Of Conception and Utero-Gestation.
The different theories which the ingenuity of the physiologist has invented for the elucidation of this mysterious and wonderful process, have been supported with so much zeal and argument by the disciples of one school, and disputed with so much warmth and plausibility by those of another,[[362]] that to recite the merits and defects of each system would be a task as laborious in its execution, as it must be unsatisfactory and unprofitable in its results; we shall therefore not attempt to ascend into the scale of causes, but rest on the phenomenon of conception, as an ultimate fact, and confine our researches to the history of its œconomy. The series of changes which constitute the phenomena of conception and gestation are clearly proved by the experiments of De Graaf to originate in the ovaries, and not in the uterus, as former physiologists had supposed. One or more of the vesicles, or ova, contained in the former of these organs, no sooner receive the vivifying impression communicated by the coitus than they are loosened from their connection, and grasped by the fimbriæ of the Fallopian tube, by whose peristaltic contractions they are, in due time, conveyed into the uterus; the spot in the ovarium from which the ovum has been thus separated, when examined after death, exhibits a slightly lacerated appearance, as if the germ had been detached from a vesicle at the moment of conception, by the rupture of its parietes; to this structure, which from the colour that it assumes has been called by physiologists corpus luteum, we shall have frequent occasion to allude during the course of the present inquiry. While these actions are proceeding, the uterus passes through several contemporary changes, in order to prepare it for the reception of the ovum; its blood-vessels are increased in size, as seen in slight cases of inflammation; the texture of its internal surface becomes softer, and more spongy, and a white mucus is secreted, which, from the extreme delicacy of its arrangement, has been compared by Harvey[[363]] to the web of the spider; it soon, however, assumes a more solid form, becomes vascular, and adheres so as to form a lining to the whole cavity of the uterus, except at the orifices which lead to the Fallopian tubes, and the os uteri. Dr. William Hunter considered it as the inner lamina of the uterus cast off, like the exuviæ of some animals, after every conception, and he accordingly called it the Decidua, and from the manner of its passing over the ovum, the Decidua Reflexa.[[364]] It is not known what exact interval is required for the fœtal primordia to pass through the Fallopian tube, and descend into the cavity of the uterus. Valisnieri and Haller have never been able to find it distinctly in the latter viscus before the seventeenth day. As the mouth of the pregnant uterus is sealed up with gelatinous matter from the moment of conception, it is, under ordinary circumstances, incapable of allowing any passage for the Catamenia, although exceptions to this law are frequently mentioned by men of science,[[365]] which have probably arisen from the observation of an occasional sanguineous discharge from the vessels of the vagina; and which, says Burns,[[366]] are neither regular as to the monthly period, nor of the same quality as that of the menses, and he concludes by remarking, that he has never known any instance where menstruation was perfect and regular during the whole of pregnancy. Dr. Denman[[367]], whose authority upon such a question must carry with it very considerable weight, says, “a suppression of the Menses is one of the never-failing consequences of conception, at least I have not met with a single instance to the contrary.”
Conception is succeeded by many important changes in the constitution, that are indicated by affections of various parts, and which, therefore, to a certain degree, afford signs of a woman having conceived; and indeed in the earlier periods of pregnancy, they afford us the only means of judging of the fact; and although they are necessarily ambiguous and uncertain, yet Dr. Denman observes, that from the common occurrence of the case, and the particular attention which is paid to it, a faculty of discrimination is acquired which generally prevents error. The medical jurist, however, can never receive such testimony as satisfactory, and it is fortunate that the law rarely requires elucidation upon this point, for in those cases of violent death in which it may be important to ascertain the fact, the light of dissection will assist our decision; and in cases where the plea of pregnancy has been set up, in bar of punishment, it will not avail, unless it be so far advanced as to render our investigation easy and satisfactory. The following symptoms may be said to afford the earliest indications of pregnancy: the disappearance of the catamenia; nauseating sickness, or vomiting, chiefly occurring in the morning, and after meals, and which in some cases is almost coeval with conception, and often resembles sea-sickness, both in the violence of its symptoms, and the obstinacy with which it resists every measure of relief; vertigo and drowsiness; heart-burn and diarrhæa, frequently supervene; the appetite becomes depraved; there is a feverish diathesis; the breasts swell, and the nipples are surrounded by an areola, or brown circle, which is more or less dark according to the complexion of the woman; the countenance becomes altered, the eyes appearing larger, and the mouth wider; and a peculiar sharpness is given to every feature; the temper also becomes unnaturally peevish, and the sleep is broken and disturbed. Subsidence, or falling in of the abdomen is recorded by the old French proverb as another sign of pregnancy,
“Dans une ventre plat
Un enfant il y a.”
In some instances, particular sympathies occur, and hence tooth-ache has been considered as affording some evidence upon such an occasion. Some midwives have supposed that the appearance of blood drawn from the veins would indicate the state of pregnancy; the blood undoubtedly becomes sizy very shortly after conception, and it differs from that of a person affected with inflammation; “in the latter case,” says Burns,[[368]] “the surface of the crassamentum is dense, firm, and of a buff colour, and more or less depressed in the centre; but in pregnancy, the surface is not depressed, the coagulum is of a softer texture, of a yellow and more oily appearance.”
It is not, however, possible to determine positively, from the inspection of the blood; for a pregnant woman may labour under some local disease, which will impart to it a truly inflammatory character, while, on the other hand, it is possible for the suppression of the menses, if accompanied with a febrile diathesis, to give the crassamentum the same appearance which it would present during pregnancy; and, in truth, the same remark will apply to all those signs to which we have before alluded; and even the swelling of the breasts, upon which so much stress has been laid, as a presumptive sign of pregnancy, cannot be considered unexceptionable, for so great a sympathy subsists between the mammæ and the uterine system, that any disturbance of the latter is not unfrequently attended with an enlargement of the former: such an occurrence is by no means uncommon in Amenorrhæa. Belloc,[[369]] however, has made an observation respecting them which merits our regard; he says, that when a woman has a suppression of the menstrual flux, with the other concomitant signs of pregnancy, we may consider her situation as yet doubtful, because these signs are common both to pregnancy and amenorrhæa; but if about the third month, while the suppression still continues, she suddenly recovers her health, and the incidental circumstances disappear, her appetite, plumpness, and colour returning, nothing can better prove the existence of pregnancy; for had the impaired health, and the accompanying symptoms been the simple effect of suppression, the derangement would have continued, and even increased during the continuance of the cause; to this observation, however, of Belloc, we have one important objection to offer: in every case of clandestine pregnancy, (and it is on such occasions that our diagnosis is principally useful) the anxiety and distress of the woman’s mind, and her desire to appear as if labouring under some serious complaint, will render her returning health at the period mentioned by Belloc as unlikely, or very equivocal; in short, we do but adopt the sentiments of the most experienced midwives,[[370]] when we assert, that it is impossible to arrive at any conclusion beyond that of suspicion; and in delivering a confident opinion upon it, the practitioner must take care that he does not compromise his character for skill and knowledge. “Notandum est magna hic prudentia opus esse medico ne facile graviditatem vel affirmet, vel neget; peritissimi enim decepti fuerunt toties; nunquam magis periclitatur fama medici, quam ubi agitur de graviditate determinanda.”[[371]] History informs us, says Capuron,[[372]] and it is attested by Ambrose Paré, Moriceau, Riolan, Devaux, and others, that pregnant women have been brought to the scaffold, after an examination by medical men and matrons, who have declared the absence of pregnancy.
At about the Fourth month after conception, that stage of utero-gestation arrives, which enables us, by means of an external examination, to place the fact beyond the reach of conjecture; for at this stage the uterus may be distinctly felt through the integuments of the abdomen; nor are we able before this period to determine the question by any examination per vaginam, for the fundus uteri is the portion first distended in consequence of conception; while the cervix, the only part that we can feel, does not begin to shorten to any appreciable extent, before the period just stated.[[373]]
The following method of examining the uterus, in order to ascertain whether it be gravid, is proposed by Tortosa,[[374]] and is well calculated to accomplish the object. The woman, being fasting, and her bowels and bladder having been previously evacuated, should be directed to lie down, with the loins low, and with the head and buttocks elevated; the knees are then to be raised and bent, so as to bring the thighs to the belly, and the heels to the buttocks, by which position the abdominal integuments will be relaxed; the midwife is then to place the hand upon the epigastric region in such a manner that the little finger may rest on the pubes, and the thumb on the navel, and ordering the woman to breathe hard, he must press the belly gently during the expiration: if the uterus be gravid, and is more than three months advanced, he will at this moment feel above the pubes an equal, hard, globular body; and if the same examination be made after the fifth month of gestation, he will probably feel at the same time the motions of the fœtus; but, in cases where no tumour can be distinctly felt, the operator must be very careful not to be deceived by motion, for the action of flatus may mislead him, and even where an obvious enlargement exists, the pulsations of the aorta may lend to it a deceptive motion; this is particularly striking where the ovarium is extensively diseased, or the uterus is distended with tumours, an occurrence which has not unfrequently induced the patient to consider herself pregnant;[[375]] in such a case the ovarium may be felt through the parietes of the abdomen, sometimes pretty high, like the uterus, or like a prominent part of a child, but the round and circumscribed nature of the tumour can never deceive an experienced midwife. Avenzoar, however, has left a confession that he was deceived about his own wife, whom he had treated as dropsical, though she had passed her fourth month of pregnancy.[[376]] We ought also to state that dropsy and utero-gestation may be coexistent, and there are unfortunate cases on record where, on such occasions, women have been sacrificed by the mistaken application of the trocar.
In order to ascertain the exact state of the os uteri, an examination must be made per vaginam, which may be conveniently effected while the woman remains in the same position, by introducing the fore and middle fingers of the right hand. For the first three months the os tincæ feels smooth and even, and its orifice is nearly as small as in the virgin state; when any difference can be perceived, it will consist in the increased length of the projecting tubercle of the uterus, and the shortening of the vagina from the descent of the fundus uteri through the pelvis: this change in the position of the uterus, by which the projecting tubercle appears to be lengthened, and the vagina proportionally shortened, chiefly happens from the third to the fifth month. The following is another mode of examination proposed by the anatomist Petit,[[377]] and sanctioned by Puzoff,[[378]] and which, with some slight and unimportant difference, coincides with that recommended by Morand[[379]] and Baudelocque.[[380]] The woman having been placed in the position above described, two fingers are to be introduced into the vagina, so far as to touch the orifice of the uterus; and at the same time, the other hand is to be applied to the abdomen; the operator is then to press internally with his fingers, so as to raise the uterus, and then lower it again by pressing on the abdomen with the other hand; if by such alternate movements a solid resistance is felt, without fluctuation, we may be assured that the uterus is gravid.
As utero-gestation advances, the question of pregnancy becomes, of course, less equivocal; for the progressive increase of the abdominal tumour, from the stretching of the fundus uteri, affords a mark too decisive to be easily mistaken. About the sixteenth or eighteenth week after conception, the uterus suddenly ascends from the pelvis into the abdomen, a change which is attended with a very peculiar sensation to the woman, and is erroneously called Quickening,[[381]] from its having been supposed to arise from the first motions of the fætus in utero, which was imagined at this period to receive the essence of vitality; the law of England still sanctions this hypothesis as a principle by which the degree of criminality[[382]] in cases of Abortus procuratus is determined, and according to which the plea of pregnancy in bar of punishment is either admitted or rejected.[[383]]
The physiologist is now satisfied that the sensation has no relation either to the life, or to the motions of the fætus, but is solely attributable to the sudden change in the position of the uterus; nor is there any difference between the aboriginal life of the child, and that which it possesses at any period of pregnancy, though there may be an alteration in the proofs of its existence by the enlargement of its size, and the acquisition of greater strength. The feeling of Quickening is very different from any that is excited by the subsequent motions of the child; it more nearly resembles that which is occasioned by terror or agitation from any other cause, and is often followed by Syncope, or Hysteria; we shall indeed cease to be surprised at this effect when we consider that from the uterus thus changing its situation, a very considerable pressure is suddenly removed from the Iliac vessels, in consequence of which the blood rushes to the lower extremities, and a temporary exhaustion of the vessels of the brain, and a general loss of balance in the circulating system, are the results. In some women the motion is so obscure as not to occasion any distress, and where the ascent of the uterus is gradual, it is often not felt at all. In the fifth month, the abdomen swells like a ball with the skin tense; the fundus uteri now extends about half way between the pubes and umbilicus, and the cervix is sensibly shortened; in the sixth, the upper edge of the fundus is a little below the umbilicus; and in the seventh the fundus, or superior part of the uterine tumour, advances just above the umbilicus, and the cervix is then nearly three-fourths distended; in the eighth it reaches midway between the navel and scrobiculus cordis itself, the neck being then entirely distended: thus at full time the uterus occupies all the umbilical and hypogastric regions, although a short time before delivery it subsides to where it was between the seventh and eighth month.
Of Parturition, or Delivery.
The term of utero-gestation is limited by nature to nine calendar months, or forty weeks, at the expiration of which, the process of labour usually commences; ingenious theorists have endeavoured to discover the principle of the expulsatory action of the uterus, and to assign the reason of its taking place at a stated period, but after all the subtle ingenuity which has been displayed upon this occasion, it is doubtful whether we are prepared with a better solution of the problem than that furnished by the physiologist in the time of Avicenna, who declared that labour came on at the appointed season, by the command of God. We shall therefore pass over the question without farther discussion, and proceed to the investigation of those practical parts of the subject, which are highly interesting on account of their numerous and important relations to medical jurisprudence; we propose, therefore, to discuss the following questions in succession:
1. Whether a woman can be delivered during a state of insensibility, and remain unconscious of the event?
2. How far the term of utero-gestation can be shortened, to be compatible with the life of the offspring?
3. Whether to any, and to what probable or possible extent, the natural term of utero-gestation can be protracted?
4. What is the value of those signs by which we seek to establish the fact of a recent delivery?
5. Are there any, and what diseases, whose effects may be mistaken for the traces of a recent delivery?
6. Can we determine by any signs, whether a woman has ever borne a child, although at a period remote from that of the examination?
7. What are the earliest and latest periods of life at which women are capable of child-bearing?
8. What is the possible number of children that may be produced at one birth?
9. Is Superfœtation possible, and under what circumstances, and at what period of gestation can a second conception take place?
10. What are the causes of Abortion?
11. Under what circumstances, and by what means, is it morally, legally, and medically proper, to induce premature labour?
12. What circumstances will justify the Cæsarean operation, and of what value is the section of the Symphysis Pubis, or Sigaultian operation?
Q. 1. Whether a woman can be delivered during a state of insensibility, and remain unconscious of the event?
In certain comatose states of the brain, as those produced by depression of bone, the operation of narcotic substances, or the violence of fever, we must admit the possibility of such an occurrence; Hippocrates[[384]] relates the case of a woman who was delivered during a state of insensibility, in the last stage of fever, from which she never recovered, and therefore died unconscious of the event. In the Causes Celèbres,[[385]] the case of the Comtesse de Saint Geran is recorded, who having been plunged into a profound sleep, by a medicated draught prepared for that purpose, brought forth a son without being in the least conscious of the act that gave it birth; and when she awoke, on the following day, bathed in her blood, and exhausted in strength, and demanded her infant, the artful attendants denied the fact of her delivery. Women have moreover given birth to an offspring in articulo mortis; and many instances have occurred where the infant has escaped from the womb during the exertions of the mother to evacuate the contents of the bowels.
Q. 2. How far the term of Utero-gestation can be shortened, to be compatible with the life (viabilité) of the offspring.
If this question could be decided by the number of recorded cases, we should be called upon to acknowledge the possibility of the fœtus surviving at extremely early periods; Capuron[[386]] relates the case of Fortunio Liceti, who, it is said, was born at the end of four months and a half, and that he lived to complete his twenty-fourth year! In the case of Marechal de Richelieu the parliament of Paris decreed that the infant at five months possessed that capability of living to the ordinary period of human existence,[[387]] (viabilité) which the law of France required for establishing its title of inheritance. The Roman law[[388]] “de suis et legitimis hœredibus” establishes, upon the authority of Hippocrates, that an infant may be born six months and two days after the term of conception; while a second law, sanctioned also by the same high authority, requires an interval of seven months between the conception and delivery; this discrepancy receives explanation from the fact that the ancients fell into many contradictions from indiscriminately using in their calculations lunar and solar months; thus, for instance, Hippocrates uses the former in his books “de Septimestri et Octomestri partu,” while in those de Alimento, de Carnibus, de Epidemicis, the latter uniformly constitute the basis of computation. Physiologists of the present day consider that a fœtus born before the completion of the seventh month has a very slender chance of surviving, although instances have occurred where the life has been preserved after a birth still more premature. Hippocrates and other ancient physicians entertained a conceit, which has even prevailed in the more modern schools of physic, that an infant could live at seven, but rarely or never at eight months; it is hardly necessary to observe with Haller, that the capability of living in an infant increases in the ratio of its maturity, or in proportion as it advances towards the natural period of delivery; the child, therefore, that is born at the expiration of eight months has of necessity a greater aptitude for living than the one which is produced at seven; and nothing could have suggested or upheld a contrary opinion but that overwhelming belief in the harmony and powers of certain numbers with which the philosophers of ancient days were infected, and of which the Pythagorean number SEVEN was deemed the most perfect and efficient,[[389]] as we have before had occasion to remark, while treating of the subject of Ages.
Q. 3. Whether to any, and to what probable extent, the natural term of Utero-gestation can be protracted?
Although the period of gestation is usually limited to nine calendar months, or forty weeks,[[390]] yet the term does not appear to be so arbitrarily established, but that Nature may occasionally transgress her usual law; and, as we have just stated that many circumstances may occur to anticipate delivery, so are we bound to admit that in some instances it may be retarded; in several tolerably well attested cases, the birth appears to have been protracted several weeks beyond the common time of delivery; and Dr. Hamilton remarks upon this occasion, that if the character of the woman be unexceptionable, a favourable report should be given for the mother, though the child should not be produced till nearly ten calendar months after the absence or sudden death of her husband. The question is one of the greatest importance in its moral and legal relations, for it may involve the honour and happiness of families, the legitimacy of offspring, and the succession of property.[[391]] We cannot, therefore, feel surprised that it should have occupied so great a portion of the attention of our most able physiologists, and have given origin to considerable controversy. Each side is supported by an equally respectable list of partisans, and we perceive that upon this occasion the two celebrated medico-jurisconsults of France are opposed to each other; Mahon having associated his name with those of Bohn, Hebenstreit, Astruc, Mauriceau, Da La Motte, Rœderer, and Baudelocque, who reject the belief in retarded delivery as impossible, and contrary to the immutable law of nature; while the name of Foderé ranges with those who support the contrary opinion, as Teichmeyer, Heister, Albert, Vallentini, Bartholin, Haller, Antoine Petit, Lietaud, Vicq d’Azyr, and Capuron, who may boast of the support of Hippocrates, Aristotle, and Pliny.
Pliny tells us that the Prætor L. Papirius was declared entitled to succeed an infant born after thirteen months, but he adds, this was because no time appeared by law “quoniam nullum certum tempus pariendi statum videretur.” We read in Aulus Gellius of an edict by the Emperor Adrian in favour of a woman of irreproachable character, who was delivered eleven months after the decease of her husband; and the parliament of Paris, in the case of a widow, decided in favour of the legitimacy of an infant born in the fourteenth month of pregnancy. Bartholin relates the case of a young woman at Leipsic who was delivered in the sixteenth month; and, if we may credit it, the account would appear to have been as unexceptionable as any case on record, for during her pregnancy she was in custody by order of the magistrates. The civil code of France has placed a limit to our credulity respecting retarded births, and decrees three hundred days, or ten months, to be the most distant period at which the legitimacy of a birth shall be allowed.[[392]] Were we called upon to deliver an opinion upon this momentous question, we should certainly consider such a law as rather inclining on the side of mercy, than on that of stern justice. For any farther information upon this question, we must refer the reader to the learned notes of Mr. Hargrave, printed in our Appendix, page 209; but before we quit the subject, we shall notice the opinion of Joubert, if it be only for the purpose of animadverting upon its absurdity; he supposes that the duration of gravidity may be influenced by sexual indulgence; supposing that excessive venery will accelerate, while abstinence may so far retard the time of delivery, that it shall not take place until after the expiration of eleven months.
Q. 4. What is the value of those Signs by which we seek to establish the fact of a recent delivery?
There are circumstances which may induce a woman to conceal the event of parturition, or to simulate a delivery which had never taken place; in either of such cases the importance of medical testimony is sufficiently obvious. In cases of alleged Infanticide the practitioner is always required to examine the supposed mother, and to give his opinion as to the fact of her having been recently delivered: and his report has not only very frequently acquitted the prisoner, but in some cases has rescued the innocent but unfortunate female from the horror and disgrace of a public trial. Capuron cites a curious case which we shall relate in this place as well adapted to exemplify the serious importance of medical evidence on such occasions:—A young woman having granted her favours to a lover who had seduced her, under the promise of wedlock, feigned pregnancy in the hope of hastening the celebration of her marriage, but the lover refused to ratify the solemn engagement into which he had entered, and she therefore determined to carry on the imposition, with a view to conciliate his affections, and to secure his future protection and support; for this purpose, after a proper interval had elapsed, she confined herself for several days to her bed-chamber, and having stained her linen and bed with bullock’s blood, she openly declared that she had been delivered, and that the infant had been committed to the care of a nurse; the young man, however, notwithstanding this supposed new pledge of affection, remained obdurate, and persisted in his refusal to complete his engagement; in consequence of which all intercourse between the parties ceased, until after the lapse of two years, when the alleged father claimed his child; in answer to this application the young woman confessed the deception which she had been induced to practise; but the criminal department of the Seine, before whom she was summoned, hesitated in giving credence to her tale; upon which a personal inspection was instituted by Capuron, Maigrier, and Louyer Villermay, in order to decide whether the woman in question had ever been delivered; and as the result of this inspection enabled the professors to decide in the negative, the prisoner was immediately discharged. A similar instance of pretended delivery has recently appeared in a Berlin Journal, as having occurred at Sirakovo in the circle of Posen, where a young woman, anxious to fulfil the ardent desire of her husband to have an heir, pretended to have been suddenly and unexpectedly delivered, and stole an infant in order to support the fiction; the case was rendered more atrocious from the real mother having, in consequence of the theft, been subjected to the accusation of infanticide; the fact was, however, happily discovered, and the culprit has been delivered to the punishment due to her crime. Such cases of pretended delivery are by no means so rare as the reader may at first be led to imagine; and the medical practitioner should be on his guard lest he become the dupe of such an imposition. Dr. Male[[393]] relates a case which occurred not long since in his own town; a surgeon was called to a pretended labour, when a dead child was presented to him, but there was no placenta; he therefore proceeded immediately to examine the woman, when he found the os tincæ in its natural state, nearly closed, and the vagina so much contracted as not to admit the hand; astonished at this circumstance he went to consult a medical friend; but before any farther steps were taken, it was discovered that he had been imposed upon; the woman, in fact, had never been pregnant, and the dead child was the borrowed offspring of another; it appears that she was induced to practise the artifice to appease the wrath of her husband, who frequently reproached her for her sterility.
The signs from which the judgment of the midwife is to be deduced may be comprised under the following general and particular heads, to each of which we shall successively direct our attention, and endeavour to establish the degree of validity to which they are singly or jointly entitled.
1. The face is pale, the eye sunken, and surrounded by a purplish or dark brown coloured ring; the pulse is full and undulating; the skin soft, supple, rather warmer than ordinary, and covered with a moisture which has a peculiar and somewhat acid odour.
2. The breasts are swelled, are harder than usual, and painful; and, in some cases, lumpy to the touch, and emit, by pressure or suction, a lactiform fluid; the nipples are thicker, and the areola, by which they are surrounded, is widened in extent, and darkened in colour.
3. The abdomen is flaccid, and its skin lies in folds, and is traversed in various directions with shining, reddish, and whitish lines, and light-coloured broken streaks, which especially extend from the groins and the pubes towards the navel.
4. There is an extraordinary swelling and tumefaction of the external parts of generation; sometimes the anterior margin of the perineum is lacerated, or it is very lax, from the distention which it has undergone.
5. The vagina is preternaturally distended; the orifice of the uterus is soft and open, and capable of admitting the point of the finger without difficulty, as if a late discharge had been made from it; the womb itself, not having properly collapsed, and resumed its natural shape and dimensions, may be felt through the parietes of the abdomen, voluminous, firm, and globular, contracting and expanding under the hand, on pressure.
6. A discharge of serous fluid mingled with blood from the vagina, called the Lochia, continues from five to thirty-five days after delivery: it differs from the common menstrual flux in being paler, but more particularly in its peculiar and characteristic sour odour; at first this discharge is decidedly sanious, but in a few days it becomes of a much paler and of a brownish, or a dirty green hue, so as to acquire the common term of green waters.
In addition to these signs, Michael Albertus mentions the hair falling off from the pubes as a sign of delivery; it is hardly necessary to caution the practitioner against relying upon any sign so extremely uncertain and precarious.
Although the period during which the consecutive signs of delivery remain evident, will vary in each case, yet as a general position we must admit with Zacchias,[[394]] Albert, Bohn, Foderé, Mahon, and Belloc, that after ten or twelve days, they may become too obscure to afford unexceptionable evidence. This conclusion was sanctioned by the arrêt of the parliament of Paris, in the case of a woman of Mantes accused of infanticide, who, in consequence of a conference with Antoine Petit and Louis[[395]] was pronounced innocent, upon the ground of the woman not having been examined as to the fact of her delivery, until after the expiration of a month. The criminal department of the Seine acquitted a woman cook of the name of Aimée Perdriat, charged with the perpetration of a similar crime, and of whose guilt no reasonable doubt could be entertained, in consequence of the same defect in the medical testimony.[[396]]
The relative value which each of the signs possesses, will be better appreciated after we have considered the diseases whose effects may resemble them; but as a general principle we are anxious to enforce the necessity of always considering the consecutive signs of parturition collectively, and not individually; under such circumstances the practitioner can never be betrayed into an erroneous conclusion; for, as Professor Chaussier has remarked, “no disease, or affection, besides parturition, can possibly produce the whole series of signs above described.”
The secretion of milk, upon which such considerable stress has been laid in ancient as well as in modern times, it is now admitted may take place independently of pregnancy, and we are accordingly bound to reject the aphorism of Aristotle, “Lac habet, ergo peperit.” In the Causes Celèbres[[397]] there is an account of a girl, who, although a virgin, suckled an infant; and in the Sloane collection of manuscripts in the British Museum, a case of a woman is related, who, although she had not borne children for more than twenty years, actually suckled her grand-children, one after the other, at the age of 68! but, what is still more extraordinary, instances have occurred where men have been able to perform this duty. The Bishop of Cork[[398]] has related a case in which a man suckled his child after the loss of his wife; and in the personal narrative of Humboldt we have an analogous instance.[[399]]
Q. 5. Are there any, and what Diseases, whose effects may be mistaken for the traces of a recent delivery?
Dropsical discharges from the uterus, uterine hæmorrhage, the expulsion of a mole, hydatid,[[400]] or polypus; or the removal of any of those diseases which constitute what has been termed a false conception, have been said to occasion effects which simulate the signs of parturition. It must be admitted that there are some signs which are common both to the diseases in question, and to the delivery, but there are at the same time others that exclusively indicate the occurrence of the latter; the irruption of fluids from the womb, menorrhagia, and leucorrhæa, may mimic the lochial discharge, but they will not remain, nor will they present that characteristic odour by which the latter is so preeminently distinguished; so again, the relaxation of the soft parts may be the consequence of disease as well as of delivery, while the paleness of the visage is the usual concomitant of profuse evacuation; but then the distention of the vagina, and the state of the neck of the uterus, and the absence of all contusions, lacerations, and discolourations will obviate the possibility of deducing any erroneous conclusion from these phenomena; the wrinkles and marks upon the abdomen may certainly follow any considerable change in the reduction of its bulk, whether it be the result of parturition, ascitic discharges, or the absorption of fat; but we may easily disarm such signs of their treachery by a previous inquiry into the state of the woman’s health, and into that of her robustness and general strength. Burns also remarks that other circumstances may concur in confirming the opinion of the practitioner, “as for instance, if the patient give an absurd account of the way in which her bulk suddenly left her, ascribing it to a perspiration, which never in a single night can carry off the size of the abdomen in the end of a supposed pregnancy.”[[401]]
Q. 6. Can we determine by any signs whether a woman has ever borne a child, although at a period remote from that of the examination?
The following are the principal indications of a woman having been delivered at a distant period, but in offering them to the attention of the practitioner, it is necessary to observe, that singly they can furnish but very slender evidence, and should they even all occur, they must be regarded as affording only a strong presumption of the fact.
1. The orifice of the womb has not its conic figure; its lips are unequal; and it is more open than in those who have never borne children.
2. There is a roughness of the abdomen, the parietes of which are also more expanded and pensile.
3. There are small white and shining lines running on the surface of the abdomen.
4. The breasts are more flaccid, and pendulous, and the lines on their surface are white and splendid.
5. The nipples are prominent, and the colour of their disks brown.
Q. 7. What are the earliest and latest periods of life, at which women are capable of child-bearing?
Zacchias and other authors have considered the commencement and cessation of menstruation as the two extreme points, beyond which the female is incapable of conception; they have very justly considered the menstrual flux as indispensably necessary for the healthy action of the uterine system. It must be also admitted that no female can conceive until her system has undergone that revolution which we have already described under the head of Puberty, although we then stated, that the period of life at which it takes place is liable to be controlled by several physical as well as moral circumstances, we have accordingly many instances upon record of very young females having borne children: during the year 1816 some girls were admitted into the Maternité at Paris as young as thirteen years; and during the revolution one or two instances occurred of females at eleven, and even below that age, being received in a pregnant state into that hospital. Schurigius[[402]] states the case of a Flemish girl, who was delivered of a son at the age of nine years; and in the notes to Metzger several instances are related where conception had occurred under the age of ten. It has been attempted to ascertain what age, and what season was most prolific: from an accurate register kept by Dr. Bland, it would appear, that more women, between the age of twenty-six and thirty years, bear children, than at any other period; of 2102 women, who bore children, 85 were from fifteen to twenty years of age, 578 from twenty-one to twenty-five, 699 from twenty-six to thirty, 407 from thirty-one to thirty-five, 291 from thirty-six to forty, 36 from forty-one to forty-five, and 6 from forty-six to forty-nine.
The time at which menstruation, and consequently child-bearing ceases, will be materially influenced by that at which it commenced; with those who commenced at ten or twelve, the discharge often ceases before the age of forty; but where the first appearance has been protracted to sixteen or eighteen, such women may continue to menstruate until they have passed the fiftieth year; but in this climate the most usual period of cessation is between the age of forty-four and fifty,[[403]] after which women never bear children, although we have in ancient[[404]] as well as in modern times, many extraordinary examples of protracted fecundity, to which but little credit ought, in general, to be attached. Marsa, a Venetian physician, relates a case of a woman who at the age of sixty brought forth a daughter, and suckled her, and whom he had previously treated for what he had considered to be ovarian dropsy; the annals of our own country[[405]] would furnish some extraordinary instances of a similar kind. Dr. Gordon Smith illustrates the subject by the case of the wife of a peruke-maker in Poland-street, in the year 1775, who at the age of fifty-four produced two sons and a daughter, although she had been married for thirty years, and had never before been pregnant.
It is probable that many of those “well authenticated instances” of old women having menstruated, like those recorded of children, are merely sanguineous discharges from the vagina, or from a diseased uterus; this we have no doubt is the true explanation of the case related by Richerand,[[406]] of a woman, who at the age of seventy had not ceased to menstruate.
Q. 8. What is the possible number of Children that can be produced at one birth?
According to the most accurate estimates, Twin cases, on an average, occur about once in ninety labours; Triplets are considerably more rare, they are stated not to take place more than once in three thousand times; and the occurrence of four at a birth is so rare an event, that no calculation has been formed upon the subject. The reader will find a very interesting paper on the “Plurality of Births,” by Dr. Garthshore, in the 77th volume of the Philosophical Transactions, to which we beg to refer him. Dr. Osborne states that he has distinctly traced as many as six fœtuses in an abortion.
It is a curious fact that the relative number of males and females born is nearly equal, there being only a small majority in favour of the former, in the proportion of 21 to 20; in consequence of which both sexes are equal at the age of 14, since more male children are still-born, or die in infancy, than females, owing, as Dr. Clarke[[407]] has supposed, to the relative size of the head, being greater in the former. Hufeland[[408]] has collected the relative number of the two sexes in all parts of the world, and has found them every where the same. “It seems very singular,” says Sir Gilbert Blane,[[409]] “and at the same time most admirable in the institution of Nature, that this relative number of the sexes should be maintained, though the primordial germs are mixed in different proportions in the ovaria of different females; for it is well known that many women produce such a number of children in succession, of the same sex, as is utterly irreconcileable with the laws of blind chance, another word for mathematical necessity.” The reader will also derive much pleasure by the perusal of a memoir[[410]] upon this subject by Dr. Arbuthnot, entitled “An Argument for Divine Providence, taken from the constant regularity observed in the birth of both Sexes” from which the learned author deduces as a scholium, that polygamy is contrary to the law of Nature and justice, and to the propagation of the human species.
Q. 9. Is Super-fœtation possible, and under what circumstances, and at what period of Gestation can a second conception take place?
The term Super-fœtation implies that a second impregnation may take place, whilst a child is in utero.
There are perhaps few questions relating to the subject of conception, that have given origin to more rigorous controversy; and indeed its important judicial bearings render it a subject of greater interest than it could ever have become intrinsically as a mere object of abstract speculation. Let us, for the sake of illustration, suppose the following case:—A woman loses her husband suddenly, tenant in tail male, a month after marriage, and at a little more than eight months after his decease she is delivered of a perfect female child, and at nine months, she declares that she is delivered of another infant, which is a male. The heir at law, who has entered, contests the fact of this latter birth; the question therefore to be determined is, whether such an event is compatible with the known laws of utero-gestation.
The ancient physicians and philosophers undoubtedly believed in the possibility of super-fœtation; and the Mythology contains a well characterised example in the instance of Iphicles and Hercules, who were begat upon Alcmæna, the former by Jupiter, and the latter by Amphitryon. Hippocrates,[[411]] Aristotle,[[412]] and Pliny,[[413]] entertained no doubt respecting the fact, and in later times we find that the most eminent physiologists have sanctioned the same belief, and have been engaged in recording facts in its support. Gasper Bauhuin[[414]] relates a case in which a woman at the end of nine months brought forth a dead child, with a deformed head, and that six weeks afterwards she was delivered of a well formed child which lived. Buffon[[415]] presents us with a still more striking example; a woman of Charles-town, in South Carolina, was delivered in 1714 of twins, which came into the world one directly after the other, but to the great surprise of the midwife, one was black and the other white; the woman herself, considering this proof of her infidelity too obvious to be denied, admitted the truth without hesitation,—that shortly after having enjoyed the embraces of her husband, a black servant entered her room, and by threats accomplished his purpose. Aristotle[[416]] speaks of an adultress who produced at the same birth two sons, the one of which resembled the husband, and the other the lover; Pliny[[417]] also relates several cases of super-fœtation, some of which are certainly no other than twin cases, and the others are merely copied from Aristotle. Musa Brassavolus[[418]] has the following remarkable observation upon the subject. “Nos vidimus super-fœtationem quandoque fuisse epidemicam affectionem.” Zacchias[[419]] also believes in the phenomenon; and in the case of one Laurette Polymnie, his testimony secured for her child the rights of inheritance; Harvey[[420]] likewise relates a case of super-fœtation, to which we beg to refer the reader; Haller[[421]] expresses his opinion in the following words: “Os uteri nunquam clausum est; ideoque potest super-fœtari non solum a die sexto ad trigessimum, aut primis duobus mensibus, sed omni omnino tempore.” Zacchias[[422]] however, thinks that it can only take place in the first two months of pregnancy, for that after this period, the developement of the fœtus renders it impossible. Plouquet observes, that immediately after a first conception, a second may easily take place, but that after a few months it can only occur under the most extraordinary circumstances. If time and space would allow we might adduce a considerable mass of similar testimony, but we shall conclude this part of the subject with the opinion of Kannegeiser, “De super-fœtationis existentia rationis quippe principiis, atque infinitis hominum et brutorum exemplis abunde comprobatu, Medicis atque jurisconsultis mens vix amplius hæret in ambiguo.”[[423]] The best authenticated case of super-fœtation that has occurred in our own times is that communicated to the College of Physicians by Dr. Maton:[[424]] Mrs. T—— an Italian lady, remarkable for her fecundity, was delivered of a male child at Palermo, on the 12th of November, 1807, under very distressing circumstances, having been dropt on a bundle of straw in an uninhabited room at midnight, and although the infant at the time of his birth had every appearance of health, he lived only nine days; on February the 2d, 1808, (not quite three calendar months from the preceding accouchement) Mrs. T—— was delivered of another male infant, completely formed, and apparently in perfect health; the child however fell a victim to the measles at the age of three months. Dr. Granville, in a paper entitled “On the Mal-formation of the Uterine System,”[[425]] takes occasion to observe with respect to the above case, that “it merely goes to prove the occasional co-existence of separate ova in utero, and proves nothing farther; the lady, whose prolific disposition is much descanted upon in that paper, and with whom twin cases were a common occurrence,” continues Dr. Granville, “was delivered of a male child sometime in November, 1807, ‘under circumstances very distressing to the parents, and on a bundle of straw,’ and again in February, 1808, of another male infant, ‘completely formed!’—mark the expression, for it was not made use of in describing the first. The former died ‘without any apparent cause’ when nine days old; the other lived longer. Now can we consider this otherwise than as a common case of twins, in which one of the fœtuses came into the world at the sixth, and the other at the ninth month of pregnancy, owing to the ova being quite distinct and separate? Had this not been the case, the distressing circumstances, which brought on the premature contraction of the womb, so as to expel part of its contents in November, as in the simplest cases of premature labour, would have caused the expulsion of the whole, or in other words, of both ova, in that same month; and we should not have heard of the second accouchement in the following February; which led the author of the paper in question to bring the case forward as one of superfœtation, in opposition to what he has called ‘the scepticism of modern physiologists.’ Had it been proved that the child, of which the body in question was delivered, had reached its full term of utero-gestation in November, and that she had brought forth another child one, two, or three months afterwards, of equally full growth, then a case something like superfœtation would have really occurred, and scepticism would have been staggered.” In consequence of the doubts thus expressed by Dr. Granville, the author of the present work, actuated only by a desire after truth, applied to Dr. Maton for a farther explanation of those particular points upon which the merits of the case would seem to turn; and he is thus enabled to clear up the doubts which might be supposed to embarrass its history; the fact is, that both the children were born perfect, the first therefore could not have been a six month’s child; and with respect to the distressing circumstances which attended the delivery, Dr. Granville appears to have fallen into an important error; he speaks of them as having “brought on the premature contraction of the womb, so as to expel part of its contents in November,” whereas upon referring to the particular expressions used by Dr. Maton in the paper alluded to, we shall soon perceive that they by no means support the assumption of the labour having been premature, nor that it was brought on by distressing circumstances; on the contrary, we find upon farther inquiry that the distressing circumstances to which the author alludes were the natural consequence, not the active cause of the labour; indeed the fact, as we learn from Dr. Maton, stood thus,—the lady could not obtain better accommodation at the time; that the labour, although quick, was not sudden, for the accoucheur was already in attendance; and that it was not premature, for the natural period of utero-gestation was supposed to have been completed. We must not omit to state that all the particular circumstances of the case were communicated to Dr. Maton by the husband of the lady, and as he could not have had any particular theory to maintain, or any private interest to serve, there cannot exist any good reason for questioning the veracity of his testimony, or the justness of our conclusions.
Several physiologists who have attempted to explain the cause of superfœtation have supposed that in such cases the uterus is virtually double; Morgagni informs us, that Catti, the Neapolitan anatomist, was the first to observe this phenomenon, and that it is owing to a strong membrane which so divides the uterus, that the mouth of a fallopian tube corresponds with each of its cavities; and he farther states, that this strange structure was found combined with a corresponding division of the vagina; Valisnieri[[426]] also met with a double uterus, and a double vulva; the same malformation has been noticed by Littre,[[427]] Bauhuin,[[428]] Eissenmann,[[429]] Haller,[[430]] and by Rhoederer; this latter physiologist in a letter, from Strasburgh, preserved among the Sloane manuscripts, says, “We have got here a great curiosity, viz. a woman body of eighteen years of age, who has the natural parts externally well formed, but internally two vaginæ, each with its hymen, to which responds also an uterus duplex having two orificia, each of ’em hanging in its proper vagina, that in such a manner there is quite a double system of generation, and if she had been living a superfœtation could have been formed.” Sabbatier says that he believes in the possibility of superfœtation, and that the above formation will explain its occurrence; an opinion which is sanctioned by Gravel[[431]] and Teichmeyer;[[432]] Duffien also observes, “Cette double matrice sert très bien a expliquer la superfœtation.”[[433]] In quadrupeds superfœtation very commonly occurs, and it has been explained by supposing that the uterus of these animals is divided into different cells, and that their ova do not attach themselves to the uterus so early as in the human subject, but are supposed to receive their nourishment for some time by absorption; hence the os uteri does not close immediately after conception; for a bitch will admit a variety of dogs while she is in season, and will bring forth puppies of these different species; thus, it is common for a greyhound to have in the same litter, one of the greyhound kind, a pointer, and a third or more, different from both.[[434]]
Those physiologists who deny the possibility of superfœtation, among whom we find some of the most celebrated names, assert that one conception can never supervene another in the same woman, because the os uteri is closed by coaguable lymph, and the entrance to the fallopian tubes is obstructed by the Decidua Uteri, soon after conception, and therefore that the semen can never find its way to the internal organs of generation, so as to impregnate a second ovum; this opinion is fortified by the well known aphorism of Hippocrates,[[435]] “οκοσαὶ εν γαστρὶ εχουσὶ; τουτεων δε στομα των υστερων ξυμμεμυκεν.” Galen[[436]] also quoting Herophilus says, “Ne specilli quidem mucronem admittere uteros antequam mulier pariat; prœterea ne vel minimum quidem hiscere ubi conceperint.” Neither Galen, however, nor Ætius, nor Paulus Ægineta, make any mention of superfœtation, a circumstance upon which the opponents of the doctrine lay considerable stress. Avicenna alludes to it, but for the purpose of expressing his disbelief in its possibility. Hebenstreit[[437]] and Ludwig,[[438]] have also expressed very strong opinions upon the subject; the former of whom observes, “Nullæ fere observationes extra omnem dubitationem positæ superfœtationem confirmant.” Baudelocque[[439]] is equally hostile to such a belief. But it may be said that the argument founded on the entire closure of the uterus is quite gratuitous, many authorities might be cited who disavow the fact, we have already adduced the opinion of Haller upon this point; besides, are we sufficiently acquainted with the manner in which impregnation is effected to authorise any deductions from our hypothesis? We are completely ignorant in what way the male semen arrives at the internal organs,[[440]] nay, we are not even convinced that its direct transmission to the ovaria is essential to fecundation; it is possible that these organs may be stimulated by sympathy with the vagina. Parsons opposes another argument to the doctrine of superfœtation; it is, says he, impossible, because the fallopian tubes become after conception too short to embrace the ovaria, but this opinion is successfully combated by Haller. The cases which have been cited to illustrate the phenomenon of superfœtation, are regarded by those who oppose the doctrine as instances in which a plurality of children has existed, and in which one of the following circumstances have occurred, viz.
1. The fœtus has prematurely died, but has remained in utero with the living child, to the full period of utero-gestation.
2. The descent of the ova into the uterus from the ovarium, has not observed the same order of time, one being more slowly evolved than another, although both might have been fecundated by the same coitus.
This latter was the favourite idea of Celoni:[[441]] “I am therefore decidedly of opinion,” says he, “that this superfœtation is no other than a later developement of a fœtus contemporaneously generated.”
We have thus presented the reader with a review of the different arguments which have been adopted by the partisans and opponents of this celebrated doctrine, and we have cited copious authorities with a view to enable the student to pursue the investigation to any extent which may be commensurate with his notions of its importance. We shall now conclude by observing that the following occurrences are essential to constitute a case of superfœtation.[[442]]
1. The pregnant woman must bear two children, each of a distinct age.
2. The delivery of these children must take place at different times, with a considerable interval between each.
3. The woman must be pregnant and a nurse at the same time.
Q. 10. What are the causes of Abortion?
A gratuitous assumption on the part of some writers respecting the viability of the fœtus, has led them to adopt a division into abortion and premature labour, according as the exclusion from the uterus takes place before, or after, the sixth month of conception; and the distinction is now generally adopted. Natural abortion may be considered as arising either from accidental or constitutional causes; we shall hereafter consider the different modes by which the premature ejectment of a fœtus may be occasioned by art. The exciting causes of accidental abortion may, in general, be easily detected[[443]]; those giving rise to the constitutional kind are often more obscure, and without great attention, the woman will go on to miscarry until either sterility or some fatal disease be induced. In many cases there can be no peculiar pre-disposing cause; as, for instance, when it is produced by blows, rupture of the membranes, or accidental separation of the decidua; but where it occurs without any very perceptible exciting cause, it is allowable to infer that some pre-disposing state exists, and this frequently consists in an imperfect mode of uterine action, induced by age, former miscarriages, and other causes. It is well known that women can only bear children until a certain age, after which the uterus is no longer capable of performing the action of gestation, or of performing it properly; now it is observable, that this incapability or imperfection takes place sooner in those who are advanced in life before they marry, than in those who have married and begun to bear children earlier; thus we find, that a woman who marries at forty shall be very apt to miscarry; whereas, had she married at thirty, she might have borne children when older than forty, from which it may be inferred, that the organs of generation lose their power of acting properly sooner, if not employed, than in the connubial state.[[444]] We also find that one miscarriage renders the woman liable to the accident at the same period of utero-gestation in subsequent labours, and to such an extent is this susceptibility carried, that it is often difficult with every precaution, for a woman to go to the full time, after she has miscarried frequently. These are circumstances which the juridical physician is, for obvious reasons, to keep in mind; females of disreputable character have been frequently known to miscarry repeatedly in succession; and in such cases we ought not, without very cogent reasons, to draw an inference that may subject them to accusation. We do not consider that any farther observations are required upon this subject, as the numerous works upon midwifery are ready to supply the practitioner with a solution of any problem which may present itself.
Q. 11. Under what circumstances, and by what means, is it morally, legally, and medically proper, to induce premature labour?
That premature labour may be induced by a mechanical operation, is too well known to the practitioner in midwifery to require any explanation in this place, while, in a work calculated for circulation beyond the confines of the profession, it would be obviously imprudent to enter into any minute details. It becomes our duty, however, to state, that in those cases of distorted pelvis, through which a full grown fœtus cannot pass without mutilation, the operation may be performed with perfect safety, and with equal advantage both to the child and to the mother. We are informed by Dr. Denman[[445]] that there was in 1756 a consultation of the most eminent men in London at that time, to consider of the moral rectitude of, and advantages which might be expected from, this practice, which met with their general approbation; the morality of this mode of practice, however, says Dr. Merriman,[[446]] has been doubted by many other persons, but probably for want of considering the question in a proper point of view; for the proposal was, that labour should be prematurely induced, in those cases only, where it had been decidedly proved that the pelvis was so much contracted in its dimensions, as to render it impossible for a full sized fœtus to pass undiminished; and it is supposed, that this proceeding, while it affords a chance of preserving the child, does not much implicate the life of the mother. Mr. J. Barlow[[447]] has given us the result of an extensive practice in inducing premature labour in cases of distorted pelvis, from which it appears that he has had recourse to this method of delivery eighteen times, in five women, all of whom had been previously delivered once, or oftener, by the crotchet, and that premature labour occurred spontaneously once in two of this number. All the women recovered, a circumstance which adds a further confirmation to the opinion, that the life of the parent is exposed to very little hazard in this way; of the children thus brought into the world, six were dead and twelve were born alive, of which some died soon after birth, one lived ten months, and five were living at the time the account was published. Mr. Barlow’s method consists in exciting premature labour early in the seventh month of pregnancy. Dr. Hull, well known for his controversial zeal on these subjects, has offered some remarks so judicious and important, that it would be an act of injustice to withhold them from the reader. “The propriety of inducing premature labour,” says he, “in any deformed woman, can rarely, if ever, be determined upon before the crotchet has been found indispensably necessary, and actually employed in a previous labour; indeed, unless the contraction of the tube or canal of the pelvis be very considerable and pretty accurately ascertained, it will scarcely be justifiable in any case to have recourse to this practice in all the subsequent pregnancies, until the woman has been delivered a second, or third time, by the crotchet; for it has happened in a very great number of instances, that a woman who has been delivered of her first child by the perforator and crotchet, has been afterwards delivered of one or more living children, at the full time; this observation is made not to discountenance the inducing of premature labour, but to prevent the abuse of it.” Dr. Merriman, whose extensive practice, and generally acknowledged judgment, stamp a peculiar value upon his opinions, has also pointed out the limitations and cautions which he deems necessary to be observed, to render this operation safe and eligible,[[448]] and he concludes by observing that “a regard to his own character should determine the accoucheur, not to perform this operation, unless some other respectable practitioner has seen the patient, and has acknowledged that the operation is advisable.”
Q. 12. What circumstances will justify the Cesarean Operation, and of what value is the section of the Symphysis Pubis, or Sigaultian operation?
Where the size of the pelvis[[449]] will not admit the passage of the child, surgical aid is indispensably necessary; but, says Dr. Merriman,[[450]] it becomes every man to set out with a determination that he will not hastily, nor without due cause, have recourse to instrumental assistance;[[451]] for he may assure himself that if he were easily to yield to his own apprehensions, or to the expressions of alarm by the attendants in the lying-in chamber, and in consequence were to try to expedite the delivery by his instruments, he would, on very many occasions, do irreparable injury to the parent or her child.
Instrumental delivery resolves itself into three classes,—
1. Where neither the mother nor the child is of necessity injured, as by the use of the Forceps[[452]] and Lever.[[453]]
2. Where the mutilation of the child is the principal object, as by the Perforator and Crotchet.
3. Where the mother is wounded, as in the Cæsarean and Sigaultian operations.
It is of the latter class we have now to speak.
Of the Cæsarean Operation:
By which a fœtus is extracted from the uterus of the mother through a wound, made for that purpose, in the abdomen. The term Cæsarean, according to some authors, is derived from the operation “cæso matris utero,” while others have supposed that it owes its origin to the fact, recorded by Suidas, of Julius Cæsar having been cut from the womb of his dead mother in the ninth month. Although Hippocrates, Celsus, Paulus, Ægineta, and Albucasis, all treat upon the subject of instrumental labours, not the slightest allusion is made to the cæsarean section. The Chirurgia Guidonis Cauliaci is the first work in which any mention is made of the operation; and this was published about the middle of the fourteenth century, but the author only describes it as a resource to save the child after the death of the mother, as, says he, happened at the birth of Julius Cæsar. Parè also considered the operation as one that ought never to be attempted on the living subject; Rousset, however, his cotemporary, published a work[[454]] in its favour, which becoming popular, was, through the medium of a latin translation by Caspar Bauhine in 1601, quickly circulated throughout Europe; from this period, the cæsarean section acquired a certain degree of vogue, and began to be performed in cases of extreme difficulty, particularly on the continent, where it has not unfrequently proved successful. In this country the operation has been generally fatal: a very extraordinary case[[455]] is, however, stated to have occurred in Ireland, and however incredible the story may appear, says Dr. Merriman,[[456]] there seems no reason to doubt its truth; it is related by Mr. Duncan Stewart, surgeon, in Dungannon, who saw the patient some days after the operation; and the account is confirmed by Dr. Gabriel King of Armagh, who says, that he drew out the needles, which the midwife had left to keep the lips of the wound together. The patient’s name was Alice O’Neil, and the operator was an illiterate midwife, one Mary Dunally; the instrument used was a razor, with which she first cut through the containing parts of the abdomen, and then the uterus. “She held the lips of the wound together with her hand, till some one went a mile and returned with silk and the common needles which tailors use; with these she joined the lips in the manner of the stitch employed ordinarily for the hare-lip, and dressed the wound with whites of eggs.” The woman recovered in twenty-seven days. It has often been an object of inquiry, why this operation[[457]] should have been more successful upon the continent than in this country? the answer to this question is obvious and satisfactory. In this country we have only had recourse to it as an operation of necessity, where we can neither accomplish the delivery by diminishing the bulk of the child, nor by any of the other resources already explained; whereas the practitioners of France, and the other states on the continent of Europe, perform it not only as an operation of necessity, but as one of election, in cases where the mother may confessedly be delivered with safety, by sacrificing the life of the fœtus; it would also appear that in general they have recourse to the operation, before the patient has suffered very much from the continuance of labour. How greatly this circumstance is capable of influencing the success of a surgical operation, we have a satisfactory demonstration in the history of that for Hernia, and in which Mr. Bell[[458]] informs us, the French were formerly more fortunate, because they proceeded more early to the operation than the surgeons of almost any other nation. It deserves notice that the religious tenets of different countries appear to have influenced the popularity of the cæsarean section; it is easy to suppose that in those catholic nations where, a belief exists of the necessity of baptism to secure the eternal happiness of the infant, the mother would become a willing sacrifice to make her offspring a christian.[[459]].
In delivering our opinion upon the propriety of performing the cæsarean section in this kingdom, we should say that there are cases in which it is the bounden duty of the accoucheur to proceed without delay, and such appears to have been that described by Dr. Merriman, of which the pelvis in the museum of Mr. Charles Bell is a sufficient proof; for so extreme is the distortion, that a marble measuring less than one inch in diameter, cannot be made to pass through it in any direction; in this case, and some others of a similar nature, the Cæsarean section was the only means of preserving the child. We are of opinion, however, that the operation ought never to be performed where by Embryulcia the child can be extricated; and although circumstances of inheritance should induce the husband to entertain a feeling like that which animated Henry VIII, the practitioner has but one broad line of duty to observe, to save if possible the mother and child, but where this is impossible, to feel no hesitation in sacrificing the life of the latter. In the event of a woman, near the full time of pregnancy, dying undelivered, the Cæsarean operation ought always to be performed with as little loss of time as possible; since by this measure a chance of preserving the child will be afforded, and Dr. Merriman states that several cases of such an operation, after the death of the mother, have been recorded, with the desired effect of saving the infant.[[460]] Numa Pompilius prohibited the burial of a pregnant woman until the fœtus shall have been extracted.[[461]] We have already stated, upon the authority of Suidas, that to such an interposition Rome owed the life of Julius Cæsar; and it has been maintained that Edward VI was thus taken from his mother after death, while others have endeavoured to render it probable, that the cæsarean operation was performed while she was yet living. How long after the death of the mother the child may survive in utero, is a question which cannot be readily answered; some authors[[462]] mention twenty-four or even forty-eight hours; and in relating this fact, Dr. Merriman adds an accompaniment which we also feel a great inclination to adopt—a note of admiration! In the late Dr. S. H. Jackson’s Cautions to Women (1798) mention is made of a child extracted by the forceps, which was restored to life, though the mother had been dead full half an hour before it was taken from the womb.
It must be admitted, that a child taken from the womb of its mother by the cæsarean section, cannot in philological strictness be said to have been born. The ingenious purpose to which Shakspeare has applied this quibble has no doubt suggested itself to the reader.
App. Macbeth! Macbeth! Macbeth!
* * * * * * *
Be bloody, bold, and resolute: laugh to scorn
The power of man; for none of woman born
Shall harm Macbeth.
Act iv, sc. 1
Macd. * * Despair thy charm;
And let the angel, whom thou still has serv’d,
Tell thee, Macduff was from his mother’s womb
Untimely ripp’d.
Act v, sc. viii.
The circumstance merits our observation, in as much as it has furnished a subtlety for disputation, as we have already noticed at page [225].