to the size of the sac, the membranes, liquor amnii, and navel-string;
at the end of the fourth week the embryo measures from 1/3 to 1/4 of an
inch in length; at the end of the eighth week, from ¾ to 1 inch: the
arms and legs become visible, the umbilical vesicle, though reduced in
size, still exists; the small body with large upper extremity is
pendent from the short, thick navel-string. At the end of the twelfth
week the embryo measures from 2 to 3 inches in length; fingers and toes
can be distinctly seen; mouth and nose are also recognizable. At the
end of the sixteenth week, the fourth month, the embryo measures some 4
to 5 inches in length; sex can be distinguished; the head assumes
shape, but it is still immense in size, perhaps an inch in length; the
features of the face are all formed. At the end of the twentieth week,
the fifth month, there is no longer doubt as to sex; the nails, which
were previously visible, have become distinct; the soft, woolly lanugo
begins to develop; hair may be noticed upon the head; motion,
inaugurated weeks before, is felt by the mother. Toward the end of the
sixth month, in the twenty-fourth week, the embryo is some 12 inches in
length. As has been before stated, with the cessation of the
development of individual organs and parts growth in size becomes more
rapid. As this was less in the earlier months, it is now very marked.
With the seventh month, as the foetus becomes viable, it is some 12 to
14 inches in length, weighing 2 to 3 pounds; the body is covered with
lanugo; the hair on the head becomes quite marked; the papular membrane
disappears.
It is well to bear in mind the leading features in the development of
the uterus, decidua, and the ovum, and more particularly its membranes,
as a guide in the treatment, that we may recognize the parts expelled
and know what remains to be removed--as an aid in diagnosis, that we
may properly judge the conditions, whether healthy or morbid, and
post-abortum, when we may be forced to determine by the corpus delicti,
as the all-important evidence in criminal cases, as to the duration of
pregnancy and the causes which led to its termination.
ETIOLOGY.--Causes of Abortion.--Interesting as the etiology of disease
is to the inquiring mind, to the progressive physician it is of great
practical importance as well; and this is eminently true of the causes
leading to abortion. More so of (A) spontaneous or accidental abortion,
though by no means to be neglected in (B) criminal abortion. Etiology
is important in both, as it is a knowledge of cause alone which can
lead to prevention, that most valuable of all methods of treatment, and
in criminal abortion to detection, thus indirectly to the prevention of
recurrence.
A. Accidental or Spontaneous Abortion, or Abortion as the Result of
Natural Causes.--The etiology of non-criminal abortion is indispensable
to the practitioner, as it is this alone which will enable him to
prevent its occurrence and recurrence, thus leading to the preservation
of the lives of mother and child, doing away with the danger and
suffering of actual treatment, and frequently serving as a guide in the
latter. We will meet with some difficulties in our endeavor to analyze
these causes, as they are so varied in their nature and differ so
greatly in the medium through which they act. There are causes
predisposing and exciting, local and general, internal and external,
and causes which depend upon father, {480} mother, and ovum. The direct
dependence of treatment upon the exciting causes seems to necessitate a
simple and practical delineation of the etiology of abortion. A direct
reference of the cause to the offending organ is understood most
readily, and will point most directly to the necessary measure of
relief; hence we will consider such causes as spring from or act
through mother and child--more properly, the maternal system and its
individual organs on the one hand, and the ovum and its parts upon the
other. We cannot, however, pass by these without giving a thought to
such causes to which great importance is attached by many, and which it
is best to consider separately.
Predisposing Causes.--Almost all abnormal conditions, whether
pertaining to the system or external to it, are more or less
predisposing causes, whilst direct exciting causes are few; they may or
may not be followed by the premature interruption of gestation; they
tend to death and expulsion of the ovum, making it likely to occur
whenever the exciting cause arises. We may say all those by which the
occurrence of abortion is favored are predisposing causes: they are
conditions under which we may expect its occurrence; and, knowing them,
it is the duty of the physician to guard his patient. The
classification is indefinite. Thus Naegele considers as predisposing
causes anæmia, congestion local and general of the maternal system,
neurotic influences; and as exciting causes--1st, those which tend to
sever the amnion from the surrounding uterine structures; 2d, those
which cause malnutrition, disease, and death of the embryo or foetus;
3d, those which directly arouse uterine contraction. Others consider
diseases acute and chronic on the part of the mother, local and
general, as well as diseases on the part of the father, predisposing
causes, whilst traumatism and neurotic influences are considered as
exciting causes. All are classifications based upon no strict
foundation. I wish, however, to call attention to certain conditions
which I look upon as predisposing to abortion: that is, a pregnant
woman while under the influence of such condition, such cause, is more
liable to abort upon the occurrence of some directly exciting cause.
The existence of one or more predisposing causes does not necessitate
abortion; pregnancy may continue without interruption if exposed to any
of the conditions which we will term as exciting causes.
First. Climate.--We find abortion, both accidental and criminal,
prevalent in certain countries and in certain districts, dependent upon
climate--in the deltas and valleys subject to malaria, upon barren soil
where food is wanting or where the work of woman is particularly
laborious.
Secondly. Number and character of the population: this mishap is most
common in large cities, where morals are lax, where the ill-fed poor
are crowded into tenement-houses and the rich live in the whirl of
social dissipation, or in thickly-settled regions where there is an
intermingling of sexes, where women are neglected and ill-fed. I may
here add an observation which truly shows the difference of locality.
Both Playfair and Philippeaux[3] claim that abortion is especially
prevalent in the country. This may be true of the rural districts of
England, France, and Germany, especially the latter military
government, where it is in the country that young, able-bodied women do
the hardest and most of the work, as is seen when passing through these
regions in harvest-time. In {481} America the very opposite is true, as
in the country here abortion is most rare.
[Footnote 3: _Annals Gynécologie_, 1881.]
Third. Certain periods in woman's life eminently predispose to
abortion. There are those important epochs in woman's life during which
her nervous system undergoes a severe strain wrought by those changes
which are all-important to her existence. These are, first, in early
married life, when intense hyperæsthesia exists due to changes wrought
in the sexual system: the young wife is, moreover, exposed to injurious
external influences, certain forms of traumatism; and secondly, toward
the approach of the menopause, as the activity of sexual function and
the uterine organ diminishes and the nervous system is undergoing those
changes with periods of intense neurotic excitement which accompany the
menopause. Finally, we may look upon the morbid conditions of the
system, all unfavorable changes in the surroundings, as predisposing
causes.
Exciting Causes.--We have seen that Naegele considers malnutrition and
all causes which lead to separation of the ovum from its surroundings,
and even uterine contractions, as exciting causes, whilst Spiegelborg
considers hemorrhage so much so that to him the history of hemorrhage
during gestation is the history of abortion. As exciting causes I
consider uterine contractions and such conditions as directly lead to
hemorrhage in the uterine or foetal membranes; but I cannot class
either as exciting causes direct and primarily, both being merely
sequents dependent upon some more remote cause. The varied importance
of predisposing and exciting causes will be best appreciated if we but
recollect the ordeals which a healthy woman may undergo--the direct
exciting causes which may act upon her--and yet abortion not occur,
provided no predisposing causes exist. Thus we have the
well-authenticated statement of a pregnant woman being run over, the
wheels of a physician's carriage passing directly over the abdomen, and
yet abortion not following. I myself know of the attempts of a husband
to produce abortion upon a willing wife by beating the abdomen, finally
stamping and sitting down upon it, and yet not succeeding. I have the
statement of a reliable physician as to the continuation of
intra-uterine application of iodine and astringents to the cavity of a
uterus supposed to be diseased, which proved to be pregnant, until the
fourth month, and yet abortion not following. We know how women with
criminal intent produce local injuries, even such as result in death,
whilst the ovum remains undisturbed. These are cases in which no
predisposing cause existed. On the other hand, the careless washing of
the feet in cold water, a single effort at the wash-tub, a rapid drive,
fright, a piece of bad news, coitus, the slightest nervous or physical
disturbance, may produce abortion where predisposing cause sufficient
does exist. We will here classify the exciting causes of abortion, in
reference to the consequent treatment and the possibility of
prevention, as maternal and foetal, dependent upon, acting by means of,
the maternal system and organs or those of the ovum. Those dependent
upon the mother are amenable to preventive treatment; not so those
dependent upon the ovum.
A. Causes of spontaneous or non-criminal abortion:
1. Causes due to pathological changes in the maternal system, general
and local. These are by far most important to the practitioner, as they
{482} are amenable to treatment. His attention should most especially
be directed to--
_a_. General causes acting through the system. These are--
(1) Diseases acute and chronic;
(2) Causes acting through the nervous system, neurotic;
(3) Physical or traumatic;
And (4) I shall classify what I might term social causes, such as
result from custom and fashion, which form an important element in the
etiology of abortion, and one more particularly open to and demanding
prevention.
_b_. Local causes on the part of the uterus and its adnexa.
2. Causes on the part of the ovum.
1. Causes Maternal.--These may be general or local. General causes,
arising either in the maternal system or exterior to it, but acting
upon it, may be either physical or nervous, arising from diseased
morbid conditions of the maternal system.
_a_. General causes acting through or resulting from changes within the
maternal system.
The premature interruption of pregnancy may frequently be traced to
disturbance of the maternal system or external influences which act
upon it, either directly by traumatism or indirectly through the
nervous system, and the uterus, hypersensitive in this state of intense
physiological activity, responds. It is the point of least resistance
to which the shock is conducted; as the electric current invariably
passes through the best conductor in a network of wires to the point of
greatest attraction, so shock follows the course of the uterine nerves,
at the time most tense, and the explosion follows in that organ.
(1) Disease, acute and chronic, on the part of mother and father
interferes with the nutrition and development of the ovum--on the part
of the father, through the semen; on the part of the mother, by
malnutrition of the growing germ.
Acute Diseases.--A vitiated condition of the blood, as well as the
increase of temperature, local and general, which accompanies
constitutional disturbance, affects nutrition and development of the
ovum. Zymotic infectious diseases, as well as those accompanied by
congestion of the pelvic viscera, are most liable to affect gestation:
the excessively high temperature of the nutrient fluid and of the
surrounding viscera, if not direct infection of the germ, leads to
death of the embryo and consequent abortion in the course of zymotic
disease. The localization of the morbid affection in the vicinity of
the uterus affects the existence of the embryo by reason of the
consequent congestion and irritation, as well as by depletion of the
system, as in dysentery; direct infection, as in variola or scarlatina.
This delicate existence is threatened in various ways by traumatic
injury, as may occur in eclampsia. Fortunately, abortion in the course
of disease is not the rule, but the exception, and usually accompanies
morbid conditions of the system only if most intense or if predisposing
causes exist; yet gestation is at all periods endangered by
intercurrent disease in the early as well as the later stages. It is in
the later stages only that the existence of direct infection can be
determined, and, though perhaps not common, well-authenticated cases
are recorded: I have myself delivered a mother, just recovering from a
severe case of {483} variola, of a seventh-month foetus covered with a
typical eruption. That abortion occurs in the course of malarial fever
is well known in the valleys and deltas of our great rivers, and it has
been most erroneously ascribed by some to the energetic medication
which is called for. If the disease attacks pregnant women, its
continuance, but not the medication, may lead to abortion: it is not
quinine given upon correct indications--it is the existing
disease--which causes the accident, and must hence be checked as
speedily as possible; it is the uterus which shelters the developing
ovum, congested, hyperæsthetic, which is at the time the centre of
physiological activity, and, we may say, the most sensitive portion of
the body, most easily affected by an accidentally existing disease, as
the non-pregnant woman, one more sensitive or feeble, always suffers
most during an accidentally existing disease in that organ which is
habitually most sensitive or weak or at the time under an unusual
strain; if throat, lungs, or heart is weakened, it is that part which
suffers most in the acme of malarial fever; if a woman is exposed to
cold during the menstrual period, the pelvic viscera will respond most
readily.
Chronic diseases affect growth and development of the ovum by reason of
malnutrition, local and general anæmia. As has before been stated, the
impregnation of even a healthy ovule by diseased semen or the semen of
a diseased father may result in morbid development, which sooner or
later ends in expulsion of the affected ovum. Of the diseases on the
part of the father it is more especially--and I may say almost
alone--syphilis which exerts a direct influence upon the ovum. Debility
of the system is more likely to result in sterility, whilst the ovum,
if impregnation takes place by such semen, remains healthy though
feeble, and the traces are indelibly marked upon the offspring. The use
of liquor, like the morphine habit, may lead to sterility, but not to
abortion; though the offspring of a phthisical father rarely escapes,
the disease is inherited, but does not develop during the early stages
of gestation, and does not affect the ovum in its growth.
Chronic diseases on the part of the mother would seem as if readily
leading to abortion, though the result is comparatively a rare one. The
diseased, badly-nourished, often anæmic system offers an unfavorable
nidus for the rapidly-developing ovum, which is so much in need of
healthy and abundant nutrition; but as the feeble, sickly mother often
has an abundance of healthy milk for the new-born child, a healthy
physiological activity seeming to exist in those parts in the time of
functional activity, so may the ovum find a sufficiency whilst other
parts are affected. The intense activity existing in the uterus
attracts an abundance of the circulating fluid; women low with chronic
diseases, phthisis, or cancerous growths, often in the last stages,
will bear children, yet they are fortunately not so free to conceive,
and if impregnation does occur the healthy growth of the ovum is soon
interrupted.
The causes which lead to an enfeebled condition of the system may lead
to abortion, whether it be an anæmia, the result of disease or lack of
food, of the mode of life, or the locality in which the sufferer
lives--of poisonous gases or poisons of other kinds slowly admitted to
the system. These poisons, however, whether acute or chronic in the
mother, may directly affect the foetus. Lead and noxious gases, like
the infection of variola or smallpox, are examples of the latter; more
rapidly-acting {484} poisons, like strychnia, opium, carbonic oxide
gas, and syphilis, of the former.
Death of the foetus and abortion may result as a consequence of
syphilis on the part of either father or mother, or of primary
infection during gestation, and are liable to occur at the same period
in successive pregnancies; if in the later stages of gestation, the
ovum, especially the foetus, bears its characteristic marks. The
effects of treatment and improvement are readily visible: abortion is
more and more delayed; if the afflicted parent but slowly improves,
abortion will occur at a later period during each subsequent gestation
until a foetus is carried to term, but stillborn--the next living,
perhaps, for a brief period. If vigorous treatment be applied in the
early stages, abortion may cease altogether. The results of disease can
be more readily seen in the foetus than in other parts of the ovum. The
gummata of the placenta, the syphilitic indurations, are difficult to
distinguish from other conditions, and appear only at later stages. The
syphilitic pemphigus, when occurring upon the foetus, is
characteristic, but the mucous membranes are most liable to show its
traces. The gummata in the large viscera are frequent, especially in
the lungs and liver; but most typical is the osteo-myelitis in the long
bones, between epiphysis and diaphysis, a pale-red line in the earlier
stages, resulting in a thickening of the parts at later periods.
(2) Causes acting through the Nervous System.--During pregnancy, that
stage of intense uterine activity, of gestation and increased growth,
we find an increased nervous excitability, motor and vaso-motor, the
nerves responding violently to slight causes which would arouse no
reaction during the normal condition. There is an increased reflex
activity which may lead to a disturbance in the circulation or in the
nutrition of the ovum, or to uterine contraction upon some slight
excitement. This condition varies exceedingly, the causes which excite
these reactions and the extent of the reaction excited differing
greatly in degree. Uterine hemorrhage, contractions, and expulsion of
the ovum in consequence of neurotic influences are more likely by far
to occur during the existence of predisposing causes. Fright, a nervous
shock of any kind which in no way affects healthy gestation in a
healthy woman, will result in abortion in a person afflicted with
uterine disease or in a system otherwise weakened.
The frequent occurrence of abortion in early married life and toward
the menopause is mainly referable to nervous influences. Marriage is a
period in woman's life comparable to puberty and the menopause--a
period of heightened nervous excitability: a change takes place in all
the modes of life, and, in addition to the many other causes which at
that time unite to interfere with conception, increased nervous
excitability is one of the most important, as it is toward the
climacterium. We shall consider this period more particularly under the
head of Social Causes. As the change of life is approached, the
activity of the sexual organs, their nutrition, the blood-supply, and
especially the healthy activity of the mucous membrane, are lessened,
and hence the growth of the ovum is endangered; but the condition of
the nervous system at this period certainly has an equally powerful
influence in producing the tendency to abortion. During this
hyperæsthesia an existing predisposing cause or some slight additional
excitement will arouse the vigorous action of the tensely-strung {485}
vaso-motor nerves; coitus even at these periods may be looked upon as
dangerous to continued gestation. It is not alone the traumatic
influences which must be considered, but the effect upon the nervous
system as well, especially the vaso-motor nerves, in the state of
intense excitement which accompanies the sexual orgasm. During these
periods of increased nervous tension during pregnancy coition is more
liable to produce abortion than at other times. It is in the coming
together of numerous causes that one more intense than the others,
though harmless alone, will be followed by sudden response.
Much has been said as to the injurious effect of coition during
pregnancy. Those who look to physical causes as mainly tending to
abortion claim the injurious effect to be purely physical, traumatic;
whilst others, and I believe more justly, claim that the influence is
strictly neurotic. Parvin says that coition is so frequent a cause that
he blames upon this half the cases which are termed spontaneous
abortions; certainly it has a most unfortunate effect, so that we
frequently see the expulsion of a healthy ovum from the second to the
fourth month in young women recently married, mainly in the higher
walks of life and among delicately organized women, who are more
intensely sensitive to the great change which they have undergone. I
have repeatedly had occasion to see these unfortunate cases, and almost
look for the occurrence of an abortion within the first six or eight
months after marriage in the bride of fashionable society. Though the
statement of Parvin may seem somewhat forcible, the fact is not to be
ignored: the ovum expelled in such an abortion gives evidence of being
of healthy growth, so that the cause must not be sought for in
malnutrition or local disease. The laws of many peoples are as strict
in regard to coition during pregnancy as they are about the care of
menstruating women: by some it is forbidden; among the ancient Mexicans
it was regulated, it being ordained that sexual intercourse should be
exercised to a moderate extent during pregnancy in order that the
healthy development might be furthered and strength given to the child.
The injurious effect of coition is everywhere acknowledged, and, I can
say, not unjustly. Total abstinence was looked upon by the Mexicans and
other peoples as likewise harmful.
The changes wrought in the nervous and physical condition of women
after marriage and toward the menopause are such that the menstrual
periodicity is interfered with, dysmenorrhoea sometimes existing, at
times menorrhagia, so that the expulsion of an ovum of from eight to
ten weeks is ignored, passing away with the clots of a profuse
menstrual flow: it is often not even known to the mother, being
considered by herself and family as merely a profuse flow; the
accompanying pains are often no greater than those of the dysmenorrhoea
common at such times; no precautious are taken, and thus the foundation
is often laid for uterine disease.
We know that the emotions--fright, fear, joy--may check the menstrual
flow or produce menorrhagia; in the gravid uterus hemorrhage may be
caused or contractions aroused, and abortion results. In a misled girl
or a young married woman the fear of pregnancy may frequently cause
cessation of the menstrual flow: the effect of the mind and nervous
system upon these organs is equally evident in the cessation of the
menses when pregnancy is longed for, though it does not exist: I have
even {486} known of the summoning of midwife and physician by an aged
bride with distended abdomen (gastric hystero-neurosis) who longed for
pregnancy and thought she felt uterine contraction and the inauguration
of labor. As the emotions affect the general health, the ovum may
likewise suffer as a part of the maternal system; but when they are
sudden, such as by fright or shock, the effect upon the vaso-motor
centres by reflex action is so forcible that the uterine vessels are
paralyzed, dilated, and hemorrhage follows; or a tetanic contraction of
the vessels may result, and then the nutrition of the embryo is
checked.