Read Ebook: 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 Burns John

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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 haemorrhage, 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.

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 haemorrhage 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 haemorrhage.

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 foetus 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 foetal 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 haemorrhage 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.

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.

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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, 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 amenorrhoea; 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.

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 amenorrhoea, 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 foetus depends on the foetal portion of the ovum. The means of nourishment, and the accommodation of the foetus in respect of lodgement, depend on the uterus; and these circumstances requiring both foetal 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 foetal and maternal actions are dependent on each other, the foetus 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 foetal 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 foetus. As long as it, and the foetal 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 foetus, 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 foetal 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 foetus does not instantly die, nor abortion immediately take place: thirdly, but it invariably happens, that, at whatever period the action ceases, the foetus will, if not expelled within a certain time, perish.

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.

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