Chapter VIII - Diagnosis of foetal obstruction

Now we shall discourse on the Nidana of Mudhagarbha (false presentations and difficult labour). 1.

Causes of Mudha-garbha:—

Sexual intercourse during pregnancy, riding on horseback, etc., or in any sort of conveyance, a long walk, a false step, a fall, pressure on the womb, running, a blow, sitting or lying down on an uneven ground, or in an uneven posture, fasting, voluntary repression of any natural urging of the body, partaking of extremely bitter, pungent, parchifying articles, eating in inordinate quantities of Shakas and alkaline substances, dysentery (Atisara), use of emetics or purgatives, swinging in a swing or hammock, indigestion, and use of medicines which induce the labour pain or bring about abortions, and such like causes tend to expel the fetus from its fixture. These causes tend to sever the child from the uterine wall with its placental attachment owing to a kind of Abhighata (uterine contraction) just as a blow tends to sever a fruit from its pedicel. 2.

Definition:—

The fetus, thus severed and dislodged from its seat, excites peristalsis not only in the uterus, but induces a sort of constant, spasmodic contraction of the intestinal cavities (Koshthas), producing pain in the liver, spleen, etc. The Apana Vayu, thus obstructed through the spasmodic contraction of her abdomen, produces any of the following symptoms, viz. a sort of spasmodic pain in the sides, or in the neck of the bladder, or in the pelvic cavity, or in the abdomen, or in the vagina, or Anaha (tympanites with obstruction, etc.) or retention of urine, and destroys the fetus, if immature, attended with bleeding. In case the fetus continues to develop and is brought in an inverted posture at the entrance to the vaginal canal, and is impacted at that place, or if the Apana Vayu gets disordered and consequently cannot help the expulsion of the same, such an obstructed fetus is called Mudha-garbhah. 3.

Classification and Symptoms:—

Cases of Mudha-garbha may be roughly divided into four different classes such as, the Kilah, the Pratikhurah, the Vijakah and the Parighah. The sort of false presentation in which the child comes with its hands, legs and head turned upward and with its back firmly obstructed at the entrance to the vagina, like a stake or a kila, is called Kilah. The sort of presentation, in which the hands, feet and head of the child come out, with its body impacted at the entrance to the vagina, is called Prathikhurah. The type in which only a single hand and the head of the child come out (with the rest of its body obstructed at the same place), is called the Vijakah. The type in which the child remains obstructing the head of the passage in a horizontal position, like a bolt, is called the Parighah. Certain authorities aver that, these are the only four kinds of Mudhagarbha. But we can not subscribe to the opinion (which recognises only four kinds of false presentations), inasmuch as the deranged Vayu (Apana) can present the fetus in various different postures at the head of the vaginal canal. Sometimes, the two thighs of the child are first presented, and sometimes it comes with a single leg flexed up. Sometimes the child comes with its body, bent double, and thighs drawn up, so that only breech is obliquely presented. Sometimes the child is presented, impacted at the head of the passage with its chest, or sides, or back. Sometimes the child is presented with its arm around its head, resting on the side, and the hand coming out first. Sometimes only the two hands are first presented, the head leaning on one side; sometimes the two hands, legs and the head of the child, the rest of the body being impacted at the exit in a doubled up posture. Sometimes one leg is presented, the other thigh being impacted at the passage (Payu). I have briefly described these eight sorts of presentation of which the last two are irremediable. The rest should be given up as hopeless if these are attended with the following complications viz., deranged sense-perception of the mother, convulsions, displacement or contraction of the reproductive organ (yoni) a peculiar pain like the after-pain of child birth, cough, difficult respiration, or vertigo. 4.

Memorial verses:—

As a fruit, fully matured, is naturally severed from its pedicel and falls to the ground and not otherwise, so the cord, which binds the fetus to its maternal part, is severed in course of time, and the child comes out of the uterus (into this world of action). On the other hand, as a fruit, worm-eaten or shaken by the wind or a blow, untimely falls to the ground, so will a fetus be expelled out of its mother’s womb, before its time. For four months after the date of fecundation, the fetus remains in a liquid state, and hence its destruction or coming out of the womb goes by the name of abortion. In the course of the fifth and sixth months the limbs of the fetus gain in firmness and density, and hence, its coming out at such a time is called miscarriage. 5 -7.

Prognosis:—

The enceinte who violently tosses her head in agony (at the time of parturition) and the surface of whose body becomes cold, compelling her to forego all natural modesty, and whose sides and abdomen are covered with nets of large blue- coloured veins, invariably dies with the dead child locked in her womb. The death of the fetus in the womb may be ascertained by the absence of movements of the fetus (in the womb) or of any pain of child-birth, by a brown or yellow complexion of the enceinta, cadeverous smell in her breath, and colic pain in the abdomen and its distension owing to the continuance of the swollen and decomposed child in the womb. 8-9.

The death of a child in the womb may result from some emotional disturbance of its mother, (such as caused by bereavement or by loss of fortune during pregnancy); while an external blow or injury (to the womb) or any serious disease of the mother may also produce the like result. A child, moving in the womb of a dead mother, who had just expired (from convulsions etc.) during parturition at term, like a goat (Vastamara) should be removed immediately by the Surgeon from the womb (by Cesarean Section);* as a delay in extracting the child may leads to its death. 10-11.

Additional Text:—

The bladder is ruptured, the dead child lies like a weight upon the placenta and is pressed upward on the spleen, liver and gall bladder. The mother shivers and is oppressed with tremor, dryness of the tongue, dyspnea and perspiration. She complains of a cadaverous smell in her breath and stands in danger of imminent death. By these symptoms a physician shall know the death of the child in the womb. This portion is partly recognised by Brahmadeva and is totally rejected by Jejjadacarya as spurious.

Note on Cesarean Section:—

Cesarean Section means incision of the uterus through the abdominal walls and extrication of the fetus therefrom. Operation like this upon a dead subject requires no skill of a surgeon. Any one can do it without the help of any anatomical knowledge. In modern times, when the mother’s life is in peril, and the expulsion of the fetus becomes nearly impossible, by the natural passage, owing to an existence of deformity either in the parturient canal or in the forms and structures of the fetus, to save both mother and child this operation is principally undertaken.

The evidence of similar attempts, in ancient India, is found recorded in passages like what we have just translated and that the operation was practised on living subjects, there is not the least doubt about it. This custom is still preserved in Central Africa, and it is possible that the Egyptians like Hindu philosophy and religion learnt this also from the Hindus. “Felkin,” says “Baas in his History of Medicine p. 70 “saw a case of the Cesarean operation in Central Africa performed by a man. At one stroke an incision was made through both the abdominal walls and the uterus. The opening in the latter organ was then enlarged, the hemorrhage checked by the actual cautery, and the child removed. While an assistant compressed the abdomen, the operator then removed the placenta. The bleeding from the abdominal walls was then checked. No sutures were placed on the walls of the uterus but the abdominal parietes were fastened together by seven figure-of-eight sutures, formed with polished iron needles and threads of bark. The wound was then dressed with a paste prepared from various roots, the woman placed quietly upon her abdomen, in order to favour perfect drainage, and the task of the African Spencer Wells was finished. It appears that the patient was first rendered half unconscious with banana wine. One hour after the operation the patient was doing well. And her temperature never rose above 101 F. nor her pulse above 108. On the eleventh day the wound was completely healed, and the woman apparently as well as usual.”

When we read this evidence of Felkin, we are reminded of the operative steps as described in our own ancient book of Surgery from which modern surgeons have been able to borrow the operation of rhinoplasty. It is a great pity that while in Africa the same practice is still retained intact, we in India by spurious attempts and disgraceful contortions, substitutions of false readings and dismal knowledge of grammar and rhetoric try to prove in the face of strong evidence that in ancient India Cesarean Section was attempted only on cases where one “might not perspire.”

If we take vipannayaḥ in the sense of “a woman whose life is in great danger” and not exactly in the sense of “a woman who is dead” as recommended by Dalian and Arundutta (and which might have been the meaning if instead of vipanna a word like vyapanna had been used in the text), we find at once that Weber’s remark in his History of Indian Literature p. 270 “that in Surgery they (the Hindus) attained to high proficiency” is not based on the solitary evidence of rhinoplasty alone.

In performing obstetric operations with success examples like this are not rare. If the two different readings vastamara and vastihara be taken con¬jointly into consideration we are impressed with the idea that in ancient India Cesarean operations were very frequently undertaken in cases of puerperal eclampsia, where the mother had been in the deplorable condition of a goat suffering from cramps and convulsions as well as in cases of an accidental death not unlike that which fell to the lot of the poor mother of him in whose name the operation is called. vasta = goat; nara = destroyer (See Monier William’s Dictionary) hence a goat-destroyer = a tiger or wolf) or in cases where the presence of deformity in the parturient canal or of malformation of the fetus prevented the natural delivery of a living child. The incision is not to be made anywhere else but exactly in the place where Felkin saw the illiterate Negro successfully apply his knife, the selection of vasti harañca as suggested by some commentators being a tempest on a tea pot especially when the subject is beyond the grave. In a living subject the selection of a proper site for the operation is of course very commendable. Hence we venture to suggest that extraction of the living fetus from the womb by making incision through this part of the pelvis was also attempted later on.

We extract here the two different readings and leave our readers to judge whether we are correct to draw the above inferences.—Ed.

vastihare vipannayaḥ kukṣiḥ praspandate yadi |
janmakale tataḥ shighraṃ paṭayitvoddharecchishum ||
      Bagabhata Sharira Sthana. ch. II. slo. 53.

vastamara vipannayaḥ kukṣiḥ praspandate yadi |
tatkṣaṇajvanmakale taṃ paṭayitvoharedbhiṣak ||

 

Thus ends the eighth Chapter of the Nidana Sthana in the Sushruta Samhita, which treats of Nidana of difficult labour and false presentations.