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