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as my experience of its employment bears me out, it never causes any considerable inconvenience; while, I may add, it always succeeds.

A good many cases of abortion, in the early stage, as from the sixth week to the tenth week, have fallen under my notice, in which the uterus was unable to expel the debris of the ovum, and in which I could not extract it. The female, in such instances, save one, has always recovered without the ovum having been visibly discharged; but there always was an excretion, continued for many days, of offensive dark-colored grumes and sanies, which I accounted for by supposing that the substances in the uterus had macerated, and came off in a state of semi-solution, as in the instances mentioned by Puzos. I think that there is no danger in leaving such occurrences in the hands of nature; and that it is better to do so than reiterate attempts to extract by force, that have already proved quite vain; especially, considering that there is as great danger of exciting inflammation by those attempts as could be anticipated from the gradual maceration of the ovum. Let the Student reflect upon the demonstration made by my Figures 69, 70, and 71, and he will perceive that an attempt to take away the ovum, before the womb has become changed from Fig. 70 to the form of Fig. 71, not only ought to fail, but must fail of success. I am not disposed to deny that the presence of a putrefying substance, even of a small size, in the womb, is capable of developing inflammation and fever; but it has not happened so in my cases, and I have advised the same course to some medical friends, by whom I have been consulted, without the least cause to regret having given such advice. Let me be clearly understood, however, to recommend that the last remainders of the ovum should be brought off, where it is practicable, by employing reasonable efforts to do so.

I shall not omit the present opportunity for repeating, with regard to the tampon, that it is not a proper remedy for those cases in which any hope is yet entertained of saving the pregnancy.

Let us suppose an instance in which the placental attachment has taken place at the fundus uteri; that a partial detachment of the placenta has occurred; and that the blood, having forced its way in a narrow stream or rivulet betwixt the womb and the outer surface of the ovum, has at length made its appearance at the pudenda. Nothing is more common than to see such cases of show suppressed by venesection, recumbency, an opiate, some doses of elixir of vitriol, or cold lemonade. Should any practitioner, anxious to promote the formation of a coagulum, and thereby stop the effusion of blood and save the pregnancy, have instant recourse to the tampon, what would be the

consequence? The blood, instead of escaping externally, would be forced back on the ovum, while newly effused portions of it, instead of flowing by the route already formed, would continue to dissect off or separate the ovum more and more, until the whole of it should be detached, and at last come off, enveloped in the centre of a compressed clot. To use the tampon, therefore, is to insure the abortion; hence, it is only a remedy for the hemorrhage of abortion, and not a remedy for miscarriage, which it not only cannot prevent, but actually insures, or renders certain. The blood which continues to flow into the womb after the vagina has been closed by the tampon may be compared to a river dammed across its channel, whose waters, in consequence, overflow their banks, drowning the adjacent country.

With regard to the tampon, I wish to add that its employment in advanced stages of pregnancy, although allowable in certain instances, demands very great discrimination, inasmuch as it is capable of converting an open into a concealed hemorrhage, as we shall have occasion more fully to remark when we come to the consideration of uterine hemorrhage in labor. It may, under the proper indications, be with safety employed up to the close of the fifth month of gestation, since the womb, until that period, is incapable of admitting a sufficient quantity of blood to give any well-grounded fears of a fatal concealed hemorrhage. But at a later stage, the capacity of the uterus is so much increased that the tampon, if employed at all, ought only to be used while the practitioner himself carefully observes its effects, remaining at hand to remove it in case the uterine cavity should. become distended and filled either with fluid or coagulated blood to a threatening amount. I was told, not long since, of an instance in which a gentleman, treating a case of hemorrhage after delivery, was pressingly called for to visit another woman in labor, and as he felt compelled to go, he tamponed the vagina with a handkerchief, by which he effectually suppressed the apparent hemorrhage, but upon returning shortly afterwards, he found the patient dead, the womb having filled with blood instead of expelling it from the vulva, just such a conclusion to the affair as ought to have been expected from the use of a tampon under such circumstances.

It has happened to me to see the tampon injudiciously employed in this way on several occasions. Two of the persons were nearly expiring, when I arrived and immediately removed them; and one other, for whom it had been applied early in a flooding labor, without placental implantation, was expiring when I reached the house-a dreadful case of mala praxis, to which I shall recur in a future page.

Prolapsus. It is commonly thought that women who suffer under repeated abortions are quite as much, if not more subject to a consequent prolapsus uteri than those who are confined at full term. The natural tendency of labor is to produce a prolapsion of the womb, and that tendency must be much greatest where the vagina has been much distended and pressed out of its ordinary form. This might lead one to deny that abortions are as likely to bring on a state of prolapsus as labors at term. But those women who miscarry are, for the most part, not sick any longer than during the actual miscarriage: they generally get up, most imprudently, the next day, or in some instances even on the same day. The solid and weighty substance of the uterus now bears down the vagina, to whose upper extremity the organ is attached; and weakened and relaxed by the discharges of the miscarriage, and ofttimes after abortion affected with vaginitis, the vagina makes less resistance than is common, so that the womb takes permanently a lower level in the pelvis than it ought to have. All the difficulties and embarrassments likely to accrue from this vicious situation of the womb might be obviated by a little patience and prudence in the beginning. The woman should be warned, in clear intelligible language, that too early a getting up exposes her to the risk of suffering from a falling or bearing down of the womb, which may ruin her health, and thereby render her unhappy for life. Unfortunately, she feels too well to believe that our words are other than useless and needless vaticinations, and so she is not willing to maintain a recumbent posture more than one or two days.

It should be considered that while a woman, lying-in, is in a physiological state, one laboring under miscarriage is in an opposite condition-that she is sick, and often needs care not less sedulous than the other one requires. The womb is in fault, as to the miscarriage in some of the cases, and any man conversant with the events of our obstetric practice knows that the organ is occasionally left by abortions inflamed, or hyperemic, and irritable to the last degree. In these instances, the organ is situated much as it is when affected with hypertrophy. Long-continued uterine tenesmus, sanguine affluxion, enfeebling discharges, and persistent pain, might well be expected to result in a descent or prolapsus, scarcely to be avoided by those who suffer frequent distressing abortions, and especially by those who pay not the least regard to the common sense dictates of the medical man.

Retroversion.-In proportion as pregnancy advances, the womb increases in longitudinal diameter; so that, if it should from any cause happen to be turned over backwards, the top of the fundus

uteri would lodge in the hollow of the sacrum, while the os tincæ would be pressed upon the symphysis of the pubes, or above it.

There is no reason to doubt that the uterus is frequently turned over backwards, but not retained; for the urinary bladder, when very full of water, extends backwards and downwards, pushing the top of the womb along with it. If this happen to a woman about two and a half or three months gone with child, she will scarcely fail to have a serious retroversio uteri, which will probably continue until the organ is reposited by some skilful hand.

There are persons who bring on these uterine deviations by a habit of retaining the urine until the bladder becomes over-full. Such, at least, is the opinion I have formed from inquiries addressed to the patients themselves.

Some women, from a fastidious delicacy, or from circumstances of the society in which they pass their waking hours, fail to yield to the ordinary solicitations of nature as to the discharge of the urinary bladder, and allow it to become so distended that it equals the bulk of a pint or even a quart measure, before they take notice of it. So great a bulk as this occupying the space behind the lower portions of the abdominal muscles and betwixt them and the sacrum, cannot but put upon the stretch both of the ligamenta rotunda, which is equivalent to the effect of thrusting the fundus uteri down upon, and even below the promontory of the sacrum; but when the womb does turn over backwards, the cervix comes forwards by a see-saw motion of the organ, and this it cannot do without inordinately stretching the utero-sacral ligaments which are in this way, for many women, completely relaxed and ruined. Some women who have what is called retroflexion of the womb seem to have very sound and strong uterosacral ligaments, which restrain the cervix from coming forwards to the pubis, as happens in ordinary retroversions. Can there be any doubt that such a habit, persisted in for years, would result in the state of retroversio uteri?

CASE. I saw this day, July 12, 1848, a young lady of 22 years of age, who has been married now ten months. She presented all the external characteristics of fine health. She has never conceived. She has a constant pelvic pain, and has suffered for eight years with the most distressing dysmenorrhoea, informing me that she never had her catamenia without violent pain; yet the menstrua are abundant and regular. She uses a dozen napkins at each period, and sometimes more than a dozen. There is severe pain in coitû, which cannot be perfectly effected.

I found the os tincæ half an inch behind and below the crown of the pubal arch-though the fundus uteri occupied the recto-vaginal cul-de-sac. It was bent, with a short turn, backwards.

Upon causing her to turn over upon the face, I readily reposited the womb-but it came down again upon the least motion. When I pressed the index finger firmly on the lips of the os tince or on the cervix, she felt acute pain, and said the pain was the same in kind as that of her dysmenorrhoea. Her habit has always been to retain the urine long, so that sixteen or twenty ounces frequently collect before she discharges it. Now this person had never had any considerable illness, or met with any accident. Can there be any doubt that this habit is the cause of the retroversion? There is no other discoverable

cause.

Suppose the fundus of a gravid uterus to be caught and detained under the promontory, as above mentioned, and that the child proceed in its growth, carrying with it the womb in which it is inclosed; the consequences must be a complete impaction of the womb into the excavation-a total prevention of the flow of urine from pressure on the urethra-a stoppage of the canal of the rectum-severe pressure upon the internal sacral foramina, with their nerves; and, unless by timely measures obviated, the certain and miserable death of the patient, as in the case related by me and illustrated by a plate in American Journal; for in the case examined by Dr. Hunter, so completely impacted or jammed was the womb into the cavity of the pelvis, that, after the death of the patient, it was found impracticable to get the uterus up out of the excavation, until the pubis was cut through with a saw, in order to admit of the enlargement of the brim of the pelvis. In my case, reported as above cited, the pubes were cut away to enable us to remove the uterus with its contents. It is difficult to conceive of a situation more frightful than that of a patient under such circumstances. The case, with the fine illustrative engraving, is contained in Hunter's Tables of the gravid womb.

My experience teaches me that most of the instances of retroversion are attributable to a distended bladder, whether after parturition or no. The modest delicacy of young women often compels them to resist the most urgent desire to pass off the urine. A female riding in a carriage, or placed in such a situation that she cannot withdraw from the company without being suspected of a desire to urinate, will allow the bladder to fill almost to bursting; and if she be pregnant about three months, she will scarcely fail to bring on retroversion of the womb. When at last she obtains an opportunity to evacuate the bladder, she finds she has a partial or total retention of urine. The usual re

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