A Comparative View of the Mortality of the Human Species, at All Ages / And of the Diseases and Casualties by Which They Are Destroyed or Annoyed. Illustrated With Charts and Tables

Female Diseases,

including obstructio-mensium, chlorosis, profluvium mensium, fluor albus, hystericks. These derangements of the human machinery, which, from the days of Hippocrates, have been discriminated by specifick morbid names, are notwithstanding unnoticed in the London registers; unless perhaps rising of the lights, spleen, and vapours are substituted as a portion of hysterick mortality. This formidable phalanx, whose frequency and fatality are of universal notoriety, must be mustered amongst the chronic host of diseases. From about the period of puberty, seldom earlier, they begin to infest numbers of the female sex.

On a careful perusal of nearly one half of the books of the Aldersgate Dispensary in London, and before mentioned, during six years, I found the total sick and diseased amounted to 29,511: by far the greater proportion of which were adults, and more females than males. Of this twenty-nine thousand, the numbers afflicted with different female complaints were as follow: Obstruct. mens. and chlorosis, 254; profluvium mens. 270; fluor albus, 446; hysteria, 1104; total, 2074. Here it is worthy of observation, that four only of the principal female infirmities constituted nearly one fourteenth part of all the diseases in that dispensary, which is open to afflicted patients of every description and age. I should, however, not omit to add, from the information of one of the learned physicians of that charity, that under Fluor Albus, a few cases of venereal gonorrhœa were concealed; and that under Hysteriæ, were arranged all female and nervous complaints, without strictly attending to its generick symptoms. We have here likewise, one proof that uterine relaxation is a more frequent female malady than obstruction in London: it is more so in warm than in cold climates: and probably, all these four female diseases are more prevalent amongst the higher and luxurious ranks; and in city than in country.

Hippocrates has truly said, “Uterus sexcentarum œrumnarum mulieri auctor merito dicatur.” Great and important changes ensue at puberty amongst the two sexes, especially the female, affecting their future health. In both, the organs of generation are then evolved, and the sexes first capable of procreation. The semen in males about this period, begins to be strained through the generative organs, the beard to sprout, and the countenance to assume a more masculine appearance. That periodical discharge of red blood from the female womb, called Menses, the index of womanhood, begins in this island to gleet monthly, about the age of 14, 15, or 16: but its first eruption and final cessation, as well as its periodical returns, are sometimes extremely variable; from 11 to 20 years of age; and its final ebb between 30 and 50; generally, however, between 40 and 50. In warm climates, the menstrual commencement is earlier, and more profuse. This discharge is not suddenly in a full stream, but continues oozing from 3 to 5 days, and even longer; the whole quantity in healthy women amounting to 4 or 6, and in others, to even 12 ounces: but the first efforts to menstruation are commonly scanty and irregular. The quantity of blood evacuated, the duration, the intervals, periodical returns and effects, are various; and are diversified by climates, seasons, constitutions, mode of life, habit, and by numerous other accidental circumstances. In different women the menstrual intervals are from 2 to 6 weeks, or longer; but when strictly regular, or the woman not pregnant, every lunar month. The first periods of menstruation, and the final cessation by age, are two very important epochs in female life, on which much of their succeeding health and longevity will hinge. But, without entailing diseases, many women are liable to some menstrual irregularity, with respect to the periods, duration, and quantity.

Morbid and Irregular Menstruation,

under the different heads of scantiness, chlorosis, or morbus virginius, retention, partial obstruction, and total suppression. The menstrual eruption is generally and naturally preceded by heat of the loins, and weight about the uterine region, frequently with pain and cholick, lassitude, headach, dulness of vision, disturbed sleep, inappetency, and nausea, pain and load about the breast: all which, with many other troublesome symptoms, usually disappear on the establishment of this salutary and critical evacuation. But where the menses do not flow at puberty, or afterwards become obstructed or suppressed, a numerous train of morbid symptoms and fatal diseases often ensue; such as inappetency, indigestion, colick, palpitation of the heart, difficulty and labour in respiration, pulmonary consumption, hectic, dropsy, fluor albus, low spirits, fainting, hystericks, insanity, apoplexy, general bad health, barrenness. Indeed, those women who have passed the stage of puberty some years without menstruation, are generally barren.—The Chlorosis appears about puberty, sometimes indeed earlier; and is more frequent amongst indolent and luxurious females. The complexion is pale, sallow, of a green sickly tinge; the lips pale, with aversion to motion, with debility, muscular flaccidity, inappetency, indigestion, craving for unusual and unnatural food, flatulence, palpitation of the heart, laborious and quick respiration on exercise or ascending any eminence; pain and weight about the loins, night sweats, hectic and emaciation, œdematous ancles, crude urine, usually obstructed menses, unusual bad health, and derangement of the animal, vital, and natural functions. It is seldom immediately dangerous to life, but often lays the foundation of some of those diseases above enumerated.

The predisposing and occasional causes of scanty menstruation, obstruction, and suppression, and of chlorosis, may be comprehended under the following: general bad health, debility, and unsound constitutions; partial weakness of the uterine vessels; too great resistance and rigidity of the uterine vessels; want of sufficient momentum in the sanguineous circulation; scarcity of florid blood; not sufficient motion nor exercise of the body; sanguine plethora; sizy blood; spasmodic constriction of the uterine vessels; sudden passions of mind, especially the depressing passions; cold wet feet; cold liquors and various cooling luxuries drank or eat at the menstrual period; crude watery diet; worms; celibacy; love; salacity stifled; lax fibre; severe parturition, and local diseases inherent in the womb and vagina.

Uterine Relaxation,

including excessive menstruation, fluor albus, leucorrhœa. There is a great similarity in all their causes. We here treat of menstrual excess in the unimpregnated state; reserving for pregnancy that uterine hemorrhage, vulgarly denominated Flooding. Menstruation may be morbid from frequency in the returns, from duration, and from quantity. It has already been said, that the quantity of the menstrual flux, the recurrence, and the duration, vary in different women: the immoderate discharge is determined not altogether by the absolute quantity, but by the effects: such as languor, debility, pale countenance, weak pulse, palpitation of the heart; depression of spirits, pain in the back and loins, inappetency, coldness of the skin and of the lower extremities; in the evening œdematous ancles. Excessive menstruation may either be sudden and within a few days, or chronic and persevering a long time beyond the natural period. There is also erroneous menstruation from various parts of the body; of which many extraordinary and monstrous examples may be seen in the records of medicine. Menstruation in excess, especially if chronic, is often accompanied with fluor albus; and may terminate in consumption and dropsy, and in many of the diseases enumerated, under obstruction and suppression.

The Fluor Albus often succeeds or accompanies excessive menstruation. It is a dripping discharge from the womb and vagina, and from the same vessels which exude the menses, sometimes pale and serous, or often variously intermixed with yellow, green, and red tinges; sometimes fetid and acrid, and either constant or irregularly intermittent. At the commencement, the usual concomitant symptoms ascribed to this disease, such as pain and weakness in the back and loins, indigestion, &c. only occur when the discharge is excessive, or long continued. It is then attended with a pale sickly colour and countenance, dejection of spirits, palpitation of the heart, lassitude and debility, pain in the stomach, loss of appetite, indigestion, flatulence, acrid and turbid urine, hectic. But notwithstanding the heat and acrimony of the excretion in many instances, especially when chronic and inveterate, yet it may easily be distinguished from venereal gonorrhœa. Women of various ages after puberty, married and unmarried, some even after the final menstrual cessation, are obnoxious to this gleet, which is not infectious. The fatal termination may be in some of the different diseases consequent of obstructed and excessive menstruation; such as barrenness, diseases of the womb; colick, piles, strangury, hystericks, low spirits, consumption, dropsy.

The predisposing and occasional causes of excessive menstruation and of fluor albus, are, many of the general causes of hemorrhages, already enumerated; plethora, sedentary, luxurious life, stimulating and nutritious diet; too long indulgence in warm soft beds; warm chambers; suppression of usual and habitual evacuations; weakness and laxity of the uterine vessels from abortion, violent evulsion of the placenta, or other injuries during parturition; difficult and lingering, and also frequent parturition; general relaxation, and delicate constitution; weak nerves; violent exercise, especially in hot climates and weather; excessive heat of the season or climate; moist watery climate; violent efforts of the body or muscles, or straining of the body and loins; external injuries, or falls near the uterine region; excess of venery and salacity, manustupration; spirituous liquors and drunkenness, intemperance, immoderate use of tea, and other warm fluids; immoderate use of warm baths or stoves; neglect of cleanliness and abstersion; passions of mind, frights; impeded perspiration; excess of serum in the blood; scorbutic habit and acrimony: purulent translation to and deposition upon the womb from other parts of the body; polypi, fungus, scirrhus, cancer, ulcers in the womb or vagina; procidentia uteri et vaginæ, emmenagogue medicines.

Final Cessation of Menstruation

from years. This is a dangerous period to women; more so, perhaps, than any other stage of maturity. In this island the menses usually cease about 48, 45, or sometimes at 41, and earlier; especially after frequent parturition. The springs of life, or generative powers, then become effete; but in the male sex, the faculty of procreation continues ten, twenty, and in some thirty years later. In most cases, women do not conceive before menstruation, nor after its cessation. Towards the final drain, women commonly are irregular in the recurrence, duration, or quantity of the discharge; which is often excessive. The longer or shorter duration of menstruation depends, in some degree, on its earlier or later commencement. Women who never had children, nor enjoyed sound health; those whose constitutions have been impaired by frequent parturition and miscarriages, and others of delicate nerves and structure, all these are frequently obnoxious to complaints and diseases at the final uterine ebb. As infirmities and bad health are frequently removed on the first flow of the menses, such are also again prone to relapse in this autumn of life, into nervous complaints, hystericks, consumption, dropsy.

Childbed

Mortality in London is nearly one eightieth part of the whole funeral catalogue. It is in storms and hurricanes; or within a very short space of time. The mortality of this group must occur between the two extremes of 16 and 50 years of age. Or, as marriages in this island, one with another, are computed to commence on the side of the woman at 25, we may, with safety, rate the principal mortality in the stage of life between 20 and 50. On this interesting subject there are several curious and useful propositions, which I have attempted to establish by demonstrative proof.

These are, 1st, The number of women who, on an average, die in childbed: 2dly, The proportion between natural, laborious, preternatural, and complex labours: 3dly, The number of abortive and stillborn infants to those brought forth alive: 4thly, The proportion of twins and tergemini to single births: 5thly, The diseases principally fatal to women during pregnancy and parturition, and afterwards, with the arithmetical ratio and fatality of each, and also of labours. To the investigation of these corollaries I proceed in a regular order.

From twenty-four years of the London, and from several country registers in England and Germany, Dr. Short calculates, that on an average, 1 of every 60 women die in childbed: others rate the decrement at 1 of 66, or 3 in 200. Upon a much broader basis I formed a puerperal estimate. From the year 1700 to 1776, the christenings in the London registers amount to 1,220,656; and the abortives and stillborn in the same interval, to 46,831. The sum total therefore of the births, including the christenings and abortives, amounts to 1,267,487. During the above period of 76 years, the deaths in childbed are 17,057; which number employed as a dividend to the former, makes about 1 of 74 pregnant women to perish in childbed. But as a considerable number of infants, after being brought into the world alive, die before baptism or christening, and consequently are excluded from the publick enrolment of births and christenings, this is an additional reason for believing that the perils of childbed are not rated by us too low.

Respecting the proportion of natural, laborious, and preternatural parturition, Dr. Smellie says, “That of 1000 women in childbed, 920 of them will be delivered in the ordinary way, with little or no accocheur trouble, skill, or assistance: 70 more of the thousand will be difficult labours, or slow and tedious, when often some skill and aid of the accocheur will be necessary; and the remaining ten of the thousand will be preternatural labours.” There will, therefore, according to this author, be about 8 per cent. of slow, laborious, preternatural, and anomalous labours, which, in different gradations, will be more tedious, difficult, and dangerous than in the usual process of nature.

It is a proposition not uninteresting in Obstetricks, and in medical jurisprudence, and in many instances it is material to the medical character, to observe that, in the preceding list, during seventy-five years in London, there were brought forth alive and christened, 1,220,656; that the abortives and stillborn in the same period were, 46831, or as 1 of 26. But, as we just now remarked, that the chrisoms and infants who die in the threshold of life, and previous to baptism, are excluded from the registered births and christenings; on that account we may venture to calculate the abortive list to those who are ushered alive into the world, as 1 of 27 or 28; perhaps more, or about 3 per cent. Were we, however, to add the abortions and miscarriages of diminutive embryos, in the early months of pregnancy, and which are much more frequent than in the latter months, the abortive catalogue would be prodigiously swelled.

Dr. Short attempted to ascertain the proportion between single births, twins, and tergemini, from a register of three large parishes, during a series of years, in which the single births amounted to 11,415; the twins and tergemini to 311, or about one of thirty-five.

Lastly, Let us examine what were the several diseases during pregnancy and parturition, and afterwards which occasioned this childbed mortality, and in what arithmetical ratio were the fatality of those respective puerperal diseases and casualties. This inquiry demands a previous analysis of pregnancy and parturition.

Conception and Pregnancy.

In some instances, there is not a more puzzling problem in midwifery, than to decide the simple question, whether or not a woman is pregnant? The symptoms in the beginning are various and obscure, not only in different women, but even in the same woman at different times, and are fallible until the end of the fourth month of gestation. In the beginning, one or more of the following indications sway our decision: a slight titillating pain, or unusual disturbance about the womb and navel; nausea and reaching to vomit in the mornings, loss of appetite, sudden unnatural cravings and longings of the stomach, heartburn, drowsiness, slothfulness, chagrin, capriciousness, dislike, moroseness, aversion to venereal dalliance, headach, tooth-ach, increased secretion of saliva, tawny circle round the eyes, and some perceptible alteration of countenance. But the most unerring signs of pregnancy are by the touch and feel of the accocheur’s finger introduced into the vagina, or rectum.

The womb, a small bag, in shape and size like a pear, situated within the pelvis, between the bladder and rectum, and terminated at its lower part by a soft tube, from three to six inches in length, called the Vagina, begins in pregnancy to be enlarged. About the third month of gestation, the womb is closely locked up, and the menses cease to flow: but in some very rare cases, there is a serous gleet during pregnancy, and in others plethoric, a small sanguineous discharge at the usual menstrual periods. About the fourth or fifth month, the womb is considerably distended, and its upper part ascends above the brim of the pelvis; by the finger it is felt weighty and enlarged, its neck shorter, and raised higher up in the pelvis; and the abdomen begins to be distended above the pubis. About this period also, the mother begins to be sensible of the infant’s motion. For although the heart and arteries of the embryo, from its earliest, rudiments, are in action, yet the other muscular efforts of the fœtus are seldom perceptible by the mother until the third or fourth month, increasing in strength and frequency to the end of pregnancy. Before the end of the fifth month, the womb reaches up half-way between the pubis and navel; in the sixth month, to the navel; in the eighth month, half-way between the navel and stomach; in the ninth and last month, to near the lower part of the stomach, filling up the whole anterior part of the abdomen. The uterine enlargement is then not only perceptible to the hand pressed on the abdomen, but is also obvious to the eye of the spectator. In different women, however, the size of this protuberance is various. Towards the latter stages of pregnancy, the mother’s breasts begin to enlarge, and the circle or areola round the nipples, is of a brown colour.

Nine solar months, or thirty-nine weeks, or 273 days, reckoning from the time of conception, is the usual period of uterine gestation in the human species. But, as conception is often obscure, unless the limited congress of the sexes can be ascertained, we must be guided by probable conjectures respecting the ultimate completion of uterine gestation; in which women themselves often err days and weeks. The usual way of regulating puerperal books, or reckonings, is by going backwards, and computing from the middle space between the last menstruation, and the immediately succeeding menstrual period which should appear, but is interrupted to support the fœtus. Some women are delivered of living children considerably earlier than the end of the ninth month; and others, probably, a little later.

The comparative growth of the fœtus infinitely surpasses that of its whole future existence. But the exact age of uterine embryos, and of abortives, is, in some degree, conjectural. Before the seventeenth day after conception, its rudiments are not even visible to the naked eye: the glary ovum has then slidden down from the ovarium, through one of the lateral tubes into the womb. The size of an abortion, comprehending the fœtus, its membranes, waters, and placenta, at the end of six weeks, does not exceed in size that of a pigeon’s or hen’s, and in three months, a goose’s egg. About the end of the fourth month, its different viscera are formed; and its length between four and five inches. At the end of the ninth month, the homunculus length, from head to foot, is from sixteen to twenty-one, and in some even twenty-six inches: its weight, from six to ten pounds. Some extraordinary fœtal giants, however, have been seen, from ten to twenty pounds in gravity. Its usual dimensions, so necessary to obstetrical knowledge, is, from the forehead to the hindhead, four inches and a half; from each temple the lateral dimensions three inches and a half; the circumference of the head from twelve to fourteen or fifteen inches; the breadth of the shoulders five or six inches, and of the breech nearly the same; the circumference of the shoulders and of the breech, from fifteen to eighteen inches. We might also have observed, that in gravity, exclusive of placenta, membranes, and waters, the mature fœtus exceeds considerably that of the whole menstrual blood, were it to be accumulated throughout pregnancy.

In the womb, the fœtus is folded together into a round oval form; and its usual position is with the head downwards, presenting at the upper brim of the pelvis, and at the mouth of the womb; the chin resting on its breast; one ear turned to the back part of the mother, the other forwards; the face and hindhead to the mother’s sides; the thighs bent up along the belly; the legs again bent backwards, with the heels to the buttocks; the arms laid along the infant’s sides, or before its breast. Thus folded together in a globular heap, it is wrapped up in four delicate transparent membranes, and is immerged in water, which continues decreasing throughout pregnancy, and at parturition is various in quantity, from one to six pints. By its blood vessels united into what is termed the navel-string, the fœtus is attached to a flat round cake, resembling a firm coagulum of blood, called the placenta, and which is closely cemented with the mother’s womb. In this natural posture the mature fœtus lays above the pelvis, and totally within the abdomen.

Previous to parturition, the fœtus must descend “inter scyllam et charybdin,” through that ossious circumvallation, or bony cavity of the mother, called Pelvis. This cavity is open, both above and below, and is inclosed between the hips, groin, and lower part of the spine. The female pelvis, for obvious reasons, is more capacious than in males. In a well formed and proportioned woman, the common standard is at the upper part of the brim, from the back part of the spine, or sacrum, four inches and a half; laterally, or from side to side, five inches and a half; below, at the lower opening of the pelvis, these dimensions are exactly reversed. But as in parturition, the os coxcygis, or lower bone of the spine, is elastic and moveable, on pressure backwards by the infant’s head, the diameter of the pelvis below is thereby enlarged in all its dimensions. The ossious depth of the pelvis, from the top of the os sacrum to the extremity of the os coxcygis, is five, or five inches and a half; at the sides four; before, or in the interval between the groins, two inches. In some deformed and ricketty women, the dimensions of the pelvis are either throughout, or in particular parts, greatly contracted, and most commonly at the upper part.

Of Parturition natural, laborious, preternatural, complex, or anomalous.

Natural labours are all those in which the infant’s head presents at the orifice of the womb; which are probably ninety-nine out of every hundred labours. But in this presentation of the infant, some are natural and easy, and a small number lingering and difficult labours. Preternatural labours are either all those wherein any other part of the fœtus spontaneously presents at the orifice of the womb, or where, notwithstanding the natural presentation of the head, yet it is necessary to turn the infant by force, and to deliver it by the feet foremost. Complex and anomalous labours are those, whether natural or preternatural, accompanied with extraordinary symptoms and danger, such as floodings, convulsions, &c.

Labour or parturition is a salutary effort of nature, to expel the contents of the womb by its own muscular contraction, and the collateral assistance of the muscles of the abdomen, diaphragm, thorax, back, and extremities. These exertions commence at intervals, called Paroxisms, or Labour Pains, which are various in strength and duration, from one to several minutes, and recurring at irregular intervals of one minute, an hour, or more. The symptoms naturally preceding and accompanying real parturition are, anxiety, shivering, violent pains, shooting from the loins to the lower part of the abdomen or womb, and extending down to the thighs; trembling of the thighs and legs; frequent micturition, tenesmus, diarrhœa, and involuntary stools, colick; the countenance and visage florid and red from the violence of the muscular efforts, with profuse perspiration and sweats; softness of the breasts, sinking of the abdomen in size, gradual dilatation of the orifice of the womb, protrusion of the membranes through its orifice in the form of a soft gut or bladder: in the absence of the labour pains the membranes and waters are retracted, at length are ruptured, when the fœtus may be felt with the finger introduced: next ensue the spiral descent of the infant’s head through the pelvis, dilatation of the external parts round the orifice of the vagina, expulsion of the infant, its membranes and waters; separation of the placenta, exclusion and extraction, together with some sanguineous discharge. Natural labours are generally terminated within a few hours, from 2 to 12 of real labour efforts; sometimes in a few minutes, and with a trifling exertion or pain. In some warm climates labours are alledged to be particularly easy.

But there are specious, or False labour pains, which are vague and irregular in frequency and force, and do not produce any sensible enlargement of the uterine orifice, and are not attended with any mucous discharge: they are generally confined to the lumbar region and abdomen, without extending down the thighs; they are most troublesome towards night, and are relieved by clysters and opiates. They generally are excited by one of the following causes, stretching of the womb, erect posture, spasm in the intestinal canal, colick, costiveness, distention of the bladder with urine, &c.

Of laborious, lingering, tedious, or difficult parturition. Every labour in which the process is prolonged beyond 24 hours, may be classed under this head, notwithstanding the natural presentation of the infant. Sometimes the labour may continue several days, either from the head not entering the pelvis, or, which is much more frequent, from some impediment during its descent through that ossious cavity. In these cases the woman becomes hot, thirsty, anxious, restless, low-spirited; is afflicted with headach, nausea, sickness, vomiting, incontinence, and difficulty of urine; she tosses incessantly, and finds no comfort in any posture. During this struggle, the infant’s head advances slowly, or stops at various parts in its descent; and the intervals of labour paroxisms are various. It is by no means necessary that childbirth pains should be incessant, or without intervals of respite and rest. In some cases, tedious and difficult labours may continue two, three, and even four days and nights, when, after reiterated paroxisms, the infant may at length be excluded by the efforts of nature alone: in some of these cases also, the mother’s recovery is surprisingly expeditious, as if she had been delivered in half the time; and unless some dangerous symptoms indicate, no manual assistance will be necessary. It is an obstetrical axiom, that in labours with the head presenting, the labour pains continuing strong, the woman not deformed, the pelvis sufficiently capacious, the constitution sound, not exhausted by labour pains nor weak, there is the strongest reason to expect that nature will be adequate to the task of delivery.

Indeed, the obstetrical cases, where instruments are required, are very rare; and in such emergencies there is often much greater difficulty to determine the ultimate propriety of employing instrumental aid, than in the mode of using the few implements peculiar to the obstetrick art; consisting principally of forceps, crotchet, and scissars. The danger of the mother, from tedious and difficult parturition, is discernible from her natural constitution, her debility, pulse, respiration, voice, countenance, the duration of the labour, the weakness of the pains, or their perseverance and severity, the space elapsed from the entrance of the head into the pelvis, and from the rupture of the membranes. The danger of the fœtus may be predicted from the time its head has been pressed into the pelvis, and the violence of that pressure, especially on the yielding cranial bones.

Preternatural labours are these wherein any other parts but the infant’s head present at the orifice of the womb; such as the feet, breech, shoulders, arms, and so on; besides those other cases in which, although the fœtal presentation may be natural, yet, for variety of reasons, and in dangerous emergencies, it is necessary to turn the infant in utero, and to extract it by the feet. The signs of the preternatural position of the fœtus are uncertain, until the accocheur can touch the presenting part. But in all cases, natural and preternatural, before the rupture of the membranes and evacuation of the waters, it is often extremely difficult to distinguish by the finger what part is felt. Preternatural postures of the infant may be suspected, if the pains from the beginning are lingering, tardy, weak, making little impression on the orifice of the womb, consequently tedious labours; if the membranes are either soon ruptured, or are pinched up into a conical form, like the finger of a glove; if no part of the infant can even be touched until the uterine orifice is moderately dilated, which remains high up in the pelvis, and when any part of the fœtus can be reached, it is indistinct and irregular, and generally small.

In some preternatural presentations delivery may be easy; but in general, they are always precarious, often difficult and troublesome to the mother and accocheur. After some continuance of labour the membranes break; but still no bulky part descends, nor is the mouth of the womb sufficiently dilated: at length the labour pains abate in strength and frequency; sometimes they intermit during a few hours, and, in some instances, a day or more. When we compare the size of the fœtus and of the pelvis, the reason is obvious why in cross postures, where the infant descends double, and is expelled by the natural efforts of the mother, such cases will be difficult, especially in first labours; and unless the child is very small, it will often be born dead. It is true, Providence has wisely provided, as far as possible, against puerperal compression, by the softness of the buttocks, belly, and shoulders, and by the over-lapping of the parietal bones of the infant’s head. Infants in the womb, we may presume, are subject to diseases as well as casualties; but probably the most frequent causes of mature abortives and stillborn, originate from laborious, preternatural, and complex parturition; which cases, as we observed, may be estimated at about eight per cent.; but the abortives and stillborn are not altogether three per cent.

In a pelvis not two inches wide at the brim, it is impossible for the fœtus to descend alive through such a narrow passage. Deformity at the brim of the pelvis is more difficult to detect than at the lower part. Some pelvises have been seen not altogether one inch in diameter either above or below: but, happily, such instances of deformity very rarely occur. We have but eight examples on record during the last hundred years in this island, three of them in London, and five in Edinburgh, wherein it was thought necessary to have recourse to the dreadful alternative of the Cesarian operation; that is, of cutting out the infant by an incision made through the mother’s abdomen and womb; and all these women died. During the above long interval of time, including three generations, of fifty or sixty puerperal women in London, whose pelvises were remarkably small and deformed, notwithstanding the unavoidable necessity of recurring to obstetrical instruments, in order to diminish and tear away the infant, yet not above five or six died. We have instances, almost miraculous, where, after five days strong labour, and a pelvis deformed and contracted in all dimensions, yet, by obstetrical perseverance and skill, the woman has been delivered, and has recovered. Instructed by these precedents, we may reasonably expect, that two barbarous and ineffectual operations, the Cesarian, and the modern attempt at improvement, by severing the anterior cartilaginous juncture of the bones of the pelvis, will both hereafter be for ever exploded, at least in this enlightened island.

Anomalous, or complex labours, are either natural or preternatural: but at the same time are accompanied with uterine hemorrhage, with convulsions, or with two or more fœtuses; and to these some add the cases of instrumental delivery. It is natural and usual for the human species, and for all large animals, to bring forth one at a birth: twins often occur; tergemini are rare: four, or at least five, are not perhaps seen in some millions of births. Plurality of fœtuses are seldom attended with peculiar circumstances of danger. Twins do not occasion much difficulty: they are generally small; and the remaining fœtus is seldom discovered before the exclusion of the first, by which the passage is stretched. Neither the number nor size, and much less the sex of fœtuses, can be predicted: a large quantity of uterine waters will sometimes produce a more prominent belly than twins, especially if the infant is at the same time large.

The predisponent and occasional causes of difficult, laborious, lingering, preternatural, and complex parturition, are, on the part of the mother, ricketty formation, and deformity of the pelvis; this narrowness generally begins in infancy, and the common obstruction or protuberance is at the jetting forward of the lower lumbar vertibra, or of the os sacrum; the pelvis may also be too small, without any deformity or projection; it may be too narrow from the fore to the back part, above and below, and at the sides: the os coxcygis rigid; too great resistance and rigidity of the uterine orifice, which is a frequent cause; rigidity of the vagina and surrounding soft parts; first child; the mother in years, or long intervals between parturition; the womb too much distended and stretched, its irregular contraction, oblique position; the membranes too soon ruptured by nature or art, and the womb contracting closely before the infant’s shoulders; the membranes rigid; the mouth of the womb strait, callous, inert, irritable; its spasmodic constriction; the bladder distended with urine; hardened feces collected in the rectum; piles; weakness of the mother; tedious labour and fatigue; passions of mind; terror and fear of the event; the mind and spirits broken, irritable; the mother delicate, fat, torpid, plethoric; diarrhœa, profuse evacuations, floodings, convulsions; heat, cordials, strong liquors; improper fatigue and torment during labour, with fruitless and officious endeavours in the accocheur to dilate the parts, and to expedite delivery: the mother’s belly pendulous; tumours and cicatrices blocking up the vagina; rupture of the womb; stone in the bladder. From the fœtus erroneous in position, and different to the natural; in laborious cases with the head detained at the brim, or after its descent into the pelvis: such postures are vertebral, occipital, auricular, mental, oral, facial. Of the preternatural and cross positions authors enumerate; the neck, breast, shoulders, arms, hands, back, loins, buttocks, breech, sides, belly, knees, feet. The fœtus may also be detained by the whole being monstrous in size, or only in particular parts; such as the head, shoulders, belly; the head dropsical; the cranial bones ossified, and not yielding in its descent: the fœtus dead, emphysematous, and blown up with putrid air: the navel string twisted round its neck; two or more fœtuses entangled; twins growing together; deformed monsters.

Having now finished the various processes of parturition, with the perils and difficulties that encompass our immediate exit from the shell, I shall return back to pregnancy, to explore the different inconveniences and maladies that ensue in consequence of that state, both before and after parturition: many of these are merely temporary morbid symptoms; some of them rarely occur; others are attended with trifling danger; and a few only with imminent hazard. We may include all these troublesome symptoms, accidents, and diseases, under the following heads; proceeding progressively from the beginning of conception to the end of parturition, with all its train of evils. These are nausea, indigestion, vomiting, pains in the stomach, acidity, unusual cravings, headach, vertigo, costiveness, difficulty and incontinence of urine, piles, varix, pains in the back and loins, cramp, colick, fainting, œdematous legs and thighs, difficulty and labour in breathing, retroverted womb, extra uterine conception, superfœtation, graviditas perennis, moles and false conceptions, rupture of the womb, protrusion or too low descent of the womb or vagina, miscarriage and abortion, dead fœtus, uterine hemorrhage, convulsions, irregularity of the lochia, including obstruction, suppression or excess, inflammation of the womb, puerperal fever, milk fever, weed, inflammation of the breasts, excess and defect of milk, insanity.

The causes of many of these complaints during the early and latter months of pregnancy, and affecting the head, thorax, stomach, intestines, rectum, bladder, and circulation, originate from sympathetic effects of conception and pregnancy; from plethora, from the bulk, weight, pressure, and irritation of the enlarged womb, and from its stretching, &c.; and either spontaneously, or by proper advice, cease before or after delivery. Several of the puerperal diseases and accidents to be immediately described rarely occur; and some of them are without danger.

Retroverted womb is a very rare accident; where it does occur, it is from the third to the sixth month after conception, when the impregnated womb is thereby prevented from rising above the brim of the pelvis; hence it falls back, and descends into the interior and posterior part of that cavity; its fundus becoming the lower part, and its mouth drawn upwards. The woman feels weight and pressure about that region; is afflicted with tenesmus and colick pains resembling labour; the feces and urine are excreted with difficulty; the finger introduced into the rectum, feels the womb, where, by crowding the whole lower part of the pelvis, it compresses and irritates the organs in that vicinity. Its general causes are imputed to violent muscular exertions, fatigue, distended bladder, obstinate costiveness, capacious pelvis.

Extra uterine conception in the ovarium or fallopian tubes, where the fecundated ovum is stopped in its descent to the womb. Some have burst into the cavity of the abdomen, and formed abscesses in its depending parts; and others have been gradually, and in fragments, discharged by the anus. Superfœtation is a miracle in medicine, and commonly happens where there is a double womb. Of graviditas perennis, there are some extraordinary instances, or of pregnant women advancing to the full period of uterine gestation, about which time the fœtus has died, the womb has not emptied any of its contents, and they have not been excluded until some years after. Moles and false conceptions often assume the semblance of pregnancy, and are generally void of danger. When the fœtus is deprived of life, and dissolved in the early months of pregnancy into a gelatinous state, the placenta and membranes remaining some time in the womb, acquire additional bulk, and are called Moles. Others again are formed merely of inorganic coagulated blood, after menstruation or flooding, and, by stagnation, assume that fibrous compact substance. Moles in general are excluded in a few months: some have grown to an enormous size, to double the weight of the natural fœtus, and remained for years incarcerated in the womb.

Rupture of the womb during parturition, is also a very rare accident, and generally fatal; it occasions severe pains, sudden cessation of the efforts of labour, and of the descent of the fœtus, which, if the laceration is large, by degrees is retracted, and cannot be felt; a considerable change and irregular protuberance is perceivable in the abdomen; the pulse and spirits soon sink, with vomiting, hiccup, convulsions. Inversion of the womb is a very dangerous but uncommon accident, and cannot happen but from gross obstetrical ignorance or rashness. Descent of the womb and vagina may be thrown into the general group of ruptures; of which hereafter. The following comprehend most of the fatal diseases and accidents during the puerperal state.

Abortion and Miscarriage; Uterine Hemorrhage, or Flooding.

Abortion or miscarriage, or premature exclusion of the fœtus, may happen through every month of pregnancy. Early miscarriages between the third and fifth month, though not recorded in the burials, are notwithstanding far more numerous than in the latter months; but are infinitely less hazardous to women. The mature abortives and stillborn, are alone thought deserving of formal interment, and of notice in the registers. To carry a diminutive embryo, a Lilliputian in miniature, to a church-yard, and to bury it with funeral pomp and obsequies, would be ridiculous. In all probability, a very great majority of the registered abortives and stillborn in London, had arrived at or near the full period of uterine maturity. Some miscarriages are sudden, with little or no warning, and with ease; others again are slow. In early gestation, the gelatinous ovum is sometimes excluded several days before the membranes; in other cases, there is a discharge of serum days and weeks before miscarriage. Abortion is usually preceded by nausea, pain in the back and loins, frequent micturition, tenesmus, discharge from the womb of water or of blood. If not in their immediate, yet in their future consequences, miscarriages are much more fatal to puerperal women than appears in the registers.

Floodings are seldom fatal to women before the two or three last months of pregnancy; the gradations of danger increasing to the end of the ninth month, at which period the uterine blood vessels are enlarged, and the hemorrhagick torrent is in proportion. The mouth of the womb also being then less distended than in ordinary parturition, is more difficultly forced open to expedite delivery. Floodings may at intervals, and some weeks precede natural parturition or miscarriage; and after a temporary cessation, are prone to return on the slighted irregularity. Their danger is estimated from the quantity of blood, the suddenness of the torrent, and the effects on the mother; such as paleness, weakness, coldness of the extremities, quick fluttering pulse and respiration, fainting, dejected countenance, weak voice, convulsions: these portend imminent danger to the mother and infant, as do floodings near the full period of gestation, and not accompanied with labour pains. Uterine hemorrhages may occur not only in abortion and natural parturition, but also immediately, or soon after the birth of the infant, and extraction of the placenta. Sometimes also during parturition, when the child’s head blocks up the pelvis, the hemorrhage has been unperceived, and often unsuspected, until after the exclusion of the infant: but the uncommon weakness and faintness of the mother, without any evident causes, might have given the alarm.

The predisposing and occasional causes of abortions and floodings are, frights, terror, anger, violent agitation of mind or body; strong muscular exertions and efforts; external injuries, blows, falls, running, leaping, coughing, crying, fainting, hystericks; plethora; errors in the non-naturals; impetuous flow of blood to the womb, salacity; too much amorous dalliance; too strait lacing and dress; hot close rooms; foul air; disagreeable smells; cravings not gratified; spirituous liquors; abuse of emmenagogue, cathartick, and diuretick medicines; hardened feces and costiveness; piles; extreme irritability of the body and womb; weak hysterical constitution; weak diseased small, contracted, not sufficiently dilatable womb; weakness of the uterine vessels from preceding abortion, irregular menstruation; poor blood; fluor albus; previous injuries during parturition; repetition from habit; the habitual tendency towards menstruation every month; hereditary; acute or chronic diseases; morbid adhesion of the placenta, and also coalescence with the womb from previous inflammation; partial separation of the placenta; rupture of the vessels on the surface of the placenta; separation of the false chorion from the womb; adhesion of the ovum or placenta to the neck of the womb; blights of the fœtus, scarcity of nourishment in the womb, its violent efforts, monstrous size, its diseases in the womb; rupture of the navel string, a noose formed upon it; long compression of the infant’s head or navel string during parturition; injuries by the hands or instruments of the accocheur; a dead fœtus.

The signs of a dead fœtus are in the mother subsidence, softness, and coldness of the abdomen and breasts, sickness, faintness, shiverings, cold sweats, sensation of a heavy tumour within the belly, cessation of the motion of the fœtus after quickening, putrid discharge from the vagina, evacuation of the waters, dejected languid countenance: if, during actual labour, the mother perceives no motion of the infant, and is cold; no pulsation can be felt between the interstices of the infant’s parietal bones, nor at its wrist, nor navel string; its outer skin easily peels off; it has a lifeless coldness; and there is a cadaverous smell and fetid discharge from the vagina.

Convulsions

may happen before, during, and after delivery. They resemble epilepsy, with froth at the mouth, distortion of the countenance and body; and are a much more terrific and frightful spectacle than hysterical and nervous spasms. In the advanced state of pregnancy, convulsions are still more dangerous, and, like the sudden impetuosity of a whirlwind, sometimes close the fatal scene; especially if at the same time a violent pain is felt at the stomach. The plethoric and robust are not exempt from this tremendous assailant; but the hysterical and delicate are the most frequent victims. The predisposing and occasional causes are morbid sensibility; profuse uterine hemorrhage; want of due quantity of blood; plethora; frights; low spirits; fear, dread, surprize, and sudden emotion and agitation of mind at this critical period; dead fœtus.

Puerperal Fever,

or Peritonitis, commonly alledged to be peculiar to women after delivery, has been dignified by the moderns, from its danger and fatality, with a generic name: happily for the fair sex, it does not often occur: sometimes it is epidemic, from some unknown quality of the atmosphere; and in such circumstances a considerable number of puerperal women are afflicted at the same time. It generally attacks one or two days, but sometimes a few hours after delivery; and rarely later than the sixth day. The assault is sudden and violent, with shivering, headach, especially in the temples and eyes, giddiness, nausea, sickness of the stomach, and vomiting of bile in large quantity, pains darting through the lower region of the abdomen, and reaching up to the stomach, with extreme sensibility and tenderness, on being pressed with the hand, or by coughing or vomiting: the pain is felt between the stomach and navel, and is higher than in the inflammation of the womb; there is unusual languor and weakness, anxiety, oppression, and load of the spirits, impaired strength, so as not to be able to render themselves any assistance in bed; no refreshing sleep, sometimes delirium; the pulse is always extremely rapid, but various in strength during the revolution of the febrile paroxisms, that is, of the cold and hot fit. When the vomiting abates, it is succeeded by a profuse diarrhœa, accompanied with colick, tormenting gripes, tenesmus. In some, the abdomen begins to swell early. At the beginning the symptoms have an inflammatory appearance; but after a very few days change undisguisedly into the nervous and putrid type, and sometimes with miliary eruption. Often neither the lochial discharge, nor the milk, are interrupted; and it has been observed to ensue even after easy labours.

The puerperal Fever will be affected and diversified by different constitutions and temperaments, whether robust, plethoric, or delicate; by the quantity of the lochial discharge, the putrid atmosphere in the sick room, the medical treatment, the state of the atmosphere and seasons, and morbid quality of the prevailing febrile epidemick. Between five and fifteen days terminates the event in recovery or death. It is always most fatal when most epidemick, and the sooner it attacks after delivery. In some of our London hospitals, one half of the women ill of this fever have died; in others, one of seven. The crisis by discussion is followed by diarrhœa, by a serous or purulent transudation from the omentum or mesentery, into the abdomen; and from this cause sometimes consumption and dropsy. Some, even after a favourable crisis, have recovered slowly. When gangrene is the direful event, it is commonly within four or six days from the attack, and is known by the usual symptoms.

The predisposing and occasional causes are, a peculiar noxious constitution of the atmosphere; errors in the non-naturals; anxiety of mind; hot cordial regimen; heated unventilated rooms after delivery, and impure air; hence miliary eruptions and profuse sweats. The immediate cause is generally ascribed to inflammation of the omentum, mesentery, or peritoneum, and the sudden contraction of the womb after delivery, dragging and tearing down with it these membranes. But it merits the most serious and mature investigation, whether to employ the remedies accommodated to inflammatory, or to nervous and putrid fever. We know that purulency in the abdomen and thorax is likewise found in the putrid fever of the West Indies.

After-Pains; Weed, Milk-Fever; Inflammation of the Breasts,

are far less formidable foes than the preceding. After parturition, women are sometimes afflicted for some days with pains resembling colick; both in torture and severity extremely harassing. The causes are, the continued and sudden contraction of the womb towards its natural dimensions; fragments of the placenta or membranes, or of clotted blood in the womb; injuries done to the fibres of the womb during parturition; violent extension of the suspensory ligaments; inflammation and irritation of the womb, or its neck: tender state of the intestines; flatulence; flatulent food; suppression of the lochia; errors in the non-naturals; a second child. Weed, or ephemera, sometimes occurs, and is the most simple and innocent species of fever; it is preceded by lassitude, slight wandering pains; a succession of shivering, heat and sweat, resembling an intermittent paroxism; and in the space of a few hours, or at the utmost days, the fever disappears. The causes are some errors in the non-naturals. Milk fever: during pregnancy and parturition the breasts sympathize greatly with the womb. This natural fever begins three or four days after delivery, with shivering and heat, pain, distention and throbbing of the breasts, shooting to the armpits, restlessness; after twenty-four hours, commonly terminating by sweat, diarrhœa, eruption of milk: the usual quantity of this nutritive fluid is from two to three pints daily. In the preceding puerperal stage, inflammation of one, but rarely of both breasts, is a frequent affliction, varying in degree and severity: its symptoms are local redness and swelling, burning heat, extreme tenderness, throbbing; and is terminated by discussion, frequently by suppuration; sometimes by scirrhus. The causes are impetuous rush of milk to the breasts; excess of milk; not suckling; milk obstructed in the breasts or lactiferous tubes; suckling too soon; obstructed lochia; cold and obstructed perspiration.