OBSERVATIONSONABORTION.
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 futuretime. 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.
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The human uterus, in the unimpregnated state, consists of a succulent substance, in which we may perceive fibresrunning 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 canobserve 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 appearanceas 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 aremore 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 differentfrom 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 thecase 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 doesreach 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 havethe 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 allthe 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, andwhen 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 dischargedoes 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 formerlywas 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 comeinto 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 earlierperiod, 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 instantlyappear. 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 profuseand 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 inmany, 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.
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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, untileither 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, afterbearing 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 generationaltogether, 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 ofit, 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 beany 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 thenerve 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 systemis 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 putpro temporeinto 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; andit 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 inconcert 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 restand 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 actioninterrupted, 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 casefeculent 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 hyocyamusor 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, moreblood 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. Onthe 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 thecervex uteri.
This, when gestation goes on regularly, is accomplished gradually andslowly 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 intimatelyconnected. 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 willsoon 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 cessationof 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 toprove, 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, andvice 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 individualfibres 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 transferredaction, 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 anodynesthey 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, andlikely 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 fatigueingdissipations 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 inits 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, theone 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 excitea 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 certainlyas 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 thesame 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 ofgestation 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 fromthe 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.
Sometimes the upper range of lacunæ yields water, whilst the under secretes jelly, which confines the water for some hours, until it accumulates, and comes out with a small gush. At other times, in the early period of gestation, it collects in considerable quantity betwixt the lower part of the decidua protrusa, which has not yet reached the cervix uteri and the cervical efflorescence, which becomes a little stronger than usual.
There is thus a species of dropsy produced, and the water is sometimes confined until a little before labour comes on; at other times it is discharged sooner, and an oozing continues for many weeks. In all these cases, we may derive some advantage from injecting three or four times a day a strong infusion of galls. The woman ought to use no exertion, as the membranes are apt to give way.
When the liquor amnii really is evacuated, sometimes a spasmodic contraction of the fibres near the cervix takes place, instead of that regular action which is necessary for expulsion; and if the whole of the liquor have not escaped, the remaining portion will be confined by the tightening of that part of the uterus round the fœtus; and this contraction may endure for a very considerabletime. If not interrupted, it may lay the foundation of future diseases in the uterus.