in the abdominal or uterine walls. The operation, according to one
opinion, takes its name from Caius Julius Caesar, who, it is said, was
brought into the world in this manner, _"a caeso matris utero"_; this,
however, is a myth.
Up to 1876 the maternal mortality from the operation was about 52 per
centum. Between 1787 and 1876 in the city of Paris there was not one
successful caesarean section as far as the mothers were concerned. At
present on an average less than 10 per centum of the women are lost,
and expert surgeons have better results. Up to about 1902 Zweifel had
made 76 such sections with only one death, and Reynolds, 23 with no
death. Leopold has performed the operation four times on the same
woman, and Ahlfeld and Birnbaum have reported instances where the same
woman has had five caesarean sections performed upon her. The
operation is, of course, capital, and always most serious, even in
city hospitals.
The indication for the operation is chiefly a narrow pelvis, which
blocks the delivery of the child. There are no reliable statistics as
to the frequency of narrow pelves in the United States; but Dr.
Williams, of the Johns Hopkins University Hospital, in a series of
2133 cases found 6.9 per centum in white women and 18.82 in negroes.
Normally the average female pelvis, at its narrowest diameter, is 11
centimetres wide. This part is called the conjugata vera, and it is
the diameter from the promontory of the sacrum behind to a point on
the inner surface of the symphysis pubis in front.
In delivery much depends upon the size of the child, and in each case
the obstetrician waits until he sees that delivery {56} is impossible
by natural means before he resorts to the caesarean section or other
operative interference. Of two women with pelves of the same
contraction one may require the section and the other may have a
normal labour. A bisischial diameter at the outlet of the parturient
canal of 7 centimetres or less is an indication for section; so are
certain tumours that block the delivery of the child.
When the conjugata vera is less than 7 centimetres in flat pelves, or
7.5 centimetres in generally contracted pelves, the treatment varies
in the customary medical practice according as the child is alive or
dead, and it varies as the condition of the mother. The common medical
doctrine will first be given here before the moral questions that may
be involved are mentioned.
If the deformity is diagnosed during pregnancy, the woman is sent to a
hospital, the caesarean section is performed, and thus all the
children, and nearly all the mothers, are saved. When the narrowness
of the pelvis is discovered only during labour, the treatment varies
with the condition. If the woman is not septic, and has not been
repeatedly examined by the vagina, and if the surroundings are
favourable, caesarean section is done; if she is septic, the
indications are for the section, or symphyseotomy or craniotomy. Where
the conjugata vera is below 5 centimetres in length, the caesarean
section is the only method to get the child out, dead or alive, and
after the child has been delivered, the uterus, if septic, is removed.
If the conjugata vera is at the least 7 centimetres long,
symphyseotomy may be done; if the conjugata vera is above 5
centimetres, the mother septic, and the child dead or dying,
craniotomy is indicated. Even if the child is not dying, some
obstetricians will do craniotomy.
In cases where the conjugata vera is above 7 centimetres in flat
pelves and 7.5 centimetres in generally contracted pelves, the
treatment can not be reduced to general rules. Delivery without
operation occurs in many of these cases, but commonly the condition is
obscure to the physician for some time. We can measure the pelves, but
the size of the child's head is not satisfactorily measurable.
If the conjugata vera is from 10 to 9 centimetres, or from {57} 9.5 to
8.5 centimetres, labour without operation is the rule, and the child
can usually be delivered by forceps. Should the child die during
labour in these cases, it is best delivered by craniotomy, unless the
longer diameter of its head has already passed the narrowest part of
the pelvis.
When the conjugata vera is from 8.9 to 7.5 centimetres, about 50 per
centum of the women will be delivered with forceps, but the other half
will not. After about two hours of the second stage of labour delivery
by forceps is tried, but prolonged traction is not applied.
Occasionally delivery will come when least expected, but often it will
not. If the head sticks, caesarean section is done in favourable
circumstances, and craniotomy in unfavourable circumstances. If there
is ground for supposing that septic infection of the mother has begun,
the conditions are explained, and if she wishes to have the caesarean
section done the risk is left to her. When the breech or face of the
child presents in contracted pelves, the condition is especially
unfavourable for the child.
There are very many varieties of deformed pelves, but the same rules
apply to them as to those already mentioned, except that the caesarean
section is oftener indicated. Difficulty also not seldom occurs in
women with normal pelves from an excessive size in the child through
prolonged pregnancy, bigness of one or both parents, or the advanced
age or multiparity of the mother. The child's head alone may be of
excessive size. Some monsters offer difficulty in delivery from size
or shape, but, of course, they are human beings, and are to be
considered as such in delivery. The technique of the caesarean section
has only a medical signification, and it need not be described here.
Symphyseotomy is an operation in which the joint of the pelvis at the
symphysis pubis is cut, and the pelvis is allowed to gape so as to let
out the child. The operation has fallen into disrepute. The mortality
as regards the mother is about the same as in the caesarean section,
but the mortality of the children is higher. In symphyseotomy the
infantile mortality is about 9 per centum, while in the caesarean
section it is practically nothing. If in symphyseotomy an error is
made in estimating the size of the pelvis or the child's head--and
{58} such an error is often possible--the child will be killed, but in
the caesarean section these errors make no difference. After the
caesarean section the woman recovers promptly; after the symphyseotomy
she recovers very slowly, and she may receive permanent injury.
Craniotomy is an operation wherein the head of the child is reduced in
size to render delivery possible. The skull is perforated and the
brain is broken up and removed or crushed out. Embryotomy is a similar
operation wherein the viscera of the child are removed through an
incision made in its thorax or belly (evisceration), or the head of
the child is cut off (decapitation). There are numerous instruments
and methods for performing craniotomy and embryotomy, but they all
open the skull or belly, remove the brain or viscera, and then extract
the child's body.
If the infant is hydrocephalic and is alive, the advocates of the
operation warn us to be careful after opening the head to push the
perforator into the base of the skull and stir it around well, so as
to be sure the child will not be born alive. Pernice has recently
reported a case of hydrocephalus which was delivered by craniotomy,
but the operator did not work his perforator efficiently, and the
child recovered, and grew up an idiot. A similar case occurred in
Baltimore.
The indications for craniotomy among those that advocate its
occasional use (and they are many) is in those cases in which the
woman is so infected that caesarean section is dangerous, or where a
child is hydrocephalic, or where an after-coming head is jammed (in
this case even a caesarean section will not effect delivery), or in
the case of a narrow pelvis and a moribund child, or finally in the
practice of a country physician, who can not in an emergency get an
assistant to do a caesarean section. One man can do craniotomy, but it
requires three to perform the caesarean section. If the woman's narrow
pelvis has a conjugata vera of five or more centimetres, craniotomy,
if properly done, is not dangerous to the mother. With a conjugata
vera less than 5 centimetres it is more fatal than the caesarean
section. If the women are septic, the mortality in {59} craniotomy is
from 10 to 15 per centum; in caesarean section about 25 per centum.
As to the morality of craniotomy on the living or moribund child, it
is not permissible under any possible circumstances: a consideration
of the ethical principles set forth in the article on Ectopic
Gestation will make this assertion clear.
The Congregation of the Holy Office on August 19, 1888, decreed that
"In scholis catholicis tuto doceri non posse licitam esse operationem
chirurgicam quam Craniotomiam appellunt." They gave a similar decision
May 28, 1884, and they repeated the prohibition, with the papal
approbation, on July 24, 1895. The text of these decrees may be found
in the article on abortion, miscarriage, and premature labour.
The Porro operation consists essentially in a removal of the uterus
after caesarean section to prevent further conceptions. As a means to
prevent conception it is altogether unjustifiable, because repeated
caesarean sections in the same woman, if the surgeon is at all
competent, are practically no more dangerous than normal labour.
AUSTIN OMALLEY.
{60}
V
MATERNAL IMPRESSIONS
There is a wide-spread persuasion that a child, while carried in the
womb of its mother, may be marked as the result of incidents that
produce violent impressions upon her nervous system. This is so old a
conviction in the human race and would seem to be substantiated by so
much evidence that it is extremely difficult to convince people that
there is no scientific basis for it. As a matter of fact, however,
there is something mysterious about the way in which certain things
that happen to the mother seem to affect the child _in utero_. As the
result of the common belief in the truth of maternal impressions,
mothers sometimes are prone to blame themselves for not having been
sufficiently circumspect during the time of their pregnancy, and
accordingly they may seek advice and consolation in the matter from
clergymen. Women sometimes become very much depressed as a consequence
of an unfortunate event of this kind, and as the simple truth is the
best possible source of consolation, it would seem that a special
chapter should be given to the subject in a work of this kind.
The evidence for the truth of the theory of maternal impression is
almost entirely due to peculiar coincidences. James I. of England, the
son of Mary Queen of Scots, could never stand, according to Sir Walter
Scott, the sight of a drawn sword with equanimity, and it is said even
that he nearly fainted at his coronation because of an unexpected
glimpse of some naked blades in the hands of courtiers. This
peculiarity was attributed to the fact that his mother, while carrying
him _in utero,_ had witnessed the violent death of her secretary, the
unfortunate David Rizzio. There have been, however, any {61} number of
men who paled at the sight of a drawn sword before and since James I.,
with regard to whom no such circumstantial story could be told to
account for it. There have been any number of women that have
witnessed bloody murders under circumstances quite as heartrending as
those surrounding Mary Queen of Scots and her secretary, and yet their
offspring, though at the time _in utero_, have not been disturbed at
the sight of drawn swords, nor of blood or any other circumstance
connected with the deep impression that must have been produced on
their mothers.
There is, of course, a striking instance related in the Old Testament,
which seems to make it very clear that a belief in maternal
impressions existed from the very earliest times among the Israelites.
The story of Jacob is well known: "Jacob took him rods of green poplar
and of the hazel and chestnut tree and pilled white streaks in them
and made the white appear which was in the rods, and he set the rods
which he had pilled before the flocks in the watering troughs when the
flocks came to drink, and the flocks conceived before the rods and
brought forth cattle, ring-streaked, speckled and spotted." In this
case it seems evident that Jacob was not looking for a miracle, but
was expecting that a law of nature would be fulfilled in the matter,
the influence of the unusual sight upon the animal mothers proving
sufficient to have a definite effect upon their unborn offspring. The
most ardent advocates of the power of maternal impressions would
scarcely concede the existence of as much influence as this of the
mother's mind over the child unborn, otherwise there would surely be a
very absurd collection of anomalous births in the race.
On the other hand, it is generally conceded that the mother's habitual
temper of mind and the thoughts with which she occupies herself may
influence her unborn offspring to a most marked degree. The story is
told of a child-murderer who delighted in fiendish deeds of cruelty
and had murdered many people in cold blood, that his mother, the wife
of a butcher, had delighted in watching the operation of slaughtering
during the course of her pregnancy. There are any number of women,
however, who have, by the necessities {62} of their occupation, had to
witness the shedding of animal blood under such circumstances and yet
without any special effect being noticeable in their offspring. It has
been said that the opposite is also true, and that if a woman occupies
herself with high and lofty thoughts, with noble deeds and unselfish
devotion to others and if she occupies her mind and senses with the
great works of art, a correspondingly beneficial effect will be noted
upon the character of the foetus. These are, however, abstruse
speculations leading to conclusions not founded upon actual
observation, but upon theorising over the supposed fitness of things.
Coincidence plays such a large part in the matter of supposed maternal
impressions that it is impossible to decide how much there is of fact
and of consequence in the many stories that are told. Most women are a
little afraid, as the time of their labour approaches, lest something
or other--usually of an indefinite nature--that has happened during
their pregnancy, may cause the marking of their child. When they find
that the child is perfectly normal, they breathe a sigh of relief and
forget all about it. If any anomaly is noted, however, then they are
sure to connect it with some incident during pregnancy, and
imagination is apt to lend details that confirm the supposed
connection. On the other hand, there are not a few cases in which such
anomalies have occurred, and good, sensible mothers have been unable
to recall anything that might possibly serve to account for the
peculiarity noticed in the child, though corresponding peculiarities
in other children were supposed to be readily traceable to maternal
impression. Even where there has been no foreboding of evil results,
something or other that has occurred during the pregnancy will often
be magnified enough by memory to account for the supposed maternal
impression.
Doctors are very familiar with this tendency to make up stories to
account for various deformities. It used to be considered that
hip-joint disease and Pott's disease were the result of injuries in
early life. They are now known to be due to tuberculous processes not
necessarily and indeed only very seldom connected with injuries of any
kind. Mothers are {63} nearly always able to account in some way,
however, for the beginnings of the disease in some accident that has
happened. Young children are apt to have so many falls that some one
of them is picked out as the probable cause of the disease that
subsequently manifests itself in the joints. It is just this state of
affairs that occurs with regard to supposed maternal impression. Some
incident that would be otherwise unthought of is magnified into an
accident that caused a serious nervous shock, and consequently led to
the marking of the child.
In general it may be said for the clergyman's direction, that if women
have, as is sometimes the case, a morbid sense of their guiltiness
with regard to some maternal impression that has set a mark upon their
child, such a state of feeling may very well be rendered less poignant
by a frank statement of the present attitude of mind of most
physicians with regard to the possible effects of maternal
impressions. Scepticism is much more the rule than it used to be, and
as time goes on fewer and fewer of the cases that used to be
considered so inexplicable in the direct relationship that seemed to
exist between maternal impression and deformity in the child are
reported. Fifty years ago nearly all the authorities on this subject
were agreed in considering that maternal impressions did play some
part, though they could not explain just how, in the production of
certain deformities. Now we venture to say that most of the thinking
physicians who have occupied themselves with this subject would
scarcely hesitate to say that they were utterly incredulous of any
such effects being produced. The lack of any direct nervous or blood
connection between mother and child is the basis for such disbelief,
and is of itself the best argument against the old tradition.
With regard to mental defects, as a rule, not so much is said as for
bodily defects. Bodily deformities are noted at once after birth, and
then the mother recalls some incident of the pregnancy to account for
them. Mental defects are, however, noticed much later, and are not so
likely to be considered as connected with incidents of the puerperal
period. There is no doubt that if the mother has had to pass through a
series of emotional strains, or has suffered from severe {64} shocks,
children are likely to be born with diminished mental capacity. This
is, however, not difficult to understand, since such incidents produce
disturbances of the nervous system of the mother, and consequently
also of her nutrition, and this is prone to be reflected in the
child's condition, especially in that most delicate part of the
child's organism, the brain. Hence it is that children born during the
siege of Paris, or shortly after, were defective to such a marked
degree that they were spoken of as "children of the siege," and this
was considered to be quite sufficient explanation of nervous
peculiarities later in life.
Baron Larrey, the distinguished French surgeon, made a report with
regard to the children born after the siege of Landau in 1793. Of 92
children, 16 died at birth, 33 died within ten months, 8 showed marked
signs of mental defects, most of them to the extent of idiocy, and two
were born with several broken bones. In this case, however, it is well
known that besides the shock of the danger consequent to the siege and
the fear and distress of the women with regard to their husbands and
relatives, there were added many privations and physical sufferings.
The nutrition of the mothers was seriously disturbed by these, and it
might well be expected that the children should suffer severely. The
statistics of such events are not available in general, and when an
effort is made to establish a cause for idiocy under other
circumstances, none is usually found. Out of nearly five hundred cases
of idiots whose histories were carefully traced in Scotland, in only
six was there any question of maternal impressions having been the
cause of the condition.
Of course there are many very wonderful coincidences that seem to
confirm the idea that impressions made upon the mother's mind are
sometimes communicated to the child in her womb. That they are not
more than coincidences, however, is rather easy to demonstrate in most
cases, since, as a matter of fact, at the time when the incident
occurred which is supposed to have caused the deformity in the foetus,
the stage of development of the intrauterine child has passed long
beyond the period when formative defects could occur. For instance, it
sometimes happens that the child-bearing woman {65} sees an accident
especially to the father of the child involving the loss of a limb.
If, by chance the child should be born with a missing member, as
sometimes happens, then there would seem almost to be no doubt of a
direct connection between the accident witnessed, the effect produced
upon the mother's mind, and the consequent deformity.
We know now that the formation of the limbs of the foetus is complete
by the end of the third month. At this time the woman is scarcely more
than conscious of the fact that she is pregnant, and it is not during
this early period, as a rule, but during a much later period, that
maternal impressions are supposed to have their influence. It is only
such maternal impressions as occur very early in pregnancy, before the
tenth week as a rule, that could possibly have any effect in the
production of such deformities. It is by no means infrequent, however,
to have children born lacking one or both limbs. Sometimes nothing but
the stumps of limbs remain. In such cases it is now well known that
intrauterine amputation has taken place. Some of the membranes that
surround the child, especially the amnion, become separated into bands
which surround tightly the growing members of the foetus and by
shutting off the blood supply through constant pressure, lead to the
dropping off of all that portion of the member lying below the band.
Not infrequently it happens that when a child is born thus deformed,
the mother, by carefully searching her memory, can find some dreadful
story that she has read, some accident that she has seen or heard of,
and that has produced a seriously depressing effect upon her at the
time, to which she now attributes the deformity that has occurred.
Until the unfortunate appearance of her child was reported to her, she
had no idea of any possible connection between the story and the
bodily state of her intrauterine child. In not a few cases, however,
the most faithful searching of the memory fails to show anything which
could, by any possible connection, be made accountable for the
deformity; and these cases, we may say at once, are in a majority.