secretes jelly, which confines the water for some hours, until it
accumulates, and comes out with a small gush. At other times, in the
early period of gestation, it collects in considerable quantity betwixt
the lower part of the decidua protrusa, which has not yet reached the
cervix uteri and the cervical efflorescence, which becomes a little
stronger than usual.
There is thus a species of dropsy produced, and the water is sometimes
confined until a little before labour comes on; at other times it is
discharged sooner, and an oozing continues for many weeks. In all these
cases, we may derive some advantage from injecting three or four times a
day a strong infusion of galls. The woman ought to use no exertion, as
the membranes are apt to give way.
When the liquor amnii really is evacuated, sometimes a spasmodic
contraction of the fibres near the cervix takes place, instead of that
regular action which is necessary for expulsion; and if the whole of the
liquor have not escaped, the remaining portion will be confined by the
tightening of that part of the uterus round the fœtus; and this
contraction may endure for a very considerable time. If not interrupted,
it may lay the foundation of future diseases in the uterus.
∽∽∽∽
_Of the Prognosis._
The danger of abortion is to be estimated by considering the previous
state of the health, by attending to the violence of the discharge, and
the difficulty of checking it; to its duration, and the disposition to
expulsion which accompanies it; to the effects which it has produced in
weakening the system, and to its combination with hysterical or
spasmodic affections. In general, we say that abortion is not dangerous,
yet in some cases it does prove fatal very speedily, either from loss of
blood, or spasms about the stomach, or convulsions.
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.
When abortion is threatened, the process is very apt to go on to
completion; and it is only by interposing, before it is fairly begun,
that we can be successful in preventing it, for whenever the muscular
action is established, nothing, I believe, can check the process. As
this is often the case before we are called, or, as in many instances it
depends on the action of gestation being stopped by causes, whose action
could not be ascertained until the effect be produced, we shall oftener
fail than succeed in preventing expulsion.
This is greatly owing to our not being called until abortion has begun;
whereas, had we been applied to upon the first unusual feeling, it might
have been prevented. What I wish then particularly to inculcate is, that
no time be lost in giving notice of any ground of alarm, and that the
most prompt measures be had recourse to in the very beginning, for when
uterine contraction has commenced, then all that we can do is to conduct
the patient safely thro’ a confinement, which the power of medicine
cannot prevent.
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.
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.
_Of the Prevention and Treatment of Abortion._
In considering the treatment, I shall first of all notice the most
likely method of preventing abortion in those who are subject to it;
next, the best means of checking it, when it is immediately threatened;
and, lastly, the proper method of conducting the woman through it, when
it cannot be avoided.
The means to be followed in preventing what may be called habitual
miscarriage, must depend on the cause supposed to give rise to it. It
will, therefore, be necessary to attend to the history of former
abortions; to the usual habitudes and constitution of the woman; and to
her condition when she becomes pregnant.
In many instances a plethoric disposition, indicated by a pretty full
habit, and copious menstruation, will be found to give rise to it. In
these cases; we shall find it of advantage to restrict the patient
almost entirely to a vegetable diet, and, at the same time, make her use
considerable and regular exercise.
The sleep should be abridged in quantity, and taken not on a bed of
down, but on a firm mattress, at the same time that we prevent the
accumulation of too much heat about the body. The bowels ought to be
kept open, or rather loose, which may be effected by drinking Cheltenham
water: and this can be artificially prepared, if necessary.
There is, in plethoric habits, a weakness of many, if not all, of the
functions; but this is not to be cured by tonics, but by continued and
very gradually increased exercise, with light diet, consisting chiefly
of vegetables.
This plan, however, must not be carried to an imprudent length, nor
established too suddenly; but regard is to be had to the previous
habits. It is a general rule, that exercise should not be carried the
length of fatigue, and that it should be taken, if possible, in the
country, whilst late hours, and many of the modes of fashionable life,
must be departed from. We may also derive so considerable advantage from
conjoining with this plan, the shower bath, or sea bathing, that they
ought not to be omitted.
After conception, the exercise must be taken with circumspection; but
the diet should still be sparing, and the use of the cold bath
continued. If the pulse be at any time full, or inclined to throb, a
little blood should be taken away; and much advantage will be derived in
all these cases, by using the digitalis, so as to affect the pulse. Half
a grain may be given, so often as may be found necessary, 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 time; but it is
seldom necessary to give it regularly, beyond the beginning of the
fourth month, unless a change of circumstances afterwards require it.
The dose must be occasionally increased, so as to produce the desired
effect; and I can vouch for the safety of the plan.
Injecting cold water into the vagina, twice or thrice a day, has often a
good effect, at the same time that we continue the shower bath every
morning. When there is much aching pain in the back, it is of service to
apply cloths to it, dipped in cold water, or gently to dash cold water
on it.
In this, and all other cases of habitual abortion, we must advise that
impregnation shall not take place until we have corrected the system;
and after the woman has conceived, it is requisite that she live absque
marito, at least until gestation be far advanced. I need scarcely add,
that when consulted respecting habitual abortion, the strictest prudence
is required on our part, and that the situation of the patient, and many
of our advices, should be concealed from the most intimate friends of
the patient.
In other cases, we find that the cause of abortion is connected with
sparing menstruation. This is often the case with women whose appearance
indicates good health, and who have a robust look. This is not often to
be rectified by medicine, but it may by regimen, &c. Here, as in the
former case, we find it useful to make the greatest part of the diet
consist of vegetables; but it is not necessary to restrict the quantity.
When, on the other hand, the patient has a weakly delicate appearance,
it will be proper to give a greater proportion of animal food, and two
or three glasses of wine, in the afternoon, with some bitter laxative,
twice a day, so as to strengthen the stomach, and at the same time keep
the bowels open.
We also derive, in both cases, advantage from the daily use of the warm
bath, made of a pleasant temperature; but this is to be omitted after
conception. The internal use of the Bath waters is often of service; or
where the circumstances of the patient will not permit this, we may
desire her to drink, morning and evening, a pint of tepid water, which
may be continued during gestation. Throwing up into the vagina tepid
salt water twice or thrice a day, seems also to have a good effect.
I 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; or, if they go to the full time, I have often observed
the child to be sickly, and of a constitution unfitting it for
living[11].
We may sometimes cure this state by giving half a grain of digitalis,
and the eighth part of a grain of the tartris antimonii, every night at
bed-time, which diminishes the stomachic action. Bleeding is also
useful, by making the organs more irritable. 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.
The accidental accession of an hysteric condition of the system,
sometimes spontaneously cures this state: and if the patient have gone
to the full time, but bear an unhealthy child from this cause; if she
meet with any accident in her confinement, inducing a nervous condition,
she is less apt afterwards to miscarry, or have dead children.
There is another case in which all the functions are healthy and firm,
except the circulation, which is accelerated by the uterine irritation.
This is more or less the case in every pregnancy, but here it is a
prominent symptom. 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.
When, 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.
Sometimes it is the stomach which is irritable, and the person is often
very sick, takes little food, and digests ill. A small blister, applied
to the pit of the stomach, often relieves this; a little of the compound
tincture of bark, taken three or four times a day, is serviceable; or a
few drops of the tincture of muriated iron in a tumbler glassful of
aerated water; at other times the bowels yield, and the patient is
obstinately costive. This is best cured by manna, with the tartarite of
potash. When the muscular system yields, producing a feeling of languor
and general weakness, the use of the cold bath, with a grain of opium,
at bed time will be of most service.
It is evident that it is only by attending minutely to the history of
former miscarriages, that we can detect these causes; and we shall
generally find, that in each individual case it is the same organ in
every pregnancy which has yielded or suffered. Previous to future
conception, we may, with propriety, endeavour to render it less easily
affected.
General weakness is another condition giving rise to abortion; and upon
this I have already made some remarks. I have here only to add, that the
use of the cold bath, the exhibition of the Peruvian bark, and wearing
flannel next the skin, constitutes the most successful practice.
Syphilis is likewise a cause of abortion. When it occurs in the mother,
it often unfits the uterus for going on with its actions. At other
times, more especially when the father labours under venereal hectic,
the child is evidently affected, and often dies before the process of
gestation can be completed.
In these cases a course of mercury alone can effect a cure. But we are
not to suppose that every child, born without the cuticle in an early
stage of pregnancy, has suffered from this cause; on the contrary, as
the majority of these instances depend on causes already mentioned, and
which cannot be cured by mercury, I wish to caution the student against
too hastily concluding that one of the parents has been diseased,
because the child is born dead or putrid in the seventh month.
It is not always easy to form a correct judgment; but we may be assisted
by finding that the other causes which I have mentioned are absent; that
we have appearances of ulceration on the child, and that there are some
suspicious circumstances in the former history and present health of the
parents.
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, and by attending minutely to the condition
of other organs during menstruation or pregnancy, we may, from the
principles formerly laid down, do some good.
It is satisfactory to know that, by great care, although we may fail
once or twice, yet the uterus comes at last to act more perfectly, and
the woman bears children at the full time.
After these observations, it is only necessary to add, that in every
instance of habitual abortion, whatever the condition may be which gives
rise to it, we find that it is essential that the greatest attention be
paid to the avoiding of the more evident and immediate exciting causes
of miscarriage, such as fatigue, dancing, &c. In some cases, it may even
be necessary to confine the patient to her room, until the period at
which she usually aborts is past.
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.
Still, as some of the means which may be supposed useful in preventing a
threatened abortion are also useful in moderating the symptoms attending
its progress, we may very properly have recourse to them. Some causes
giving rise to abortion, do not immediately produce it, but give warning
of their operation, producing uneasiness in the vicinity of the uterus,
before the action of that organ be materially affected.
The detraction of a little blood at this time, if the pulse be in any
measure full or frequent, and the subsequent exhibition of an anodyne
clyster, or a full dose of digitalis and opium, together with a state of
absolute rest for some days, will often be sufficient to prevent farther
mischief, and constitute the most efficacious practice.
This is the time at which we can interfere with the most certain
prospect of success; and the greatest attention should be paid to the
state of the rest of the system, removing uneasiness, wherever it is
present, and preventing any organ from continuing in a state of undue
action. It is difficult to persuade the patient to comply with that
strict attention which is necessary at this period; but being persuaded
that if this period be allowed to pass over with neglect, nothing can
afterwards prevent abortion. I wish particularly to impress the mind of
the student with a due sense of its importance; and I must add, that as
after every appearance of morbid uterine action is over, the slightest
cause will renew our alarm, it is necessary that great attention be paid
for some time to the patient.
Often, instead of an uneasy feeling about the loins, or lower belly, we
have, before the action of gestation stops, a discharge of blood,
generally in a moderate, sometimes in a trifling degree. This is more
especially the case when abortion is threatened, owing to an external
cause, and, if immediately checked, we may prevent contraction from
beginning.
Even in those cases where we do not expect to keep off abortion, it is
useful to prevent, as far as we can, the loss of blood, for as I cannot
see that the hemorrhage is necessary for its accomplishment, although it
always attend it, I conclude that our attempts to prevent bleeding can
never do harm, for if they succeed in checking abortion, we gain our
object; if they fail, they do not increase, but diminish the danger.
It should be carefully remembered, that the more we can save blood, the
more do we serve our patient. As the means for checking the discharge
will be immediately pointed out, it is unnecessary here to enter into
any detail.
Sometimes the vessels which furnish the cervical efflorescence in the
beginning of gestation, do not assume that action, but yield blood,
which passes for the menses, and makes the woman mistake her condition.
As the uterine vessels increase in size, the discharge becomes greater
and more frequent. It is now apt to pass for menorrhagia.
If it be allowed to continue, it tends to injure the action of the
uterus, and produce expulsion, which sometimes is the first thing which
shews the woman her situation. This discharge is best managed by rest,
and the frequent injection of saturated solution of the sulphat of
alumine, or decoction of oak bark.
When a slight discharge takes place, in consequence of a slip of the
foot, or some other external cause, we may also derive advantage from
the use of the injection, but not so certainly as in the former case;
and if the discharge be considerable, the injection will fail. It is
better, in this case, to trust to the formation of a coagulum.
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 to
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.
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.
This is not always the case, and therefore, unless the vessels be at or
above the natural force or strength of action, the lancet is not at this
stage necessary. The fulness and strength of the pulse are lost much
sooner in abortion than can be explained, by the mere loss of blood.
It depends on an affection of the stomach, which has much influence on
the pulse; and the proper time for bleeding is before this has taken
place. When abortion has made so much progress before we are called, as
to have rendered the pulse small and feeble; or when this is the case
from the first, bleeding evidently can do no good.
Instead of this, we may use the digitalis, which I have already highly
recommended as a preventative; but I do not say that, in ordinary cases,
where the contraction is brisk, and the process quick, it is at this
stage absolutely necessary; and I shall afterwards mention that, when
the stomachic affection is urgent, and the pulse much affected by it,
the use of this medicine is improper. When, however, the case is
tedious, and the discharge long continued, at the same time that the
sickness is not considerable, the digitalis will be of essential
service.
Nauseating doses of emetic medicines act in the same way with the
digitalis, but are much less effectual, and more disagreeable, as well
as uncertain in their operation.
Internal astringents have been proposed, but they have no effect, unless
they excite sickness, which is a different operation 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 astringents, and
ought always to be had recourse to. If the digitalis have been
exhibited, it assists that medicine in moderating the circulation.
Even when trusted to alone, it lessens the action of the sanguiferous
system, particularly of the uterine vessels. The introduction of a small
piece of smooth ice into the vagina has been recommended, and has often
a very speedy effect in retarding the hemorrhage, whilst it never, if
properly managed, does any harm. A small snow-ball, wrapped in a bit of
linen, will have the same effect; but neither of these must be continued
so long as to produce pain, or much and prolonged shivering. The heat of
the surface is also to be moderated, by having few bed clothes, and a
free circulation of cool air.
But the most effectual local method of stopping the hemorrhage, is by
plugging the vagina. This is best done by taking a pretty large piece of
soft cloth, and dipping it in oil, and then wringing 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
pressed firmly on the orifice, and held there for some time. This acts
by giving the effused blood time to coagulate. It gives no pain; it
produces no irritation, and those who condemn it, surely must either not
have tried it, or have misapplied it.
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 clotted blood in the upper part of the vagina,
and the flooding ceases.
In obstinate cases we may, before introducing the plug, insert a little
powdered ice, when it can be procured, tied up in a rag.
Faintness operates in the same way, in many cases, by allowing coagula
to form in consequence of the blood flowing more slowly; and, when the
faintness goes off, the coagula still restrain the hemorrhage in the
same way as when the plug has been used. This naturally points out the
advantage of using the plug, together with the digitalis, as we thus
produce coagulation at the mouths of the vessels, and also diminish the
vascular action. It will likewise shew the impropriety of using
injections at this time, for, by washing out the coagula, we do more
harm than can be compensated by any astringent effect produced on the
vessels.
The principal means, then, which we employ for restraining the
hemorrhage, are bleeding, if the pulse be full and sharp; if not, we
trust to the digitalis, stuffing 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 state of absolute rest, which must be
continued during the whole process, however long it may in some cases
be. The drink should be cold, and the food, if the patient desires any,
light, and taken in small portions.