Chapter II: Part 2

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.

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.

It occasionally happens, that no hemorrhage accompanies this retention, but the remains of the ovum putrify, and after many days come away in a very fœtid state. Until this expulsion takes place, we have very offensive discharge from the vagina, and not unfrequently loss of appetite, prostration of strength, frequent and small, but sharp pulse, hot and parched state of the skin of the hands and feet, with other febrile symptoms, even to an alarming degree, and generally accompanied with hysterical affections.

When this disease proves fatal, there are often, but not always, conjoined towards the termination symptoms of inflammatory action in the uterus.

The practice, at one time, was to endeavour, with the fingers or forceps, to extract the remains of the ovum; but this is not always successful, and is productive of much irritation. We find it most useful to keep the parts clean, by injecting infusion of camomile flowers with a small quantity of oxygenated muriatic acid, to open the bowels with gentle laxatives or clysters, to support the strength by light nourishment with small portions of wine frequently repeated, if agreeable to the patient, and plenty of subacid fruit, whilst, at the same time, we, if necessary, procure rest, or allay irritation by opiates.

FINIS.

ERRATA.

Page 24, line 9, for _ar every_, read _are very_.

34, — 8, for _expanding_, read _expending_.

40, — 16, for _takes_, read _take_.

41, — 5, for _in_, read _rise_.

64, — 11, for _urerus_, read _uterus_.

74. — 12, dele the comma after _frequently_.

94. The paragraph beginning with _I wish_, &c. ought to form a
part of the preceding sentence.

_Printed by C. Stower, 32, Pater-noster Row._

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Footnote 1:

Both arteries and veins enlarge, but the latter increase more rapidly
in size than the former, so much so, that even before the descent of
the ovum into the uterus, and while the viscus is not itself
materially enlarged, the venous system has assumed the appearance of
sinews, each branch being larger than a goose quill.

Footnote 2:

Vide Anatomy of the gravid uterus, with practical inferences relative
to pregnancy and labour.

Footnote 3:

The placenta, contrary to some plans, is not formed exactly at the
fundus uteri, stretching equally down on the two faces of the uterus,
with the membranes hanging perpendicularly from it. But it lies
chiefly on one face of the uterus, whilst the membranes are turned to
the other. The centre of the membranous bag, therefore, at this early
period, is not directed to the os uteri, but either to the fore or
back part of the uterus. In proportion, however, as the bag enlarges,
it elongates, its centre, or apex, descends, and ultimately
corresponds with the long axis of the uterus.

Footnote 4:

In some instances, the uterus seems to have the power of forming a
vascular substance from its inner surface, although impregnation have
not taken place; and, in this case, we may have the symptom of early
abortion attending its expulsion. But much oftener we find that this
appears as a derangement of the menstrual action, the vessels
secreting a semi-organized substance, instead of the usual quantity of
bloody fluid; hence, as has been observed by that ingenious and
excellent practitioner, Dr. Denman, we have sparing and painful
menstruation.

Footnote 5:

For a fuller explanation and defence of this doctrine, I beg leave to
refer the reader to some observations on the animal economy, prefixed
to the first volume of my Dissertation on Inflammation.

Footnote 6:

Vide Dissertations on Inflammation, Vol. I.

Footnote 7:

This contraction is sometimes so firm after the membranes have burst,
as to produce the same effect upon the child, as the natural pains
would have done had the pelvis been deformed; that is to say, the
presentation becomes unshapely, and the part below the stricture is
swelled and livid. This spasm, like that which sometimes retains the
placenta, is very difficult to be relaxed, and, in general, requires
artificial management. If it come on at the full time, before the
membranes break, it may give such a feeling to the lower part of the
ovum, as to make it resemble a preternatural presentation, although
the head really present. In this case, the band is generally pretty
broad, but its contraction is not violent. It has the effect, however,
of retarding labour, until we break the membranes, which excites a
more general and effective action in the uterine fibres.

Footnote 8:

The same effect is observable in the stomach and other organs. If a
delicate person, after a hearty meal, use exercise to the extent of
fatigue, he feels that the food is not digested, the stomach having
been weakened or injured in its actions.

Footnote 9:

It has even been known, that, in consequence of the death of one
child, the uterus has suffered partially, and expulsion takes place;
but the other child continuing to live, has preserved the action of
gestation in that part of the uterus, which, properly speaking,
belonged to it, and pregnancy has still gone on. This, however, is an
extremely rare occurrence; for, in almost every instance, the death of
one child produces an affection of the action of gestation in the
whole uterus, and the consequent expulsion of both children.

Footnote 10:

It is an old observation, that these purgatives, which produce much
tenesmus, will excite abortion; and this is certainly true, if their
operation be carried to a considerable extent, and continue long
violent. Hence dysentery is also apt to bring on a miscarriage. Those
strong purges which are sometimes taken to promote premature
expulsion, not only act by exciting tenesmus, but likewise by
inflaming the stomach and bowels, and thus affect the uterus in two
ways. It cannot be too generally known, that when these medicines do
produce abortion, the mother can seldom survive their effects. It is a
mistaken notion, that abortion can be most readily excited by drastic
purges, frequent and copious bleeding, &c. immediately after the woman
discovers herself to be pregnant; on the contrary, the action of the
uterus is then more independent of that of other organs, and therefore
not so easily injured by changes in their condition. I have already
shewn, that abortion more frequently happens when the pregnancy is
farther advanced, because then not only the uterus is more easily
affected, but the fœtus seems to suffer more readily. It is apt,
either from diseases directly affecting itself, or from changes in the
uterine action, to die about the middle of the third month, in which
case expulsion follows within a fortnight.

Footnote 11:

In these circumstances I have sometimes found the children liable to a
formidable disease, described by Dr. Heberden, in his little treatise
on the diseases of children, “Cap. De Duritie Cutis.” I have met with
this oftener than once in the same family, until the constitution of
the mother was attended to, on the principle I have mentioned, after
which the children were healthy.

Footnote 12:

Hiccup sometimes accompanies this complaint: at other times it attacks
the patient as a disease by itself, or alternates with palpitation. It
is best treated by giving large doses of ether. It is also necessary
to clear the bowels; afterwards the compound tincture of bark is
useful.

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TRANSCRIBER’S NOTES

1. Items mentioned in the ERRATA were corrected. 2. Silently corrected obvious typographical errors and variations in spelling. 3. Retained archaic, non-standard, and uncertain spellings as printed. 4. Enclosed italics font in _underscores_.