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.
_Irregularity of the Lochia_, comprehending excess, obstruction,
and suppression. After delivery, there is generally a gush of red
blood, from about a half to two pounds. The mother is then weak and
infirm, from the fatigue and efforts of parturition; from the great
evacuation and diminution of the womb and abdomen; from the loss of
blood; from the agitation and anxiety of mind; and from the increased
irritability: and, according to certain states of the air and seasons
not yet explained, women are then more than at any other time prone
to fevers. In most cases the placenta is expelled in ten, twenty,
or thirty minutes after the infant. Afterwards, the orifices of the
uterine vessels continue to discharge red blood, which gradually
becomes thin and serous, and even in some degree purulent. This
discharge named _Lochia_, is various in duration and quantity, from
two to ten ounces daily, and, gradually decreasing, in about ten or
twenty days is dried up; nature having then restored the womb to its
natural size: and at this stage all immediate puerperal danger is
escaped. Sometimes there are great variations in the lochial duration
in different women: in some, they cease after a few days; in most,
after two or three weeks; and in a few others, not until after one or
two months: the duration and quantity being varied by climate, season,
constitution, mode of life, and state of the breasts. Lochial excess is
determined more by the morbid effects than the absolute quantity; such
as weakness, paleness, dejected countenance, feeble voice and pulse,
fainting, convulsions. Or in its consequences it may more slowly sap
the pillars of health, and occasion consumption or dropsy. Obstruction
and suppression of the lochia is much more frequent and dangerous than
excess. Most of the usual complaints after delivery, says Smellie,
originate from obstruction of the lochia, or of milk: the former is
accompanied with pain of the back and loins, pudenda, and groins;
heat, shivering, hard quick pulse, restlessness; sometimes colick and
diarrhœa, and difficult oppressed perspiration.
_Inflammation of the Womb_ begins generally between the fourth and
ninth day after delivery, and commonly with retention of the lochia:
with fever, heat, and pain about the uterine region, elevation and
hardness of the abdomen below, with tenderness and acute sensibility
on pressure, irritation to urine and stools, colick, intense headach,
strong full pulse. The whole, or different parts only, of the womb
may be inflamed, whence the contiguous viscera of the pelvis will
be differently affected. Where the inflammation is not violent, the
crisis is about the fourth or seventh day from the attack; but if
severe, may be protracted to the ninth, eleventh, and fourteenth,
and be then discussed with some sensible evacuation, by perspiration
and sweat, urine, diarrhœa, lochial discharge, or current of milk
from the breasts; or may terminate fatally in gangrene, delirium, and
convulsions.
The predisposing and occasional _causes_ of irregularity of the lochia,
and of uterine inflammation, are, of Excess, grumous clots of blood in
the womb; violence done to the womb during parturition; retention of
the placenta, or part of it; great weakness; passions of mind; a second
child; spasm; repulsion of milk from the breasts; too early and violent
motion or walking about; diseased state of the womb; inverted womb;
errors in food, drink, passions of mind, excretions, &c. Of Obstruction
and Suppression; clots of blood in the vagina; cold admitted to the
naked body, either externally or internally; cold rooms, cloaths, and
drink; obstructed perspiration; impure air and close heated rooms;
passions of mind; hystericks; errors in the non-naturals, diarrhœa.
Of inflammation of the womb, suppression of the lochia; external
violence; falls; rude extraction of the placenta; morbid adhesion of
the placenta; miscarriage; too tight bandages round the belly: its
termination is by discussion or gangrene.
_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.
* * * * *
_Infant diseases_ every where furnish a vast supply to the gloomy
realms of Pluto; and this calamity is infinitely aggravated by the
noxious atmosphere of cities and towns. At birth, an infant is not
only ushered into a new world, but every function of its frail body
undergoes new and sudden changes. From the human oven of 96 degrees
of heat, it is launched into a variable climate of heat and cold.
A new element of many thousand pounds weight then presses upon the
surface of its body. This atmospherick fluid, adulterated in cities
with innumerable impurities and feculencies is drawn into its lungs:
its diaphragm and muscles of respiration then begin to act, the lungs
expand, and the respiration commences. The passage between the auricles
of its heart and arterial duct are gradually closed up; the sphere
of the circulation is extended; the whole current of blood in its
frequent revolution hourly, passes through the lungs; the circulation
through the navel-string, and through which it had till then drawn its
principal nourishment, instantly ceases: food, for the first time,
begins to be taken in by its mouth; the digestive, with all the
numerous secretory and excretory organs, then begin to perform their
different offices; the tender creature is exposed to sounds, in a few
days to light; the bones at the superior part of its head gape, and
the brain is there defended by skin only; its head, belly, liver, and
lymphatic glands, are large, and its extremities slender; the fetal
brain is destitute of ideas; its bones are little more than gristles
and cartilages; its muscles are soft, flabby, and without swell or
expression; the greatest part of its time is spent in a state of
inactive vegetation; it is unable for several months to support its
own weight, or to take nourishment, and is then the most feeble and
helpless of all the animal creation. With such delicate machinery,
it has soon to encounter pain and disease; the assaults of internal
and external enemies; when its crazy beams and bolts are easily shook
asunder in the first storm.
The acute diseases of early infancy; that is, under two years of
age (small pox, measles, and a few others excepted) are in the
London registers, principally accumulated into two aggregate heaps,
_Convulsions and Teething_: the former of which forms a dreary
catalogue of astonishing magnitude in London funerals; amounting
to nearly one third of the whole mortality in the metropolis. But
convulsions and teething are terms too indefinite. Every infant
disease, not immediately obvious to the senses, is thrust into these
two articles by the ignorant reporters. If we consider the term
scientifically, convulsions, in multitudes of cases, convey no more
intelligence of the nature of the disease, than if they had said the
child died from want of breath. Let us therefore examine, whether the
collected observations of medical authors will not illuminate many
dark and defective parts of the publick registers, respecting infant
mortality. Infants are exempt from a multitude of the acute and chronic
diseases of adults: they rarely suffer so early in life from hereditary
diseases, cares, passions of mind, painful impulses of retentive
memory, severe study, intemperance, hard labour, the inclemency
and vicissitudes of the seasons, and so on. The principal diseases
of infancy may be comprehended under the following: convulsions,
inward spasms and tetanus, colick, vomiting, acidity, indigestion,
flatulence, diarrhœa and gripes, thrush, dentition, hectic fever and
atrophy, rickets, scald head, rash, dropsy of the head and spine,
inguinal ruptures; together with small pox, measles, hooping cough,
worms, and a few others already described.
As infants cannot by speech express their pain, we are too often
under the necessity to guess at their complaints by physiognomy,
gestures, and dumb signs: these are principally manifested by nausea,
indigestion, vomiting, flatulence, refusal of food, or the breast,
diarrhœa and its different colour and consistence, restlessness, cries,
shrieks, agitation and contraction of the lower extremities, disturbed
sleep, injured respiration, cuticular eruptions, pustules, and ulcers.
In infancy the pulse and urine are precarious symptoms: their arterial
pulsations in fevers are sometimes so rapid, that the most minute
divisions of time in horological instruments, cannot keep pace with
them.