Chapter XV: Introduction (3)

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.