A moderate discharge of blood from the vagina, although showing that a separation has taken place between the ovum and the uterus, cannot be looked upon as an unfavourable sign, for it relieves the pelvic vessels, diminishes the pain in the back, and makes the patient feel more light and comfortable; but if it be at all brisk, and continues so after the employment of the above remedies, if also there be heat and throbbing in the region of the uterus, it will be necessary to apply cloths wrung out of cold water to the lower part of the abdomen and vulva, and to the groins and sacrum; and this treatment must be continued in full force until the symptoms of congestion have abated, and the discharge lessened or stopped.
If the hæmorrhage be really profuse, it shows that the separation of the ovum from the uterus must be of considerable extent; and as there will be no chance of preserving the life of the fœtus under such circumstances, the expulsion of the ovum is no longer to be avoided, but rather to be promoted; our attention therefore must now be directed to assist the uterus in the evacuation of its contents, with as little injury and danger to the mother as possible. It is, however, no easy matter to decide with certainty when we must give up all hope of preserving the ovum, for a large quantity of blood may be lost without expulsion being a necessary consequence. Uterine contractions may have even taken place, and yet by careful management the mischief may be sometimes averted, and the patient be enabled to go her full time. Even where they have been of sufficient force and duration to dilate the os uteri, we are not justified in discontinuing remedial measures unless the flooding has seriously affected the patient’s strength, and the ovum be actually projecting through the os uteri. “We might often prevent abortion (says Baudelocque) if we were perfectly acquainted with its cause, even when the labour is already begun. A very plethoric woman felt the pains of childbirth towards the seventh month of her pregnancy, and the labour was very far advanced when I was called to her assistance, since the os uteri was then larger than half a crown; two little bleedings restored a calm, so much that the next day the orifice in question was closed again, and the woman went the usual time. Food of easy digestion prudently administered quieted a labour not less advanced in another woman, where it was suspected to be the consequence of a total privation of every species of nourishment for several successive days. Delivery did not take place till two months and a half afterwards, and at the full time. Emollient glysters and a very gentle cathartic procured the same advantage to a third woman, in whom labour pains came on between the sixth and seventh months of pregnancy, after a colic of several days’ continuance, accompanied with diarrhœa and tenesmus.” (Baudelocque,) § 2232. Nor is it always easy to decide whether it be the ovum or not which we feel protruding through the os uteri. “When the abortion is in the second or third month, the practitioner must bear in mind that it may have been retention of the menses, and, therefore, what he feels in the os uteri may either be an ovum or a coagulum of blood. To decide this point he must keep his finger in contact with the substance lying in the os uteri, and wait for the accession of a pain (for where clots come away, pains like those of labour are present,) and ascertain whether the presenting mass becomes tense, advances lower, and increases somewhat in size; this will be the case where it is the ovum pressing through the os uteri. On the other hand, if it be a coagulum, which it is well known assumes a fibrous structure, it will neither become tense nor descend lower, but be rather compressed. Generally speaking, the ovum feels like a soft bladder, and at its lower end is rather round than pointed, whereas, a plug of coagulum feels harder, more solid, and less compressible, and is more or less pointed at its lower end, becoming broader higher up, so that we generally find that the coagulum has taken a complete cast of the uterine cavity. If we try to move the uterus by pressing against this part, it will instantly yield to the pressure of the finger, if it be the ovum; whereas, the extremity of a coagulum under these circumstances is so firmly fixed, that when pressed against by the finger the uterus will move also. When abortion happens at a later period of pregnancy, we shall be able to feel the different parts of the child as the os uteri generally dilates, viz. the feet, or perhaps the sharp edges of bones, although we cannot distinguish the form of the head from the cranial bones being so compressed and strongly overlapping each other.” (Hohl, on Obstetric Exploration.)
Although expulsion must be looked upon as the only means of placing the patient in a state of safety, where the symptoms have advanced so far as to preclude all hopes of preserving the life of the fœtus, there are so many steps of this process to be gone through before it can be entirely completed, that more or less time must necessarily be required for that purpose. The ovum must be completely separated from its attachments to the uterus, and the contractions of that organ must have been of sufficient strength and duration to produce such a degree of dilatation of its mouth and neck as to allow the ovum to pass; but before this can be effected, such a quantity of blood may have been lost as greatly to endanger the life of the patient. Hence we must use such means as shall enable us to control the hæmorrhage, whilst we give the os uteri time to dilate sufficiently: this object will be gained most effectually by plugging the vagina. The best mode of performing this operation is that recommended by Dr. Dewees of Philadelphia: a piece of soft sponge, of sufficient size to fill the vagina without producing uneasiness, must be wrung out of pretty sharp vinegar, and introduced into the passage up to the os uteri; the blood, in filling the cells of the sponge, coagulates rapidly, and forms a firm clot, which completely seals up the vagina without producing any of those unpleasant effects which are produced by the insertion of a napkin rolled up for the purpose. A hard unyielding mass of this nature frequently produces so much tension, pain of back, and irresistible efforts to bear down, as to render it incapable of being borne for any length of time. The sponge plug may be borne for hours without inconvenience; we may either leave it to be expelled with the ovum, or after awhile remove it for the purpose of ascertaining what progress has been made. If the os uteri be still undilated, and the hæmorrhage going on, the plug must be returned. It is however by no means a remedy to be used in every case of hæmorrhage, for in most instances the treatment already mentioned will be sufficient to keep it within safe bounds. Where, however, the flooding has become very alarming, and the os uteri still remains firm and but little dilated, the plug will prove an invaluable remedy; and so long as the os uteri remains in this condition, and the uterus itself shows no disposition to contract, we may safely trust to perfect rest, cold applications, and the plug. Opium, which in the early stages of the attack is so useful in keeping off contractions of the uterus, will now for this very reason be contra-indicated; it will diminish the power of the uterus, and interfere with the process of expulsion.
The acetate of lead has been extolled as a powerful remedy for stopping hæmorrhage, more especially by Dr. Dewees, who states that “in many cases it seems to exert a control over the bleeding vessels as prompt as the ergot of rye does upon the uterine fibre.” (System of Midwifery, § 1045.) We have never tried this remedy in premature expulsion, having found the means of treatment above mentioned sufficient; the authority however of such an author demands respect, the more so as it is known to be a valuable remedy in certain forms of menorrhagia.
Where a considerable quantity of blood has been lost, and the patient is much reduced, we must endeavour not only to excite the contractile power of the uterus, but also to assist this organ in the expulsion of its contents: syncope in these cases is a dangerous symptom, because, as the patient is in the horizontal posture, it will seldom be induced except by a serious loss of blood; although we must not therefore allow her to flood until she faints, still, however, when the pulse has become considerably affected, the os uteri dilates more readily, and in this way facilitates the expulsion; we must no longer trust to the plug, for the whole system is beginning to sympathize and grow irritable, the pulse grows quicker and smaller, and the stomach rejects its contents. Although vomiting as well as syncope are symptoms which we cannot safely wait for, they are nevertheless means which nature adopts to relieve herself from the impending danger: by syncope she not only produces greater dilatability of the os uteri, but also, by causing a temporary cessation of the heart’s action, she favours the coagulation of blood, and thus checks the discharge; whereas, by the involuntary effort of muscles which she excites by the action of vomiting, the ovum is more speedily separated and expelled.
Where it becomes evident that expulsion cannot be prevented, it is our duty to promote this process before nature has had recourse to the means just mentioned. The ergot of rye is here a valuable remedy, for by inducing or increasing the contractions of the uterus we shorten the process and diminish the danger: the powder given in cold water is decidedly the best form in which it can be given; in infusion its powers seem to be injured by the heat of the water, and in tincture by the action of the spirit: the addition of about half its quantity of borax renders its action more powerful and certain. Borax has been long considered in Germany to possess a specific power in exciting uterine contraction, but it was first recommended for that purpose in this country by Dr. Copland. (Dict. Pract. Med. art Abortion.) A scruple or half a drachm of ergot powder with ten grains of borax may be given in cinnamon water, and this repeated every hour for several times.
In all cases threatening premature expulsion, wherever there has been much pain and discharge, the napkins which come from the patient should be carefully examined by her medical attendant, for otherwise the ovum may escape among the coagula and not be perceived. Where the separation is nearly complete, a portion of it protrudes at the os uteri; and this we can sometimes hook down with one or two fingers, and bring away: a still better mode is recommended by Levret, viz. of throwing up a pretty powerful stream of warm water by means of a syringe. Dr. Dewees has recommended a wire crotchet, which he has used with very good effect. (Op. cit. § 1011.)[64] We ought not, however, to be in a hurry to bring away the ovum, for when the uterine contractions have been of sufficient strength to dilate the os uteri, it will generally come away of itself. One objection to the wire crotchet is, that it tears the membranes, and lets out the liquor amnii, and perhaps the embryo.[65] This is by all means to be avoided; the larger the body which is to be expelled, the more powerfully and effectually does the uterus contract upon it: hence, therefore, if the membranes of a three or four months’ ovum be imprudently pierced with a view of hastening the expulsion, the liquor amnii and embryo escape, but the secundines remain and require protracted efforts of the uterus to expel them, during which time the sufferings of the patient are prolonged, and the hæmorrhage kept up; whereas, if the ovum had remained whole, it would have been expelled more easily and quickly. On the other hand, where the fœtus has already attained a considerable size (fifth month,) the plan recommended by Puzos of rupturing the membranes is very desirable; by this means the size of the uterus is reduced by the escape of liquor amnii, and thus the hæmorrhage checked; and the fœtus remaining in the uterus is of sufficient weight and bulk to excite contractions to expel itself and the membranes.
The treatment after abortion varies considerably: in many cases it will be merely necessary for the patient to remain in bed for a few days afterwards; but where she has been much reduced, a mild course of tonics will be necessary, in order to prevent that disposition to leucorrhœa and menstrual derangement which is so common a result: this, where it is possible, should be combined with removal into the country, or to the sea-side, or, what is still better to a watering place, where there are mineral springs of chalybeate character. For the treatment of anæmia we must refer our readers to the chapter on Hæmorrhage.