Part 2
This is the case with all organs whose action is increased, other parts being deprived in proportion as they are supplied, except when irritation raises general action above the natural degree; the consequence of which is, that the power is not sufficient for the action, which becomes irregular, and the system is exhausted, as we see in febrile conditions[5].
There being increased action of the uterus in gestation, requiring an increased quantity of energy to support it, we find that the system is put _pro tempore_ into an artificial state, and obliged either to form more energy, which cannot be so easily done, or to spend less in some other part. Thus the function of nutrition, or the action by which organic matter is deposited, in room of that which is absorbed, often yields, or is lessened, and the person becomes emaciated, or the stomach has its action diminished, or the bowels producing costiveness and inflation. If no part give way, and no more energy than usual be formed, gestation cannot go on, or goes on imperfectly. Hence some women have abortion induced by being too vigorous; that is to say, all the organs persist in keeping up their action in perfection and complete degree.
A tendency to abortion also results from a contrary cause, from organs yielding too readily, allowing the uterus to act too easily. In this state it is as liable to go wrong, as the general system is when it is at the highest degree of action, compatible with health, the most trifling cause deranges it. Thus, sometimes, the intestines yield too readily, and become almost torpid, so that a stool can with difficulty be procured. Here costiveness is not a cause of abortion, though it may be blamed. In like manner, the muscular system may yield and become enfeebled; and in this instance debility is accused as the cause of abortion, although it be, indeed, only an effect of too much energy being destined for the uterus. In this case, the woman is always weaker during menstruation and gestation than at other times.
Now this is not a piece of idle speculation, but is of much practical importance, especially in considering the means of correcting habitual abortion; and much attention should be paid to the state of the principal organs in the body; for, if we confine our attention merely to the uterus, we shall often fail when otherwise we might succeed; and it will be necessary to remember, that the chain of sympathies in gestation is often extensive and complicated.
The state of the stomach, for example, may give rise to head-ach, tooth-ach, &c. and often it is dangerous suddenly to remove these remote effects. It throws too much energy to the uterus; its action is too much exerted; contraction and abortion take place: but in the unimpregnated state, the removal of these effects may, on the contrary, be useful: thus the pulling of a pained tooth sometimes speedily produces the return of the menses in cases of obstruction.
If the neighbouring parts do not accommodate themselves to the changes in the direction of energy, and act in concert with the uterus, their action becomes irregular, and consequently painful. In this case the uterus may have its just degree of power and action; but other parts may not be able to act so well under the change of circumstances. This is chiefly the case in early gestation, for, by time, the parts come to act better. It often gives rise to unnecessary alarm, being mistaken for a tendency to abortion; but the symptoms are different. The pain is felt chiefly at night, a time at which weakened parts always suffer most; it returns pretty regularly for several weeks, but the uterus continues to enlarge, the breasts to distend, and all things are as they ought to be, if we except the presence of the pain. This may be alleviated sometimes by anodynes, but can only be cured by time, and avoiding, by means of rest and care, any additional injury to parts already irregular and ticklish in the performance of their actions. If this be neglected, they will re-act on the uterus at last, and impede its function.
Even although the different organs, both near and remote, may have accommodated themselves to the changes in the uterine action, in the commencement of gestation, the proper balance may yet be lost at a subsequent period; and this is most apt to take place about the end of the third, or beginning of the fourth month, when the uterus is rising out of the pelvis; and hence a greater number of abortions take place at that time than at any other stage of pregnancy. There is from that time, to the period of quickening, a greater susceptibility in the uterus to have its action interrupted, than either before or afterwards, which points out the necessity of redoubling our vigilance in watching against the operation of any of the causes giving rise to abortion from the tenth to the sixteenth week.
If the uterus, in its unimpregnated state, become very torpid, as in some cases of amenorrhœa, the abdominal muscles sometimes have their action much increased; and there is absolutely an attempt made to expel it, violent paroxysms of contraction coming on, and repeated daily for a length of time.
These may be lessened by opiates, but can only be cured by exciting the natural action of the uterus. I mention this fact, from its singularity, although it do not immediately refer to abortion.
If the action of gestation go on under restraint, as, for instance, by a change of position in the uterus, or by its prolapsing too low in the vagina, it is very apt to be accompanied by uneasy feelings, for, whenever any action is constrained, sensation is produced. The woman feels irregular, and pretty sharp pains in the region of the uterus, and from sympathetic irritation both the bladder and rectum may be affected, and occasionally a difficulty is felt in making water, by which a suspicion is raised that retroversion is taking place.
Sometimes the cervical vessels in these circumstances yield a little blood, as if abortion were going to happen; but by keeping the patient at rest, and attending to the state of the rectum and bladder, no harm is done: and when the uterus rises out of the pelvis, no farther uneasiness is felt.
Retroversion of the uterus likewise constrains very much its action, and may give rise to abortion, though in a greater number of instances, by care, gestation will go on, and the uterus gradually ascend.
Sometimes in irritable or hysterical habits, the process of gestation produces a considerable degree of disturbance in the actions of the abdominal viscera, particularly the stomach, exciting frequent and distressing retching or vomiting, which may continue for a week or two, and sometimes is so violent, as to invert the peristaltic motion of the intestines near the stomach, in which case feculent matter, and, in some instances, lumbrici, are vomited.
This affection is often accompanied by an unsettled state of mind, which adds greatly to the distress. We sometimes, in these circumstances, have painful attempts made by the muscles to force the uterus downward, and these are occasionally attended by a very slight discharge of blood. We have, however, no regular uterine pain; and, if we are careful of our patient, abortion is rarely produced.
The best practice is to take away a little blood at first, to keep the bowels open, to lessen the tendency to vomit, by applying an opium plaster, or a small blister, to the region of the stomach, and to allay pain by doses of hyocyamus or opium, conjoined with carminatives. When the mind is much affected, or the head painful, it is proper to shave the head, and wash it frequently with cold vinegar, or apply a blister at the same time that we keep the patient very quiet, and have recourse to a soothing management.
The uterus being a large vascular organ, is obedient to the laws of vascular action, whilst the ovum is more influenced by those regulating new-formed parts; with this difference, however, that new-formed parts or tumors are united firmly to the part from which they grow by all kinds of vessels, and generally by fibrous or cellular substance, whilst the ovum is united to the uterus only by very tender and fragile arteries and veins. If, therefore, more blood be sent to the maternal part of the ovum, than it can easily receive and circulate and act under, rupture of the vessels will take place, and an extravasation and consequent separation be produced; or, even when no rupture is occasioned, the action of the ovum may be so oppressed and disordered, as to unfit it for continuing the process of gestation. There must, therefore, be a perfect correspondence betwixt the uterus and the ovum, not only in growth and vascularity, but in every other circumstance connected with their functions.
Even when they do correspond, if the uterus be plethoric, the ovum also must be full of blood, and rupture very apt to take place; and this is a frequent cause of abortion, more especially in those who menstruate copiously. On the other hand, when the uterus is deficient in vascularity, which often happens in those who menstruate sparingly or painfully, the child generally dies before the seventh month, and is expelled. The process is prematurely and imperfectly finished.
Abortion necessarily implies separation of the ovum, which may be produced mechanically or by spontaneous rupture of the vessels, or by an affection of the muscular fibres. It unavoidably requires, for its accomplishment, contraction of those fibres which formerly were in a dormant state. A natural and necessary effect of this contraction is to develope the cervex uteri.
This, when gestation goes on regularly, is accomplished gradually and slowly by the extension and formation of fibres. In abortion, no fibres are formed; but muscular action does all, except in those instances where the action of gestation goes on irregularly and too fast; in which case the cervix distends, sometimes by the third month, by the same process which distends the fundus. But much more frequently the cervix only relaxes during abortion, as the os uteri does in natural labour, and yields to the muscular action of the fundus, or distended part.
The existence and growth of the fœtus depends on the fœtal portion of the ovum. The means of nourishment, and the accommodation of the fœtus in respect of lodgement, depend on the uterus; and these circumstances requiring both fœtal and maternal action, are intimately connected. The condition of the uterus qualifying it to enlarge, to continue the existence and operation of the maternal portion of the placenta or ovum, and to transmit blood to the ovum, exactly in the degree correspondent to its wants, constitutes the action of gestation.
When this condition ceases, then muscular contraction begins, provided the cessation be universal in the uterus. This is necessary, for as the fœtal and maternal actions are dependent on each other, the fœtus would suffer if it were not expelled. The injury, indeed, will not be immediate; otherwise, in labour, the child would die before it could be born, because labour implies a cessation of the action of gestation. On the other hand, the loss of action in the fœtal part will soon influence the maternal part, and stop its action.
In labour, and at other times, when the action of gestation ceases, the circulation is still kept up in the maternal vessels of the placenta, until either separation and expulsion take place, or the vessels suffer so much as to cease to transmit blood. The cessation of action then does not necessarily immediately affect the fœtus. As long as it, and the fœtal portion of the ovum connected with it, remain stationary, the same quantity of blood will do. But the uterus cannot now increase its actions along with those of the fœtus, so as gradually to enlarge and send more blood.
This is one cause of disagreement. Another is, that, in consequence of cessation of action in the uterus, the maternal portion of the placenta or ovum ultimately suffers, and flags or decays, whilst the fœtal portion must sympathize with it.
From this it results, first, that even in tedious labour the child does not die: secondly, that when the action ceases in the early months of pregnancy, the fœtus does not instantly die, nor abortion immediately take place: thirdly, but it invariably happens, that, at whatever period the action ceases, the fœtus will, if not expelled within a certain time, perish.
I have elsewhere[6] endeavoured to prove, that we have a certain quantity of action present in the system at large, and properly distributed amongst the different organs, forming an equilibrium of action; and that if one organ act in an over degree, another, which is connected with it, will have its action lessened, and _vice versa_.
The same holds true with regard to different actions belonging to the same organ; and the fact is of considerable importance, both in explaining and curing diseases. During pregnancy, the muscular fibres of the uterus are dormant, possessing no contractile action; at least, none qualifying them for contracting, so as to make the uterus smaller.
I doubt much if even the individual fibres possess a power of alternately contracting and relaxing, as in other muscles, in any degree whatever. But, whenever the action of gestation ceases, action is communicated to these fibres; and whenever this loss on the one part, and gain upon the other, is universally begun in the womb, the transference will be completed, and the ovum can no longer be preserved in the uterus.
The loss of action is generally speedy, when once begun. Perhaps in most instances it takes place instantaneously, and then the fibres begin individually to act; but they may not, for some hours, contract universally, and all at one and the same time producing pains.
But if some other organ shall receive the surplus of action, or the transferred action, then the uterine fibres either will not contract, or will receive an inferior and insufficient degree of action, and expulsion will not take place until the organ sympathizing shall cease to have the increased action, whether it be the brain, the stomach, or the external muscles of the body. Sometimes also the action seems to be divided betwixt the uterus and other organs, or they alternate in their actions.
This fact is of importance in explaining and correcting many of the irregularities attending labour, which it would be impossible here to specify.
Sometimes the action is chiefly communicated to one part of the uterine fibres, whilst the rest are more torpid; and this part contracts in an undue degree, clasping the child firmly, and retarding labour[7]; and, after expulsion, it is apt to return, and retain the placenta, whilst the rest of the uterus becomes torpid, producing flooding.
If, then, the action of gestation cease universally in the uterus, another action, namely, muscular contraction, begins, and then all hope of retaining the ovum any longer is at an end. I know that we have been told of instances where contraction, after beginning, stopped for several weeks.
The os uteri may be prematurely developed; it may be open for some weeks, even without pain; but no man will say that, in this case, labour or uterine contraction has begun. We may even have partial muscular action, in a few very rare cases, about the os uteri, which has less to do with the action of gestation than any other part of the uterus; but regular and universal action of the muscular fibres never yet has been stopped. It may, like other muscular actions, be suspended by anodynes or artificial treatment; but it never has, and never can be stopped, otherwise than by the expulsion of the ovum, when a new train of actions commence.
Whenever, then, at any period of pregnancy, we have paroxysms of pain in the back, and region of the uterus, more especially if these be attended with feeling of weight in that region, tenesmus, micturition, descent of the uterus in the pelvis, and opening of the os uteri, we may be sure that expulsion, though retarded, will soon take place.
This fact is not always attended to in abortion, for many think that if by anodynes they can abate the pain, they will make the woman go to the full time.—This is true, with regard to many painful sensations, which may attend a threatened abortion, or which may be present, although there be no appearance of abortion; but it does not hold with regard to those regular pains proceeding from universal action of the uterine fibres; and we may save both ourselves and our patients some trouble, by keeping this in remembrance.
Seeing, then, that contraction is brought on by stopping the action of gestation, and that when it is brought on it cannot be checked, nor the action of gestation restored, we must next enquire how this action may be stopped. I have already mentioned several circumstances affecting the uterus, and likely to injure its actions; and these I shall not repeat, but go on to notice some others, which are often more perceptible; and first I shall mention violence, such as falls, blows, and much fatigue, which may injure the child, and detach part of the ovum.
If part of the ovum be detached, we have not only a discharge of blood, but also the uterus, at that part, suffers in its action, and may influence the whole organ, so as to stop the action universally. But the time required to do this is various, and opportunity is often given to prevent the mischief from spreading, and to stop any farther effusion—perhaps to accomplish a re-union.
Violent exercise, as dancing, for instance, or much walking, or the fatigueing dissipations of fashionable life, more especially in the earlier months, by affecting the circulation, may vary the distribution of blood in the uterus, so much as to produce rupture of the vessels, or otherwise to destroy the ovum. There is also another way in which fatigue acts, namely, by subducting action and energy from the uterus: for the more energy that is expended on the muscles of the inferior extremities, the less can be afforded or directed to the uterus; and hence abortion may be induced at an early stage of gestation[8].
Even at a more advanced period, inconvenience will be produced upon the principle formerly mentioned; for the nerves of the loins conveying less energy, in many instances, though not always to the muscles, they are really weaker than formerly, and are sooner wearied, producing pain, and prolonged feeling of fatigue, for many days, after an exertion which may be considered as moderate.
This feeling must not be confounded with a tendency to abortion, though it may sometimes be combined with it, for generally by rest the sensation goes off. Neither must we suppose that the child is dead, from its being usually quiet during that period, for as soon as the uterus, which has been a little impaired in its action, recovers, it moves as strongly as ever.
In the next place, I mention the death of the child, which may be produced by syphilis, or many diseases perhaps peculiar to itself, or by injury of the functions of the placenta. But in whatever way it is produced, the effect is the same in checking the action of gestation, unless there be twins, in which case it has been known that the uterus sometimes did not suffer universally, but the action went on, and the one child was born of the full size, the other small and injured[9].
The length of time required for producing abortion from this cause is various; sometimes it is brought on in a few hours: at other times not for a fortnight, or even longer. In these and similar cases, when the muscular action is commencing, the discharge is trifling, like menstruation, until the contraction becomes greater, and more of the ovum be separated.
A third cause is a disproportioned action betwixt the uterus and ovum, the one not increasing in the same ratio with the other, yet both continuing to act. This is productive of frequent discharges of blood, repeated at different, but always at short intervals, for several weeks, until at length the uterus suffers so much, that its action stops, or the fœtus dies.
Another cause is, any strong passion of the mind. The influence of fear, joy, and other emotions on the muscular system, is well known; and the uterus is not exempted from their power; any sudden shock, even of the body, has much effect on this organ. The pulling of a tooth, for instance, sometimes suddenly produces abortion.
Emmenagogues, or acrid substances, such as savine and other irritating drugs, more especially those which tend to excite a considerable degree of vascular action, may produce abortion.
Such medicines, likewise, as exert a violent action on the stomach or bowels will, upon the principle formerly mentioned, frequently excite abortion; and very often are taken designedly for that purpose in such quantity as to produce fatal effects; and here I must remark, that many people at least pretend to view attempts to excite abortion as different from murder, upon the principle that the embryo is not possessed of life, in the common acceptation of the word. It undoubtedly can neither think nor act; but, upon the same reasoning, we should conclude it to be innocent to kill the child in the birth.
Whoever prevents life from continuing, until it arrive at perfection, is certainly as culpable as if he had taken it away after that had been accomplished. I do not, however, wish, from this observation, to be understood as in any way disapproving of those necessary attempts which are occasionally made to procure premature labour, or even abortion, when the safety of the mother demands this interference, or when we can thus give the child a chance of living, who otherwise would have none.
If any part with which the uterus sympathizes have its action greatly increased during pregnancy, the uterus may come to suffer, and abortion be produced. Hence the accession of morbid action or inflammation in any important organ, or on a large extent of cuticular surface, may bring on miscarriage, which is one cause why smallpox often excites abortion, whilst the same degree of fever, unaccompanied with eruption, would not have had that effect.
Hence also increased secretory action in the vagina, if to a great degree, though it may have even originally been excited in consequence of sympathy with the uterus, may come to incapacitate the uterus for going on with its actions, and therefore it ought to be checked by means of an astringent injection.
In this case the uterus has, without any proof, been supposed to become too much relaxed, whilst in other cases, as for instance when the abdomen was harder than usual, it has with as little foundation been supposed to be preternaturally rigid.
Mechanical irritations of the os uteri, or attempts to dilate it prematurely, will also be apt to bring on muscular contraction. At the same time, it is worthy of remark, that the effect of these irritations is generally at first confined to the spot on which they act, a partial affection of the fibres in the immediate vicinity of the os uteri being all that is, for some time, produced; and therefore slight uneasiness at the lower part of the belly, with or without a tendency in the os uteri to move or dilate, whether brought on by irritation at the upper part of the vagina or os uteri, or by affection of the neck, of the bladder, &c.[10] may be often prevented from extending farther, and destroying the action of gestation by rest, anodynes, and having immediate recourse to such means as the nature of the irritation may require for its removal.
Tapping the ovum, by which the uterus collapses and its fibres receive a stimulus to action, is another cause by which abortion may be produced; and this is sometimes, with great propriety, done at a particular period, in order to avoid a greater evil.