OBSERVATIONS ON ABORTION: CONTAINING AN ACCOUNT OF THE MANNER IN WHICH IT TAKES PLACE, THE CAUSES WHICH PRODUCE IT, AND THE METHOD OF PREVENT- ING OR TREATING IT. By JOHN BURNS, .Lecturer on Midwifery, and Member of the Faculty of Physicians and Surgeons in Glasgow. Jfir^t American tftoittotu TROY, N. Y. '\/:^y- > H/.'-' jfRiNTF.D BY WRIGHT, GOODENOW, A N Q. SXQ C K W F Li» . AND SOLD BY THEM AT THE R EN S SE LA F •< BOOS- STORii, AND BY GOODENOW AND CO. BOSTON. iboS, ANNS* TO THE GENTLEMEN WHO ATTENDED THE AUTHOR'S LECTURES IN THE SLSSluN 1802—3, THIS BOOK IS INSCRIBED, / AS A ORATEFUL AND AFFECTIONATE REMEMBRANCE OF THE VERY FLATTERING COMPLIMENT WHICH THEY BESTOWED UPON HIM. AD VER TISEMENT. The Author has carefully JRnised the present Edition, and has made such Additions and verbal Alterations as will, he hopes, render his Observa- tions and Practical Directions still more definite and precise. OBSERVATIONS OR ABORTION. J3Y abortion is generally underftood the expulfion of the contents of the gravid uterus, at a period of geftation fo early as to render it impoflible for the fcetus to live. It is an accident or difeafe which is very frequent in its occurrence, which is always attended with difagreeable cir- cumftances, and which, although u iel- dom prove immediately fatal, may ) et be productive of much mifchief at a xuture A 2 time The confideration, therefore, of the manner in which it takes place, of the caufes which give rife to it, and of the moft likely means of preventing it, or of obviating thofe unpleafant fymptoms 'which accompany it, mult form a mbject of very great importance to the medical ftudent. But before proceeding to con- sider thefe points, it will be neceilary to undemand the itructure and formation or the ovum, which 1 fhall theretore, tirft of all explain. OF THE FORMATION OF THE OVUM. The human uterus in the unimpreg- nated ftate, confifts of a fucculent fub- ftance in which we may perceive fibres running in every direction. In the inter- Hices of thefe we find a ferous fluid which can eaiily be fqueezed out. By injecting 7 the velTels finely with fize or mercury, we obferve them to be humeroufly ir ter- n ixed with the fibres, but fmall in their, ramifications, a portion of thefe veiels follows an irregular courfe toward the in-. rer furtace or cavity ot the uterus and opens theie upon the memorai.e which lines it. At tiie menuruai pciiod tiie vef- fcls enlarge or dihite a iiu.e, ai-d their orifices become more diliinct over the iur~ face of the cavity, as may oe aicertamed by inflecting thole who nave died at that time.—Sometimes a flight temporary ie- rous fecretion precedes the flow or the nienfes, and fucceeds it. More frequent- ly the veiieis yield a bloody fluid at c/i.ce which continues to be dilcharged for a certain number of days. When impregnation takes place, the veffcls enlarge ipeedily and diiiinctly. We can obferve fmall trunks forming in the fubftance of the uterus, the largeft of 8 which are to be found at the two fides where the fpermatick and hypogaftrick branches meet. Both arteries and veins enlarge, but the latter are moft confpicu- ous. Even before the embryo has de- fcended into the uterus, and whilft the vifcus itfelf is not materially enlarged, the veinous fyftem has aflumed the ap- pearance of finufes, each principal branch being larger than the barrel of a goofe quill. The old fibres are more feparated and new ones are added, elpecially at the fundus. The quantity of interftitial flu- id is increafed fo that the uterus becomes manifeftly fotter, and from the enlarge- ment of the veins it foon aflumes a doughy feel. The veflels as they enlarge tend to the uterine cavity, but iniiead of opening there, and yielding a fluid ab in menftruation, they either^ongate them- fcivcs, or which is more probaole, torm new and very delicate veiTels which pro- ject from the inner furface of the uterus, 9 giving it an appearance as if covered w'th down. This takesr place firft at the ori- fice of the fallopian tube, and then ex- tends to the fundus, whilft the body re- mains quite fmooth. Thefe veflels pro- ject for about a lire in lereth at right an- gles, from the furface whirh yields them, and as they corfift of arteries and veins, the down oreffiorefcf rce which they form, has, after death a ftriated appearance; the empty arteries being white, ihe ful- ler veins red or black. T!>efe veflels con- ftitute the outer layer of the decidua, which may be called decidua ftriata, al- though the ftriae be obliterated as gefta- tion advances ; almoft immediately after the formation of thefe primary veflels, they fecretc from their extremities a membrane, or rather an irregular tii.ue of vtflels, which, on account or their or- igin, may be called fecondary. "Ihefe are very different from the primary, tor -whilft the latter are lhoit, ftrai0ht, and IO parallel to ea~h other, the former are m re extended, intermix, and ramify to- gether, fo as to form a fheet of vafcular fubftance, which aflumes a direction at right ingles to the ftriae, fo that as they thus crofs them, it follows that any body coming d »wn through the fallopian tube into the uterus, mult, before it can get fully into.its cavity, either rupture this vafcular fheet or pufh it before it. In this laft manner it is, that the veficular ovum enters the cavity of the womb, the vafrulir web formed by the fecondary veflels, or the inner layer of the decidua, being protruded before it, conftituting decidua reflexa or protrufa. Such is the ftructure of the decidua externa and interna at three weeks after impregnation, and at this period no foe- tus is to be found in the uterus. In one cafe I detects! the veficular ovum in the tube. It was about half way betwixt the II. two extremities, was rather fmaller than a full grown pea, and contained a little fluid. In another cafe, I found it ftili in the ovarium, covered by the tin briated extremity of the tube By puncturing the peritoneal coat of the e.lard, the vcfi- de efcaped. When the foetus does de- fcend into the uterus, it is contained in a double membrane; the internal one is the amnion, and poflefies no diftinct vef- fels ; the external one is the chorion, and is from the firft vafcular, and loon be- comes fo much fo, that its veflels have by fome been deicribed as forming a dif- tinct tunick. From what has been faid, it will be evident, that when this veficle does reach the uterus, it will be received among the primary veflels, which will furround it whilft the feccndary veflels or decidua ii terna will lie before it, and prevent any direct communication betwixt it and the 12 "uterine cavity. But it cannot long re- main thus, for in proportion as the vefi- cular part of the ovum increafes, it will pufh the decidua intejna before it, and encroach on the cavity of the uterus. This circumftance, together with the in- timate connexion formed betwixt the veflels of the chorion, and thofe of the decidua, with the confequent production of a placenta, I have elfewhere* fully de- tailed. When the ovum defcends, and the fubfequent changes are beginning to take place, the body of the uterus comes alfo to form decidua; for I have already ftat- ed that until the fcetus comes into the uterus, the fundus alone yields this pro- duction.! By the extenflon of this ac- * Vide anatomy of the gravid uterus with practical inferences relative to pregnancy and labour. ■j- It has been the general op;nion fince the time of Dr. Hunter, that the decidua extended a little way into 13 tion and the gradual enlargement of the membrane.-, the whole body comes to be filed up, and the cervix is fealed as it were with a lymphatick or gelatinous plug. By opening the gravid uterus in the end of the fecond month, we fhall find it quite filled up, the placenta and membrane* occupying the fundus, the decidua protrufa coveting the mem- branes, and the lower part of the body fT.ed up with vafcular fubftance, or de- cidua vera as it ras been called, extend- ?; all the way down to the gelatinous iecretion at the cervix. If at tills time we take the ovum out of the uterus, or, if we cut off the face 9 the tube, and on his authority I dated this to be the cafe, in an account which 1 formerly published. By Careful examination I am now convinced that this is not the cafe ; my bmth; r, a moft accurate anatomift, in his difleftions even thuught that the uterine extremity of the tube was lefs c!u< yi-u in roi:.'. ci" vafeubrty, ti'ar. any other part of it. » *4 of the uterus, and remove the decidua from the front of the membranes, we {hall fee at the upper part of the placenta and membranes, like a thick old fafhion- ed watch, the placenta* refembling the cafe, and the membranes the glass of the watch; then, at the lower part of the membranes we fee the remains or mar- gins of the decidua protrufa, which has been removed to fliow the chorion, whilft ftill lower down, we obferve the decidua externa occupying the inferiour part of the uterus forming a fhort ftalk * The placenta, contrary to fome plans, is not in general formed exadtly at the fundus uteri, ftretching 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, moft frequently on the pofteriour face, whilft the membranes are turned to the other. The centre of the membranous bag, therefore, at this early period, is not generally directed to the os uteri, but either to the fore or back part of the uterus. In proportion, however, as the bag enlarges it alfo elongates. Its centre or apex dtfernds, and ultimately conefponds with the long axis of the uterus. '5 to the flattened fphere above. As the layers of decidua, furnifhed by the oppo- lite fides of the uterus, do not intermix when they meet in its axis, we may trace a fmall canal or perforation leading up from cervix uteri to the bottom of the decidua protrufa, and correfponding to the long axis of the uterus. In propor- tion as the membranes elongate and en- large ; the decidua gradually proceeds before them down this canal, until at laft it reaches the bottom, or in other words the membranes occupy all the uterine ca- vity. Now from this general view of the for- mation of the ovum, it will appear, that very foon after impregnation the circu- lation in the uterus is confiderably aug- mented, and a progrefiivt ly increafing ac- tion is eftabliihed ; new fibres are daily formed, and very tender and delicate vef- fcls fprout out from the furface. Thefe ift are fo fine, that they much refemblc the down which is formed on putrifying meat. But notwithflanding this, they are not only circulating blood regularly, but arc alfo engaged in a powerful ac- tion. Whoever confiders thefe circum* fiances, will be lefs aftonifhed that rup- ture fhould fbmetimes take place, than that they fhould ever remain for a week entire, an 1 will be moft forcibly ftruck with, the neceflity of preventing the blood from being ftrongly or rapidly propelled into this tender ftructure. He will con- fider the great rifk of abortion as at firft proceeding almoft entirely from caufes connected with the circulation of the blood, and will perceive the indifpenfa- ble neceflity 0f preventing plethora, and moderating the action of the veflels, and the ftrong probability of inducing abor- tion, when to thefe general caufes are add- ed any of thofe which particularly oper, ate on the uterus. *7 When the fcetus has defcended, anct the fringed veflels of the uterus have come to intermix and communicate with thofe of the chorion, and efpecially when about the third month he finds the ovum to be almoft a ball, thickly furrounded with innumerable veflels, circulating much blood, and performing ftrong ac- tion, he will without hefitation pro- nounce that great danger muft proceed from a tendency in the veflels to rupture, and that the chief fecurity againft this arifes from a ftrict attention to the cir- culition,"and to care which is requifite in order to preferve the integrity of the vends. But this is not the only fource of dan- ger. The uterus is greatly influenced in its actions by a variety of circumftances.* * Some of thefe are connected with a ftate oppofitc to that in which plethora exifts and will require a differ- ent treatrm it. $ 2 iS The health and exiflence of the fcetus depend much upon the ftate of the ute- rus, and the condition of the vafcular in- volucra; it is, moreover, fubject to acci- dents and difeafes proceeding from pecu- liar affections of its own fyftem, and which bring on an early death. «3F THE MANNER IN WHICH ABORTION TAKES PLACE. The procefs of geftation may be flop- ped, even before the fcetus, or veficular part of the ovum, has defcended into the uterus, and when only the primary vef- fels are formed In this cafe, which oc-' curs within three weeks after impregna- tion, the fymptoms are much the fame with thofe of menorrha^ia. There is A- 19 ways a confiderable, and often a copious difcharge of blood, which coagulates or forms clots. This is accompanied with marks of uterine irritation, fuch as pain in the back and loins, frequently fpaf- modick affections of the bowels, and oc- cafionally a flight febrile ftate of the fyf- tem. In plethorick habits, and when abortion proceeds from .overraction, or hasmorrhagick action of the uterine vet fels, the fever is idiopathick, and pre- cedes the difcharge. In other circumftances it is either ab* ient, or when prefent, it is fymptomat- ick, and ftill more inconfiderable, arifing merely from pain or irritation. As the primary veflels are very fmall, and are foo^i difplaccd, they cannot be detected in the difcharge. Nothing but coagulum can be perceived ; and this, a$ in other cies of uterine haemorrhage, is often fo i'nii, and the globule* and lymph lo dif- \, 20 pofed, as to give it, more efpecially if it have been retained for fome time about the uterus or vagina, a ftreaked or fi- brous appearance, which fometimes gives rife to a fuppofition, that it is an organ- ized fubftance. The difcharge does not ceafe, when the primary veflels are de- ftroyed, but generally continues until the fmall veficle pafies out of the fallopian tube. Then it ftops, and an oozing of ferous fluid finifhes the proccfs. The only interruption to the difcharge in this cafe of abortion, proceeds from the formation of clots, which, however, are foon difplaccd. Women, if pletho- rick, fometimes fufler confidcrably from the profufion of the difcharge j but, in general, they foon recover. « When the fecondary veflels are formed, the fymptoms are ftill pretty much t^he- fame ; but if the veficle 1 .vs defcended in- 21 t6 the uterus, they are fomewhat diffet - ent. We have an attempt in the uterus, to contract, which formerly was not ne- ceflary ; we have pains more or lefs reg- ular in the back and hypogaftrick, re- gion; we have more dilturbarce of the abdominal vifcera, particularly the ftom- 2ch. The dicharge is copious, and fmall bits of fibrous fubftance can often be ob- served.* * la fomc inftance?, the utenn feems to have the power of forming a vafcular fub'tance from its iuner furface, although impregnation have not taken place; and, in this cafe, we may have the fymptom of early abortion attending its expulfion. But much oftener we f]rd that this appears as a derangement of the menftrual aclton, the verltlt fecrcting a femi-organized fubftance, inttjad of thr ufual quantity of bloody fluid ; hence, as Jns been obiuved by that ingenious and txcelitnt prac- titioner, Dr. Dcnman, we have fparing and painful men- fhuation. Sometime- after this fubftance is formed it is expelled with confiderable difcharge. A very diftindt cat'o of this Lind is to be found in the Epiftles of Mor- gsgu'.; r. r.^ble n/atron after bearing feveral children, and iniu-rlng fevtral abortions became fubjecl: to a new and very trouMefume cornpbi:'!.; for at ' !v_* menftrual peri*- Sometimes, when the veficle has come into the uterus, before abortion takes place, it may be delected in the firft dif- charge of blood, and will be found to be ftreaked over with pale veflels, giving it an appearance as if it had bc::i flightly macerated. When ail the contents are expelled, a bio ;dy difcharge continues for a few hours, and is then fucceeded by a ferous fluid at this time; and, in later abortion, if the fymptoms come on grad- ually, we may icmetimes obferve a gela- tinous matter to come away before the haemorrhage appears. od pains like thofe of labour came on, and there was ex- pelled a triangular membrane, correfponding to the ihape of the uterine cavity. The inner furface of this fubftance was fmooth and moift as if it had contained a fluid ; the outer was rough and irregular. The exelu- lion of this was attended with confiderable difcharge, and was.followed by lochia. Thin continued to be reg- ularly repeated every month, during the unimpregnaied ftate. " She, therefore," adds he, " determined to lie no longer alone, w Urefore, in the month of Maich, i?»4, flie became again pn wrui...'' ErtsT.xlviii. Art. i:. 23 In fome inftances there is no difcharge of blood, but the ovum decays and comes away flowly and piece-meal, in a putrid ftate ; and the fecretion about the vagina has an oftenfive fmell. If the breafts had been tenfe they become flacid and foft, and fometimes a ferous and milky fluid runs out at the nipple for feveral weeks or even months. The woman feels lan- guid and hot at night, and very frequent- ly hyfterical affections fupervene. The merus continues fomewhat enlarged, and its orifice foft until all its contents are difchir/cd; nor is the health or fpirits re-eftablifhed until that take place. If the uterus have' been filled up, as in the beginning of the third month, the veficle never efcapes firft; but we havp for fome time a difcharge of blood, ac- companied or fucceeded by uterine pain. Then the irferiour part or fnort ftalk of the ovum is expelled, gorged with bloody unci afterwards the upper part equall/in* jured. Sometimes the whole comes awa/ at once and entire ; but this is rare. As confiderable contraction is now required in the uterus, the pains are pretty fevere. The derangement of the ftomach is alfo greater than formerly, giving rife to fick- nefs or faintnefs, which is a natural con- trivance for abating the hiarrforrhage. When the membranes come to ocra* py more of the uterus, and a ftill greater diflereuce exitls betwixt the placenta and decidua, v/e have again a change of the procefs; wc have more bearing down pain, and greater regularity in its attack; we have a more rapid difcharge, owing to the greater fize of the veflels; but there is not always more blood loft now, than at an earlier period, for coagula form readily from temporary fits of faint* nefs and other caufes, and interrupt t'rs flow v.ntil r.cw and increafed ci)i:tra;t*.en = 5 difplaces them. Often the membranes give way, and the fcetus efcapes with the liquor amnii, whilft the reft of the ovum is retained for fome hours or even days,* when it is expelled with coagulated blood feparating and confounding its different parts or layers. At other times the fcetal and maternal portions feparate, and the firft is expelled before the fecond, form- ing a very beautiful preparation. In fome rare inftarices we find the whole ovum expelled entire, and in high preler, vation. After the expulfion, the haemorrhage goes off, and is fucceeded by a difcharge fome- what refembling the lochia. In cafes of twins, after one child is ex pelled, either alone or with its fecundines, the difcharge fometimes flops, and the woman continues pretty well for fome * In all cafes the placenta is retained much longer af- ter the expulfion of the child in abortion, than in labour ?t the ful! time. C at hours, or even for a day or two, when a repetition of the procefs takes place, and if fhe has been ufmg any exertion, there is generally a pretty rapid and profufe dif- charge. This is one reafon, amongft ma- ny others, for confining women to bed for feveral days after abortion. There is frequently, for a longer or fhorter time before the commencement of abortion, a pain and other irregular ac- tion in the neighbouring parts, which give warning of its approach before either difcharge or contraction take place* un- lefs when it proceeds from violence, in which cafe the difcharge may inflantly ap- pear. This is the period at wh'ch we can molt effectually interfere for the preven- tion of abortion. I need not be particular in adding, that * In fome cafes, fhooting pains and tenfion ire r-lt ia {he brealts before abortion, and the patient is tcvuifh. 27 we arc not to confound thefe fymptoms with the more chronick ailments which accompany pregnancy. Similar difturb- ances in the action of the neighbouring parts are very commonly found to pre- cede labour at the fame time; and even then, we may, by proper mear.s, poftpone or retard expulfion for fome hours or days. A great diverfity obtains in different inftances with regard to the fymptoms and duration of abortion. Infome cafes the pains are very fevere and long con- tinued ; in others, fhort and trifling.* Sometimes the haemorrhage is profufef and alarming; at other times, although * The degree of pain is not always a correct index of the force or degree of contraction. f Thofe who are plethorick generally lofe moft blood unlefs the contraction have been hrifk. In fome ofes lix or feven pounds of blood have been loft in a few hour6. 28 circumftances may not be apparently very different, it is moderate or inconfider- able. Often the fympathetick effects on the ftomach and bowels are fcarcely pro- ductive of inconvenience, whilft in a greater number of inftances they are very prominent fymptoms. I may only add, that, catcrisparibus', we fliall find, that the farther the pregnancy is advanced beyond the third m>nth and the nearer it approaches to the end of the fixth, the lefs chance is there of abortion being accompanied, but the greater of its being fucceeded, by nervous affection. As there is a diverfity in the fymp* toms, fo is there alfo in the duration of abortion : for, whilft a few hours in ma- ny, and not above three days in the ma- jority of cafes, is fufticient to complete the procefs, we find other inltances in which it is threatened for a lonsr time, 29 and a number of weeks elapfe before the expulfion take place. In fome cafes the child appears to be dead for a confiderable time before the fymptoms of which accompany expulfion appear. But in a great majority of cafes' it is living, when the firft figns of abor- tion are perceived, and in fome inftances is born alive. The figns by which we judge that the child in utero is dead, afe the fudden ceflation of the morning fick- nefs, or of any other fympathetick fymp- tom which may have been prefent. The brcafts become flaccid. If milk had been formerly fecreted, it fometimes difap- pears, but in other inftances the contrary happens, and no evident fecretion takes place until the action of geftation, or at lcaft the life of the child be loft. In al- moft every cafe, however, the breafts will be found to have loft their firmnefs. If the pregnancy had advanced beyond the C 2 33 -period of quickening, the motion of the child will be loft, and a feeling of heavi- nefs will be felt about the pelvis; when all trufe Asms are obferved, and when they are followed by difcharge, and efpe- cially when this is attended with pain, there can be no doubt that expulfion will take place, and it would be improper to prevent it. We are not, however, to conclude that the child is dead, merely becaule it does not move, and when abor« tion is threatened before the term of quickening, this fign does not enter into. our confederation. OF THE CAUSES GIVING RISE TO ABORTION. Abortion may very properly be di- vided into accidental and liabitual. The exciting cautes of the firft clafs may, in 31 general, be eafily detected; thofe giving rife to the lecond are often more ob- fcure ; and, without great attention, the woman will go on to mifcarry, until eith- er ftcrility, or fome fatal difeafe, be in- duced. In many cafes there can be no peculiar pre-difpofing caufe of abortion \ as, for inftance, when it is produced by blows, rupture of the membranes, or accidental feparation of the decidua: but when it • occurs without any very perceptible ex- citing caufe, it is allowable'to infer, that fome pre-difpofing ftate exifts ; and this generally confifts in an imperfect mode of uterine action, induced by age, former mifcai riages, and other caufes. 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 geftation or of 32 performing it properly. Now, it is ob- iervable, that this incapability or imper- fection takts place fooner in thofe who are advanced in life, before they marry, than in thofe who have married and be- gun to bear children earlier. Thus we find, that a woman who marries at forty, fliall be very apt to mifcarry ; whereas, had {he married at thirty, fhe might have born children when older than forty ; from which it may be inierred, that the organs of generation loie their power of acting properly fooner, if not employed, than in the connuuial ftate. The fame caufe which tends to induce abortie.n at a certain age in thofe who have remained until that time Angle, will alio, at a period fomewhat later, induce it in thoie who have been younger mar- ried: for in them we find, that, after bearing feveral children, it is not uncom- mon to conclude with an abortion; or, ♦ 33' fometimes after this incomplete action, the uterus, after a confiderable time, re- cruits, as it were, and the woman carries a child to the full time, after which flie ceafes to conceive. In the next place, I mention that one abortion paves the way tor another, be- caufe, fetting other circumftances aficie, it gives the uterus a tendency to flop its action of geftation at an early period af* ter conception, and therefore it is diill. cult to make a woman go to the full time, after fhe has mifcarried frequently. This fact has alfo been explained, upon the principle of repeated abortion weak- ening the uterus,* and this certainly may have fome influence. The renewred ope- * Per hanc vero confuetudinem nihil aliud intelligo, fuam pravam vaforum utori laxitatem et i"de pn.xci.i- entem humorum ftagnationem, ex abortiendi lab -re f?pius rcpetito inductam. Hoffman, tom. iii. p. i«a 34 ration of thofe caufes which formerly in- duced abortion, may alfo account in ma- ny cafes for its repetition. But I am alfo inclined to attribute the recurrence, fometimes, to habit alone, by which, I underftand, that tendency, which a part has to repeat or continue thofe modes of acting which it has frequently perform- ed, as we fee in many difeafes of the fto- madr and windpipe, fpafmodick affec- tions of thefe and other organs, beirg apt to return at the fame hour, for a long tirre. With regard to the uterus, one remarkable inftance is related by Sihubzins, of a woman, who in fpite of every remedy, n ifcarried twenty-three tires in the third month. In this and fiiei'.ar cafes, flighter caufes applied at the period when abortion formerly happen- ed, will be fufficient to induce it, than. would be required at another time. The ordinary and unavoidable exertions of lire ma) be fufficient to excite abortion in this circumftance. 35 We alfo find that an exceflive or indif- criminate ufe of venery, either detroys the power of the organs of generation altogether, making the woman barren, or it difpofes to abortion, by enfeebling thefe organs. Some flight change of flructure in part of the uterus, by influencing its ac- tions, may, if it do not prevent concep- tion, interfere with the procefs of gefta- tion, and produce premature expulfion. If, however, the part affected be very fmall, and near the os uteri, it is poflible for pregnancy to go on to the full time. Indeed, it generally does go on, and the labour, as may be forefeen, will be very tedious ; but the operation ot cutting the indurated os uteri, which has been pro- pofed, is feldom ncceffary. I have known one inftarice, in which a very confiderable pait ot tae uterus, I 3^ may fay almoft the whole of it, was found, after delivery, to be extremely hard, and nearly oflified: but this ftate could not have exifted before impregna- tion took place, for I cannot conceive that fb great a proportion of the uterus fhould have been originally difeafed, and yet that conception, and its confequent ac- tions, fhould take place ; but there is no difficulty in iuppofing, that, during the enlarging of the uterus, the veflels de- poTifed ofleous or cartilaginous matter, inftcad of fibres. In this cafe, it is evi- dent that the delivery muft beinftrumen- tal, owing to the deficiency of fibres, and recovery can feldom take place. Often we find this morHid action affect the pla- centa, inftead of the uterus ; but this is' not dangerous ;* unlefs to fo great a de* *In fome inftances, when the offification is extenfivej it may give rife to has-norrhage during labour, or af^r delivery. When this ftate l-> complicated with ftror.- cdhefibn to the uterus, it will require attention to pre- 37 grce as to effect the vitality of the child, in which cafe, death and premature ex- pulfion mult be the confequence. A general weaknefs of the fyftem,* which muft affect the actions of the ute- rus, in common with thofe of other or* gans, is likewife to be confidered as giv* ing rife to abortion, though not fo fre- quently as was at one time fuppofed. A local weaknefs of the uterus fome- times ex'uci when the general fyftem is not very feeble, or when the conftitution is delicate, the uterus may be weaker in proportion than other organs. In this cafe it cannot perform its funo- tion with the neceflary activity and per* vent bad confequence9 after the child is expelled; but by care, danger may in general be prevented, and ths placenta be g*>t away entire. n 3« fection, but is very apt, after a time to flag. We cannot operate with medicines directly upon the womb,for the purpofc of ftrengthening it, but muft act on it by in- vigorating the general fyftem, and attend- ing to all the other functions. Sea-bath- ing is of great fervice, and after impreg- nation, even exciting caufe of abortion muft be guarded againft. Women of this defcription are generally pale, of a weak- ly, flabby habit, apd fubject to irregular, often to copious menftruation, or flour albus. When they conceive, the cold- bath, light digeftible food, open bowels, and free air fhould be enjoined j and if any uneafy fenfation be felt about the uterus or back, or the pulfe throb a lit- tle, blood fhould be flowly taken away, and the woman keep her room for fome days. Bleeding prevents the womb from tjejng opprefled, and it is as neceflary to attend to this, as it is to prevent the fto- ■mach fiom being loaded in a dylpeptick 39 patient. But, on the other nand, were we to bleed copioufly, we might injure the action of the uterus, and deftroy tho child. It has been fuppofed that abortion might arife from a rigidity of the uterus, which prevented its diftention. But the uterus does not diftend like a dead part, upon which preflure is applied, but it grows, and therefore I apprehend that an effect is here confidcred as a primary caufe.* The uterus is not only affected by the general conditions of the fyftem, mora * Sometimes a chronicle inflammation of the throat is excited by, or connected with a tumour in the fide of the neck preffing on the eighth pair of nerves, and pro- ducing varying affections of the ftomach and bread, Thefe, as well as the fize of the tumour, are generally increafed by pregnancy, and fometimes abortion fecme to proceed from this cauie. 4$ efpecially with regard to fenfibility, afrd the ftate of the blood veflels ; but it like. wife fympathizes with the principal or- gans, and may undergo changes in con- ic euence of alterations in their ftate. Thus we often find that lofs of tone, or diminifhed action o*f the ftomach pro- duces amenorrhcea; and it may alfo on the fame principle induce abortion; on the other hand, the action of the uterus may influence that of other vifcera, as we fee in pulmonary confumption, which is fometimes fufpended in its progrefs during pregnancy; or, if there be any difpofition in an organ to difeafe, fre- quent abort on, partly by fympathy be- twixt the uterus and that organ, and partly b) the weaknefs which it induces, and the general injury which it does to the fyftem at large, may excite the irreg- ular or movbid action of the organ fo d& poied,. 4* As the action of the uterus is increafed during pregnancy, it muft require more nervous energy; but the fize of the nerves of the uterus is not increafed in, proportion to the action j we muft there- fore depend for the increafed fupply upon the trunks, or larger portion of nervous fubftance, from which they arife, for we well know that the quantity of energy expended in an organ, does not depend upon the fize of the nerve in its fub- ftance, but on the trunk which furnifhe* it. Whenever action is increafed in arv Organ, it muft either perifh, or the larger nerve muft fend the branches more ener. gy, for the branches themfelves cannot form it, their extremities being only in* tended for expending it; from which it follows, that in pregnancy there muft bo more energy fent to the uterus, and left. to fome other part. This is the cafe with all organs whofe action is increafed, other parts being de- prived in proportion as they are fupplied, except when irritation raifes general ac- tion above the natural degree; the confe- quence of which i*, that the power is not fufficient for the action, which becomes irregular, and the fyftem is exhaulL'd, as \ve fee in febrile conditions.* There being increafed action of the ute- rus in geftation, requiring an increafed quantity oi energy to fupport it, we find that the fyftem is put pro tempore into a:; artificial ftate, and obliged either to foria snore energy, which cannot be fo eafily done* or to lpend lefs in fome other part. Thus the junction of nutrition, or the ^ccion by which organick matter is dc- * For a fuller explanation and defence of ll.io doc- trine, 1 beg leave tu refer the reader to i'oinc o^c\ va. tions on the animal economy, prelixed to the firft vol- ume of my Dilatation on iuDammauon. 43 pofitcd, in room of that which is abforbed., often yields, or h Ieiiei.cd,and the perfon becomes emaciated, or the flomach has its action diminifhed, or the bowels pro- ducing coftivenefs and iiillai'oe.. If nq part give way, and no more energy than ufual be formed, geftation cannot go on, or roes on impeded!*/. i xe.ee fome women have abortion induced by being too vigorous ; that is to fay, all the or- gans periift in keeping up their action in perfection and complete degree. A tendency to abortion alfo refults from a contrary caufe, (rom organs yield- ing tco readily, allowing the uterus to act too eafily. In this ftate it h as liable to go wrong, as the general fyftem is when it is at the hi'rhef. decree of action, compatible with health, the moft trifling caufe deranges it. Thus, fometimes, the intcftines yield too readily, ^nd become a! moft torpid, fo J hat a flool can witrj 44 difSculty be procured. Here coftivenefs is not a caufe of abortion, though it may be blamed. In like manner, the mufcu- lar fyftem may yield and become enfee- bled ; and in this inftance debility is ac- cufed as the caufe of abortion, although it be, indeed, only an effect of too much energy being deftined for the uterus. In this cafe, the woman is always weaker during menftruation and geftation than at other times. Now this is not a piece of idle fpecula- tion, but is of much practical impor- tance, eipecially in conlidering the means of correcting habitual abortion : and much attention ihouM be paid to the ftate of the principal organs in the body ; for, if we confine our attention merely to the •uterus, we fhall often fail when other- wife we might fucceed; and it will be necefiary to remember, that the chain of fym^athies in geftation is often extenfive and complicated. 45 The ftate of the ftoma Ji, for example, may give rife to head-ach, tooth-ach, &c. and often it is dangerous fuddenly to re- move thefe remote effects. It throws too much energy to the uterus ; its action is too much exerted ; contraction and abor- tion take place : but in the unimpregna- ted ftate, the removal of thefe effects may, on the contrary, be ufeful: thus the pull- ing of a pained tooth fometimes fpeedily produces the return of the menfes in, cafes of obftruction. . If the neighbouring parts do not ac- commodate themielves to the changes iu the direction of energy, and act in con*. cert with the uterus, their action become^ irregular, and confequently painful. In this cafe the uterus may have its juft de- gree of power and action ; but other part$ may not be able to act fo well under the change of circumftances. This is chiefly the cafe in early geilauon, for, by t;nip 46 the parts come to act better. It often gives fhe to uuneceffary alarm, being miftaken for a tendency to abortion ; but the fy mptoins are different. The pain is felt chieny at night, a time at which Weakened parts always iutier moil j it re- turns pretty regularly for leveral weeks, but the uterus continues to enlarge, the brealts to diftend, and all things are as they ought to be, if we except the pref- ence of the pain. This may be alleviated by bleeding, and fometimes by anodyne1', but can only be cured by time, and avoiding, by means of reft and care, any * additional injury to parts already irregular and ticklifh in the performance of their actions. If this be neglected, they will re-act on the uterus at laft, and impede its function. It is therefore highly ne- cefiary, efpecially in thofe difpofed to abortion, to pay attention to pains about the back, loins, or pubes; and to infill upon reft, open bowels, and detracting ; 47 blood, if the ftate of the vafcular fyftena indicate evacuation. Even although the different organs, both near and remote, may have accom- modated themfelves to the changes in the uterine action, in the commencement of geftation, the proper balance may yet be loft at a fubfequent period; and this is moft apt to take place about the end of the third, or beginning of the fourth month, when the uterus is riling out of the pel- vis : and hence a greater number of abor- tions take place at that time than at any other ftage of pregnancy. There is from that time, to the period of quickening, a greater fufceptibility in the uterus to have its action interrupted, than either before or afterwards, which points out the ncceffity of redoubling our vigilance in watching againft the operation of any of the caufes giving rife to abortion frdm the tenth to the fixteenth week. 4a ff the uterus, in its Unimpregnated &ate, become very torpid, as in fome cafes of amenorrhcea, the abdominal mufcles fometimes have their action much in- creafed ; and there is abfolutely an at- tempt made to expel it, violent paroxyfms of contraction coming on, and repeated daily for a length of time. Thefe may be leflened by opiates, but can only be cured by exciting the natural action of the uterus. I mention this fact, from its fingularity, although it do not immediately refer to abortion. If the action of geftation go on under reftraint, as, for inftance, by a change of pofition in the uterus, or by its prolapf- ing too low in the vagina, it is very apt to be accompanied by uneafy feelings, for, whenever any action is conftrained, fen- fation is produced. The woman feels Ir- ~ The lofs of action is generally fpeedy, when once begun. Perhaps in moft in- ftances it takes place inftantaneoufly,and then the fibres begin individually to act; but they may not, for fome hours, con- trad univerialiy, and all at one and the fame time producing pains.* But if fome other organ fliall receive the furplus of action, or the transferred action, then the uterii c fibres either will Hot contract, or will receive an interiour • In fome cafes, the fibres about the os uteri or low- er part of the cervix, aflume the contractile action long before the reft, and produce flight irregular motions, which, if neglected, may excite general contraction. But if the fibres about the body or iundus of the uterus, af- fume this action, then nothing can prevent expulfion, for mc action ut ^citation is ucilioyul in ever; inttance before tucy btjjiu to contract. 64 and infufEcient degree of action, and ex* puifion will not take place unt 1 the or^aq fympathizing fhall ceafe to have the in* creafed action, whether it be the brain, the ftomach, or the external mufcles o£ the body. Sometimes alfo the action feems 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 inu poflible here to fpecify. Sometimes the action is chie^v commu* nieated to one part of the merine fibres, whilft the reft are more torpid ; and this part contracts in an undue degree, clafp- ing the child firmly, and retarding la* bour ;* and, after expulfion, it is apt to * This contraction is fometim?R fo firm after the inembranes have burft, as to produce the fame efftvt up* ** return, and retain the placenta, whilft the reft of the uterus becomes torpid, pro-* ducing flooding. If, then, the action of geftation ceafe Univerfally in the uterus, another action, namely, mufcular contraction, begins, and then all hope of retaining the ovum any longer is at an end. I know that we have been told of inftances where contraction, after beginning, ftopped for feveral weeks. on the child, as the natural pains would have done had tbe pelvis been deformed ; that is to fay, the prefenta- tion becomes unlhapeiy, and the part below the ftricture is ('.veiled and livid. This fpafm, like that which fome- times 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 fuch a feeling to the lower part of the ovum, as to make it rcfcmble a preternatural prefehtation, al- though the head really prefent. In this cafe, the band i3 generally pretty broad, but its contraction is not violent. It ha» the effect, however, of retarding labour, until we break the membranes, which excites a more general and ef'cSivc action in the uterine fibres. F 2 66 The os uteri may be prematurely de- veloped ; it may be open for fome weeks, even without pain ; but no man will fay that, in this cafe, labour or uterine con- traction has begun. We may even have partial mufcular action, in a few very rare cafes, about the os uteri, which has lefs to do with the action of geftation than any other part of the uterus ; and this action is often attended with confiderable pain or uneafinefs. Sometimes it is con- nected with convulfive arritauon of fcve- ral of the external inufclcs of the body. Even in this cafe, expulfion does not al- ways immediately take place; for by bleeding, and reft, and opiates, the mo- tion may fvmetimes be checked ; but reg- ular and univerfai action of the mufcu- lar fibres never yet has been flopped. It may, Lke other mufcular actions, be fuf- pen Jed by anodynes or artlilcial^ treat- ment ; but it never has, and never can be flopped, otherwise than bv the ex ml- ' A 6y Jon of the ovum, when a new train of actions commence. Whenever, then, at any rieriod of preg- nancy, we have paroxyfms of pain in the back,* and region of the uterus, more ef- pecially if thefe be attended with feeling of weight in that region, tenefmus, mic- turition, del :ent of th: uterus in the pel- vis, and opening of the os uteri, we may * * It may not be improper to mention, that in fome febrile jri(.-tions we have pain in the back and loins, oc- calioning remitting or dyfmtcry altogether for a (hort fpace, and then returning. Sometimes along with this we have, owing to the affection of the circulation, and iu fome inftances to previous exertion, a flight difcharge rom the veflels about the os uteri. Thib ftate is diftin- guilhed from uterine contraction, by our finding that the cervix is unaffected, that the pains are increafed by motion or prefiurc, and are more irregular than thofe attending labours. This ftate may be prevented from inducing abortion by reft, by keeping the bowels open, by anodynes preceded by venefoction, if the puhe indi- cate it. Frictions, with camphorated fpirits of wine or laudanum, give relief. Any exertion, during the remain- ing period of j;cft.ati«n, will renew the pain in the back. 68 be fure that expulfion, though retarded will foon take place.* This fact is rot always attended to in abortion, for many think that if by ano- dynes they can abate the pain, they will make the woman go to the full time. This is true, with regard to many painful fenfations, which may attend a threatened abortion, or which may be prefent, al- though there be no appearance of abor- tion ; but it does not hold with regard to thofe regular pains proceeding front univerfai action oi the uterine fibres ; and we may fave both ourielves and our pa- tients fome trouble, L»y keeping mis in rcmembiance. * We are careful to examine the (rate of the uterus, afccrtaining us univciial contraction by finding thai .lie membranes become a little tight during a pain, provided tl-x pregnancy be fo far advanced as to allow them 14 be iei: in the early part of the piocefs. 6$ Seeing, then, that contraction is brought on by ftopping the action of gef. tation, and that when it is brought on it cannot be checked, nor the action of gef- tation reftored, we muft next inquire how this action may be ftopped. I have alrea- dy mentioned feveral circumftances af- fecting the uterus, and likely to injure its actions; and thefe I fhall not repeat, but go on to notice fome others, which are often more perceptible ; and firft I fhall mention violence, fuch as falls, blows, and much fatigue, which may injure the chiid^ and detach part of the ovum. If part"of the ovum be detached, we hrwe not only a difcharge of blood, but alfo the uterus, at that part, fuffers in its action, and may influence the whole or- gm, fo as to ftop the action univerfally. But the time required to do this is vari- ous, ai d opportunity is often given to prevent the miichief from fpreadirg, and ?• to flop any farther effufion—perhaps to accomplifh a re-union. Violent exercife, as dancing, for in. fiance, or much walking, or the fatiguing diffipations of fafhionable life, more efpe- cially in the earlieft months, by effecting the circulation, may vary the diftribution of blood in the uterus, fo much as to pro- duce rupture of the vefiels, or otherwife to deftroy the oVum. There is alfo an- other way in which fatigue acts, namely, by fubductirg adtion and energy from the uterus : for the more erergy that is ex- pended on the mufcles of the inferiour extremities, the lefs can be afforded or directed to the uterus ; and hence abor- tion may be induced at an early ftage of geftation.* *. The fame effect is obfervable in the ftomach and Other organs. If a delicate perfon, after a hearty meal, tife exercife to the extent of fatigue, he feels that >hc food is not digeftc.d, the ftomach having betH weakened •r injured in its attion. 7r Even at a more advanced period, in- con vsnience will be produced upon the principle formerly mentioned; for the nerves of the loins conveying lefs energy, in many inftances, though not always to the mufcles, they are really weaker than formerly, and are fooner wearied, produ- cing pain, and prolonged feeling of fa- tigue, for many days, after an exertion which may be confidered as moderate. This feeling muft not be confounded with a tendency to abortion, though it may fometimes be combined with it, for generally by reft the fenfation goes ofK Meither muft we fuppofe that the child is dead, from its being ufually quiet dar- ing that period, for as foon as the uterus, which has been a little impaired in its ac- tion, recovers, it moves as itrongly aS ever. £a In the r.ex* pi ice, I mention the deatK of the child, which may be produced by fyphilis, or many difeafes pei haps peculiar to itfeif,or by injury of the functions of the placenta, which may arilefrom an improper Itructure of that gland itlelf, or aneurifm, or other difeafes of the cord. But in what- ever way it is produced, the effect is the fame in checking the action of geftation, unlefs there be twins, in which cafe it has been known that the uterus fometimes did not fufFer univerialiy, but the action went on, and the one child was born of the full fize, the other fmall and injured.* * It has even been known, that, in confluence of the death of one child, the uterus has filtered partially, ;.n 1 expulfion takes place; but the other child continuum to live, has preferved the adion of pi ftation in that p.irt of the uteru?, which, properly fpeaking, belonged to it, and pregnancy has ftill gone on. This, however, is an extremely rare occurrence ; for, in almoft every inftance, the death of one child produces an afTedion of the action of geftation in the whole uterus, and theconfrqiKre ex- puKion of both childrcr. 73 The length of time required for pre* during abortion from this caufe is vari* ous; fometimes it is brought on in a few liours : at other times not for a fortnight, or even longer. In thefe and fimilar ca- fes, when the mufcular action is com- mencing, the difcharge is trifling, like mcnftruation, until the contraction be- comes greater, and more of the ovum be feparated. When fymptoms of abortion proceed from this caufe, it is not poflible to prevent its completion ; and it womd be hurtful even if it were poflible. When, therefoijp, after great fatigue, profufe evacuations in delicate habits, violent col- ick, or Other caufes, the motion of the child ceafes, the breafts become flaccid, and the figns of geftation difappear. We need not attempt to retard expulfion, but (hould direct' our principal attention to conduct the woman fafely through the procefe, G 74 A third caufe is a difproportioned ac- tion betwixt the uterus and ovum, the one not increafing in the fame ratio with the other, yet both continuing to act. This is productive of frequent difcharges of blood, repeated at different, but always at fhort intervals, for feveral weeks, until at length the uterus fuffers fo much, that its action ftops, or the foetus dies, Another caufe is, any ftrong paflion of the mind. The influence of fear, joy, and other emotions on the mufcular fyftem, is well known ; and the uterus is not ex- empted from their power; any fudden fhock, even of the body, has much effect on this organ. The pulling of a tooth, for inftance, fometimes fuddenly produ- ces abortion. Emmenagogues, or acrid fubftances, .fuch as favine and other irritating drugs, more efpecially thofe which tend to ex- 75 rite a confiderable degree of vafcular ac- tion, may produce abortion. Such medicines, likewife, as exert a vio- lent action on the ftomach or bowels will, upon the principle formerly mentioned, frequently excite abortion; and very of- ten are taken defignedly for that purpofe in fuch quantity as to produce fatal ef- fects ; and here I muft remark, that many people at leaft pretend to view attempts to excite abortion as different from mur- der, upon the principle that the embryo is not pollened of life, in the common ac- ceptation of the word. It undoubtedly can neither think nor act; but, upon the time reafoning, we fhould conclude it 10 be innocent to kill the child in the birth. Whoever prevents life from continu- ing, until it arrive at perfection, is cer- tainly as culpable as if he had taken it away after that had been accomplished. 16 I do not, however, wifh, from this obfer- vation, to be underftood as in any way difapproving of thofe necefiary attempts which are occafionally made to procure premature labour, or even abortion, when the fafety of the mother demands this in- terference, or when we can thus give the child a chance of living, who otherwife would have none. If any part with which the uterus fym- pathizes have its action greatly increafed during pregnancy, the uterus may come to iuffer, and abortion be produced.— Hence the acceffion of morbid action or inflammation in any important organ, or on a large extent of cuticular furface, may bring on mifcarriage, which is one caufe why fmall-pox often excites abortion, whilft the fame degree of fever, unaccom- panied with eruption, would not have- lud that effect. 11 Hence alfo increafed fecretory action in the vagina, if to a great degree, though it may have even originally been excited in confequence of fympathy with the uterus, may come to incapacitate the ute- rus for going on with its actions, and therefore it ought to be checked by means of an aftringent injection. In this cafe the uterus has, without: any proof, been fuppofed to become too much relaxed, whilft in other cafes, as for inftance when the abdomen was harder than ufual, it has with as little foundation been fuppofed to be preter- naturally rigid.* * RoeJerer fuppofes, that periodick abortion pro. qeeds tVom the uterus being incapable of diftending be- yond a certain lizo. Vide Elementa exxii.—Roderick Araltro fuppofes, that it proceeds " animia humiditate nificiis matiicis." Vide De Morb. Mulier, p. 46s* <\ a 78 Mechanical irritations of the os uteri, or attempts to dilate v prematurely, will alfo be apt to bring on mufcular contrac- tion. At the fame time, it is worthy of remark, that the effect of thefe irritation- is generally at firft confined to the fpot on which they act, a partial affection of the fibres in the immediate vicinity of the os uteri being all that is, for fome time, produced; and therefore flight un- eafinefs at the lower part of the belly, with or without a tendency in the oa. uteri to move or cliuie, whether brought on by irritaion at tfie upper part of the vagina or os uteri, or by affection, ot the neci* ot the biaader, &c* may be often * It is an old obferyation, that thefe purgatives, which produce much tenefmus, will excite abortion; and this, is certainly true, if their operation be carried to a confiderable extent, and continue long violent.— Hence dyfentery is alio apt to bring on, a mifc3r^iage^ {Thofe ftrong purges which are fometimes taken to pro- j-.iou- premature expullion, not only act by exciting te- ihrJUjiuo, out like wile by inflaming the ftomach and boro^« n prevented from extending farther, and dcftroying the action of geftation by reft, anodynes, and having immediate recourfe to fuch means as the nature of irritation may require for its removal.* els, and thus affect the uterus in two ways. It cannot be too generally known, that when thefe medicines do produce abortion, the mother can feldom furvive their effects. It is a miftaktn notion, that abortion can be moft readily excited by draftick purges, frequent and co- pious bleeding, &c. immediately after the woman difcov« er6 herfelf to be pregnant; on the contrary, the action of the uterus is then moie independent of that of other organs, and therefore not fo canty injured by changes in their condition. I have already (hewn, that abortion more frequently happens when the pregnancy is farther advanced, becaufe then not only the uterus is more ealily sflcctcd, but the fcetus feems to lufFer more readily.— It is apt, either from difeafes directly affe&ing itfelf, or from changes in the uterine action, to die about the middle of the third mouth, in which cafe expulfion fol- lows within a fortnight. * Chronick inflammation of the heart is generally at- tended with pain at the bottom of the abdomen, which is fometimes miftaken for fymptoms of calculus. In one cafe abortion feemed to proceed from this difeafe iftb.c hear*. 8o The irritation of a prolapfus ani, or of inflamed piles, with or without much fanguinous difcharge, may excite the uterus to contract; and if the bleeding; from the anus have been profufe and the woman weakly, it may deftroy the child. The piles ought, therefore, never to be neglected. The bowels fhould be kept open. An anodyne clyfter may be given if the pain be great, and a poultice appli- ed, confifting of curd of milk, and a little laudanum, or a linament made up of thick * cream, with a little of the extract of lead, or exprefied juice of belladona. Tapping the ovum, by which the ute- - rus collapfes and its fibres receive a hamu- lus to action, is another caufe by which abortion may be produced ; and this is fometimes, with great propriety, done at a particular period, in order, to avoid a greater evil. Si It is now the general Opinion, that contraction will unavoidably follow the evacuation of the waters. But we can fuppofe the action of geftation to be in fome cafes fb ftrong as not, at leaft for a very confiderable time, to ftop in confe- quence of this violence, and, if it do not ftop, contraction will not take place. I do not, however, mean to fay, that all dif- charges of watery fluid from the uterus, not followed by abortion, are difcharges of the liquor amnii, and inftances of this failing fpeedily to produce contraction. On the contrary, I know that moft of thefe dropfical cffufions are the confe- rence of morbid action about the os uteri, the glands yielding a ferous, inftead of a gelatinous fluid, and this action may continue for many months. Sometimes the upper range of lacuna; yields water, whilft the under fecretes jelly, which confines the water for fome hours. 8* Until it accumulates, and comes out with a fmall gufh. At other times, in the ear- ly period of geftation, it collects in con- fiderable quantity betwixt the lower part of the decidua protrufa, which has not yet reached the cervix uteri and the gela- tinous plug, which becomes a little ftrong. er than ufual. There is thus a fpecies of dropfy pro- duced, and the water is fometimes confin- ed until a little before labour comes on j at other times it is difcharged fooner, and an oozing continues for many weeks. In fome inftances water is collected be- twixt the chorion and amnion, or a large hydatid occupies the lower part of the uterus, whilft the ovum lies above it.— But in whatever way we may fuppofe the water to be collected, there are exam- ples of a very aftonifhing quantity hav- ing been difcharged about the middle or end of pregnancy, without exciting ths *3 expuifive action of the uterus. In all thefe cafes the woman muft be confined to bed and have an anodyne every night at bed-time, for fome time, premifmg vene- fction if the pu'fe indicate it, and con- joining gentle laxatives. There is juft fo much probability of geftation going on as to encourage us to ufe endeavours to con- tjnue it. In thole inftances where the dif- charge is fmall, and the oozing pretty conftant, wc conclude that it is yielded cliicily by the glands about the os uteri, and may derive advantage from injecting three or four times a day a ftrong infufion of gills, or folution of alum. The wo- man ought to ufe no exertion, as the membranes are apt to give way. When the liquor amnii really is evacu- ated, fometimes a fpafmodick contraction of the fibres near the cervix takes place, inftead of that regular action which is Hccefiary for expulfion ; and if the whole 84 of the liquor have not efcaped, the re- maining portion will be confined by the tightening ot that part of the uterus round the fcetus; and this contraction may endure for a very confiderable time. If not interrupted, it may lay the founda- tion of future difeafes in the uterus, OF THE PROGNOSIi. The danger of abortion is to be efti- mated by confidering the previous ftate of the health, by attending to the vio- lence of the difcharge, and the difficulty of-checking it j to its duration, and the difpofition to expulfion which accompa- nies it j to the effects which it has pro- duced in weakening the fyftem, and to its combination with hyfteri; al or fpaf- modick affections. In general, we fay that abortion is not dangerous, yet in 8* fome cafes it does prove fatal very fpeedily, either from iofs of blood, or fpafms about the ftomach, or convulfions. It is fatisfactory, however, to know, that this termination is rare, that thefe dangerous attendants are feldom pre- fent, and that a great haemorrhage may be fuftained, and yet the ftrength foon recover. But if there be any difpofition in a particular organ to difeafe, abortion may make it active, and thus, at a re- mote period, carry off the patient. Mif* carriages, if frequently repeated, are alio very apt to injure the health, and break up the conftitution. When abortion is threatened, the pro- cefs is very apt to go on to completion ; and it is only by interpofing, before the expulfive efforts are begun, that we can be fuccefsful in preventing it, for when- ever the mufcular contraction is univer- H 86* fally eftablifhed, marked by regular pains, and a< tempts to diitend the cervix and os uteri, nothing, I believe, can check the procefs. As this is often the cafe before we are called, or, as in many iuftances abortion depends on the action of geftation being ftopped by caufes whbfe action could not be afcertained until the effect be produced, we fhall frequently fail in preventing expulfion. This is greatly owing to our not be- ing called until abortion, that is to fay, the expulfive procefs has begun ; where- as, had we been applied to upon the firft unufual feeling, it might have been pre- vented. What I wiih then particularly to inculcate is, that no time be loft in giving notice of any ground of alarm, and that the moft prompt meafurcs be had recourfe to in the very beginning; for when uterine contraction has com- menced, then all that we can do is to con- «7 duct the patient fafely through a con- finement, which the power of medicine cannot prevent. The cafe of threatened abortion, ir: which we moft frequently fucceed, is that arifing from flipping of the foot, or caufes exciting a temporary over-action of the veflels, producing a flight.fepa- ration, becaufe here the haemorrhage im- mediately gives alarm, and we are called before the action of geftation be much affected. Could we imprefs upon our patients the neceflity of equal attention to other preceding fymptoms and circumftances, we might fucceed in many cafes where we fail from a delay, occafioned by their not underftanding that an expulfion can only be prevented by interfering before it begins, but that, when fenfible figns of contraction appear, the mifchief has 88 proceeded too far to be checked. Prompt and decided means uted upon the firft approach of fymptoms indicating a haz- ardous ftate of the uterus, or on the carlieft appearance of hacmorrhagix may, provided the child be ftill alive, be at- tended with fuccefs. OF THE PREVENTION AND TREATMENT OF ABORTION. In confidering the treatment, I fhall firft of all notice the moft likely method of preventing abortion in thofe who are mbject to it; next, the beft means of checking it, when it is immediately threatened ; and, laftly, the proper me* thod of conducting the wonian through it, when it cannot be avoided. 89 The means to be followed in prevent- - ing what may be called habitual mhcar- riage, muft depend on the caufe fup- pofed to give rife to it. It will, there- fore, be rtecefiary to attend to the hif- tory of former abortions ; to the ufual habitudes and conftitution of the wo- man ; and to her condition when fhe becomes pregnant. In many inftances a plethorick dif- pofition, indicated by a pretty full habit, and copious menftruation, will be found to give riie to it. In thefe cafes, we fhall find it of advantage to reftrict the pa- tier.t akneft entirely to a vegetable diet, and at the fame time make her ufe con- fiderable and regular exercife. The fleep mould be abridged in quan- tity, and taken not on a bed of down^ but on a firm matrels, at the fame time that: we prevent the accumulation of too H Z QQ much heat about the body. The bowels ought to be kept open, or rather loofe, which may be effected by drinking Cheltenham water : and this can be arti- ficially prepared, if necefiary. There is, in plethorick habits, a weak- nefs of many, if not all, of the func- tions ;x but this is not to be cured by tonics, but by continued and very gradu- ally increafed exercife, with light diet, confifting chiefly of vegetables. This plan, however, muft not be carried to an im- prudent length, nor eftablifhed too lud- denly ; but regard is to be had to the pre- vious habits. It is a general rule, that exercife fliould not be carried the length of fatigue, and that it fhould be taken, ifpoffible, in the country, whilft late hours, and many of the modes of fafhion- able life, muft be departed from. We may alfo derive fome confiderable advan- tage from conjoining with this plan, the 9l fhower bath, or fea-bafhing, that they ought not to be omitted. There is, I believe, no remedy more powerful in preventing abortion than the cold bath, and the beft time for iifing it is in the morning. By meant, of this, conjoined with attention to the vafcular fyftem, and prudent conduct on the part of the patient, I fuppofe that nine-tenths of thofe who are lubject to abortion, may go on to the ful 1 time. It the fhower- Latfi be employed, we mult begin with a fmall quantity of water j and, in fome inltances, may at firft add lomuch watm water as fhall make it juft feel told, but not give too great a fhock. After con- ception, the exercife muft be taken with circumfpection : but the diet fhould ftill be fparing, and the ufe of the cold bath continued. If the pulfe be at any time full, or in- clined to throb, or if the patient be of a S2 vigorous habit, a little blood fliould be taken away at a very early period. In fome cafes where the action is great, we muft bleed almoft immediately after the fupprefiion of the menfes. It is not ne- cefiary to bleed copioufly: it is much better to take away only a few ounce3, and repeat the evacuation when requir-. ed, and we fhould manage fo as to avoid faintino*. The cold bath fhould be con- joined, and we may dc - re much advan- tage by ufing the digitalis,* fo as flight- ly to affect the pulfe, keeping it at or below its natural frequency, and dimin- ifi-ing its throbbing. But it is net re- quifite to be given to the degree employ- ed in fome other complaints ; 'and, if it be pufhed to an imprudent length, the * The acetite of lead has been recommend:d by tir- Ingenious and jutlly celebrated Dr. Rufli of Philadelphia, in dofes from one to three grains, given three titnjs a day. Of this practice I cannot fpeak from my nwn ex- perience; but Dr. P„uih informs me, that in his hande it Las li.cn attended with great Iujcl-i";. 9$ ■ child may fuffer. Half a grain may be given, fo often as may be found necef- iary, 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 timp.; but it is feldom neceilary to give it be- yond the beginning of the fourth month, unlefs a change of circumftances after- wards require it.* The dofe muft be occafionally increaf- ed, fb as to produce the defired effect; and I can vouch for the fafety of the plan, Injecting cold water into the vagina, twice or thrice a day, has often a good effect, at the fame time that we continue. the fliower-bath every morning. When * In thofe cafes where the digitalis produces feeble- refs it is evidently improper to continue it regularly, Indeed, when this effect takes place, its farther exhibition u unneccflaty* 94 there is much aching pain in the back, it is of fervice to apply cloths to it, dipped in cold water, or gently to dafh cold water on it; or employ a partial ihower-bath, by means of a fmall water* ing can. In this, and all other cafes of habitual abortion, we muft advife that impregna- tion fhall not take place until we have corrected the fyftem ; and after the wo- man has conceived, it is requifite that fhe live abfque marito, at leaft until geftation be far advanced. I need fcarcely add, that when confulted refpedting habitual abortion, the ftricteft prudence is requir- ed on our part, and that the fituation of the patient, and many of our advices, fliould be concealed.from the moft inti- mate friends of the patient. In other cafes, we find that the caufe of abortion is connected with fparing 95 menftruation. This is often t he cafe with women whofe appearance indicates good health, and who have a robuft look. This is not often to be ratified by medi- cine, but it may by regimen, &c. Here, as in the former cafe, we find it ufeful to make the greateft part of the diet confift of vegetables ; but it is not necefiary to rcitrict the quantity. When, op the other hand, the patienfe has a weakly delicate appearance, it will be proper to give a greater proportion of animal food, and two or three glaffes of wine, in the afternoon, with fome bitter laxative, twice a day, fo as to ftrengthen the ftomach, and at the fame time keep the bowels open. Wc alfo derive, in both cafes, advan- tage from the daily ufe of the warm bath, made of a pleafant temperature ; but this is to be omitted after conception : at leaftg 98 'for the firft ten or twelve weeks, after which, if there be fymptoms of irritation, or feeling of tenfion about the belly, or pain about the groins, or pubis, it may be employed, and is both fafe and ad- vantageous. But when the patient is of a phlegmatick habit, or fubject to profufe flour albus, it is not indicated, and fome- times is pernicious. The internal ufe of the Bath waters is often of fervice; or where the circumftances of the patient will not permit this, we may defire her to drink, morning and evening, a pint of tepid water, which may be continued during geftation. Throwing up into the vagina tepid fait water twice or thrice a day, feems alfo to have a good effect. I have already, mentioned, that abor- tion is fometimes the confequence of too firm action, the different organs refufing to yield to the uterus, which is thus pre- vented from enjoying the d'!e quantity o 97 energy and action. Thtfe women have none of the difeafes of pregrancy, or they have them in a flight degree. They have good health at all times, but they cither mifcarry, or have labour in the feventh or eighth month, the child be- ing dead ; or, if they go to the full time, 1 have often obferved the child to be fieldy, and of a conftitution unfitting it for living. We may fometimes cure this ftate by giving half a grain of digitalis, and the eighth part of a grain of the tartris an- timonii, every night at bed-time, which dimmiihes the ftonlachick action. Bleed- ing is al.o uleful, by making the organs more irritable. Kxercifc, fo as to prove tonic, is hurtful in this fpecies of abor- tion ; iniiead of wifhing to increafe the action of any organ, our object is to di- miiiilh it. and make the different parts more eafily acted on. The warm or tepid i 9$ bath is, in general, of advantage, and may be employed every fccond evening for fome time. The accidental acceffion of an hyfte- rick condition of the fyftem, fometimes fpontaneoufly cures this ftate: and if the patient have gone to the full time, but bear an unhealthy child from this caufe; if fhe meet with any accident in her con- finement, inducing a nervous condition, fhe is lefs apt afterwards to mifcarry, or have dead children. There is another cafe in which all the functions are healthy and firm, except the circulation, which 1S accelerated by the uterine irritation. This is more or lefs the cafe in every pregnancy, but here it is a prominent fymptom. The woman is very reftlefs, and even feverifh, and ■apt to mifcarry, efpecially if fire be of a fall habit. Immediate relief is given by 99 vtncfection, and afterwards we may, fdr fome 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 arifes, from too eafy yielding of fome organ, we muft keep down uterine ac- tion, by avoiding venery, and injecting cold water often into the vagina; or, pouring cold water every morning from a watering can, upon the loins and ilia. Clyfters of cold water are alfo ufeful; but from the unpleafant fenfation which they give, they ought not to be fre- quently employed : at the fame time we muft attend to the organ fympathiz- ing with the uterus. Sometimes it is the ftomach which is irritable, and the perfon is often very fick, takes little food, and digefts ill. A fmall blifter applied to the pit of tho IOQ Stomach, often relieves this; a little of the compound tincture of bark, taken three or four times a day, is ferviceable; or a few drops of the tincture of muriated iron in a tumbler glafs full of aerated water ; at other times the bowels yield, and the patient is obitinately coftive. This is beft cured by manna, with the tartarite of potafh. When the mufcu- lar fyftem yields, producing a feeling of langour and general weaknefs, the ufe or the cold bath, with a grain of opium, at bed-time, will be of moit fervice, ft is evident that it is only by attend- in^ minutely to the hiflory of former mifcarriages, that \ve can detect thefe caufes ; and we fhall generally find, that in each individual cafe it is the lame prgan in every pregnancy which has yielded or fuffercd. Previous to future conception, we v ay, wiih propriety, endeavour to render it lefs eafily af- fected, lOf General weaknefs is another condition giving rife to abortion ; and upon this I have already made fome remarks. I have here only to add, that the ufe of the cold bath, the exhibition of the Peruvian bark, and wearing flannel next the fkin, conftitutes the moft fuccefsful practice. Syphilis is likewife a caufe of abortion. When it occurs in the mother, it often unfits the uterus for going on with its actions. At other times, more efpecially when the father labours under venereal heclick, or has not been completely cured, the child is evidently affected, and or'tcn dies before the procefs of geftation can be cou^ ieied. In thefe cafes a courfe of mercury alone can effect a cuie. But we are not to fup- pofe that every child, born without the t elide in an early ftage of pregnancy, ' i " 102 has fuffered from this caufe ; on the con- trary, as the majority of theie inftances depend on caufes already mentioned, and which cannot be cured by mercury, I with to caution the ftudent againft too haftily concluding that one of the parents has been difeafed, becaufc the child is born dead or putrid in the feventh month. It is not always eafy to form a correct judgment; but we may be afiifted by finding that the other caufes which I have mentioned are abfent; that we have ap- pearances of ulceration on the child, and that there are fome fufpicious circumftan- ces in the former hiftory and prcient health of the parents. Advancement in life, before marriage, i.i another caufe of frequent abortion, the uterus being then fomewhat imper- fect in its action. In general, we cannot do much in this cae, except avoiding i<>3 carefully the excitine caufes of abortion, and by attending minutely to the condi- li ,n of other organs, during menftruation or rre^nancy, we may, horn the pi'inci- jiea formerly laid down, do fome good. !' is fatisfactory to know that, although we may rail once or twice, yet by great care the uterus comes at laft to act more perfectly, and the woman bears chiidien a; the full time. After thefe obfervations, it is only necefiary to add, that in every inftance of habitual abortion, whatever the con- dition may be which gives rife to it, v/e Imd that it is eflential that the greateft attention be mid to the avoiding of the more evident and immediate exciting caufes of mifcarrige, fuch as fatigue, dancing, &c. In fome cafes, it may even be neeeflary to confine the patient to her room, until the period at which the uluallv aborts is pail. 104- When abortion is threatened, vft come to cenfider whether and by what means it can be flopped. I have already ftated my opinion, that when the ac- tion of geftation ceafes, it cannot be re- newed, and that general contraction of the uterine fibres is a criterion of this ceiiation. Still as fome of the means which s may be fuppofed ufeful in preventing a threatened abortion, are alfo ufeful in moderating the fymptoms attending its progrefs we may very properly have recourfe to them. Some caufes giving rife to abortion, do not immediately produce it, but give warning of their operation, producing uneafmefs in the vicinity of the uterus, before the action of that organ be materially affected. The detraction of a !ittle blood at lA* -hue, if the pulie be in any meafure full 19 5 or frequent; or, if the pitient be not of a habit forbidding evacuations, and the fubfequent exhibition of an anodyne clyfter, or a full dofe of digitalis and opium,* together with a ftate of abfo- lute reft for fome days, will often be fufficient to prevent farther mifchief, and conftitute the moft efficacious prac- tice, fae patient fhould be ftrictly confined to bed, fleeping with few bed- clothes, a'.'.! ';,hout a ihe in her apart- ments. The ,!:■■' the :M, in general, be low, confiiling or d.; t'"ft,t'^uit, and fruit: and much fluid, cL.^^u^j warm fluid, fhould be avoided, This is the time at which we can in- terfere wiih the molt certain profpect of fuccefs; and the greateft attention fhould be paid to the lUte of the reft of the • Opiates are of fignal benefit in this fituation, anYl fywuld fchiom be omitted after vencfe&ion. 1.Q& ayttem, removing uneafinefs, wherevet it is prefent, and preventing any organ from continuing in a ftate of undue ac- tion. It is difficult to perfuade the pa- tient to comply with that ftrict atten- tion Which is necefiary at this period; but being perfuaded that if this period be allowed to pals over with neglect, and contraction begins, nothing can afterwards prevent abortion. I wifh particularly to imprefs the mind of the ftudent with-a due fenfe of its impor- tance : and I muft add, that as after every appearance of morbid uterine action is over, the flight eft caufe will renew our alarm, it is necefiary that great attention be paid for fome time to the patient. Often, inftead of an uncafy feeling about the loins, or lower belly, we have, before the action of geftation ftops, a dif- charge of blood, generally in a moderate, fometiaies in a trifling degree. This fe io; more efpecially the cafe when abortion is threatened, owing to an external caufe, and, if immediately checked, we may prevent contraction from beginning. Even in thofe cafes where we do not expect to ward off expulfion, it is ufeful to prevent, as far as we can, the lofs of blood ; for as I cannot fee that the hae- morrhage i i neceilary for its accomplifh- ment, although it always attend it, I con- clude that our a.tempts to prevent bleed- ing can never do harm, for if they fuc- ceed in checking abortion, we gain our object; if they fail, they do not increafe, but diminifh the danger. It fliould be carefully remembered, that the more we can fave blood, the more do we ihx^ our patient. As the means for checking the difcharge will be immedi- ately pointed out, it is unneceflary here to enter into any detail. ic8 Sovwc'""t>?s ihe vefftls about the cervix ana c,s> ui.eu ;:>'-ld, poft coitvm, a little blood, and this may « c:ur either in thofe who have the uterus in a high ftate of activity, or more frequently where it is feeble in its functions. The fame dif- charge may fometimes appear in rather greater quantity after impregnation, patt- ing perhaps for the menfes, and making the woman uncertain as to her fituation ; but it is generally, though not always irregular in its appearance, and feldom returns above once or twice. In fon.e inftances, however, it becomes greater and n.ore frequent in proportion as the veifels ii-creafe in fize. It is now apt to pais ior menonhagta. If it be allowed to continue, it tend; to injure the action of the uterus, ai d produces expulfion, which fometimes is the frft thing which fliows the woman he: fitvation.° Thisdiithurgcis bellman- 109 aged by reft, and the , frequent injectioa of faturated folution of the fulphat of alumine, or decoction of oak bark. When a flight difcharge takes place, in confequence of a flip of the foot, or fome other external caufe, we may alfo derive advantage from the ufe of the injection, but not fo certainly as in the former cafe ; and if the difcharge be c nfiderable, the injection will fail. It is better, in thi& cafe, to truft to the formation of a coag* ulum. When in a plethorick habit abortion is threatened, from a fright, or mental agi- tation, we have often palpitation, ra-' pidity of the pulfe, head-ach, flufhed face, and pain about the back or pubis, bleeding relieves immediately the unea- finefs in the head, and often the pain in the back; afterwards the patient is to be kept cool and quiet, and an anodyne admin ill c red. 110 In thofe cafes, where regular uterine pain precedes or accompanies the dif- charge, expulfion cannot be prevented; but when the difcharge precedes the pain, it fometimes may ; nay, if the child be ftill alive, it frequently may. Reft is abfolutely necefiary, if we wiih the per- fon to go to the full time: and it is occa- fionally necefiary to confine her to bed. for feveral weeks, at the fame time that we put her upon an effective courfe of digi- talis, and give an anodyne at bed-time, taking care alfo to keep the bowels in a proper ftate by gentle medicine. Blood ought alfo, unlets the pulfe and habit of the patient forbid it, to be detracted. This is a very critical fituation: much depends on the vigour and promptitude of our practice; and much very much, upon the prudence of the patient. It is teaming to find that, fometimes after all our care and exertions, one rafli act de- Ill ftroys in a fingle day the effect of the whole. When we cannot prevent abortion, the next thing is to conduct the patient fafe- ly through the procefs; and the firft point which naturally claims our attention is the haemorrhage. Many practitioners, upon a general principle, bleed, in order to check this, and prevent mifcarriage, but mifcarriage cannot be prevented, if the uterine contraction have commenced; and the difcharge cannot be prudently moderated by venefection, unlefs there be undue or ftrong action in the veflels ; or much blood in the fyftem ; and if fo, a vein may be opened with advantage. This is not always the cafe, and there- fore, unlefs the veflels be at or above the natural force or ftrength of action, the lancet is not at this ftage necefiary. The fulnefs and ftrength of the pulfe are loft; 112 much fooner in abortion than can be ex- plained, by the mere lofs of blood. It depends on an affection of the fto- mach, which has much influence on the pulfe ; and the proper time for bleeding is before this has taken place. When abortion has made fo much progrefs be- fore we are called, as to have rendered the pulfe fmall and feeble; or when this is the cafe from the firft, bleeding evi- dentiy can do no good. Inftead of this, we may ufe the dig- italis, which I have already highly re- commended as a preventive; but I do not fay that, in ordinary cafes, where the contraction is brifk, and the procefs jquitk, it is at this ftage abfolutely ne- cefiary ; and I fhall afterwards mention that, when the ftomachick affection is urgent, and the pulfe much affected by it, the ufe of this medicine is improper. i*3 When, however, the cafe is tedious, and the difcharge long continued, at the fame time that the ficknefs is not confiderable^ the digitalis will be of eflential fervice. Naufeating dofes of emetick medicines act in the fame way with the digitalis, but are much lefs effectual, and more dif- agreeable, as well as uncertain in their operation. Internal aftringents have been propof- ed, but they have no effect, unlefs they excite ficknefs, which is a different oper- ation 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 aftringents, and ought always to be had recourfe, to. If the digitalis have been & 2 ii4 exhibited, it aflifts that medicine immod- erating the circulation. Even when trufted to alone, it leffens the action of the fanguiferous fyftem, par- ticularly of the uterine veffels. The in- troduction of a fmall piece of fmooth ice into the vagina has been recommended, and has often a very fpeedy effect in re- tarding the haemorrhage, whilft it never, if properly managed, does any harm. A fmall -mow-ball, wrapped in a bit of linen, wiil have the fame effect; but neither of thefe muft be continued fo long as to pro- duce pain, or much and prolonged fhiv- ering. The heat of the furface is alio to be moderated, b> having tew bed clothes, and a free circulation of cool air. •But the moft effeaual local method of ftoppii g the haemorrhage, is by plug- ging the vagina. This is belt done by taking a pietty large piece of iott cloth, ii5 and dipping it in oil, and then wring- ing 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 prefled firmly on the orifice, and held there for fome time. This acts by giving the effufed blood time to coagulate. It gives no pain; it produces no irritation, and thole who condemn it, furely muft either not have tried it, or have naif- appiied it. If we believe that abortion requires for its completion a continued flow of blood, we ought not, in thofe cafes where the procefs muft go on, to have recourfe to cold, or other means of re- ftraining haemorrhage. f i6 If we do not believe this, then fufely the moft effectual method of moderat- ing it is the beft. Plugging can never retard the procefs, nor prevent the ex- pulfion of the ovum; for when the uterus contracts, it fends it down into the clotted blood in the upper part of the vagina, and the flooding ceafes. In obftinate cafes we may, before in- troducing the plug, infert a little pow- dered ice, when it can be procured, tied up in a rag. Faintnefs operates in the fame way, in many cafes, by allowing coagula to form in confequence of the blood flow- ing more flowly; and, when the faint- nefs goes off, the coagula ftill reftrain the haemorrhage in the fame way as when the plug has been ufed. This nat« urally points out the advantage of ufing the plug, together with the digitalis, as iiy we thus produce coagulation at tne mouths of the veflels, and alfo diminifh the vafcular action. It will likewife fhow the impropriety of ufmg injections at this time, for, by wafhing out the coagula, we do more harm than can be compenfated by any aftringent effect produced on the veflels. The principal means, then, which wev employ for reft raining the haemorrhage, are bleeding, if the pulfe be full and fharp; if not, wre truft to the digitalis, fluffing 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 ftate of abfolute reft, which muft be continued during the whole procefs, however long it may, in fome cafes, be The drink fliould be cold, and the food, if the pa- tient defires any, light, and taken in fmall portion?. i iS Opiates have been advifed, in order tq abate the difcharge, and are, by many, ufed in every cafe of abortion, and in every ftage. But as we cannot finifh the procefs without mufcular contrac- tion, and as they tend to fufpend that, I do not fee that their exhibition can be defended on rational principles. If given in fmall quantity, they do no good in the prefent point of view ; if in larger dofes, they only poftpone the evil, for they cannot check abortion after con- traction has begun. Nothing can do this, for it proceeds from the ceflation of the action of geftation, which we cannot re- ftore. But I will not argue againft the ufe of opiates from their abufe. They are very ufeful in cafes of threatened abortion, ' more efpecially in accidental feparation of the membranes and confequent difcharge. ii9 They do not directly preferve the action of geftation, but they prevent the tend- ency to mufcular contraction, and thus do good; for we find in the animal economy, that when two actions oppofe each other, or alternately, preventing a tendency to the one, has an effect in pre- ferving the other. In weakly or emaciat- ed habits, opiates alone if given upon the firft appearance of mifchief, are often fuf- ficient to prevent abortion; and, in op- pofite conditions, when preceded by ven- cfection, they are of great fcrvice. Opiates are likewife ufeful for allaying thofe fympathetick pains about the bow- els, and many of the nervous affections which precede or accompany abortion. They are alfo, efpecially if conjoined with digitalis, of much benefit in cafes where we have confiderable and protracted dif- charge, with trifling pains, as the uterus is not contracting fufliciently to expel ISO fhe ovum, but merely to feparate veflels, and excite haemorrhagias. By fufpending, for a time, its action, it returns afterwards with more vigour and perfection, and finifhes the procefs. But when the procefs is going on regu- larly, opiates will only tend to interfere with it, and prolong the complaint. It was, at one time, a very frequent practice to endeavour, with the finger or fmall forceps, to extract the fcetus and placenta, in order to ftop the difcharge. Puzos ftrongly oppofcd this practice, and it is now very properly given up as a gen- eral rule. I do not wifh, however, to be underftood as altogether forbidding man- ual affiftance ; but I am much inclined to confider it as a ufeful precept, not to be, halty in attempting to extract the ovum. If the difcharge be protracted, and the membranes entire, we may, if the fitua- I2X tion of the patient require it, fometime* accelerate expulfion, by evacuating the liquor amnii. But if the pregnancy be not advanced beyond the fourth month, it will be better to truft to fmart clyf- ters, and reftrain the haemorrhage by means of the plug. We ,thus have a greater likelihood. of getting all the ovum off at once, and may excite the action by gently dilating the os uteri, and moving the finger round it. If the membranes have given way, and the fce- tus be ftill retained, we may, by infirruat- jng a finger within the uterus cautioufly, hook it out; or, in many cafes, it will be found partly expelled through the os uteri, and may eafily be helped away. But the moft tedious and troublefome cafe generally is that in which the fcetus has been expelled, but the fecundines are ftill retained. Now, we never can con- fider the patient as fecure from haemor- rhage until thefe be thrown off, and L 122 therefore fhe muft be carefully watched, efpecially when geftation is confiderably advanced. In a great majority of in- ftances, the uterus, within a few hours, contracts and expels them. But in fome cafes the haemorrhage does become pro- fufe, and there is little difpofition to fep- arate them. By ftu^ng the vagina, we fhall often find that the difcharge is fafe- ly flopped, and the womb excited to act in a fhort time. But if we be difappoint- ed, or the fymptoms urgent, the finger muik be introduced within the uterus,* and the remains of the ovum flowly de- tached by very gentle motion; and we muft be very careful not to endeavour to pull away the fecundines until they be fully loofened, for we thus leave part behind, which fometimes gives a great * In fome inftances, the half of the fecundines will be found in the vagina, and the other half ftill in the ute- rus. In this cafe, all that is neceiTary is gently to bring them o\;t. 123 dear of trouble; and farther, if we ralh> ly endeavour to extract, we irritate the uterus, and are apt to excite inflamma- tion or a train of hyfterical, and fome- times fatal fymptoms. It is thefe two caufes which make me cautious'in advif- ing manual afliftance; and, fortunately, fhe proportion of cafes requiring it is not great in abortion at an early period. When part of the ovum is left, or the whole of the fecundines are retained, then we have another danger befides haemorrhage; for, within a few days, putrefaction comes on, and much irrita- tion is given to the fyftem, until the foetid fubftance be expelled. Sometimes, if geftation have not been far advanced, or the piece which is left is not very large, it continues to come away in fmall bits for many months ; and during the whole time, the woman is languid, hyfterical, and fubject to irregularities of the men-- ts4 ftrua, very often to obftruction; but more frequently the fymptoms are very acute. We have lofs of appetite, proftra- tion of ftrength, tumid or tender belly, frequent fmali and fharp pulfe, hot and parched irate of the fkin, of the hands and feet, nocturnal fweats, and various hyfterical fymptoms. The difcharge from the vagina is abominably foetid, and hae- morrhage fometimes occurs to a violent degree.* When this difeafe proves fatal, there are often, though not always, conjoined fymptoms of gangrene, weak fluttering pulfe, cold fweats, and hiccup, * This is efpecially apt to take place in thofe cafes Inhere the adhefion of the placenta to the uterus has been unufually firm. When, after being retained for fome days, the connection loofens, the detachment is generally attended with haemorrhage ; and, if the fepa- racion (hould be complete, and expulfion take place we can difcover the fpot which adhered longeft by its dUfer* «moc of colour. tl$ The practice ought to be, to endea- vour with the finger to loofen the putrid fubftance, and wafh it out with tepid water thrown into the uterus by a fy- ringe with a long pipe. The parts fhould be kept clean in injecting infu- fion of chamomile flowers, with a fmall quantity of oxygenated muriatick acid- The bowels fhould be kept open with gentle laxatives and clyfters ; the ftrength fupported with light nourifhment and fmall portions of wine, or tincture of bark frequently repeated. Plenty of fuba- cid fruit may be allowed, and reft fhould be obtained, or irritation leffened by opi- ates. In the outfet of the difeafe, emet- icks fometimes excite the expulfion of the uterine contents; but when the ftrength is much impaired, they are of more doubtful fervice.* * The* the full time, but is in danger of being feiztd witli. convulfions in the courfe of labour, with the expulfive efforts of the womb, by very cautious manual afiiftance; and thefe endeavours, if the convuie.ons have not arifen from lofs of blood, ought to be preceded by liberal evacii.itu>r,s. It is proper to diflinguifh carefully be- twixt tli-.:^ two iUtcs; for, in U.j one cafe, the difeafe *34 Epilepfy is to be diftinguifhed from a combination of hyfteria and fyncope, which occafioually occurs during labour, whether natural or premature, and which is by no means equally dangerous. This is known by the fmallnefs of the pulfe, the palenefs of the face, the flight- nefs of the convulfions, the ab fence of foam at the mouth, and an appearance ' of ftruggling about the throat. It attacks fuddenly, generally on getting into an erect pofture. It is at firft little different from fyn< cope, and during the whole time the mus- cles of the face are not much affected, the countenance having rather a deadly af- pect. This is removed by an horizontal is entirely connected with the ftate of the uterus ; in the other, it is chiefly dependent on lofs of blood ; and, in fome, a comparatively fmall difcharge is fufficient to produce it. *3S pofture, fprinkling the face fmartty with cold water, and the ufe of volatiles. The patient, in this cafe, as in epilepfy, is of- ten unconfcious of having been ill. Regular hyfterick paroxyfms alfo fome- times accompany abortion, and are more dangerous than at other times, more efpecially if they feem to have been ex- cited by the profufion of the difcharge. If they laft long, they either end in mor- tal fyncope, or in ftupor. If they have been brought on by fome agitation of mind, they are lefs to be feared, though not even then void of danger. Befides attending to the ftate of the difcharge, the beft practice is to keep the perfon very cool, and exhibit thirty or forty drops of tincture of opium, and two drams of tinctura Valerianae ammoniata in a little peppermint water. A clyfter, compofed of a pound of cold water and i3° two drams of tincture of aflafoetida, is alfo fometimes of fervice. Thofe difagreeable fymptoms which J have defcribed, fortunately do not often attend abortion ; but the procefs goes on fafely, and without difturbance. In this cafe, after it is over, we only find it ne- cefiary to confine the perfon to bed for a few days, as getting up too foon is apt to produce debilitating difcharge. We muft alfo, by proper treatment, re- move any morbid fymptoms which may be prefent, but which depending on the peculiarities of individuals, or their pre- vious ftate of health, cannot here be fpe- cified. When the patient continues weak- ly, the ufe of the cold bath, and fome- times of the bark, will be, of much fer- vice in reftoring the ftrength ; and, in future pregnancies, great care muft be *57 taken that abortion may not happen agaiu at the fame period. Unfortunately we meet with fome Cafes where the recovery does not take place with that promptitude and regularity which could be wiflied. This fometimes depends upon a continuance of the hae- morrhage after the ovum is expelled, by which the patient is greatly weakened, and even her life put into danger. The haemorrhage may either continue from the time of expulfion, or it may come on a week, or even longer, after it. It feems to proceed from the uterus not going on in the procefs of reftoration to the unimpregnated ftate, but remaining too long enlarged, the confequence of which is, that very foon the veflels pour out blood, and fill the cavity, forming a coagulum, which prcfently is expelled ivith a confiderable flow of fluid blood ; M 2 '38 and this procefs may be very frequently repeated. This, which is often connected with .an hyfterical condition, is more efpecially apt to occur in thofe who are fubjcct to flooding after the expulfion of the child, as this marks a natural fecblenefs in tVe womb, and a difpofition to flag in its actions after delivery. This difeafe may take place at any pe- riod of geftation ; it may follow abortion - in the fecond month, or expulfion at the full time; it is moft frequent, however, in the early months, but moft dangerous in the latter ; it may attack only once or twice, or it may be often renewed for many weeks, and it is wonderful how the fyftem can be fupported under thefe re- peated difcharges, but we find that an incredible quantity of blood may be 10ft it it be taken away at intervals. »39 Each- paroxyfm is accompanied by flight pain in the back and belly, with confiderable langour and depreffion of fpirit. The difcharge continues until the clot efcapes out of the uterus, and for fome time after that, until a new coagu- lum forms in the cavity of the uterus which has not fully contracted; and dur- ing this laft procefs we have a confidera- ble oozing of ferum. This difeafe is not eafily diftinguifhect from tfie repeated haemorrhage which fometimes attends the retention of part of the fecundines ; but we may be afiift- ed by obferving that the clot which is difcharged is generally firm, and poffeffe'i exactly the fhape of the uterine cavity, fhowing that no fubftance is adhering to its fur race. No portions of organized or fibrous fubftance are difcharged, and liic putrid fmell attending the difeafe pro- ceedi evidently from the clot, which is *4* fometimes retained for five or fix days b the womb. This complaint either termi- nates fatally by a convulfion, or by fyn- cope, or the uterus contracts more brifk - ly, and fpeedily regains the proper fize for the unimpregnated ftate. If any lmall coagulum fhall form after the brifk con- traction which roufes the uterus to its healthy action, it gradually breaks down, and is expelled with the cleanfings. In abortion, during the early ftages of geftation, we cannot take any other pre- caution to prevent this than keeping the patient for fome time very quiet, as mo- tion, or even any agitation of mind, might interfere with the procefs of re- covery. In more advanced geftation, as, for in- ftance, in the feventh month, and after- wards, if we fhould be obliged, on ac- count of flooding, after the birth of the *4* child, to introduce the hand, and extract the placenta, we muft be careful'not to withdraw it, until we find the uterus' con- tracting round it, which will be a mean, though not an infallible one, of making it go regularly on in the procefs of reftora- tion to the unimpregnated ftate. The beft method of treating this com- plaint is on the very firft appearance of hae- morrhage, to introduce a firm plug into the vagina, which will prevent it from go- ing to an exceffive degree. Afterwards we muft take meafures to prevent a re% turn. This is beft done by keeping the circu* lation flow, by means of the digitalis, and putting the patient on a mild vegetable diet. We cannot afiift the procefs of res- toration otherwife than by endeavouring to excite the contraction of the uterus. This may be done by injecting an aftringfc 14a ent fluid two or three times a day, and by ordering faline clyfters, which have al- fo the effect of keeping the bowels open, an object of very great importance. We may alfo find it ufeful to excite gentle Vomiting by fmall dofes of ipecacuanha. This has an excellent effect in making the uterus contract, and often is the me- thod which nature takes to bring about recovery. This complaint is different from the me- norrhagia lochialis, or copious difchafge of blood brought on by exertion after abortion or delivery, at the full time.* In this cafe we have no large clot difcharg- ed, but juft the ufual appearances of me- * In fome cafes, howevrr, exertion fpeedily after abor- tion or child-birth d^es interfere with the adrion of the uterus, and prevent it from going on in thf procefs of di- minution with regularity. In thef? inftances, clots are difchareed wi>b hymnrrhapia*, and tbrfe of>rn pafc for moles or falfe conceptions, or portions af the fecundines. H3 norrhagia. This fometimes feems to be- come aflbciated with other morbid con. ditions of the fyftem : and in thofe cafes is more or lefs obftinate as they are intrao- tible. It is generally cured by reft, the ap- plication of cold, and the ufe of the digi- talis, if the pulfe be frequent. The confe- quent weaknefs is removed by bark, or preparation of iron, with the cold bath. Either of thefe difcharges are very apt to produce painful head-achs, vertigo, and often flight paralytick fymptoms, which, however foon go off. Any confiderable increafe of the haemorrhage gives relief to the head-ach, but it returns afterwards with greater violence. It is frequently relieved by the ufe of fmall dofes of the faline laxatives. In pro- tracted cafes, efpecially when the heack ach puts on an intermittent form, obferv- 144 kig pretty regular periods, the bark com. bined with valerian will be of fervice. Sometimes the mind is affected after abortion, although we may have had little difcharge; .and the perfon becomes either melancholy, or, which is much oftener the cafe, mad, with great volubility of tongue. This mania is, in general, fud- den in its attack, and is often preceded by a violent fit of palpitation, or fome other nervous affection. It occafionally .alternates with external pain or fwelling of fome of the joints; and, though frequently a tedious com- plaint, is oftener got the better of than any other fpecies of mania. The head, vn;>!i a general principle, ought to be fhaved and bliP.ercd, and a free difcharge kept up from it. The bowels are to be carefully attended to, and no indurated fecces iIioi.-.id be allowed to remain in ■I AS them. The camphorated emulfion may be given through the day in its ufual qu intity; and a full dofe of extract of hyofciainus exhibited at night. The pa- tient is to be kept, in every refpect, as quiet and eafy as poflible. When there is a permanent confufion of the head, or deep pulfating pain, or feeling of contraction ; when the patient .becomes reftlefs, the eye fparkles, the pulfe frequent, and delirium fupervenes, the cafe is much worfe, for the brain is inflamed, and nothing but the moft prompt and liberal evacuation can fave the patient. This difeafe rarely fucceeds abortion, but fometimes follows prema- ture labour. Another diftrefling confequence of abor- tion, as well as of labour at the full time, is hyfteria appearing in various forms, but more efpecially under that of palpita- 146 tion of the heart. This attacks fudden- ly, often in confequence of a fright. The patient has a violent beating in the brcaft, and fometimes a fenfe of fuffo- cation. She feels alfo a knocking within the head, attended with a fenfe of heat, and often a rednefs in the face. The pulfe becomes extremely rapid and irregular, and continues fo until the fit goes off, which fometimes is not for a confiderable time. During the paroxyfm, the patient is much terrified, and imprefied with a be- liet that fhe is going to die. After it is •ver, the mind is left timid, and the bo- dy in a ftate of langour. Sometimes the fit is fucceeded by a profufe perfpiration, Avhilft betwixt the attacks the tempera- ture is very verfatile. 147 This, like all other complaints of the. fame clafs, is very obftinate ; but it is not in general dangerous,* unlefs when it proceeds from uterine difeafe, marked by pain in the hypo^aftrick region and ten- fion of the belly. In this cafe, the dan- ger is great, and is only to be averted by the early ufe of purgatives, followed by antifpafmodicks, whilft fomentations are applied to the belly. The olhcr cafe, which is purely hyfteri- cal, is to Le relieved by giving, during the paroxyfm, a liberal dofe of tincture of opium and ether. ■ Small dofes have no clk-it. Dining the intervals we i-",ay fiive a tabie-f >oonful of the folio win ;• mix- tuie five or fix times a day. • When the patient is predifpoil-d to puimoniek dif- tr.L, violent p.u^iiaiij'i, dpcculiy if accompanied or fucceeded by the febrile ftate, to be afterwards, noticed, nny excite confamptiun, wruch m this cafe foincUsn* piout u4:ivii/ l.a.J, * T48 R Tine, digitalis 3ifs. E.vtr. H)ofcyami 3b Einuls. Camphorat. 3iv. mifce. It is alfo an effential point, that the bowels be kept open, and the patient put upon a light diet. As the attacks are ve- ry apt to come on at night, when the per- ton is about to fall afleep,- we fometimes find it ufeful to give a dofe of tincture of of hyofyamus and ether at bed-time, and- muft take great care that the patient be not afterwards difturbed or put off her reft. When flie is much troubled with flat- ulence, during the intervals-the tinctu a Valeriana ammoniata is of confiderable fervice. Tonics and the cold bath are alfo proper. Hyfteria either confifts in or depends upon a preternatural aptitude in the different organs, to have their ac- tions nurbidiy increafed, or rendered » *49 irregular; and hence it may affect fecret- ing as well as mufcular parts ; and many of the difcharges of lying-in women will be found to be, in this fenfe, hyfterical, and to alternate with other fymptoms,. fuch as globus, palpitation, head-ach, &c. and even the moft troublefome of all the diicharges, that proceeding from the uterus not recovering or contracting pro- perly, is, 1 believe, properly fpeaking, an hyfterical affection, connected with feve- ral others, and alternating with them. The next difeafe which I fhall mention, is alto, 1 believe, altogether hyfterical. I mean that refemblance of fever which is often met with after abortion or delivery, at the full time, and which is, like the reft of its tribe abundantly obftinate. This is not to be confounded with miik-fever, or other general difeafe? a- if- in^ from local injury. It is foaieiiaies V Z tfb jfreceded by palpitation, frightful dream.-*, and other nervous affection.* At other times it attacks directly with a fhivering fit, which is foon alternated" with heat; then the heat becomes fteady and dif- trefling, and continues until a profufc, ' perfpiration carries it off. The head is generally pained in the two firft ftages, and the pulfe is frequent in them ail. The thirft is confiderable, the ftomach filled with flatus, and the belly bound. Often we have irregular action of the heart occurring in ail the ftages, whilft the mind is weakened, and the patient is much afraid of dying. The paroxyfm continues for feveral hours, * Hiccup fometimes accompanies tin? eomphint: at other times it attacks the patient as a difeafe by illlf, or alternates with palpitation. It is belt treated by giv- ing larg^ dofes of ether. It is alfo necefiary to clear the bowels; afterwards the compound tinduie *>i" barfc li UlVul. ks* and, like ague, is apt to return regularly for a length of time. In the cold ftage, we g've fmall quan- tities of warm fluid. In the hot ftage, we leffen the number of bed-clothes ; bu* muft not do this fuddenly, as the fhiver- ingis very apt, in either this or thefweat- ing ftage, to return, upon flight expofure to cold. We alfo give fmall quantities of tepid fluid, in order to haften the accef- fion of the concluding ftage. In the laft ftage, we are careful not to encourage the perfpiration too much, by refraining from warm drink, for much fweatingf only tends to render the difeafe more obltinate. A repetition is to be prevented, by keeping the bowels open, by the ufe of the bark, conjoined with antifpafmodicks, and by carrying the patient, as foon as poflible, to tke country.