OBSERVATIONS
ON
ABORTION.
CONTAINING
An Account of the Manner in which it is accomplished, the Causes which
produced it, and the Method of preventing or treating it.
∽∽∽∽
BY JOHN BURNS,
LECTURER ON MIDWIFERY, AND MEMBER OF THE FACULTY OF PHYSICIANS AND
SURGEONS IN GLASGOW.
∽∽∽∽
_LONDON_:
PRINTED FOR LONGMAN, HURST, REES, AND ORME,
PATER-NOSTER ROW.
1806.
TO
THE GENTLEMEN
WHO ATTENDED THE AUTHOR’S
LECTURES
IN THE SESSION
1802–3,
THIS BOOK IS INSCRIBED,
AS A
GRATEFUL AND AFFECTIONATE
REMEMBRANCE
OF THE
VERY FLATTERING COMPLIMENT
WHICH THEY
BESTOWED UPON
HIM.
OBSERVATIONS
ON
ABORTION.
[Illustration]
By abortion is generally understood the expulsion of the contents of the
gravid uterus, at a period of gestation so early as to render it
impossible for the fœtus to live. It is an accident or disease which is
very frequent in its occurrence, which is always attended with
disagreeable circumstances, and which, although it seldom prove
immediately fatal, may yet be productive of much mischief at a future
time. The consideration, therefore, of the manner in which it takes
place, of the causes which give rise to it, and of the most likely means
of preventing it, or of obviating those unpleasant symptoms which
accompany it, must form a subject of very great importance to the
medical student. But before proceeding to consider these points, it will
be necessary to understand the structure and formation of the ovum,
which I shall, therefore, first of all explain.
∽∽∽∽
_Of the Formation of the Ovum._
The human uterus, in the unimpregnated state, consists of a succulent
substance, in which we may perceive fibres running in every direction.
In the interstices of these we find a serous fluid, which can easily be
squeezed out. By injecting the vessels finely with size or mercury, we
observe them to be numerously intermixed with the fibres, but very
small. A portion of these vessels follow an irregular course toward the
inner surface or cavity of the uterus, and open there upon the membrane
which lines it. At the menstrual period the vessels enlarge or dilate a
little, and their orifices become more distinct over the surface of the
cavity, as may be ascertained by inspecting those who have died at this
time. Sometimes a slight temporary serous secretion precedes the flow of
the menses, and succeeds it. More frequently the vessels yield a bloody
fluid at once, which continues a certain number of days.—When
impregnation takes place, the vessels enlarge still more; and we can
observe small trunks forming in the substance of the uterus, the largest
of which are at the two sides where the spermatic and hypogastric
branches meet[1]. The old fibres are more separated, and new ones added,
especially at the fundus.—The quantity of interstitial fluid is also
increased, so that the uterus becomes manifestly softer. The vessels, as
they enlarge, tend to the uterine cavity; but instead of opening there,
and yielding a fluid, as in menstruation, they either elongate
themselves, or, which is more probable, form new and very delicate
vessels, which project from the inner surface of the uterus, giving it
an appearance as if covered with down. This takes place first and
chiefly at the fundus, and, in a slighter degree, immediately above the
narrow cervix, whilst the intermediate body remains still quite smooth.
These vessels project for about a line in length, at right angles, from
the surface which yields them; and as they consist of arteries and
veins, the down, or efflorescence, which they form, has, after death, a
striated or radiated appearance, the empty arteries being white, the
fuller veins black or red. These vessels constitute the outer layer of
the decidua, or what may be called decidua striata, although the stria
be obliterated as gestation advances.
Almost immediately after the formation of these primary vessels, they
secrete from their extremities a membrane, or rather an irregular tissue
of vessels, which, on account of their origin, may be called secondary.
These assume a direction at right angles to those which formed them, so
that they cross the stria or primary vessels, and therefore any body
coming down through the first set of vessels, must, before it can get
into the cavity of the uterus, either rupture this secondary organ, or
push it before it. It is in this manner that the inner layer of decidua
is formed, part of which is afterwards protruded before the vesicular
ovum, constituting decidua reflexa, or protrusa.
The primary vessels adhere pretty closely together at their roots, but
are more loose or separated at their termination. They are at first only
yielded by the fundus, and in a small degree by the surface, immediately
above the cervix, whilst the cervix itself produces from the lacunæ,
which are increased in magnitude, a jelly, which sometimes fills up the
os uteri completely; at other times there is only a small quantity
formed in the cervix, leaving the os uteri quite patent. The inferior
part of the uterine surface, which yields the primary vessels, is not a
quarter of an inch in breadth; and the cavity being there small and
narrow, the vessels from the opposite sides soon come in contact, and
intermix without forming any secondary vessels. This portion may be
called the cervical efflorescence.
The secondary vessels are very different from the primary; for, whilst
the latter are short, straight, and parallel to each other, the former
are more extended, intermix, and ramify together, so as to form an
irregular tissue or sheet of vascular substance, the fibres or vessels
of which assume a direction at right angles to the down or primary
vessels which formed them. This direction seems to be very naturally
produced by the weight of the secondary vessels, which makes them hang
down or point to the os uteri. Very soon we can perceive ragged
irregular processes, hanging into the cavity of the uterus, and
extending toward the cervix, so that this layer of decidua presently
appears to consist of a number of torn floating membranes, like portions
of spiders’ webs, pendulous in the uterine cavity; but nearer
examination shows that there has been no laceration, the margins being
smooth and well defined. These I would call the processes of the decidua
interna.
Such is the structure of the decidua externa and interna, at three weeks
or a month after impregnation; and at this period no fœtus is in the
uterus. In one case I detected the vesicular ovum in the tube. It was
about half way betwixt the two extremities, was rather smaller than a
full-grown pea, and contained a little fluid. In another case I found it
still in the ovarium, covered by the fimbriated extremity of the tube.
By puncturing the peritoneal coat of the gland, the vesicle escaped.
It has been the general opinion, since the time of Dr. Hunter, that the
decidua extended a little way into the tube; and on his authority I
stated this to be the case in an account which I formerly published. By
careful examination, I am now convinced that this is not the case. My
brother, in his dissections, even thought that the uterine extremity of
the tube was less changed in point of vascularity, than any other part
of it.
When the fœtus does descend into the uterus, it is contained in a double
membrane. The internal one is the amnion, and possesses no distinct
vessels. The external one is the chorion, and is from the first
vascular, and soon becomes so much so, that its vessels have by some
been described as forming a distinct tunic.
From what has been said, it will be evident, that, when this vesicle
does reach the uterus, it will be received amongst the primary vessels
which will surround it, whilst the secondary vessels, or decidua
interna, will lie before it, and prevent any communication betwixt it
and the uterine cavity. But it cannot remain long thus; for, in
proportion as the vesicular part of the ovum increases, it will push the
decidua interna before it, and encroach upon the cavity of the uterus.
This circumstance, together with the intimate connection formed betwixt
the vessels of the chorion and those of the decidua, with the consequent
production of a placenta, I have already very fully detailed in a former
publication, to which I refer[2].
When the ovum descends, and the subsequent changes are beginning to take
place, the body of the uterus comes also to form decidua; for I have
formerly said, that, until the fœtus comes into the uterus, the fundus
alone yields this production. At the same time, the processes of the
decidua interna elongate still more, and, together with those which are
now formed by the portion produced by the newly-formed decidua externa
(for additional primary vessels imply additional secondary ones) at the
lower part of the uterus, will come to fill up all the intervening space
betwixt the bottom of the chorion or decidua reflexa and the cervical
efflorescence; so that, by the end of the second or beginning of the
third month, the cavity of the uterus is quite filled, and we have the
ovum perfectly organized. We have the fœtus inclosed in its membranes,
and swimming in water; we have the placenta thick and well formed, and
large in proportion to the membranes; we have the decidua reflexa
distinctly seen, and the lower part of the uterus filled with the two
layers of decidua, and the processes of the internal one.
If at this time we take the ovum, composed of all these different parts,
out of the uterus; or, if we cut off the face of the uterus, and remove
the decidua from the front of the membranes, we shall see at the upper
part the placenta and membranes like an old fashioned watch, the
placenta resembling the case, and the membranes (when the decidua is
taken off) the glass of the watch[3]; then, at the lower part of the
membranes, we see the remains or margins of the decidua reflexa, which
has been removed to shew the chorion; whilst, still lower down, we
observe the decidua externa, and the processes of the interna, filling
up the cervix and inferior part of the body of the uterus, forming a
kind of firm stalk to the globe above. This stalk is thick, so as to
occupy all the lower part of the uterus; but the layers and processes,
furnished by the different sides, do not adhere when they meet in the
axis of the uterus; but we have always a small canal or perforation
leading up in the axes of the uterus from the cervical efflorescence, or
the gelatinous plug, to the bottom of the decidua reflexa.
In proportion as the membranes enlarge and elongate, the decidua reflexa
gradually protrudes before them down this canal, until at last it
reaches the bottom; or, in other words, the membranes come to occupy all
the uterine cavity.
_Of the Manner in which Abortion takes place._
The process of gestation may be stopped, even before the fœtus, or
vesicular part of the ovum, has descended into the uterus, and when only
the primary vessels are formed. In this case, which occurs within three
weeks after impregnation, the symptoms are much the same with those of
menorrhagia. There is always a considerable, and often a copious
discharge of blood, which coagulates or forms clots. This is accompanied
with marks of uterine irritation, such as pain in the back and loins,
frequently spasmodic affections of the bowels, and occasionally a slight
febrile state of the system. In plethoric habits, and when abortion
proceeds from over-action, or hemorrhagic action of the uterine vessels,
the fever is idiopathic, and precedes the discharge.
In other circumstances it is either absent, or, when present, it is
symptomatic, and still more inconsiderable, arising merely from pain or
irritation. As the primary vessels are very small, and are soon
displaced, they cannot be detected in the discharge. Nothing but
coagulum can be perceived; and this, as in other cases of uterine
hæmorrhage, is often so firm, and the globules and lymph so disposed, as
to give it, more especially if it have been retained for some time about
the uterus or vagina, a streaked or fibrous appearance, which sometimes
gives rise to a supposition, that it is an organized substance. The
discharge does not cease, when the primary vessels are destroyed, but
generally continues until the small vesicle passes out of the fallopian
tube. Then it stops, and an oosing of serous fluid finishes the process.
The only interruption to the discharge in this case of abortion,
proceeds from the formation of clots, which, however, are soon
displaced. Women, if plethoric, sometimes suffer considerably from the
profusion of the discharge; but, in general, they soon recover.
When the secondary vessels are formed, the symptoms are still pretty
much the same; but if the vesicle have descended into the uterus, they
are somewhat different. We have an attempt in the uterus to contract,
which formerly was not necessary; we have pains more or less regular in
the back and hypogastric region; we have more disturbance of the
abdominal viscera, particularly the stomach. The discharge is copious,
and small bits of fibrous substance can often be observed[4].
Sometimes, when the vesicle has come into the uterus, before abortion
takes place, it may be detected in the first discharge of blood, and
will be found to be streaked over with pale vessels, giving it an
appearance as if it had been slightly macerated. When all the contents
are expelled, a bloody discharge continues for a few hours, and is then
succeeded by a serous fluid at this time; and, in later abortion, if the
symptoms come on gradually, we may sometimes observe a gelatinous matter
to come away before the hæmorrhage appears.
If the uterus have been filled up, as in the beginning of the third
month, the vesicle never escapes first; but we have for some time a
discharge of blood, accompanied or succeeded by uterine pain. Then the
inferior part or stalk of the ovum is expelled, gorged with blood, and
afterwards the upper part equally injured. Sometimes the whole comes
away at once and entire; but this is rare. As considerable contraction
is now required in the uterus, the pains are pretty severe. The
derangement of the stomach is also greater than formerly, giving rise to
sickness or faintness, which is a natural contrivance for abating the
hæmorrhage.
When the membranes come to occupy more of the uterus, and a still
greater difference to exist betwixt the placenta and decidua, we have
again a change of the process; we have more bearing down pain, and
greater regularity in its attack; we have a more rapid discharge, owing
to the greater size of the vessels; but there is not always more blood
lost now than at an earlier period, for coagula form readily from
temporary fits of faintness and other causes, and interrupt the flow
until new and increased contraction displaces them. Often the membranes
give way, and the fœtus escapes with the liquor amnii, whilst the rest
of the ovum is retained for some hours or even days, when it is expelled
with coagulated blood separating and confounding its different parts or
layers. At other times the fœtal and maternal portions separate, and the
first is expelled before the second, forming a very beautiful
preparation. In some rare instances we find the whole ovum expelled
entire, and in high preservation. After the expulsion, the hemorrhage
goes off, and is succeeded by a discharge somewhat resembling the
lochia.
In cases of twins, after one child is expelled, either alone or with its
secundines, the discharge sometimes stops, and the woman continues
pretty well for some hours, or even for a day or two, when a repetition
of the process takes place, and if she have been using any exertion,
there is generally a pretty rapid and profuse discharge. This is one
reason, amongst many others, for confining women to bed for several days
after abortion.
There is generally, for a longer or shorter time before the commencement
of abortion, a pain and other irregular actions in the neighbouring
parts, which give warning of its approach before either discharge or
contraction take place, unless when it proceeds from violence, in which
case the discharge may instantly appear. This is the period at which we
can most effectually interfere for the prevention of abortion.
I need not be particular in adding, that we are not to confound these
symptoms with the more chronic ailments which accompany pregnancy.
Similar disturbances in the action of the neighbouring parts are very
commonly found to precede labour at the full time; and even then we may,
by proper means, postpone or retard expulsion for some hours or days.
A great diversity obtains in different instances with regard to the
symptoms and duration of abortion. In some cases the pains are very
severe and long continued; in others, short and trifling. Sometimes the
hæmorrhage is profuse and alarming: at other times, although
circumstances may not be apparently very different, it is moderate or
inconsiderable. Often the sympathetic effects on the stomach and bowels
are scarcely productive of inconvenience, whilst in a greater number of
instances they are very prominent symptoms.
I may only add, that, _cæteris paribus_, we shall find that the farther
that the pregnancy is advanced beyond the third month, and the nearer it
approaches to the end of the sixth, the less chance is there of abortion
being accompanied, but the greater of its being succeeded, by nervous
affection.
As there is a diversity in the symptoms, so is there also in the
duration of abortion; for, whilst a few hours in many, and not above
three days in the majority of cases, is sufficient to complete the
process, we find other instances in which it is threatened for a long
time, and a number of weeks elapse before the expulsion take place.
∽∽∽∽
_Of the Causes giving rise to Abortion._
Abortion may very properly be divided into accidental and habitual. The
exciting causes of the first class may, in general, be easily detected;
those giving rise to the second are often more obscure; and, without
great attention, the woman will go on to miscarry, until either
sterility, or some fatal disease, be induced.
In many cases there can be no peculiar pre-disposing cause of abortion:
as, for instance, when it is produced by blows, rupture of the
membranes, or accidental separation of the decidua: but when it occurs
without any very perceptible exciting cause, it is allowable to infer,
that some pre-disposing state exists; and this generally consists in an
imperfect mode of uterine action, induced by age, former miscarriages,
and other causes.
It is well known, that women can only bear children until a certain age;
after which, the uterus is no longer capable of performing the action of
gestation, or of performing it properly. Now, it is observable, that
this incapability or imperfection takes place sooner in those who are
advanced in life, before they many, than in those who have married and
begun to bear children earlier. Thus we find, that a woman who marries
at forty, shall be very apt to miscarry; whereas, had she married at
thirty, she might have born children when older than forty; from which
it may be inferred, that the organs of generation lose their power of
acting properly sooner, if not employed, than in the connubial state.
The same cause which tends to induce abortion at a certain age in those
who have remained until that time single, will also, at a period
somewhat later, induce it in those who have been younger married: for in
them we find, that, after bearing several children, it is not uncommon
to conclude with an abortion; or, sometimes after this incomplete
action, the uterus, after a considerable time, recruits, as it were, and
the woman carries a child to the full time, after which she ceases to
conceive.
In the next place, I mention that one abortion paves the way for
another, because, setting other circumstances aside, it gives the uterus
a tendency to stop its action of gestation at an early period after
conception, and therefore it is difficult to make a woman go to the full
time, after she has miscarried frequently.
We also find that an excessive or indiscriminate use of venery either
destroys the power of the organs of generation altogether, making the
woman barren, or it disposes to abortion, by enfeebling these organs.
Some slight change of structure in part of the uterus, by influencing
its actions, may, if it do not prevent conception, interfere with the
process of gestation, and produce premature expulsion. If, however, the
part affected be very small, and near the os uteri, it is possible for
pregnancy to go on to the full time. Indeed, it generally does go on,
and the labour, as may be foreseen, will be very tedious; but the
operation of cutting the indurated os uteri, which has been proposed, is
seldom necessary.
I have known one instance, in which a very considerable part of the
uterus, I may say almost the whole of it, was found, after delivery, to
be extremely hard, and nearly ossified: but this state could not have
existed before impregnation took place, for I cannot conceive that so
great a proportion of the uterus should have been originally diseased,
and yet that conception, and its consequent actions, should take place;
but there is no difficulty in supposing, that, during the enlarging of
the uterus, the vessels deposited osseous or cartilaginous matter,
instead of fibres. In this case, it is evident that the delivery must be
instrumental, owing to the deficiency of fibres, and recovery can seldom
take place. Often we find this morbid action affect the placenta,
instead of the uterus; but this is not dangerous.
A general weakness of the system, which must affect the actions of the
uterus, in common with those of other organs, is likewise to be
considered as giving rise to abortion, though not so frequently as was
at one time supposed. The uterus is not only affected by the general
conditions of the system, more especially with regard to sensibility,
and the state of the blood-vessels; but it likewise sympathizes with the
principal organs, and may undergo changes in consequence of alterations
in their state.
Thus we often find that loss of tone, or diminished action of the
stomach, produces amenorrhœa; and it may also on the same principle
induce abortion; on the other hand, the action of the uterus may
influence that of other viscera, as we see in pulmonary consumption,
which is sometimes suspended in its progress during pregnancy; or, if
there be any disposition in an organ to disease, frequent abortion,
partly by sympathy betwixt the uterus and that organ, and partly by the
weakness which it induces, and the general injury which it does to the
system at large, may excite the irregular or morbid action of the organ
so disposed.
As the action of the uterus is increased during pregnancy, it must
require more nervous energy; but the size of the nerves of the uterus is
not increased in proportion to the action; we must therefore depend for
the increased supply upon the trunks, or larger portion of nervous
substance, from which they arise, for we well know that the quantity of
energy expended in an organ, does not depend upon the size of the nerve
in its substance, but on the trunk which furnishes it. Whenever action
is increased in an organ, it must either perish, or the larger nerve
must send the branches more energy, for the branches themselves cannot
form it, their extremities being only intended for expending it: from
which it follows, that in pregnancy there must be more energy sent to
the uterus, and less to some other part.
This is the case with all organs whose action is increased, other parts
being deprived in proportion as they are supplied, except when
irritation raises general action above the natural degree; the
consequence of which is, that the power is not sufficient for the
action, which becomes irregular, and the system is exhausted, as we see
in febrile conditions[5].
There being increased action of the uterus in gestation, requiring an
increased quantity of energy to support it, we find that the system is
put _pro tempore_ into an artificial state, and obliged either to form
more energy, which cannot be so easily done, or to spend less in some
other part. Thus the function of nutrition, or the action by which
organic matter is deposited, in room of that which is absorbed, often
yields, or is lessened, and the person becomes emaciated, or the stomach
has its action diminished, or the bowels producing costiveness and
inflation. If no part give way, and no more energy than usual be formed,
gestation cannot go on, or goes on imperfectly. Hence some women have
abortion induced by being too vigorous; that is to say, all the organs
persist in keeping up their action in perfection and complete degree.
A tendency to abortion also results from a contrary cause, from organs
yielding too readily, allowing the uterus to act too easily. In this
state it is as liable to go wrong, as the general system is when it is
at the highest degree of action, compatible with health, the most
trifling cause deranges it. Thus, sometimes, the intestines yield too
readily, and become almost torpid, so that a stool can with difficulty
be procured. Here costiveness is not a cause of abortion, though it may
be blamed. In like manner, the muscular system may yield and become
enfeebled; and in this instance debility is accused as the cause of
abortion, although it be, indeed, only an effect of too much energy
being destined for the uterus. In this case, the woman is always weaker
during menstruation and gestation than at other times.
Now this is not a piece of idle speculation, but is of much practical
importance, especially in considering the means of correcting habitual
abortion; and much attention should be paid to the state of the
principal organs in the body; for, if we confine our attention merely to
the uterus, we shall often fail when otherwise we might succeed; and it
will be necessary to remember, that the chain of sympathies in gestation
is often extensive and complicated.
The state of the stomach, for example, may give rise to head-ach,
tooth-ach, &c. and often it is dangerous suddenly to remove these remote
effects. It throws too much energy to the uterus; its action is too much
exerted; contraction and abortion take place: but in the unimpregnated
state, the removal of these effects may, on the contrary, be useful:
thus the pulling of a pained tooth sometimes speedily produces the
return of the menses in cases of obstruction.
If the neighbouring parts do not accommodate themselves to the changes
in the direction of energy, and act in concert with the uterus, their
action becomes irregular, and consequently painful. In this case the
uterus may have its just degree of power and action; but other parts may
not be able to act so well under the change of circumstances. This is
chiefly the case in early gestation, for, by time, the parts come to act
better. It often gives rise to unnecessary alarm, being mistaken for a
tendency to abortion; but the symptoms are different. The pain is felt
chiefly at night, a time at which weakened parts always suffer most; it
returns pretty regularly for several weeks, but the uterus continues to
enlarge, the breasts to distend, and all things are as they ought to be,
if we except the presence of the pain. This may be alleviated sometimes
by anodynes, but can only be cured by time, and avoiding, by means of
rest and care, any additional injury to parts already irregular and
ticklish in the performance of their actions. If this be neglected, they
will re-act on the uterus at last, and impede its function.
Even although the different organs, both near and remote, may have
accommodated themselves to the changes in the uterine action, in the
commencement of gestation, the proper balance may yet be lost at a
subsequent period; and this is most apt to take place about the end of
the third, or beginning of the fourth month, when the uterus is rising
out of the pelvis; and hence a greater number of abortions take place at
that time than at any other stage of pregnancy. There is from that time,
to the period of quickening, a greater susceptibility in the uterus to
have its action interrupted, than either before or afterwards, which
points out the necessity of redoubling our vigilance in watching against
the operation of any of the causes giving rise to abortion from the
tenth to the sixteenth week.
If the uterus, in its unimpregnated state, become very torpid, as in
some cases of amenorrhœa, the abdominal muscles sometimes have their
action much increased; and there is absolutely an attempt made to expel
it, violent paroxysms of contraction coming on, and repeated daily for a
length of time.
These may be lessened by opiates, but can only be cured by exciting the
natural action of the uterus. I mention this fact, from its singularity,
although it do not immediately refer to abortion.
If the action of gestation go on under restraint, as, for instance, by a
change of position in the uterus, or by its prolapsing too low in the
vagina, it is very apt to be accompanied by uneasy feelings, for,
whenever any action is constrained, sensation is produced. The woman
feels irregular, and pretty sharp pains in the region of the uterus, and
from sympathetic irritation both the bladder and rectum may be affected,
and occasionally a difficulty is felt in making water, by which a
suspicion is raised that retroversion is taking place.
Sometimes the cervical vessels in these circumstances yield a little
blood, as if abortion were going to happen; but by keeping the patient
at rest, and attending to the state of the rectum and bladder, no harm
is done: and when the uterus rises out of the pelvis, no farther
uneasiness is felt.
Retroversion of the uterus likewise constrains very much its action, and
may give rise to abortion, though in a greater number of instances, by
care, gestation will go on, and the uterus gradually ascend.
Sometimes in irritable or hysterical habits, the process of gestation
produces a considerable degree of disturbance in the actions of the
abdominal viscera, particularly the stomach, exciting frequent and
distressing retching or vomiting, which may continue for a week or two,
and sometimes is so violent, as to invert the peristaltic motion of the
intestines near the stomach, in which case feculent matter, and, in some
instances, lumbrici, are vomited.
This affection is often accompanied by an unsettled state of mind, which
adds greatly to the distress. We sometimes, in these circumstances, have
painful attempts made by the muscles to force the uterus downward, and
these are occasionally attended by a very slight discharge of blood. We
have, however, no regular uterine pain; and, if we are careful of our
patient, abortion is rarely produced.
The best practice is to take away a little blood at first, to keep the
bowels open, to lessen the tendency to vomit, by applying an opium
plaster, or a small blister, to the region of the stomach, and to allay
pain by doses of hyocyamus or opium, conjoined with carminatives. When
the mind is much affected, or the head painful, it is proper to shave
the head, and wash it frequently with cold vinegar, or apply a blister
at the same time that we keep the patient very quiet, and have recourse
to a soothing management.
The uterus being a large vascular organ, is obedient to the laws of
vascular action, whilst the ovum is more influenced by those regulating
new-formed parts; with this difference, however, that new-formed parts
or tumors are united firmly to the part from which they grow by all
kinds of vessels, and generally by fibrous or cellular substance, whilst
the ovum is united to the uterus only by very tender and fragile
arteries and veins. If, therefore, more blood be sent to the maternal
part of the ovum, than it can easily receive and circulate and act
under, rupture of the vessels will take place, and an extravasation and
consequent separation be produced; or, even when no rupture is
occasioned, the action of the ovum may be so oppressed and disordered,
as to unfit it for continuing the process of gestation. There must,
therefore, be a perfect correspondence betwixt the uterus and the ovum,
not only in growth and vascularity, but in every other circumstance
connected with their functions.
Even when they do correspond, if the uterus be plethoric, the ovum also
must be full of blood, and rupture very apt to take place; and this is a
frequent cause of abortion, more especially in those who menstruate
copiously. On the other hand, when the uterus is deficient in
vascularity, which often happens in those who menstruate sparingly or
painfully, the child generally dies before the seventh month, and is
expelled. The process is prematurely and imperfectly finished.
Abortion necessarily implies separation of the ovum, which may be
produced mechanically or by spontaneous rupture of the vessels, or by an
affection of the muscular fibres. It unavoidably requires, for its
accomplishment, contraction of those fibres which formerly were in a
dormant state. A natural and necessary effect of this contraction is to
develope the cervex uteri.
This, when gestation goes on regularly, is accomplished gradually and
slowly by the extension and formation of fibres. In abortion, no fibres
are formed; but muscular action does all, except in those instances
where the action of gestation goes on irregularly and too fast; in which
case the cervix distends, sometimes by the third month, by the same
process which distends the fundus. But much more frequently the cervix
only relaxes during abortion, as the os uteri does in natural labour,
and yields to the muscular action of the fundus, or distended part.
The existence and growth of the fœtus depends on the fœtal portion of
the ovum. The means of nourishment, and the accommodation of the fœtus
in respect of lodgement, depend on the uterus; and these circumstances
requiring both fœtal and maternal action, are intimately connected. The
condition of the uterus qualifying it to enlarge, to continue the
existence and operation of the maternal portion of the placenta or ovum,
and to transmit blood to the ovum, exactly in the degree correspondent
to its wants, constitutes the action of gestation.
When this condition ceases, then muscular contraction begins, provided
the cessation be universal in the uterus. This is necessary, for as the
fœtal and maternal actions are dependent on each other, the fœtus would
suffer if it were not expelled. The injury, indeed, will not be
immediate; otherwise, in labour, the child would die before it could be
born, because labour implies a cessation of the action of gestation. On
the other hand, the loss of action in the fœtal part will soon influence
the maternal part, and stop its action.
In labour, and at other times, when the action of gestation ceases, the
circulation is still kept up in the maternal vessels of the placenta,
until either separation and expulsion take place, or the vessels suffer
so much as to cease to transmit blood. The cessation of action then does
not necessarily immediately affect the fœtus. As long as it, and the
fœtal portion of the ovum connected with it, remain stationary, the same
quantity of blood will do. But the uterus cannot now increase its
actions along with those of the fœtus, so as gradually to enlarge and
send more blood.
This is one cause of disagreement. Another is, that, in consequence of
cessation of action in the uterus, the maternal portion of the placenta
or ovum ultimately suffers, and flags or decays, whilst the fœtal
portion must sympathize with it.
From this it results, first, that even in tedious labour the child does
not die: secondly, that when the action ceases in the early months of
pregnancy, the fœtus does not instantly die, nor abortion immediately
take place: thirdly, but it invariably happens, that, at whatever period
the action ceases, the fœtus will, if not expelled within a certain
time, perish.
I have elsewhere[6] endeavoured to prove, that we have a certain
quantity of action present in the system at large, and properly
distributed amongst the different organs, forming an equilibrium of
action; and that if one organ act in an over degree, another, which is
connected with it, will have its action lessened, and _vice versa_.
The same holds true with regard to different actions belonging to the
same organ; and the fact is of considerable importance, both in
explaining and curing diseases. During pregnancy, the muscular fibres of
the uterus are dormant, possessing no contractile action; at least, none
qualifying them for contracting, so as to make the uterus smaller.
I doubt much if even the individual fibres possess a power of
alternately contracting and relaxing, as in other muscles, in any degree
whatever. But, whenever the action of gestation ceases, action is
communicated to these fibres; and whenever this loss on the one part,
and gain upon the other, is universally begun in the womb, the
transference will be completed, and the ovum can no longer be preserved
in the uterus.
The loss of action is generally speedy, when once begun. Perhaps in most
instances it takes place instantaneously, and then the fibres begin
individually to act; but they may not, for some hours, contract
universally, and all at one and the same time producing pains.
But if some other organ shall receive the surplus of action, or the
transferred action, then the uterine fibres either will not contract, or
will receive an inferior and insufficient degree of action, and
expulsion will not take place until the organ sympathizing shall cease
to have the increased action, whether it be the brain, the stomach, or
the external muscles of the body. Sometimes also the action seems to be
divided betwixt the uterus and other organs, or they alternate in their
actions.
This fact is of importance in explaining and correcting many of the
irregularities attending labour, which it would be impossible here to
specify.
Sometimes the action is chiefly communicated to one part of the uterine
fibres, whilst the rest are more torpid; and this part contracts in an
undue degree, clasping the child firmly, and retarding labour[7]; and,
after expulsion, it is apt to return, and retain the placenta, whilst
the rest of the uterus becomes torpid, producing flooding.
If, then, the action of gestation cease universally in the uterus,
another action, namely, muscular contraction, begins, and then all hope
of retaining the ovum any longer is at an end. I know that we have been
told of instances where contraction, after beginning, stopped for
several weeks.
The os uteri may be prematurely developed; it may be open for some
weeks, even without pain; but no man will say that, in this case, labour
or uterine contraction has begun. We may even have partial muscular
action, in a few very rare cases, about the os uteri, which has less to
do with the action of gestation than any other part of the uterus; but
regular and universal action of the muscular fibres never yet has been
stopped. It may, like other muscular actions, be suspended by anodynes
or artificial treatment; but it never has, and never can be stopped,
otherwise than by the expulsion of the ovum, when a new train of actions
commence.
Whenever, then, at any period of pregnancy, we have paroxysms of pain in
the back, and region of the uterus, more especially if these be attended
with feeling of weight in that region, tenesmus, micturition, descent of
the uterus in the pelvis, and opening of the os uteri, we may be sure
that expulsion, though retarded, will soon take place.
This fact is not always attended to in abortion, for many think that if
by anodynes they can abate the pain, they will make the woman go to the
full time.—This is true, with regard to many painful sensations, which
may attend a threatened abortion, or which may be present, although
there be no appearance of abortion; but it does not hold with regard to
those regular pains proceeding from universal action of the uterine
fibres; and we may save both ourselves and our patients some trouble, by
keeping this in remembrance.
Seeing, then, that contraction is brought on by stopping the action of
gestation, and that when it is brought on it cannot be checked, nor the
action of gestation restored, we must next enquire how this action may
be stopped. I have already mentioned several circumstances affecting the
uterus, and likely to injure its actions; and these I shall not repeat,
but go on to notice some others, which are often more perceptible; and
first I shall mention violence, such as falls, blows, and much fatigue,
which may injure the child, and detach part of the ovum.
If part of the ovum be detached, we have not only a discharge of blood,
but also the uterus, at that part, suffers in its action, and may
influence the whole organ, so as to stop the action universally. But the
time required to do this is various, and opportunity is often given to
prevent the mischief from spreading, and to stop any farther
effusion—perhaps to accomplish a re-union.
Violent exercise, as dancing, for instance, or much walking, or the
fatigueing dissipations of fashionable life, more especially in the
earlier months, by affecting the circulation, may vary the distribution
of blood in the uterus, so much as to produce rupture of the vessels, or
otherwise to destroy the ovum. There is also another way in which
fatigue acts, namely, by subducting action and energy from the uterus:
for the more energy that is expended on the muscles of the inferior
extremities, the less can be afforded or directed to the uterus; and
hence abortion may be induced at an early stage of gestation[8].
Even at a more advanced period, inconvenience will be produced upon the
principle formerly mentioned; for the nerves of the loins conveying less
energy, in many instances, though not always to the muscles, they are
really weaker than formerly, and are sooner wearied, producing pain, and
prolonged feeling of fatigue, for many days, after an exertion which may
be considered as moderate.
This feeling must not be confounded with a tendency to abortion, though
it may sometimes be combined with it, for generally by rest the
sensation goes off. Neither must we suppose that the child is dead, from
its being usually quiet during that period, for as soon as the uterus,
which has been a little impaired in its action, recovers, it moves as
strongly as ever.
In the next place, I mention the death of the child, which may be
produced by syphilis, or many diseases perhaps peculiar to itself, or by
injury of the functions of the placenta. But in whatever way it is
produced, the effect is the same in checking the action of gestation,
unless there be twins, in which case it has been known that the uterus
sometimes did not suffer universally, but the action went on, and the
one child was born of the full size, the other small and injured[9].
The length of time required for producing abortion from this cause is
various; sometimes it is brought on in a few hours: at other times not
for a fortnight, or even longer. In these and similar cases, when the
muscular action is commencing, the discharge is trifling, like
menstruation, until the contraction becomes greater, and more of the
ovum be separated.
A third cause is a disproportioned action betwixt the uterus and ovum,
the one not increasing in the same ratio with the other, yet both
continuing to act. This is productive of frequent discharges of blood,
repeated at different, but always at short intervals, for several weeks,
until at length the uterus suffers so much, that its action stops, or
the fœtus dies.
Another cause is, any strong passion of the mind. The influence of fear,
joy, and other emotions on the muscular system, is well known; and the
uterus is not exempted from their power; any sudden shock, even of the
body, has much effect on this organ. The pulling of a tooth, for
instance, sometimes suddenly produces abortion.
Emmenagogues, or acrid substances, such as savine and other irritating
drugs, more especially those which tend to excite a considerable degree
of vascular action, may produce abortion.
Such medicines, likewise, as exert a violent action on the stomach or
bowels will, upon the principle formerly mentioned, frequently excite
abortion; and very often are taken designedly for that purpose in such
quantity as to produce fatal effects; and here I must remark, that many
people at least pretend to view attempts to excite abortion as different
from murder, upon the principle that the embryo is not possessed of
life, in the common acceptation of the word. It undoubtedly can neither
think nor act; but, upon the same reasoning, we should conclude it to be
innocent to kill the child in the birth.
Whoever prevents life from continuing, until it arrive at perfection, is
certainly as culpable as if he had taken it away after that had been
accomplished. I do not, however, wish, from this observation, to be
understood as in any way disapproving of those necessary attempts which
are occasionally made to procure premature labour, or even abortion,
when the safety of the mother demands this interference, or when we can
thus give the child a chance of living, who otherwise would have none.
If any part with which the uterus sympathizes have its action greatly
increased during pregnancy, the uterus may come to suffer, and abortion
be produced. Hence the accession of morbid action or inflammation in any
important organ, or on a large extent of cuticular surface, may bring on
miscarriage, which is one cause why smallpox often excites abortion,
whilst the same degree of fever, unaccompanied with eruption, would not
have had that effect.
Hence also increased secretory action in the vagina, if to a great
degree, though it may have even originally been excited in consequence
of sympathy with the uterus, may come to incapacitate the uterus for
going on with its actions, and therefore it ought to be checked by means
of an astringent injection.
In this case the uterus has, without any proof, been supposed to become
too much relaxed, whilst in other cases, as for instance when the
abdomen was harder than usual, it has with as little foundation been
supposed to be preternaturally rigid.
Mechanical irritations of the os uteri, or attempts to dilate it
prematurely, will also be apt to bring on muscular contraction. At the
same time, it is worthy of remark, that the effect of these irritations
is generally at first confined to the spot on which they act, a partial
affection of the fibres in the immediate vicinity of the os uteri being
all that is, for some time, produced; and therefore slight uneasiness at
the lower part of the belly, with or without a tendency in the os uteri
to move or dilate, whether brought on by irritation at the upper part of
the vagina or os uteri, or by affection of the neck, of the bladder,
&c.[10] may be often prevented from extending farther, and destroying
the action of gestation by rest, anodynes, and having immediate recourse
to such means as the nature of the irritation may require for its
removal.
Tapping the ovum, by which the uterus collapses and its fibres receive a
stimulus to action, is another cause by which abortion may be produced;
and this is sometimes, with great propriety, done at a particular
period, in order to avoid a greater evil.
It is now the general opinion, that contraction will unavoidably follow
the evacuation of the waters. But we can suppose the action of gestation
to be in some cases so strong as not to stop in consequence of this
violence, and, if it do not stop, contraction will not take place. I do
not, however, mean to say, that all discharges of watery fluid from the
uterus, not followed by abortion, are discharges of the liquor amnii,
and instances of this failing to produce contraction. On the contrary, I
know that most of these are the consequence of morbid action about the
os uteri, the glands yielding a serous instead of a gelatinous fluid,
and this action may continue for many months.