The seven books of Paulus Ægineta, volume 2 (of 3)

by Aegineta Paulus

SECT. LXXIV.—ON EMBRYULCIA AND EMBRYOTOMY.

We have described the treatment of difficult labours in the [Third Book]. If the process of parturition be not rectified by the means there laid down, we must proceed to the surgical operation, after having formed a probable conjecture whether the woman will survive or not; and if she may be saved, then we are to operate; but if not, we must decline attempting the operation. Those in a dying state are affected with coma, lethargy, and loss of muscular motion; they are difficult to rouse, or if roused by loud cries, they return a feeble answer, and again sink into a comatose state. Some have convulsive contractions, or subsultus tendinum, or insensibility to food. The pulse is found to be greatly inflated, but obscure and feeble. Those who are to recover have none of these symptoms. Having placed the woman in a supine posture, with her head rather depressed, her thighs are to be kept elevated by women on each side, or by certain assistants; or if they are not at hand, her chest is to be first fastened to the bed by ligatures, so that when the fœtus is pulled the woman’s body may not follow, and diminish the force of the pulling. Then the alæ pudendi being separated by an assistant, we must introduce the left hand lubricated with some unctuous substance, the fingers being contracted, to the mouth of the uterus, and dilate it, and having got it relaxed by lubricating it with oil, we seek for the most convenient place for fastening the hook (embryulcus). The most convenient places in presentations of the head are—the eyes, the occiput, the roof of the mouth, the chin, the clavicles, and the parts about the sides and hypochondrium; and in feet presentations, the bones of the pubes, the middle of the ribs, or, again, the clavicles. The hook is to be held in the right hand, and its curvature grasped with the fingers, and it is to be gently introduced with the left hand, and fixed on some of the afore-mentioned places, being pushed to the cavity of the uterus. And another is to be applied opposite to it in order that the pulling may be straight down and not to one side. Then we are to pull gently, not only straight-forward but also from side to side, as in the extraction of teeth; and there ought to be no relaxation of the pulling in the intervals. Then introducing the index-finger or more fingers besmeared with fat between the mouth of the womb and the impacted body, we must lubricate it all around. When the hook comes down properly it must be changed to a part above, and so on until the fœtus is completely extracted. When a hand presents, and is so impacted that it cannot be returned, we must wrap a cloth round it so that it may not slip, and pull it so far, and when it is properly fallen down it should be cut off at the shoulder. The same thing is to be done when two hands fall down into the vagina; and in like manner, when the feet come down, and the rest of the body does not come along, we must amputate at the groins, and then endeavour to turn the rest of the body. If the impaction take place owing to the head being larger than natural, if it be a hydrocephalous fœtus, we must open its skull with a polypus-scalpel, or a needle, or a sharp-pointed knife concealed between the fingers, in order that it may collapse when evacuated; but if it be a naturally large head, we must open the skull in like manner, and break down its bones with a tooth-forceps or a bone-forceps, and if the bones project they ought to be extracted. If, after the head has been delivered, an impediment should take place at the chest, the parts about the clavicles should be divided down to the cavity of the thorax with the same instrument, so that the thorax may collapse when its fluid contents are discharged; but if it do not collapse we may divide the clavicles and extract them, when the thorax will collapse. If the belly be inflated, owing to the death of the child, or its being dropsical, we must evacuate its contents with the intestines in the same way. In presentations by the feet the wrong direction may be easily rectified at the mouth of the womb. But if the fœtus stick at the chest or belly, we must wrap a cloth about it and draw it down, and making a division in the same manner, evacuate its contents. If, after the other parts are cut off, the head retreat backwards and is retained, we must introduce the left hand, and if the mouth of the womb be open, push up the hand to the cavity of the womb, and having found the head, bring it down with the fingers fixed in the mouth, and extract by one or two hooks fixed in it; but when there is inflammation at the mouth of the womb we must use no violence, but lubricate the parts with unctuous and fatty applications, and have recourse to hip-baths, embrocations, and cataplasms, in order that when the mouth is dilated extraction may be accomplished in the manner described above. Cross presentations, if they can be rectified, may be treated according to the afore-mentioned methods; but if not, the whole fœtus must be cut asunder within, and extracted in pieces, taking care that none of the parts of it be left behind. After the operation we must have recourse to the treatment for inflammations of the uterus. If hemorrhage come on, you have already had the management of it described.

Commentary. There is a curious treatise commonly published along with the works of Hippocrates on the extraction of the fœtus; but, as it is not mentioned by Erotian and Galen, it is now generally admitted not to be genuine. The author of it directs us, when the arm presents, to pull it down and amputate at the shoulder-joint; after which the head is to be brought to the proper position and delivery accomplished accordingly. This is not now the general rule of practice, and yet we were once compelled by necessity to deliver in this way, after we and an intelligent assistant had been foiled in all our attempts to turn the child. We have known of similar cases happening in the practice of other surgeons; and, in fact, this method of procedure was advocated lately by a sensible writer in the ‘Edinburgh Medical and Surgical Journal.’ The author of the ancient treatise in question recommends us to bring down the head in its natural state, if possible, but if this be found impracticable, to break it down. He directs us to give for drink a white, sweet, undiluted wine.

Celsus gives an interesting account of this subject, and his practice is deserving of much consideration. He recommends us, when the position is unnatural, to turn the child either to the head or the feet; adding, afterwards, that delivery may generally be accomplished easily enough by the feet. In arm presentations, he approves of turning to the head, that is to say, in cases when it is ascertained that the fœtus is dead. If the head is at hand, a smooth hook with a small point is to be fastened at the eye, the ear, the mouth, or the forehead, and its body is to be thus dragged down. This, however, must not be attempted when the mouth of the womb is not properly dilated. The right hand is to be employed in dragging down the fœtus, and the left in directing the instrument and the fœtus. When the body of the fœtus is distended with a fluid, it is to be let out, and the body brought down with a hook. If the child lie across and the position cannot be got rectified, the hook is to be inserted at the armpit, and extraction gradually performed. In extreme cases he recommends us to cut the neck asunder, and extract the parts separately, beginning with the head, for fear of its being left in the uterus. Should such an accident occur, however, he directs us to get the belly compressed so as to force the head down to the os uteri; after which it may be extracted with a hook in the manner described above. (Smellie relates histories of such cases.) When one foot presents, and the breech sticks at the os uteri, he recommends us, when the other foot cannot be found, to separate the one which protrudes; after which the body of the child may be pushed up, and the other leg found and brought down. It is to be recollected that this practice is only recommended when the child is dead. He adds, that other difficulties may give rise to the necessity of performing embryotomy. (vii, 29.)

Aëtius has an interesting chapter on the Extraction of the Dead Fœtus, copied from the works of Philumenus. His description of embryotomy is similar to our author’s. He directs us to apply two hooks to certain parts of the head, such as the eye, mouth, and chin, and thus to drag down the body. If the head is large or hydrocephalic, he advises us to open it and evacuate its contents; and if even then it is found to be too large for the passage, he recommends us to break down the bones of the skull and remove them with a forceps, after which the instrument is to be fixed and the fœtus dragged down. If obstruction to the delivery take place at the chest or the belly, he directs us to evacuate their contents in like manner. When an arm or both present, he recommends us to amputate at the shoulder-joint. If the child come down doubled, and the position cannot be got rectified, he advises us, if the head can be reached, to break down its bones, and then extract the other parts accordingly; but if the legs are got at most easily and cannot be brought down, they are to be amputated at the hip-joint, and then the head will be got delivered. When the body is so impacted in a doubled state that it cannot be moved, he directs us to separate the vertebra at the neck, and then to drag down the lower part of the body; after which the head is to be sought for by the hand introduced into the uterus, and brought along with two hooks. (xvi, 23.)

No ancient author has described the operation of embryotomy so accurately as Soranus; but as his account of the process is lengthy and does not differ essentially from that of Aëtius, (indeed the latter evidently copies from Soranus,) we need not seek to give any outline of it. (Op. 51, 52, 53.)

Avicenna takes his chapter on the extraction of the dead fœtus from our author. (iii, 21, 2, 24.) We have mentioned in the [Third Book] that he was acquainted with the forceps.

Albucasis, in like manner, takes his account of embryotomy from Paulus. He relates a singular case that came under his own knowledge of an extra-uterine conception; the most remarkable circumstance about which was, that the bones of the fœtus after a time were discharged at the umbilicus. The work of Albucasis contains drawings of the instruments used in his time for obstetrical operations. There are several forcipes among them, but as they all have teeth, it is to be presumed that they were used only for delivering the fœtus when dead. It is to be regretted that he has entirely omitted the forceps mentioned by Avicenna. (See Chirurg. ii, 76 and 77.)

Rhases directs us when the child’s head is large and cannot be brought down with fillets, to open it and deliver with hooks. When it is ascertained that the child is dead, he recommends us to break down the bones of the head and evacuate the brain. In preternatural presentations he recommends us to deliver, if possible, by the head or feet, but if this cannot be got accomplished, he directs us to cut off the protruding part. Upon the whole his rules of practice are much the same as our author’s. (Cont. xxii.)

Haly Abbas gives ample directions for the management of these cases. When the head presents (the child being dead and delivery found otherwise impracticable), he directs us to fix hooks in the hollows of the eyes, neck, or jaw-bone; or if the feet present, at the tops of the thighs. The body of the child is then to be dragged along. When a hand presents, he recommends us to pull down the arm and amputate at the shoulder; and in like manner he directs us to amputate at the hip-joint when in footling presentations the delivery cannot be otherwise accomplished. When the head is preternaturally large, he directs us to open it and evacuate its contents; and to do so in like manner with the chest when any obstruction takes place at it. He makes no mention of any instrument resembling the modern forceps. (Pract. ix, 57.)