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diff --git a/.gitattributes b/.gitattributes new file mode 100644 index 0000000..d7b82bc --- /dev/null +++ b/.gitattributes @@ -0,0 +1,4 @@ +*.txt text eol=lf +*.htm text eol=lf +*.html text eol=lf +*.md text eol=lf diff --git a/LICENSE.txt b/LICENSE.txt new file mode 100644 index 0000000..6312041 --- /dev/null +++ b/LICENSE.txt @@ -0,0 +1,11 @@ +This eBook, including all associated images, markup, improvements, +metadata, and any other content or labor, has been confirmed to be +in the PUBLIC DOMAIN IN THE UNITED STATES. + +Procedures for determining public domain status are described in +the "Copyright How-To" at https://www.gutenberg.org. + +No investigation has been made concerning possible copyrights in +jurisdictions other than the United States. Anyone seeking to utilize +this eBook outside of the United States should confirm copyright +status under the laws that apply to them. diff --git a/README.md b/README.md new file mode 100644 index 0000000..39cf27b --- /dev/null +++ b/README.md @@ -0,0 +1,2 @@ +Project Gutenberg (https://www.gutenberg.org) public repository for +eBook #66506 (https://www.gutenberg.org/ebooks/66506) diff --git a/old/66506-0.txt b/old/66506-0.txt deleted file mode 100644 index 72f72bb..0000000 --- a/old/66506-0.txt +++ /dev/null @@ -1,2301 +0,0 @@ -The Project Gutenberg eBook of Observations on Abortion, by John Burns - -This eBook is for the use of anyone anywhere in the United States and -most other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms -of the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you -will have to check the laws of the country where you are located before -using this eBook. - -Title: Observations on Abortion - Containing an account of the manner in which it is accomplished, - the causes which produced it, and the method of preventing or - treating it - -Author: John Burns - -Release Date: October 10, 2021 [eBook #66506] - -Language: English - -Character set encoding: UTF-8 - -Produced by: Richard Tonsing and the Online Distributed Proofreading Team - at https://www.pgdp.net (This file was produced from images - generously made available by The Internet Archive) - -*** START OF THE PROJECT GUTENBERG EBOOK OBSERVATIONS ON ABORTION *** - - - - - OBSERVATIONS - ON - ABORTION. - CONTAINING - An Account of the Manner in which it is accomplished, the Causes which - produced it, and the Method of preventing or treating it. - - - ∽∽∽∽ - - BY JOHN BURNS, - LECTURER ON MIDWIFERY, AND MEMBER OF THE FACULTY OF PHYSICIANS AND - SURGEONS IN GLASGOW. - - ∽∽∽∽ - - - _LONDON_: - PRINTED FOR LONGMAN, HURST, REES, AND ORME, - PATER-NOSTER ROW. - - 1806. - - - - - TO - - THE GENTLEMEN - - WHO ATTENDED THE AUTHOR’S - - LECTURES - - IN THE SESSION - - 1802–3, - - THIS BOOK IS INSCRIBED, - - AS A - - GRATEFUL AND AFFECTIONATE - - REMEMBRANCE - - OF THE - - VERY FLATTERING COMPLIMENT - - WHICH THEY - - BESTOWED UPON - - HIM. - - - - - OBSERVATIONS - ON - ABORTION. - - -[Illustration] - -By abortion is generally understood the expulsion of the contents of the -gravid uterus, at a period of gestation so early as to render it -impossible for the fœtus to live. It is an accident or disease which is -very frequent in its occurrence, which is always attended with -disagreeable circumstances, and which, although it seldom prove -immediately fatal, may yet be productive of much mischief at a future -time. The consideration, therefore, of the manner in which it takes -place, of the causes which give rise to it, and of the most likely means -of preventing it, or of obviating those unpleasant symptoms which -accompany it, must form a subject of very great importance to the -medical student. But before proceeding to consider these points, it will -be necessary to understand the structure and formation of the ovum, -which I shall, therefore, first of all explain. - - ∽∽∽∽ - - - _Of the Formation of the Ovum._ - -The human uterus, in the unimpregnated state, consists of a succulent -substance, in which we may perceive fibres running in every direction. -In the interstices of these we find a serous fluid, which can easily be -squeezed out. By injecting the vessels finely with size or mercury, we -observe them to be numerously intermixed with the fibres, but very -small. A portion of these vessels follow an irregular course toward the -inner surface or cavity of the uterus, and open there upon the membrane -which lines it. At the menstrual period the vessels enlarge or dilate a -little, and their orifices become more distinct over the surface of the -cavity, as may be ascertained by inspecting those who have died at this -time. Sometimes a slight temporary serous secretion precedes the flow of -the menses, and succeeds it. More frequently the vessels yield a bloody -fluid at once, which continues a certain number of days.—When -impregnation takes place, the vessels enlarge still more; and we can -observe small trunks forming in the substance of the uterus, the largest -of which are at the two sides where the spermatic and hypogastric -branches meet[1]. The old fibres are more separated, and new ones added, -especially at the fundus.—The quantity of interstitial fluid is also -increased, so that the uterus becomes manifestly softer. The vessels, as -they enlarge, tend to the uterine cavity; but instead of opening there, -and yielding a fluid, as in menstruation, they either elongate -themselves, or, which is more probable, form new and very delicate -vessels, which project from the inner surface of the uterus, giving it -an appearance as if covered with down. This takes place first and -chiefly at the fundus, and, in a slighter degree, immediately above the -narrow cervix, whilst the intermediate body remains still quite smooth. - -These vessels project for about a line in length, at right angles, from -the surface which yields them; and as they consist of arteries and -veins, the down, or efflorescence, which they form, has, after death, a -striated or radiated appearance, the empty arteries being white, the -fuller veins black or red. These vessels constitute the outer layer of -the decidua, or what may be called decidua striata, although the stria -be obliterated as gestation advances. - -Almost immediately after the formation of these primary vessels, they -secrete from their extremities a membrane, or rather an irregular tissue -of vessels, which, on account of their origin, may be called secondary. -These assume a direction at right angles to those which formed them, so -that they cross the stria or primary vessels, and therefore any body -coming down through the first set of vessels, must, before it can get -into the cavity of the uterus, either rupture this secondary organ, or -push it before it. It is in this manner that the inner layer of decidua -is formed, part of which is afterwards protruded before the vesicular -ovum, constituting decidua reflexa, or protrusa. - -The primary vessels adhere pretty closely together at their roots, but -are more loose or separated at their termination. They are at first only -yielded by the fundus, and in a small degree by the surface, immediately -above the cervix, whilst the cervix itself produces from the lacunæ, -which are increased in magnitude, a jelly, which sometimes fills up the -os uteri completely; at other times there is only a small quantity -formed in the cervix, leaving the os uteri quite patent. The inferior -part of the uterine surface, which yields the primary vessels, is not a -quarter of an inch in breadth; and the cavity being there small and -narrow, the vessels from the opposite sides soon come in contact, and -intermix without forming any secondary vessels. This portion may be -called the cervical efflorescence. - -The secondary vessels are very different from the primary; for, whilst -the latter are short, straight, and parallel to each other, the former -are more extended, intermix, and ramify together, so as to form an -irregular tissue or sheet of vascular substance, the fibres or vessels -of which assume a direction at right angles to the down or primary -vessels which formed them. This direction seems to be very naturally -produced by the weight of the secondary vessels, which makes them hang -down or point to the os uteri. Very soon we can perceive ragged -irregular processes, hanging into the cavity of the uterus, and -extending toward the cervix, so that this layer of decidua presently -appears to consist of a number of torn floating membranes, like portions -of spiders’ webs, pendulous in the uterine cavity; but nearer -examination shows that there has been no laceration, the margins being -smooth and well defined. These I would call the processes of the decidua -interna. - -Such is the structure of the decidua externa and interna, at three weeks -or a month after impregnation; and at this period no fœtus is in the -uterus. In one case I detected the vesicular ovum in the tube. It was -about half way betwixt the two extremities, was rather smaller than a -full-grown pea, and contained a little fluid. In another case I found it -still in the ovarium, covered by the fimbriated extremity of the tube. -By puncturing the peritoneal coat of the gland, the vesicle escaped. - -It has been the general opinion, since the time of Dr. Hunter, that the -decidua extended a little way into the tube; and on his authority I -stated this to be the case in an account which I formerly published. By -careful examination, I am now convinced that this is not the case. My -brother, in his dissections, even thought that the uterine extremity of -the tube was less changed in point of vascularity, than any other part -of it. - -When the fœtus does descend into the uterus, it is contained in a double -membrane. The internal one is the amnion, and possesses no distinct -vessels. The external one is the chorion, and is from the first -vascular, and soon becomes so much so, that its vessels have by some -been described as forming a distinct tunic. - -From what has been said, it will be evident, that, when this vesicle -does reach the uterus, it will be received amongst the primary vessels -which will surround it, whilst the secondary vessels, or decidua -interna, will lie before it, and prevent any communication betwixt it -and the uterine cavity. But it cannot remain long thus; for, in -proportion as the vesicular part of the ovum increases, it will push the -decidua interna before it, and encroach upon the cavity of the uterus. -This circumstance, together with the intimate connection formed betwixt -the vessels of the chorion and those of the decidua, with the consequent -production of a placenta, I have already very fully detailed in a former -publication, to which I refer[2]. - -When the ovum descends, and the subsequent changes are beginning to take -place, the body of the uterus comes also to form decidua; for I have -formerly said, that, until the fœtus comes into the uterus, the fundus -alone yields this production. At the same time, the processes of the -decidua interna elongate still more, and, together with those which are -now formed by the portion produced by the newly-formed decidua externa -(for additional primary vessels imply additional secondary ones) at the -lower part of the uterus, will come to fill up all the intervening space -betwixt the bottom of the chorion or decidua reflexa and the cervical -efflorescence; so that, by the end of the second or beginning of the -third month, the cavity of the uterus is quite filled, and we have the -ovum perfectly organized. We have the fœtus inclosed in its membranes, -and swimming in water; we have the placenta thick and well formed, and -large in proportion to the membranes; we have the decidua reflexa -distinctly seen, and the lower part of the uterus filled with the two -layers of decidua, and the processes of the internal one. - -If at this time we take the ovum, composed of all these different parts, -out of the uterus; or, if we cut off the face of the uterus, and remove -the decidua from the front of the membranes, we shall see at the upper -part the placenta and membranes like an old fashioned watch, the -placenta resembling the case, and the membranes (when the decidua is -taken off) the glass of the watch[3]; then, at the lower part of the -membranes, we see the remains or margins of the decidua reflexa, which -has been removed to shew the chorion; whilst, still lower down, we -observe the decidua externa, and the processes of the interna, filling -up the cervix and inferior part of the body of the uterus, forming a -kind of firm stalk to the globe above. This stalk is thick, so as to -occupy all the lower part of the uterus; but the layers and processes, -furnished by the different sides, do not adhere when they meet in the -axis of the uterus; but we have always a small canal or perforation -leading up in the axes of the uterus from the cervical efflorescence, or -the gelatinous plug, to the bottom of the decidua reflexa. - -In proportion as the membranes enlarge and elongate, the decidua reflexa -gradually protrudes before them down this canal, until at last it -reaches the bottom; or, in other words, the membranes come to occupy all -the uterine cavity. - - - _Of the Manner in which Abortion takes place._ - -The process of gestation may be stopped, even before the fœtus, or -vesicular part of the ovum, has descended into the uterus, and when only -the primary vessels are formed. In this case, which occurs within three -weeks after impregnation, the symptoms are much the same with those of -menorrhagia. There is always a considerable, and often a copious -discharge of blood, which coagulates or forms clots. This is accompanied -with marks of uterine irritation, such as pain in the back and loins, -frequently spasmodic affections of the bowels, and occasionally a slight -febrile state of the system. In plethoric habits, and when abortion -proceeds from over-action, or hemorrhagic action of the uterine vessels, -the fever is idiopathic, and precedes the discharge. - -In other circumstances it is either absent, or, when present, it is -symptomatic, and still more inconsiderable, arising merely from pain or -irritation. As the primary vessels are very small, and are soon -displaced, they cannot be detected in the discharge. Nothing but -coagulum can be perceived; and this, as in other cases of uterine -hæmorrhage, is often so firm, and the globules and lymph so disposed, as -to give it, more especially if it have been retained for some time about -the uterus or vagina, a streaked or fibrous appearance, which sometimes -gives rise to a supposition, that it is an organized substance. The -discharge does not cease, when the primary vessels are destroyed, but -generally continues until the small vesicle passes out of the fallopian -tube. Then it stops, and an oosing of serous fluid finishes the process. - -The only interruption to the discharge in this case of abortion, -proceeds from the formation of clots, which, however, are soon -displaced. Women, if plethoric, sometimes suffer considerably from the -profusion of the discharge; but, in general, they soon recover. - -When the secondary vessels are formed, the symptoms are still pretty -much the same; but if the vesicle have descended into the uterus, they -are somewhat different. We have an attempt in the uterus to contract, -which formerly was not necessary; we have pains more or less regular in -the back and hypogastric region; we have more disturbance of the -abdominal viscera, particularly the stomach. The discharge is copious, -and small bits of fibrous substance can often be observed[4]. - -Sometimes, when the vesicle has come into the uterus, before abortion -takes place, it may be detected in the first discharge of blood, and -will be found to be streaked over with pale vessels, giving it an -appearance as if it had been slightly macerated. When all the contents -are expelled, a bloody discharge continues for a few hours, and is then -succeeded by a serous fluid at this time; and, in later abortion, if the -symptoms come on gradually, we may sometimes observe a gelatinous matter -to come away before the hæmorrhage appears. - -If the uterus have been filled up, as in the beginning of the third -month, the vesicle never escapes first; but we have for some time a -discharge of blood, accompanied or succeeded by uterine pain. Then the -inferior part or stalk of the ovum is expelled, gorged with blood, and -afterwards the upper part equally injured. Sometimes the whole comes -away at once and entire; but this is rare. As considerable contraction -is now required in the uterus, the pains are pretty severe. The -derangement of the stomach is also greater than formerly, giving rise to -sickness or faintness, which is a natural contrivance for abating the -hæmorrhage. - -When the membranes come to occupy more of the uterus, and a still -greater difference to exist betwixt the placenta and decidua, we have -again a change of the process; we have more bearing down pain, and -greater regularity in its attack; we have a more rapid discharge, owing -to the greater size of the vessels; but there is not always more blood -lost now than at an earlier period, for coagula form readily from -temporary fits of faintness and other causes, and interrupt the flow -until new and increased contraction displaces them. Often the membranes -give way, and the fœtus escapes with the liquor amnii, whilst the rest -of the ovum is retained for some hours or even days, when it is expelled -with coagulated blood separating and confounding its different parts or -layers. At other times the fœtal and maternal portions separate, and the -first is expelled before the second, forming a very beautiful -preparation. In some rare instances we find the whole ovum expelled -entire, and in high preservation. After the expulsion, the hemorrhage -goes off, and is succeeded by a discharge somewhat resembling the -lochia. - -In cases of twins, after one child is expelled, either alone or with its -secundines, the discharge sometimes stops, and the woman continues -pretty well for some hours, or even for a day or two, when a repetition -of the process takes place, and if she have been using any exertion, -there is generally a pretty rapid and profuse discharge. This is one -reason, amongst many others, for confining women to bed for several days -after abortion. - -There is generally, for a longer or shorter time before the commencement -of abortion, a pain and other irregular actions in the neighbouring -parts, which give warning of its approach before either discharge or -contraction take place, unless when it proceeds from violence, in which -case the discharge may instantly appear. This is the period at which we -can most effectually interfere for the prevention of abortion. - -I need not be particular in adding, that we are not to confound these -symptoms with the more chronic ailments which accompany pregnancy. -Similar disturbances in the action of the neighbouring parts are very -commonly found to precede labour at the full time; and even then we may, -by proper means, postpone or retard expulsion for some hours or days. - -A great diversity obtains in different instances with regard to the -symptoms and duration of abortion. In some cases the pains are very -severe and long continued; in others, short and trifling. Sometimes the -hæmorrhage is profuse and alarming: at other times, although -circumstances may not be apparently very different, it is moderate or -inconsiderable. Often the sympathetic effects on the stomach and bowels -are scarcely productive of inconvenience, whilst in a greater number of -instances they are very prominent symptoms. - -I may only add, that, _cæteris paribus_, we shall find that the farther -that the pregnancy is advanced beyond the third month, and the nearer it -approaches to the end of the sixth, the less chance is there of abortion -being accompanied, but the greater of its being succeeded, by nervous -affection. - -As there is a diversity in the symptoms, so is there also in the -duration of abortion; for, whilst a few hours in many, and not above -three days in the majority of cases, is sufficient to complete the -process, we find other instances in which it is threatened for a long -time, and a number of weeks elapse before the expulsion take place. - - ∽∽∽∽ - - - _Of the Causes giving rise to Abortion._ - -Abortion may very properly be divided into accidental and habitual. The -exciting causes of the first class may, in general, be easily detected; -those giving rise to the second are often more obscure; and, without -great attention, the woman will go on to miscarry, until either -sterility, or some fatal disease, be induced. - -In many cases there can be no peculiar pre-disposing cause of abortion: -as, for instance, when it is produced by blows, rupture of the -membranes, or accidental separation of the decidua: but when it occurs -without any very perceptible exciting cause, it is allowable to infer, -that some pre-disposing state exists; and this generally consists in an -imperfect mode of uterine action, induced by age, former miscarriages, -and other causes. - -It is well known, that women can only bear children until a certain age; -after which, the uterus is no longer capable of performing the action of -gestation, or of performing it properly. Now, it is observable, that -this incapability or imperfection takes place sooner in those who are -advanced in life, before they many, than in those who have married and -begun to bear children earlier. Thus we find, that a woman who marries -at forty, shall be very apt to miscarry; whereas, had she married at -thirty, she might have born children when older than forty; from which -it may be inferred, that the organs of generation lose their power of -acting properly sooner, if not employed, than in the connubial state. - -The same cause which tends to induce abortion at a certain age in those -who have remained until that time single, will also, at a period -somewhat later, induce it in those who have been younger married: for in -them we find, that, after bearing several children, it is not uncommon -to conclude with an abortion; or, sometimes after this incomplete -action, the uterus, after a considerable time, recruits, as it were, and -the woman carries a child to the full time, after which she ceases to -conceive. - -In the next place, I mention that one abortion paves the way for -another, because, setting other circumstances aside, it gives the uterus -a tendency to stop its action of gestation at an early period after -conception, and therefore it is difficult to make a woman go to the full -time, after she has miscarried frequently. - -We also find that an excessive or indiscriminate use of venery either -destroys the power of the organs of generation altogether, making the -woman barren, or it disposes to abortion, by enfeebling these organs. - -Some slight change of structure in part of the uterus, by influencing -its actions, may, if it do not prevent conception, interfere with the -process of gestation, and produce premature expulsion. If, however, the -part affected be very small, and near the os uteri, it is possible for -pregnancy to go on to the full time. Indeed, it generally does go on, -and the labour, as may be foreseen, will be very tedious; but the -operation of cutting the indurated os uteri, which has been proposed, is -seldom necessary. - -I have known one instance, in which a very considerable part of the -uterus, I may say almost the whole of it, was found, after delivery, to -be extremely hard, and nearly ossified: but this state could not have -existed before impregnation took place, for I cannot conceive that so -great a proportion of the uterus should have been originally diseased, -and yet that conception, and its consequent actions, should take place; -but there is no difficulty in supposing, that, during the enlarging of -the uterus, the vessels deposited osseous or cartilaginous matter, -instead of fibres. In this case, it is evident that the delivery must be -instrumental, owing to the deficiency of fibres, and recovery can seldom -take place. Often we find this morbid action affect the placenta, -instead of the uterus; but this is not dangerous. - -A general weakness of the system, which must affect the actions of the -uterus, in common with those of other organs, is likewise to be -considered as giving rise to abortion, though not so frequently as was -at one time supposed. The uterus is not only affected by the general -conditions of the system, more especially with regard to sensibility, -and the state of the blood-vessels; but it likewise sympathizes with the -principal organs, and may undergo changes in consequence of alterations -in their state. - -Thus we often find that loss of tone, or diminished action of the -stomach, produces amenorrhœa; and it may also on the same principle -induce abortion; on the other hand, the action of the uterus may -influence that of other viscera, as we see in pulmonary consumption, -which is sometimes suspended in its progress during pregnancy; or, if -there be any disposition in an organ to disease, frequent abortion, -partly by sympathy betwixt the uterus and that organ, and partly by the -weakness which it induces, and the general injury which it does to the -system at large, may excite the irregular or morbid action of the organ -so disposed. - -As the action of the uterus is increased during pregnancy, it must -require more nervous energy; but the size of the nerves of the uterus is -not increased in proportion to the action; we must therefore depend for -the increased supply upon the trunks, or larger portion of nervous -substance, from which they arise, for we well know that the quantity of -energy expended in an organ, does not depend upon the size of the nerve -in its substance, but on the trunk which furnishes it. Whenever action -is increased in an organ, it must either perish, or the larger nerve -must send the branches more energy, for the branches themselves cannot -form it, their extremities being only intended for expending it: from -which it follows, that in pregnancy there must be more energy sent to -the uterus, and less to some other part. - -This is the case with all organs whose action is increased, other parts -being deprived in proportion as they are supplied, except when -irritation raises general action above the natural degree; the -consequence of which is, that the power is not sufficient for the -action, which becomes irregular, and the system is exhausted, as we see -in febrile conditions[5]. - -There being increased action of the uterus in gestation, requiring an -increased quantity of energy to support it, we find that the system is -put _pro tempore_ into an artificial state, and obliged either to form -more energy, which cannot be so easily done, or to spend less in some -other part. Thus the function of nutrition, or the action by which -organic matter is deposited, in room of that which is absorbed, often -yields, or is lessened, and the person becomes emaciated, or the stomach -has its action diminished, or the bowels producing costiveness and -inflation. If no part give way, and no more energy than usual be formed, -gestation cannot go on, or goes on imperfectly. Hence some women have -abortion induced by being too vigorous; that is to say, all the organs -persist in keeping up their action in perfection and complete degree. - -A tendency to abortion also results from a contrary cause, from organs -yielding too readily, allowing the uterus to act too easily. In this -state it is as liable to go wrong, as the general system is when it is -at the highest degree of action, compatible with health, the most -trifling cause deranges it. Thus, sometimes, the intestines yield too -readily, and become almost torpid, so that a stool can with difficulty -be procured. Here costiveness is not a cause of abortion, though it may -be blamed. In like manner, the muscular system may yield and become -enfeebled; and in this instance debility is accused as the cause of -abortion, although it be, indeed, only an effect of too much energy -being destined for the uterus. In this case, the woman is always weaker -during menstruation and gestation than at other times. - -Now this is not a piece of idle speculation, but is of much practical -importance, especially in considering the means of correcting habitual -abortion; and much attention should be paid to the state of the -principal organs in the body; for, if we confine our attention merely to -the uterus, we shall often fail when otherwise we might succeed; and it -will be necessary to remember, that the chain of sympathies in gestation -is often extensive and complicated. - -The state of the stomach, for example, may give rise to head-ach, -tooth-ach, &c. and often it is dangerous suddenly to remove these remote -effects. It throws too much energy to the uterus; its action is too much -exerted; contraction and abortion take place: but in the unimpregnated -state, the removal of these effects may, on the contrary, be useful: -thus the pulling of a pained tooth sometimes speedily produces the -return of the menses in cases of obstruction. - -If the neighbouring parts do not accommodate themselves to the changes -in the direction of energy, and act in concert with the uterus, their -action becomes irregular, and consequently painful. In this case the -uterus may have its just degree of power and action; but other parts may -not be able to act so well under the change of circumstances. This is -chiefly the case in early gestation, for, by time, the parts come to act -better. It often gives rise to unnecessary alarm, being mistaken for a -tendency to abortion; but the symptoms are different. The pain is felt -chiefly at night, a time at which weakened parts always suffer most; it -returns pretty regularly for several weeks, but the uterus continues to -enlarge, the breasts to distend, and all things are as they ought to be, -if we except the presence of the pain. This may be alleviated sometimes -by anodynes, but can only be cured by time, and avoiding, by means of -rest and care, any additional injury to parts already irregular and -ticklish in the performance of their actions. If this be neglected, they -will re-act on the uterus at last, and impede its function. - -Even although the different organs, both near and remote, may have -accommodated themselves to the changes in the uterine action, in the -commencement of gestation, the proper balance may yet be lost at a -subsequent period; and this is most apt to take place about the end of -the third, or beginning of the fourth month, when the uterus is rising -out of the pelvis; and hence a greater number of abortions take place at -that time than at any other stage of pregnancy. There is from that time, -to the period of quickening, a greater susceptibility in the uterus to -have its action interrupted, than either before or afterwards, which -points out the necessity of redoubling our vigilance in watching against -the operation of any of the causes giving rise to abortion from the -tenth to the sixteenth week. - -If the uterus, in its unimpregnated state, become very torpid, as in -some cases of amenorrhœa, the abdominal muscles sometimes have their -action much increased; and there is absolutely an attempt made to expel -it, violent paroxysms of contraction coming on, and repeated daily for a -length of time. - -These may be lessened by opiates, but can only be cured by exciting the -natural action of the uterus. I mention this fact, from its singularity, -although it do not immediately refer to abortion. - -If the action of gestation go on under restraint, as, for instance, by a -change of position in the uterus, or by its prolapsing too low in the -vagina, it is very apt to be accompanied by uneasy feelings, for, -whenever any action is constrained, sensation is produced. The woman -feels irregular, and pretty sharp pains in the region of the uterus, and -from sympathetic irritation both the bladder and rectum may be affected, -and occasionally a difficulty is felt in making water, by which a -suspicion is raised that retroversion is taking place. - -Sometimes the cervical vessels in these circumstances yield a little -blood, as if abortion were going to happen; but by keeping the patient -at rest, and attending to the state of the rectum and bladder, no harm -is done: and when the uterus rises out of the pelvis, no farther -uneasiness is felt. - -Retroversion of the uterus likewise constrains very much its action, and -may give rise to abortion, though in a greater number of instances, by -care, gestation will go on, and the uterus gradually ascend. - -Sometimes in irritable or hysterical habits, the process of gestation -produces a considerable degree of disturbance in the actions of the -abdominal viscera, particularly the stomach, exciting frequent and -distressing retching or vomiting, which may continue for a week or two, -and sometimes is so violent, as to invert the peristaltic motion of the -intestines near the stomach, in which case feculent matter, and, in some -instances, lumbrici, are vomited. - -This affection is often accompanied by an unsettled state of mind, which -adds greatly to the distress. We sometimes, in these circumstances, have -painful attempts made by the muscles to force the uterus downward, and -these are occasionally attended by a very slight discharge of blood. We -have, however, no regular uterine pain; and, if we are careful of our -patient, abortion is rarely produced. - -The best practice is to take away a little blood at first, to keep the -bowels open, to lessen the tendency to vomit, by applying an opium -plaster, or a small blister, to the region of the stomach, and to allay -pain by doses of hyocyamus or opium, conjoined with carminatives. When -the mind is much affected, or the head painful, it is proper to shave -the head, and wash it frequently with cold vinegar, or apply a blister -at the same time that we keep the patient very quiet, and have recourse -to a soothing management. - -The uterus being a large vascular organ, is obedient to the laws of -vascular action, whilst the ovum is more influenced by those regulating -new-formed parts; with this difference, however, that new-formed parts -or tumors are united firmly to the part from which they grow by all -kinds of vessels, and generally by fibrous or cellular substance, whilst -the ovum is united to the uterus only by very tender and fragile -arteries and veins. If, therefore, more blood be sent to the maternal -part of the ovum, than it can easily receive and circulate and act -under, rupture of the vessels will take place, and an extravasation and -consequent separation be produced; or, even when no rupture is -occasioned, the action of the ovum may be so oppressed and disordered, -as to unfit it for continuing the process of gestation. There must, -therefore, be a perfect correspondence betwixt the uterus and the ovum, -not only in growth and vascularity, but in every other circumstance -connected with their functions. - -Even when they do correspond, if the uterus be plethoric, the ovum also -must be full of blood, and rupture very apt to take place; and this is a -frequent cause of abortion, more especially in those who menstruate -copiously. On the other hand, when the uterus is deficient in -vascularity, which often happens in those who menstruate sparingly or -painfully, the child generally dies before the seventh month, and is -expelled. The process is prematurely and imperfectly finished. - -Abortion necessarily implies separation of the ovum, which may be -produced mechanically or by spontaneous rupture of the vessels, or by an -affection of the muscular fibres. It unavoidably requires, for its -accomplishment, contraction of those fibres which formerly were in a -dormant state. A natural and necessary effect of this contraction is to -develope the cervex uteri. - -This, when gestation goes on regularly, is accomplished gradually and -slowly by the extension and formation of fibres. In abortion, no fibres -are formed; but muscular action does all, except in those instances -where the action of gestation goes on irregularly and too fast; in which -case the cervix distends, sometimes by the third month, by the same -process which distends the fundus. But much more frequently the cervix -only relaxes during abortion, as the os uteri does in natural labour, -and yields to the muscular action of the fundus, or distended part. - -The existence and growth of the fœtus depends on the fœtal portion of -the ovum. The means of nourishment, and the accommodation of the fœtus -in respect of lodgement, depend on the uterus; and these circumstances -requiring both fœtal and maternal action, are intimately connected. The -condition of the uterus qualifying it to enlarge, to continue the -existence and operation of the maternal portion of the placenta or ovum, -and to transmit blood to the ovum, exactly in the degree correspondent -to its wants, constitutes the action of gestation. - -When this condition ceases, then muscular contraction begins, provided -the cessation be universal in the uterus. This is necessary, for as the -fœtal and maternal actions are dependent on each other, the fœtus would -suffer if it were not expelled. The injury, indeed, will not be -immediate; otherwise, in labour, the child would die before it could be -born, because labour implies a cessation of the action of gestation. On -the other hand, the loss of action in the fœtal part will soon influence -the maternal part, and stop its action. - -In labour, and at other times, when the action of gestation ceases, the -circulation is still kept up in the maternal vessels of the placenta, -until either separation and expulsion take place, or the vessels suffer -so much as to cease to transmit blood. The cessation of action then does -not necessarily immediately affect the fœtus. As long as it, and the -fœtal portion of the ovum connected with it, remain stationary, the same -quantity of blood will do. But the uterus cannot now increase its -actions along with those of the fœtus, so as gradually to enlarge and -send more blood. - -This is one cause of disagreement. Another is, that, in consequence of -cessation of action in the uterus, the maternal portion of the placenta -or ovum ultimately suffers, and flags or decays, whilst the fœtal -portion must sympathize with it. - -From this it results, first, that even in tedious labour the child does -not die: secondly, that when the action ceases in the early months of -pregnancy, the fœtus does not instantly die, nor abortion immediately -take place: thirdly, but it invariably happens, that, at whatever period -the action ceases, the fœtus will, if not expelled within a certain -time, perish. - -I have elsewhere[6] endeavoured to prove, that we have a certain -quantity of action present in the system at large, and properly -distributed amongst the different organs, forming an equilibrium of -action; and that if one organ act in an over degree, another, which is -connected with it, will have its action lessened, and _vice versa_. - -The same holds true with regard to different actions belonging to the -same organ; and the fact is of considerable importance, both in -explaining and curing diseases. During pregnancy, the muscular fibres of -the uterus are dormant, possessing no contractile action; at least, none -qualifying them for contracting, so as to make the uterus smaller. - -I doubt much if even the individual fibres possess a power of -alternately contracting and relaxing, as in other muscles, in any degree -whatever. But, whenever the action of gestation ceases, action is -communicated to these fibres; and whenever this loss on the one part, -and gain upon the other, is universally begun in the womb, the -transference will be completed, and the ovum can no longer be preserved -in the uterus. - -The loss of action is generally speedy, when once begun. Perhaps in most -instances it takes place instantaneously, and then the fibres begin -individually to act; but they may not, for some hours, contract -universally, and all at one and the same time producing pains. - -But if some other organ shall receive the surplus of action, or the -transferred action, then the uterine fibres either will not contract, or -will receive an inferior and insufficient degree of action, and -expulsion will not take place until the organ sympathizing shall cease -to have the increased action, whether it be the brain, the stomach, or -the external muscles of the body. Sometimes also the action seems to be -divided betwixt the uterus and other organs, or they alternate in their -actions. - -This fact is of importance in explaining and correcting many of the -irregularities attending labour, which it would be impossible here to -specify. - -Sometimes the action is chiefly communicated to one part of the uterine -fibres, whilst the rest are more torpid; and this part contracts in an -undue degree, clasping the child firmly, and retarding labour[7]; and, -after expulsion, it is apt to return, and retain the placenta, whilst -the rest of the uterus becomes torpid, producing flooding. - -If, then, the action of gestation cease universally in the uterus, -another action, namely, muscular contraction, begins, and then all hope -of retaining the ovum any longer is at an end. I know that we have been -told of instances where contraction, after beginning, stopped for -several weeks. - -The os uteri may be prematurely developed; it may be open for some -weeks, even without pain; but no man will say that, in this case, labour -or uterine contraction has begun. We may even have partial muscular -action, in a few very rare cases, about the os uteri, which has less to -do with the action of gestation than any other part of the uterus; but -regular and universal action of the muscular fibres never yet has been -stopped. It may, like other muscular actions, be suspended by anodynes -or artificial treatment; but it never has, and never can be stopped, -otherwise than by the expulsion of the ovum, when a new train of actions -commence. - -Whenever, then, at any period of pregnancy, we have paroxysms of pain in -the back, and region of the uterus, more especially if these be attended -with feeling of weight in that region, tenesmus, micturition, descent of -the uterus in the pelvis, and opening of the os uteri, we may be sure -that expulsion, though retarded, will soon take place. - -This fact is not always attended to in abortion, for many think that if -by anodynes they can abate the pain, they will make the woman go to the -full time.—This is true, with regard to many painful sensations, which -may attend a threatened abortion, or which may be present, although -there be no appearance of abortion; but it does not hold with regard to -those regular pains proceeding from universal action of the uterine -fibres; and we may save both ourselves and our patients some trouble, by -keeping this in remembrance. - -Seeing, then, that contraction is brought on by stopping the action of -gestation, and that when it is brought on it cannot be checked, nor the -action of gestation restored, we must next enquire how this action may -be stopped. I have already mentioned several circumstances affecting the -uterus, and likely to injure its actions; and these I shall not repeat, -but go on to notice some others, which are often more perceptible; and -first I shall mention violence, such as falls, blows, and much fatigue, -which may injure the child, and detach part of the ovum. - -If part of the ovum be detached, we have not only a discharge of blood, -but also the uterus, at that part, suffers in its action, and may -influence the whole organ, so as to stop the action universally. But the -time required to do this is various, and opportunity is often given to -prevent the mischief from spreading, and to stop any farther -effusion—perhaps to accomplish a re-union. - -Violent exercise, as dancing, for instance, or much walking, or the -fatigueing dissipations of fashionable life, more especially in the -earlier months, by affecting the circulation, may vary the distribution -of blood in the uterus, so much as to produce rupture of the vessels, or -otherwise to destroy the ovum. There is also another way in which -fatigue acts, namely, by subducting action and energy from the uterus: -for the more energy that is expended on the muscles of the inferior -extremities, the less can be afforded or directed to the uterus; and -hence abortion may be induced at an early stage of gestation[8]. - -Even at a more advanced period, inconvenience will be produced upon the -principle formerly mentioned; for the nerves of the loins conveying less -energy, in many instances, though not always to the muscles, they are -really weaker than formerly, and are sooner wearied, producing pain, and -prolonged feeling of fatigue, for many days, after an exertion which may -be considered as moderate. - -This feeling must not be confounded with a tendency to abortion, though -it may sometimes be combined with it, for generally by rest the -sensation goes off. Neither must we suppose that the child is dead, from -its being usually quiet during that period, for as soon as the uterus, -which has been a little impaired in its action, recovers, it moves as -strongly as ever. - -In the next place, I mention the death of the child, which may be -produced by syphilis, or many diseases perhaps peculiar to itself, or by -injury of the functions of the placenta. But in whatever way it is -produced, the effect is the same in checking the action of gestation, -unless there be twins, in which case it has been known that the uterus -sometimes did not suffer universally, but the action went on, and the -one child was born of the full size, the other small and injured[9]. - -The length of time required for producing abortion from this cause is -various; sometimes it is brought on in a few hours: at other times not -for a fortnight, or even longer. In these and similar cases, when the -muscular action is commencing, the discharge is trifling, like -menstruation, until the contraction becomes greater, and more of the -ovum be separated. - -A third cause is a disproportioned action betwixt the uterus and ovum, -the one not increasing in the same ratio with the other, yet both -continuing to act. This is productive of frequent discharges of blood, -repeated at different, but always at short intervals, for several weeks, -until at length the uterus suffers so much, that its action stops, or -the fœtus dies. - -Another cause is, any strong passion of the mind. The influence of fear, -joy, and other emotions on the muscular system, is well known; and the -uterus is not exempted from their power; any sudden shock, even of the -body, has much effect on this organ. The pulling of a tooth, for -instance, sometimes suddenly produces abortion. - -Emmenagogues, or acrid substances, such as savine and other irritating -drugs, more especially those which tend to excite a considerable degree -of vascular action, may produce abortion. - -Such medicines, likewise, as exert a violent action on the stomach or -bowels will, upon the principle formerly mentioned, frequently excite -abortion; and very often are taken designedly for that purpose in such -quantity as to produce fatal effects; and here I must remark, that many -people at least pretend to view attempts to excite abortion as different -from murder, upon the principle that the embryo is not possessed of -life, in the common acceptation of the word. It undoubtedly can neither -think nor act; but, upon the same reasoning, we should conclude it to be -innocent to kill the child in the birth. - -Whoever prevents life from continuing, until it arrive at perfection, is -certainly as culpable as if he had taken it away after that had been -accomplished. I do not, however, wish, from this observation, to be -understood as in any way disapproving of those necessary attempts which -are occasionally made to procure premature labour, or even abortion, -when the safety of the mother demands this interference, or when we can -thus give the child a chance of living, who otherwise would have none. - -If any part with which the uterus sympathizes have its action greatly -increased during pregnancy, the uterus may come to suffer, and abortion -be produced. Hence the accession of morbid action or inflammation in any -important organ, or on a large extent of cuticular surface, may bring on -miscarriage, which is one cause why smallpox often excites abortion, -whilst the same degree of fever, unaccompanied with eruption, would not -have had that effect. - -Hence also increased secretory action in the vagina, if to a great -degree, though it may have even originally been excited in consequence -of sympathy with the uterus, may come to incapacitate the uterus for -going on with its actions, and therefore it ought to be checked by means -of an astringent injection. - -In this case the uterus has, without any proof, been supposed to become -too much relaxed, whilst in other cases, as for instance when the -abdomen was harder than usual, it has with as little foundation been -supposed to be preternaturally rigid. - -Mechanical irritations of the os uteri, or attempts to dilate it -prematurely, will also be apt to bring on muscular contraction. At the -same time, it is worthy of remark, that the effect of these irritations -is generally at first confined to the spot on which they act, a partial -affection of the fibres in the immediate vicinity of the os uteri being -all that is, for some time, produced; and therefore slight uneasiness at -the lower part of the belly, with or without a tendency in the os uteri -to move or dilate, whether brought on by irritation at the upper part of -the vagina or os uteri, or by affection of the neck, of the bladder, -&c.[10] may be often prevented from extending farther, and destroying -the action of gestation by rest, anodynes, and having immediate recourse -to such means as the nature of the irritation may require for its -removal. - -Tapping the ovum, by which the uterus collapses and its fibres receive a -stimulus to action, is another cause by which abortion may be produced; -and this is sometimes, with great propriety, done at a particular -period, in order to avoid a greater evil. - -It is now the general opinion, that contraction will unavoidably follow -the evacuation of the waters. But we can suppose the action of gestation -to be in some cases so strong as not to stop in consequence of this -violence, and, if it do not stop, contraction will not take place. I do -not, however, mean to say, that all discharges of watery fluid from the -uterus, not followed by abortion, are discharges of the liquor amnii, -and instances of this failing to produce contraction. On the contrary, I -know that most of these are the consequence of morbid action about the -os uteri, the glands yielding a serous instead of a gelatinous fluid, -and this action may continue for many months. - -Sometimes the upper range of lacunæ yields water, whilst the under -secretes jelly, which confines the water for some hours, until it -accumulates, and comes out with a small gush. At other times, in the -early period of gestation, it collects in considerable quantity betwixt -the lower part of the decidua protrusa, which has not yet reached the -cervix uteri and the cervical efflorescence, which becomes a little -stronger than usual. - -There is thus a species of dropsy produced, and the water is sometimes -confined until a little before labour comes on; at other times it is -discharged sooner, and an oozing continues for many weeks. In all these -cases, we may derive some advantage from injecting three or four times a -day a strong infusion of galls. The woman ought to use no exertion, as -the membranes are apt to give way. - -When the liquor amnii really is evacuated, sometimes a spasmodic -contraction of the fibres near the cervix takes place, instead of that -regular action which is necessary for expulsion; and if the whole of the -liquor have not escaped, the remaining portion will be confined by the -tightening of that part of the uterus round the fœtus; and this -contraction may endure for a very considerable time. If not interrupted, -it may lay the foundation of future diseases in the uterus. - - ∽∽∽∽ - - - _Of the Prognosis._ - -The danger of abortion is to be estimated by considering the previous -state of the health, by attending to the violence of the discharge, and -the difficulty of checking it; to its duration, and the disposition to -expulsion which accompanies it; to the effects which it has produced in -weakening the system, and to its combination with hysterical or -spasmodic affections. In general, we say that abortion is not dangerous, -yet in some cases it does prove fatal very speedily, either from loss of -blood, or spasms about the stomach, or convulsions. - -It is satisfactory, however, to know, that this termination is rare, -that these dangerous attendants are seldom present, and that a great -hemorrhage may be sustained, and yet the strength soon recover. But if -there be any disposition in a particular organ to disease, abortion may -make it active, and thus, at a remote period, carry off the patient. -Frequently repeated miscarriages are also very apt to injure the health, -and break up the constitution. - -When abortion is threatened, the process is very apt to go on to -completion; and it is only by interposing, before it is fairly begun, -that we can be successful in preventing it, for whenever the muscular -action is established, nothing, I believe, can check the process. As -this is often the case before we are called, or, as in many instances it -depends on the action of gestation being stopped by causes, whose action -could not be ascertained until the effect be produced, we shall oftener -fail than succeed in preventing expulsion. - -This is greatly owing to our not being called until abortion has begun; -whereas, had we been applied to upon the first unusual feeling, it might -have been prevented. What I wish then particularly to inculcate is, that -no time be lost in giving notice of any ground of alarm, and that the -most prompt measures be had recourse to in the very beginning, for when -uterine contraction has commenced, then all that we can do is to conduct -the patient safely thro’ a confinement, which the power of medicine -cannot prevent. - -The case of threatened abortion, in which we most frequently succeed, is -that arising from slipping of the foot, or similar causes, producing a -slight separation, because here the hemorrhage immediately gives alarm, -and we are called before the action of gestation be much affected. - -Could we impress upon our patients the necessity of equal attention to -other preceding symptoms and circumstances, we might succeed in many -cases where we fail from a delay, occasioned by their not understanding -that an abortion can only be prevented by interfering before it begins, -but that, when sensible signs of it appear, the mischief has proceeded -too far to be checked. - - - _Of the Prevention and Treatment of Abortion._ - -In considering the treatment, I shall first of all notice the most -likely method of preventing abortion in those who are subject to it; -next, the best means of checking it, when it is immediately threatened; -and, lastly, the proper method of conducting the woman through it, when -it cannot be avoided. - -The means to be followed in preventing what may be called habitual -miscarriage, must depend on the cause supposed to give rise to it. It -will, therefore, be necessary to attend to the history of former -abortions; to the usual habitudes and constitution of the woman; and to -her condition when she becomes pregnant. - -In many instances a plethoric disposition, indicated by a pretty full -habit, and copious menstruation, will be found to give rise to it. In -these cases; we shall find it of advantage to restrict the patient -almost entirely to a vegetable diet, and, at the same time, make her use -considerable and regular exercise. - -The sleep should be abridged in quantity, and taken not on a bed of -down, but on a firm mattress, at the same time that we prevent the -accumulation of too much heat about the body. The bowels ought to be -kept open, or rather loose, which may be effected by drinking Cheltenham -water: and this can be artificially prepared, if necessary. - -There is, in plethoric habits, a weakness of many, if not all, of the -functions; but this is not to be cured by tonics, but by continued and -very gradually increased exercise, with light diet, consisting chiefly -of vegetables. - -This plan, however, must not be carried to an imprudent length, nor -established too suddenly; but regard is to be had to the previous -habits. It is a general rule, that exercise should not be carried the -length of fatigue, and that it should be taken, if possible, in the -country, whilst late hours, and many of the modes of fashionable life, -must be departed from. We may also derive so considerable advantage from -conjoining with this plan, the shower bath, or sea bathing, that they -ought not to be omitted. - -After conception, the exercise must be taken with circumspection; but -the diet should still be sparing, and the use of the cold bath -continued. If the pulse be at any time full, or inclined to throb, a -little blood should be taken away; and much advantage will be derived in -all these cases, by using the digitalis, so as to affect the pulse. Half -a grain may be given, so often as may be found necessary, to bridle the -circulation. It may be continued for two days, and then omitted for a -day; and in this way it may be continued for a length of time; but it is -seldom necessary to give it regularly, beyond the beginning of the -fourth month, unless a change of circumstances afterwards require it. - -The dose must be occasionally increased, so as to produce the desired -effect; and I can vouch for the safety of the plan. - -Injecting cold water into the vagina, twice or thrice a day, has often a -good effect, at the same time that we continue the shower bath every -morning. When there is much aching pain in the back, it is of service to -apply cloths to it, dipped in cold water, or gently to dash cold water -on it. - -In this, and all other cases of habitual abortion, we must advise that -impregnation shall not take place until we have corrected the system; -and after the woman has conceived, it is requisite that she live absque -marito, at least until gestation be far advanced. I need scarcely add, -that when consulted respecting habitual abortion, the strictest prudence -is required on our part, and that the situation of the patient, and many -of our advices, should be concealed from the most intimate friends of -the patient. - -In other cases, we find that the cause of abortion is connected with -sparing menstruation. This is often the case with women whose appearance -indicates good health, and who have a robust look. This is not often to -be rectified by medicine, but it may by regimen, &c. Here, as in the -former case, we find it useful to make the greatest part of the diet -consist of vegetables; but it is not necessary to restrict the quantity. - -When, on the other hand, the patient has a weakly delicate appearance, -it will be proper to give a greater proportion of animal food, and two -or three glasses of wine, in the afternoon, with some bitter laxative, -twice a day, so as to strengthen the stomach, and at the same time keep -the bowels open. - -We also derive, in both cases, advantage from the daily use of the warm -bath, made of a pleasant temperature; but this is to be omitted after -conception. The internal use of the Bath waters is often of service; or -where the circumstances of the patient will not permit this, we may -desire her to drink, morning and evening, a pint of tepid water, which -may be continued during gestation. Throwing up into the vagina tepid -salt water twice or thrice a day, seems also to have a good effect. - -I have already mentioned, that abortion is sometimes the consequence of -too firm action, the different organs refusing to yield to the uterus, -which is thus prevented from enjoying the due quantity of energy and -action. These women have none of the diseases of pregnancy, or they have -them in a slight degree. They have good health at all times, but they -either miscarry, or have labour in the seventh or eighth month, the -child being dead; or, if they go to the full time, I have often observed -the child to be sickly, and of a constitution unfitting it for -living[11]. - -We may sometimes cure this state by giving half a grain of digitalis, -and the eighth part of a grain of the tartris antimonii, every night at -bed-time, which diminishes the stomachic action. Bleeding is also -useful, by making the organs more irritable. Exercise, so as to prove -tonic, is hurtful in this species of abortion; instead of wishing to -increase the action of any organ, our object is to diminish it, and make -the different parts more easily acted on. - -The accidental accession of an hysteric condition of the system, -sometimes spontaneously cures this state: and if the patient have gone -to the full time, but bear an unhealthy child from this cause; if she -meet with any accident in her confinement, inducing a nervous condition, -she is less apt afterwards to miscarry, or have dead children. - -There is another case in which all the functions are healthy and firm, -except the circulation, which is accelerated by the uterine irritation. -This is more or less the case in every pregnancy, but here it is a -prominent symptom. The woman is very restless, and even feverish, and -apt to miscarry, especially if she be of a full habit. Immediate relief -is given by venesection, and afterwards we may, for some time, give -every night half a grain or a grain of digitalis, with two grains of the -extract of hyocyamus. - -When, on the contrary, abortion arises, from too easy yielding of some -organ, we must keep down uterine action, by avoiding venery, and -injecting cold water often into the vagina. Clysters of cold water are -also useful; at the same time we must attend to the organ sympathizing -with the uterus. - -Sometimes it is the stomach which is irritable, and the person is often -very sick, takes little food, and digests ill. A small blister, applied -to the pit of the stomach, often relieves this; a little of the compound -tincture of bark, taken three or four times a day, is serviceable; or a -few drops of the tincture of muriated iron in a tumbler glassful of -aerated water; at other times the bowels yield, and the patient is -obstinately costive. This is best cured by manna, with the tartarite of -potash. When the muscular system yields, producing a feeling of languor -and general weakness, the use of the cold bath, with a grain of opium, -at bed time will be of most service. - -It is evident that it is only by attending minutely to the history of -former miscarriages, that we can detect these causes; and we shall -generally find, that in each individual case it is the same organ in -every pregnancy which has yielded or suffered. Previous to future -conception, we may, with propriety, endeavour to render it less easily -affected. - -General weakness is another condition giving rise to abortion; and upon -this I have already made some remarks. I have here only to add, that the -use of the cold bath, the exhibition of the Peruvian bark, and wearing -flannel next the skin, constitutes the most successful practice. - -Syphilis is likewise a cause of abortion. When it occurs in the mother, -it often unfits the uterus for going on with its actions. At other -times, more especially when the father labours under venereal hectic, -the child is evidently affected, and often dies before the process of -gestation can be completed. - -In these cases a course of mercury alone can effect a cure. But we are -not to suppose that every child, born without the cuticle in an early -stage of pregnancy, has suffered from this cause; on the contrary, as -the majority of these instances depend on causes already mentioned, and -which cannot be cured by mercury, I wish to caution the student against -too hastily concluding that one of the parents has been diseased, -because the child is born dead or putrid in the seventh month. - -It is not always easy to form a correct judgment; but we may be assisted -by finding that the other causes which I have mentioned are absent; that -we have appearances of ulceration on the child, and that there are some -suspicious circumstances in the former history and present health of the -parents. - -Advancement in life, before marriage, is another cause of frequent -abortion, the uterus being then somewhat imperfect in its action. In -general, we cannot do much in this case, except avoiding carefully the -exciting causes of abortion, and by attending minutely to the condition -of other organs during menstruation or pregnancy, we may, from the -principles formerly laid down, do some good. - -It is satisfactory to know that, by great care, although we may fail -once or twice, yet the uterus comes at last to act more perfectly, and -the woman bears children at the full time. - -After these observations, it is only necessary to add, that in every -instance of habitual abortion, whatever the condition may be which gives -rise to it, we find that it is essential that the greatest attention be -paid to the avoiding of the more evident and immediate exciting causes -of miscarriage, such as fatigue, dancing, &c. In some cases, it may even -be necessary to confine the patient to her room, until the period at -which she usually aborts is past. - -When abortion is threatened, we come to consider whether and by what -means it can be stopped. I have already stated my opinion, that when the -action of gestation ceases, it cannot be renewed, and that general -contraction of the uterine fibres is a criterion of this cessation. - -Still, as some of the means which may be supposed useful in preventing a -threatened abortion are also useful in moderating the symptoms attending -its progress, we may very properly have recourse to them. Some causes -giving rise to abortion, do not immediately produce it, but give warning -of their operation, producing uneasiness in the vicinity of the uterus, -before the action of that organ be materially affected. - -The detraction of a little blood at this time, if the pulse be in any -measure full or frequent, and the subsequent exhibition of an anodyne -clyster, or a full dose of digitalis and opium, together with a state of -absolute rest for some days, will often be sufficient to prevent farther -mischief, and constitute the most efficacious practice. - -This is the time at which we can interfere with the most certain -prospect of success; and the greatest attention should be paid to the -state of the rest of the system, removing uneasiness, wherever it is -present, and preventing any organ from continuing in a state of undue -action. It is difficult to persuade the patient to comply with that -strict attention which is necessary at this period; but being persuaded -that if this period be allowed to pass over with neglect, nothing can -afterwards prevent abortion. I wish particularly to impress the mind of -the student with a due sense of its importance; and I must add, that as -after every appearance of morbid uterine action is over, the slightest -cause will renew our alarm, it is necessary that great attention be paid -for some time to the patient. - -Often, instead of an uneasy feeling about the loins, or lower belly, we -have, before the action of gestation stops, a discharge of blood, -generally in a moderate, sometimes in a trifling degree. This is more -especially the case when abortion is threatened, owing to an external -cause, and, if immediately checked, we may prevent contraction from -beginning. - -Even in those cases where we do not expect to keep off abortion, it is -useful to prevent, as far as we can, the loss of blood, for as I cannot -see that the hemorrhage is necessary for its accomplishment, although it -always attend it, I conclude that our attempts to prevent bleeding can -never do harm, for if they succeed in checking abortion, we gain our -object; if they fail, they do not increase, but diminish the danger. - -It should be carefully remembered, that the more we can save blood, the -more do we serve our patient. As the means for checking the discharge -will be immediately pointed out, it is unnecessary here to enter into -any detail. - -Sometimes the vessels which furnish the cervical efflorescence in the -beginning of gestation, do not assume that action, but yield blood, -which passes for the menses, and makes the woman mistake her condition. -As the uterine vessels increase in size, the discharge becomes greater -and more frequent. It is now apt to pass for menorrhagia. - -If it be allowed to continue, it tends to injure the action of the -uterus, and produce expulsion, which sometimes is the first thing which -shews the woman her situation. This discharge is best managed by rest, -and the frequent injection of saturated solution of the sulphat of -alumine, or decoction of oak bark. - -When a slight discharge takes place, in consequence of a slip of the -foot, or some other external cause, we may also derive advantage from -the use of the injection, but not so certainly as in the former case; -and if the discharge be considerable, the injection will fail. It is -better, in this case, to trust to the formation of a coagulum. - -In those cases, where uterine pain precedes or accompanies the -discharge, abortion cannot be prevented; but when the discharge precedes -the pain, it sometimes may. Rest is absolutely necessary, if we wish the -person to go to the full time: and it is occasionally necessary to -confine her to bed for several weeks, at the same time that we put her -upon an effective course of digitalis, and give an anodyne at bed-time, -taking care also to keep the bowels in a proper state by gentle -medicine. - -When we cannot prevent abortion, the next thing is to conduct the -patient safely through the process; and the first point which naturally -claims our attention is the hemorrhage. Many practitioners, upon a -general principle, bleed, in order to check this, and prevent -miscarriage: but miscarriage cannot be prevented, if the uterine -contraction have commenced; and the discharge cannot be prudently -moderated by venesection, unless there be undue or strong action in the -vessels. - -This is not always the case, and therefore, unless the vessels be at or -above the natural force or strength of action, the lancet is not at this -stage necessary. The fulness and strength of the pulse are lost much -sooner in abortion than can be explained, by the mere loss of blood. - -It depends on an affection of the stomach, which has much influence on -the pulse; and the proper time for bleeding is before this has taken -place. When abortion has made so much progress before we are called, as -to have rendered the pulse small and feeble; or when this is the case -from the first, bleeding evidently can do no good. - -Instead of this, we may use the digitalis, which I have already highly -recommended as a preventative; but I do not say that, in ordinary cases, -where the contraction is brisk, and the process quick, it is at this -stage absolutely necessary; and I shall afterwards mention that, when -the stomachic affection is urgent, and the pulse much affected by it, -the use of this medicine is improper. When, however, the case is -tedious, and the discharge long continued, at the same time that the -sickness is not considerable, the digitalis will be of essential -service. - -Nauseating doses of emetic medicines act in the same way with the -digitalis, but are much less effectual, and more disagreeable, as well -as uncertain in their operation. - -Internal astringents have been proposed, but they have no effect, unless -they excite sickness, which is a different operation from that which is -expected from them. - -The application of cloths dipped in cold water to the back and external -parts will have a much better effect than internal astringents, and -ought always to be had recourse to. If the digitalis have been -exhibited, it assists that medicine in moderating the circulation. - -Even when trusted to alone, it lessens the action of the sanguiferous -system, particularly of the uterine vessels. The introduction of a small -piece of smooth ice into the vagina has been recommended, and has often -a very speedy effect in retarding the hemorrhage, whilst it never, if -properly managed, does any harm. A small snow-ball, wrapped in a bit of -linen, will have the same effect; but neither of these must be continued -so long as to produce pain, or much and prolonged shivering. The heat of -the surface is also to be moderated, by having few bed clothes, and a -free circulation of cool air. - -But the most effectual local method of stopping the hemorrhage, is by -plugging the vagina. This is best done by taking a pretty large piece of -soft cloth, and dipping it in oil, and then wringing it gently. - -It is to be introduced with the finger, portion after portion, until the -lower part of the vagina be well filled. The remainder is then to be -pressed firmly on the orifice, and held there for some time. This acts -by giving the effused blood time to coagulate. It gives no pain; it -produces no irritation, and those who condemn it, surely must either not -have tried it, or have misapplied it. - -If we believe that abortion requires for its completion a continued flow -of blood, we ought not, in those cases where the process must go on, to -have recourse to cold or other means of restraining hemorrhage. - -If we do not believe this, then surely the most effectual method of -moderating it is the best. Plugging can never retard the process, nor -prevent the expulsion of the ovum; for when the uterus contracts, it -sends it down into the clotted blood in the upper part of the vagina, -and the flooding ceases. - -In obstinate cases we may, before introducing the plug, insert a little -powdered ice, when it can be procured, tied up in a rag. - -Faintness operates in the same way, in many cases, by allowing coagula -to form in consequence of the blood flowing more slowly; and, when the -faintness goes off, the coagula still restrain the hemorrhage in the -same way as when the plug has been used. This naturally points out the -advantage of using the plug, together with the digitalis, as we thus -produce coagulation at the mouths of the vessels, and also diminish the -vascular action. It will likewise shew the impropriety of using -injections at this time, for, by washing out the coagula, we do more -harm than can be compensated by any astringent effect produced on the -vessels. - -The principal means, then, which we employ for restraining the -hemorrhage, are bleeding, if the pulse be full and sharp; if not, we -trust to the digitalis, stuffing the vagina, the application of cold to -the external parts, keeping the heat of the body in general at a low -temperature, and enforcing a state of absolute rest, which must be -continued during the whole process, however long it may in some cases -be. The drink should be cold, and the food, if the patient desires any, -light, and taken in small portions. - -Opiates have been advised, in order to abate the discharge, and are, by -many, used in every case of abortion, and in every stage. But as we -cannot finish the process without muscular contraction, and as they tend -to suspend that, I do not see that their exhibition can be defended on -rational principles. - -If given in small quantity, they do no good in the present point of -view; if in larger doses, they only postpone the evil, for they cannot -check abortion, after it has begun. Nothing can do this, for it proceeds -from the cessation of the action of gestation, which we cannot restore. - -But I will not argue against the use of opiates from their abuse. They -are very useful in cases of threatened abortion, more especially in -accidental separation of the membranes and consequent discharge. They do -not directly preserve the action of gestation, but they prevent the -tendency to muscular contraction, and thus do good; for we find in the -animal economy, that when two actions oppose each other, or alternately, -preventing a tendency to the one has an effect in preserving the other. - -Opiates are likewise useful for allaying those sympathetic pains about -the bowels, and many of the nervous affections which precede or -accompany abortion. They are also, especially if conjoined with -digitalis, of much benefit in cases where we have considerable and -protracted discharge, with trifling pains, as the uterus is not -contracting sufficiently to expel the ovum, but merely to separate -vessels. - -By suspending, for a time, its action, it returns afterwards with more -vigour and perfection, and finishes the process. But when the process is -going on regularly, opiates will only tend to interfere with it, and -prolong the complaint. - -It was at one time the practice to endeavour to extract the fœtus and -placenta, in order to stop the discharge; but this is now very properly -abandoned. If the whole ovum come away at once, the discharge stops; if -only the fœtus come away, it continues until the placenta and decidua -are expelled; and where this process is tedious, we may derive advantage -from gently irritating the os uteri with the finger, or using pretty -strong saline clysters, or throwing cold water into the uterus by means -of a female catheter, fitted to the elastic gum bottle used for -injecting hydrocele. These means are much safer than the attempts to -pull out the placenta with the finger or pincers, which were formerly so -often made, and which are very apt to injure the womb. - -In cases where the discharge is protracted and profuse, with little or -no pain, and the ovum is still entire, we may, if the pregnancy be -considerably advanced, excite the expulsive action, by rupturing the -membranes. - -The stomach very soon suffers, and becomes debilitated, producing a -general languor and feebleness, with a disposition to faint, which -seems, in abortion, to depend more upon this cause than directly upon -loss of blood. Indeed, the hemorrhage produces both slighter and less -permanent effects in abortion than at the full time, although less blood -may have been lost in the latter than in the former case, for the -vessels are smaller, and the discharge is not so sudden. - -There is still another cause for this; namely, that the action of the -uterus is less in the early than in the late months. Now, we know that -the effect of hemorrhage from any organ is, _cæteris paribus_, in -proportion to its degree of action. Hence the discharge is less -dangerous than at the full time, and still less in menorrhagia than in -abortion. - -It is likewise less in cases where hydatids are contained in the uterus, -than when a child is present, very astonishing discharges being -sometimes sustained in that case with impunity. - -The effect of abortion on the stomach seems to be in proportion to the -period at which that takes place, being greater when it occurs before -the fourth month than after it. - -The effect, though distressing, and often productive of alarm, is -nevertheless beneficial, lessening the action of the vessels in the same -way with digitalis, the use of which is improper when this condition is -present. - -The strength of the pulse is much abated; sometimes it becomes slower; -but in general it remains much as formerly in point of frequency; we are -therefore not to be too anxious in removing this condition, which -restrains hemorrhage; yet as it may go beyond due bounds, and produce -dangerous syncope, we must check it in time. - -We must likewise be very attentive to the state of the discharge when -this affection is considerable, for if, notwithstanding this, the -hemorrhage should continue, it will produce greater and more immediately -hurtful effects than if this were absent. - -The best method of abating this sinking and feebleness, is to keep the -body perfectly at rest, and the head low. If necessary, we give small -quantities of stomachic cordials, such as a little tincture of cinnamon, -or a few drops of ether in a glass of aerated water; or we may give a -little peppermint water, with fifteen drops of tincture of opium. In -urgent cases, Madeira or undiluted brandy may be given; but these are -not to be frequently repeated, and are very rarely necessary. - -Sometimes, instead of a feeling of sinking and faintness, the fibres of -the stomach are thrown into a spasmodic contraction, producing sudden -and violent pain. This is a most alarming symptom, and may kill the -patient very unexpectedly. It is to be instantly attacked by a mixture -of sulphuric ether and tincture of opium, in a full dose, whilst a -senapism is applied to the epigastric region. - -Spasms about the intestines are more frequent, and much less dangerous. -They are very readily relieved by thirty drops of tincture of opium, in -a dessert spoonful of aromatic tincture, or forty drops of the tincture -of hyocyamus in two tea-spoonfuls of the compound tincture of lavender. - -The brain may also be affected, producing epilepsy, which is a very -dangerous symptom. This is sometimes preceded by headach, flushing of -the face, and feeling of fulness about the head and neck; but at other -times it attacks without any precursory symptom, and sometimes seems to -arise directly from copious hemorrhage. - -Nothing can be done to the uterus in the way of manual assistance, or -extracting the ovum; but our chief attention should be directed to the -brain. It will, indeed, be proper to attend to the state of the pains -and discharge. If the latter be profuse, we must take measures to check -it; if the former be absent, or seem to alternate with the convulsions, -we may derive advantage from the use of a saline clyster, which will -excite the contraction of the uterus, and confine the action more to -itself. - -The same effect may sometimes be obtained by injecting cold water into -the os uteri. Whilst we thus endeavour to excite the regular action of -the uterus, we must likewise act directly on the brain, by shaving the -head, and applying a senapism to the scalp. We also detract blood, if -the pulse indicate an evacuation. If, on the other hand, the disease -seem to have arisen from the profusion of the discharge, it will be -proper to give volatiles, or a full dose of laudanum, in a little warm -brandy. - -This state is to be distinguished from a combination of hysteria and -syncope, which occasionally occurs during labour, whether natural or -premature, and which is by no means equally dangerous. - -This is known by the smallness of the pulse, the paleness of the face, -the slightness of the convulsions, the absence of foam at the mouth, and -an appearance of struggling about the throat. It attacks suddenly, -generally on getting into an erect posture. - -It is at first little different from syncope, and during the whole time -the muscles of the face are not much affected, the countenance having -rather a deadly aspect. This is removed by an horizontal posture, -sprinkling the face smartly with cold water, and the use of volatiles. -The patient, in this case, as in epilepsy, is often unconscious of -having been ill. - -Regular hysteric paroxysms also sometimes accompany abortion, and are -more dangerous than at other times, more especially if they seem to have -been excited by the profusion of the discharge. If they last long, they -either end in mortal syncope, or in stupor. If they have been brought on -by some agitation of mind, they are less to be feared, though not even -then void of danger. - -Besides attending to the state of the discharge, the best practice is to -keep the person very cool, and exhibit thirty or forty drops of tincture -of opium, and two drams of tinctura valerianæ ammoniata in a little -peppermint water. A clyster, composed of a pound of cold water and two -drams of tincture of asafœtida, is also sometimes of service. - -Those disagreeable symptoms which I have described, fortunately do not -often attend abortion; but the process goes on safely, and without -disturbance. In this case, after it is over, we only find it necessary -to confine the person to bed for a few days, as getting up too soon is -apt to produce debilitating discharge. - -We must also, by proper treatment, remove any morbid symptoms which may -be present, but which depending on the peculiarities of individuals, or -their previous state of health, cannot here be specified. When the -patient continues weakly, the use of the cold bath, and sometimes of the -bark, will be of much service in restoring the strength; and, in future -pregnancies, great care must be taken that abortion may not happen again -at the same period. - -Unfortunately we meet with some cases where the recovery does not take -place with that promptitude and regularity which could be wished. This -sometimes depends upon a continuance of the hemorrhage after the ovum is -expelled, by which the patient is greatly weakened, and even her life -put into danger. - -The hemorrhage may either continue from the time of expulsion, or it may -come on a week, or even longer, after it. It seems to proceed from the -uterus not going on in the process of restoration to the unimpregnated -state, but remaining too long enlarged, the consequence of which is, -that very soon the vessels pour out blood, and fill the cavity, forming -a coagulum, which presently is expelled with a considerable flow of -fluid blood; and this process may be very frequently repeated. - -This, which is often connected with an hysterical condition, is more -especially apt to occur in those who are subject to flooding after the -expulsion of the child, as this marks a natural feebleness in the womb, -and a disposition to flag in its actions after delivery. - -In such patients it is often preceded by ill-smelled lochial discharge, -which proceeds sometimes from the original state of the secretion, but -more frequently from its being retained for some time, and acquiring -this smell. - -This has given rise sometimes to an idea that the complaint proceeded -from the retention of part of the placenta or membranes; but this -retention often takes place without any such discharge succeeding; and, -on the other hand, in several instances of this complaint we have -certain knowledge that no part of the placenta has remained, whilst in -almost every case we have a coagulum expelled, possessing exactly the -shape of the uterine cavity, shewing that nothing else has been -contained within it. - -Indeed, the opinion is not very tenable, for a small part of the -placenta or decidua would, if the uterus were contracting, be soon -expelled, and would then surely cease to have any farther influence; -whilst, on the other hand, if the uterus do not regularly contract in -size, or recover itself, the hemorrhage will take place from this cause -alone, independently of all considerations relating to the placenta. - -By attending to this fact, we shall not only refrain from blaming -midwives unjustly, but also from adding to the danger, by endeavouring -to remove a substance which has no existence in the uterus, and which, -even were it to a certainty within, it is there not as a cause of the -hemorrhage, but as an effect of the cause which produces that. - -This disease may take place at any period of gestation. It may follow -abortion in the second month, or expulsion at the full time; but it is -dangerous in proportion as we approach to the term of natural labour. It -may attack only once or twice, or it may make many attacks for several -weeks; and it is wonderful how the system can be supported under these -continued and repeated discharges: but we find that an incredible -quantity of blood may be lost, if it be discharged at intervals. - -We read in a foreign journal of a woman who, in the space of nineteen -years, was bled no less than one thousand and twenty times without -material injury. Each paroxysm is accompanied by slight pain in the back -and belly, with considerable languor and feeling of depression. The -discharge continues until the clot escapes out of the uterus, and for -some time after that until a new one forms; and during this last process -we have a considerable oozing of serous fluid. - -The old clot drops out of the vagina the first time that the patient is -raised, or, if retained, it breaks down by putrefaction. On examining -these clots, they will be found to be pretty firm, and often contain, -intermixed, a quantity of whitish matter, proceeding from the morbid -condition of the lochia, for the vessels, after bleeding often, throw -out a secretion, and bleed no more until the next paroxysm, which may -not take place for one or two days. - -This complaint either terminates fatally by a convulsion or syncope, or -the uterus diminishes in size, and, instead of expelling the contained -clot with hemorrhage, the coagulum seems to break down and come away -gradually in a fluid form. - -In abortion, during the early stages of gestation, we cannot take any -other precaution to prevent this than keeping the patient for some time -very quiet, as motion, or even any agitation of mind, might interfere -with the process of recovery. - -In more advanced gestation, as, for instance, in the seventh month, and -afterwards, if we should be obliged, on account of flooding, after the -birth of the child, to introduce the hand, and extract the placenta, we -must be careful not to withdraw it, until we find the uterus contracting -round it, which will be a mean, though not an infallible one, of making -it go regularly on in the process of restoration to the unimpregnated -state. - -The best method of treating this complaint is on the very first -appearance of hemorrhage, to introduce a firm plug into the vagina, -which will prevent it from going to an excessive degree. Afterwards we -must take measures to prevent a return. - -This is best done by keeping the circulation slow, by means of the -digitalis, and putting the patient on a mild vegetable diet. We cannot -assist the process of restoration otherwise than by endeavouring to -excite the contraction of the uterus. This may be done by injecting an -astringent fluid two or three times a day, and by ordering saline -clysters, which have also the effect of keeping the bowels open, an -object of very great importance. We may also find it useful to excite -gentle vomiting by small doses of ipecacuanha. - -This has an excellent effect in making the uterus contract, and often is -the method which nature takes to bring about recovery. - -This complaint is different from the menorrhagia lochialis, or copious -discharge of blood brought on by exertion after abortion or delivery. In -this case we have no large clot discharged, but just the usual -appearances of menorrhagia. This sometimes seems to become associated -with other morbid conditions of the system: and in those cases is more -or less obstinate as they are intractable. It is generally cured by -rest, the application of cold, and the use of the digitalis. The -consequent weakness is removed by bark, or preparation of iron, with the -cold bath. - -Either of these discharges are very apt to produce painful headachs, -vertigo, and often slight paralytic symptoms, which, however, soon go -off. Any considerable increase of the hemorrhage gives relief to the -headach, but it returns afterwards with greater violence. - -It is frequently relieved by the use of small doses of the saline -laxatives. In protracted cases, especially when the headach puts on an -intermittent form, observing pretty regular periods, the bark combined -with valerian will be of service. - -Sometimes the mind is affected after abortion, although we may have had -little discharge; and the person becomes either melancholy, or, which is -much oftener the case, mad, with great volubility of tongue. This mania -is, in general, sudden in its attack, and is often preceded by a violent -fit of palpitation, or some other nervous affection. - -It occasionally alternates with external pain or swelling of some of the -joints; and, though frequently a tedious complaint, is oftener got the -better of than any other species of mania. The head, upon a general -principle, ought to be shaved and blistered, and a free discharge kept -up from it. The bowels are to be carefully attended to, and no indurated -faces should be allowed to remain in them. The camphorated emulsion may -be given through the day in its usual quantity; and a full dose of -extract of hyosciamus exhibited at night. The patient is to be kept, in -every respect, as quiet and easy as possible. - -Another distressing consequence of abortion, as well as of labour at the -full time, is hysteria appearing in various forms, but more especially -under that of palpitation of the heart. This attacks suddenly, often in -consequence of a fright. - -The patient has a violent beating in the breast, and sometimes a sense -of suffocation. She feels also a knocking within the head, attended with -a sense of heat, and often a redness in the face. The pulse becomes -extremely rapid and irregular, and continues so until the fit goes off, -which sometimes is not for a considerable time. - -During the paroxysm, the patient is much terrified, and impressed with a -belief that she is going to die. After it is over, the mind is left -timid, and the body in a state of languor. Sometimes the fit is -succeeded by a profuse perspiration, whilst betwixt the attacks the -temperature is very versatile. - -This, like all other complaints of the same class, is very obstinate; -but it is not in general dangerous, unless when it proceeds from uterine -disease, marked by pain in the hypogastric region and tension of the -belly. In this case, the danger is great, and is only to be averted by -the early use of purgatives, followed by antispasmodics, whilst -fomentations are applied to the belly. - -The other case, which is purely hysterical, is to be relieved by giving, -during the paroxysm, a liberal dose of tincture of opium and ether. -Small doses have no effect. During the intervals we may give a table -spoonful of the following mixture five or six times a day. - - ℞ Tinc. digitalis ℥iss. - Extr. Hyociami ʒi. - Emuls. Camphorat. ℥iv. misce. - -It is also an essential point, that the bowels be kept open, and the -patient put upon a light diet. As the attacks are very apt to come on at -night, when the person is about to fall asleep, we sometimes find it -useful to give a dose of tincture of hyocyamen and ether at bed-time, -and must take great care that the patient be not afterwards disturbed or -put off her rest. - -When she is much troubled with flatulence, during the intervals the -tincture valeriana ammoniata is of considerable service. Tonics and the -cold bath are also proper. Hysteria either consists in or depends upon a -preternatural aptitude in the different organs, to have their actions -morbidly increased, or rendered irregular; and hence it may affect -secreting as well as muscular parts; and many of the discharges of -lying-in women will be found to be, in this sense, hysterical, and to -alternate with other symptoms, such as globus, palpitation, headach, &c. -and even the most troublesome of all the discharges, that proceeding -from the uterus not recovering or contracting properly, is, I believe, -properly speaking, an hysterical affection, connected with several -others, and alternating with them. - -The next disease which I shall mention is also, I believe, altogether -hysterical. I mean that resemblance of fever which is often met with -after either abortion or delivery, at the full time, and which is, like -the rest of its tribe, abundantly obstinate. - -This is not to be confounded with milk-fever, or other general diseases -arising from local injury. It is sometimes preceded by palpitation, -frightful dreams, and other nervous affection[12]. At other times it -attacks directly with a shivering fit; which is soon alternated with -heat; then the heat becomes steady and distressing, and continues until -a profuse perspiration carries it off. - -The head is generally pained in the two first stages, and the pulse is -frequent in them all. The thirst is considerable, the stomach filled -with flatus, and the belly bound. Often we have irregular action of the -heart occurring in all the stages, whilst the mind is weakened, and the -patient is much afraid of dying. The paroxysm continues for several -hours, and, like ague, is apt to return regularly for a length of time. - -In the cold stage, we give small quantities of warm fluid. In the hot -stage, we lessen the number of bed clothes; but must not do this -suddenly, as the shivering is very apt, in either this or the sweating -stage, to return, upon slight exposure to cold. - -In the last stage, we are careful not to encourage the perspiration too -much, by refraining from warm drink, for much sweating only tends to -render the disease more obstinate. A repetition is to be prevented, by -keeping the bowels open, by the use of the bark, conjoined with -antispasmodics, and by carrying the patient, as soon as possible, to the -country. - -The last disease, which I shall speak of, proceeds from the retention of -the whole, or a part of the secundines, for a length of time after the -expulsion of the fœtus. This circumstance, as I have formerly mentioned, -may sometimes occur in that state of the uterus, which gives rise to -hemorrhage, appearing as a joint effect with it. In this case, however, -we must not conclude that the one symptom is dependant on the other, for -both proceed from a common cause, the want of contraction of the uterine -fibres. - -It occasionally happens, that no hemorrhage accompanies this retention, -but the remains of the ovum putrify, and after many days come away in a -very fœtid state. Until this expulsion takes place, we have very -offensive discharge from the vagina, and not unfrequently loss of -appetite, prostration of strength, frequent and small, but sharp pulse, -hot and parched state of the skin of the hands and feet, with other -febrile symptoms, even to an alarming degree, and generally accompanied -with hysterical affections. - -When this disease proves fatal, there are often, but not always, -conjoined towards the termination symptoms of inflammatory action in the -uterus. - -The practice, at one time, was to endeavour, with the fingers or -forceps, to extract the remains of the ovum; but this is not always -successful, and is productive of much irritation. We find it most useful -to keep the parts clean, by injecting infusion of camomile flowers with -a small quantity of oxygenated muriatic acid, to open the bowels with -gentle laxatives or clysters, to support the strength by light -nourishment with small portions of wine frequently repeated, if -agreeable to the patient, and plenty of subacid fruit, whilst, at the -same time, we, if necessary, procure rest, or allay irritation by -opiates. - - - FINIS. - - - - - ERRATA. - - - Page 24, line 9, for _ar every_, read _are very_. - - 34, — 8, for _expanding_, read _expending_. - - 40, — 16, for _takes_, read _take_. - - 41, — 5, for _in_, read _rise_. - - 64, — 11, for _urerus_, read _uterus_. - - 74. — 12, dele the comma after _frequently_. - - 94. The paragraph beginning with _I wish_, &c. ought to form a - part of the preceding sentence. - - - _Printed by C. Stower, 32, Pater-noster Row._ - ------ - -Footnote 1: - - Both arteries and veins enlarge, but the latter increase more rapidly - in size than the former, so much so, that even before the descent of - the ovum into the uterus, and while the viscus is not itself - materially enlarged, the venous system has assumed the appearance of - sinews, each branch being larger than a goose quill. - -Footnote 2: - - Vide Anatomy of the gravid uterus, with practical inferences relative - to pregnancy and labour. - -Footnote 3: - - The placenta, contrary to some plans, is not formed exactly at the - fundus uteri, stretching equally down on the two faces of the uterus, - with the membranes hanging perpendicularly from it. But it lies - chiefly on one face of the uterus, whilst the membranes are turned to - the other. The centre of the membranous bag, therefore, at this early - period, is not directed to the os uteri, but either to the fore or - back part of the uterus. In proportion, however, as the bag enlarges, - it elongates, its centre, or apex, descends, and ultimately - corresponds with the long axis of the uterus. - -Footnote 4: - - In some instances, the uterus seems to have the power of forming a - vascular substance from its inner surface, although impregnation have - not taken place; and, in this case, we may have the symptom of early - abortion attending its expulsion. But much oftener we find that this - appears as a derangement of the menstrual action, the vessels - secreting a semi-organized substance, instead of the usual quantity of - bloody fluid; hence, as has been observed by that ingenious and - excellent practitioner, Dr. Denman, we have sparing and painful - menstruation. - -Footnote 5: - - For a fuller explanation and defence of this doctrine, I beg leave to - refer the reader to some observations on the animal economy, prefixed - to the first volume of my Dissertation on Inflammation. - -Footnote 6: - - Vide Dissertations on Inflammation, Vol. I. - -Footnote 7: - - This contraction is sometimes so firm after the membranes have burst, - as to produce the same effect upon the child, as the natural pains - would have done had the pelvis been deformed; that is to say, the - presentation becomes unshapely, and the part below the stricture is - swelled and livid. This spasm, like that which sometimes retains the - placenta, is very difficult to be relaxed, and, in general, requires - artificial management. If it come on at the full time, before the - membranes break, it may give such a feeling to the lower part of the - ovum, as to make it resemble a preternatural presentation, although - the head really present. In this case, the band is generally pretty - broad, but its contraction is not violent. It has the effect, however, - of retarding labour, until we break the membranes, which excites a - more general and effective action in the uterine fibres. - -Footnote 8: - - The same effect is observable in the stomach and other organs. If a - delicate person, after a hearty meal, use exercise to the extent of - fatigue, he feels that the food is not digested, the stomach having - been weakened or injured in its actions. - -Footnote 9: - - It has even been known, that, in consequence of the death of one - child, the uterus has suffered partially, and expulsion takes place; - but the other child continuing to live, has preserved the action of - gestation in that part of the uterus, which, properly speaking, - belonged to it, and pregnancy has still gone on. This, however, is an - extremely rare occurrence; for, in almost every instance, the death of - one child produces an affection of the action of gestation in the - whole uterus, and the consequent expulsion of both children. - -Footnote 10: - - It is an old observation, that these purgatives, which produce much - tenesmus, will excite abortion; and this is certainly true, if their - operation be carried to a considerable extent, and continue long - violent. Hence dysentery is also apt to bring on a miscarriage. Those - strong purges which are sometimes taken to promote premature - expulsion, not only act by exciting tenesmus, but likewise by - inflaming the stomach and bowels, and thus affect the uterus in two - ways. It cannot be too generally known, that when these medicines do - produce abortion, the mother can seldom survive their effects. It is a - mistaken notion, that abortion can be most readily excited by drastic - purges, frequent and copious bleeding, &c. immediately after the woman - discovers herself to be pregnant; on the contrary, the action of the - uterus is then more independent of that of other organs, and therefore - not so easily injured by changes in their condition. I have already - shewn, that abortion more frequently happens when the pregnancy is - farther advanced, because then not only the uterus is more easily - affected, but the fœtus seems to suffer more readily. It is apt, - either from diseases directly affecting itself, or from changes in the - uterine action, to die about the middle of the third month, in which - case expulsion follows within a fortnight. - -Footnote 11: - - In these circumstances I have sometimes found the children liable to a - formidable disease, described by Dr. Heberden, in his little treatise - on the diseases of children, “Cap. De Duritie Cutis.” I have met with - this oftener than once in the same family, until the constitution of - the mother was attended to, on the principle I have mentioned, after - which the children were healthy. - -Footnote 12: - - Hiccup sometimes accompanies this complaint: at other times it attacks - the patient as a disease by itself, or alternates with palpitation. It - is best treated by giving large doses of ether. It is also necessary - to clear the bowels; afterwards the compound tincture of bark is - useful. - ------------------------------------------------------------------------- - - - - - TRANSCRIBER’S NOTES - - - 1. Items mentioned in the ERRATA were corrected. - 2. Silently corrected obvious typographical errors and variations in - spelling. - 3. Retained archaic, non-standard, and uncertain spellings as printed. - 4. Enclosed italics font in _underscores_. - -*** END OF THE PROJECT GUTENBERG EBOOK OBSERVATIONS ON ABORTION *** - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the -United States without permission and without paying copyright -royalties. 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} - .x-ebookmaker .ol_1 li {padding-left: 1em; text-indent: 0em; } - body {font-family: Georgia, serif; text-align: justify; } - table {font-size: .9em; padding: 1.5em .5em 1em; page-break-inside: avoid; - clear: both; } - div.titlepage {text-align: center; page-break-before: always; - page-break-after: always; } - div.titlepage p {text-align: center; text-indent: 0em; font-weight: bold; - line-height: 1.5; margin-top: 3em; } - .ph1 { text-indent: 0em; font-weight: bold; font-size: xx-large; - margin: .67em auto; page-break-before: always; } - .ph2 { text-indent: 0em; font-weight: bold; font-size: x-large; margin: .75em auto; - page-break-before: always; } - .x-ebookmaker p.dropcap:first-letter { float: left; } - </style> - </head> - <body> - -<div style='text-align:center; font-size:1.2em; font-weight:bold'>The Project Gutenberg eBook of Observations on Abortion, by John Burns</div> - -<div style='display:block; margin:1em 0'> -This eBook is for the use of anyone anywhere in the United States and -most other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms -of the Project Gutenberg License included with this eBook or online -at <a href="https://www.gutenberg.org">www.gutenberg.org</a>. If you -are not located in the United States, you will have to check the laws of the -country where you are located before using this eBook. -</div> - -<p style='display:block; margin-top:1em; margin-bottom:0; margin-left:2em; text-indent:-2em'>Title: Observations on Abortion</p> -<p style='display:block; margin-top:0; margin-bottom:1em; margin-left:2em; text-indent:0;'>Containing an account of the manner in which it is accomplished, the causes which produced it, and the method of preventing or treating it</p> - -<div style='display:block; margin-top:1em; margin-bottom:1em; margin-left:2em; text-indent:-2em'>Author: John Burns</div> - -<div style='display:block; margin:1em 0'>Release Date: October 10, 2021 [eBook #66506]</div> - -<div style='display:block; margin:1em 0'>Language: English</div> - -<div style='display:block; margin:1em 0'>Character set encoding: UTF-8</div> - -<div style='display:block; margin-left:2em; text-indent:-2em'>Produced by: Richard Tonsing and the Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive)</div> - -<div style='margin-top:2em; margin-bottom:4em'>*** START OF THE PROJECT GUTENBERG EBOOK OBSERVATIONS ON ABORTION ***</div> - -<div class='tnotes covernote'> - -<p class='c000'><strong>Transcriber’s Note:</strong></p> - -<p class='c000'>The cover image was created by the transcriber and is placed in the public domain.</p> - -</div> - -<div class='titlepage'> - -<div> - <h1 class='c001'><span class='xlarge'>OBSERVATIONS</span><br /> <span class='small'>ON</span><br /> ABORTION.<br /> <span class='small'>CONTAINING<br /> An Account of the Manner in which it is accomplished, the Causes which produced it, and the Method of preventing or treating it.</span></h1> -</div> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='large'>∽∽∽∽</span></div> - <div class='c003'><span class='large'>BY JOHN BURNS,</span></div> - <div><span class='small'>LECTURER ON MIDWIFERY, AND MEMBER OF THE FACULTY OF PHYSICIANS AND SURGEONS IN GLASGOW.</span></div> - <div class='c003'><span class='large'>∽∽∽∽</span></div> - <div class='c002'><span class='large'><em>LONDON</em>:</span></div> - <div>PRINTED FOR LONGMAN, HURST, REES, AND ORME,</div> - <div>PATER-NOSTER ROW.</div> - <div class='c003'>1806.</div> - </div> -</div> - -</div> - -<div class='nf-center-c0'> -<div class='nf-center c004'> - <div>TO</div> - <div class='c003'>THE GENTLEMEN</div> - <div class='c003'>WHO ATTENDED THE AUTHOR’S</div> - <div class='c003'>LECTURES</div> - <div class='c003'>IN THE SESSION</div> - <div class='c003'>1802–3,</div> - <div class='c003'>THIS BOOK IS INSCRIBED,</div> - <div class='c003'><span class='small'>AS A</span></div> - <div class='c003'>GRATEFUL AND AFFECTIONATE</div> - <div class='c003'>REMEMBRANCE</div> - <div class='c003'><span class='small'>OF THE</span></div> - <div class='c003'>VERY FLATTERING COMPLIMENT</div> - <div class='c003'>WHICH THEY</div> - <div class='c003'>BESTOWED UPON</div> - <div class='c003'>HIM.</div> - </div> -</div> - -<div class='chapter'> - <span class='pageno' id='Page_1'>1</span> - <h2 class='c005'><span class='large'>OBSERVATIONS</span><br /> <span class='small'>ON</span><br /> ABORTION.</h2> -</div> - -<div class='figcenter id001'> -<img src='images/i_005.jpg' alt='' class='ig001' /> -</div> - -<p class='drop-capa0_0_6 c006'>By abortion is generally understood -the expulsion of the contents of the -gravid uterus, at a period of gestation so -early as to render it impossible for the -fœtus to live. It is an accident or disease -which is very frequent in its occurrence, -which is always attended with disagreeable -circumstances, and which, although -it seldom prove immediately fatal, may yet -be productive of much mischief at a future -<span class='pageno' id='Page_2'>2</span>time. The consideration, therefore, of -the manner in which it takes place, of -the causes which give rise to it, and of -the most likely means of preventing it, -or of obviating those unpleasant symptoms -which accompany it, must form a -subject of very great importance to the -medical student. But before proceeding -to consider these points, it will be -necessary to understand the structure -and formation of the ovum, which I -shall, therefore, first of all explain.</p> - -<div class='nf-center-c0'> - <div class='nf-center'> - <div><span class='large'>∽∽∽∽</span></div> - </div> -</div> - -<h3 class='c007'><em>Of the Formation of the Ovum.</em></h3> - -<p class='c008'>The human uterus, in the unimpregnated -state, consists of a succulent substance, -in which we may perceive fibres -<span class='pageno' id='Page_3'>3</span>running in every direction. In the interstices -of these we find a serous fluid, which -can easily be squeezed out. By injecting -the vessels finely with size or mercury, -we observe them to be numerously intermixed -with the fibres, but very small. -A portion of these vessels follow an irregular -course toward the inner surface -or cavity of the uterus, and open there -upon the membrane which lines it. At -the menstrual period the vessels enlarge -or dilate a little, and their orifices become -more distinct over the surface of the cavity, -as may be ascertained by inspecting -those who have died at this time. Sometimes -a slight temporary serous secretion -precedes the flow of the menses, and succeeds -it. More frequently the vessels -yield a bloody fluid at once, which continues -a certain number of days.—When -impregnation takes place, the -vessels enlarge still more; and we can -<span class='pageno' id='Page_4'>4</span>observe small trunks forming in the substance -of the uterus, the largest of which -are at the two sides where the spermatic -and hypogastric branches meet<a id='r1' /><a href='#f1' class='c009'><sup>[1]</sup></a>. The -old fibres are more separated, and new -ones added, especially at the fundus.—The -quantity of interstitial fluid is also -increased, so that the uterus becomes -manifestly softer. The vessels, as they -enlarge, tend to the uterine cavity; but -instead of opening there, and yielding a -fluid, as in menstruation, they either -elongate themselves, or, which is more -probable, form new and very delicate -vessels, which project from the inner -surface of the uterus, giving it an appearance -<span class='pageno' id='Page_5'>5</span>as if covered with down. This -takes place first and chiefly at the fundus, -and, in a slighter degree, immediately -above the narrow cervix, whilst -the intermediate body remains still quite -smooth.</p> - -<p class='c010'>These vessels project for about a line -in length, at right angles, from the surface -which yields them; and as they -consist of arteries and veins, the down, -or efflorescence, which they form, has, -after death, a striated or radiated appearance, -the empty arteries being -white, the fuller veins black or red. -These vessels constitute the outer layer -of the decidua, or what may be called -decidua striata, although the stria be -obliterated as gestation advances.</p> - -<p class='c010'><span class='pageno' id='Page_6'>6</span>Almost immediately after the formation -of these primary vessels, they secrete -from their extremities a membrane, -or rather an irregular tissue of vessels, -which, on account of their origin, may -be called secondary. These assume a -direction at right angles to those which -formed them, so that they cross the stria -or primary vessels, and therefore any -body coming down through the first set -of vessels, must, before it can get into -the cavity of the uterus, either rupture -this secondary organ, or push it before -it. It is in this manner that the inner -layer of decidua is formed, part of which -is afterwards protruded before the vesicular -ovum, constituting decidua reflexa, -or protrusa.</p> - -<p class='c010'>The primary vessels adhere pretty -closely together at their roots, but are -<span class='pageno' id='Page_7'>7</span>more loose or separated at their termination. -They are at first only yielded -by the fundus, and in a small degree by -the surface, immediately above the cervix, -whilst the cervix itself produces -from the lacunæ, which are increased in -magnitude, a jelly, which sometimes -fills up the os uteri completely; at other -times there is only a small quantity -formed in the cervix, leaving the os uteri -quite patent. The inferior part of the -uterine surface, which yields the primary -vessels, is not a quarter of an inch in -breadth; and the cavity being there -small and narrow, the vessels from the -opposite sides soon come in contact, and -intermix without forming any secondary -vessels. This portion may be called the -cervical efflorescence.</p> - -<p class='c010'>The secondary vessels are very different -<span class='pageno' id='Page_8'>8</span>from the primary; for, whilst -the latter are short, straight, and parallel -to each other, the former are -more extended, intermix, and ramify -together, so as to form an irregular -tissue or sheet of vascular substance, -the fibres or vessels of which assume -a direction at right angles to the -down or primary vessels which formed -them. This direction seems to be very -naturally produced by the weight of the -secondary vessels, which makes them -hang down or point to the os uteri. -Very soon we can perceive ragged irregular -processes, hanging into the cavity -of the uterus, and extending toward the -cervix, so that this layer of decidua -presently appears to consist of a number -of torn floating membranes, like portions -of spiders’ webs, pendulous in the -uterine cavity; but nearer examination -shows that there has been no laceration, -<span class='pageno' id='Page_9'>9</span>the margins being smooth and well defined. -These I would call the processes -of the decidua interna.</p> - -<p class='c010'>Such is the structure of the decidua -externa and interna, at three weeks or a -month after impregnation; and at this -period no fœtus is in the uterus. In one -case I detected the vesicular ovum in -the tube. It was about half way betwixt -the two extremities, was rather -smaller than a full-grown pea, and contained -a little fluid. In another case I -found it still in the ovarium, covered by -the fimbriated extremity of the tube. By -puncturing the peritoneal coat of the -gland, the vesicle escaped.</p> - -<p class='c010'>It has been the general opinion, since -the time of Dr. Hunter, that the decidua -extended a little way into the tube; and -on his authority I stated this to be the -<span class='pageno' id='Page_10'>10</span>case in an account which I formerly -published. By careful examination, I -am now convinced that this is not the -case. My brother, in his dissections, -even thought that the uterine extremity -of the tube was less changed in point -of vascularity, than any other part of -it.</p> - -<p class='c010'>When the fœtus does descend into the -uterus, it is contained in a double membrane. -The internal one is the amnion, -and possesses no distinct vessels. The -external one is the chorion, and is from -the first vascular, and soon becomes so -much so, that its vessels have by some -been described as forming a distinct -tunic.</p> - -<p class='c010'>From what has been said, it will be -evident, that, when this vesicle does -<span class='pageno' id='Page_11'>11</span>reach the uterus, it will be received -amongst the primary vessels which will -surround it, whilst the secondary vessels, -or decidua interna, will lie before -it, and prevent any communication betwixt -it and the uterine cavity. But it -cannot remain long thus; for, in proportion -as the vesicular part of the ovum -increases, it will push the decidua interna -before it, and encroach upon the -cavity of the uterus. This circumstance, -together with the intimate connection -formed betwixt the vessels of the chorion -and those of the decidua, with the -consequent production of a placenta, I -have already very fully detailed in a former -publication, to which I refer<a id='r2' /><a href='#f2' class='c009'><sup>[2]</sup></a>.</p> - -<p class='c010'><span class='pageno' id='Page_12'>12</span>When the ovum descends, and the -subsequent changes are beginning to -take place, the body of the uterus comes -also to form decidua; for I have formerly -said, that, until the fœtus comes -into the uterus, the fundus alone yields -this production. At the same time, the -processes of the decidua interna elongate -still more, and, together with those -which are now formed by the portion -produced by the newly-formed decidua -externa (for additional primary vessels -imply additional secondary ones) at the -lower part of the uterus, will come to -fill up all the intervening space betwixt -the bottom of the chorion or decidua reflexa -and the cervical efflorescence; so -that, by the end of the second or beginning -of the third month, the cavity of -the uterus is quite filled, and we have -the ovum perfectly organized. We have -<span class='pageno' id='Page_13'>13</span>the fœtus inclosed in its membranes, and -swimming in water; we have the placenta -thick and well formed, and large -in proportion to the membranes; we -have the decidua reflexa distinctly seen, -and the lower part of the uterus filled -with the two layers of decidua, and the -processes of the internal one.</p> - -<p class='c010'>If at this time we take the ovum, composed -of all these different parts, out of -the uterus; or, if we cut off the face of -the uterus, and remove the decidua from -the front of the membranes, we shall -see at the upper part the placenta and -membranes like an old fashioned watch, -the placenta resembling the case, and -the membranes (when the decidua is -taken off) the glass of the watch<a id='r3' /><a href='#f3' class='c009'><sup>[3]</sup></a>; -<span class='pageno' id='Page_14'>14</span>then, at the lower part of the membranes, -we see the remains or margins -of the decidua reflexa, which has been -removed to shew the chorion; whilst, -still lower down, we observe the decidua -externa, and the processes of the interna, -filling up the cervix and inferior -part of the body of the uterus, forming -a kind of firm stalk to the globe above. -This stalk is thick, so as to occupy all -<span class='pageno' id='Page_15'>15</span>the lower part of the uterus; but the -layers and processes, furnished by the -different sides, do not adhere when they -meet in the axis of the uterus; but we -have always a small canal or perforation -leading up in the axes of the uterus from -the cervical efflorescence, or the gelatinous -plug, to the bottom of the decidua -reflexa.</p> - -<p class='c010'>In proportion as the membranes enlarge -and elongate, the decidua reflexa -gradually protrudes before them down -this canal, until at last it reaches the -bottom; or, in other words, the membranes -come to occupy all the uterine -cavity.</p> - -<div> - <span class='pageno' id='Page_16'>16</span> - <h3 class='c007'><em>Of the Manner in which Abortion takes place.</em></h3> -</div> - -<p class='c008'>The process of gestation may be stopped, -even before the fœtus, or vesicular -part of the ovum, has descended into -the uterus, and when only the primary -vessels are formed. In this case, which -occurs within three weeks after impregnation, -the symptoms are much the same -with those of menorrhagia. There is -always a considerable, and often a copious -discharge of blood, which coagulates -or forms clots. This is accompanied -with marks of uterine irritation, -such as pain in the back and loins, frequently -spasmodic affections of the bowels, -and occasionally a slight febrile state -of the system. In plethoric habits, and -<span class='pageno' id='Page_17'>17</span>when abortion proceeds from over-action, -or hemorrhagic action of the uterine -vessels, the fever is idiopathic, and -precedes the discharge.</p> - -<p class='c010'>In other circumstances it is either absent, -or, when present, it is symptomatic, -and still more inconsiderable, arising -merely from pain or irritation. As -the primary vessels are very small, and -are soon displaced, they cannot be detected -in the discharge. Nothing but -coagulum can be perceived; and this, -as in other cases of uterine hæmorrhage, -is often so firm, and the globules and -lymph so disposed, as to give it, more -especially if it have been retained for -some time about the uterus or vagina, -a streaked or fibrous appearance, which -sometimes gives rise to a supposition, that -it is an organized substance. The discharge -<span class='pageno' id='Page_18'>18</span>does not cease, when the primary -vessels are destroyed, but generally -continues until the small vesicle -passes out of the fallopian tube. Then -it stops, and an oosing of serous fluid -finishes the process.</p> - -<p class='c010'>The only interruption to the discharge -in this case of abortion, proceeds from -the formation of clots, which, however, -are soon displaced. Women, if -plethoric, sometimes suffer considerably -from the profusion of the discharge; but, -in general, they soon recover.</p> - -<p class='c010'>When the secondary vessels are formed, -the symptoms are still pretty much -the same; but if the vesicle have descended -into the uterus, they are somewhat -different. We have an attempt in -the uterus to contract, which formerly -<span class='pageno' id='Page_19'>19</span>was not necessary; we have pains more -or less regular in the back and hypogastric -region; we have more disturbance -of the abdominal viscera, particularly -the stomach. The discharge is copious, -and small bits of fibrous substance can -often be observed<a id='r4' /><a href='#f4' class='c009'><sup>[4]</sup></a>.</p> - -<p class='c010'>Sometimes, when the vesicle has come -<span class='pageno' id='Page_20'>20</span>into the uterus, before abortion takes -place, it may be detected in the first -discharge of blood, and will be found -to be streaked over with pale vessels, -giving it an appearance as if it had been -slightly macerated. When all the contents -are expelled, a bloody discharge -continues for a few hours, and is then -succeeded by a serous fluid at this time; -and, in later abortion, if the symptoms -come on gradually, we may sometimes -observe a gelatinous matter to come -away before the hæmorrhage appears.</p> - -<p class='c010'>If the uterus have been filled up, as -in the beginning of the third month, the -vesicle never escapes first; but we have -for some time a discharge of blood, accompanied -or succeeded by uterine pain. -Then the inferior part or stalk of the -ovum is expelled, gorged with blood, -<span class='pageno' id='Page_21'>21</span>and afterwards the upper part equally -injured. Sometimes the whole comes -away at once and entire; but this is -rare. As considerable contraction is now -required in the uterus, the pains are -pretty severe. The derangement of the -stomach is also greater than formerly, -giving rise to sickness or faintness, which -is a natural contrivance for abating the -hæmorrhage.</p> - -<p class='c010'>When the membranes come to occupy -more of the uterus, and a still -greater difference to exist betwixt the -placenta and decidua, we have again a -change of the process; we have more -bearing down pain, and greater regularity -in its attack; we have a more rapid -discharge, owing to the greater size -of the vessels; but there is not always -more blood lost now than at an earlier -<span class='pageno' id='Page_22'>22</span>period, for coagula form readily from -temporary fits of faintness and other -causes, and interrupt the flow until new -and increased contraction displaces them. -Often the membranes give way, and the -fœtus escapes with the liquor amnii, -whilst the rest of the ovum is retained -for some hours or even days, when it is -expelled with coagulated blood separating -and confounding its different parts -or layers. At other times the fœtal and -maternal portions separate, and the first -is expelled before the second, forming a -very beautiful preparation. In some -rare instances we find the whole ovum -expelled entire, and in high preservation. -After the expulsion, the hemorrhage -goes off, and is succeeded by a -discharge somewhat resembling the lochia.</p> - -<p class='c010'><span class='pageno' id='Page_23'>23</span>In cases of twins, after one child is -expelled, either alone or with its secundines, -the discharge sometimes stops, -and the woman continues pretty well for -some hours, or even for a day or two, -when a repetition of the process takes -place, and if she have been using any -exertion, there is generally a pretty rapid -and profuse discharge. This is one -reason, amongst many others, for confining -women to bed for several days -after abortion.</p> - -<p class='c010'>There is generally, for a longer or -shorter time before the commencement -of abortion, a pain and other irregular -actions in the neighbouring parts, which -give warning of its approach before either -discharge or contraction take place, -unless when it proceeds from violence, -in which case the discharge may instantly -<span class='pageno' id='Page_24'>24</span>appear. This is the period at -which we can most effectually interfere -for the prevention of abortion.</p> - -<p class='c010'>I need not be particular in adding, that -we are not to confound these symptoms -with the more chronic ailments which -accompany pregnancy. Similar disturbances -in the action of the neighbouring -parts are very commonly found to precede -labour at the full time; and even -then we may, by proper means, postpone -or retard expulsion for some hours -or days.</p> - -<p class='c010'>A great diversity obtains in different -instances with regard to the symptoms -and duration of abortion. In some cases -the pains are very severe and long continued; -in others, short and trifling. -Sometimes the hæmorrhage is profuse -<span class='pageno' id='Page_25'>25</span>and alarming: at other times, although -circumstances may not be apparently -very different, it is moderate or inconsiderable. -Often the sympathetic effects -on the stomach and bowels are -scarcely productive of inconvenience, -whilst in a greater number of instances -they are very prominent symptoms.</p> - -<p class='c010'>I may only add, that, <i><span lang="la" xml:lang="la">cæteris paribus</span></i>, -we shall find that the farther that the -pregnancy is advanced beyond the third -month, and the nearer it approaches to -the end of the sixth, the less chance is -there of abortion being accompanied, -but the greater of its being succeeded, by -nervous affection.</p> - -<p class='c010'>As there is a diversity in the symptoms, -so is there also in the duration of -abortion; for, whilst a few hours in -<span class='pageno' id='Page_26'>26</span>many, and not above three days in the -majority of cases, is sufficient to complete -the process, we find other instances -in which it is threatened for a long -time, and a number of weeks elapse before -the expulsion take place.</p> - -<div class='nf-center-c0'> - <div class='nf-center'> - <div><span class='large'>∽∽∽∽</span></div> - </div> -</div> - -<h3 class='c007'><em>Of the Causes giving rise to Abortion.</em></h3> - -<p class='c008'>Abortion may very properly be divided -into accidental and habitual. The -exciting causes of the first class may, in -general, be easily detected; those giving -rise to the second are often more obscure; -and, without great attention, the -woman will go on to miscarry, until -<span class='pageno' id='Page_27'>27</span>either sterility, or some fatal disease, be -induced.</p> - -<p class='c010'>In many cases there can be no peculiar -pre-disposing cause of abortion: as, -for instance, when it is produced by -blows, rupture of the membranes, or -accidental separation of the decidua: -but when it occurs without any very -perceptible exciting cause, it is allowable -to infer, that some pre-disposing -state exists; and this generally consists -in an imperfect mode of uterine action, -induced by age, former miscarriages, -and other causes.</p> - -<p class='c010'>It is well known, that women can -only bear children until a certain age; -after which, the uterus is no longer capable -of performing the action of gestation, -or of performing it properly. Now, -<span class='pageno' id='Page_28'>28</span>it is observable, that this incapability or -imperfection takes place sooner in those -who are advanced in life, before they -many, than in those who have married -and begun to bear children earlier. Thus -we find, that a woman who marries at -forty, shall be very apt to miscarry; -whereas, had she married at thirty, she -might have born children when older -than forty; from which it may be inferred, -that the organs of generation -lose their power of acting properly -sooner, if not employed, than in the -connubial state.</p> - -<p class='c010'>The same cause which tends to induce -abortion at a certain age in those -who have remained until that time single, -will also, at a period somewhat later, -induce it in those who have been younger -married: for in them we find, that, after -<span class='pageno' id='Page_29'>29</span>bearing several children, it is not uncommon -to conclude with an abortion; -or, sometimes after this incomplete action, -the uterus, after a considerable -time, recruits, as it were, and the woman -carries a child to the full time, after -which she ceases to conceive.</p> - -<p class='c010'>In the next place, I mention that one -abortion paves the way for another, because, -setting other circumstances aside, -it gives the uterus a tendency to stop its -action of gestation at an early period after -conception, and therefore it is difficult -to make a woman go to the full -time, after she has miscarried frequently.</p> - -<p class='c010'>We also find that an excessive or indiscriminate -use of venery either destroys -the power of the organs of generation -<span class='pageno' id='Page_30'>30</span>altogether, making the woman -barren, or it disposes to abortion, by enfeebling -these organs.</p> - -<p class='c010'>Some slight change of structure in -part of the uterus, by influencing its actions, -may, if it do not prevent conception, -interfere with the process of -gestation, and produce premature expulsion. -If, however, the part affected -be very small, and near the os uteri, it is -possible for pregnancy to go on to the -full time. Indeed, it generally does go -on, and the labour, as may be foreseen, -will be very tedious; but the operation -of cutting the indurated os uteri, which -has been proposed, is seldom necessary.</p> - -<p class='c010'>I have known one instance, in -which a very considerable part of the -uterus, I may say almost the whole of -<span class='pageno' id='Page_31'>31</span>it, was found, after delivery, to be extremely -hard, and nearly ossified: but -this state could not have existed before -impregnation took place, for I cannot -conceive that so great a proportion of -the uterus should have been originally -diseased, and yet that conception, and -its consequent actions, should take place; -but there is no difficulty in supposing, -that, during the enlarging of the uterus, -the vessels deposited osseous or cartilaginous -matter, instead of fibres. In this -case, it is evident that the delivery must -be instrumental, owing to the deficiency -of fibres, and recovery can seldom take -place. Often we find this morbid action -affect the placenta, instead of the -uterus; but this is not dangerous.</p> - -<p class='c010'>A general weakness of the system, -which must affect the actions of the uterus, -<span class='pageno' id='Page_32'>32</span>in common with those of other organs, -is likewise to be considered as -giving rise to abortion, though not so -frequently as was at one time supposed. -The uterus is not only affected by the -general conditions of the system, more -especially with regard to sensibility, and -the state of the blood-vessels; but it likewise -sympathizes with the principal organs, -and may undergo changes in consequence -of alterations in their state.</p> - -<p class='c010'>Thus we often find that loss of tone, -or diminished action of the stomach, -produces amenorrhœa; and it may also -on the same principle induce abortion; -on the other hand, the action of the uterus -may influence that of other viscera, -as we see in pulmonary consumption, -which is sometimes suspended in its progress -during pregnancy; or, if there be -<span class='pageno' id='Page_33'>33</span>any disposition in an organ to disease, -frequent abortion, partly by sympathy -betwixt the uterus and that organ, and -partly by the weakness which it induces, -and the general injury which it does to -the system at large, may excite the irregular -or morbid action of the organ so -disposed.</p> - -<p class='c010'>As the action of the uterus is increased -during pregnancy, it must require more -nervous energy; but the size of the -nerves of the uterus is not increased in -proportion to the action; we must therefore -depend for the increased supply -upon the trunks, or larger portion of -nervous substance, from which they -arise, for we well know that the quantity -of energy expended in an organ, -does not depend upon the size of the -<span class='pageno' id='Page_34'>34</span>nerve in its substance, but on the trunk -which furnishes it. Whenever action is -increased in an organ, it must either -perish, or the larger nerve must send -the branches more energy, for the -branches themselves cannot form it, -their extremities being only intended for -expending it: from which it follows, -that in pregnancy there must be more -energy sent to the uterus, and less to -some other part.</p> - -<p class='c010'>This is the case with all organs whose -action is increased, other parts being -deprived in proportion as they are supplied, -except when irritation raises general -action above the natural degree; -the consequence of which is, that the -power is not sufficient for the action, -which becomes irregular, and the system -<span class='pageno' id='Page_35'>35</span>is exhausted, as we see in febrile -conditions<a id='r5' /><a href='#f5' class='c009'><sup>[5]</sup></a>.</p> - -<p class='c010'>There being increased action of the -uterus in gestation, requiring an increased -quantity of energy to support it, -we find that the system is put <i><span lang="la" xml:lang="la">pro tempore</span></i> -into an artificial state, and obliged -either to form more energy, which cannot -be so easily done, or to spend less in -some other part. Thus the function of -nutrition, or the action by which organic -matter is deposited, in room of -that which is absorbed, often yields, or -is lessened, and the person becomes emaciated, -or the stomach has its action diminished, -<span class='pageno' id='Page_36'>36</span>or the bowels producing costiveness -and inflation. If no part give -way, and no more energy than usual be -formed, gestation cannot go on, or goes -on imperfectly. Hence some women -have abortion induced by being too vigorous; -that is to say, all the organs -persist in keeping up their action in perfection -and complete degree.</p> - -<p class='c010'>A tendency to abortion also results -from a contrary cause, from organs yielding -too readily, allowing the uterus to -act too easily. In this state it is as liable -to go wrong, as the general system -is when it is at the highest degree of -action, compatible with health, the most -trifling cause deranges it. Thus, sometimes, -the intestines yield too readily, -and become almost torpid, so that a -stool can with difficulty be procured. -<span class='pageno' id='Page_37'>37</span>Here costiveness is not a cause of abortion, -though it may be blamed. In like -manner, the muscular system may yield -and become enfeebled; and in this instance -debility is accused as the cause of -abortion, although it be, indeed, only -an effect of too much energy being destined -for the uterus. In this case, the -woman is always weaker during menstruation -and gestation than at other -times.</p> - -<p class='c010'>Now this is not a piece of idle speculation, -but is of much practical importance, -especially in considering the -means of correcting habitual abortion; -and much attention should be paid to -the state of the principal organs in the -body; for, if we confine our attention -merely to the uterus, we shall often fail -when otherwise we might succeed; and -<span class='pageno' id='Page_38'>38</span>it will be necessary to remember, that -the chain of sympathies in gestation is -often extensive and complicated.</p> - -<p class='c010'>The state of the stomach, for example, -may give rise to head-ach, tooth-ach, -&c. and often it is dangerous suddenly -to remove these remote effects. It -throws too much energy to the uterus; -its action is too much exerted; contraction -and abortion take place: but in the -unimpregnated state, the removal of -these effects may, on the contrary, be -useful: thus the pulling of a pained -tooth sometimes speedily produces the -return of the menses in cases of obstruction.</p> - -<p class='c010'>If the neighbouring parts do not accommodate -themselves to the changes -in the direction of energy, and act in -<span class='pageno' id='Page_39'>39</span>concert with the uterus, their action becomes -irregular, and consequently painful. -In this case the uterus may have -its just degree of power and action; but -other parts may not be able to act so -well under the change of circumstances. -This is chiefly the case in early gestation, -for, by time, the parts come to act -better. It often gives rise to unnecessary -alarm, being mistaken for a tendency -to abortion; but the symptoms are -different. The pain is felt chiefly at -night, a time at which weakened parts -always suffer most; it returns pretty regularly -for several weeks, but the uterus -continues to enlarge, the breasts to -distend, and all things are as they ought -to be, if we except the presence of the -pain. This may be alleviated sometimes -by anodynes, but can only be cured by -time, and avoiding, by means of rest -<span class='pageno' id='Page_40'>40</span>and care, any additional injury to parts -already irregular and ticklish in the performance -of their actions. If this be -neglected, they will re-act on the uterus -at last, and impede its function.</p> - -<p class='c010'>Even although the different organs, -both near and remote, may have accommodated -themselves to the changes in -the uterine action, in the commencement -of gestation, the proper balance -may yet be lost at a subsequent period; -and this is most apt to take place about -the end of the third, or beginning of the -fourth month, when the uterus is rising -out of the pelvis; and hence a greater -number of abortions take place at that -time than at any other stage of pregnancy. -There is from that time, to the -period of quickening, a greater susceptibility -in the uterus to have its action -<span class='pageno' id='Page_41'>41</span>interrupted, than either before or afterwards, -which points out the necessity -of redoubling our vigilance in watching -against the operation of any of the causes -giving rise to abortion from the tenth to -the sixteenth week.</p> - -<p class='c010'>If the uterus, in its unimpregnated -state, become very torpid, as in some -cases of amenorrhœa, the abdominal -muscles sometimes have their action -much increased; and there is absolutely -an attempt made to expel it, violent paroxysms -of contraction coming on, and -repeated daily for a length of time.</p> - -<p class='c010'>These may be lessened by opiates, but -can only be cured by exciting the natural -action of the uterus. I mention this -fact, from its singularity, although it do -not immediately refer to abortion.</p> - -<p class='c010'><span class='pageno' id='Page_42'>42</span>If the action of gestation go on under -restraint, as, for instance, by a change -of position in the uterus, or by its prolapsing -too low in the vagina, it is very -apt to be accompanied by uneasy feelings, -for, whenever any action is constrained, -sensation is produced. The -woman feels irregular, and pretty sharp -pains in the region of the uterus, and -from sympathetic irritation both the -bladder and rectum may be affected, -and occasionally a difficulty is -felt in making water, by which a suspicion -is raised that retroversion is taking -place.</p> - -<p class='c010'>Sometimes the cervical vessels in these -circumstances yield a little blood, as if -abortion were going to happen; but by -keeping the patient at rest, and attending -to the state of the rectum and bladder, -<span class='pageno' id='Page_43'>43</span>no harm is done: and when the -uterus rises out of the pelvis, no farther -uneasiness is felt.</p> - -<p class='c010'>Retroversion of the uterus likewise -constrains very much its action, and -may give rise to abortion, though in a -greater number of instances, by care, -gestation will go on, and the uterus gradually -ascend.</p> - -<p class='c010'>Sometimes in irritable or hysterical -habits, the process of gestation produces -a considerable degree of disturbance in -the actions of the abdominal viscera, -particularly the stomach, exciting frequent -and distressing retching or vomiting, -which may continue for a week or -two, and sometimes is so violent, as to -invert the peristaltic motion of the intestines -near the stomach, in which case -<span class='pageno' id='Page_44'>44</span>feculent matter, and, in some instances, -lumbrici, are vomited.</p> - -<p class='c010'>This affection is often accompanied -by an unsettled state of mind, which -adds greatly to the distress. We sometimes, -in these circumstances, have painful -attempts made by the muscles to force -the uterus downward, and these are occasionally -attended by a very slight discharge -of blood. We have, however, -no regular uterine pain; and, if we are -careful of our patient, abortion is rarely -produced.</p> - -<p class='c010'>The best practice is to take away a -little blood at first, to keep the bowels -open, to lessen the tendency to vomit, -by applying an opium plaster, or a small -blister, to the region of the stomach, -and to allay pain by doses of hyocyamus -<span class='pageno' id='Page_45'>45</span>or opium, conjoined with carminatives. -When the mind is much affected, or the -head painful, it is proper to shave the -head, and wash it frequently with cold -vinegar, or apply a blister at the same -time that we keep the patient very quiet, -and have recourse to a soothing management.</p> - -<p class='c010'>The uterus being a large vascular organ, -is obedient to the laws of vascular -action, whilst the ovum is more influenced -by those regulating new-formed -parts; with this difference, however, -that new-formed parts or tumors are -united firmly to the part from which -they grow by all kinds of vessels, and -generally by fibrous or cellular substance, -whilst the ovum is united to the -uterus only by very tender and fragile -arteries and veins. If, therefore, more -<span class='pageno' id='Page_46'>46</span>blood be sent to the maternal part of the -ovum, than it can easily receive and circulate -and act under, rupture of the vessels -will take place, and an extravasation -and consequent separation be produced; -or, even when no rupture is occasioned, -the action of the ovum may -be so oppressed and disordered, as to -unfit it for continuing the process of gestation. -There must, therefore, be a perfect -correspondence betwixt the uterus -and the ovum, not only in growth and -vascularity, but in every other circumstance -connected with their functions.</p> - -<p class='c010'>Even when they do correspond, if the -uterus be plethoric, the ovum also must -be full of blood, and rupture very apt -to take place; and this is a frequent -cause of abortion, more especially in -those who menstruate copiously. On -<span class='pageno' id='Page_47'>47</span>the other hand, when the uterus is deficient -in vascularity, which often happens -in those who menstruate sparingly -or painfully, the child generally dies before -the seventh month, and is expelled. -The process is prematurely and imperfectly -finished.</p> - -<p class='c010'>Abortion necessarily implies separation -of the ovum, which may be produced -mechanically or by spontaneous -rupture of the vessels, or by an affection -of the muscular fibres. It unavoidably -requires, for its accomplishment, contraction -of those fibres which formerly -were in a dormant state. A natural and -necessary effect of this contraction is to -develope the <span lang="la" xml:lang="la">cervex uteri</span>.</p> - -<p class='c010'>This, when gestation goes on regularly, -is accomplished gradually and -<span class='pageno' id='Page_48'>48</span>slowly by the extension and formation -of fibres. In abortion, no fibres are -formed; but muscular action does all, -except in those instances where the action -of gestation goes on irregularly and -too fast; in which case the cervix distends, -sometimes by the third month, by -the same process which distends the -fundus. But much more frequently the -cervix only relaxes during abortion, as -the os uteri does in natural labour, and -yields to the muscular action of the fundus, -or distended part.</p> - -<p class='c010'>The existence and growth of the fœtus -depends on the fœtal portion of the -ovum. The means of nourishment, and -the accommodation of the fœtus in respect -of lodgement, depend on the uterus; -and these circumstances requiring -both fœtal and maternal action, are intimately -<span class='pageno' id='Page_49'>49</span>connected. The condition of the -uterus qualifying it to enlarge, to continue -the existence and operation of the -maternal portion of the placenta or -ovum, and to transmit blood to the -ovum, exactly in the degree correspondent -to its wants, constitutes the action -of gestation.</p> - -<p class='c010'>When this condition ceases, then muscular -contraction begins, provided the -cessation be universal in the uterus. This -is necessary, for as the fœtal and maternal -actions are dependent on each other, -the fœtus would suffer if it were not -expelled. The injury, indeed, will not -be immediate; otherwise, in labour, the -child would die before it could be born, -because labour implies a cessation of the -action of gestation. On the other hand, -the loss of action in the fœtal part will -<span class='pageno' id='Page_50'>50</span>soon influence the maternal part, and -stop its action.</p> - -<p class='c010'>In labour, and at other times, when -the action of gestation ceases, the circulation -is still kept up in the maternal -vessels of the placenta, until either separation -and expulsion take place, or the -vessels suffer so much as to cease to transmit -blood. The cessation of action then -does not necessarily immediately affect -the fœtus. As long as it, and the fœtal -portion of the ovum connected with it, -remain stationary, the same quantity of -blood will do. But the uterus cannot -now increase its actions along with those -of the fœtus, so as gradually to enlarge -and send more blood.</p> - -<p class='c010'>This is one cause of disagreement. -Another is, that, in consequence of cessation -<span class='pageno' id='Page_51'>51</span>of action in the uterus, the maternal -portion of the placenta or ovum -ultimately suffers, and flags or decays, -whilst the fœtal portion must sympathize -with it.</p> - -<p class='c010'>From this it results, first, that even -in tedious labour the child does not die: -secondly, that when the action ceases in -the early months of pregnancy, the fœtus -does not instantly die, nor abortion -immediately take place: thirdly, but it -invariably happens, that, at whatever -period the action ceases, the fœtus will, -if not expelled within a certain time, -perish.</p> - -<p class='c010'>I have elsewhere<a id='r6' /><a href='#f6' class='c009'><sup>[6]</sup></a> endeavoured to -<span class='pageno' id='Page_52'>52</span>prove, that we have a certain quantity of -action present in the system at large, -and properly distributed amongst the -different organs, forming an equilibrium -of action; and that if one organ act in -an over degree, another, which is connected -with it, will have its action lessened, -and <i><span lang="la" xml:lang="la">vice versa</span></i>.</p> - -<p class='c010'>The same holds true with regard to -different actions belonging to the same -organ; and the fact is of considerable -importance, both in explaining and curing -diseases. During pregnancy, the -muscular fibres of the uterus are dormant, -possessing no contractile action; -at least, none qualifying them for contracting, -so as to make the uterus -smaller.</p> - -<p class='c010'>I doubt much if even the individual -<span class='pageno' id='Page_53'>53</span>fibres possess a power of alternately contracting -and relaxing, as in other muscles, -in any degree whatever. But, -whenever the action of gestation ceases, -action is communicated to these fibres; -and whenever this loss on the one part, -and gain upon the other, is universally -begun in the womb, the transference -will be completed, and the ovum can -no longer be preserved in the uterus.</p> - -<p class='c010'>The loss of action is generally speedy, -when once begun. Perhaps in most instances -it takes place instantaneously, -and then the fibres begin individually to -act; but they may not, for some hours, -contract universally, and all at one and -the same time producing pains.</p> - -<p class='c010'>But if some other organ shall receive -the surplus of action, or the transferred -<span class='pageno' id='Page_54'>54</span>action, then the uterine fibres either will -not contract, or will receive an inferior -and insufficient degree of action, and -expulsion will not take place until the -organ sympathizing shall cease to have -the increased action, whether it be the -brain, the stomach, or the external muscles -of the body. Sometimes also the -action seems to be divided betwixt the -uterus and other organs, or they alternate -in their actions.</p> - -<p class='c010'>This fact is of importance in explaining -and correcting many of the irregularities -attending labour, which it would -be impossible here to specify.</p> - -<p class='c010'>Sometimes the action is chiefly -communicated to one part of the uterine -fibres, whilst the rest are more torpid; -and this part contracts in an undue degree, -<span class='pageno' id='Page_55'>55</span>clasping the child firmly, and retarding -labour<a id='r7' /><a href='#f7' class='c009'><sup>[7]</sup></a>; and, after expulsion, -it is apt to return, and retain the placenta, -<span class='pageno' id='Page_56'>56</span>whilst the rest of the uterus becomes -torpid, producing flooding.</p> - -<p class='c010'>If, then, the action of gestation cease -universally in the uterus, another action, -namely, muscular contraction, begins, -and then all hope of retaining the ovum -any longer is at an end. I know that -we have been told of instances where -contraction, after beginning, stopped for -several weeks.</p> - -<p class='c010'>The os uteri may be prematurely developed; -it may be open for some weeks, -even without pain; but no man will -say that, in this case, labour or uterine -contraction has begun. We may even -have partial muscular action, in a few -very rare cases, about the os uteri, which -has less to do with the action of gestation -than any other part of the uterus; -<span class='pageno' id='Page_57'>57</span>but regular and universal action of the -muscular fibres never yet has been stopped. -It may, like other muscular actions, -be suspended by anodynes or artificial -treatment; but it never has, and -never can be stopped, otherwise than by -the expulsion of the ovum, when a new -train of actions commence.</p> - -<p class='c010'>Whenever, then, at any period of -pregnancy, we have paroxysms of pain -in the back, and region of the uterus, -more especially if these be attended with -feeling of weight in that region, tenesmus, -micturition, descent of the uterus -in the pelvis, and opening of the os -uteri, we may be sure that expulsion, -though retarded, will soon take place.</p> - -<p class='c010'>This fact is not always attended to in -abortion, for many think that if by anodynes -<span class='pageno' id='Page_58'>58</span>they can abate the pain, they will -make the woman go to the full time.—This -is true, with regard to many painful -sensations, which may attend a -threatened abortion, or which may be -present, although there be no appearance -of abortion; but it does not hold -with regard to those regular pains proceeding -from universal action of the uterine -fibres; and we may save both ourselves -and our patients some trouble, by -keeping this in remembrance.</p> - -<p class='c010'>Seeing, then, that contraction is -brought on by stopping the action of -gestation, and that when it is brought -on it cannot be checked, nor the action -of gestation restored, we must next enquire -how this action may be stopped. -I have already mentioned several circumstances -affecting the uterus, and -<span class='pageno' id='Page_59'>59</span>likely to injure its actions; and these I -shall not repeat, but go on to notice -some others, which are often more perceptible; -and first I shall mention violence, -such as falls, blows, and much -fatigue, which may injure the child, and -detach part of the ovum.</p> - -<p class='c010'>If part of the ovum be detached, we -have not only a discharge of blood, but -also the uterus, at that part, suffers in -its action, and may influence the whole -organ, so as to stop the action universally. -But the time required to do this -is various, and opportunity is often given -to prevent the mischief from spreading, -and to stop any farther effusion—perhaps -to accomplish a re-union.</p> - -<p class='c010'>Violent exercise, as dancing, for instance, -or much walking, or the fatigueing -<span class='pageno' id='Page_60'>60</span>dissipations of fashionable life, more -especially in the earlier months, by affecting -the circulation, may vary the -distribution of blood in the uterus, so -much as to produce rupture of the vessels, -or otherwise to destroy the ovum. -There is also another way in which fatigue -acts, namely, by subducting action -and energy from the uterus: for -the more energy that is expended on the -muscles of the inferior extremities, the -less can be afforded or directed to the -uterus; and hence abortion may be induced -at an early stage of gestation<a id='r8' /><a href='#f8' class='c009'><sup>[8]</sup></a>.</p> - -<p class='c010'><span class='pageno' id='Page_61'>61</span>Even at a more advanced period, inconvenience -will be produced upon the -principle formerly mentioned; for the -nerves of the loins conveying less energy, -in many instances, though not always -to the muscles, they are really -weaker than formerly, and are sooner -wearied, producing pain, and prolonged -feeling of fatigue, for many days, after -an exertion which may be considered -as moderate.</p> - -<p class='c010'>This feeling must not be confounded -with a tendency to abortion, though it -may sometimes be combined with it, for -generally by rest the sensation goes off. -Neither must we suppose that the child -is dead, from its being usually quiet during -that period, for as soon as the uterus, -which has been a little impaired in -<span class='pageno' id='Page_62'>62</span>its action, recovers, it moves as strongly -as ever.</p> - -<p class='c010'>In the next place, I mention the death -of the child, which may be produced by -syphilis, or many diseases perhaps peculiar -to itself, or by injury of the functions -of the placenta. But in whatever -way it is produced, the effect is the same -in checking the action of gestation, unless -there be twins, in which case it has -been known that the uterus sometimes -did not suffer universally, but the action -went on, and the one child was born of -the full size, the other small and injured<a id='r9' /><a href='#f9' class='c009'><sup>[9]</sup></a>.</p> - -<p class='c010'><span class='pageno' id='Page_63'>63</span>The length of time required for producing -abortion from this cause is various; -sometimes it is brought on in a few -hours: at other times not for a fortnight, -or even longer. In these and similar -cases, when the muscular action is -commencing, the discharge is trifling, -like menstruation, until the contraction -becomes greater, and more of the ovum -be separated.</p> - -<p class='c010'>A third cause is a disproportioned action -betwixt the uterus and ovum, the -<span class='pageno' id='Page_64'>64</span>one not increasing in the same ratio with -the other, yet both continuing to act. -This is productive of frequent discharges -of blood, repeated at different, but always -at short intervals, for several weeks, -until at length the uterus suffers so much, -that its action stops, or the fœtus dies.</p> - -<p class='c010'>Another cause is, any strong passion -of the mind. The influence of fear, joy, -and other emotions on the muscular -system, is well known; and the uterus -is not exempted from their power; any -sudden shock, even of the body, has -much effect on this organ. The pulling -of a tooth, for instance, sometimes suddenly -produces abortion.</p> - -<p class='c010'>Emmenagogues, or acrid substances, -such as savine and other irritating drugs, -more especially those which tend to excite -<span class='pageno' id='Page_65'>65</span>a considerable degree of vascular -action, may produce abortion.</p> - -<p class='c010'>Such medicines, likewise, as exert a -violent action on the stomach or bowels -will, upon the principle formerly mentioned, -frequently excite abortion; and -very often are taken designedly for that -purpose in such quantity as to produce -fatal effects; and here I must remark, -that many people at least pretend to -view attempts to excite abortion as different -from murder, upon the principle -that the embryo is not possessed of life, -in the common acceptation of the word. -It undoubtedly can neither think nor -act; but, upon the same reasoning, we -should conclude it to be innocent to kill -the child in the birth.</p> - -<p class='c010'>Whoever prevents life from continuing, -until it arrive at perfection, is certainly -<span class='pageno' id='Page_66'>66</span>as culpable as if he had taken it -away after that had been accomplished. -I do not, however, wish, from this observation, -to be understood as in any -way disapproving of those necessary attempts -which are occasionally made to -procure premature labour, or even abortion, -when the safety of the mother demands -this interference, or when we can -thus give the child a chance of living, -who otherwise would have none.</p> - -<p class='c010'>If any part with which the uterus -sympathizes have its action greatly increased -during pregnancy, the uterus -may come to suffer, and abortion be -produced. Hence the accession of morbid -action or inflammation in any important -organ, or on a large extent of -cuticular surface, may bring on miscarriage, -which is one cause why smallpox -often excites abortion, whilst the -<span class='pageno' id='Page_67'>67</span>same degree of fever, unaccompanied -with eruption, would not have had that -effect.</p> - -<p class='c010'>Hence also increased secretory action -in the vagina, if to a great degree, though -it may have even originally been excited -in consequence of sympathy with -the uterus, may come to incapacitate -the uterus for going on with its actions, -and therefore it ought to be checked by -means of an astringent injection.</p> - -<p class='c010'>In this case the uterus has, without -any proof, been supposed to become too -much relaxed, whilst in other cases, as -for instance when the abdomen was -harder than usual, it has with as little -foundation been supposed to be preternaturally -rigid.</p> - -<p class='c010'><span class='pageno' id='Page_68'>68</span>Mechanical irritations of the os uteri, -or attempts to dilate it prematurely, will -also be apt to bring on muscular contraction. -At the same time, it is worthy -of remark, that the effect of these irritations -is generally at first confined to -the spot on which they act, a partial -affection of the fibres in the immediate -vicinity of the os uteri being all that is, -for some time, produced; and therefore -slight uneasiness at the lower part of the -belly, with or without a tendency in -the os uteri to move or dilate, whether -brought on by irritation at the upper -part of the vagina or os uteri, or by affection -of the neck, of the bladder, &c.<a id='r10' /><a href='#f10' class='c009'><sup>[10]</sup></a> -<span class='pageno' id='Page_69'>69</span>may be often prevented from extending -farther, and destroying the action of -<span class='pageno' id='Page_70'>70</span>gestation by rest, anodynes, and having -immediate recourse to such means as the -nature of the irritation may require for -its removal.</p> - -<p class='c010'>Tapping the ovum, by which the uterus -collapses and its fibres receive a stimulus -to action, is another cause by -which abortion may be produced; and -this is sometimes, with great propriety, -done at a particular period, in order to -avoid a greater evil.</p> - -<p class='c010'>It is now the general opinion, that -contraction will unavoidably follow the -evacuation of the waters. But we can -suppose the action of gestation to be in -some cases so strong as not to stop in -consequence of this violence, and, if it -do not stop, contraction will not take -place. I do not, however, mean to say, -that all discharges of watery fluid from -<span class='pageno' id='Page_71'>71</span>the uterus, not followed by abortion, -are discharges of the liquor amnii, and -instances of this failing to produce contraction. -On the contrary, I know that -most of these are the consequence of -morbid action about the os uteri, the -glands yielding a serous instead of a gelatinous -fluid, and this action may continue -for many months.</p> - -<p class='c010'>Sometimes the upper range of lacunæ -yields water, whilst the under secretes -jelly, which confines the water for some -hours, until it accumulates, and comes -out with a small gush. At other times, -in the early period of gestation, it collects -in considerable quantity betwixt -the lower part of the decidua protrusa, -which has not yet reached the cervix -uteri and the cervical efflorescence, which -becomes a little stronger than usual.</p> - -<p class='c010'><span class='pageno' id='Page_72'>72</span>There is thus a species of dropsy produced, -and the water is sometimes confined -until a little before labour comes -on; at other times it is discharged -sooner, and an oozing continues for -many weeks. In all these cases, we -may derive some advantage from injecting -three or four times a day a strong -infusion of galls. The woman ought to -use no exertion, as the membranes are -apt to give way.</p> - -<p class='c010'>When the liquor amnii really is evacuated, -sometimes a spasmodic contraction -of the fibres near the cervix takes -place, instead of that regular action -which is necessary for expulsion; and if -the whole of the liquor have not escaped, -the remaining portion will be confined -by the tightening of that part of the uterus -round the fœtus; and this contraction -may endure for a very considerable -<span class='pageno' id='Page_73'>73</span>time. If not interrupted, it may lay -the foundation of future diseases in the -uterus.</p> - -<div class='nf-center-c0'> - <div class='nf-center'> - <div><span class='large'>∽∽∽∽</span></div> - </div> -</div> - -<h3 class='c007'><em>Of the Prognosis.</em></h3> - -<p class='c008'>The danger of abortion is to be estimated -by considering the previous state -of the health, by attending to the violence -of the discharge, and the difficulty -of checking it; to its duration, and the -disposition to expulsion which accompanies -it; to the effects which it has produced -in weakening the system, and to -its combination with hysterical or spasmodic -affections. In general, we say -that abortion is not dangerous, yet in -some cases it does prove fatal very speedily, -<span class='pageno' id='Page_74'>74</span>either from loss of blood, or spasms -about the stomach, or convulsions.</p> - -<p class='c010'>It is satisfactory, however, to know, -that this termination is rare, that these -dangerous attendants are seldom present, -and that a great hemorrhage may -be sustained, and yet the strength soon -recover. But if there be any disposition -in a particular organ to disease, abortion -may make it active, and thus, at a remote -period, carry off the patient. Frequently -repeated miscarriages are also -very apt to injure the health, and break -up the constitution.</p> - -<p class='c010'>When abortion is threatened, the process -is very apt to go on to completion; -and it is only by interposing, before it -is fairly begun, that we can be successful -in preventing it, for whenever the -muscular action is established, nothing, -<span class='pageno' id='Page_75'>75</span>I believe, can check the process. As -this is often the case before we are called, -or, as in many instances it depends on -the action of gestation being stopped by -causes, whose action could not be ascertained -until the effect be produced, we -shall oftener fail than succeed in preventing -expulsion.</p> - -<p class='c010'>This is greatly owing to our not being -called until abortion has begun; -whereas, had we been applied to upon -the first unusual feeling, it might have -been prevented. What I wish then -particularly to inculcate is, that no time -be lost in giving notice of any ground of -alarm, and that the most prompt measures -be had recourse to in the very beginning, -for when uterine contraction -has commenced, then all that we can -do is to conduct the patient safely thro’ -<span class='pageno' id='Page_76'>76</span>a confinement, which the power of medicine -cannot prevent.</p> - -<p class='c010'>The case of threatened abortion, in -which we most frequently succeed, is -that arising from slipping of the foot, or -similar causes, producing a slight separation, -because here the hemorrhage immediately -gives alarm, and we are called -before the action of gestation be much -affected.</p> - -<p class='c010'>Could we impress upon our patients -the necessity of equal attention to other -preceding symptoms and circumstances, -we might succeed in many cases where -we fail from a delay, occasioned by their -not understanding that an abortion can -only be prevented by interfering before -it begins, but that, when sensible signs -of it appear, the mischief has proceeded -too far to be checked.</p> - -<div> - <span class='pageno' id='Page_77'>77</span> - <h3 class='c007'><em>Of the Prevention and Treatment of Abortion.</em></h3> -</div> - -<p class='c008'>In considering the treatment, I shall -first of all notice the most likely method -of preventing abortion in those who are -subject to it; next, the best means of -checking it, when it is immediately -threatened; and, lastly, the proper method -of conducting the woman through -it, when it cannot be avoided.</p> - -<p class='c010'>The means to be followed in preventing -what may be called habitual miscarriage, -must depend on the cause supposed -to give rise to it. It will, therefore, -be necessary to attend to the history -of former abortions; to the usual -habitudes and constitution of the woman; -<span class='pageno' id='Page_78'>78</span>and to her condition when she -becomes pregnant.</p> - -<p class='c010'>In many instances a plethoric disposition, -indicated by a pretty full habit, -and copious menstruation, will be found -to give rise to it. In these cases; we -shall find it of advantage to restrict the -patient almost entirely to a vegetable -diet, and, at the same time, make her -use considerable and regular exercise.</p> - -<p class='c010'>The sleep should be abridged in quantity, -and taken not on a bed of down, -but on a firm mattress, at the same time -that we prevent the accumulation of too -much heat about the body. The bowels -ought to be kept open, or rather loose, -which may be effected by drinking Cheltenham -water: and this can be artificially -prepared, if necessary.</p> - -<p class='c010'><span class='pageno' id='Page_79'>79</span>There is, in plethoric habits, a weakness -of many, if not all, of the functions; -but this is not to be cured by tonics, -but by continued and very gradually -increased exercise, with light diet, -consisting chiefly of vegetables.</p> - -<p class='c010'>This plan, however, must not be carried -to an imprudent length, nor established -too suddenly; but regard is to -be had to the previous habits. It is a -general rule, that exercise should not be -carried the length of fatigue, and that -it should be taken, if possible, in the -country, whilst late hours, and many of -the modes of fashionable life, must be -departed from. We may also derive so -considerable advantage from conjoining -with this plan, the shower bath, or sea -bathing, that they ought not to be omitted.</p> - -<p class='c010'><span class='pageno' id='Page_80'>80</span>After conception, the exercise must -be taken with circumspection; but the -diet should still be sparing, and the use -of the cold bath continued. If the pulse -be at any time full, or inclined to throb, -a little blood should be taken away; and -much advantage will be derived in all -these cases, by using the digitalis, so as -to affect the pulse. Half a grain may be -given, so often as may be found necessary, -to bridle the circulation. It may -be continued for two days, and then -omitted for a day; and in this way it -may be continued for a length of time; -but it is seldom necessary to give it regularly, -beyond the beginning of the -fourth month, unless a change of circumstances -afterwards require it.</p> - -<p class='c010'>The dose must be occasionally increased, -so as to produce the desired -<span class='pageno' id='Page_81'>81</span>effect; and I can vouch for the safety of -the plan.</p> - -<p class='c010'>Injecting cold water into the vagina, -twice or thrice a day, has often a good -effect, at the same time that we continue -the shower bath every morning. -When there is much aching pain in the -back, it is of service to apply cloths to -it, dipped in cold water, or gently to -dash cold water on it.</p> - -<p class='c010'>In this, and all other cases of habitual -abortion, we must advise that impregnation -shall not take place until we -have corrected the system; and after the -woman has conceived, it is requisite that -she live <span lang="la" xml:lang="la">absque marito</span>, at least until -gestation be far advanced. I need -scarcely add, that when consulted respecting -habitual abortion, the strictest -<span class='pageno' id='Page_82'>82</span>prudence is required on our part, and -that the situation of the patient, and -many of our advices, should be concealed -from the most intimate friends of -the patient.</p> - -<p class='c010'>In other cases, we find that the cause -of abortion is connected with sparing -menstruation. This is often the case -with women whose appearance indicates -good health, and who have a robust -look. This is not often to be rectified -by medicine, but it may by regimen, -&c. Here, as in the former case, -we find it useful to make the greatest -part of the diet consist of vegetables; -but it is not necessary to restrict the -quantity.</p> - -<p class='c010'>When, on the other hand, the patient -has a weakly delicate appearance, it will -<span class='pageno' id='Page_83'>83</span>be proper to give a greater proportion -of animal food, and two or three glasses -of wine, in the afternoon, with some -bitter laxative, twice a day, so as to -strengthen the stomach, and at the same -time keep the bowels open.</p> - -<p class='c010'>We also derive, in both cases, advantage -from the daily use of the warm -bath, made of a pleasant temperature; -but this is to be omitted after conception. -The internal use of the Bath waters -is often of service; or where the -circumstances of the patient will not -permit this, we may desire her to drink, -morning and evening, a pint of tepid -water, which may be continued during -gestation. Throwing up into the vagina -tepid salt water twice or thrice a day, -seems also to have a good effect.</p> - -<p class='c010'><span class='pageno' id='Page_84'>84</span>I have already mentioned, that abortion -is sometimes the consequence of too -firm action, the different organs refusing -to yield to the uterus, which is thus -prevented from enjoying the due quantity -of energy and action. These women -have none of the diseases of pregnancy, -or they have them in a slight degree. -They have good health at all times, but -they either miscarry, or have labour in -the seventh or eighth month, the child -being dead; or, if they go to the full -time, I have often observed the child to -be sickly, and of a constitution unfitting -it for living<a id='r11' /><a href='#f11' class='c009'><sup>[11]</sup></a>.</p> - -<p class='c010'><span class='pageno' id='Page_85'>85</span>We may sometimes cure this state by -giving half a grain of digitalis, and the -eighth part of a grain of the <span lang="la" xml:lang="la">tartris antimonii</span>, -every night at bed-time, which -diminishes the stomachic action. Bleeding -is also useful, by making the organs -more irritable. Exercise, so as to prove -tonic, is hurtful in this species of abortion; -instead of wishing to increase the -action of any organ, our object is to diminish -it, and make the different parts -more easily acted on.</p> - -<p class='c010'>The accidental accession of an hysteric -condition of the system, sometimes -spontaneously cures this state: and if -<span class='pageno' id='Page_86'>86</span>the patient have gone to the full time, -but bear an unhealthy child from this -cause; if she meet with any accident in -her confinement, inducing a nervous -condition, she is less apt afterwards to -miscarry, or have dead children.</p> - -<p class='c010'>There is another case in which all the -functions are healthy and firm, except -the circulation, which is accelerated by -the uterine irritation. This is more or -less the case in every pregnancy, but -here it is a prominent symptom. The -woman is very restless, and even feverish, -and apt to miscarry, especially if -she be of a full habit. Immediate relief -is given by venesection, and afterwards -we may, for some time, give every night -half a grain or a grain of digitalis, with -two grains of the extract of hyocyamus.</p> - -<p class='c010'><span class='pageno' id='Page_87'>87</span>When, on the contrary, abortion -arises, from too easy yielding of some -organ, we must keep down uterine action, -by avoiding venery, and injecting -cold water often into the vagina. Clysters -of cold water are also useful; at the -same time we must attend to the organ -sympathizing with the uterus.</p> - -<p class='c010'>Sometimes it is the stomach which is -irritable, and the person is often very -sick, takes little food, and digests ill. A -small blister, applied to the pit of the -stomach, often relieves this; a little of -the compound tincture of bark, taken -three or four times a day, is serviceable; -or a few drops of the tincture of muriated -iron in a tumbler glassful of aerated -water; at other times the bowels yield, -and the patient is obstinately costive. -This is best cured by manna, with the -<span class='pageno' id='Page_88'>88</span>tartarite of potash. When the muscular -system yields, producing a feeling of -languor and general weakness, the use -of the cold bath, with a grain of opium, -at bed time will be of most service.</p> - -<p class='c010'>It is evident that it is only by attending -minutely to the history of former -miscarriages, that we can detect these -causes; and we shall generally find, that -in each individual case it is the same organ -in every pregnancy which has yielded -or suffered. Previous to future conception, -we may, with propriety, endeavour -to render it less easily affected.</p> - -<p class='c010'>General weakness is another condition -giving rise to abortion; and upon -this I have already made some remarks. -I have here only to add, that the use of -the cold bath, the exhibition of the Peruvian -<span class='pageno' id='Page_89'>89</span>bark, and wearing flannel next -the skin, constitutes the most successful -practice.</p> - -<p class='c010'>Syphilis is likewise a cause of abortion. -When it occurs in the mother, it -often unfits the uterus for going on with -its actions. At other times, more especially -when the father labours under -venereal hectic, the child is evidently -affected, and often dies before the process -of gestation can be completed.</p> - -<p class='c010'>In these cases a course of mercury -alone can effect a cure. But we are not -to suppose that every child, born without -the cuticle in an early stage of pregnancy, -has suffered from this cause; on -the contrary, as the majority of these -instances depend on causes already mentioned, -and which cannot be cured by -<span class='pageno' id='Page_90'>90</span>mercury, I wish to caution the student -against too hastily concluding that one -of the parents has been diseased, because -the child is born dead or putrid in the -seventh month.</p> - -<p class='c010'>It is not always easy to form a correct -judgment; but we may be assisted -by finding that the other causes which I -have mentioned are absent; that we -have appearances of ulceration on the -child, and that there are some suspicious -circumstances in the former history -and present health of the parents.</p> - -<p class='c010'>Advancement in life, before marriage, -is another cause of frequent abortion, -the uterus being then somewhat imperfect -in its action. In general, we cannot -do much in this case, except avoiding -carefully the exciting causes of abortion, -<span class='pageno' id='Page_91'>91</span>and by attending minutely to the -condition of other organs during menstruation -or pregnancy, we may, from -the principles formerly laid down, do -some good.</p> - -<p class='c010'>It is satisfactory to know that, by -great care, although we may fail once -or twice, yet the uterus comes at last to -act more perfectly, and the woman bears -children at the full time.</p> - -<p class='c010'>After these observations, it is only -necessary to add, that in every instance -of habitual abortion, whatever the condition -may be which gives rise to it, we -find that it is essential that the greatest -attention be paid to the avoiding of the -more evident and immediate exciting -causes of miscarriage, such as fatigue, -dancing, &c. In some cases, it may -<span class='pageno' id='Page_92'>92</span>even be necessary to confine the patient -to her room, until the period at which -she usually aborts is past.</p> - -<p class='c010'>When abortion is threatened, we -come to consider whether and by what -means it can be stopped. I have already -stated my opinion, that when the action -of gestation ceases, it cannot be renewed, -and that general contraction of -the uterine fibres is a criterion of this -cessation.</p> - -<p class='c010'>Still, as some of the means which -may be supposed useful in preventing a -threatened abortion are also useful in -moderating the symptoms attending its -progress, we may very properly have -recourse to them. Some causes giving -rise to abortion, do not immediately -produce it, but give warning of their -<span class='pageno' id='Page_93'>93</span>operation, producing uneasiness in the -vicinity of the uterus, before the action -of that organ be materially affected.</p> - -<p class='c010'>The detraction of a little blood at this -time, if the pulse be in any measure full -or frequent, and the subsequent exhibition -of an anodyne clyster, or a full -dose of digitalis and opium, together -with a state of absolute rest for some -days, will often be sufficient to prevent -farther mischief, and constitute the most -efficacious practice.</p> - -<p class='c010'>This is the time at which we can interfere -with the most certain prospect of -success; and the greatest attention should -be paid to the state of the rest of the -system, removing uneasiness, wherever -it is present, and preventing any organ -from continuing in a state of undue action. -<span class='pageno' id='Page_94'>94</span>It is difficult to persuade the patient -to comply with that strict attention -which is necessary at this period; -but being persuaded that if this period -be allowed to pass over with neglect, -nothing can afterwards prevent abortion. -I wish particularly to impress the mind -of the student with a due sense of its -importance; and I must add, that as after -every appearance of morbid uterine -action is over, the slightest cause will -renew our alarm, it is necessary that -great attention be paid for some time to -the patient.</p> - -<p class='c010'>Often, instead of an uneasy feeling -about the loins, or lower belly, we have, -before the action of gestation stops, a -discharge of blood, generally in a moderate, -<span class='pageno' id='Page_95'>95</span>sometimes in a trifling degree. -This is more especially the case when -abortion is threatened, owing to an external -cause, and, if immediately checked, -we may prevent contraction from -beginning.</p> - -<p class='c010'>Even in those cases where we do not -expect to keep off abortion, it is useful -to prevent, as far as we can, the loss of -blood, for as I cannot see that the hemorrhage -is necessary for its accomplishment, -although it always attend it, -I conclude that our attempts to prevent -bleeding can never do harm, for if they -succeed in checking abortion, we gain -our object; if they fail, they do not increase, -but diminish the danger.</p> - -<p class='c010'>It should be carefully remembered, -that the more we can save blood, the -<span class='pageno' id='Page_96'>96</span>more do we serve our patient. As the -means for checking the discharge will -be immediately pointed out, it is unnecessary -here to enter into any detail.</p> - -<p class='c010'>Sometimes the vessels which furnish -the cervical efflorescence in the beginning -of gestation, do not assume that -action, but yield blood, which passes -for the menses, and makes the woman -mistake her condition. As the uterine -vessels increase in size, the discharge becomes -greater and more frequent. It is -now apt to pass for menorrhagia.</p> - -<p class='c010'>If it be allowed to continue, it tends -to injure the action of the uterus, and -produce expulsion, which sometimes is -the first thing which shews the woman -her situation. This discharge is best -managed by rest, and the frequent injection -<span class='pageno' id='Page_97'>97</span>of saturated solution of the sulphat -of alumine, or decoction of oak -bark.</p> - -<p class='c010'>When a slight discharge takes place, -in consequence of a slip of the foot, or -some other external cause, we may also -derive advantage from the use of the injection, -but not so certainly as in the -former case; and if the discharge be -considerable, the injection will fail. It -is better, in this case, to trust to the formation -of a coagulum.</p> - -<p class='c010'>In those cases, where uterine pain -precedes or accompanies the discharge, -abortion cannot be prevented; but when -the discharge precedes the pain, it sometimes -may. Rest is absolutely necessary, -if we wish the person to go to the -full time: and it is occasionally necessary -<span class='pageno' id='Page_98'>98</span>to confine her to bed for several -weeks, at the same time that we put her -upon an effective course of digitalis, and -give an anodyne at bed-time, taking care -also to keep the bowels in a proper state -by gentle medicine.</p> - -<p class='c010'>When we cannot prevent abortion, -the next thing is to conduct the patient -safely through the process; and the first -point which naturally claims our attention -is the hemorrhage. Many practitioners, -upon a general principle, bleed, -in order to check this, and prevent miscarriage: -but miscarriage cannot be prevented, -if the uterine contraction have -commenced; and the discharge cannot -be prudently moderated by venesection, -unless there be undue or strong action -in the vessels.</p> - -<p class='c010'><span class='pageno' id='Page_99'>99</span>This is not always the case, and therefore, -unless the vessels be at or above -the natural force or strength of action, -the lancet is not at this stage necessary. -The fulness and strength of the pulse -are lost much sooner in abortion than -can be explained, by the mere loss of -blood.</p> - -<p class='c010'>It depends on an affection of the stomach, -which has much influence on the -pulse; and the proper time for bleeding -is before this has taken place. When -abortion has made so much progress before -we are called, as to have rendered -the pulse small and feeble; or when this -is the case from the first, bleeding evidently -can do no good.</p> - -<p class='c010'>Instead of this, we may use the digitalis, -which I have already highly recommended -<span class='pageno' id='Page_100'>100</span>as a preventative; but I do -not say that, in ordinary cases, where -the contraction is brisk, and the process -quick, it is at this stage absolutely necessary; -and I shall afterwards mention -that, when the stomachic affection is -urgent, and the pulse much affected by -it, the use of this medicine is improper. -When, however, the case is tedious, and -the discharge long continued, at the -same time that the sickness is not considerable, -the digitalis will be of essential -service.</p> - -<p class='c010'>Nauseating doses of emetic medicines -act in the same way with the digitalis, -but are much less effectual, and more -disagreeable, as well as uncertain in -their operation.</p> - -<p class='c010'>Internal astringents have been proposed, -<span class='pageno' id='Page_101'>101</span>but they have no effect, unless -they excite sickness, which is a different -operation from that which is expected -from them.</p> - -<p class='c010'>The application of cloths dipped in -cold water to the back and external -parts will have a much better effect -than internal astringents, and ought always -to be had recourse to. If the digitalis -have been exhibited, it assists -that medicine in moderating the circulation.</p> - -<p class='c010'>Even when trusted to alone, it lessens -the action of the sanguiferous system, -particularly of the uterine vessels. The -introduction of a small piece of smooth -ice into the vagina has been recommended, -and has often a very speedy -effect in retarding the hemorrhage, whilst -<span class='pageno' id='Page_102'>102</span>it never, if properly managed, does any -harm. A small snow-ball, wrapped in -a bit of linen, will have the same effect; -but neither of these must be continued -so long as to produce pain, or -much and prolonged shivering. The -heat of the surface is also to be moderated, -by having few bed clothes, and a -free circulation of cool air.</p> - -<p class='c010'>But the most effectual local method -of stopping the hemorrhage, is by plugging -the vagina. This is best done by -taking a pretty large piece of soft cloth, -and dipping it in oil, and then wringing -it gently.</p> - -<p class='c010'>It is to be introduced with the finger, -portion after portion, until the lower -part of the vagina be well filled. The -remainder is then to be pressed firmly -<span class='pageno' id='Page_103'>103</span>on the orifice, and held there for some -time. This acts by giving the effused -blood time to coagulate. It gives no -pain; it produces no irritation, and -those who condemn it, surely must either -not have tried it, or have misapplied -it.</p> - -<p class='c010'>If we believe that abortion requires -for its completion a continued flow of -blood, we ought not, in those cases -where the process must go on, to have -recourse to cold or other means of restraining -hemorrhage.</p> - -<p class='c010'>If we do not believe this, then surely -the most effectual method of moderating -it is the best. Plugging can never -retard the process, nor prevent the expulsion -of the ovum; for when the uterus -contracts, it sends it down into the -<span class='pageno' id='Page_104'>104</span>clotted blood in the upper part of the -vagina, and the flooding ceases.</p> - -<p class='c010'>In obstinate cases we may, before introducing -the plug, insert a little powdered -ice, when it can be procured, tied -up in a rag.</p> - -<p class='c010'>Faintness operates in the same way, -in many cases, by allowing coagula to -form in consequence of the blood flowing -more slowly; and, when the faintness -goes off, the coagula still restrain -the hemorrhage in the same way as -when the plug has been used. This naturally -points out the advantage of using -the plug, together with the digitalis, as -we thus produce coagulation at the -mouths of the vessels, and also diminish -the vascular action. It will likewise -shew the impropriety of using injections -<span class='pageno' id='Page_105'>105</span>at this time, for, by washing out the -coagula, we do more harm than can be -compensated by any astringent effect -produced on the vessels.</p> - -<p class='c010'>The principal means, then, which we -employ for restraining the hemorrhage, -are bleeding, if the pulse be full and -sharp; if not, we trust to the digitalis, -stuffing the vagina, the application of -cold to the external parts, keeping the -heat of the body in general at a low -temperature, and enforcing a state of -absolute rest, which must be continued -during the whole process, however long -it may in some cases be. The drink -should be cold, and the food, if the patient -desires any, light, and taken in -small portions.</p> - -<p class='c010'>Opiates have been advised, in order to -<span class='pageno' id='Page_106'>106</span>abate the discharge, and are, by many, -used in every case of abortion, and in -every stage. But as we cannot finish -the process without muscular contraction, -and as they tend to suspend that, -I do not see that their exhibition can be -defended on rational principles.</p> - -<p class='c010'>If given in small quantity, they do no -good in the present point of view; if in -larger doses, they only postpone the evil, -for they cannot check abortion, after it -has begun. Nothing can do this, for it -proceeds from the cessation of the action -of gestation, which we cannot restore.</p> - -<p class='c010'>But I will not argue against the use of -opiates from their abuse. They are -very useful in cases of threatened abortion, -more especially in accidental separation -<span class='pageno' id='Page_107'>107</span>of the membranes and consequent -discharge. They do not directly preserve -the action of gestation, but they -prevent the tendency to muscular contraction, -and thus do good; for we find -in the animal economy, that when two -actions oppose each other, or alternately, -preventing a tendency to the one has -an effect in preserving the other.</p> - -<p class='c010'>Opiates are likewise useful for allaying -those sympathetic pains about the -bowels, and many of the nervous affections -which precede or accompany -abortion. They are also, especially if -conjoined with digitalis, of much benefit -in cases where we have considerable and -protracted discharge, with trifling pains, -as the uterus is not contracting sufficiently -to expel the ovum, but merely to -separate vessels.</p> - -<p class='c010'><span class='pageno' id='Page_108'>108</span>By suspending, for a time, its action, -it returns afterwards with more vigour -and perfection, and finishes the process. -But when the process is going on regularly, -opiates will only tend to interfere -with it, and prolong the complaint.</p> - -<p class='c010'>It was at one time the practice to endeavour -to extract the fœtus and placenta, -in order to stop the discharge; -but this is now very properly abandoned. -If the whole ovum come away at once, -the discharge stops; if only the fœtus -come away, it continues until the placenta -and decidua are expelled; and -where this process is tedious, we may -derive advantage from gently irritating -the os uteri with the finger, or using -pretty strong saline clysters, or throwing -cold water into the uterus by means -of a female catheter, fitted to the elastic -<span class='pageno' id='Page_109'>109</span>gum bottle used for injecting hydrocele. -These means are much safer than the -attempts to pull out the placenta with -the finger or pincers, which were formerly -so often made, and which are very -apt to injure the womb.</p> - -<p class='c010'>In cases where the discharge is protracted -and profuse, with little or no -pain, and the ovum is still entire, we -may, if the pregnancy be considerably -advanced, excite the expulsive action, by -rupturing the membranes.</p> - -<p class='c010'>The stomach very soon suffers, and -becomes debilitated, producing a general -languor and feebleness, with a disposition -to faint, which seems, in abortion, -to depend more upon this cause than directly -upon loss of blood. Indeed, the -hemorrhage produces both slighter and -<span class='pageno' id='Page_110'>110</span>less permanent effects in abortion than -at the full time, although less blood may -have been lost in the latter than in the -former case, for the vessels are smaller, -and the discharge is not so sudden.</p> - -<p class='c010'>There is still another cause for this; -namely, that the action of the uterus is -less in the early than in the late months. -Now, we know that the effect of hemorrhage -from any organ is, <i><span lang="la" xml:lang="la">cæteris paribus</span></i>, -in proportion to its degree of action. -Hence the discharge is less dangerous -than at the full time, and still less -in menorrhagia than in abortion.</p> - -<p class='c010'>It is likewise less in cases where hydatids -are contained in the uterus, than -when a child is present, very astonishing -discharges being sometimes sustained -in that case with impunity.</p> - -<p class='c010'><span class='pageno' id='Page_111'>111</span>The effect of abortion on the stomach -seems to be in proportion to the period -at which that takes place, being greater -when it occurs before the fourth month -than after it.</p> - -<p class='c010'>The effect, though distressing, and -often productive of alarm, is nevertheless -beneficial, lessening the action of the -vessels in the same way with digitalis, -the use of which is improper when this -condition is present.</p> - -<p class='c010'>The strength of the pulse is much -abated; sometimes it becomes slower; -but in general it remains much as formerly -in point of frequency; we are -therefore not to be too anxious in removing -this condition, which restrains hemorrhage; -yet as it may go beyond due -<span class='pageno' id='Page_112'>112</span>bounds, and produce dangerous syncope, -we must check it in time.</p> - -<p class='c010'>We must likewise be very attentive to -the state of the discharge when this affection -is considerable, for if, notwithstanding -this, the hemorrhage should -continue, it will produce greater and -more immediately hurtful effects than if -this were absent.</p> - -<p class='c010'>The best method of abating this sinking -and feebleness, is to keep the body -perfectly at rest, and the head low. If -necessary, we give small quantities of -stomachic cordials, such as a little tincture -of cinnamon, or a few drops of -ether in a glass of aerated water; or we -may give a little peppermint water, with -fifteen drops of tincture of opium. In -<span class='pageno' id='Page_113'>113</span>urgent cases, Madeira or undiluted -brandy may be given; but these are not -to be frequently repeated, and are very -rarely necessary.</p> - -<p class='c010'>Sometimes, instead of a feeling of -sinking and faintness, the fibres of the -stomach are thrown into a spasmodic -contraction, producing sudden and violent -pain. This is a most alarming -symptom, and may kill the patient very -unexpectedly. It is to be instantly attacked -by a mixture of sulphuric ether -and tincture of opium, in a full dose, -whilst a senapism is applied to the epigastric -region.</p> - -<p class='c010'>Spasms about the intestines are more -frequent, and much less dangerous. -They are very readily relieved by thirty -drops of tincture of opium, in a dessert -<span class='pageno' id='Page_114'>114</span>spoonful of aromatic tincture, or forty -drops of the tincture of hyocyamus in -two tea-spoonfuls of the compound tincture -of lavender.</p> - -<p class='c010'>The brain may also be affected, producing -epilepsy, which is a very dangerous -symptom. This is sometimes -preceded by headach, flushing of the -face, and feeling of fulness about the -head and neck; but at other times it attacks -without any precursory symptom, -and sometimes seems to arise directly -from copious hemorrhage.</p> - -<p class='c010'>Nothing can be done to the uterus in -the way of manual assistance, or extracting -the ovum; but our chief attention -should be directed to the brain. It -will, indeed, be proper to attend to the -state of the pains and discharge. If the -<span class='pageno' id='Page_115'>115</span>latter be profuse, we must take measures -to check it; if the former be absent, or -seem to alternate with the convulsions, -we may derive advantage from the use -of a saline clyster, which will excite -the contraction of the uterus, and confine -the action more to itself.</p> - -<p class='c010'>The same effect may sometimes be -obtained by injecting cold water into the -os uteri. Whilst we thus endeavour to -excite the regular action of the uterus, -we must likewise act directly on the -brain, by shaving the head, and applying -a senapism to the scalp. We also -detract blood, if the pulse indicate an -evacuation. If, on the other hand, the -disease seem to have arisen from the profusion -of the discharge, it will be proper -to give volatiles, or a full dose of -laudanum, in a little warm brandy.</p> - -<p class='c010'><span class='pageno' id='Page_116'>116</span>This state is to be distinguished from -a combination of hysteria and syncope, -which occasionally occurs during labour, -whether natural or premature, and which -is by no means equally dangerous.</p> - -<p class='c010'>This is known by the smallness of the -pulse, the paleness of the face, the -slightness of the convulsions, the absence -of foam at the mouth, and an appearance -of struggling about the throat. -It attacks suddenly, generally on getting -into an erect posture.</p> - -<p class='c010'>It is at first little different from syncope, -and during the whole time the -muscles of the face are not much affected, -the countenance having rather a deadly -aspect. This is removed by an horizontal -posture, sprinkling the face smartly -with cold water, and the use of volatiles. -<span class='pageno' id='Page_117'>117</span>The patient, in this case, as in -epilepsy, is often unconscious of having -been ill.</p> - -<p class='c010'>Regular hysteric paroxysms also sometimes -accompany abortion, and are more -dangerous than at other times, more -especially if they seem to have been excited -by the profusion of the discharge. -If they last long, they either end in -mortal syncope, or in stupor. If they -have been brought on by some agitation -of mind, they are less to be feared, though -not even then void of danger.</p> - -<p class='c010'>Besides attending to the state of the -discharge, the best practice is to keep -the person very cool, and exhibit thirty -or forty drops of tincture of opium, and -two drams of tinctura valerianæ ammoniata -in a little peppermint water. A -<span class='pageno' id='Page_118'>118</span>clyster, composed of a pound of cold -water and two drams of tincture of asafœtida, -is also sometimes of service.</p> - -<p class='c010'>Those disagreeable symptoms which -I have described, fortunately do not often -attend abortion; but the process -goes on safely, and without disturbance. -In this case, after it is over, we only -find it necessary to confine the person -to bed for a few days, as getting up too -soon is apt to produce debilitating discharge.</p> - -<p class='c010'>We must also, by proper treatment, -remove any morbid symptoms which -may be present, but which depending -on the peculiarities of individuals, or -their previous state of health, cannot -here be specified. When the patient -continues weakly, the use of the cold -<span class='pageno' id='Page_119'>119</span>bath, and sometimes of the bark, will -be of much service in restoring the -strength; and, in future pregnancies, -great care must be taken that abortion -may not happen again at the same -period.</p> - -<p class='c010'>Unfortunately we meet with some -cases where the recovery does not take -place with that promptitude and regularity -which could be wished. This -sometimes depends upon a continuance -of the hemorrhage after the ovum is -expelled, by which the patient is greatly -weakened, and even her life put into -danger.</p> - -<p class='c010'>The hemorrhage may either continue -from the time of expulsion, or it may -come on a week, or even longer, after -it. It seems to proceed from the uterus -<span class='pageno' id='Page_120'>120</span>not going on in the process of restoration -to the unimpregnated state, but remaining -too long enlarged, the consequence -of which is, that very soon the -vessels pour out blood, and fill the cavity, -forming a coagulum, which presently -is expelled with a considerable -flow of fluid blood; and this process may -be very frequently repeated.</p> - -<p class='c010'>This, which is often connected with -an hysterical condition, is more especially -apt to occur in those who are subject -to flooding after the expulsion of the -child, as this marks a natural feebleness -in the womb, and a disposition to flag -in its actions after delivery.</p> - -<p class='c010'>In such patients it is often preceded -by ill-smelled lochial discharge, which -proceeds sometimes from the original -<span class='pageno' id='Page_121'>121</span>state of the secretion, but more frequently -from its being retained for some -time, and acquiring this smell.</p> - -<p class='c010'>This has given rise sometimes to an -idea that the complaint proceeded from -the retention of part of the placenta or -membranes; but this retention often -takes place without any such discharge -succeeding; and, on the other hand, in -several instances of this complaint we -have certain knowledge that no part of -the placenta has remained, whilst in almost -every case we have a coagulum -expelled, possessing exactly the shape of -the uterine cavity, shewing that nothing -else has been contained within it.</p> - -<p class='c010'>Indeed, the opinion is not very tenable, -for a small part of the placenta or -decidua would, if the uterus were contracting, -<span class='pageno' id='Page_122'>122</span>be soon expelled, and would -then surely cease to have any farther influence; -whilst, on the other hand, if -the uterus do not regularly contract in -size, or recover itself, the hemorrhage -will take place from this cause alone, independently -of all considerations relating -to the placenta.</p> - -<p class='c010'>By attending to this fact, we shall not -only refrain from blaming midwives unjustly, -but also from adding to the danger, -by endeavouring to remove a substance -which has no existence in the -uterus, and which, even were it to a -certainty within, it is there not as a cause -of the hemorrhage, but as an effect of -the cause which produces that.</p> - -<p class='c010'>This disease may take place at any period -of gestation. It may follow abortion -<span class='pageno' id='Page_123'>123</span>in the second month, or expulsion -at the full time; but it is dangerous in -proportion as we approach to the term -of natural labour. It may attack only -once or twice, or it may make many attacks -for several weeks; and it is wonderful -how the system can be supported -under these continued and repeated discharges: -but we find that an incredible -quantity of blood may be lost, if it be -discharged at intervals.</p> - -<p class='c010'>We read in a foreign journal of a woman -who, in the space of nineteen -years, was bled no less than one thousand -and twenty times without material -injury. Each paroxysm is accompanied -by slight pain in the back and belly, with -considerable languor and feeling of depression. -The discharge continues until -the clot escapes out of the uterus, and -<span class='pageno' id='Page_124'>124</span>for some time after that until a new one -forms; and during this last process we -have a considerable oozing of serous -fluid.</p> - -<p class='c010'>The old clot drops out of the vagina -the first time that the patient is raised, -or, if retained, it breaks down by putrefaction. -On examining these clots, -they will be found to be pretty firm, -and often contain, intermixed, a quantity -of whitish matter, proceeding from -the morbid condition of the lochia, for -the vessels, after bleeding often, throw -out a secretion, and bleed no more until -the next paroxysm, which may not -take place for one or two days.</p> - -<p class='c010'>This complaint either terminates fatally -by a convulsion or syncope, or the -uterus diminishes in size, and, instead -<span class='pageno' id='Page_125'>125</span>of expelling the contained clot with hemorrhage, -the coagulum seems to break -down and come away gradually in a fluid -form.</p> - -<p class='c010'>In abortion, during the early stages -of gestation, we cannot take any other -precaution to prevent this than keeping -the patient for some time very -quiet, as motion, or even any agitation -of mind, might interfere with the process -of recovery.</p> - -<p class='c010'>In more advanced gestation, as, for -instance, in the seventh month, and afterwards, -if we should be obliged, on -account of flooding, after the birth of -the child, to introduce the hand, and -extract the placenta, we must be careful -not to withdraw it, until we find the -uterus contracting round it, which will -<span class='pageno' id='Page_126'>126</span>be a mean, though not an infallible one, -of making it go regularly on in the process -of restoration to the unimpregnated -state.</p> - -<p class='c010'>The best method of treating this complaint -is on the very first appearance of -hemorrhage, to introduce a firm plug -into the vagina, which will prevent it -from going to an excessive degree. Afterwards -we must take measures to prevent -a return.</p> - -<p class='c010'>This is best done by keeping the circulation -slow, by means of the digitalis, -and putting the patient on a mild vegetable -diet. We cannot assist the process -of restoration otherwise than by -endeavouring to excite the contraction -of the uterus. This may be done by injecting -an astringent fluid two or three -<span class='pageno' id='Page_127'>127</span>times a day, and by ordering saline clysters, -which have also the effect of keeping -the bowels open, an object of very -great importance. We may also find it -useful to excite gentle vomiting by small -doses of ipecacuanha.</p> - -<p class='c010'>This has an excellent effect in making -the uterus contract, and often is the method -which nature takes to bring about -recovery.</p> - -<p class='c010'>This complaint is different from the -menorrhagia lochialis, or copious discharge -of blood brought on by exertion -after abortion or delivery. In this case -we have no large clot discharged, but -just the usual appearances of menorrhagia. -This sometimes seems to become -associated with other morbid conditions -<span class='pageno' id='Page_128'>128</span>of the system: and in those cases is more -or less obstinate as they are intractable. -It is generally cured by rest, the application -of cold, and the use of the digitalis. -The consequent weakness is removed -by bark, or preparation of iron, -with the cold bath.</p> - -<p class='c010'>Either of these discharges are very -apt to produce painful headachs, vertigo, -and often slight paralytic symptoms, -which, however, soon go off. Any considerable -increase of the hemorrhage -gives relief to the headach, but it returns -afterwards with greater violence.</p> - -<p class='c010'>It is frequently relieved by the use of -small doses of the saline laxatives. In -protracted cases, especially when the -headach puts on an intermittent form, -observing pretty regular periods, the -<span class='pageno' id='Page_129'>129</span>bark combined with valerian will be of -service.</p> - -<p class='c010'>Sometimes the mind is affected after -abortion, although we may have had -little discharge; and the person becomes -either melancholy, or, which is much -oftener the case, mad, with great volubility -of tongue. This mania is, in general, -sudden in its attack, and is often -preceded by a violent fit of palpitation, -or some other nervous affection.</p> - -<p class='c010'>It occasionally alternates with external -pain or swelling of some of the -joints; and, though frequently a tedious -complaint, is oftener got the better of -than any other species of mania. The -head, upon a general principle, ought to -be shaved and blistered, and a free discharge -kept up from it. The bowels -<span class='pageno' id='Page_130'>130</span>are to be carefully attended to, and no -indurated faces should be allowed to remain -in them. The camphorated emulsion -may be given through the day in -its usual quantity; and a full dose of -extract of hyosciamus exhibited at night. -The patient is to be kept, in every respect, -as quiet and easy as possible.</p> - -<p class='c010'>Another distressing consequence of -abortion, as well as of labour at the full -time, is hysteria appearing in various -forms, but more especially under that -of palpitation of the heart. This attacks -suddenly, often in consequence of a -fright.</p> - -<p class='c010'>The patient has a violent beating in -the breast, and sometimes a sense of suffocation. -She feels also a knocking -within the head, attended with a sense -<span class='pageno' id='Page_131'>131</span>of heat, and often a redness in the face. -The pulse becomes extremely rapid and -irregular, and continues so until the fit -goes off, which sometimes is not for a -considerable time.</p> - -<p class='c010'>During the paroxysm, the patient is -much terrified, and impressed with a -belief that she is going to die. After it -is over, the mind is left timid, and the -body in a state of languor. Sometimes -the fit is succeeded by a profuse perspiration, -whilst betwixt the attacks the -temperature is very versatile.</p> - -<p class='c010'>This, like all other complaints of the -same class, is very obstinate; but it is -not in general dangerous, unless when -it proceeds from uterine disease, marked -by pain in the hypogastric region and -tension of the belly. In this case, the -<span class='pageno' id='Page_132'>132</span>danger is great, and is only to be averted -by the early use of purgatives, followed -by antispasmodics, whilst fomentations -are applied to the belly.</p> - -<p class='c010'>The other case, which is purely hysterical, -is to be relieved by giving, during -the paroxysm, a liberal dose of tincture -of opium and ether. Small doses -have no effect. During the intervals we -may give a table spoonful of the following -mixture five or six times a day.</p> - -<div class='lg-container-b c011'> - <div class='linegroup'> - <div class='group'> - <div class='line'>℞ Tinc. digitalis ℥iss.</div> - <div class='line'>Extr. Hyociami ʒi.</div> - <div class='line'>Emuls. Camphorat. ℥iv. misce.</div> - </div> - </div> -</div> - -<p class='c010'>It is also an essential point, that the -bowels be kept open, and the patient -put upon a light diet. As the attacks -are very apt to come on at night, when -the person is about to fall asleep, -<span class='pageno' id='Page_133'>133</span>we sometimes find it useful to give a -dose of tincture of hyocyamen and ether -at bed-time, and must take great care -that the patient be not afterwards disturbed -or put off her rest.</p> - -<p class='c010'>When she is much troubled with flatulence, -during the intervals the tincture -valeriana ammoniata is of considerable -service. Tonics and the cold bath -are also proper. Hysteria either consists -in or depends upon a preternatural -aptitude in the different organs, to have -their actions morbidly increased, or rendered -irregular; and hence it may affect -secreting as well as muscular parts; and -many of the discharges of lying-in women -will be found to be, in this sense, -hysterical, and to alternate with other -symptoms, such as globus, palpitation, -<span class='pageno' id='Page_134'>134</span>headach, &c. and even the most troublesome -of all the discharges, that proceeding -from the uterus not recovering -or contracting properly, is, I believe, -properly speaking, an hysterical affection, -connected with several others, and -alternating with them.</p> - -<p class='c010'>The next disease which I shall mention -is also, I believe, altogether hysterical. -I mean that resemblance of fever -which is often met with after either -abortion or delivery, at the full time, -and which is, like the rest of its tribe, -abundantly obstinate.</p> - -<p class='c010'>This is not to be confounded with -milk-fever, or other general diseases -arising from local injury. It is sometimes -preceded by palpitation, frightful -<span class='pageno' id='Page_135'>135</span>dreams, and other nervous affection<a id='r12' /><a href='#f12' class='c009'><sup>[12]</sup></a>. -At other times it attacks directly with a -shivering fit; which is soon alternated -with heat; then the heat becomes steady -and distressing, and continues until a -profuse perspiration carries it off.</p> - -<p class='c010'>The head is generally pained in the -two first stages, and the pulse is frequent -in them all. The thirst is considerable, -the stomach filled with flatus, and the -belly bound. Often we have irregular -action of the heart occurring in all the -stages, whilst the mind is weakened, and -<span class='pageno' id='Page_136'>136</span>the patient is much afraid of dying. The -paroxysm continues for several hours, -and, like ague, is apt to return regularly -for a length of time.</p> - -<p class='c010'>In the cold stage, we give small quantities -of warm fluid. In the hot stage, -we lessen the number of bed clothes; -but must not do this suddenly, as the -shivering is very apt, in either this or -the sweating stage, to return, upon slight -exposure to cold.</p> - -<p class='c010'>In the last stage, we are careful not -to encourage the perspiration too much, -by refraining from warm drink, for much -sweating only tends to render the disease -more obstinate. A repetition is to be -prevented, by keeping the bowels open, -by the use of the bark, conjoined with -antispasmodics, and by carrying the patient, -<span class='pageno' id='Page_137'>137</span>as soon as possible, to the country.</p> - -<p class='c010'>The last disease, which I shall speak -of, proceeds from the retention of the -whole, or a part of the secundines, for -a length of time after the expulsion of -the fœtus. This circumstance, as I have -formerly mentioned, may sometimes occur -in that state of the uterus, which -gives rise to hemorrhage, appearing as a -joint effect with it. In this case, however, -we must not conclude that the one -symptom is dependant on the other, -for both proceed from a common cause, -the want of contraction of the uterine -fibres.</p> - -<p class='c010'>It occasionally happens, that no hemorrhage -accompanies this retention, -but the remains of the ovum putrify, and -<span class='pageno' id='Page_138'>138</span>after many days come away in a very -fœtid state. Until this expulsion takes -place, we have very offensive discharge -from the vagina, and not unfrequently -loss of appetite, prostration of strength, -frequent and small, but sharp pulse, hot -and parched state of the skin of the -hands and feet, with other febrile symptoms, -even to an alarming degree, and -generally accompanied with hysterical -affections.</p> - -<p class='c010'>When this disease proves fatal, there -are often, but not always, conjoined towards -the termination symptoms of inflammatory -action in the uterus.</p> - -<p class='c010'>The practice, at one time, was to endeavour, -with the fingers or forceps, to -extract the remains of the ovum; but -this is not always successful, and is productive -<span class='pageno' id='Page_139'>139</span>of much irritation. We find it -most useful to keep the parts clean, by -injecting infusion of camomile flowers -with a small quantity of oxygenated muriatic -acid, to open the bowels with gentle -laxatives or clysters, to support the -strength by light nourishment with small -portions of wine frequently repeated, if -agreeable to the patient, and plenty of -subacid fruit, whilst, at the same time, -we, if necessary, procure rest, or allay -irritation by opiates.</p> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><span class='small'>FINIS.</span></div> - </div> -</div> - -<div class='chapter'> - <span class='pageno' id='Page_140'>140</span> - <h2 id='ERRATA' class='c005'>ERRATA.</h2> -</div> - - <dl class='dl_1 c002'> - <dt>Page <a href='#Page_24'>24</a>,</dt> - <dd>line 9, for <em>ar every</em>, read <em>are very</em>. - </dd> - <dt> <a href='#Page_34'>34</a>,</dt> - <dd> — 8, for <em>expanding</em>, read <em>expending</em>. - </dd> - <dt> <a href='#Page_40'>40</a>,</dt> - <dd> — 16, for <em>takes</em>, read <em>take</em>. - </dd> - <dt> <a href='#Page_41'>41</a>,</dt> - <dd> — 5, for <em>in</em>, read <em>rise</em>. - </dd> - <dt> <a href='#Page_64'>64</a>,</dt> - <dd> — 11, for <em>urerus</em>, read <em>uterus</em>. - </dd> - <dt> <a href='#Page_74'>74</a>.</dt> - <dd> — 12, dele the comma after <em>frequently</em>. - </dd> - <dt> <a href='#Page_94'>94</a>.</dt> - <dd>The paragraph beginning with <em>I wish</em>, &c. ought to form a part of the preceding - sentence. - </dd> - </dl> - -<div class='nf-center-c0'> -<div class='nf-center c002'> - <div><em>Printed by C. Stower, 32, Pater-noster Row.</em></div> - </div> -</div> - -<hr class='c012' /> -<div class='footnote' id='f1'> -<p class='c010'><a href='#r1'>1</a>. Both arteries and veins enlarge, but the latter -increase more rapidly in size than the former, so -much so, that even before the descent of the ovum -into the uterus, and while the viscus is not itself -materially enlarged, the venous system has assumed -the appearance of sinews, each branch being larger -than a goose quill.</p> -</div> -<div class='footnote' id='f2'> -<p class='c010'><a href='#r2'>2</a>. Vide Anatomy of the gravid uterus, with practical -inferences relative to pregnancy and labour.</p> -</div> -<div class='footnote' id='f3'> -<p class='c010'><a href='#r3'>3</a>. The placenta, contrary to some plans, is not -formed exactly at the fundus uteri, stretching equally -down on the two faces of the uterus, with the membranes -hanging perpendicularly from it. But it lies -chiefly on one face of the uterus, whilst the membranes -are turned to the other. The centre of the -membranous bag, therefore, at this early period, is -not directed to the os uteri, but either to the fore or -back part of the uterus. In proportion, however, -as the bag enlarges, it elongates, its centre, or apex, -descends, and ultimately corresponds with the long -axis of the uterus.</p> -</div> -<div class='footnote' id='f4'> -<p class='c010'><a href='#r4'>4</a>. In some instances, the uterus seems to have -the power of forming a vascular substance from its -inner surface, although impregnation have not taken -place; and, in this case, we may have the symptom -of early abortion attending its expulsion. But -much oftener we find that this appears as a derangement -of the menstrual action, the vessels secreting -a semi-organized substance, instead of the usual -quantity of bloody fluid; hence, as has been observed -by that ingenious and excellent practitioner, -Dr. Denman, we have sparing and painful menstruation.</p> -</div> -<div class='footnote' id='f5'> -<p class='c010'><a href='#r5'>5</a>. For a fuller explanation and defence of this -doctrine, I beg leave to refer the reader to some observations -on the animal economy, prefixed to the -first volume of my Dissertation on Inflammation.</p> -</div> -<div class='footnote' id='f6'> -<p class='c010'><a href='#r6'>6</a>. Vide Dissertations on Inflammation, Vol. I.</p> -</div> -<div class='footnote' id='f7'> -<p class='c010'><a href='#r7'>7</a>. This contraction is sometimes so firm after the -membranes have burst, as to produce the same effect -upon the child, as the natural pains would have -done had the pelvis been deformed; that is to say, -the presentation becomes unshapely, and the part -below the stricture is swelled and livid. This spasm, -like that which sometimes retains the placenta, is -very difficult to be relaxed, and, in general, requires -artificial management. If it come on at the full -time, before the membranes break, it may give such -a feeling to the lower part of the ovum, as to make -it resemble a preternatural presentation, although -the head really present. In this case, the band is -generally pretty broad, but its contraction is not -violent. It has the effect, however, of retarding -labour, until we break the membranes, which excites -a more general and effective action in the uterine -fibres.</p> -</div> -<div class='footnote' id='f8'> -<p class='c010'><a href='#r8'>8</a>. The same effect is observable in the stomach -and other organs. If a delicate person, after a -hearty meal, use exercise to the extent of fatigue, -he feels that the food is not digested, the stomach -having been weakened or injured in its actions.</p> -</div> -<div class='footnote' id='f9'> -<p class='c010'><a href='#r9'>9</a>. It has even been known, that, in consequence -of the death of one child, the uterus has suffered -partially, and expulsion takes place; but the other -child continuing to live, has preserved the action of -gestation in that part of the uterus, which, properly -speaking, belonged to it, and pregnancy has still -gone on. This, however, is an extremely rare occurrence; -for, in almost every instance, the death -of one child produces an affection of the action of -gestation in the whole uterus, and the consequent -expulsion of both children.</p> -</div> -<div class='footnote' id='f10'> -<p class='c010'><a href='#r10'>10</a>. It is an old observation, that these purgatives, -which produce much tenesmus, will excite abortion; -and this is certainly true, if their operation -be carried to a considerable extent, and continue -long violent. Hence dysentery is also apt to bring -on a miscarriage. Those strong purges which are -sometimes taken to promote premature expulsion, -not only act by exciting tenesmus, but likewise by -inflaming the stomach and bowels, and thus affect -the uterus in two ways. It cannot be too generally -known, that when these medicines do produce -abortion, the mother can seldom survive their effects. -It is a mistaken notion, that abortion can -be most readily excited by drastic purges, frequent -and copious bleeding, &c. immediately after the -woman discovers herself to be pregnant; on the -contrary, the action of the uterus is then more independent -of that of other organs, and therefore -not so easily injured by changes in their condition. -I have already shewn, that abortion more frequently -happens when the pregnancy is farther advanced, -because then not only the uterus is more easily affected, -but the fœtus seems to suffer more readily. -It is apt, either from diseases directly affecting itself, -or from changes in the uterine action, to die -about the middle of the third month, in which case -expulsion follows within a fortnight.</p> -</div> -<div class='footnote' id='f11'> -<p class='c010'><a href='#r11'>11</a>. In these circumstances I have sometimes found -the children liable to a formidable disease, described -by Dr. Heberden, in his little treatise on the diseases -of children, “<span lang="la" xml:lang="la">Cap. De Duritie Cutis.</span>” I -have met with this oftener than once in the same -family, until the constitution of the mother was -attended to, on the principle I have mentioned, -after which the children were healthy.</p> -</div> -<div class='footnote' id='f12'> -<p class='c010'><a href='#r12'>12</a>. Hiccup sometimes accompanies this complaint: -at other times it attacks the patient as a -disease by itself, or alternates with palpitation. It -is best treated by giving large doses of ether. It is -also necessary to clear the bowels; afterwards the -compound tincture of bark is useful.</p> -</div> - -<div class='pbb'> - <hr class='pb c003' /> -</div> -<div class='tnotes x-ebookmaker'> - -<div class='chapter ph2'> - -<div class='nf-center-c0'> -<div class='nf-center c004'> - <div>TRANSCRIBER’S NOTES</div> - </div> -</div> - -</div> - - <ol class='ol_1 c002'> - <li>Items mentioned in the <a href='#ERRATA'>ERRATA</a> were corrected. - </li> - <li>Silently corrected obvious typographical errors and variations in spelling. - - </li> - <li>Retained archaic, non-standard, and uncertain spellings as printed. - </li> - </ol> - -</div> - -<div style='display:block; margin-top:4em'>*** END OF THE PROJECT GUTENBERG EBOOK OBSERVATIONS ON ABORTION ***</div> -<div style='text-align:left'> - -<div style='display:block; margin:1em 0'> -Updated editions will replace the previous one—the old editions will -be renamed. -</div> - -<div style='display:block; margin:1em 0'> -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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