We now come to the consideration of a subject, in respect to which there
exists much misapprehension and ignorance, causing useless and
unnecessary alarm and anxiety to those who may be so unfortunate as to
be subject, at particular periods of gestation, to abortion or
miscarriage.
The dangers of abortion or miscarriage are often magnified and
exaggerated. It is dangerous if produced by a fall, a blow, a kick from
a horse, or any other external bodily violence or injury, causing
internal contusion, or rupture of some blood-vessels; and, also, but not
to the same extent, if produced by sudden fright, violent fits of
passion, &c., or from general debility or disease of the uterus; but the
danger arises more from the cause which produces the miscarriage, than
from the miscarriage itself; as it is well known by those versed in
obstetrics that, where it is deemed indispensable to effect a
miscarriage, either because of the existence of a deformed pelvis,
diseased uterus, or other causes, if skilfully effected, it is attended
with no danger, especially in the earlier stages of pregnancy.[43]
_Symptoms._
When miscarriage is about to take place, its first symptoms are
generally occasional stinging pains at the bottom of the belly,
extending across and around the loins and hips; a feeling of fatigue of
the legs, pain in the forehead, burning sensation of the eyes. The
breasts, which before were distended, become soft and flabby, hot and
cold flashes, attended with thirst, fever, and shiverings. In a day or
two after the appearance of these symptoms, a discharge from the womb
takes place of yellow matter, tinctured with red. If not arrested at
this stage, the pains across the loins become more severe and frequent,
attended with a sense of dead weight, and bearing down about the womb,
the water is discharged, and the expulsion of the contents of the womb
takes place. The symptoms of miscarriage, however, vary with the causes
which produce them, or the state of habit, age, or health of the
patient; some recovering immediately, and rapidly, and with but little
inconvenience. Where miscarriage arises from a serious accident, such as
violent falls, bruises, &.c., the symptoms are somewhat aggravated, and
more severe, and are often preceded and accompanied with violent and
profuse floodings and discharges of coagula, in addition to the other
symptoms; although moderate flowing is not an unfrequent symptom in
miscarriages.
It is always accompanied with two circumstances, separation of the
membranous bag, and expulsive efforts or contraction of the womb itself.
The first is productive of discharge, the second of pains like those of
labor. Sometimes the separation or detachment of part of the conception
takes place before any pain is felt; on other occasions, the pain, or
contraction of the womb, takes place first, and produces a separation.
In the first of these cases, the symptoms of abortion take place
suddenly, and are usually occasioned by fatigue, sudden exertion, or
fright. In the second, the pains come on, and there are particular
feelings, and changes, which indicate that a miscarriage is likely to
take place; as, for instance, the cessation of the morning sickness, the
subsidence of the breasts, &c.
Miscarriage is preceded by floodings, pains in the back, loins, and
lower part of the abdomen, evacuation of the water, shiverings,
palpitation of the heart, nausea, anxiety, fainting, subsiding of the
breasts and belly, pain in the inside of the thighs, opening and
moisture of the womb.
_Causes._
The principal causes of miscarriage are blows or falls; great exertion
or fatigue; sudden frights and other violent emotions of the mind; a
diet too sparing or too nutritious; the abuse of spirituous liquors;
other diseases, particularly fevers and hæmorrhages; likewise excessive
bleeding, profuse diarrhœa or colic, particularly from accumulated
fæces; immoderate venery, &c.
_Treatment._
When a woman is threatened with a miscarriage, there are two objects to
attend to; the first is, to prevent it if we can; the second is to
manage it so that as little blood as possible be lost; and both these
are obtained by the same means. With this view, the patient should
immediately, on the first alarm, undress and go to bed, lightly covered,
with a firm determination not to rise till the process be either checked
or completely over. There should be little fire in the room, though it
be winter; and in summer, the windows must be opened. Cloths wet with
cold water, should instantly be applied to the lower part of the belly,
and back: the drink must be cold, and everything stimulating should
carefully be avoided.
In robust habits, or when the symptoms have been brought on suddenly by
some such cause as a fall or exertion, it is proper to bleed; and, in
cases of sickness or great feebleness, to give a dose of laudanum; or,
what is better, to administer the anodyne clysters.[44]
Opiates are useful in every case where we hope to prevent abortion, and
must be repeated more often or seldom, according to the effect they
produce. They are, however, improper in those cases where miscarriages
must decidedly take place. Their tendency to occasion costiveness, when
employed, must be obviated by clysters, or some gentle laxative
medicine, such as calcined magnesia, Epsom salts, or a little castor
oil. If there be a continued but trifling discharge, great advantage may
be derived from injecting, three or four times a day, up the vagina, a
solution of alum. Indeed, in all protracted cases, this is of much
benefit. The solution ought to be thrown up pretty high, that it may
reach the womb.
When these means produce not the desired effect, and along with the
discharge of blood large clots come off attended with bearing down or
pains in the back and loins, especially if the symptoms which precede
abortion have appeared, there must be every probability that the
threatening event cannot be avoided; then we must conduct the patient
through the process.
In all cases during the last stage of pregnancy, where our endeavors to
stop or repress the hemorrhage prove abortive, it will be advisable to
deliver her as soon as possible.
When the whole conception come away at once, the pain and discharge
usually go off; but, if only the fœtus come away, all the symptoms
either continue and increase till the placenta come away, or, if they be
for a time suspended, they are sure to return, except in early
miscarriages of ten or twelve weeks pregnancy, when sometimes the fœtus
is expelled separately, and the placenta comes immediately after, but
the latter frequently remains several days. The most prudent mode in
such cases is to leave it to nature, which sooner or later expels this
foreign body.
After the process is over, if the discharge be profuse, and do not stop
on the application of cold water to the lower part of the belly, it will
be proper to plug up the vagina, and this is best done by taking a piece
of soft sponge, dipping it in sweet oil, and then wringing it gently.
This 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
firmly pressed on the orifice; and held there some time for the effused
blood to coagulate. In obstinate cases, previously to the introduction
of the plug, we may insert a little pounded ice, or snow tied up in a
rag, if to be procured,[45] but neither of these should be continued so
long as to produce pain or much shivering. In addition to this mode of
treatment, it will be advisable to have recourse to the astringent
medicines, as advised under the head of _Immoderate Flow of Menses_.
_Regimen._
Arrow-root, tapioca, sago, panada, or rice milk, constitute a proper
regimen. If the process be protracted, and the strength much impaired,
the diet may be more liberal. In every case, ripe fruit is safe and
useful. The bowels are to be kept regular, and sleep, if necessary, is
to be procured by an anodyne.
_Prevention._
It requires great attention to prevent abortion in subsequent
pregnancies, whenever it has happened.
In all such cases, it will be highly necessary to attend to the usual
habitudes and constitution of the woman, and to remove that condition
which is found to dispose to abortion.
A woman that is subject to miscarriage, and who is of a full plethoric
habit, ought to take the tincture of foxglove, twice or thrice a day,
for two or three weeks.
She should likewise keep her body perfectly open with gentle aperient
medicines, use a spare diet, and avoid all agitations of the mind. The
sleep should be abridged in quantity, and taken on a mattress, instead
of a feather bed. Regular and moderate exercise should be taken daily,
being cautious, at the same time, not to carry it to the length of
exciting fatigue.
In women of a weak, lax habit, a nutritive and generous diet, moderate
exercise, and tonic medicines, will be required. And, along with
nourishing diet, a moderate use of wine should be allowed, if it do not
heat the patient, or otherwise disagree. The cold bath is of signal
service in every instance where it is not followed by chilliness.
Until gestation be far advanced, it would be advisable for the woman to
sleep alone, and strictly avoid every cause which is ascertained to be
capable of producing abortion.
Women more frequently miscarry in the second or third month than at any
other time; but some have a certain period at which they usually go
wrong, and do not vary a week from it. In such cases, the woman should
confine herself to the house, avoid the least exercise, and frequently
recline on the sofa or bed, till that period be past.
When a female has suffered several abortions, it becomes almost
impossible to prevent a repetition at the same period of gestation in a
subsequent pregnancy. Nothing, however, will be so successful in
preventing a recurrence of a similar misfortune, as in allowing the
uterine vessels to recover their tone; for which purpose tonics must be
given. Attend to particular symptoms as they occur; with proper diet and
exercise. _Sea Bathing_ and the _shower bath_ are both excellent.[46]
_When necessary to effect Miscarriage or Artificial Delivery._
During pregnancy, deformities of the pelvis become objects of solicitude
to the accoucheur, when they are of such a character as to render
delivery at full term impossible without the interference of cutting
operations. At this period only can he guard against the deplorable
consequences of these deformities.
_Pelvic Deformities._
The accoucheur may be consulted by a mother anxious to know whether the
pelvis of her daughter is such as to justify marriage. His opinion may
also be desired by a female pregnant for the first time, in whose mind
there may exist fears as to the formation of her pelvis. In this case,
he will have to reply to the following questions:
Is delivery at full term compatible with the safety of the child? What
influence will the deformity have on pregnancy? What precautions are
necessary to guard against accident until the completion of gestation,
and to facilitate delivery?
When the accoucheur states that delivery will not be possible without
the interference of art, he will then be asked whether this interference
will compromise the life of the mother or child; and whether this
operation cannot be avoided by some process during pregnancy, either
saving the life of mother and child, or sacrificing the child for the
benefit of the mother?
In order to answer these questions satisfactorily, and to furnish
himself with a rule of conduct in advance, it will be necessary for the
accoucheur to know precisely the condition of the pelvis, and the
dimensions of the diameters, &c.
However, it must not be supposed that this mensuration can be made with
mathematical accuracy; our means will not enable us to obtain this
precision; but even if we could, the object we have in view would not be
completely accomplished, for, in order to arrive at a rigorous
appreciation of the consequences of the deformity and the operations it
might require, it would be necessary also to know the exact size of the
fœtus, which is not possible.
Happily, in practice, an approximation as to the absolute condition of
the pelvis will suffice, and it is easy to arrive at this result. With
this view, the accoucheur should, in the first place, learn the previous
history of the patient in infancy and youth, and afterward proceed to an
external and internal examination.
When the accoucheur is called upon to pass an opinion as to the natural
or unnatural conformation of a female, he should, says M. P. Dubois,
inquire minutely into the antecedent condition of this woman during her
infancy and youth. The history of early life will often, of itself,
cause him to suspect the state of the pelvis. He should address the
following questions to the parent:
_What diseases was the infant affected with? At what age did they
manifest themselves? At what age did the child walk? After walking, did
it appear weak in the inferior extremities? Was the erect position
possible? Was it easy? Were the articulations large?_
If all these phenomena appeared in infancy, it is highly probable that
the pelvis is deformed; and, moreover, it may be affirmed that the
symptoms arose from rickets, a disease peculiar to infancy. It commences
rarely before eighteen or twenty months, and very seldom after thirteen
of fourteen years of age. If there should be curvatures of the spinal
column and extremities, it will be almost certain that the pelvis is
deformed; and if the curvature commenced in the inferior extremities, we
may conclude that it is owing to rachitis, for this disease exerts its
influence first on the tibias, then on the bones of the thighs, pelvis,
and vertebral column. On the contrary, if the first ten years have been
passed without disturbance of the general health, then curvatures must
be attributed to malacosteon, especially if the curvature of the spine
has preceded that of the lower limbs. Deformity of the spine may exist
alone; then we may legitimately hope that the pelvis is not contracted.
Experience, indeed, proves that the vertebral column may be considerably
curved without the pelvis participating in the deformity, when the
inferior extremities are straight; and that, in general, curvatures of
the extremities alone accompany pelvic malformations.
Indeed, it is not on simple probabilities that the accoucheur is to
interdict the marriage[47] of a young girl, or determine, during
pregnancy, to perform an operation, with the view of protecting the
mother against the dangers of delivery at full term.
_Premature Artificial Delivery._
Thanks to the efforts of MM. Stoltz, Dezeimeris, P. Dubois, and Velpeau,
delivery brought on before the full term is an operation hereafter
recognised in French midwifery. For a long time it proved useful to our
neighbors in England and Germany, while a foolish prejudice caused it to
be rejected by French practitioners, who did not hesitate even to have
recourse to the Cæsarean section and symphyscotomy.
We have not within the walls of Paris one solitary example of a woman
who had survived the Cæsarean section. She who lived the longest was one
of those on whom I assisted M. P. Dubois to operate. She died on the
seventeenth day of a tetanic affection, when everything promised a most
successful result.—(_Bull. of the Acad. of Med._, t. iii., p. 694; t.
v., p. 25.)
When the contraction is such that a living fœtus cannot be brought
forth, the accoucheur has then to choose between the Cæsarean section or
miscarriage.
During pregnancy, abortion will present an extreme and last resource.
And it would seem more humane to sacrifice, before the period of
viability, an embryo whose existence is so uncertain, in order to
protect the mother from the perilous chances of symphyscotomy and the
Cæsarean section.
I must confess that, if such an alternative were presented to me, the
diameter of the pelvis being only two inches, I should not hesitate to
propose this means.
The abuse and criminal extension of such a resource is reprehensible,
but not its proper and authorized employment. This operation should
always be undertaken with great care, and all necessary precaution used
to satisfy the public mind of its necessity.