Since early modern medicine was largely based on the humoral theories of Hippocrates as modified by Galen and Avicenna, I feel it’s important to look at what was really going on with medicine during antiquity. I get a little tired of reading bad takes on the practices and opinions of historical figures. There’s no excuse for it when the primary source documents are so readily available these days.

In this post I am going to discuss abortion as explained by two of the physicians whose work informed early modern medicine. Hippocrates (5^th Century BCE) who was the originator of humoral medicine and Soranus of Ephaseus (2^ndCentury CE). Soranus was one of the more well-known physicians of the Methodic school of medicine who practiced in Alexandria and subsequently in Rome during the early Imperial era. I chose him because his work was cited frequently by Eucharius Rosslin who wrote A Garden of Roses for Pregnant Women and Midwives in 1526, and because I have a thing for the Methodics.

When I am teaching history at conferences, one of the roadblocks I hit in explaining ancient healthcare are modern misconceptions about their materia medica and their methods. Their materia medica incorporated a wide variety of minerals and animal ingredients. Hipprocates “potion” for improving scanty menses was four blister beetles, six black pomegranate seeds, eggs of cuttlefish, and a little linseed oil.[1]   This potion was given as part of a regimen that consisted of other therapies like dietary interventions, medicated baths, massage, fomentations, and venesection. I can’t recall one time when I read one of these physicians, take this beverage three times a day and you will be better.

One of the only contraceptives that Hippocrates mentions is misy a preparation made from a crude copper ore that would prevent pregnancy in women who must not get pregnant.[2] Khálkanthon (literally flowers of copper) is a water-soluble powder of oxidized copper used as one ingredient for contraceptive suppositories. It is called blue vitriol in early modern medicine. So here we have our historical precedent for copper IUDs.

They also had an array of surprisingly modern looking medical equipment available. (What might be more surprising is that we haven’t progressed further than we have.) Hippocrates wrote regularly of using pine dilators to dilate the cervix and insert medicines into the cervical cavity with a uterine sound – usually made of lead. The pine dilators were rounded on both ends and someone like modern Hegar dilators. Hippocrates walks you through a surgical abortion of a dead fetus. Soranus wrote of using a uterine syringe or a small clyster [enema] pipes to flush the uterus with various medicinal solutions. They were very much about topical application. While Soranus mentions using a speculum, Egyptian physician Metrodora’s On the Diseases and Cures of Women, published in the 3rd century, contains more instruction.

So, the idea that midwives didn’t have any tools at their disposal to perform a mechanical abortion is nonsense. In fact, one of Soranus’ tips for a stalled labor is not to let the midwives “dilate the uterus forcibly”[3] for too long, but we will get to that in a bit.

I suppose I should start where most people start with the Hippocratic Oath. It is sometimes incorrectly translated to “I will not give to a woman an abortive remedy to procure an abortion” when it should read “I will not give to a woman a destructive pessary to procure an abortion.” This had led to a lot of wild speculation (I believe that might be John Riddle’s middle name) as to what Hippocrates meant but if you read Soranus, he clears that up saying,

“But a controversy has arisen. For one party banishes abortives, citing the testimony of Hippocrates who says: “I will give to no one an abortive”; moreover, because it is the specific task of medicine to guard and preserve what has been engendered by nature. The other party prescribes abortives, but with discrimination, that is, they do not prescribe them when a person wishes to destroy the embryo because of adultery or out of consideration for youthful beauty; but only to prevent subsequent danger in parturition if the uterus is small and not capable of accommodating the complete development, or if the uterus at its orifice has knobby swellings and fissures, or if some similar difficulty is involved.[4]

So yes, physicians of the era believed Hippocrates meant what he said. He was more likely to mention preventing abortion as in Aphorisms where he says, “If a woman with child be bled, she will have an abortion, and this will be the more likely to happen, the larger the fetus.” [5] He’s most likely correct about that because bloodletting would concentrate the levels of oxytocin in the blood and the further along a pregnancy, the more sensitive the uterus is to oxytocin. He might also have been right about in saying that purgatives which “violently disturb her cavity (intestines)” caused the uterus to react. Soranus also mentions purgatives in the excerpt I share below.

Unfortunately, he had a lot of less credible ideas about what led to abortion including the uterus being filled with air, eating foods that were sharper or more bitter than usual, exertion, fear, and my personal favorite- shouting and losing her temper.[6] That’s right …physicians used fear of losing their child as a way of policing women’s behavior.

Hippocrates warned of the danger of abortion (spontaneous or induced they didn’t specify) saying, “Abortions are more dangerous than births because it is impossible for an embryo to be aborted by medicine or by a potion or by food or by pessaries or in any way at all without applying force, and force is a painful thing. The risk here is that the womb will become lacerated or inflamed and this is dangerous.” Hippocrates might have been opposed to performing elective abortions, but he certainly shares plenty of information on how to open the cervix for cleaning or flushing the uterus as a means of promoting healthful menstruation and expelling the afterbirth, or a dead fetus.

Soranus who lived 500 years later was a little less reticent and just laid the process out saying, “For a woman who intends to have an abortion, it is necessary for two or even three days before hand to take protracted baths, little food, and to use softening vaginal suppositories also to abstain from wine; then to be bled and a relatively great quantity taken away…Following the venesection one must shake her by means of draught animals (for now the shaking is more effective on the parts which previously have been relaxed) and one must use softening vaginal suppositories. But if a woman reacts unfavorably to venesection and is languid, one must first relax the parts by means of sitz baths, full baths, softening vaginal suppositories, by keeping her on water and limited food, and by means of aperients [laxatives] and the application of a softening clyster; [this means enema but I have seen it used for uterine flushes also so I am unsure as to the meaning here] afterwards one must apply an abortive vaginal suppository.”[7]

The softening suppositories contained a lot of the “procure the courses” herbs and that makes sense because they seemed to think that “wind” one of the things that caused the uterus to move about the body and become hardened. And to be fair carminatives may have the effect of relaxing smooth muscle when applied topically. They were combined with astringent ingredients which likely functioned as osmotic dilators, absorbing moisture from tissues around the cervix to cause it to open. This would be the functions of a lot of the resins you see in their formulas. This was more likely the effective part of the preparations. Some physicians still use laminaria which are small tubes made of dried seaweed to dilate the cervix before certain procedures today, although others use synthetic dilators made of sterile, dry sponge.

The softening suppositories were far more gentle than other techniques used to open the cervix. You can read about the way Hippocrates used pine dilators and applied medicines to the cervical canal with uterine sounds, as part of his cleaning process and to provoke obstructed menses as well. It’s quite the process and sounds a bit like torture.

Hippocrates shared formulas for abortive suppositories for the purposes of expelling a fetus that has died. One was grinding a dram of powdered alum, another of myrrh, and three obols of black hellebore with enough dark wine to form them into small suppositories to be inserted in the cervix.[8] As I said earlier, many of the herbs that you read about as herbal abortions were incorporated into preparations that were made to be inserted near or into the cervix. Some were even inserted in the cervical canal or injected into the dilated uterus.

Hippocrates suggested “sharp” suppositories for stubborn cases. These were made by wrapping a root or a feather in wool that has been soaked in some sort of medicinal substance. They would leave a bit of the hard stalk of the feather or tip of a root outside of the wool and that was meant to be inserted into the mouth of the cervix left in until bleeding occurred.

Dioscorides talked about using the root of wild carrot for this in a previous post. Hippocrates suggests using a six-inch shoot of black hellebore.[9] Soranus didn’t seem to be a fan of the sharp suppositories saying, “Many different things have been mentioned by others; one must, however, beware of things that are too powerful and of separating the embryo by means of something sharp-edged, for danger arises that some of the adjacent parts be wounded.”[10]

Given how much Hippocrates talks treating about ulcerations of the uterus, I am going to agree with Soranus. Ancient Greek medicine was intense. The things Hippocrates wrote about doing to women in the name of promoting normal menses and fertility still appalls me every time I read through Diseases on Women.

My point here is that at no point did these physicians just give a person a tea to abort a fetus and then expect that nature would just take its course. They weren’t idiots. They understood that incomplete abortions [spontaneous or induced] could kill a woman if they didn’t take additional measures to cause the expulsion of the fetus, and they didn’t have modern antibiotics to fall back on.

A pessary for provoking the menses has been explained by many physicians of antiquity including Paul of Aegina and in the vernacular Greek text written by John the Physician. ‘Grind indigo and nigella seed, mix it with honey and make a bundle from a cloth and put it inside. Then give it to another woman and let her put it into the womb with her hand. But tie a thread to the bundle, and when you want to remove it, you have to pull the thread to remove it. This is called pessary by the doctors.’

The application of pessaries was clearly a known practice in the Middle Ages. Recommendation such as this one from Tadhg O Cuinn’s Irish Materia Medica written in 1415, were common, “place the juice of this herb in the vagina, as a pessary is applied, and it will provoke menstruation surely and gently, and if benedicta is added to it, it will provoke menstruation all the more.”

Herbal preparations played a part in the process in the same way we use medicines as part of the process now, but it was far more likely to see them applied topically than it was to make infusions. It just doesn’t work like that. I clapped my hands in joy at the scene in Bridgerton where the physician asked Marina Thompson if she really thought a tea would work to cause an abortion and then followed up with “They never do.”

The last point I want to make about Greek medicine is that male physicians were discouraged from performing gynecological exams on women, but not prohibited. Hippocrates wrote of having women perform procedures themselves or finding another woman to do it, but he also mentioned doing so himself. So, they had to train these women to work with them. Soranus’ Gynecology has been argued by some to be a textbook for training midwives as his first requirement was that they be literate.

Soranus was all about midwives, which probably speaks to early Imperial Rome’s more enlightened view on the education of women. According to Soranus “the best midwife if she goes further and in addition to her management of cases is well versed in theory. And more particularly, we call a person the best midwife if she is trained in all branches of therapy (for some cases must be treated by diet, others by surgery, while still others must be cured by drugs) ; if she is moreover able to prescribe hygienic regulations for her patients, to observe the general and the individual features of the case, and from this to find out what is expedient. “[11]

The most illuminating thing Soranus writes is that our midwife “must not be greedy for money, lest she give an abortion wickedly for payment.” [12] I promise you that any time someone says someone should not do something or passes a law against a practice, it is because it is being done. Midwives were being trained in how to perform these procedures in antiquity and they kept doing it right up until midwifery was outlawed in the mid 1900’s.

The takeaway here is that medical text written in the early modern era was paraphrased and handed down from these older texts, each time leaving the chance for operant information to be left out, which has clearly happened.

I for one am concerned about the number of people who are citing them as sources for giving women toxic beverages, when that wasn’t the process used and even if it was, it was on the advice of a guy who thought the reason people with uteruses threw up blood was because their uterus moved up in their body and their menses were exiting the body through their mouth.

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