Part 1

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.

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BY JOHN BURNS, LECTURER ON MIDWIFERY, AND MEMBER OF THE FACULTY OF PHYSICIANS AND SURGEONS IN GLASGOW.

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_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.

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.

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_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.

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_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.