among people civilized and savage, ancient and modern--local and
general. Among the local measures external violence is the most simple,
as among the Tasmanians, who practise abortion by striking the belly,
just as it is done by the priestesses of Formosa; and this is quite
common in our day and in our communities. The introduction of
instruments and implements into the womb is more intricate, but
likewise common; the knitting-needle is a favorite resort in our
country, and among primitive peoples a similar practice is resorted to;
thus some of the negroes of Africa introduce the sprouting stem of a
plant into the uterine cavity. Venesection, the drawing of blood from
the vulva, anus, and foot, was often resorted to for the purpose of
producing abortion.
Among the more common remedies used in former times are emetics, which
are still very often resorted to, cantharides, emmenagogues, sabin,
snakeroot, and the famous pennyroyal; so also ergot; the compound
cathartic pill of the United States Pharmacopoeia is a favorite
remedy,--all of which maim or kill the patient as often as they produce
abortion. In New Caledonia a decoction of red-bud and banana-peel or
green fruit is taken boiling: in China aperient medicines are publicly
advertised for sale, and aphrodisiacs under the name of remedies to
free the stomach and give back virginity. Certain negro tribes bring on
abortion by manipulation of the abdomen and the use of purgative
substances, such as the bark of the koche and sonnaly, which are also
used to facilitate labor. Pen-tsae enumerates a large number of
remedies as accelerators of abortion or purgatives according to the
dose; many of them have a very doubtful action, however. The natives of
India most commonly use the black annin, vulgarly called black anise or
fourspice; fifteen grammes is an emmenagogue and larger doses produce
abortion. The Arab women seek to produce sterility and escape the
annoyance of numerous pregnancies, and imagine that they can arrive at
that end by drinking a solution of sal soda, a decoction of
peach-leaves, and the sap of the male fig tree.
{473} Among peoples savage and civilized, for good reasons and bad,
villains sufficient are found to do the bidding of thoughtless and
misguided women; the remedies used, internal and external, local and
general, are very often so violent as to be followed by the death of
the victim. The plea of limited resources, of the inability of
supporting a large family, is one common to people of all races in all
stages of civilization: permitted by the unwritten law among some, it
is practised with equal frequency by others, though strictly condemned.
As we have stated, among many of the American nations it is legalized.
Again, there have been people at all times who have scorned the crime,
but this is only among those pure, primitive, and still-developing
peoples, as, for instance, the ancient Goths and Germans; and the Noxes
of South America, as well as some of the negroes of Africa, even permit
the husband without hesitation to kill his wife if she should abort. It
is among those of the primitive peoples where the blessing of offspring
is held in high esteem that the crime of abortion is most condemned and
most rare. With the progress of civilization and religion, of
refinement and knowledge, this crime, strange as it may seem, rapidly
develops. It is not among the low and ignorant--it is among the
educated and refined, among the wealthy--that it is most common; and
the plea given in excuse of this crime is one most especially urged by
the educated and refined, by the devout Christian, that the embryo is
not an animated being, not an individual existence--that it does not
attain the dignity of a living being until the time of quickening,
until the middle of pregnancy. Religious and scientific reasoning is
brought to bear in support of this theory in excuse of the many refined
criminals; and it is this very point which the physician must urge:
that the ovum, the embryo, from the moment of conception is an animated
being, an individual existence with a life of its own. Important as the
treatment of abortion, in consequence of natural causes, is, its
prevention, and, above all, the prevention of criminal abortion, is
still more so; and it is this which lies in the hands of the physician,
whose most forcible argument must be in the evident and glaring crime
which is committed by the destruction of a living being, as is the
embryo from the moment of conception, not to forget the injury
resulting to the mother. The former appeals to the moral, the latter to
the physical, elements of womanly nature.
Whilst abortion, in consequence of natural causes, is a condition more
dangerous than labor at term, the interruption of pregnancy by forcible
means--criminal abortion--must necessarily be more grave in its
consequences. The interference is often a violent one; the aborting
woman is in mental distress, unable to seek the necessary comfort or
attention; she is oppressed by the crime in her inner conscience; under
unfavorable conditions, physical and mental, for the suffering which is
most likely to follow.
With the progress in the practice of medical science the art of the
abortionist keeps pace, and in civilized communities of to-day one
cause of this growing frequency is in the increased numbers and the
increased skill of practitioners ready to pander to all the whims of
their degenerated customers: but the greater should be the efforts of
honorable physicians to dispel the false illusions by which women seem
to justify their doings, and to erase this darkest of all thoughts that
lurks amid the {474} noblest sentiments in woman's mind. A strong
effort was made not long ago by the American Medical Association to
urge the importance of this matter upon the profession, resulting from
the earnest efforts of that honored obstetrician Hugh L. Hodge, which
culminated in a report of the Committee on Criminal Abortion, read
before the American Medical Association in 1871, and a number of papers
written upon the subject at that time, prominent among which I would
mention those of Van de Warker, Tabor Johnson, and John W. Trader. The
wave has swept by: what has been accomplished may be gleaned from the
police records of our cities.
PHYSIOLOGY OF EARLY PREGNANCY.--For an understanding of the
pathological conditions which determine, precede, and accompany this
accident a knowledge of the physiological state is as important as
normal anatomy is to the pathologist. But as this subject is treated of
in full in other articles, we will confine ourselves to a few of the
leading features which are most important for purposes of diagnosis and
treatment.
The changes, local and general, resulting from the physiological state
of pregnancy are extremely variable, often approximating or simulating
pathological conditions, so that we must differentiate and discriminate
between such as pertain to the normal condition and such as indicate
pathological changes and threatening danger. This is necessary, as
prevention is, above all, important, it being often possible thus to
save two lives with by far less danger and suffering to the mother than
is to be expected from the treatment of abortion once inaugurated after
the time of possible prevention has passed. Moreover, a correct
post-abortum diagnosis is important for the future welfare of the
patient, if not from a medico-legal point of view; and this is equally
impossible without a knowledge of the physiological condition. This
will enable us to determine whether the ovum expelled is healthy or
not--whether the causes are traumatic or criminal, or whether the
abortion is due to pathological changes; which, again, must guide us in
treatment.
Abortion is the expulsion of an ovum the product of a conception, and
can only occur during the period of menstrual life, as conception, the
impregnation of the female ovule by the male semen, is the consequence
of fruitful intercourse, liable to take place at any time during the
period of womanhood, the thirty years of female menstrual life from
puberty--the appearance of the catamenia--to the time of their
cessation. Its occurrence is followed by intense physiological activity
of the maternal organism, lasting throughout gestation to the time of
its natural termination with the expulsion of the fully-developed ovum
at term at the end of the tenth lunar month. This is made evident by
striking changes in the entire system, but especially in the sexual
organs, which in the earlier period of pregnancy are entirely
progressive, developmental, whilst in the later months, toward term,
the character is changed to that of a retrograde metamorphosis,
preparatory to the separation and expulsion of the ovum and final
restitution of the organs. This hyper-activity inaugurated by
impregnation becomes evident by marked changes in the system of the
mother, in the sexual organs, and in the ovum itself.
Changes in the Maternal System.--These are most peculiar and varied,
differing in repeated pregnancies in the same patient, sometimes
entirely absent, at others most distressing, even fatal; sometimes
appearing at one {475} period, sometimes at another. Healthy, robust
women may suffer throughout the entire period of gestation, whilst
those at other times ailing are well only in this condition. The most
marked of these symptoms are the hystero-neuroses, disturbances of the
entire nervous system, central and peripheral; mental depression, more
rarely excitement; gastric disturbances, nausea and vomiting; increased
activity, renal and pulmonary, consequent upon changes in the
circulation; discoloration of the skin upon the forehead, the linea
alba, and areola; oedema and varicosities of the veins upon the lower
extremities. All these, and many others still more erratic, may
accompany the normal physiological condition.
Changes in the Uterus and Pelvic Viscera.--Whilst the ovum develops in
the uterus, this organ, its appendages, and the viscera surrounding it,
enclosed together within the pelvic cavity, undergo the most marked
changes. The early months of pregnancy are those of greatest
physiological activity in the uterine muscle, the period of its
hypertrophy. This is inaugurated from the very moment of conception, at
first increasing, then gradually lessening, until within the last
months, when it becomes passive, the rapidly-growing ovum merely
distending the hypertrophied uterus, apparently increasing in size, but
merely distended by its contents, as a rubber bag would be. In the
earlier months the growth of the uterus is entirely due to muscular
development--after the fifth month to distension. The individual
muscular cells attain enormous growth, and a large number of
pre-existing embryonic cells are developed; so also in the interlacing
connective tissue. The blood-vessels as well as the lymphatics increase
in size and length; the arteries become tortuous; the capillary
circulation is to a great extent supplanted by sinuses.
Weighing in its normal condition, when at rest, little above an ounce,
the uterus attains within the first four or five months a weight almost
fifteen times greater. Remaining the first four months within the
pelvic cavity, the increase in size is not of that diagnostic
importance which it attains in the later months, when it is to be felt
beneath the abdominal walls, though at the end of this period it is
distinctly perceived above the symphysis; about the fifth month,
between navel and symphysis; and at the sixth month, at the height of
the navel. At the end of the third month the uterus is some 4½ to 5
inches in length, by 4 in breadth and 3 in thickness; at the end of the
fourth month, 5½ to 6 inches in length, by 5 in breadth and 4 in
thickness; at the end of the fifth month, 6 to 7 inches in length, 5½
in breadth, and 5 in thickness; at the end of the sixth month it is
some 8 to 9 inches in length.
The changes which take place in the cervix are a merely passive
accompaniment of the uterine hypertrophy, it being enlarged more
especially by reason of the succulence of its tissues consequent upon
the congestion and activity of the body. It is somewhat enlarged in all
its dimensions, thickened, and elongated, soft, velvety to the touch,
appearing, however, somewhat shortened by reason of the hypertrophy of
the vaginal attachment--a condition that approximates rather that of
the vagina and external sexual organs than that of the uterus,
softened, succulent, somewhat hypertrophied, congested, of a deeper
bluish-red wine color, its cavity occluded by thick tenacious mucus, as
the secretions of the mucous membrane of the vagina and external sexual
organs are also augmented. In the first and second months the uterus is
retroverted, the cervix seems to {476} descend as the enlarged organ,
by reason of its weight, settles in the pelvis, the fundus sinking down
in the hollow of the sacrum, the cervix consequently pointing more
forward; as the organ increases in size and rises above the brim in its
endeavor to escape the confining space of the pelvic cavity, the
enlarged fundus, meeting with the resistance of the promontory, seeks
the point of least resistance, and the uterus begins to assume that
position of anteversion which continues to become more marked as
pregnancy progresses: the cervix points backward into the hollow of the
sacrum, and rises gradually (as the fundus increases in size and
withdraws from the pelvic cavity).
The Uterine Mucosa.--This structure is as interesting as it is
important. The wonderful changes which it undergoes go hand in hand
with the various changes and stages of female life: it is the nidus for
the reception of the impregnated ovum; it serves to shelter and nourish
the delicate ovum, and if diseased, affording insufficient nutrition,
leads to the death and expulsion of the embryo. Its shreds when
expelled are of diagnostic importance, and in early abortions its
massive thick tissues, changed by disease, often cause greater trouble
than the ovum itself, forming, alone or with the membranes proper of
the ovum, what is so commonly but erroneously called the placenta in
abortion. The membrane which lines the cavity proper of the uterus,
passing at the internal os into the mucous membrane of the cervical
canal, is characterized by the absence of even the slightest trace of
submucous or areolar tissue--by its peculiar substratum of connective
tissue abounding in cells and tubular glands. It is closely and
inseparably attached to the muscular coat. In a state of rest it is a
little over 0.04 inch in thickness at the fundus,[2] and the anterior
and posterior walls diminishing toward the sides, the cervical and
tuber ostea. It is traversed by a series of tubular glands, wavy in
their upper part, bifurcated toward their base, running more or less
parallel to each other. In this membrane, so important for the
preservation and development of the ovum, the physiological activity of
the system is inaugurated, and seems to centre during the first week of
gestation. With the impregnation of the ovule the uterine mucosa, its
earliest shelter, begins to hypertrophy: the rapid development which
now takes place is owing to the proliferation of the cells of the
stroma and the enlargement of the individual cells of all kinds,
including those of the glands themselves, as well as the increase of
the succulent homogeneous and cellular substance. The glands throughout
their greatest extent are enlarged: the increase in thickness is more
especially due to the hypertrophy of the superficial layer, the upper
half, in which the stroma appears less compact, growing far above the
original gland-openings, circumvallating the enlarged ostea, and thus
causing those funnel-shaped depressions which give the membrane its
sieve-like, cribriform appearance when seen from above. In the third
month of pregnancy the mucous membrane attains its greatest thickness,
forming a soft succulent lining to the uterine cavity, by its
distension closing the various ostea. It is then as much as 0.236 inch
in thickness in the anterior and posterior walls, lessening toward the
ostea, and begins to present the characteristic layers which become so
distinct in the later months--a dense upper and a very loose lower one,
comparable to a lax meshwork. Its growth now ceases, {477} and as the
uterine cavity increases in size and the ovum in growth, it is
distended to cover the rapidly-expanding surface, and becomes thinner
and thinner, the upper dense layer remaining as such, whilst the
glandular sinuses of the lower layer of the membrane are stretched
transversely until they become mere flat meshes like a network
stretched along the surface of the womb.
[Footnote 2: Engelmann _Mucous Membranes of the Uterus_.]
The impregnated ovum, as it rapidly enlarges during the first two or
three weeks, becomes imbedded in the thickened succulent decidua; and
we may compare this to the sinking of a bullet into soft dough: the
soft mass of the dough yields to the weight of the superimposed body,
and gradually closes over it, so the tissue of these overlapping folds
soon unites, completely surrounding the ovum, the nidus thus formed, in
which the ovum settles, being usually in the upper portion of the
fundus upon the posterior wall of the right side. We now distinguish in
the mucous membrane of the uterus three parts: the decidua vera, the
greater part of the membrane lining the cavity of the womb where it is
not in contact with the ovum; the decidua serotina, which is that part
directly beneath the ovum, between it and the uterine wall, which is in
connection with the tufts of the chorion, later in part develops to
form the placenta; and the decidua reflexa, that part of the mucosa
which overlaps and has overgrown the ovum. This membrane is little
known and rarely recognized, though always present. It is of no
practical importance; a delicate membrane even at the time when it is
the great safeguard of the tender ovum, serving to protect it and hold
it within the soft bed formed by the decidua serotina; this function of
the reflexa continues until the third month, when the ovum has
developed sufficiently to occupy the entire uterine cavity and is
everywhere in contact with its walls. The thin tissues of the reflexa
become more transparent and delicate as they are distended and
compressed between ovum and decidua vera, which now with the muscular
wall of the uterus surround the ovum and continue the previous function
of the reflexa.
The Development of the Ovum.--Practically, we may distinguish two
periods in the development of the ovum: the first, that in which we are
here interested, before the development of the placenta, where it is a
cyst-like body surrounded by the shaggy chorion, the chorion velosum;
and after the development of the placenta, after the fourth or fifth
month, when the foetus is more fully developed and the ovum is covered
with the smooth chorion, the chorion levæ.
The period scientifically the first, and the most interesting stage of
development, during the first three or four weeks, when segmentation
takes place and the form is moulded, we shall in no way consider. The
ovum may then be cast off, perhaps at a succeeding monthly period,
unbeknown to any one, perhaps not even to the unconscious mother:
certainly the services of an accoucheur are not called for. In the
third or fourth week it is a delicate cyst-like body of the size of a
hazel-nut, some half an inch in diameter, surrounded by its translucent
chorion, and is crushed in the passages or disappears amid the clots of
blood of an apparently profuse menstrual flow. The following periods of
development are, however, of practical importance, as they will serve
diagnostic purposes, as well as an understanding of the appearance of
the ovum and the symptoms accompanying miscarriage.
{478} The ovum during the first months of pregnancy is an oval
cyst-like body surrounded by the chorion, the shaggy tufts of which
give it a characteristic readily-recognized appearance. Enclosed within
is the delicate transparent amnion, and the embryo, attached to the
navel-string, floating in the clear liquor. At six weeks the size of
the ovum is likened to that of a pigeon's egg; at eight or nine weeks
to that of a hen's egg, perhaps 1½ inches in length; at the twelfth
week, to that of a goose-egg, some 4 inches in length. In the second
month the ovum forms a bulging prominence in the uterine cavity,
usually toward the fundus, and reveals all the parts recognized at term
with the exception of the placenta and the still distinct umbilical
vesicle: its surface is covered by the tufts of the chorion and
surrounded by the decidua reflexa. In the third month it is so far
developed as to completely occupy the uterine cavity, as yet but
slightly adherent, approximated, a part of it agglutinated to the
uterine mucosa, to the decidua serotina, the greater mass of the
chorion being in no way adherent to the surrounding reflexa. The tufts
of the chorion begin to sprout and develop more fully at its point of
contact with the uterine wall above the decidua serotina, whilst upon
the remaining and greater portion of its surface their growth ceases,
and as the membrane distends the delicate filaments gradually
disappear. At the end of the third month, in the fourth month, the
tufts of the chorion have sufficiently developed in its adherent
portion to form the rudimentary placenta, and at the end of the fourth
month this is developed still more--has become more dense and large,
whilst the remaining portion of the membrane appears smooth and barely
shows a few scanty remnants of the once-shaggy tufts.
The growth of the ovum now rapidly outstrips that of the uterine
cavity; the membranes are pressed more firmly against its walls,
approximated to the decidua vera, but not by any means agglutinated. In
the sixth month the placenta has been thoroughly formed--it has become
dense and large, the foetal membranes beginning to agglutinate to the
uterine wall, and the conditions existing at term are rapidly
approached. The embryonic tissues are supplied with the necessary
nutriment by endosmosis from the surrounding maternal structures during
the first months; the entire surface of the chorion absorbs, whilst
this function is delegated to the proliferating villi as they develop
and agglutinate with the decidua serotina, foreshadowing the activity
of the placenta by which the foetus is nourished to term.
Practically, the most important period in the development of the ovum
is the one most dangerous to its existence--in the third and fourth
month, that period of intense activity of chorion and decidua, the time
of the formation of the placenta, when hemorrhage is likely to occur
from the congestion of the vessels so necessary to the nutrition of the
rapidly-growing and delicate tissues. Nutriment is no longer merely
absorbed by the succulent embryonic cells of the ovum from the tissue
in which they are in contact, but the embryo is forced to seek
sustenance through those now fully-developed tufts of the chorion--from
the proper site, the decidua serotina and the surrounding
vessels--directly from the uterine structures. If hemorrhage interferes
or disease prevails, the healthy growth of the ovum is checked, and a
morbid development ensues, to result sooner or later in death of the
embryo and expulsion.