predecessors—beyond even his Arabic authorities Albucasis and Avicenna—Mondeville itemized twenty-three different diseases of the female genitalia that were within the surgeon’s purview.77 None of these, to be sure, are obstetrical conditions: Mondeville continues to see the surgeon’s work as lying in the excision or repair of excessively growing or damaged flesh, though he also envisions surgical intervention in such gynaecological conditions as ‘wind’ in the uterus, prolapse,78 and uterine suffocation. Mondeville may perhaps have imagined that the surgeon would be involved in birth after the fact: in his chapter 29 on the perineum, Mondeville included, as two of five conditions afflicting that anatomical structure, both complete and partial rupture in women. Rupture of the perineum could conceivably be due to rape or sexual violence (a story in the thirteenth-century Spanish Cantigas de Santa Maria, for example, tells a horrific tale of a man who cut open his wife when she took a vow of virginity and refused to have sex with him). Its most common cause, however, is childbirth and it thus seems likely that Mondeville is the first surgical writer to identify this quite common obstetrical affliction since Trota had described it in the twelfth century.79
Unfortunately, we don’t know how Mondeville proposed to treat any of these conditions, nor how he suggested male surgeons should negotiate with midwives or other female assistants in examining or manipulating the female patient’s genitalia. Mondeville never completed this part of his Surgery and we have no other evidence to reconstruct his clinical practices. It would seem, however, that he was not alone in seeing the surgeon’s province expanding. Writing in 1363, the other great French surgical synthesizer Guy de Chauliac claimed that ‘the diseases of the parts of the pelvic region which properly pertain to surgeons’ include ‘diseases of the uterus, such as obstruction of the vagina [clausio] and its enlargement, enlarged clitoris [tentigo], extraction of the foetus and the afterbirth and the [uterine] mole;… and prolapse of the uterus’.80 Obstruction of the vagina and an enlarged clitoris (or some kind of fleshy growth) had, of course, been made standard items in the surgeon’s repertoire more than half a century earlier. And Mondeville had at least planned to include uterine prolapse, a topic that had been addressed by physicians ever since Salerno. Yet Guy is the first surgical author to include any element of obstetrics, despite the powerful influence for over one hundred years of the Surgery of Albucasis, who had dedicated his longest sections on women to precisely that topic.
In all, Albucasis had devoted a total of ten chapters of his Surgery to women’s conditions, three of which addressed obstetrical procedures. Avicenna, too, had included three detailed chapters on obstetrical interventions that employed surgical techniques. The long time lag between the availability of these two works in Latin translation (both had been translated by Gerard of Cremona before 1187) and the first mention of obstetrics by a surgical writer in 1363 shows how powerful the sexual division of labour was in regard to hands-on treatment of the female genitalia. Yet both these great Arabic authorities had in fact laid out a model for how the male surgeon could play a role in childbirth. For Albucasis, the midwife (obstetrix) was unquestionably subordinate to the surgeon: ‘How the midwife ought to be instructed’ is the rubric he uses to introduce the first of his obstetrical chapters and Guy himself seems to have taken to heart this presumption that the male surgeon should rightly serve in a supervisory capacity. Interestingly, although Guy (like Albucasis) makes clear that it is the midwife who is administering fomentations and unctions and other aids to ease the birth, when he comes to the use of instruments to extract the dead foetus, his verbal forms shift to the passive. He also uses a passive form in describing the excision of the living foetus from its dead mother. Guy cites no personal experiences of attendance at birth so we cannot be entirely sure how extensive his own involvement with childbirth or midwives may have been. But there is other evidence that the taboo that had kept male surgeons marginal to the birthing process was slowly breaking down.
Right around the same time that Lanfranc, prior to his exile to France, would have been formulating his new vision of surgical science writing in northern Italy, we find several copies of Albucasis’s Surgery that incorporate the series of sixteen foetus-in-utero figures that had originally accompanied Muscio’s late antique Gynaecology.81 Muscio’s work had fallen into desuetude by the early thirteenth century and may have been considered no more than a curiosity even by those few, like Richard de Fournival, who continued to have the whole text copied. The star of Albucasis’s surgery, in contrast, was rising. The latter text had, ever since its original composition in Arabic, been accompanied by illustrations of surgical instruments, an illustrative tradition that carried through into most of the thirty-three surviving copies of the Latin text. Yet aside from a couple of early manuscripts that add scenes of cautery or a procedure to reduce spinal dislocation, there was no anatomical or clinical iconographic tradition such as the one found in the French translation of Roger Frugardi cited above. It must have seemed very fortuitous indeed, therefore, when manuscript illuminators in Italy in the late 1200s realized that the Muscian figures conformed quite well to the instructions in Albucasis’s text for addressing the different kinds of foetal malpresentation. With their often vibrant colours, the foetal images would have signalled to the owners of these manuscripts that knowledge of obstetrical interventions was as much a part of the learned surgeon’s repertoire as reducing dislocations or treating head wounds. One manuscript, now in Budapest, not only incorporates the Muscian figures, but also, on the page presenting Albucasis’s description of extraction of the dead foetus, depicts a heart-rending scene of (to judge from her attire) a queen lying near death and a male physician giving instructions from his book.82
Interests in obstetrical surgery were also rising in another respect, one in which Christian Europe went beyond even what the Arabs had described. This had its origin, not among surgeons (or any other kind of medical practitioner), but among theologians and priests. Beginning apparently in the early eleventh century, clerics began to discuss the merits of excising the living foetus out of its mother’s womb when she had died before or in childbirth. By the twelfth century, injunctions were being pronounced that the foetus must be removed in such cases, in order that it might be baptized and its eternal life saved. Since there was no expectation that the foetus would survive much beyond baptism, these ‘Caesarean births’ could hardly be deemed ‘medical’ procedures.83 Nothing in the early ecclesiastical records suggests that surgeons (or even midwives, for that matter) were specifically charged with performing the procedure. Nevertheless, the procedure began to attract the attention of physicians and surgeons by the late thirteenth century. A manuscript of Avicenna’s Canon made in Paris in the last quarter of the century includes, at the head of the chapter on the anatomy of the uterus, an image of a male physician directing two midwives in the performance of a Caesarean section (Fig. 2.4).84 The illuminator has gone beyond the obstetrical practices of Avicenna’s text which, although greatly detailed, had only described means to remove the dead child from its still living mother; the life of the child was, by itself, of no concern to Avicenna and hence we find, in terms of surgical recommendations, only vaginal procedures of extraction being offered.85 The illuminator of this Latin manuscript, in contrast, depicts a scenario that reflected the new Christian concerns with extraction of the living foetus through incision of the dead mother’s abdomen. The image in this quite deluxe manuscript of Avicenna’s masterpiece, moreover, depicts the social scenario we would expect its literate male readers to have considered normative: the male physician is not himself touching the dead mother but rather is instructing the two midwives. The point is clear: it is his responsibility to supervise, theirs to do the manual labour.86 Bernard de Gordon, writing in 1305, referred in passing to a procedure (artificium) of opening the mouth of the dead mother (so that the foetus could continue to breathe) and having her belly opened to extract the foetus. He gives no details on where the incision was to be made or any other specific surgical information. Yet other sources confirm that male practitioners were increasingly involved in such procedures. A preacher in Florence, also in 1305, notes with pride how he called in four doctors and midwives to extract a foetus when its mother died.87 A legal case from Marseille in 1331 describes how, when a woman named Boneta died in childbirth, the attending midwives sent for a male barber ‘who was experienced in this [procedure]’ so that he might extract the living child from its mother’s womb. The earliest known image of a male surgeon performing a Caesarean section with his own hand appears in a mid fourteenth-century Venetian copy of a French life of Caesar.88
FIG. 2.4 Male physician instructing two midwives in the performance of a Caesarean section on a dead mother, from a later thirteenth-century copy of Avicenna’s Canon.
When in 1296 Lanfranc laid out his detailed description of the field of surgery and the duties of the surgeon, he identified, after invasive procedures like phlebotomy and cutting for bladder stones, and reconstructive procedures like repairing wounds or broken bones, a third task of removing superfluous growths: polyps from the nose, for example, or warts or a sixth finger. Included in his list was the removal of any flesh that closed off the vagina.89 The frequency with which a surgeon in the late thirteenth or fourteenth century might have actually been called upon to open a closed vagina may have been not much greater than the number of times he was asked to cut off a sixth finger. But when a situation arose needing the intervention of a surgeon, they seem to have risen to the task. An account from the early fourteenth century tells the following story:
In a town near Bern… a woman lived for ten years with a man. Since she could not have sex with a man, she was separated [from her partner] by the spiritual court. In Bologna (on her way to Rome), her vagina was cut open by a surgeon, and a penis and testicles came out. She returned home, married a wife, did hard [physical labour], and had proper and adequate sexual congress with her wife.90
Perhaps it is too convenient for the narration that the surgery happens to be performed in Bologna, the veritable capital of surgery at the time. But we know of a similar case from Catalonia from just about the same period; in that case, no ‘cure’ was effected but it is notable that is was a surgeon who was called in to examine this woman who ‘has a male penis and testicles like a man’ and various other abnormalities of her genitalia.91 The statistical probability that surgeons may have been presented with cases of hermaphroditism was probably just as high then as it is now: an estimated 1.728 cases for every 100 live births.92 The teachings of Lanfranc and others on repairs of genital lesions or growths may thus have been as relevant as most other rare but potentially debilitating conditions.
But such gynaecological and obstetrical conditions as vaginal lacerations (whether from birth or forced intercourse), fistulae, and prolapsed uteruses were probably not rare at all. A story from fourteenth-century northern Italy reminds us how severe women’s suffering must have been. Among the miracle stories collected during the canonization proceedings of the Tuscan saint, Chiara of Montefalco, in 1318–19 is the story of Flore Nicole. She suffered from ‘a horrible infirmity in her womb, namely, that her womb had exited outside her body’. In her testimony, she recounted how ‘because of the extreme pain, she wished to have her womb cut [out] with a knife’. She suffered thus for three years. Her mother, seeing how severely she was afflicted, suggested that Flore pray to Saint Chiara ‘that she liberate you from this infirmity or kill you’. Saint Chiara did of course (as is the nature of miracle stories) cure her, but Flore’s testimony provides us with one other crucial detail: asked if she had ‘made medicines’ for her condition, she responded ‘many, and they seemed to harm her and do no good. And beyond that she consulted many physicians’.93 It is notable, therefore, that even though Flore herself envisaged her real need to have surgical intervention—cutting with a knife—she only consulted physicians (medicos) who, as we have seen, had long since been willing to offer various non-surgical treatments for her kind of condition. In fact, it may be that gynaecological surgery developed because patients or their kin insisted that surgeons bring the same skills to women’s afflictions that they brought to men’s.94
Surgeons’ hesitating entry into gynaecological and obstetrical conditions can be contrasted with the extraordinary developments they made in male urological surgery in this same period. The illustrator of the thirteenth-century French translation of Roger Frugardi’s Surgery, discussed above in relation to its depictions of the female breast, had no compunctions about graphically depicting the male genitalia when the text moved to detailed examination of wounds, cancers, and swellings of the penis and testicles (Fig. 2.3 above). Operations for inguinal hernia in particular (a condition nearly unique to men because of the anatomical structure of the male genitalia in relation to the abdominal wall) were discussed in excruciating detail, becoming a point of controversy between practitioners who offered different methods. Surgical techniques varied from simple trussing to cauterization to excision of one of the testicles.95 In other words, there was no reticence about dealing with the sexual organs as such. It was only the female sexual organs that proved an inhibiting factor and, as we have seen, even here male surgeons seem to have only gradually become emboldened by the confident pronouncements of their Arabic authorities.
When the plague struck in the first great pandemic of 1347–9, learned medicine had established itself as a major intellectual and social presence throughout much of western Europe. Whereas intellectuals as late as the eleventh century were still debating whether medicine was anything more than a mechanical art, by the mid fourteenth century it was taught formally at at least one-third of Europe’s universities, often as one of the higher faculties alongside theology and law. This prestige extended to practitioners even on the margins of university culture. Surgical writers, only some of whom had university affiliations, attempted to claim that they, too, had authoritative textual traditions; they had produced works of considerable sophistication that circulated widely both in their Latin originals and in numerous vernacular translations. In Spain, France, Italy, Germany, and England, to varying degrees learned practitioners were licensed, granted municipal appointments, and served as expert witnesses in court. This enormous prestige survived the crisis of the Black Death more or less unscathed, largely because the expectations made of such practitioners were not that they could cure every condition presented to them, but rather that they could explain the condition and make acceptable predictions about the possibility of cure. There is no reason to believe that these expectations were any different in the area of women’s medicine.96
How, then, might we imagine scenarios of such cross-sex practice of gynaecology? One of the manuscripts mentioned before as an example of the new later thirteenth-century focus on generation merits discussion again. This codex, Ashmole 399, includes an inserted bifolium of images that predates the rest of the manuscript by about a quarter of a century.97 Whether it was originally part of another codex or circulated alone is unclear. What is clear is that it presents, in a striking series of images, a learned perspective on women’s health and women’s relations to their male healers. The first four images (on the recto and verso sides of folio 33) depict the disease of uterine suffocation: its major symptom (a falling as in epilepsy, but without that disease’s characteristic foaming at the mouth), its likely victims (widows and virgins), its seemingly lethal effects (an afflicted woman, thought to be dead, is laid out on her bier ready for burial, with her servants wailing around her), and its therapy (fumigations to the genitalia and foul odours to the nose).98 The next two images (on the recto of folio 34; fig. 2.5) show a different practitioner, or at least the same one coming on a different day: his clothing is of a different colour than that of the male physician in the first sequence. Here, no scrolls are added that might have incorporated some explanatory text. The upper image shows a woman in her sick bed, with three distressed attendants by her side. The physician, who has just examined her urine, drops the urine glass, apparently a gesture foreboding her imminent death. The lower image on that page depicts, it has been suggested, either an anatomy scene of the deceased woman or an embalming.
The final two images (on the verso of folio 34; Figs 2.5 and 2.6) shift subject matter again: I believe they are meant to depict the scenario of practice that the author of the Salernitan Women s Cosmetics envisioned. In the upper image, five women stand in line waiting their turn to be seen by the physician seated in front of them. The first woman gestures toward her hair; the second toward her face; the third, holding a vial, gestures back toward the fourth who seems to be troubled by bad breath, a wisp of foul vapours coming out of her mouth. The fifth, with money bag in hand, suffers from blackened teeth. Every single one of these conditions had been addressed in the Salernitan Women’s Cosmetics. In the lower image, the physician is taking his leave (apparently to go hawking), with the women mourning his departure. As the author of Women’s Cosmetics had promised, he has earned ‘glory [and] a delightful multitude of friends’. This single bifolium comes closer than anything else known in medieval Europe to a narrative of women’s encounters with the medical profession. It may, indeed, have been created precisely as a kind of advertisement for the services that a physician trained in the Salernitan tradition had on offer. The male physicians never touch the woman; even in death, it is only a surgeon or barber (depicted as a buffoonish rustic) who touches the body. Rather, with his finger lifted in the classic gesture of instruction, the male physician doles out his learning, expecting that either some female attendant or the woman herself will carry out the necessary applications or procedures.
FIGS. 2.5 AND 2.6 Illustrations of women’s medical encounters, from England, third quarter of the thirteenth century.
The ubiquity of male practice of gynaecology can be gauged by the surprisingly rare instances where female patients or gynaecological conditions are deliberately excluded from discussion. After the composition of Gariopontus’s Passionarius in the eleventh century, hardly a single general medical encyclopedia did not address conditions of the female reproductive organs in at least perfunctory fashion. Those that did not can often be traced to religious communities that housed no women.99 These cases stand out precisely because they are so rare. John de Greenborough (or Grandborough, d. after 1383), for example, spent, according to his own testimony, more than thirty years attending to the sick at the male Benedictine house of St Mary’s in Coventry. In and around a copy of Gilbert the Englishman’s Compendium of Medicine, he made copious notes of his own cures and those he had read in the books of ‘English, Irish, Jewish, Saracen, Lombard, and Salernitan physicians’.100 One of the few areas where he omitted commentary was the gynaecological section where, unsurprisingly given his exclusive clientele, he has nothing whatsoever to say. In contrast, another English cleric, John Mirfield (d. 1407), was preparing an even more sizable compendium of medical knowledge for the hospital of Saint Bartholomew in London. Mirfield, never pretending to any originality as a medical writer, drew upon the readily available works of Gilbert and such surgical authorities as Roger Frugardi and Lanfranc. There was no skimping whatsoever on the gynaecological material: all of Roger Frugardi’s and Lanfranc’s material on conditions of the breasts was synthesized here; all of Gilbert’s and Lanfranc’s chapters on gynaecological conditions were incorporated. Mirfield even included topics like procedures to ‘restore’ virginity and contraceptives which, one would think, would be quite problematic for a cleric to approve—as in fact they were, for the latter topic appears in cipher in at least one of the extant manuscripts.101 Obstetrical chapters included aid in difficult birth and means to expel the dead foetus, both of which may have been important at Saint Bartholomew’s since, included among the poor and sick whom it took into its walls, there were pregnant singlewomen who had ‘done amiss’ (and who may have been particularly desirous to ‘restore’ their virginity).102
Most of these transformations in male gynaecological practice had begun well before the major demographic catastrophes of the fourteenth century: the famines that devastated northern Europe between 1314 and 1317, and the Black Death itself. But the latter catastrophe in particular may have been doubly influential in solidifying the changes and (as we will see in Chapter 6) perhaps even hastening the rate of change. Boccaccio clearly saw the plague as altering how physical exposure of the female body to male gaze was to be negotiated, and it may not be irrelevant that the bubonic plague (which Guy de Chauliac had himself survived) often manifests itself by large necrotic swellings of the lymph nodes, including those in the groin.103 Secondly, because of the hitherto unthinkable mortality of the pandemic, the ‘science of generation’ took on an urgent social import far beyond the intellectual curiosity it had previously elicited.104 The formulation of new logical understandings of infertility by the Montpellierain physicians and the growing confidence of Bolognese surgeons and their heirs in their skill in treating structural defects of the female genitalia that impeded conception—as well as what seems to be surgeons’ increasing concern to become knowledgeable about emergency obstetrical interventions—all prepared them, long before the awful onslaught of the plague, to claim competence in certain areas of women’s medicine.
According to a collection of miracle stories gathered for the canonization of Saint Louis of Toulouse, around the year 1297 a poor young woman in Marseille named Dulceta suffered from a prolonged labour with a foetus dead in utero. A midwife extracted what she could, but some material remained lodged in Dulceta’s vagina and she remained an invalid for two years thereafter, having to pull her bedclothes over her with her teeth because she had no use of either her hands or her feet, suffering from worms growing in sores on her thighs and buttocks, and ‘stinking so badly that scarcely anyone could stand to be near her’.105 Although Dulceta would eventually be cured (of course) by the sainted Louis, prior to the saint’s intervention her husband sought out a male surgeon to extract the retained material. The surgeon agreed to do it, but only on condition that the husband or others of his kinsfolk be present. The account does not suggest that Dulceta herself feared compromising her virtue by having a male surgeon see and touch her genitalia; rather, she feared the inevitable pain of the surgical intervention. It was then, after more than two years of suffering, that she prayed to Saint Louis for aid.
As we saw in Chapter 1, ever since the Hippocratics it had been suggested that women’s shame in baring their ills had been the biggest impediment to their receiving proper medical care. Yet as Dulceta’s story reminds us, it is not sufficient only to ask if women were willing to accept the ministrations of male practitioners. Clearly, women’s acquiescence, even if given with some reluctance, was necessary for there to be any male practice of gynaecology. But something else was necessary, too: the acquiescence of men. Dulceta’s story shows that decisions of medical care may have been made by male kin as much as by women themselves; in this case in particular, not simply was Dulceta herself bedridden, but her husband was a full twenty-five years older than her and may have been accustomed to making all the major decisions in the family. Moreover, in depicting the male surgeon’s reluctance to operate without a chaperone, Dulceta’s story shows that notions of shame or compromised honour in cross-sex medical practice may have been generated as much by men as by women themselves.
Neither the developments in medicine nor those in surgery we surveyed above had by themselves eliminated the social problems surrounding the male-practitioner/female-patient encounter. The rhetoric of women’s shame continues, as does a sexual division of medical labour. The segregation seems to have been strongest in the Kingdom of Naples. Southern Italy had a tradition of medical licensing going back to 1140, when King Roger of Sicily first decreed that those wishing to practise in his kingdom must present themselves to ‘our officials and judges’ for examination.106 During the reigns of the Angevin monarchs Charles II (r. 1285–1309), Robert I (1309–43, including the regency of his son Charles of Calabria, 1318–24), and Joanna I (1343–81), 3670 licences to practise medicine or surgery were copied into notarial registers of the Kingdom of Naples.107 Licences to practise surgery were given to twenty-three women, a tiny proportion of the total, yet these few documents offer powerful evidence of the social forces that kept women in medical practice. At least thirteen of the women are licensed specifically to treat female patients, usually for conditions of the genitalia. (The breasts, which as we have already seen, were regularly treated by male surgeons, are mentioned only once.)108 Beginning in 1321, we see the first explicit rhetorical justification for specialized female practice of women’s medicine. Francisca, wife of Matteo de Romano of Salerno and an acknowledged illiterate, was given a licence at Naples on the grounds that ‘although it should be alien to female propriety to be interested in the affairs of men lest they rush into things abusive of matronly shame and incur the first sin of forbidden transgression, nevertheless… the office of medicine is expediently conceded to women by an unspoken rule of law, mindful that by honesty of morals women are more suited to treat sick women than men’.109 The licence of Maria Incarnata, who was approved for practice by Queen Joanna in 1343, similarly states that ‘females, by their honesty of character, are more suitable than men to treat sick women, especially in their own diseases’.110 As late as 1404, women in southern Italy are still being licensed ‘because females are more suitable to treat women than men’.111
As powerful as this logic of women’s modesty is in leading to the conclusion that of course women should take care of other women’s conditions—hearkening back to the story of Agnodice—in fact female modesty was not the overwhelming motive force behind the social structuring of women’s medical care throughout the rest of Europe. No strict sexual segregation on the southern Italian model, with its separate (and apparently tiny) cadre of female practitioners, was observed anywhere else in Europe. Even Jacoba Felicie in Paris may have argued for the need for female practitioners because she came from a small town in Provence which, at the time, was under the same rulership as the Kingdom of Naples. In any case, it is clear from the testimony given at her trial in 1322 that she was treating both women and men, and as was noted in the Introduction above, the university masters who were accusing her of illicit practice gave no credence whatsoever to her argument for same-sex practice.
Nevertheless, it may well be that the university masters of Paris preferred to avoid the discussion altogether, not because they thought Jacoba’s argument ‘frivolous’ and ‘worthless’ (which is what they claimed), but precisely because they knew that the encounter between male practitioner and female patient was problematic. Not simply could a private encounter impugn the woman’s honour, it could also threaten the reputation of the male practitioner himself. One continuing strand of polemic against cross-sex medical practice was directed against male clergy. In 1114, King Henry I of England wished to appoint Faritius, the abbot of Abingdon, as archbishop of Canterbury. The bishops of Salisbury and Lincoln thereupon objected that it was unseemly to have as archbishop anyone who inspected women’s urine (non debere archepiscopum urinas mulierum inspicere). Faritius is, in fact, known to have attended upon Henry’s queen, Matilda, when she gave birth in 1101, and his fellow bishops apparently felt that this pollution alone was sufficient to disqualify him from the archbishopric.112 Hildebert of Lavardin (d. 1133/4), bishop of Le Mans, suggested that physicians were regularly exposed to three great temptations: women, ambition, and greed.113 Similarly, a twelfth- or thirteenth-century condemnation of the hypocrisy of monks lays out the particular dangers of monks practising medicine:
Moreover, not only do they routinely inspect the urine of men but also—for shame!—the urine of women, too; and making up a story from the pulse of the vein whether death will come soon or health, they deceive the sick person. What, I ask you, is this religion, or rather insane obstinacy, that causes a young woman to consult a young monk, her alone with him, about the secret diseases of her genitals…?114
To be sure, there is obviously an element of this diatribe that touches on concerns about the pastoral care of women. The intimacy necessary to provide spiritual guidance to a woman was also recognized as fraught with dangers of temptation or, at the very least, as giving rise to unseemly gossip.115 Indeed, it was in large part concern about the potentially compromising treatment of female patients that motivated various injunctions by Dominican authorities to control the medical practices of the preaching friars.116 The starkest evidence that contact with female patients was thought to be actively corrupting is from male Cathar medical practitioners in southern France; they may, indeed, in some cases have turned female patients away for precisely the reason that they feared women’s corrupting influence.117
For most male practitioners, however, the threat of involvement with women was to their professional reputation rather than their souls. Various medical writers followed the lead of the Hippocratics and the Salernitan Archimattheus in warning male physicians, cleric or lay, to shun any sexual involvement with females in the patient’s household lest they compromise their professional judgement. The Italian surgeon Lanfranc asserts that the good practitioner ‘should not presume to regard the woman of the house of the sick man with an impertinent look, nor should he talk with her in counsel unless it is necessary for treatment’.118 The mid fourteenth-century English surgeon John Arderne more conservatively advises the surgeon not to ‘look too openly on the lady or the daughters or other fair women in great men’s houses, or kiss them, or touch their breasts, or their hands, or their private parts, lest he anger the lord of the house’.119 As with statements about women’s shame, of course, there was clearly a certain amount of rhetorical formulicity here. Yet the social context of medical practice was, to some extent, largely unchanged since Hippocratic times: the medical practitioner (particularly the physician) had no office or clinic but rather came into the patient’s household when his services were needed. Arderne’s advice to surgeons identifies the potentially injured party not as the women whose sexual propriety might be compromised, but as the male head of the household whose honour was at stake. The dynamics, therefore, are as much between men (the physician and his real client, the male head of house) as between male practitioners and female patients. Which brings us back to the real import of Dulceta’s case: the husband needed to be willing to allow a male surgeon to operate on his wife and the surgeon needed to set the conditions under which he would do so without being accused of impropriety. Dulceta, at least as the story is recounted to us, feared additional pain, not shame—something she had already suffered dreadfully for years in her invalid condition.
Despite the Salernitan Conditions of Women’s expression of concern that women did not wish to show the diseases ‘of their more secret place’ to male physicians, and despite a variety of other evidence, ranging from oblique remarks to full out polemics, that similarly reflected the general sense that male inspection of the female genitalia—or even discussion of them—breached the norms of propriety and threatened both men and women with ignominy, women’s medicine did, in fact, become a regular part of the average male practitioner’s practice well before the collapse of the social moral order noted by Boccaccio. Only in southern Italy do we find evidence that concerns for women’s modesty trumped the claims of men’s learning: it is only there that we find women, despite their illiteracy, being licensed to practise surgery with the explicit argument that they are more suitable to treat women than are men.120 Elsewhere, women did practice medicine (as we will see in more detail in the following chapter), but not with the same mandate to care for female patients exclusively. With rare exceptions, male practitioners never, not even in southern Italy, disqualified themselves as caretakers of female patients, since they could always use females as assistants when ocular inspection or manual intervention was needed. Rather than taking the assertion of women’s shame in the Conditions of Women preface as an injunction against their practice, male healers seem to have taken it as an argument for their need to come to the patient interview armed with a text that already explained women’s diseases for them, saving them and their patients an embarrassing interrogation. The treatment of women’s unique disorders had become more a matter of delicate negotiation than complete taboo. The Latin Trotula, as well as the gynaecological and obstetrical material to be found in other texts, thus served as a validation for men’s claims to expertise in women’s medicine.
Part of that delicate negotiation of male gynaecological and obstetrical practice, ironically, necessitated leaving open a space for women’s continued involvement as caretakers of other women. With no successful resolution of the problem of sexual shame or the social impropriety of male contact with women’s bodies, visual or tactile, the world of medical guilds, licensing, and university training constructed by men still required women’s participation if male practitioners were to treat the wives and daughters of their male clientele. Male practitioners needed female assistants who would implement the therapeutic procedures they prescribed and, obviously, they needed acquiescence from female patients themselves. Women had a real, and not always passive, place in the masculinized world of literate medicine. But it was not an equal one.