LETTER XXXI.. Of Twins, Triplets, Etc.

OF TWINS, TRIPLETS, ETC.

Twins, Triplets, and Quadrigemini of comparatively rare Occurrence—Of the Signs of two or more Children in the Womb—Management of Twin and Triplet Cases—The Nursing of Twins.

It sometimes happens that the woman gives birth to two or more children 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.