Some women have the genital parts imperforate, sometimes naturally, and sometimes owing to some previous disease. And sometimes it is deep-seated, sometimes in the alæ pudendi, or in the intermediate places, and is sometimes occasioned by an adhesion of the parts, and sometimes by obstruction. The obstructing substance is either flesh or membrane. The disease occasions great impediment sometimes in coition, sometimes in conception, or in parturition, and occasionally during the menstrual purgation, provided the membrane or flesh occasion a complete obstruction; for in certain cases there is a perforation in the middle. Having ascertained the cause, either from its being obvious to the sight, or by introducing the speculum, if it be a simple adhesion only, it may be separated by a straight incision, made with a scalpel, for operating upon fistulæ. But if it is an obstruction, having transfixed the connecting body, whether it be membrane or flesh, with hooks, we stretch it and divide with a scalpel for fistulæ; and having stopped the hemorrhage with such applications as are desiccative without being stimulant, we have then recourse to such medicines as promote cicatrization, applying a priapus-shaped tent covered with some epulotic medicine, in those cases especially in which the operation is performed upon a part not very deep-seated, in order that the parts may not unite again. And the phimus which is formed at the mouth of the uterus is operated upon in the same manner.
Commentary. Aristotle makes mention of imperforate vagina. (De Generat. Animal. iv, 4.) Aëtius treats of these diseases at considerably greater length than our author, but his practice is nearly the same. Upon the whole the amount of his directions respecting the treatment is, that when the obstruction is occasioned by a membrane, it is to be divided and the lips of the incision prevented from adhering by the introduction of suitable tents; or, if it is a fleshy body, it is to be dissected out, and the parts separated by a piece of sponge or tents. (xvi, 96.) The same operation is described by Soranus. (219.)
The same method of treatment, however, had been previously recommended by Celsus. Thus, when the obstruction is occasioned by a simple membrane, he recommends us to divide it by two transverse incisions like the letter Χ, taking great care not to wound the urinary passage, and then the membrane is to be cut out. When the obstruction is produced by a fleshy tumour, he directs us to expose it by making a straight incision; then, having seized it with a forceps or hook, to dissect it out, and introduce an oblong tent (λημνίσκος) soaked in vinegar, and apply externally wool moistened with vinegar. The dressings are to be removed on the third day, and the sore treated upon general principles. When the wound is healing, he advises us to introduce a leaden tube smeared with some suitable ointment to prevent adhesion. (vii, 28.)
Albucasis makes mention of a singular substitute for the leaden tube recommended by Celsus: “Coeat mulier omni die ut non consolidetur locus vice alia!!” The same advice is gravely given by Rhases (Cont. xxii), and by Alsaharavius, who, as we have formerly stated, was probably the same person as Albucasis. (Pract. xxv, 2, 19.) But when the obstruction arises from a fleshy tumour, Albucasis recommends us to make use of the leaden tube. (Chirurg. ii, 72.) Alsaharavius directs us to remove the obstruction by corrosive medicines or with the knife.
Rhases briefly describes the phimus, and directs us to perforate it with an instrument of iron, and then to introduce a tent moistened in some styptic wine.
Haly Abbas states that obstruction of the uterus may arise either from a natural, that is to say, a congenital impediment, or from the effects of ulceration. He recommends us to make the midwife clear away the obstruction with a scalpel or any other convenient instrument. The Arabians were very delicate in allowing male practitioners to perform surgical operations about the genital organs of women. (Pract. ix, 66.)
SECT. LXXIII.—ON ABSCESS OF THE WOMB.
When the abscess is situated at the mouth of the womb, so as that it can be operated upon, we must not be in haste in having recourse to incision, nor until the disease be ripened, and the inflammation has increased to its utmost, and the vascular bodies which surround it have become attenuated, owing to the importance of the uterus in the system. In operating, the woman should be placed on a seat in a supine posture, having her legs drawn up to the belly, and her thighs separated from one another. Let her arms likewise be brought down to her legs and secured by proper ligatures about the neck. The operator, sitting on her right side, is to make an examination with a speculum proportionate to her age. The person using the speculum should measure with a probe the depth of the woman’s vagina, lest the stalk (fistula) of the speculum being too long it should happen that the uterus should be pressed upon. If it be ascertained that the stalk is larger than the vagina, folded compresses are to be laid upon the alæ pudendi, in order that the speculum may be placed upon them. The stalk (fistula) is to be introduced, having a screw at the upper part, and the speculum is to be held by the operator, but the screw is to be turned by the assistant, so that the laminæ of the stalk being separated the vagina may be distended. When the abscess is exposed, if it be soft and thin (which may be ascertained by touching it with the finger), it is to be divided at the top by a scalpel or needle, and after the discharge of the pus, a soft oblong tent well smeared with rose-oil is to be introduced into the incision, or rather external to the opening into the woman’s vagina, so as not to produce compression. And externally to the alæ pudendi and the region of the pubes and loins unwashed wool, or clean wool dipped in oil, is to be applied. On the third day she is to be placed in a hip-bath of warm oil or water, or of a decoction of mallows; and having wiped the parts, we introduce the tent gently into the opening, spread with the ointment tetrapharmacon, either alone or with clarified honey; its strength, however, ought to be reduced with butter or oil of roses. The external parts are to be covered with cataplasms until the inflammation subside and the sore become clean. If it is got cleansed with difficulty, an injection of the decoction of iris, of birthwort, or of honey, may be thrown up with an ear-syringe. The healing process may be promoted by the calamine ointment diluted with wine and applied upon a pledget. But if the abscess be within the mouth of the uterus, we must decline operating.
Commentary. A similar description of the method of opening abscesses in the vagina is given by Aëtius. (xvi, 85.) The only difficulty in comprehending his description or our author’s arises from our unacquaintance with the construction of the ancient dioptræ or specula. Drawings of several sorts of them are given in the surgery of Albucasis and by Scultet. (Arsenal de Chirurg. tab. 18.) One of the simplest of them consists of two laminæ or plates so united that by turning a vice or screw they separated to the proper distance. Albucasis evidently copies our author’s description. (Chirurg. ii, 71.) The account given by Haly Abbas is quite similar. (Pract. ix, 57.)