It is probable that there are many constitutional and individual peculiarities predisposing to miscarriage, with which we are not much acquainted, and which may account for the constant occurrence of that accident in many females, notwithstanding all we can do. A scrofulous taint is with good reason supposed to be one of these, and it is probable that the disease of the placenta, and its consequent separation from the womb, before referred to, is mostly caused by a taint of this kind. In many instances, where a female has miscarried from no apparent cause, if the placenta be carefully examined it will be found dotted here and there with diseased spots, sometimes like scrofulous sores! It is advisable always to ascertain this, and to carefully examine the fœtus and its appendages. In all cases the advice I gave to keep from being pregnant for some time, will be found most likely to succeed in averting the accident, both because it gives the womb time to regain its strength and break through its habit, and also because it gives us time to operate upon the constitutional taint, if there be reason to suppose it exists.
It is a curious fact, but one often observed, that living in certain localities even predisposes to miscarriage. There is a certain district in France where the females are so liable to it, that all who can do so leave the place when they become pregnant, and thus escape the greater risk. Miscarriage also becomes epidemic at certain times, and prevails like contagious diseases; several instances of this are recorded in history.
Bleeding is also supposed to be a cause of abortion, and probably it may lead to it in certain states of the system, but by no means so certainly as many suppose. Instances have been known of pregnant females being bled from ten to twenty times without any evil result, even though carried so far as to make them faint. Mauriceau tells us of one who was bled ninety times, and yet was delivered of a healthy living child at full term. In like manner many other ordinary causes of abortion will often fail entirely of their usual effects. Thus Mauriceau informs us that a female seven months gone fell upon the hard pavement from a three story window and broke her arm, but yet did not miscarry. Madame Lachapelle also tells us of a young pregnant woman who threw herself down stairs purposely, from fear that she should have to submit to the Cesarean operation, she having a deformed pelvis. The fall caused her death soon after, but did not make her miscarry. Certain powerful medicines are also taken by some, a very small quantity of which, in most cases, produces abortion immediately, but without effecting what they desire, though it sometimes poisons themselves.
Indeed the power which the womb sometimes exhibits to retain its contents in spite of the most violent disturbing agencies, is truly astonishing. Cases have been known even where the womb itself has been severely wounded, and yet miscarriage did not take place; as in the case of a poor country-woman whom I heard of, who accidentally fell upon a sharp wooden stake, and run it far into the body, injuring the womb in a terrible manner, but strange to say, though far advanced in pregnancy, she recovered and went safely through her full time. I have often known women begin to flood and suffer from dreadful pain, with other common symptoms of abortion, as early as the second month, and yet they went safely the full time, though these signs continued the whole time. In some cases the waters have even been partially discharged, and yet abortion did not result. M. Velpeau tells us of an instance where the bag of waters broke, in a female six months gone, and one arm of the child even came down into the vagina, and yet the arm returned, the discharge ceased, and she went her full term.
The progress of a miscarriage varies according to the time at which it occurs, and the causes from which it arises. When it results from any violence or accident, it usually takes place in a short time, and is preceded by abundant flooding, which comes on immediately. The discharge of blood however, is lesser the nearer we approach the full term, so that a female six months gone is not in nearly so much danger from flooding as one only two or three months gone. The reason is this, in the early months nearly the whole of the fœtal membranes are attached to the womb, so that in case of their being separated, it bleeds from nearly all its internal surface, but in the latter months the only point of attachment is the placenta. In the latter months also the womb contracts vigorously, and so closes its vessels, but in the early months its contractions are comparatively feeble. In those cases also, where the child has been dead a considerable time before its expulsion, there is seldom much flooding, the connection between it and the mother having been more or less destroyed by decay of the parts. The same result mostly follows a miscarriage from internal disease, particularly of the placenta. Indeed in some of these cases, the blood-vessels connecting the fœtus with the mother have been so completely destroyed, that no blood whatever could escape from them.
In regard to the probable consequences of premature delivery, it has already been remarked that it is more dangerous in the early months than the latter. It may also be added that it is much more dangerous, at any time, when caused by violence of any kind, or by forcing medicines, than when it occurs naturally. The danger is much increased if it occurs during fever, or any eruptive disease, or if the patient be suffering from diarrhœa or convulsions. As a general rule we may say, in all cases, that miscarriage or abortion is always more dangerous to mother and child than natural labor, both in its present and in its future consequences. During an attack of jaundice an abortion may terminate fatally in a few hours; and very frequently the trouble with the after treatment is very great and long-continued.
The treatment in an accident of this kind must vary according as we are required to prevent it, or to remedy the evils that follow when it has occurred.
If an abortion be threatened from any cause, the same general practice must be adopted as recommended for flooding, the indications being the same. I believe myself that in most cases, except from accidental violence or internal disease, miscarriage may be averted. I knew a lady who had miscarried many times, always at the same period, who avoided it at last by simply preventing constipation from the first commencement of pregnancy, and by using an enema every evening of warm starch and water, pretty thick, with about thirty drops of laudanum. This was administered by means of a common injection pipe, just before going to bed, and continued till after she had quickened, and repeated occasionally after that, if she felt any premonitory symptoms of uterine disturbance. If the patient be of a full habit, she should also, from the very beginning, live low, keep the bowels free, and the skin in good action, and take gentle regular exercise in the open air.
When all the means used are found of no avail, and it becomes evident that the fœtus must be expelled, every endeavor should be used to assist nature in its removal as early and as safely as possible. For this purpose the same treatment, as far as practicable, must be pursued as in a real labor. If the hand can be conveniently introduced, without undue force, it may be so, to remove clots, or to take hold of any part of the fœtus which may present, and assist in its extraction. In the early months considerable help may be given, sometimes by introducing the finger into the mouth of the womb, with a little extract of Belladonna, to promote its relaxation, but no force must be exerted in doing so. If any part of the after-birth can be laid hold of it should be withdrawn, but no extraordinary effort must be used to reach it. Frequently it happens that a portion of the after-birth remains in spite of all attempts to take it away, and there is a possibility that it may produce inflammation of the womb, but no very serious apprehensions need be felt of such a result, providing the patient is properly attended to in other respects. The retained portion gradually decays, and passes away, merely occasioning inconvenience and being very offensive. The danger from leaving it except at a very late period, is generally thought to be less than that from using any forcible means to remove it.
The best means for correcting the offensive discharge are cleansing and antiseptic injections. Warm soap suds are very good, or a decoction of Peruvian bark in water. Strong coffee is also excellent, or a weak solution of chloride of lime. The bowels must be kept free, and the skin carefully cleansed and well rubbed. On all occasions when the hand can be introduced with moderate and safe efforts it should be so, and the after-birth removed.