John Burns

“ But, whenever the action of gestation ceases, action is communicated to these fibres; and whenever this loss on the one part, and gain upon the other, is universally begun in the womb, the transference will be completed, and the ovum can no longer be preserved in the uterus.
The loss of action is generally speedy, when once begun. Perhaps in most instances it takes place instantaneously, and then the fibres begin individually to act; but they may not, for some hours, contract universally, and all at one and the same time producing pains. ”

“ My brother, in his dissections, even thought that the uterine extremity of the tube was less changed in point of vascularity, than any other part of it.
When the fœtus does descend into the uterus, it is contained in a double membrane. The internal one is the amnion, and possesses no distinct vessels. The external one is the chorion, and is from the first vascular, and soon becomes so much so, that its vessels have by some been described as forming a distinct tunic. ”

“ When we cannot prevent abortion, the next thing is to conduct the patient safely through the process; and the first point which naturally claims our attention is the hemorrhage. Many practitioners, upon a general principle, bleed, in order to check this, and prevent miscarriage: but miscarriage cannot be prevented, if the uterine contraction have commenced; and the discharge cannot be prudently moderated by venesection, unless there be undue or strong action in the vessels. ”

“ I have already shewn, that abortion more frequently happens when the pregnancy is farther advanced, because then not only the uterus is more easily affected, but the fœtus seems to suffer more readily. It is apt, either from diseases directly affecting itself, or from changes in the uterine action, to die about the middle of the third month, in which case expulsion follows within a fortnight. ”

“ The uterus being a large vascular organ, is obedient to the laws of vascular action, whilst the ovum is more influenced by those regulating new-formed parts; with this difference, however, that new-formed parts or tumors are united firmly to the part from which they grow by all kinds of vessels, and generally by fibrous or cellular substance, whilst the ovum is united to the uterus only by very tender and fragile arteries and veins. ”

“ When abortion is threatened, we come to consider whether and by what means it can be stopped. I have already stated my opinion, that when the action of gestation ceases, it cannot be renewed, and that general contraction of the uterine fibres is a criterion of this cessation. ”

“ Often the membranes give way, and the fœtus escapes with the liquor amnii, whilst the rest of the ovum is retained for some hours or even days, when it is expelled with coagulated blood separating and confounding its different parts or layers. At other times the fœtal and maternal portions separate, and the first is expelled before the second, forming a very beautiful preparation. In some rare instances we find the whole ovum expelled entire, and in high preservation. After the expulsion, the hemorrhage goes off, and is succeeded by a discharge somewhat resembling the lochia. ”

“ As considerable contraction is now required in the uterus, the pains are pretty severe. The derangement of the stomach is also greater than formerly, giving rise to sickness or faintness, which is a natural contrivance for abating the hæmorrhage.
When the membranes come to occupy more of the uterus, and a still greater difference to exist betwixt the placenta and decidua, we have again a change of the process; we have more bearing down pain, and greater regularity in its attack; we have a more rapid discharge, owing to the greater size of the vessels ”

“ Could we impress upon our patients the necessity of equal attention to other preceding symptoms and circumstances, we might succeed in many cases where we fail from a delay, occasioned by their not understanding that an abortion can only be prevented by interfering before it begins, but that, when sensible signs of it appear, the mischief has proceeded too far to be checked. ”

“ Hence dysentery is also apt to bring on a miscarriage. Those strong purges which are sometimes taken to promote premature expulsion, not only act by exciting tenesmus, but likewise by inflaming the stomach and bowels, and thus affect the uterus in two ways. It cannot be too generally known, that when these medicines do produce abortion, the mother can seldom survive their effects. It is a mistaken notion, that abortion can be most readily excited by drastic purges, frequent and copious bleeding, &c. ”

“ The process of gestation may be stopped, even before the fœtus, or vesicular part of the ovum, has descended into the uterus, and when only the primary vessels are formed. In this case, which occurs within three weeks after impregnation, the symptoms are much the same with those of menorrhagia. There is always a considerable, and often a copious discharge of blood, which coagulates or forms clots. This is accompanied with marks of uterine irritation, such as pain in the back and loins, frequently spasmodic affections of the bowels, and occasionally a slight febrile state of the system. ”

“ Whenever action is increased in an organ, it must either perish, or the larger nerve must send the branches more energy, for the branches themselves cannot form it, their extremities being only intended for expending it: from which it follows, that in pregnancy there must be more energy sent to the uterus, and less to some other part. ”

“ By abortion is generally understood the expulsion of the contents of the gravid uterus, at a period of gestation so early as to render it impossible for the fœtus to live. It is an accident or disease which is very frequent in its occurrence, which is always attended with disagreeable circumstances, and which, although it seldom prove immediately fatal, may yet be productive of much mischief at a future 2time. ”

“ Such medicines, likewise, as exert a violent action on the stomach or bowels will, upon the principle formerly mentioned, frequently excite abortion; and very often are taken designedly for that purpose in such quantity as to produce fatal effects; and here I must remark, that many people at least pretend to view attempts to excite abortion as different from murder, upon the principle that the embryo is not possessed of life, in the common acceptation of the word. ”

“ A tendency to abortion also results from a contrary cause, from organs yielding too readily, allowing the uterus to act too easily. In this state it is as liable to go wrong, as the general system is when it is at the highest degree of action, compatible with health, the most trifling cause deranges it. ”

“ The woman is very restless, and even feverish, and apt to miscarry, especially if she be of a full habit. Immediate relief is given by venesection, and afterwards we may, for some time, give every night half a grain or a grain of digitalis, with two grains of the extract of hyocyamus.
87When, on the contrary, abortion arises, from too easy yielding of some organ, we must keep down uterine action, by avoiding venery, and injecting cold water often into the vagina. Clysters of cold water are also useful; at the same time we must attend to the organ sympathizing with the uterus. ”

“ If we believe that abortion requires for its completion a continued flow of blood, we ought not, in those cases where the process must go on, to have recourse to cold or other means of restraining hemorrhage.
If we do not believe this, then surely the most effectual method of moderating it is the best. Plugging can never retard the process, nor prevent the expulsion of the ovum; for when the uterus contracts, it sends it down into the 104clotted blood in the upper part of the vagina, and the flooding ceases. ”

“ There being increased action of the uterus in gestation, requiring an increased quantity of energy to support it, we find that the system is put pro tempore into an artificial state, and obliged either to form more energy, which cannot be so easily done, or to spend less in some other part. ”

“ It is satisfactory, however, to know, that this termination is rare, that these dangerous attendants are seldom present, and that a great hemorrhage may be sustained, and yet the strength soon recover. But if there be any disposition in a particular organ to disease, abortion may make it active, and thus, at a remote period, carry off the patient. Frequently repeated miscarriages are also very apt to injure the health, and break up the constitution. ”

“ Thus the function of nutrition, or the action by which organic matter is deposited, in room of that which is absorbed, often yields, or is lessened, and the person becomes emaciated, or the stomach has its action diminished, 36or the bowels producing costiveness and inflation. If no part give way, and no more energy than usual be formed, gestation cannot go on, or goes on imperfectly. Hence some women have abortion induced by being too vigorous; that is to say, all the organs persist in keeping up their action in perfection and complete degree. ”

“ Exercise, so as to prove tonic, is hurtful in this species of abortion; instead of wishing to increase the action of any organ, our object is to diminish it, and make the different parts more easily acted on. ”

“ Sometimes the mind is affected after abortion, although we may have had little discharge; and the person becomes either melancholy, or, which is much oftener the case, mad, with great volubility of tongue. This mania is, in general, sudden in its attack, and is often preceded by a violent fit of palpitation, or some other nervous affection. ”

“ We sometimes, in these circumstances, have painful attempts made by the muscles to force the uterus downward, and these are occasionally attended by a very slight discharge of blood. We have, however, no regular uterine pain; and, if we are careful of our patient, abortion is rarely produced.
The best practice is to take away a little blood at first, to keep the bowels open, to lessen the tendency to vomit, by applying an opium plaster, or a small blister, to the region of the stomach, and to allay pain by doses of hyocyamus 45or opium, conjoined with carminatives. ”

“ Opiates are likewise useful for allaying those sympathetic pains about the bowels, and many of the nervous affections which precede or accompany abortion. They are also, especially if conjoined with digitalis, of much benefit in cases where we have considerable and protracted discharge, with trifling pains, as the uterus is not contracting sufficiently to expel the ovum, but merely to separate vessels. ”

“ Violent exercise, as dancing, for instance, or much walking, or the fatigueing 60dissipations of fashionable life, more especially in the earlier months, by affecting the circulation, may vary the distribution of blood in the uterus, so much as to produce rupture of the vessels, or otherwise to destroy the ovum. There is also another way in which fatigue acts, namely, by subducting action and energy from the uterus: for the more energy that is expended on the muscles of the inferior extremities, the less can be afforded or directed to the uterus ”

“ The case of threatened abortion, in which we most frequently succeed, is that arising from slipping of the foot, or similar causes, producing a slight separation, because here the hemorrhage immediately gives alarm, and we are called before the action of gestation be much affected. ”

“ In cases where the discharge is protracted and profuse, with little or no pain, and the ovum is still entire, we may, if the pregnancy be considerably advanced, excite the expulsive action, by rupturing the membranes. ”

“ If any part with which the uterus sympathizes have its action greatly increased during pregnancy, the uterus may come to suffer, and abortion be produced. Hence the accession of morbid action or inflammation in any important organ, or on a large extent of cuticular surface, may bring on miscarriage, which is one cause why smallpox often excites abortion, whilst the 67same degree of fever, unaccompanied with eruption, would not have had that effect. ”

“ In those cases, where uterine pain precedes or accompanies the discharge, abortion cannot be prevented; but when the discharge precedes the pain, it sometimes may. Rest is absolutely necessary, if we wish the person to go to the full time: and it is occasionally necessary 98to confine her to bed for several weeks, at the same time that we put her upon an effective course of digitalis, and give an anodyne at bed-time, taking care also to keep the bowels in a proper state by gentle medicine. ”

“ If the neighbouring parts do not accommodate themselves to the changes in the direction of energy, and act in 39concert with the uterus, their action becomes irregular, and consequently painful. In this case the uterus may have its just degree of power and action; but other parts may not be able to act so well under the change of circumstances. This is chiefly the case in early gestation, for, by time, the parts come to act better. It often gives rise to unnecessary alarm, being mistaken for a tendency to abortion; but the symptoms are different. ”

“ Throwing up into the vagina tepid salt water twice or thrice a day, seems also to have a good effect.
84I have already mentioned, that abortion is sometimes the consequence of too firm action, the different organs refusing to yield to the uterus, which is thus prevented from enjoying the due quantity of energy and action. These women have none of the diseases of pregnancy, or they have them in a slight degree. They have good health at all times, but they either miscarry, or have labour in the seventh or eighth month, the child being dead ”

“ Whoever prevents life from continuing, until it arrive at perfection, is certainly 66as culpable as if he had taken it away after that had been accomplished. I do not, however, wish, from this observation, to be understood as in any way disapproving of those necessary attempts which are occasionally made to procure premature labour, or even abortion, when the safety of the mother demands this interference, or when we can thus give the child a chance of living, who otherwise would have none. ”

“ Advancement in life, before marriage, is another cause of frequent abortion, the uterus being then somewhat imperfect in its action. In general, we cannot do much in this case, except avoiding carefully the exciting causes of abortion, 91and by attending minutely to the condition of other organs during menstruation or pregnancy, we may, from the principles formerly laid down, do some good. ”

“ The same effect may sometimes be obtained by injecting cold water into the os uteri. Whilst we thus endeavour to excite the regular action of the uterus, we must likewise act directly on the brain, by shaving the head, and applying a senapism to the scalp. We also detract blood, if the pulse indicate an evacuation. If, on the other hand, the disease seem to have arisen from the profusion of the discharge, it will be proper to give volatiles, or a full dose of laudanum, in a little warm brandy. ”

“ The same cause which tends to induce abortion at a certain age in those who have remained until that time single, will also, at a period somewhat later, induce it in those who have been younger married: for in them we find, that, after 29bearing several children, it is not uncommon to conclude with an abortion; or, sometimes after this incomplete action, the uterus, after a considerable time, recruits, as it were, and the woman carries a child to the full time, after which she ceases to conceive. ”

“ Thus, sometimes, the intestines yield too readily, and become almost torpid, so that a stool can with difficulty be procured. 37Here costiveness is not a cause of abortion, though it may be blamed. In like manner, the muscular system may yield and become enfeebled; and in this instance debility is accused as the cause of abortion, although it be, indeed, only an effect of too much energy being destined for the uterus. In this case, the woman is always weaker during menstruation and gestation than at other times. ”