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.
Avicenna has treated of difficult parturition with his usual accuracy,
which exhausts every subject he handles. He states that the expulsion of
the child is performed by the abdominal muscles. This was the opinion of
Galen; and we are inclined, upon the whole, to think it pretty correct.
He approves greatly of the bath, both before labour has come on and
during the time of it. When delivery is difficult, owing to the size
of the child, he directs us to apply a fillet round the child’s head,
and endeavour to extract it. When this does not succeed, the _forceps_
are to be applied, and the child extracted by them. If this cannot be
accomplished, the child is to be extracted by incision, as in the case
of a dead fœtus. This passage puts it beyond a doubt that the Arabians
were acquainted with the method of extracting the child alive by the
_forceps_.
Albucasis recommends us, when the membranes are tough, to perforate
them by the finger or a _spatumile_. When the waters are discharged,
he directs us to press down the woman’s belly so as to make the head
descend. If it does not come down readily, he advises us to give a
clyster, and afterwards to apply compression to the belly. Albucasis also
approves of the tepid bath. To promote the delivery of the secundines, he
recommends us to make the woman sneeze and retain her breath.
Alsaharavius (probably the same as Albucasis) treats fully of the causes
of difficult labours. When occasioned by dryness and constriction of
the vagina, he recommends baths, fomentations, and clysters, containing
the decoctions of mallows, fenugreek, and linseed; and also directs the
parts to be rubbed with warm oil. When obstruction of the rectum by fæces
prevents delivery, he advises us to administer a clyster. When intense
cold is the cause of the difficulty, he recommends clysters of hot oil,
and the warm bath. When the membranes are tough and retard delivery, he
directs the midwife to break them with a sort of reed or needle.
Haly Abbas mentions imperforate hymen among the causes of difficult
labour. Such cases have been reported by modern writers on midwifery. See
Baudelocque (§ 341), and Burns (Midwifery, x.) Fabricius ab Aquapendente
relates a very curious case in which conception had taken place without
rupture of the hymen. (Œuvres Chirurg. ii, 81.) When the difficulty
arises from fatness and debility of the expulsive powers, Haly directs
us to rub the parts with warm olive-oil, or other such emollients, and
to make the woman sit in a bath prepared with chamomile, melilot, &c.
He mentions, as an internal remedy, the infusion of a swallow’s nest
(alcyonium?) When the difficulty proceeds from cold, he recommends the
use of the tepid bath; and when from the contrary cause, he advises
cooling things to be applied. According to Rhases, difficult parturition
may arise from the mother, the fœtus, or the secundines. He appears to
have considered all presentations unnatural except the head. In the other
cases, he says, the life of the mother or child is endangered, although,
he adds, many living children are born by the feet. When delivery of the
head is found difficult, he recommends ligatures or fillets. When the
feet or hands present, he directs us to restore the position, or if that
is impossible, to bring down the feet. Many of his authorities mention
the warm bath and lubricants.
From the sketch which we have given above, it will be seen that the
Arabians have made mention of the forceps; but that most probably the
Greeks and Romans were unacquainted with this instrument, as far, at
least, as appears from their works on medicine which have come down
to us. It is deserving of remark, however, that in the house of an
_obstetrix_ which has been excavated in Pompeii, there was found an
instrument of art bearing a very considerable resemblance to the modern
forceps. It is a well-known fact in the history of inventions that many
useful discoveries have long been kept as family secrets. This was the
case even of a late date with the Chamberlains, who were the first in
modern times to use the forceps.