Part 4
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.
Opiates have been advised, in order to abate the discharge, and are, by 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.