Bad History, diseases, remedies, sex, virginity, vulva

Making a disease from a remedy: Trotula and vaginismus


Here’s a particularly fine case of Bad History, showing that while it’s bad enough to modify an ancient text to make it into a precursor of a modern condition, it’s even worse to misread a remedy as a symptom in order to make a historical text do what you want it to do!

Trotula says…

Like me, my colleague Monica Green has a number of Google alerts set up so that she can keep an eye on new developments in her historical field. This week she drew to my attention a recent claim that ‘Trotula’ described vaginismus. This isn’t the place to get into the issues of the ‘Trotula’ texts, the complexities of which Monica has done more than anyone else to sort out, but ‘Trotula’ isn’t a person. The word has been used for a group of texts from the 12th century, only one of which was dictated or in some way put together by a woman, Trota: the ‘Treatments for Women’, De curis mulierum. Trota was one of a number of women in Salerno who practised medicine, and not just women’s medicine. Here’s Monica’s latest update explaining the textual transmission in more detail; versions of this basic guide have been available online since 2008 so if you’re interested in ‘Trotula’ there’s no excuse not to know about them. If you want to know more, Monica’s 2001 book, a full edition and English translation of the various ‘Trotula’ texts, is the place to go.

The claim which came to Monica’s attention this week was from the 2017 Textbook of Clinical Sexual Medicine, edited by Waguih William IsHak. The alert says that the chapter on ‘Treatment of Genito-Pelvic Pain/Penetration Disorder’ by Andrea Rapkin, Salome Masghati and Tamara Grisales includes the statement that ‘Vaginismus was described in 1547 by Trotula of Salerno as a condition of “tightening of the vulva so that even a women who has been seduced may appear a virgin”’.

Let’s unpack that. The claim that someone who didn’t exist, Trotula, wrote this in 1547 – actually, not the date when it was ‘written’, but the date of a Latin printed edition of a text which had existed for centuries in manuscript form – turns out to be much-repeated in modern discussions of what used to be called vaginismus but which, since DSM-5 in 2013, has been incorporated into ‘genito-pelvic pain/penetration disorder’. For example, from a 2004 article by Cherng-Jye Jeng, ‘The pathology and etiology of vaginismus’, p.10,

However, it was probably Trotula Of Salerno, in her 1547 treatise on “The Diseases of Women”, who provided the first description of what we now call vaginismus: “a tightening of the vulva so that even a woman who has been seduced may appear a virgin” [5].

Note 5 here takes you to the rather oddly arranged reference ‘Of Salerno T.’ which cites the source as the 1940 Elisabeth Mason-Hohl translation of that 1547 Latin text, a translation identified in the 1980s as having ‘many significant problems’ because it merges the three different component ‘Trotula’ texts, so the reader isn’t even aware that there are different authorial voices in here (Green, The Trotula, p.xvi). In Mason-Hohl, the translation of the 1547 text given is ‘On the manner of tightening the vulva so that even a woman who has been seduced may appear a virgin’ (Mason-Hohl, The Diseases of Women by Trotula of Salerno, p.37, corresponding to ¶307 in Green, The Trotula).

Trotula goes on saying…

Monica Green’s 2001 edition and translation is based on an exhaustive survey of all the medieval texts rather than being limited to the 1547 printed Latin version on which Mason-Hohl based her English translation. However, because nobody is connecting to this up-to-date scholarship, the same wording goes on and on being repeated. You’ll find it all over the place; not just on websites aimed at the public, but in apparently scholarly literature reviews by medical writers, such as the 1999 Journal of Mental and Nervous DiseaseDoes vaginismus exist?

One of the problems here is that PubMed, the first port of call for writers in the medical sciences, doesn’t index scholarship from the humanities. PubMed includes plenty of dodgy articles on historical themes by physicians unaware of current scholarship, but is blind to most articles and books by historians. So, when a medical writer looks for recent work on her theme, she won’t find the best ones.

Trotula never said…

But back to the vaginismus claim. It turns out that it’s not quite as simple as repeating the wording. Two things happen to Mason-Hohl’s 1940 translation, ‘On the manner of tightening of the vulva’. This wording correctly suggests the text is about how to do it: how to make a vulva tight so that the woman appears to be a virgin. And that’s what the original Latin text is about – not describing a medical problem, but offering a way of concealing lost virginity. However, the version used by medical writers may simply drop the first four words, thus obscuring this central point. For example, from Maria Engman’s 2007 dissertation on Partial vaginismus – definition, symptoms and treatment:

Vaginismus is probably a very old problem. Painful coitus has been described as far back as in ancient Egypt in the Ramesseum Papyri Scrolls (Costa Talens and Colorado Vicente 1971). The first known written description of vaginismus is nearly a thousand years old. Trotula of Salerno described in “The Diseases of Women” “a tightening of the vulva so that even a woman who has been seduced may appear a virgin” (Trotula 1547/1940). The term vaginismus was introduced by the gynaecologist J. Marion Sims in 1862 (Sims 1862).

There are other questions here, of course, like ‘What part of the body are we talking about?’ The term ‘vulva’, for example, has in the past sometimes been used for the uterus. There is still plenty of confusion between ‘vulva’ and ‘vagina’ in the world of marketing, as usefully identified by Dr Jen Gunter.

If you are trying to find an early description of painful coitus, you could do worse than use another text from the Trotula ensemble; the one by Trota herself. In De curis mulierum (¶150) there’s a description of uterine prolapse as a result of a woman having sex with a man with a large penis (in terms either of size or of length). But, of course, nobody in this story is really interested in engaging with the texts, only in repeating the ‘tightening’ story ad nauseam.

Alternatively, rather than dropping the first four words of the key sentence, the medical user may change ‘manner’ to ‘matter’, as happens in the 2006 edition of Principles and Practice of Sex Therapy (ed. Sandra R. Leiblum, New York and London: Guilford Press), p.126, which represents it as ‘the first mention of a condition similar to vaginismus’ by having ‘Trotula’ write ‘On the matter of tightening of the vulva, so that even a woman who has been seduced may appear a virgin’. The end result is the same: the sentence becomes about a condition, when originally it was a remedy.

From a remedy to a medical condition

It’s very clear that what the text was originally about was providing a way of disguising lost virginity; in this, it’s one of many such remedies. In the original version of De curis mulierum (¶231), such a remedy appears at the end of a section on other ‘tightening’ remedies, this time for haemorrhoids resulting from giving birth; a suppository of white alum ‘renders a violated woman tighter than a virgin’ (scias quia alumen solum sic puluerizatum et suppositum uiolatam strictiorem reddit quam uirginem). In one of the sections added to the combined ‘Trotula’ texts after they began to circulate outside of Salerno (¶307), remedies are given ‘so that the vagina might be constricted’; these include dragon’s blood (a term used for a range of red gums and resins), pomegranate rind, oak apples and various spices. Tightening is the remedy: not the problem!

If only this claim that a person who didn’t exist described vaginismus was an isolated example of medical writers keeping alive a myth about the medicine of the past… But the pattern is only too common. Medical journals still don’t use historians as referees. Medicine still feels the need to find historical precursors. If possible, medicine pushes right back to Hippocrates, as champion of watercress, or developer of a sure-fire remedy for baldness, but if he won’t supply the necessary out-of-context soundbite, then medieval medicine will do. Enter Trotula…

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