Part 100

The ancients appear not to have used pessaries made of solid materials, such as wood and metals.

SECT. LXXIII.—ON PHIMUS IN THE UTERUS.

Phimus takes place about the mouth of the womb, either in consequence of ulceration or of inflammation terminating in scirrhus. We must cure it by emollient hip-baths of oil and water, and of the decoction of fenugreek, applying cataplasms of a like kind, and introducing emollient pessaries. But if the complaint be protracted, we must have recourse to vapour-baths and fumigation with aromatics. The phimus may be dissolved by a pessary of the sordes of unwashed wool, nitre, and turpentine-rosin, being simply an obstruction of the mouth of the womb.

* * * * *

COMMENTARY. Imperforate hymen and other obstructions of the vagina requiring a surgical operation will be treated of in the Sixth Book. The case here treated of is simply an obstruction of the os uteri by a callous substance. The emollient treatment by pessaries here recommended appears very proper. Aëtius makes mention of a more efficacious but dangerous application, namely, a piece of sponge spread with an ointment containing arsenic, alum, &c. Hippocrates had recommended an application containing verdegris. (De Steril. xii.)

Avicenna treats the complaint solely by a surgical operation. Alsaharavius approves of the emollient treatment, such as decoctions of mallows, fenugreek, linseed, &c.

SECT. LXXIV.—THE CURE OF STERILITY.

It is a common direction, applicable both to the man and the woman, to preserve the whole body in a proper temperament, by exercise, food, baths, and everything else in moderation. What is most especially to be attended to is, not to allow them to get into a fat habit of body; for fat persons are unfit for the propagation of children, owing to the want of agreement in their genital organs, and because they do not emit much semen. Nor are those who are much emaciated more so. All things which are heating and moderately flatulent assist, such as taking heating wine in moderation; and of pot-herbs, the rocket, clary (horminum), hedge-mustard, and the like; but they must, by all means, abstain from calamint and rue. When conception will not take place, owing to some cacochymy, we must purge it away, or dilute it by a proper diet. But women must attend particularly to the state of the uterus, and that the menstrual evacuation be not obstructed. When, therefore, the monthly purgation is near, the woman must attend particularly to take food and drink in moderation, and also some of those things which promote the discharge, such as the fragrant and acrid pot-herbs, as scandix, samphire, fennel, parsley, and alsander. And the intemperaments of the womb must be rectified. Wherefore the cold intemperaments of the uterus are indicated by retention of the menses, a cold and incrassating diet, and some torpor about the pubes, loins, and legs; and these persons, if they become perfectly congealed in habit, have no venereal desires at all. Wherefore we must endeavour, in every other way, but particularly by all kinds of fomentations, and by fumigation with aromatics, to recall the natural heat. And it will not be at all improper to drink of castor and of some of the aromatic seeds, such as cumin, anise, the flowers of pennyroyal, and the fruit of junipers, mixing some pepper with each. Fumigations of the womb may be applied either by sitting on a proper chair, and receiving the vapours which arise, or by injections of hot water in which sage, mugwort, rue, cumin, pennyroyal, sweet flag, and the aromatic seeds have been boiled. A cataplasm of any of them may also be applied to the lower part of the belly. The epitheme of Polyarchus is also appropriate. Frictions of the lower part of the belly and nates are no less proper. The woman may also use pessaries of myrrh, rue, galbanum, and castor, having previously fomented with honied water or salt water. The pessary called Goné is also an excellent one. Warmer intemperaments of the uterus are indicated by the whole body being hotter than usual, by the menses being voided in small quantity and with pain, and by the privy parts of the woman being ulcerated. They are to be remedied by such things as are moderately moistening and cooling, such as the pot-herbs, lettuces, mallows, blite, gourd, cucumber, pompion, orach, and purslain, and by the other articles of food of a like nature; and we must apply to the bladder, abdomen and loins, all cooling things, such as cataplasms and liniments made of the juices of herbs. If the woman cannot conceive owing to humidity of the uterus, it is indicated by there being much moisture of the parts during the venereal act, and by the menses being thin and in great quantity. A desiccative diet, therefore, suits with these cases; also exercises and frictions of the upper parts; emetics and dry food in moderate quantities. It will likewise answer well to strengthen the uterus by austere medicines, such as the decoction of lentisk, of myrtles, of roses, and of sumach; or also by that of pomegranate flowers, of the tender shoots of bramble, and of galls. When the uterus is drier than common, it is to be cured by the opposite remedies, I mean by baths and unguents, a moistening diet of pot-herbs, wine in moderation, and that not very old. But if conception be prevented by thick humours, and if they be of a pungent nature, the woman must be purged in a way suitable to each humour, and more particularly with the picra from aloes; then an injection with the whey of women’s milk is to be administered, and a more suitable diet thought of. Pituitous humours are to be evacuated by exercise, sudorifics and emetics, or downwards by the bowels. The following medicine may be given: Of dodder of thyme, of euphorbium, of pepper, of carrot-seed, of the seed of Macedonian parsley, equal parts; triturate all together, and give to the amount of two drachms to drink. This purges well and heats the womb, so that it often makes the menses flow in cases where this discharge was stopped. As soon as this correction has become apparent, and the menses flow properly, then one must enjoy the woman as soon as the menstrual evacuation stops. When flatus in the womb prevents conception, the symptoms of which may be recognized from what we have said on inflation of the uterus, it is to be cured first by a spare diet, and administering cumin, dill, parsley-seed, and that of rue and anise; and by giving many of the aromatics, some to drink and others by pessaries. When the mouth of the uterus is shut up, it must be opened by injections of aromatics, and by using fomentations from mallows, linseed, fenugreek and oil, and sometimes of honey; or, by the stronger ones, composed of mugwort, fleabane, calamint, pennyroyal and chamomile. In addition to these we may use turpentine, nitre, wild cucumber, elaterium, cassia, and tar-water. When the mouth of the womb gapes, the diet, fomentations and medicines should be of a desiccant nature and astringent; and the flowers of pomegranates, lentisk, the roots of brambles, myrtle-berries, and those things applicable for a humid intemperament. Distortions of the uterus are to be rectified by fomentations and emollient pessaries. In such cases, coition a posteriori would seem to promote conception.

* * * * *

COMMENTARY. Hippocrates, in his ingenious work on Sterility, assigns the following causes for a woman’s not conceiving: First, because the os uteri is turned obliquely from the passage to it. Second, because the inside of the uterus being too smooth, either naturally or in consequence of the cicatrices of ulcers, it will not retain the semen. Third, when, owing to suppression of the menses, any obstruction takes place about the os uteri, it is apt to prevent impregnation. Fourth, when menstruation does not take place, the veins of the uterus become so gorged with blood that they do not retain the semen; or, on the contrary, the same effect may arise from profuse menstruation whereby the retentive faculty of the vessels is weakened; or a return of the menstrual fluid in too great quantity may wash away the semen. Fifth, prolapsus uteri, by rendering the mouth of the womb hard and callous, prevents impregnation. The treatment is delivered at so great length that we cannot venture even to give an abridgment of it.

Aëtius treats very fully of sterility, but his views are much the same as our author’s. See also Oribasius (Synops. ix, 45.)

In cases of sterility, Octavius Horatianus directs us to ascertain whether the os uteri be turned aside or shut up. He delivers the treatment of these cases with singular minuteness. His principal remedies are pessaries, which of course are composed of various ingredients. We shall give the composition of one of the simplest of them in his own words: “Nullo etenim remedio meliore et magis innoxio, aut corrigi matrix poterit, aut purgari, quam usus nitri suppositione.” That is to say, a suppository of soda is one of the safest and most effectual remedies.

Serapion, like Aëtius and Paulus, regulates his treatment entirely upon the principle of correcting the intemperaments, which he considers as the most common causes of sterility. A humid intemperament, he says, occasions sterility in the same manner that wet ground proves injurious to seed which is sown upon it; and a hot intemperament dries up the semen as the earth scorches the seed during the heat of the dog-days. Such being his ideas of the causes of sterility, one can readily comprehend his principles of treatment. Avicenna, Rhases, and Avenzoar likewise direct their attention to the correction of the intemperaments, but also recommend attention to any other local complaint about the genital organs. Haly Abbas, among other remedies, directs us to correct the state of the uterus by means of stimulant fumigations. One of his prescriptions contain arsenic. This would prove a potent but dangerous application. Alsaharavius expresses his distrust in the virtues of many specifics which had long retained celebrity for the cure of sterility. Like the others, he directs us to find out the cause of it, and remove it if possible by suitable remedies.

Plutarch thus enumerates the causes which had been supposed to explain why a woman does not conceive after every act of coition. Diocles, the physician, maintained that it is either because no semen has been emitted, or less than necessary; or because it does not contain the prolific principle; or from a deficiency of heat, coldness, moisture, or dryness; or from relaxation of the uterus. The Stoics held that it is from the obliquity of the penis, so that it does not project the semen straight forward; or from the disproportion between the genital members. Erasistratus taught that it is occasioned by callosities and fleshy excrescences; or from the uterus being more spongy or smaller than natural. (De Placit. Philos. v, 9.) The causes of barrenness are fully and ingeniously treated of in the tenth book of Aristotle’s ‘History of Animals,’ which, however, is of very doubtful authenticity.

SECT. LXXV.—ON FISSURES, CONDYLOMATA, AND HEMORRHOIDS OF THE UTERUS.

Fissures occur about the mouth of the uterus from difficult parturition, and at first they escape notice while the pains from the labour are recent; but afterwards they are slightly felt, either upon manual inspection or during coition, when they bleed, owing to the friction. They are also discovered when the vagina is distended, for ruptures in the circle of the mouth are perceived. In these cases all surgical aid, and medicines of an irritating nature, must be avoided, and recourse had to the simpler hip-baths and pessaries. The medicine called Tetrapharmacon diluted is befitting. But if it be callous, we must use that from paper, with rose-oil. If they cannot bear the strength of it, mix Illyrian iris with turpentine, and apply it. When the ulcers are cicatrized, it will be proper to use the medicine from cadmia, or some of the applications to the anus, such as that from litharge. It sometimes happens that these fissures, becoming chronic, are converted into condylomata, in which case the callus is to be removed by similar remedies, and the condylomata cicatrized. Hemorrhoids form about the mouth and neck of the uterus, which will be discovered by the speculum; for eminences may be detected which, during the exacerbations, are painful, bloody, and red, but, during the remissions, are wrinkled, free from pain, somewhat livid, and emit a slight discharge. If possible, therefore, in these cases, one must seize upon them during the remissions with a forceps and cut them out; or if not, we may touch them with astringent medicines, sometimes applying dried pomegranate-rind with galls, or something such; and sometimes using those recommended for hemorrhages of the uterus, which will apply both for fluxes and hemorrhoids. These are recognized by the uterus discharging blood constantly, or if at intervals, not in the menstrual period.

* * * * *

COMMENTARY. This section is mostly compiled from Aëtius (xvi, 97, 107.) The astringent applications recommended by Aëtius contain alum, pomegranate-rind, ceruse, litharge, burnt lead, hypocistis, &c. For condylomata, the Pseudo-Dioscorides recommends an application containing arsenic. (Euporist. ii, 218.)

Avicenna and Rhases give a similar account of these complaints. They direct us to apply to hemorrhoids either such astringents as those directed above, or to remove them by a ligature. Haly forbids caustic medicines, as they may prove injurious to the uterus; and prefers extirpating them by a surgical operation. For fissures he directs us to use basilicon, with the fat of a duck or hen, and oil of violets, along with pitching and cataplasms. Alsaharavius directs us to extirpate hemorrhoids by an operation; and when the basilicon ointment does not succeed with the condylomata, to treat them similarly. As the ancients have not described polypus uteri by name, we are inclined to think that they must have comprehended it and all the other tumours about the uterus under the general appellation of hemorrhoids.

SECT. LXXVI.—ON DIFFICULT LABOUR.

Difficult labour arises either from the woman who bears the child, or from the child itself, or from the secundines, or from some external circumstances. From the woman in labour, either because she is gross and fat, or because her whole womb is small, or because she has no pains, or is affected with fear, or because the uterus or some other part is inflamed or otherwise diseased, or because, from some natural weakness, she is unable to expel the fœtus, or because the labour is premature. From the child, either because it is too large; or small, and of little weight; or from its having a hydrocephalous head; or from being a monster, such as having two heads; or because it is dead; or, although alive, because it is weak and unable to advance outwards; or because there happens to be several children, as Herophilus relates a case of five; or because the position is preternatural. For the natural position of the child is, first, when its head presents with the hands bent upon the thighs, and having its head directly applied to the mouth of the womb; and next to that, when it descends by the feet, and there is no turning aside. All the other positions except these are preternatural. Or from the secundines, either because the membranes cannot be torn, owing to their thickness; or because they have been torn prematurely, owing to their thinness; for when the waters are evacuated unseasonably, the fœtus gets out with difficulty, from the dryness of the parts. From external circumstances, either from cold contracting or immoderate heat dissipating the powers, or from some accidental occurrence. Wherefore, if the difficulty of parturition arise from constriction, and, as it were, impaction of the fœtus, we must first endeavour to produce relaxation by injecting frequently hot sweet-oil with the decoction of fenugreek, of mallows, of linseed, or with eggs, as a paregoric. Then we must apply cataplasms to the pubes, abdomen, and loins, of linseed, or of honied water, or of oil and water; and use hip-baths of a similar nature. We must also avail ourselves of the relaxation produced by baths, if neither fever nor any other cause prohibit; and the woman is to be moved on a couch in a moderately warm air. Some have had recourse to powerful shaking, and have applied sternutatories. If the woman be in low spirits, she is to be encouraged; and if she is inexperienced in labour, she is to be directed to keep in her breath strongly, and to press down to the flanks. If she be in a swoon, she is to be resuscitated by such strong-smelling things as are not stimulant; and when moderately recovered, she is to be supported with a little food. A woman that is fat is to be placed in bed in a prone position, bending her knees upon her thighs, in order that the womb, being carried to the abdomen, may present with its mouth direct. By means of the fingers the mouth is to be smeared with cerates or fatty substances, and gently dilated. And if there be any complaint in the parts, it must be previously attended to; and hardened fæces when retained must be expelled by an emollient clyster. The membranes may be divided either by the fingers, or by a scalpel concealed within them, the left hand directing it. And some of the fatty liquids may be thrown up into the uterus by a syringe. When the fœtus is in a preternatural position, we may restore the natural position, by sometimes pressing it back, sometimes drawing it down, sometimes pushing it aside, and sometimes rectifying the whole. If a hand or foot protrude, we must not seize upon the limb and drag it down, for thereby it will be the more wedged in, or may be dislocated, or fractured; but fixing the fingers about the shoulders or hip-joint of the fœtus, the part that had protruded is to be restored to its proper position. If there be a wrong position of the whole fœtus, attended with impaction, we must first push it upwards from the mouth of the womb, then lay hold of it, and direct it properly to the mouth of the uterus. If more than one child have descended, they are to be raised upwards again, and then brought downwards. Everything is to be done gently, and without pressure, the parts being smeared with oil. The time for placing the woman on the stool is when the mouth of the womb is open and meets the finger, and when rupture of the membranes is at hand. If, owing to the death of the child, or any other cause, it do not advance, we must proceed to embryotomy.

* * * * *

COMMENTARY. Hippocrates has treated fully of Difficult Parturition in the first book of his treatise ‘de Morbis Mulierum,’ from which we shall select a few remarks to give the reader some idea of his practice in these cases. When the child presents doubled at the mouth of the womb he directs us to push it upwards, and rectify the position so that the head may come down. When a hand or foot of a living child protrudes, it is to be pushed up in like manner, and the head made to present. When the leg or arm of a dead child protrudes, it is best, he says, to proceed in the same manner if possible; but otherwise they are to be amputated at a joint and the head opened. The process of opening the head is minutely described by him. He advises us likewise to open the chest when any difficulty of delivering it is experienced. When in feet presentations the head is retained after the body is delivered, he advises us to introduce a hand between the os uteri and the head and deliver it. When the secundines are retained, he orders us to extract them slowly, and for this purpose directs that the woman being placed on a stool, the child not having been separated is to be allowed to hang down, so that by its weight it may produce separation; and, lest its weight should occasion too strong pulling, he advises it to be laid on wool, or bladders filled with water, which being perforated, the child shall sink down gradually and draw away the placenta. We shall have occasion to treat of this practice further in the Sixth Book.

Aristotle states that delivery takes place naturally by the head, but sometimes preternaturally by the feet. (H. A. vii, 7.)

Celsus directs us when the child is dead, to introduce the hand, finger by finger, into the womb, and examine the presentation, which will be the head, the feet, or the body laid transverse. He states that the object of the operator is to bring down the body either by the head or the feet. When the arm presents, he directs us to bring down the head, which is to be seized by means of a hook fixed in the eye, ear, mouth, or forehead, and cautiously pulled along; and in doing this he properly directs us to pull with one hand and keep the other fixed at the instrument. When the feet present, they are to be brought down and delivery accomplished in this way. When the child lies across, he recommends us, if the position cannot be got rectified, to fix the hook in one of the armpits and pull it down; but if other means fail, he directs us to divide the body at the neck and extract the parts separately. In extracting the secundines, he properly directs us to stretch the cord gently with the left hand, and introducing the right into the uterus, to separate the placenta from the womb and remove it along with the coagula of blood lying there.

The causes of difficult parturition, and the methods of remedying them, are more fully treated of by Aëtius than by any other ancient writer; but, as Paulus evidently copies from him, we shall merely supply a few things which our author has omitted. Among the causes of difficult labour, he mentions too compact a union of the ossa pubis. When the woman is too young or too old, he justly remarks that she wants strength to accomplish delivery readily. He mentions that in the delivery of twins, the two children may get entangled. He means, probably, that the head of the one may follow the delivery of the breach of the other. Of this singular complication, a fatal case was published in the ‘Edinburgh Medical and Surgical Journal’ some years ago. He expresses himself favorably with respect to feet presentations. All cross presentations are said to be difficult to rectify, but the child is to be brought by the head or the feet according to circumstances. When delivery is retarded by rigidity of the parts, he strongly recommends the warm bath. When fulness of the bladder occasions obstruction, he properly directs the urine to be drawn off by a catheter. When a foot or hand presents, he directs us not to pull down the part, lest it become more firmly impacted, or lest it should be fractured or dislocated; but the projecting part is to be pushed up and the position restored.

According to Eros, one of the most common causes of difficult parturition is heat and tumefaction of the external parts. In this and in other cases, he directs the patient to sit in a bath prepared with emollient herbs, and to get the parts about the belly rubbed with oil of violets or of roses.

Serapion treats this subject in nearly the same terms as our author. Like the Greeks, he approves of emollient oils and baths to produce relaxation. The same practice is recommended likewise by Rhases. When the membranes are tough, he advises us to tear them with the fingers, or to open them with a knife.