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.