many, used in every case of abortion, and in every stage. But as we
cannot finish the process without muscular contraction, and as they tend
to suspend that, I do not see that their exhibition can be defended on
rational principles.
If given in small quantity, they do no good in the present point of
view; if in larger doses, they only postpone the evil, for they cannot
check abortion, after it has begun. Nothing can do this, for it proceeds
from the cessation of the action of gestation, which we cannot restore.
But I will not argue against the use of opiates from their abuse. They
are very useful in cases of threatened abortion, more especially in
accidental separation of the membranes and consequent discharge. They do
not directly preserve the action of gestation, but they prevent the
tendency to muscular contraction, and thus do good; for we find in the
animal economy, that when two actions oppose each other, or alternately,
preventing a tendency to the one has an effect in preserving the other.
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.
By suspending, for a time, its action, it returns afterwards with more
vigour and perfection, and finishes the process. But when the process is
going on regularly, opiates will only tend to interfere with it, and
prolong the complaint.
It was at one time the practice to endeavour to extract the fœtus and
placenta, in order to stop the discharge; but this is now very properly
abandoned. If the whole ovum come away at once, the discharge stops; if
only the fœtus come away, it continues until the placenta and decidua
are expelled; and where this process is tedious, we may derive advantage
from gently irritating the os uteri with the finger, or using pretty
strong saline clysters, or throwing cold water into the uterus by means
of a female catheter, fitted to the elastic gum bottle used for
injecting hydrocele. These means are much safer than the attempts to
pull out the placenta with the finger or pincers, which were formerly so
often made, and which are very apt to injure the womb.
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.
The stomach very soon suffers, and becomes debilitated, producing a
general languor and feebleness, with a disposition to faint, which
seems, in abortion, to depend more upon this cause than directly upon
loss of blood. Indeed, the hemorrhage produces both slighter and less
permanent effects in abortion than at the full time, although less blood
may have been lost in the latter than in the former case, for the
vessels are smaller, and the discharge is not so sudden.
There is still another cause for this; namely, that the action of the
uterus is less in the early than in the late months. Now, we know that
the effect of hemorrhage from any organ is, _cæteris paribus_, in
proportion to its degree of action. Hence the discharge is less
dangerous than at the full time, and still less in menorrhagia than in
abortion.
It is likewise less in cases where hydatids are contained in the uterus,
than when a child is present, very astonishing discharges being
sometimes sustained in that case with impunity.
The effect of abortion on the stomach seems to be in proportion to the
period at which that takes place, being greater when it occurs before
the fourth month than after it.
The effect, though distressing, and often productive of alarm, is
nevertheless beneficial, lessening the action of the vessels in the same
way with digitalis, the use of which is improper when this condition is
present.
The strength of the pulse is much abated; sometimes it becomes slower;
but in general it remains much as formerly in point of frequency; we are
therefore not to be too anxious in removing this condition, which
restrains hemorrhage; yet as it may go beyond due bounds, and produce
dangerous syncope, we must check it in time.
We must likewise be very attentive to the state of the discharge when
this affection is considerable, for if, notwithstanding this, the
hemorrhage should continue, it will produce greater and more immediately
hurtful effects than if this were absent.
The best method of abating this sinking and feebleness, is to keep the
body perfectly at rest, and the head low. If necessary, we give small
quantities of stomachic cordials, such as a little tincture of cinnamon,
or a few drops of ether in a glass of aerated water; or we may give a
little peppermint water, with fifteen drops of tincture of opium. In
urgent cases, Madeira or undiluted brandy may be given; but these are
not to be frequently repeated, and are very rarely necessary.
Sometimes, instead of a feeling of sinking and faintness, the fibres of
the stomach are thrown into a spasmodic contraction, producing sudden
and violent pain. This is a most alarming symptom, and may kill the
patient very unexpectedly. It is to be instantly attacked by a mixture
of sulphuric ether and tincture of opium, in a full dose, whilst a
senapism is applied to the epigastric region.
Spasms about the intestines are more frequent, and much less dangerous.
They are very readily relieved by thirty drops of tincture of opium, in
a dessert spoonful of aromatic tincture, or forty drops of the tincture
of hyocyamus in two tea-spoonfuls of the compound tincture of lavender.
The brain may also be affected, producing epilepsy, which is a very
dangerous symptom. This is sometimes preceded by headach, flushing of
the face, and feeling of fulness about the head and neck; but at other
times it attacks without any precursory symptom, and sometimes seems to
arise directly from copious hemorrhage.
Nothing can be done to the uterus in the way of manual assistance, or
extracting the ovum; but our chief attention should be directed to the
brain. It will, indeed, be proper to attend to the state of the pains
and discharge. If the latter be profuse, we must take measures to check
it; if the former be absent, or seem to alternate with the convulsions,
we may derive advantage from the use of a saline clyster, which will
excite the contraction of the uterus, and confine the action more to
itself.
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.
This state is to be distinguished from a combination of hysteria and
syncope, which occasionally occurs during labour, whether natural or
premature, and which is by no means equally dangerous.
This is known by the smallness of the pulse, the paleness of the face,
the slightness of the convulsions, the absence of foam at the mouth, and
an appearance of struggling about the throat. It attacks suddenly,
generally on getting into an erect posture.
It is at first little different from syncope, and during the whole time
the muscles of the face are not much affected, the countenance having
rather a deadly aspect. This is removed by an horizontal posture,
sprinkling the face smartly with cold water, and the use of volatiles.
The patient, in this case, as in epilepsy, is often unconscious of
having been ill.
Regular hysteric paroxysms also sometimes accompany abortion, and are
more dangerous than at other times, more especially if they seem to have
been excited by the profusion of the discharge. If they last long, they
either end in mortal syncope, or in stupor. If they have been brought on
by some agitation of mind, they are less to be feared, though not even
then void of danger.
Besides attending to the state of the discharge, the best practice is to
keep the person very cool, and exhibit thirty or forty drops of tincture
of opium, and two drams of tinctura valerianæ ammoniata in a little
peppermint water. A clyster, composed of a pound of cold water and two
drams of tincture of asafœtida, is also sometimes of service.
Those disagreeable symptoms which I have described, fortunately do not
often attend abortion; but the process goes on safely, and without
disturbance. In this case, after it is over, we only find it necessary
to confine the person to bed for a few days, as getting up too soon is
apt to produce debilitating discharge.
We must also, by proper treatment, remove any morbid symptoms which may
be present, but which depending on the peculiarities of individuals, or
their previous state of health, cannot here be specified. When the
patient continues weakly, the use of the cold bath, and sometimes of the
bark, will be of much service in restoring the strength; and, in future
pregnancies, great care must be taken that abortion may not happen again
at the same period.
Unfortunately we meet with some cases where the recovery does not take
place with that promptitude and regularity which could be wished. This
sometimes depends upon a continuance of the hemorrhage after the ovum is
expelled, by which the patient is greatly weakened, and even her life
put into danger.
The hemorrhage may either continue from the time of expulsion, or it may
come on a week, or even longer, after it. It seems to proceed from the
uterus not going on in the process of restoration to the unimpregnated
state, but remaining too long enlarged, the consequence of which is,
that very soon the vessels pour out blood, and fill the cavity, forming
a coagulum, which presently is expelled with a considerable flow of
fluid blood; and this process may be very frequently repeated.
This, which is often connected with an hysterical condition, is more
especially apt to occur in those who are subject to flooding after the
expulsion of the child, as this marks a natural feebleness in the womb,
and a disposition to flag in its actions after delivery.
In such patients it is often preceded by ill-smelled lochial discharge,
which proceeds sometimes from the original state of the secretion, but
more frequently from its being retained for some time, and acquiring
this smell.
This has given rise sometimes to an idea that the complaint proceeded
from the retention of part of the placenta or membranes; but this
retention often takes place without any such discharge succeeding; and,
on the other hand, in several instances of this complaint we have
certain knowledge that no part of the placenta has remained, whilst in
almost every case we have a coagulum expelled, possessing exactly the
shape of the uterine cavity, shewing that nothing else has been
contained within it.
Indeed, the opinion is not very tenable, for a small part of the
placenta or decidua would, if the uterus were contracting, be soon
expelled, and would then surely cease to have any farther influence;
whilst, on the other hand, if the uterus do not regularly contract in
size, or recover itself, the hemorrhage will take place from this cause
alone, independently of all considerations relating to the placenta.
By attending to this fact, we shall not only refrain from blaming
midwives unjustly, but also from adding to the danger, by endeavouring
to remove a substance which has no existence in the uterus, and which,
even were it to a certainty within, it is there not as a cause of the
hemorrhage, but as an effect of the cause which produces that.
This disease may take place at any period of gestation. It may follow
abortion in the second month, or expulsion at the full time; but it is
dangerous in proportion as we approach to the term of natural labour. It
may attack only once or twice, or it may make many attacks for several
weeks; and it is wonderful how the system can be supported under these
continued and repeated discharges: but we find that an incredible
quantity of blood may be lost, if it be discharged at intervals.
We read in a foreign journal of a woman who, in the space of nineteen
years, was bled no less than one thousand and twenty times without
material injury. Each paroxysm is accompanied by slight pain in the back
and belly, with considerable languor and feeling of depression. The
discharge continues until the clot escapes out of the uterus, and for
some time after that until a new one forms; and during this last process
we have a considerable oozing of serous fluid.
The old clot drops out of the vagina the first time that the patient is
raised, or, if retained, it breaks down by putrefaction. On examining
these clots, they will be found to be pretty firm, and often contain,
intermixed, a quantity of whitish matter, proceeding from the morbid
condition of the lochia, for the vessels, after bleeding often, throw
out a secretion, and bleed no more until the next paroxysm, which may
not take place for one or two days.
This complaint either terminates fatally by a convulsion or syncope, or
the uterus diminishes in size, and, instead of expelling the contained
clot with hemorrhage, the coagulum seems to break down and come away
gradually in a fluid form.
In abortion, during the early stages of gestation, we cannot take any
other precaution to prevent this than keeping the patient for some time
very quiet, as motion, or even any agitation of mind, might interfere
with the process of recovery.
In more advanced gestation, as, for instance, in the seventh month, and
afterwards, if we should be obliged, on account of flooding, after the
birth of the child, to introduce the hand, and extract the placenta, we
must be careful not to withdraw it, until we find the uterus contracting
round it, which will be a mean, though not an infallible one, of making
it go regularly on in the process of restoration to the unimpregnated
state.
The best method of treating this complaint is on the very first
appearance of hemorrhage, to introduce a firm plug into the vagina,
which will prevent it from going to an excessive degree. Afterwards we
must take measures to prevent a return.
This is best done by keeping the circulation slow, by means of the
digitalis, and putting the patient on a mild vegetable diet. We cannot
assist the process of restoration otherwise than by endeavouring to
excite the contraction of the uterus. This may be done by injecting an
astringent fluid two or three times a day, and by ordering saline
clysters, which have also the effect of keeping the bowels open, an
object of very great importance. We may also find it useful to excite
gentle vomiting by small doses of ipecacuanha.
This has an excellent effect in making the uterus contract, and often is
the method which nature takes to bring about recovery.
This complaint is different from the menorrhagia lochialis, or copious
discharge of blood brought on by exertion after abortion or delivery. In
this case we have no large clot discharged, but just the usual
appearances of menorrhagia. This sometimes seems to become associated
with other morbid conditions of the system: and in those cases is more
or less obstinate as they are intractable. It is generally cured by
rest, the application of cold, and the use of the digitalis. The
consequent weakness is removed by bark, or preparation of iron, with the
cold bath.
Either of these discharges are very apt to produce painful headachs,
vertigo, and often slight paralytic symptoms, which, however, soon go
off. Any considerable increase of the hemorrhage gives relief to the
headach, but it returns afterwards with greater violence.
It is frequently relieved by the use of small doses of the saline
laxatives. In protracted cases, especially when the headach puts on an
intermittent form, observing pretty regular periods, the bark combined
with valerian will be of service.
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.
It occasionally alternates with external pain or swelling of some of the
joints; and, though frequently a tedious complaint, is oftener got the
better of than any other species of mania. The head, upon a general
principle, ought to be shaved and blistered, and a free discharge kept
up from it. The bowels are to be carefully attended to, and no indurated
faces should be allowed to remain in them. The camphorated emulsion may
be given through the day in its usual quantity; and a full dose of
extract of hyosciamus exhibited at night. The patient is to be kept, in
every respect, as quiet and easy as possible.
Another distressing consequence of abortion, as well as of labour at the
full time, is hysteria appearing in various forms, but more especially
under that of palpitation of the heart. This attacks suddenly, often in
consequence of a fright.
The patient has a violent beating in the breast, and sometimes a sense
of suffocation. She feels also a knocking within the head, attended with
a sense of heat, and often a redness in the face. The pulse becomes
extremely rapid and irregular, and continues so until the fit goes off,
which sometimes is not for a considerable time.
During the paroxysm, the patient is much terrified, and impressed with a
belief that she is going to die. After it is over, the mind is left
timid, and the body in a state of languor. Sometimes the fit is
succeeded by a profuse perspiration, whilst betwixt the attacks the
temperature is very versatile.
This, like all other complaints of the same class, is very obstinate;
but it is not in general dangerous, unless when it proceeds from uterine
disease, marked by pain in the hypogastric region and tension of the
belly. In this case, the danger is great, and is only to be averted by
the early use of purgatives, followed by antispasmodics, whilst
fomentations are applied to the belly.
The other case, which is purely hysterical, is to be relieved by giving,
during the paroxysm, a liberal dose of tincture of opium and ether.
Small doses have no effect. During the intervals we may give a table
spoonful of the following mixture five or six times a day.
℞ Tinc. digitalis ℥iss.
Extr. Hyociami ʒi.
Emuls. Camphorat. ℥iv. misce.
It is also an essential point, that the bowels be kept open, and the
patient put upon a light diet. As the attacks are very apt to come on at
night, when the person is about to fall asleep, we sometimes find it
useful to give a dose of tincture of hyocyamen and ether at bed-time,
and must take great care that the patient be not afterwards disturbed or
put off her rest.
When she is much troubled with flatulence, during the intervals the
tincture valeriana ammoniata is of considerable service. Tonics and the
cold bath are also proper. Hysteria either consists in or depends upon a
preternatural aptitude in the different organs, to have their actions
morbidly increased, or rendered irregular; and hence it may affect
secreting as well as muscular parts; and many of the discharges of
lying-in women will be found to be, in this sense, hysterical, and to
alternate with other symptoms, such as globus, palpitation, headach, &c.
and even the most troublesome of all the discharges, that proceeding
from the uterus not recovering or contracting properly, is, I believe,
properly speaking, an hysterical affection, connected with several
others, and alternating with them.
The next disease which I shall mention is also, I believe, altogether
hysterical. I mean that resemblance of fever which is often met with
after either abortion or delivery, at the full time, and which is, like
the rest of its tribe, abundantly obstinate.
This is not to be confounded with milk-fever, or other general diseases
arising from local injury. It is sometimes preceded by palpitation,
frightful dreams, and other nervous affection[12]. At other times it
attacks directly with a shivering fit; which is soon alternated with
heat; then the heat becomes steady and distressing, and continues until
a profuse perspiration carries it off.
The head is generally pained in the two first stages, and the pulse is
frequent in them all. The thirst is considerable, the stomach filled
with flatus, and the belly bound. Often we have irregular action of the
heart occurring in all the stages, whilst the mind is weakened, and the
patient is much afraid of dying. The paroxysm continues for several
hours, and, like ague, is apt to return regularly for a length of time.
In the cold stage, we give small quantities of warm fluid. In the hot
stage, we lessen the number of bed clothes; but must not do this
suddenly, as the shivering is very apt, in either this or the sweating
stage, to return, upon slight exposure to cold.
In the last stage, we are careful not to encourage the perspiration too
much, by refraining from warm drink, for much sweating only tends to
render the disease more obstinate. A repetition is to be prevented, by
keeping the bowels open, by the use of the bark, conjoined with
antispasmodics, and by carrying the patient, as soon as possible, to the
country.
The last disease, which I shall speak of, proceeds from the retention of
the whole, or a part of the secundines, for a length of time after the
expulsion of the fœtus. This circumstance, as I have formerly mentioned,
may sometimes occur in that state of the uterus, which gives rise to
hemorrhage, appearing as a joint effect with it. In this case, however,
we must not conclude that the one symptom is dependant on the other, for
both proceed from a common cause, the want of contraction of the uterine
fibres.
It occasionally happens, that no hemorrhage accompanies this retention,
but the remains of the ovum putrify, and after many days come away in a
very fœtid state. Until this expulsion takes place, we have very
offensive discharge from the vagina, and not unfrequently loss of
appetite, prostration of strength, frequent and small, but sharp pulse,
hot and parched state of the skin of the hands and feet, with other
febrile symptoms, even to an alarming degree, and generally accompanied
with hysterical affections.
When this disease proves fatal, there are often, but not always,
conjoined towards the termination symptoms of inflammatory action in the
uterus.
The practice, at one time, was to endeavour, with the fingers or
forceps, to extract the remains of the ovum; but this is not always
successful, and is productive of much irritation. We find it most useful
to keep the parts clean, by injecting infusion of camomile flowers with
a small quantity of oxygenated muriatic acid, to open the bowels with
gentle laxatives or clysters, to support the strength by light
nourishment with small portions of wine frequently repeated, if
agreeable to the patient, and plenty of subacid fruit, whilst, at the
same time, we, if necessary, procure rest, or allay irritation by
opiates.
FINIS.
ERRATA.
Page 24, line 9, for _ar every_, read _are very_.
34, — 8, for _expanding_, read _expending_.
40, — 16, for _takes_, read _take_.
41, — 5, for _in_, read _rise_.
64, — 11, for _urerus_, read _uterus_.
74. — 12, dele the comma after _frequently_.
94. The paragraph beginning with _I wish_, &c. ought to form a
part of the preceding sentence.
_Printed by C. Stower, 32, Pater-noster Row._
-----
Footnote 1:
Both arteries and veins enlarge, but the latter increase more rapidly
in size than the former, so much so, that even before the descent of
the ovum into the uterus, and while the viscus is not itself
materially enlarged, the venous system has assumed the appearance of
sinews, each branch being larger than a goose quill.
Footnote 2:
Vide Anatomy of the gravid uterus, with practical inferences relative
to pregnancy and labour.
Footnote 3: