Part 3

It is now the general opinion, that contraction will unavoidably follow the evacuation of the waters. But we can suppose the action of gestation to be in some cases so strong as not to stop in consequence of this violence, and, if it do not stop, contraction will not take place. I do not, however, mean to say, that all discharges of watery fluid from the uterus, not followed by abortion, are discharges of the liquor amnii, and instances of this failing to produce contraction. On the contrary, I know that most of these are the consequence of morbid action about the os uteri, the glands yielding a serous instead of a gelatinous fluid, and this action may continue for many months.

Sometimes the upper range of lacunæ yields water, whilst the under 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.

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_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.