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tionably slight, and as the extent of surface which the ovum now presents is very small to that which it offers in the more advanced state of pregnancy, and as it can of course be affected by smaller causes, it will be seen that a separation will be more easily induced, and prove much more injurious to the well-being of the embryo, than a larger one at another stage." (Dewees, Compendious System of Midwifery, § 929.) Abortions coming on at a later period, viz. from the sixteenth to the twentyeighth week, which corresponds to the second division, or miscarriages, of the continental authors, are not only more dangerous than abortions at an early stage, for the reasons above-mentioned, but also than premature labours, as in this last division the uterus has attained such a size as to make the process rather resemble that of natural labour at the full term. Causes. Premature expulsion may be induced by a great variety of causes, which may be brought under the two following heads: those which act indirectly, by destroying the life of the embryo, and those which act directly on the uterus itself. These various causes may be general or local; the process of nutrition for the growth and development of the embryo may be defective and scanty, from general debility or disease: hence, whatever depresses the tone of the patient's health renders her liable to abortion by causing the death of the embryo. Thus, dyspepsia and derangement of the chylopoietic viscera; debilitating evacuations; depressing passions of the mind; bad or insufficient nourishment; intense pain, as in toothach; severe suffering from existing disease, especially where the health is much broken down by some chronic affection; syphilis, and febrile attacks, all act as indirect causes of abortion.* Salivation from mercury not unfrequently has a similar effect; in some instances, however, febrile affections appear to act much more directly, stimulating the uterus to powerful contractions and rapid expulsion of its contents. The symptoms which indicate the death of the child have already been detailed in the chapter upon that subject.

The period which may elapse between the death and the expulsion of the embryo varies exceedingly: in the early months the one usually follows the other pretty quickly, owing probably to the slight attachment of the ovum to the uterus; during the middle third of pregnancy the interval may be of considerable duration, and cases every now and then occur where the fœtus is retained, not only several weeks, but even some months after its death; whereas, during the latter third of pregnancy, expulsion follows the death of the child after a short interval, seldom exceeding two or three days; for now the weight of the dead foetus speedily irritates the uterus to contraction, and, as has been observed by Smellie, the membranes, running gradually into putrefaction, and being now unable to bear the weight of the liquor amnii, burst, and expulsion soon follows.

Among the causes which act locally in inducing premature expulsion by first destroying the child, may be enumerated external violence applied to the abdomen, such as blows, falls, and other violent concussions: these act indirectly by producing separation of the ovum from the uterus, and thus destroying the life of the child. Under the same head may be classed all violent exertions, as lifting heavy weights, straining to reach something

During the great influenza epidemic, abortions were remarkably frequent.

high above the head, &c. The mere act of walking, when carried to such an extent as to induce exhaustion, will suffice, in weakly delicate females, to bring on expulsion; sudden and violent action of the abdominal muscles, when excited by a half-involuntary effort to save herself from falling, or receiving any other injury, may produce a similar effect: if the fœtus be so young that its movements cannot be felt by the mother, she feels from this moment more or less pain in the pelvis, with a sensation of weight and bearing down; and this, in all probability, will be followed by a discharge of blood from the vagina: where pregnancy has sufficiently advanced for the motions of the foetus to be perceptible, the mother will frequently feel them in an unusually violent degree for a short time immediately after the injury, and then they cease entirely.

Premature expulsion may also be induced immediately without the previous death of the child, by causes which directly excite the uterus to action: thus, various violent mental emotions, as rage, joy, horror, may act in this manner, although they may also act more indirectly; sudden exposure to cold, as sudden immersion in cold water, will occasionally produce it instantly. Irritation in the intestinal canal will directly excite uterine contraction; hence an attack of dysentery is frequently a cause of abortion, and we not unfrequently meet with patients who are liable to this affection in every pregnancy: a similar effect may be produced by the improper use of drastic purgatives, which irritate the lower bowels, viz. aloes, scammony, savin, &c.; or the uterus may, in some cases, be excited to contract from the peculiar action of secale cornutum. On the other hand, a loaded state of the bowels equally predisposes to abortion, by impeding the free return of blood from the pelvis. A state of general plethora acts in the same manner; and this is more particularly the case if it takes place at what would, in the unimpregnated state, have been a menstrual period; for, occurring in conjunction with the increased vascular action which prevails at these periods in the uterine system, it produces, as it were, an apoplectic state of the uterine sinuses, which form the maternal portion of the placenta; blood is extravasated between the ovum and uterus; their connexion is more or less destroyed, and the death of the fœtus becomes unavoidable: hence, in these cases the expulsion may result either from this latter circumstance, or from the uterus being irritated to contract by the effused blood between itself and the membranes. In patients who have suffered from attacks of dysmenorrhoea in the unimpregnated state, the irritable uterus, when pregnant, is very apt to contract upon its contents and expel them. This usually happens at what would have been a menstrual period, and not unfrequently takes place so soon after impregnation as merely to be looked upon as an unusually severe attack, the little ovum having been imperceptibly expelled among the discharges. Under this head must be brought those cases of spasmodic affection of the uterus, which Dr. Burns has described, and where, from the diminutive size of the ovum, the case has rather resembled one of menorrhagia. Cases of abortion are also mentioned by authors where the uterus is stated to be incapable of undergoing the necessary dilatation and increase of size which pregnancy requires; but we are strongly disposed to refer them to the above head of great uterine irritability, as we neither know of any diagnostic marks which will enable us to detect this condition

during life, nor are we aware of any physical condition of the uter of actual disease, to be detected after death, which can produce t bility.

The uterus may be also excited to expel the fœtus, without its previous death by local causes, as acute leucorrhoea, or other inflammatory affections of the vagina, by inflammation and other affections of the bladder, as calculus, &c. Too frequent sexual intercourse during the early months of pregnancy is peculiarly liable to excite abortion: this is especially observed among primiparæ of the better ranks, where, from luxurious living, &c., there is but little physical strength in proportion to the great irritability of the system; hence we find that a fifth, or even a fourth, of these females abort in their first pregnancies. In conclusion we may briefly state that the same circumstances which in the unimpregnated condition produce menstrual derangement and other disorders of the uterine system, now act as so many causes of abortion.

The sudden cessation of the breeding symptoms, with sense of weight and coldness in the lower part of the belly, flaccid breasts, pain in the back and loins, and discharge of blood from the uterus, are pretty sure signs of abortion: they are those which are " produced by separation of the ovum and contraction of the uterus," (Burns;) the one is attended by hæmorrhage, the other by pain. Although these are two chief symptoms which characterize a case of threatened abortion, and although they must necessarily be present more or less in every instance where premature expulsion actually happens, still neither of them, either separately or conjointly, can be considered as a certain proof that the uterus will carry its contents no longer. Cases not unfrequently happen where patients have repeated attacks of hæmorrhage during the early months of pregnancy, and sometimes to a considerable amount, without any apparent disturbance to the process of gestation, and are delivered of a living healthy child at the full term: on the other hand, we have known instances where the pain of the back was severe, and where, on assuming the erect posture, even for a minute, the sense of weight and bearing down in the lower part of the abdomen was so great as to make the patient fear that the ovum was on the point of coming away; still even these threatening symptoms have gradually subsided, and the pregnancy has continued its natural period. Puzos considered that neither pain nor hæmorrhage were necessarily followed by expulsion. (Mém. de l'Acad. de Chir. vol. i. p. 203.) When, however, both occur together, and to a considerable extent, the case must be looked upon as one of at least doubtful if not unfavourable termination. Where pain comes on at regular intervals, with hardness of the uterus, and dilatation of its mouth, this is a serious symptom, for it shows that the uterus will no longer retain its contents, but is evidently preparing to expel them.

The part of the ovum at which the separation of it from the uterus has taken place, not only determines which of the above symptoms will appear first, but also the probability of expulsion. "When a considerable separation takes place, as must be the case when it commences at the upper parts of the uterus, pain will more likely occur than when it happens near the neck; hence we sometimes have pain before the blood issues externally. The uterus in this instance suffers irritation from partial dis

tention from the blood insinuating itself behind the ovum; contraction ensues; the blood is thus forced downwards, and is made to separate the attachment between the ovum and the uterus in its course, until it finally gains an outlet at the os tincæ. In consequence of the uterus being excited to contraction, the friendly coagula which may have formed from time to time are driven away, and the bleeding each time is renewed, and accompanied most probably with increased separation of the ovum, until at last from its extent the ovum becomes almost an extraneous body, and is finally cast off. Hence a separation at or near the os uteri will not be so dangerous, and in all probability there will be hæmorrhage without pain, which is the contrary when it takes place near the fundus." (Dewees, Compend. System of Midwifery, § 981, 982.) The pain during the abortion is sometimes exceedingly severe, and not unlike that of dysmenorrhea: this is probably owing to the violent contractions of the uterus, which are required to dilate the os and cervix before the ovum can pass: they are frequently attended with nausea, vomiting, and fainting, and sometimes with more or less general fever and local inflammatory action; the pain is generally attended with much irritability of the bladder, and frequent desire to pass water; the pulse is mostly quick and small, and where there is arterial excitement, it is sharp, and resists the finger

Treatment. The treatment of premature expulsion consists in 1, that which is intended to guard the patient against its occurrence, or prophylactic; and 2, in that which is required during an attack.

A knowledge of the various causes of premature expulsion will materially assist us in the prophylactic treatment; under all circumstances, even where there is not the remotest fear of such an accident coming on, it is nevertheless highly important to pay strict attention to the state of the stomach and bowels, for these are almost always more or less influenced by the presence of pregnancy; the vomiting and sickness must be relieved in the manner already pointed out under the chapter on the TREATMENT OF PREGNANCY; the bowels, if constipated, must be moved by the mildest laxatives, such as castor oil, Confect. sennæ, or a Seidlitz powder; and thus all sources of irritation in the primæ viæ prevented as far as possible. The patient must carefully avoid every thing which may excite the circulation, such as violent affections of the mind, rich indigestible and stimulating food, violent exertion, &c. The diet should be light, nourishing, and moderate; heavy meals must be forbidden, and especially suppers; she should keep early hours, take gentle and regular exercise, and, in fact, endeavour by every means in her power to raise her health to a full degree of tone and regularity. In those patients who have already miscarried in their previous pregnancies, these precautions must be enforced with double vigilance; for the system becomes exceedingly irritable, and the uterus soon acquires, as it were, a habit of retaining its contents only to a certain period, and then prematurely expelling them. When this is the case, it becomes exceedingly difficult, and is often actually impossible, to make it carry the ovum to the full term of uterogestation, and, despite of the greatest care, the symptoms of premature expulsion will come on at about the same time at which they occurred in former pregnancies, and sometimes to the very same week.

In the treatment of such cases, where there is so much liability to abortion, we must first examine the precise condition of the circulation, and ascertain whether it be above or below the natural standard of strength; for as abortion may arise from very opposite conditions of the circulation, our treatment must consequently vary. If there be signs of arterial excitement, a small bleeding may be necessary; it unloads the congested vessels, diminishes the force of the circulation, and therefore also the chance of an extravasation of blood between the uterus and ovum; the bowels must be kept open by cooling saline laxatives, and the circulation may be still farther controlled by the use of nitre two or three times a day. The diet must be spare; she must take regular exercise in the open air, wear light clothing, dress loosely, and sleep upon a hard mat

tress.

In these cases we are often warned that congestion of the uterine vessels is present, by pain and throbbing, and sense of fulness in the groins: leeches applied to these parts give much relief, and frequently render venesection unnecessary. Tight lacing ought to be strictly prohibited in all cases of pregnancy, particularly where there is a disposition to plethora: among other bad effects, it prevents the proper development of the breasts, the nipples are pressed so flat as to be nearly useless, the child being unable to get sufficient hold of them: this may in some degree be avoided, by putting thick ivory rings upon the breasts, and thus shielding the nipples from injurious pressure. It will, however, be much better to have the dress made loosely, to allow for the development of the breasts, which takes place during pregnancy; for there can be little doubt, that irritation of these glands is very liable to be followed by a corresponding state in the uterus.

The common but erroneous notion that it is necessary to take an extra quantity of nourishment for the support of the child as well as of the mother, must be strenuously opposed. Nature contradicts it in the most striking manner; for, by the nausea and sickness which most women experience during the first half of their pregnancy, she raises an effectual obstacle to any error of this kind. "It certainly cannot be intended for any other purpose, since it is not only almost universal, but highly important, when it occurs, as it would seem, to add much to the security of the foetus; for it is a remark as familiar as it is well grounded, that very sick women rarely miscarry; while on the contrary, women of very full habits are disposed to abortion, if exempt from this severe, but, as it would seem, important process." (Dewees, on Children, § 45.)

Where the case has become one of habitual abortion, the patient's only chance will be by living separate from her husband for twelve or more months: the uterus, not being exposed to any sexual excitement during this period, becomes less irritable, and it gradually loses the disposition which it has acquired of expelling its contents prematurely. In such a case, when pregnancy has again commenced, it requires to be watched most narrowly; every possible source of irritation must be removed by the strictest attention to diet and regimen, and the patient must make up her mind to be entirely subservient to the rules laid down by her medical attendant. Although the chances are against her escaping without premature expulsion, still we are not to despair, experience showing that

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