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.