withdrawal of nutrition from the ovum, but in part to the contraction
of the uterus and its vessels, which may result as a reflex symptom
from the irritation of the nipples, and thus cause abortion. The
frequent occurrence of abortion upon ships at sea is due in part to
traumatic influence, the vomiting of sea-sickness; in part it is
neurotic, due to the changed mode of life, the leaving of a home by the
emigrant for foreign lands, just as the menstrual flow is stopped for
months and months in the immigrant girl upon her first arrival in a
strange country.
(3) Traumatic influences are comparatively rare as a cause of natural
spontaneous abortion; and it is true of these as of every other cause
that it depends upon existing conditions whether abortion will result
or not. The pounding of the belly is an ordinary method of producing
abortion among primitive peoples: a fall, a jump from a wagon, may
disturb the progress of gestation, while traumatism far more violent
may not affect it, as in the case of the woman in the later months of
pregnancy over whose abdomen the wheels of a physician's carriage
passed without causing any injury whatever.
In the earlier months, while the ovum is still sheltered in the pelvic
cavity, injuries are still less liable to cause abortion. I have myself
seen a pregnant woman severely bruised about the lower bowels and go to
term. I have been told by reliable physicians that local treatment of
uterine disease has been continued by reason of the non-cessation of
the menses to the third and fourth month, when pregnancy was
discovered, and yet abortion did not follow, though I regret to say
that quite a number of cases have come to my knowledge where the
treatment of supposed uterine disease, especially of uterine
tumor--pregnancy in fact--was suddenly terminated by the appearance of
the corpus delicti, a four or five months' embryo. The intensity of the
resistance is well illustrated in a case which it was my good fortune
to see in consultation, where the most brutal local treatment had been
resorted to for three or four months and abortion did not occur; the
patient had left her persecutor and travelled hundreds of miles to seek
treatment. The manipulations had been so violent as to produce metritis
and cellulitis, yet the growth of the ovum continued, as demonstrated
by the healthy foetus of five months which was at last expelled. I have
but recently examined a lady who has been treated locally for uterine
disease, and found her in the beginning of the third month of
pregnancy, so far undisturbed.
We may well place the uterine sound and applicator among the traumatic
causes. The physician himself, especially the gynecologist, has been
sought out by women to aid in relieving them from the product of
conception, and it is through sound or applicator that {487} he is
expected to accomplish the work. Among the many devices to which
women--and, I am sorry to say, those in the most fortunate
circumstances, in the best walks of life--resort to attain this end is
one which certainly shows knowledge and shrewd calculation, but most
villainous intent, which is not unfrequently practised, and against
which it is well for the physician to be on his guard. It is that of
forcing the attendant to uterine examination and treatment upon the
plea of disease, well knowing that the germ must thus be destroyed. The
woman calls upon a physician--in preference upon some specialist not
attending in her family--upon the plea of uterine suffering, well
knowing, either from personal experience or the gossip so common among
ladies, some of the more common symptoms of this disease--backache,
pains in the side, nervousness, weakness, menstrual suffering. She
relates her case; upon questioning states that the period is just
passed; and, though the examination may reveal nothing, though no
application may be made, she well knows the uterine sound will be used.
That is what she desires. If an application of iodine or nitrate of
silver follows, all the better. Though for reasons far more important
the physician should listen to the history of a patient with distrust,
and rely must thoroughly upon his own examination, this course is
especially indicated in gynecological cases without distinct sign of
disease; and these very cases again point to the importance of a
careful bimanual examination, and a resort to all other methods before
the sound is used; and that in case of an enlargement of the uterus,
discoloration of the cervix and vagina, we should under no
circumstances introduce an instrument into the cavity unless it is
established with absolute certainty that the congestion and increased
size are due to pathological and not physiological causes.
Social Causes.--I wish to call attention more particularly to some of
the abuses of modern life which not unfrequently interfere with
gestation. These exist among all classes of society, high and low:
among the poor they are unfortunately forced; among the wealthy they
are the result of devotion to fashion and society. As we have seen that
in the Old World abortion is common in the rural districts, it is an
evidence of hard labor, especially in the field, at the wash-tub, and
labor by which the abdomen is compressed, the abdominal muscles freely
exercised. It is not only physical labor, but exposure to cold and wet,
cold feet, which are to blame; in those more fortunately situated tight
lacing, dancing, and consequent colds have a like injurious influence.
I would again allude to the newly-married, who are so subject to the
lighter forms of traumatism, the always greater frequency of coition,
the congestion and mechanical insult, the bridal trip being especially
injurious. During this period of hyperæsthesia it is too great a strain
upon the body as well as upon the nervous system: the young husband,
unacquainted with woman's strength and needs, is always liable to judge
her powers by his own. Railroad travel, the fatigues of sight-seeing,
pleasures, theatre, and the dance, are all borne by the patient bride,
anxious to please the groom: upon returning home the cares of the new
house, excessive social duties, all combine to undermine the strength
of a delicate woman in her first gestation. Enfeebled, often depressed
by reason of gestation or nervous changes, excessive pleasures are
forced upon her by reason of her condition--_i.e._ bride--and abortion
follows; and, we {488} may say, follows in consequence of traumatism.
In other walks of life we find other conditions, still with the same
unfortunate developments--excessive labor and pleasure during this
period, when rest and care are so necessary. It is in young married
women partly the pleasures of society, partly the unaccustomed duties
imposed, which lead to injury. Ignorant of their condition, ignorant of
the care necessary, even when aware of injury unwilling to acknowledge
it, desiring to bear up, to show no weakness, they lay the foundation
of much future suffering. The cause of so much uterine and pelvic
disease in the unmarried, in the society girl, exists to the same
extent in the newly-married, only that the injuries caused are far
greater in the first period of married life, as the strain both of body
and mind is increased in this most susceptible condition.
Local Causes.--Though the local causes on the part of the mother which
lead to abortion, diseases of the uterus, especially of its mucous
membrane, are equally frequent and equally amenable to treatment, they
are of less practical interest to the general practitioner. Diseases of
the uterus itself are not so important etiologically as those of its
lining membrane: uterine tumors, unless of enormous size, usually admit
of the completion of gestation; flexions and versions rarely interfere
with the development of the ovum; a prolapsed uterus may bear the
foetus to term unless the adhesions are unyielding and impregnation is
impossible, because the uterus as it develops with the growth of the
ovum rises beyond the confines of the pelvic cavity, and the
displacement is thus remedied. Anteflexions and anteversions are always
rectified; retroversions in rare cases only lead to abortion; adherent
retroflexions are most to be dreaded; when the uterine body, bound down
to the pelvic floor, expands within the cavity to such a size as to
make escape through the brim impossible, abortion must necessarily
follow. Deep lacerations of the cervix make conception improbable and
interfere with gestation; cervical catarrh in no way affects its
progress. Those morbid conditions of the uterine tissues which are
unaccompanied by disease of its mucous membrane rarely lead to
abortion.
Uterine contractions due to reflex nervous excitability are perhaps the
most common of all these causes, yet here the uterus primarily is not
at fault. A state of intense excitability is very often due to general
causes, to intense febrile action, to congestion or anæmia; high or low
temperature, whether due to external or internal causes, and irritation
of the surrounding parts,--all of which conditions tend to increased
contractility. Such diseases of the uterus as cause induration of the
walls may lead to abortion, like the incarceration of the organ in the
pelvic cavity, by reason of prevented distension.
Uterine Mucosa, Decidua.--Of far greater consequence than the
conditions existing in the muscular tissue of the uterine wall upon the
vitality and development of the ovum are those of the uterine mucosa in
its state of physiological hypertrophy as the decidua of pregnancy.
This soft, succulent tissue, rich in lymphatics and blood-vessels, is
the nidus in which the ovum rests, its immediate protecting shelter,
and the source from which nutrition is derived; hence morbid changes of
this structure react promptly and forcibly upon the ovum--most so in
the earliest stages, when it is altogether dependent upon this
structure; less so as gestation progresses. As the ovum grows it
becomes more resistant, its {489} tissues more dense, and the source of
nourishment is gradually changed to the large uterine sinuses at the
placental site. Moreover, the decidua after the third and fourth month,
when it has served its term, performed its function, gradually
diminishes in thickness, until toward term retrograde metamorphosis is
initiated preparatory to the expulsion of this structure, at that time
merely forming a line of demarcation in the lax meshwork in its lower
layer between the healthy tissue which remains and those structures
which are passed off in labor. An inactivity of the mucous membrane, an
imperfect development of the deciduous structure due to disease of the
mucosa, is a frequent source of abortion. In chronic disease of the
uterus or its lining membrane this rapid and healthy development of the
decidua after conception is prevented, the delicate membranes of the
ovum do not absorb the necessary nutrition, the development of the
embryo is checked, morbid conditions of the ovum follow, and abortion
results, especially at that time of active development, the period of
placental formation. The decidua vera is the least important part of
this structure, serving nutritive purposes only in the very first weeks
at the site of placental formation, and sheltering the delicate ovum in
the nest formed by its soft tissue: it is the decidua serotina, and
especially that membrane which holds the ovum in place, the decidua
reflexa, which claims attention. But morbid conditions of the vera, the
greater part of the mucous membrane, are naturally accompanied by
imperfect development of serotina and reflexa, and hence the imperfect
imbedding and nutrition of the ovum.
Hypertrophy or excessive morbid development of the decidua may
accompany acute infectious diseases, as we find similar conditions in
other organs of the body, especially in the larger viscera. These
changes, morbid in their character, interfere with development as do
the atrophic forms. These hypertrophies may, however, exist independent
in their nature, due to local disease of the uterus and its parts, as
in chronic endometritis, where in place of the succulent deciduous
structure we find an induration and a proliferation of the active
tissue usually throughout the entire membrane, rarely localized, of a
polypoid form: the chronic catarrhal affections are accompanied by an
increase of secretion, morbid in character, which is liable to
interfere with the development of the germ. Moreover, hemorrhage more
readily occurs under these pathological conditions, usually secondary
in character, brought about by minor insults, trivial causes, which
would not affect healthy tissues. These hemorrhages, all-important in
the early stages, affect development less and less as gestation
advances, the importance of the decidua lessening and its functions
being superseded. Where a slight extravasation of blood within the
deciduous structure may lead to separation and expulsion of the ovum in
the first and second months, larger hemorrhages are often without
consequence when occurring within the same tissues in the fifth or
sixth.
2. The Ovum.--Pathological changes of the ovum itself, of the embryo,
of the surrounding membranes are less frequent as primary causes of
abortion, and they are of less importance to the practitioner as being
in no way amenable to treatment. When they do occur they usually lead
to expulsion in the earlier months.
Those conditions liable to lead to abortion are especially diseases of
the {490} chorion, placenta, and umbilical cord, rarely of the amnion,
the embryo itself, or the amniotic fluid.
Chorion and Placenta.--The chorion being the nutritive organ, supplying
the means of communication between mother and child in the earlier
stages by the villi over its entire surface, later by the placenta,
must necessarily determine the progress or cessation of foetal
development by the conditions existing within its own tissues. One of
the most striking and notable changes to which it is subject is the
hydatiform degeneration of the villi, leading to a formation of the
grape mole or hydatiform mole. This is a cystic degeneration of the
terminal sprouts, an hypertrophy of the germinal tissue, the young
connective-tissue cells, which usually begins at a very early stage:
the vascular development is interfered with, the nutritive material is
directed to the morbid activity of the chorion, which in its exuberant
growth, usually inaugurated in the first weeks, destroys that of the
other structures; the delicate tissues of the embryo are soon absorbed,
and even the amniotic sac may disappear, the within-lying cavity, which
always remains in every malformation as an unmistakable trace of the
ovum--a characteristic which serves at once to mark the product of
conception. A mole of this kind usually attains the size of an apple,
but may grow to that of a child's head, and the period to which it is
carried is much longer than that of the mola carnosa--usually five to
seven months, sometimes eight or ten. The appearance is that of a
conglomeration of cysts, usually the size of a currant or gooseberry,
though they are often from that of a pinhead upward, connected
everywhere by thin connective-tissue strands; they consist of a
delicate transparent membrane enclosing a pale, colorless fluid: in the
earlier stages the amnion with its cavity remains, but with the
development of the growth that is destroyed, and the appearance of the
hydatiform mole as a product of conception even becomes unrecognizable
when no longer surrounded by the decidua; as in cases of excessive
development, the morbidly-enlarged villi may even break through the
decidua vera in their growth, and we find a dense mass consisting of a
conglomerate of small cysts united by connective-tissue shreds enclosed
in the cavity of the uterus.
Hemorrhage.--In the third or fourth month, at the time of most active
development of the villi at the placental site, primary hemorrhage may
occur, due to the active vascular development, and thus lead to
abortion, but this is rare; frequent as hemorrhage is, it is almost
invariably to be traced to some cause.
The Placenta.--In later stages, when the greater part of the chorion
appears as a more firm, non-vascular membrane, that part which in
connection with the decidua serotina is developed to the placental
formation is the most vulnerable point, as it is the connecting link
between the foetus and the maternal tissues, and the one source of
nutrition. Hemorrhage in this structure, whether in its maternal or
foetal portion, if excessive, must lead to a cessation of development,
to abortion. Slight hemorrhages, such as must have proved fatal in the
earlier stages, no longer interfere with the growth of the ovum, but
are absorbed or remain as small hemorrhagic spots, the tufts or
cotyledons in which they have occurred appearing as a hard whitish mass
of connective tissue. If the hemorrhage is more profuse or widespread,
it may lead to abortion directly or to inanition--to death of the
foetus, and secondarily to {491} abortion. Inflammation may occur
throughout the entire placental site or localized, as in all other
points in the connective tissue of the structure, accompanied by
vascular development in the first place, followed by induration and
shrinkage; frequently remaining as small irregular or conical
indurations between the villi or cotyledons, leading to abortion,
either by the tendency to hemorrhage thereby excited or the death of
the foetus if sufficient of the tissue is destroyed to cause inanition.
Fatty degeneration occasionally results in consequence of insufficient
nutrition due to hemorrhage, or after death of the foetus preparatory
to premature expulsion--a morbid approximation to the condition upon
its maternal surface and in the decidua serotina at term.
Syphilis.--The changes in the chorion and placental tissue accompanying
syphilitic disease are rarely the direct cause of abortion or premature
expulsion of the ovum; as a rule, they are mere local manifestations of
the morbid condition existing in all the foetal structures, and
frequently in those of the mother. In the early months, during the
period of the chorion frondosum, abortion results from insufficiency of
the nutriment absorbed by the indurated villi of the chorion, lacking
in vascularity and in succulent embryonic tissue; the structures are
more dense, the villi hypertrophied, in the more aggravated cases the
vessels entirely obliterated, whilst after the formation of the
placenta in later months the existence of syphilis is made evident by
appearances similar to those which accompany other chronic inflammatory
conditions. The appearance presented by a syphilitic placenta is
usually that of cellular hypertrophy, the centre in a state of whitish
induration or fatty degeneration according to the stage of the disease.
But it is hardly possible to diagnose syphilis with certainty from the
appearance of the placenta alone, nor is the placenta usually affected
to such an extent as to appear as the prime cause of foetal death. The
placenta is usually large as compared to the size of the child, in
appearance similar to other inflammatory conditions presented by the
placenta, the growth of the foetus being interfered with, whilst that
of the placental structure continues until the retrograde metamorphosis
is sufficient to result in expulsion. The placenta in a syphilitic
foetus is larger than ordinary, 1 to 4, whilst usually 1 to 6. Gummata
are rare, so also tumors of the placenta. A myxoma developing from the
embryonic tissue is occasionally found. If the foetal portion of the
placenta alone is affected, or in the earlier stages the chorion and
the decidua healthy, we may with safety infer syphilis on the part of
the father alone previous to impregnation.
The Amnion.--The amnion, which serves merely as a container for the
preserving fluid, is wanting in vascularity, and consequently but
little subject to morbid changes. The only pathological condition which
we find in this structure is an inflammatory development, the formation
of amniotic bands stretching across this delicate sheath or from some
portion of it to the foetus, crippling or cutting its membranes in such
a way as to interfere with gestation. Nor does an abundance or want of
amniotic fluid affect the development of the embryo or ovum during the
earlier stages. It is no more a cause of abortion than the slight
changes occasionally found in the amnion itself.
The Umbilical Cord.--The navel-string, however--the sheath stretching
from amnion to foetus, enclosing the umbilical vessels--is subject to
quite {492} a number of changes, frequently the cause of abortion,
occasionally mere results of other complications. Excessive or
insufficient length of the cord, which may seriously complicate labor
at term, in no way affects the development of the ovum; in the third or
fourth month the length of the cord is naturally much greater than that
of the embryo, and the resulting coils and knots seem in no way to
endanger its existence. Knotting of the navel-string may lead to death
of the foetus, but only in the last months, rarely at earlier periods.
Stenosis of one or the other of the vessels sometimes occurs, leading
to the death of the embryo and consequent abortion: a condition which I
have found remarkably frequent is that of torsion of a very long and
thin cord in the third and fourth months; but this torsion of the cord
seems so frequent in abortion that it must appear as a consequence,
movement of the dead foetus apparently leading to a twisting during
inactivity of the tissue. A very striking condition of the cord has
frequently attracted my attention--lack of embryonic tissue, the
gelatin of Wharton, with excessive torsion; the cord flat, thin, in
parts thread-like, and usually very much twisted; the embryo retarded
in development as compared to the size of the ovum, no other cause
being at the same time discernible, neither disease of the uterus nor
affection of the system. The torsion is secondary, often wanting, the
cord being very thin and thread-like in places, consisting of the
amniotic sheath and the vessels, obliterated entirely or in part.
Torsion I believe to be secondary, as I have noticed these excessively
twisted cords otherwise healthy in cases of abortion; but this peculiar
state, which I cannot term otherwise than atrophy of the cord, appears
as a frequent primary cause of abortion in the second to the fourth
month; torsion and knots may occur at later periods. Ruge of Berlin,[4]
who has investigated this subject, thinks that stenosis of the cord in
the vicinity of the umbilical insertion is rarely the primary cause of
abortion, though often a secondary, resulting from motion and traction
on the inactive, dead vessels; whilst Leopold seems to look upon it as
the primary cause.
[Footnote 4: _Zeitschrift für Gynäcol. u. Geburtsh._, vol. i. 1, p.
57.]