A tragic case of complicated labour in early Byzantium (404 A.D.)

OBJECTIVES

Presentation and comment on the problematic delivery of the Byzantine empress Eudoxia's stillborn child.

STUDY DESIGN

The original Greek language Byzantine histories, chronicles and hagiographical sources were investigated. Comparisons were then made of the knowledge of obstetrics among contemporary and ancient physicians.

RESULTS

The case of Eudoxia's delivery is described in various literary sources with details regarding the fatal clinical picture of the parturient after the embryo's death. The study of early and contemporary medical texts proves that in similar cases conservative treatment was preferred but embryotomy was followed in the event of failure.

CONCLUSIONS

Eudoxia's labour represents a characteristic paradigm of the difficulties involved in the confrontation of complicated deliveries in mediaeval times, often resulting in the death of both the mother and embryo. The treatments follow the ancient Hippocratic, Hellenistic and Roman traditions and influence medieval European medicine, thus constituting significant roots of obstetrics.

Obstetric complications and schizophrenia: historical and meta-analytic review

OBJECTIVE

This paper reviews the literature on obstetric complications as a risk factor for schizophrenia. The authors trace the evolution of this literature through different methods and carry out a quantitative review of the results from prospective, population-based studies.

METHOD

Relevant papers were identified by a MEDLINE search, by examination of reference lists of published papers, and through personal contact with researchers in the field. Studies were grouped in chronological order according to common themes or methods. Meta-analytic techniques were used to summarize the findings of prospective population-based studies.

RESULTS

The meta-analytic synthesis of the prospective population-based studies revealed that three groups of complications were significantly associated with schizophrenia: 1) complications of pregnancy (bleeding, diabetes, rhesus incompatibility, preeclampsia); 2) abnormal fetal growth and development: (low birthweight, congenital malformations, reduced head circumference), and 3) complications of delivery (uterine atony, asphyxia, emergency Cesarean section). Pooled estimates of effect sizes were generally less than 2.

CONCLUSIONS

Current methods of investigating the relationship between obstetric complications and schizophrenia are reaching the limit of their usefulness. Lack of statistical power to measure small and interactive effects and lack of detailed information about the prenatal period are major problems with current approaches. A combination of disciplines and approaches will be needed to elucidate the mechanisms underlying these small but important associations.

[3-dimensional models of actual or simulated cesarean sections]

Following upon an etymological and historical introduction, this report refers to two three-dimensional wax models of Caesarean sections, which have recently been acquired by the Pathological-anatomical Federal Museum in Vienna. Information is given on origin, dating and kind of production; questions of indication and operation technique, and--when in doubt--obduction technique, are being considered.

The chapel and the operating room: the struggle of Roman Catholic clergy, physicians, and believers with the dilemmas of obstetric surgery, 1800-1900

By 1800, the Roman Catholic Church and organized medicine faced the dilemma of how to resolve cases of obstructed births. American physicians usually practiced destructive operations, like craniotomy, in an attempt to save the lives of mothers. The church allowed such operations after the death of the infant. A new technique of surgery, the cesarean operation, offered hope that both patients would survive childbirth. Medical progress, and an emerging Catholic belief that the fetus was human, prompted Catholic physicians to advocate the new operation, and stirred a renewed debate among European theologians on the propriety of craniotomy. In America, the broad Christian tradition promoted by the Catholic Church began to inform medicine on the moral and ethical parameters of surgery. American physicians, for their part, engaged in their own debate on the propriety of the cesarean operation. This article, focusing on the cesarean debate, reveals the intersections of Catholicism and medical progress amid the growth of obstetric surgery from 1800 to 1900.

[Ethics of medical management of inability to give birth. Johannes Stahelin and his plea for embryotomy]

Confronted with the inability to give birth to a child, delivery could be achieved by embryotomy--that was only permitted, when the foetus was dead--or by Caesarean section--where the chance to save mother and child as well was merely theoretical until the end of the 19th century. In two statements of the Theological Faculty of the Sorbonne in Paris embryotomy was absolutely rejected (1648), in nearly all cases of impossible delivery the Caesarean section was required (1733). In 1749 Johannes Stähelin starts a daring attempt to justify embryotomy by application of natural law to the situation of critical childbirth. Keywords of the theological statements are confronted with categories of the natural law in a sophisticated way, nevertheless the basis of Christian confession is maintained. This argumentation in order to justify embryotomy as a lawful method to deliver a woman seemed to be more adequate to the medical sphere than claiming the Caesarean section. The ethical debate continued until the problem was solved by mastering Caesarean section.

[Obstetrics--a gear in the machinery of history]

It was not Julius Caesar who was born by Caesarean section, as generally assumed, but Scipio Cornelius Africanus, who subdued Spain 100 years before Caesar's time. In chambers with walls of porphyrite, the Byzantine empresses used to give birth to the heirs to the throne. In England, the infertility of Queen Anne, who suffered from porphyria, led to the succession of the Protestant House of Hannover following the Catholic Stuarts. Christina of Sweden, called 'queen of baroque, rebel and scholar', was born in the 'caul'. At the age of 39 years, Johanna of Pfirt, married to Albrecht the Lame, secured the continuation of the Habsburg dynasty by giving birth to Rudolf the Founder. Maria Theresia, who had 16 children, was called 'mother-in-law of Europe'. She was delivered of her first child at the age of 19. The death of her sister Maria-Anna in childbed was one of the reasons why Gerard van Swieten was called to Vienna. Elisabeth of Württemberg, first wife of Franz I of Austria, died, not as a consequence of. but after a forceps operation carried out by Johann Lukas Boër. In England, Princess Charlotte, daughter of George IV, and her baby son died at the delivery; Sir Richard Croft, who had not used the forceps, committed suicide after this tragic incident. Being the next in succession, Victoria ascended the throne. The term 'narcose au chloroforme' (first used by James Young Simpson) was changed to 'narcose à la reine' after this method had been used at the birth of Victoria's eighth child by John Snow. It was Queen Victoria, who passed on haemophilia in European dynasties. When Marie Louise of Habsburg had her first child, Napoleon's son, the later Duke of Reichstadt, Antoine Dubois had to perform a turning of the transverse presentation and use the forceps on the head following after. The birth of Napoleon himself was a case of precipitate labour. Johann Klein, the successor of Boër, applied the forceps when Archduchess Sophie was delivered of her first child, the later Emperor Franz Joseph I of Austria, the first of the four 'salt princes'. The later Emperor Wilhelm II of Prussia was delivered by Eduard Arnold Martin the Elder, the obstetrician of Princess Victoria, the eldest daughter of Queen Victoria; the breech presentation became even more complicated by the raised arms of the child. Both latter monarchs had been 'asphyctic' after their birth. Johann Wolfgang von Goethe was also among those who were apparently dead after their birth.

[Labor-induced bladder injuries: historical observations]

Injuries to the urinary bladder with development of a fistula during birth were first mentioned around 1030 AD in the opus called 'Al-Kanoun' by the Arabic physician and philosopher Avicenna (Ali Ibn Sina). The observations of D.E. Derry in the mummy of Henhenit seem to have made sure that this obstetric complication already existed earlier on. Henhenit lived at the court of king Mentuhotep II (around 2050 BC). During the second half of the 19th century injury-related and necrosis-related fistulas were distinguished for the first time. Jobert de Lamballe (1852), Marion Sims (1852), and Gustav Simon (1854) created the basis for successful operative treatment of vesicovaginal fistulas.

[Repeat cesarean delivery by the Zurich city wound physician Johann Jakob Locher 1817/18]

Caesarean delivery was rarely practised in the early nineteenth century and was considered highly dangerous, being both technically and morally controversial. In view of this, Johann Jakob Locher's performance of two consecutive caesareans attracted international attention. Not only contemporary printed literature, but also the archive material and specimens presented in this journal for the first time provide a uniquely detailed account of the operations. The University of Zurich's Institute and Museum of the History of Medicine were able to acquire the preserved pelvis of the patient in 1983.

Dr William Smellie (1697-1763), the master of British midwifery

Images

Reflections on Dr Henderson of Perth's case of impracticable labour: an early case (1820) in which the caesarean operation was performed

The rediscovery of a female pelvis with features characteristic of osteomalacia stimulated an enquiry into the clinical history of the woman involved. It was established that she died in 1820, aged 30. Despite being severely debilitated and confined to bed for some years with increasing skeletal deformities, she became pregnant, and in due course laboured unsuccessfully for about 102 hours. An elective caesarean section was performed, but she died some hours later, though her daughter survived and was appropriately christened Caesar Anna. This represents one of the earliest cases in which the caesarean operation was performed where the full obstetric history was carefully recorded by the obstetrician involved, Dr. Henderson of Perth. The case was clearly considered important, and in 1836 engravings of this pelvis were used to illustrate Professor Hamilton's "Practical Observations of Various Subjects Related to Midwifery". Such cases are now of great rarity in the developed world.

[Evolution of surgical delivery during the past 35 years according to the data of the All-Union Research Center for Maternal and Child Health of the Ministry of Public Health of the USSR]

A distinct evolution of surgical delivery has been demonstrated over the past 35 years. In the past decade, the proportion of surgical deliveries has grown considerably owing to the increasing rate of cesarean sections. In most cases, the operation is performed for combined indications and, quite frequently, for the sake of the fetus. Perinatal parameters have improved while there has been no clear-cut correlation between the increasing rate of cesarean section and declining perinatal mortality. Further development of rational labor management principles is necessary.

Did Princess Charlotte die of pulmonary embolism?

The cause of death of the Princess Charlotte of Wales in 1817 has been attributed to postpartum haemorrhage. Although an autopsy was performed, pulmonary embolism was not diagnosed because this condition was not recognized until 1846, but the clinical description of her last hours clearly points to pulmonary embolization as the most likely cause of death.

[The ill-fated delivery and death of Princess Charlotte of England 6 November 1817]

What took place following the delivery of princess Charlotte of England's 4 000 gm stillborn infant? Two hours after manual removal of the placenta she suddenly developed malaise and weakness, followed by somnolence then agitation, with progressive worsening and death. Professor Dumont comments on the accounts describing this event at that time in history and offers a retrospective diagnosis.