at the same time. When a mother has twins it is usually the case that
both children are smaller than the natural size; they are not, however,
both of the same weight; one may be of moderate size, while the other is
still more diminutive. But cases have been known to occur, in which both
children were above the natural standard. The average weight of twelve
twins, examined by Dr. Clarke, as quoted by Dr. Burns, was eleven pounds
the pair, or five and a half pounds each, bringing each child
considerably under the average weight of a child born singly. Usually
the two children, taken together, weigh considerably more than the one
at a single birth.
Twins are fortunately of comparatively rare occurrence; so much so as to
render it difficult to establish the proportion between them and single
births; the cause of their production is evidently mysterious, and
altogether beyond the power of human control.
In the Middlesex Hospital, London, according to Dr. Dewees, there was on
an average but one case of twins in about ninety-one of births. In
Dublin the proportion is greater; in the hospital of that city it was
found that one woman in fifty-eight had twins; in the Westminster
Hospital, in London, one in eighty; in Dr. Burns’ practice, one in
ninety-five; in La Maison d’Accouchement, in Paris, there were, in
twenty years, thirty-seven thousand, four hundred and forty-one single
births, and four hundred and forty-four twins; in the l’Hospice de la
Maternité (Hospital of Maternity) of Paris, the proportion was about one
in eighty-eight, according to one return, but according to the testimony
of Madame Boivin, of the same institution, the proportion was only one
in about one hundred and thirty or forty, while in that of La Maison
d’Accouchement the proportion was about one in ninety-one. Dr. Dewees
regards, that in this country the proportion of twin cases is, on an
average, one in seventy-five. In Wurtemberg, in Germany, there were,
according to Dr. Burns, twins once in about eighty-six cases of births.
_Triplets._—These are very much more rare than twins. In the returns of
the cases in La Maison d’Accouchement, as furnished by Baudelocque,
there appears to have been but one in more than eight thousand cases; in
the returns of Madame Boivin, of the cases in the l’Hospice de la
Maternité, there is one in rather less than seven thousand. In La Maison
d’Accouchement there were, according to Dr. Burns, in twenty years,
thirty-seven thousand four hundred and forty-one single births, and five
triplets. At Wurtemberg, in Germany, there were triplets once in about
seven thousand.
_Quadrigemini._—Instances of four children at a birth must be
exceedingly rare. It is not uncommon to find the announcement of such
cases in our public prints; but the truth of these ought evidently to be
questioned in most cases; and yet such an occurrence has been known to
take place. An instance was said, on good authority, to have occurred in
Paris, in October, 1823. Dr. Dewees cites a German author, as giving the
case of a woman in Strasburg, who had eleven children at three
deliveries, making, of course, four of each at two of the births, and
three at the other. The same author quotes from the Albany Argus what he
designates an account of “unparalleled fecundity.” Dr. O. F. Paddock, a
respectable physician of Fort Covington, Franklin County, gives, in the
Franklin Telegraph, an account of an extraordinary birth of five
children at one time, from the same mother—three daughters and two sons.
Four of them were born alive, but lived a short time. The birth was
premature three months, but they were perfectly well-formed and
well-shaped. The average weight was about two pounds, and not much
difference in their size. Their parents had lately emigrated from
Ireland, and arrived in this country in August, 1825. This case is
rendered more remarkable by the fact that the mother of these five was
delivered, on the 20th of February, 1826, of two; making, in the whole,
seven children in less than nine months. The last were born on the 25th
November, of the same year.
The same author quotes also another account of remarkable fertility from
Dr. Ryan, editor of the London Medical and Surgical Journal. This
learned gentleman was called to a patient, aged forty-one, of a sanguine
temperament, who had menstruated at the age of twelve, and married
between eighteen and nineteen. She had a seven months’ child in the
eighth month of her marriage; had twins about the fourth month three
times during the year 1829, and again, December 31, when she was
attended by Mr. Whitemore, of Cold Bath Fields, and delivered of two
infants; and on January 28th, 1830, she was attended by Mr. Thomas, of
Bagnigge Wells Road, and delivered of an infant, which he considered of
the same age as the preceding. On the seventh of June, 1830, she aborted
at the third month; and on the ninth, a second fetus was expelled; and
as there was no discharge whatever from that time to the period when Dr.
Ryan wrote, she considered herself still pregnant. The abdomen was about
the size of a woman’s in the fifth month of utero-gestation. She had
twenty-four children in twenty-one years, and menstruated regularly
before marriage, and was always in good health when suckling, and ill
when breeding; and always became pregnant about the fifth month of
lactation. Her mother was seventy years of age, and in good health; she
had eighteen children born alive. A relation of her husband had
thirty-two children, including miscarriages.
Dr. Dewees gave a case some years since, of a lady with whom he
conversed, who was then in her thirty-eighth year, and who declared to
him that she had been pregnant two-and-thirty times. Of this number
eleven children had been born alive, and at the full time. She
repeatedly miscarried of twins, and no abortion was less than near three
months. She had been married nearly twenty-three years.
As regards the number of fetuses that may exist in the womb at a time,
fable has exerted itself to an almost endless extent; thus, the story of
the Countess of Hannenberg may be cited as an instance. She, in
consequence of a curse pronounced by a beggar-woman, to whom she had
refused money, was delivered of three hundred and sixtyfive fetuses;
that is, one for every day in the year, in fulfillment of the wish of
the offended mendicant, which was, “that she might have as many children
at a birth as there are days in the year.” The curse was said to be
accomplished; and, in proof of it, the fetuses are shown to strangers
that visit the museum at Leyden. This fable did very well for the year
1276; but, if such cases were said to happen now, they would be more
scrupulously investigated, and more rationally accounted for. In the
case first noticed, the sexes were pretended to be discoverable, and all
the males were called John, and all the females Elizabeth, at their
baptism.
_Signs of Twins._—A vast deal of thought and investigation have been put
forth on the subject of ascertaining twin cases before birth. The
physician is often consulted on this subject; but, it need hardly be
said that the wisest and most experienced can hardly do more than
_guess_ upon so important a matter. Dr. Dewees tells us, we should
always answer the question in the negative, and for two reasons,
especially; first, because it is impossible to decide it positively;
and, secondly, if it could be so decided, it never should be, as much
mischief might arise from the uneasiness and fear it might produce.
It may not, however, be wholly uninteresting to our readers to know
something of the signs which have been supposed to indicate the presence
of more than one child in the uterus. Women who are more than ordinarily
large, are apt to suspect themselves pregnant with twins; we very often
see such cases, and yet, in few instances, comparatively, the surmises
of such patients prove true; they are in general happily disappointed,
for no mother, I think, would prefer to run the greater risk of bearing
twins.
If a woman be unusually large in the early part of pregnancy, and
increase proportionably to the full period, there is some reason, as Dr.
Denman regards, that she will have twins; but people will vary very much
in regard to what constitutes “large,” and what “small,” in reference to
the size of the abdomen in pregnancy: a few will suppose themselves very
large when they are, in fact, only of common or moderate size.
Particularly in cases of first pregnancy patients are apt to be misled
on this subject; there can be no surprise if conjectures on the subject
of twins often prove fallacious.
The abdomen of all women with child is in general uniformly distended,
without any inequality. It sometimes, however, happens that the tendons,
which form what is called the linea alba, which leads from the navel to
the middle of the ossa pubis, being less distensible than the sides of
the abdomen, which are muscular, divide the abdomen, as it were, into
two equal parts by a raphé or indentation through its inferior part.
This presumed sign of twins is as ancient as the time when the human
uterus, like that of quadrupeds, was supposed to be divided into cornua,
a child being thought to be contained in each horn. But as the form of
the human uterus is now well understood and known to be equally
distensible to its contents, whatever the form of the abdomen may be,
unless it is constrained by external means, even less regard is paid to
the form of this than to its degree of distention, when we are judging
whether it be probable that a woman is pregnant with more than one
child.
Women with child—those who have passed through one or more previous
pregnancies—are sometimes apprehensive that they have twins, from a
greater, a more distant, or other peculiar motion they feel during the
period. But sensations of this kind, it hardly need be said, are
generally fallacious, as affording any probable evidence of there being
more than one child in the uterus. Besides, it is to be remembered, that
women never experience the same sensations during any two pregnancies.
Tardiness of labor has sometimes been considered a sign of twins; but
this may be occasioned by so great a variety of circumstances, it cannot
be at all relied on as an evidence of compound pregnancy. It is true,
however, that when two or more children are to be born at a time, the
labor of the first is almost universally slow; and this slowness is to
be attributed to the greater distention of the womb.
There is one method of which I should speak, that some, in modern times,
place much reliance upon in ascertaining the presence of twins in the
uterus. Dr. Kennedy, of Dublin, and others, have affirmed that the
motion of two fetal hearts may be ascertained by means of auscultation;
others again have less confidence in this matter, so that on the whole,
it is doubtful whether much reliance is to be placed upon this method.
It would be difficult, I apprehend, in most instances, for two
practitioners to agree upon this point.
_Management of Twin Cases._—The labor of a woman pregnant with two or
more children begins, in all respects, like that in which there is but
one; its progress, however, is not in general so regular or rapid. The
reason why labor is more tedious in these cases is, that neither child
can be subjected so well to the expulsive force of the uterus as when
there is but one fetus in its cavity.
It is inculcated as a rule among physicians, to keep a patient as long
as possible ignorant of there being more than one child, when this is
known. But in almost every conceivable instance, the physician is not
aware that he is encountering a case of twins until the first child has
been born. After the first child is expelled, we may suspect the
presence of another from the following circumstances: first, when the
child is small in comparison with the abdomen of the mother; and second,
when we find the uterus still large, extending high in the abdomen, and
not contracted into a comparatively small and hard tumor, as is usually
the case at single birth.
It happens in the greater number of twin cases, that while the physician
is waiting for the pulsation in the umbilical cord to cease, or is
employed in tying it, or waiting for a pain to expel the placenta, the
patient complains with more than ordinary earnestness; on examination it
is then found that there is a second child on the point of being born,
or the bag of waters may be protruding with more than ordinary firmness,
so that almost instantly on their breaking, the child is expelled, and
this not unfrequently before there is time to give either the mother or
friends notice that a second child is to be born; and fortunately it
happens in the great majority of cases that, save the exception of the
labor being more protracted and severe in the beginning of those cases,
the ultimate births are effected with as little danger and trouble as in
the average of single cases.
The rules of practice in twin cases, after the birth of the first child,
are plain and not at all ambiguous, as some authors would have them.
After the expulsion of the first child, one of two things must happen;
first, that pretty severe pains will quickly ensue, and if the position
be natural, quickly cause the birth; or second, there will be an entire
suspension of pain. In the first case the labor must be conducted in all
respects the same as if it were an original one; nor is it at all to be
interfered with so long as there is any reasonable prospect that nature
will prove adequate to relieve herself; and this she is generally able
to do. When pains follow the expulsion of the first child, there is
every reason to believe that they will in proper time accomplish the
birth of the second, because it will receive the whole influence of the
expulsive efforts of the uterus, whereas before it was expended upon
both fetuses, and because the subsequent pains will be more powerful,
since the uterus is now smaller, and its contractions consequently more
perfect; and lastly, because the parts have been already dilated by the
passage of the first child.
But if there is a suspension of pain, the rule of practice is equally
plain as in the former case; if there should be flooding—which will
seldom happen—we are to proceed as we would in any other case of
hemorrhage preceding the birth of the child; we are to endeavor to
arrest the hemorrhage, and if this cannot be accomplished—which I think
it usually may be—we are driven to the necessity of delivering the child
by means of art. If there be no hemorrhage present, we are to solicit
the contraction of the uterus by frictions and kneading on the abdomen,
by cold, wet compresses freely used, by general ablutions; the cold
hip-bath, perhaps, in some cases, the frequent drinking of very cold
water, taking small pieces of ice into the stomach, and by cold
injections in the bowels. But we may safely allow nature to rest herself
somewhat before we enter upon these means. A meddlesome midwifery, we
should remember, is always bad. As things have been in the healing art,
nature has been hindered in her processes, probably scores of times, by
manual operations, where she has been really aided once!
_The Placenta._—Usually in twin cases, each child has its own placenta,
but this is not always the case.
When there are two placentæ, they are usually connected together;
sometimes, also, they are entirely separated.
The number of placentæ is usually in proportion to the number of
children. To this rule there are also exceptions. A single placenta and
a single cord has been found in a case of twins, the cord branching off
into two, some distance from the after-birth. In some rare instances,
likewise, the cords are found so closely twined together, that they have
the appearance of one.
Before any attempt is made to deliver the placenta, when we have reason
to suspect there is another child in the womb, or where we have
ascertained such to be the case, we should, at the proper time, separate
the cord of the first child, and place a ligature on the part next the
mother. The cut extremity of the cord, in such cases, is supposed to
yield a more than usual quantity of blood, even to the exhaustion of the
second child.
When the placentæ are separate, that of the first child should not be
delivered before the birth of the second child. Should it be so
delivered, there must necessarily follow a considerable discharge of
blood, which might amount to a profuse or fatal hemorrhage. But in some
instances the after-birth has been expelled by the natural efforts,
without any considerable effusion of blood. In some cases of hemorrhage,
when there is only one child, the placenta is thrown off first, and yet
without any detriment or danger, such as is usually looked for in such
cases.
In cases where it is necessary to extract the child by art, it is also
generally looked upon as necessary to deliver the placenta by the same
means; but such is not necessarily the case. If there is no hemorrhage,
or other cause of alarm, there is no more reason for giving assistance
to deliver the placenta than if only one child had been present; we
ought either to wait for the spontaneous operation of nature, or, at
most, give very little assistance, precisely as we would in a case of
single birth.
Whenever it is found necessary to give assistance in the matter of
removing the after-births, we are to recollect that the two placentæ
should be extracted together, or in quick succession, as the patient
would not be freed from the peril of her situation if we did not proceed
in this way. If the hand is to be introduced into the uterus, it should
not be withdrawn till both the placentæ are detached, and ready to come
away. If we are to give assistance by making traction at the cord or
cords, we must be careful that each shall bear an equal proportion of
the force we think it advisable to use.
We are not to be alarmed if more blood is lost in twin cases than is
usual at single births. The discharge is commonly greater in the former
cases, and longer continued than in the latter.
_Nursing of Twins._—Should a mother undertake herself to suckle her own
children, when both live, in twin cases? If she has strength enough, and
a sufficiency of milk, it is better that she do so. No one else can be
expected to feel that interest in a child which a mother naturally does.
Inasmuch, then, as the period of nursing—if every thing be properly
managed—is that in which woman enjoys probably better health and a
greater immunity from disease than at any other time of her life, let
her, I say, if it be at all within the range of consistency, nurse her
own child; and if there is need of aid from any source, it is better, as
a general thing, to depend upon pure cow’s milk, with the addition,
perhaps, of a very little pure, soft water, but of no other substance
whatever, not even sugar, which is so frequently resorted to. By this
simple means, in connection with prudent management throughout, the
child may be nourished; wholly, if the mother is not able to give it
suck, or in part, if it need more nutriment than she is able to afford
it.
LETTER XXXII.
TREATMENT OF AFTER-PAINS.
The Nature of After-Pains—The different Kinds—Their Causes—Treatment—The
great Value of Water-Cure.
Usually after delivery, the woman experiences more or less pain in or
about the abdomen, generally in the womb or the back, constituting what
is termed “_after-pains_;” these are called after-pains, because they
occur after delivery.
It is an important fact, one well worth considering, that as a rule, no
after-pains worth mentioning are experienced during the first
confinement. Do women become weakened necessarily by giving birth to
children? Are their cares and duties too many as they become mothers, in
the present state of society? Are the plans of medical treatment, such
as are usually adopted in childbirth, calculated more and more to
undermine the constitution? Are people almost universally in the habit
of debilitating themselves by connubial excesses in the married state?
These are questions of vital importance to all who expect to be mothers.
After-pains proceed from the contraction of the uterus, caused by the
presence of bloody clots, the blood having oozed from the orifices of
the torn vessels, and becoming coagulated in its cavity. The pains come
on usually very soon after the expulsion of the after-birth, and may
last a few hours, or for a number of days, according to the nature of
the case and the treatment employed. Each severe pain usually expels a
clot; they are often increased when the child attempts to suck, a fact
showing the great sympathy existing between the uterus and the mammary
glands.
After-pains may also be caused by costiveness, or, rather, by the
presence of hardened fecal matter in the colon. They may also proceed
from flatulency.
Dr. Dewees mentions one kind of after-pains of very distressing
character, which he had not seen noticed by other writers. He met with a
few cases, and I have myself seen one or two instances of the same kind.
It is a most severe and constant pain at the very extremity of the
sacrum and coccyx (the extreme lower portion of the spinal column). It
begins, Dr. Dewees says, the instant the child is born, and continues,
with the most agonizing severity, until overcome by the rapid and
liberal use of camphor and opium. The sedative effect of cold water is,
I hold, altogether better than these so-called remedies. This pain, it
is declared by the patient, is vastly more insupportable than the pains
of labor, for it is as intense in character, and holds on almost without
intermission, which the pains of labor do not.
After-pains are, no doubt, sometimes rendered much worse than they
otherwise would be, by improper management at the time of confinement;
if the labor is hurried in an unnatural way, the probability of more
severe pains is evidently increased; especially if the after-birth is
hurried away before the uterus has sufficient time to contract itself
they are rendered more protracted and severe; the better the womb
contracts, the less the blood will flow into its cavity.
We should be careful always to distinguish these pains from inflammation
of the uterus, peritoneum, or other parts within the abdomen.
After-pains are remittent; the abdomen is not particularly painful to
the touch; the lochial discharge is not obstructed; the patient has no
shivering; milk is secreted in due time; there is no general
feverishness worth mentioning; and the pulse is not affected. But in
case of inflammation, the opposite of these symptoms obtains. There may
be, it is true, and sometimes is, more or less increase of heat when
there is simply after-pain, but this heat does not at all amount to
inflammation.
There is still another kind of after-pains, different somewhat from any
I have yet mentioned. They are called spasmodic. The uterus, like all
other parts of the human system, and especially those which are highly
endowed with nervous sensibility, is liable to take on spasmodic action.
These spasmodic pains are sometimes very violent; the patient writhes in
agony, tossing herself from side to side upon the bed, and sometimes it
is necessary for a number of persons to hold her. These symptoms
sometimes become so violent as to end in convulsions, it is said.
Spasmodic after-pains appear to happen, for the most part, with those
who are excessively nervous, and particularly with such as have been in
the habit of using strong tea and coffee, opium, and other narcotic
substances. The fashionable tea and coffee drinking, and the use of
morphine and other preparations of opium, which have been so much
resorted to in this country these later years, depend upon it, have a
great deal to do in these things.
_Treatment._—How are we best to manage these formidable difficulties in
midwifery practice? Shall we stupefy the patient with camphor, opium, or
prussic acid, as many have done? Shall we do better than this, and tell
our patients, as many do, that these pains are natural, and should not
therefore be interfered with, and are to be borne with as much patience
as the sufferer can put forth? Or shall we adopt a process which is, on
the one hand, more potent, more effective, and more powerful than any
other known to quell pain and spasm, from whatever cause they may arise;
while, on the other, it does not at all injure the constitution, or
leave after it any bad effects?