lead to abortion, but it is almost impossible to place an estimate upon
their relative importance. Whilst uterine contractions, hemorrhage, and
abortion may result in one case from a slight nervous excitement, a
trifling annoyance, the most violent nervous irritation will in no way
affect another; whilst a fall, a jump from a buggy, may lead to a
mishap in one patient, the crushing of the abdomen beneath its wheels
will not affect another; a trifling fever may appear as the cause in
one, and again the most severe pneumonia or typhoid condition will not
impair development in another; the child may be carried to term by a
mother in the last stages of consumption, whilst a very trifling
affection may lead to abortion at other times. So it is with remedies
taken internally, though as a rule they have but little effect: a
violent aperient may cause abortion, and again, as in one instance
which I recall, a woman in the fourth month of pregnancy died rapidly
of dysentery resulting from the taking of cathartic pills to produce
abortion, and the post-mortem revealed a perfectly healthy ovum in a
healthy uterus, whilst the dysentery consequent upon the remedy killed
the mother. The careful introduction of a sound into the gravid uterus
has led to a separation of the ovum, to hemorrhage, {493} and to
abortion, whilst a knitting-needle has been passed into the uterine
cavity and through the womb, causing the death of the criminal mother,
without in any way disturbing the ovum. The uterus has been regularly
treated for supposed disease for three and five months by internal
applications, and gestation has progressed. So it is with all these
cases: at one time, especially with pre-existing disposition, a slight
interference may result in the cessation of development, and at another
the most violent insults in no way disturb gestation.
B. Causes of Criminal Abortion.--The causes proper of criminal abortion
are immorality among all classes, high and low--among the wealthy
fashion, the pleasures of society, and the desire to limit the number
of children--a common cause, strange to say, mostly among those very
people who can actually afford the expense. The cause direct, the means
by which the crime is accomplished, should be known to the practitioner
in order that he may detect the deception which is so frequently
practised upon him--that he may prevent it if possible, and at least
not, by reason of ignorance, be made particeps criminis.
The means resorted to are either external or internal, traumatic and
instrumental, or by medication.
Traumatic.--When produced by the patient herself it is either by
violent exercise, running up and down stairs, walking and dancing,
occasionally by pressure upon the abdomen or by the use of the
knitting-needle, catheter, or similar instrument. The more expert or
daring only attempt to enter the uterine cavity, as the organ itself
may be pierced; if the catheter is successfully introduced, the
attachment of the ovum is severed, and with the knitting-needle the sac
is punctured.
These attempts are usually made in the second or third month at the
second or third missed period. There is, however, a class of experts
among the most elegant who have attained such remarkable dexterity as
invariably to introduce the instrument successfully into the uterine
cavity; and these are in the habit of regularly practising this
dangerous experiment when the first days of the expected period have
passed without the coming of the flow.
The abortionist either injects fluid into the uterus or introduces a
probe or catheter into the cavity. Customs vary in different countries;
so Van de Warker states that in France puncture of the membranes is
fashionable, whilst here a syringe or sound is used.
Among the most common--and perhaps most harmless--means is the hot
foot- and hip-bath, the "sitz-bath," often with the addition of
mustard: this, as well as the steaming of the parts by sitting over a
chamber filled with hot chamomile tea, is the first step taken by the
nervous wife when the menstrual flow has failed to appear sharp on time
and she still lives in hopes that it is but a cold which has interfered
with the regularity of its return. Even physicians, respectable men in
good practice, who may not venture upon bolder measures and wish to
keep their conscience clear, are known to advocate this course, though
they well know what such a cold means.
Medication is perhaps more commonly attempted, but less successfully,
notwithstanding the injuries caused to the system. To follow Van de
Warker's thorough study, the remedies used are mainly of two
classes--those which act directly, the emmenagogues, oxytoxics, and
reflex {494} abortifacients. Notwithstanding the firm popular belief in
their efficiency, they are less harmful to the ovum than to the system
of the mother, and, as Van Warker says, there is more science and skill
used than is generally supposed in the various pills and teas, which
are less simple, but no less common, than the foot-baths and the
gin-bottle. Ergot is almost sure to be called upon to perform its
office. Its action is very uncertain, but if persistently used is
readily recognized by its effect upon the vascular and nervous
system--uterine or ovarian pains and depressed action of the heart
where in spontaneous abortion an acceleration is to be expected; the
temperature is lowered, and the sphygmograph shows a remarkably
flattened apex with an almost senile pulse. Cotton-root is also
commonly used, especially in the South, and is marked by its narcotic
action.
Among those termed reflex abortifacients, acting more indirectly by
their effect upon surrounding organs, we may notice cathartics,
principal among them aloes, which, notwithstanding its purgative
action, does not appear to deplete the circulation, but, on the
contrary, results in pelvic congestion; but even its excessive use need
not in any way affect gestation. I have seen a patient dying amid the
resulting dysenteric symptoms, frequent, scanty, and bloody
evacuations, accompanied by excessive tenesmus, inflammatory
conditions, and abdominal pain, though the uterus did not react and the
ovum remained intact. The odor of the drug is imparted, it is said, so
intensely to the evacuations that it is unmistakably noticed.
Juniper and black hellebore, the latter especially endangering the life
of the patient, are both toxic in their effects. The painful fluid
evacuations, accompanied by bearing down, tenderness of the abdomen,
pain and sickness at the stomach, dry throat, would characterize the
former; the odor the latter, as well as the flushed appearance of the
face, with heaviness and pain in the head and frequent micturition. But
one of the first and most common remedies to which the desperate woman
resorts when she finds a day of the menstrual period passing by without
the appearance of the flow is tansy, which seems to act by reason of
the uterine congestion which it causes. Though undoubtedly effective at
times, it will, like all other drugs thus used, more often cause
injury, and even the death of the mother, without disturbing gestation.
"Disturbance of the nervous system, profuse salivation, immobility and
dilatation of the pupils, and severe strangury," are noted as the
symptoms of such poisoning. Hardly less popular is the still more
dangerous cantharides.
The female pills and various mixtures more or less openly sold by
druggists are, according to the researches of Van de Warker, composed
of one or more of the above-mentioned ingredients, and the immense
quantities disposed of show how truly abortion is called the crime of
the period. Knowledge of the remedies used for these purposes will aid
the physician in arriving at a correct diagnosis and enable him to save
the child and guard his patient.
PATHOLOGY AND MORBID ANATOMY.--I have endeavored to describe with some
accuracy the appearance of the healthy ovum, the sac, and surrounding
structures during the various periods of early pregnancy, as it is the
comparison with these which will enable the practitioner to distinguish
between spontaneous and criminal abortion, enable him to determine the
duration of pregnancy, guide him as to the cause, and thus serve to
{495} facilitate treatment and perhaps to prevent recurrence. Knowing
what has been expelled, whether it is ovum and decidua entire or only
in part, the line of action is evident. In all abortions due to an
immediate and active exciting cause, whether criminal or resulting from
shock or accidental trauma, the ovum is healthy, normal in all its
parts, size and development of the embryo corresponding to the period
of pregnancy at which the accident occurred; whilst in spontaneous
abortions due to accidental causes more or less marked changes exist:
the development of the embryo especially is retarded; its life has been
destroyed, and growth has ceased, whilst the morbid development of the
membranes continues, so that the mass expelled presents more or less of
a mole formation--comparatively solid, with thick walls formed by the
foetal membranes infiltrated with blood, the cavity often compressed by
the surrounding extravasation, the embryo comparatively small or
disintegrated in whole or in part.
The ovum is usually separated in its upper portion by hemorrhage, which
comes from that point at which the vessels are most fully developed,
the future placental site, though still agglutinated. With the
inauguration of uterine contractions separation takes place at its
lower pole by dilatation of the os, and retraction of the uterine walls
from the ovum proper surrounded by the reflexa; as the abortion
progresses, the muscular fibres of the fundus force it down into the
dilating cervix through the still partially adherent decidua, and the
intact ovum is expelled, the inverted decidua following it as the
membranes do the placenta in labor at term. Yet these conditions vary
greatly with the existing morbid changes.
In traumatic or criminal abortion the perfectly-formed ovum, the
delicate cystic body surrounded by its shaggy chorion, is first
expelled, to be followed by the decidua, usually--when in a healthy
state--first by its anterior and then by its posterior half; whilst if
the abortion has been inaugurated by some slowly-acting cause the
decidua is hardened, infiltrated with compressed and clotted blood, the
small ovum forming merely a part of the solid mass; and thus a firm
oval body, coated with blood upon its rough, irregular exterior,
appears.
Up to the third month the ovum is, as a rule, expelled as a whole,
often even in the fourth. Later, unless decided pathological changes
have taken place, the membranes are mostly ruptured and the embryo
separately expelled, as in labor at term. In later months this is
always the case, and the progress of abortion is greatly impaired by
the adherent tissues: the mass of the ovum, which serves so much to
excite uterine contractions and promote expulsion, is destroyed by the
collapse of the amniotic sac, and separation and expulsion of the
membranes are hindered by reason of the smaller amount of resistance
offered. Hemorrhage is most likely to occur in the villi of the
chorion, between its tissues and the surrounding decidua; if occurring
in the latter structure, it appears thick, hard, infiltrated with
blood, and no longer presents that soft, succulent appearance, but is
firm and brittle.
The ovum as expelled presents three typical forms: First, as above
stated, in accidentally-occurring traumatic or criminal abortion we
find a healthy ovum with its shaggy chorion, and the inverted decidua
attached or soon following, usually in two sections; most common,
however, and almost without exception in spontaneous non-criminal
abortion, is the {496} mole formation, rarely the hydatiform mole,
which has been described, and results only from the peculiar
pathological condition of the chorion. The common form is the flesh
mole, the mola carnosa, characteristic in appearance, resembling a
polypoid growth, a reddish oval or rather pyriform mass with shreds of
tissue (the decidua) adherent to its larger upper extremity, darker
clots at the elongated lower pole. Upon section the walls show a
brittle reddish structure, that of compressed and inspissated coagula,
and in the centre a cavity containing fluid and detritus, if not the
embryo, lined with a delicate membrane, amnion or amnion and chorion:
the shape of the cavity is rather irregular by reason of the bulging
protuberances formed by the contraction of the inspissated mass of
blood extravasated between or within the tissues. These moles have very
much the appearance of uterine polypi, and are often considered as such
by physicians who pride themselves greatly upon curing their patients
of tumors and the accompanying hemorrhage by a few doses of ergot.
Though the macroscopic resemblance is such as to be quite deceptive,
the mole upon section will always reveal a cavity, even if very small,
containing fluid; and this cavity reveals the above-described
characteristic slight bulging protuberances lined with a delicate
membrane; whilst the microscopic examination shows the firm walls to
consist of nothing but blood-corpuscles: the outer covering, often
thoroughly infiltrated with blood, consists of the decidua serotina and
reflexa, with more or less of the infiltrated shreds of the vera
usually pendent from its upper extremity; when floated in water and
cleansed, the outer or uterine surface of these shreds is ragged,
rough, often appearing somewhat like the villi of the chorion, hence
looked upon as placenta; this peculiar appearance is caused by the torn
tissue in the line of demarcation in the lower or central meshy layer
of the decidua vera, where it is separated from the lowest layer which
remains adherent to the uterine wall. The inner surface toward the ovum
will show a slightly wavy, cribriform appearance, the openings of the
ducts appearing as fine depressions in the surface. (It must be
remembered that this smooth inner surface is in the expelled specimen
generally the outer one, as the decidua follows the ovum mostly as the
membranes do the placenta at term--inverted.) If the disturbance
causing the abortion has been of rapid progress, the cavity is large,
the embryo approximating in development the period of expulsion; whilst
if the changes have taken place slowly, the walls are thick, the cavity
small, and the embryo may appear merely as a small mass pendent from
the navel-string, or may have entirely disappeared, and can be traced
only by the fine detritus in the amniotic fluid, the cord itself
perhaps only in part remaining, and even this may have disappeared. The
cavity will always be found toward the pendent pole of the decidua
reflexa, as the extravasation takes place mainly in the serotina,
giving it the appearance of a thick mass of clotted, compressed blood,
and forcing the cavity toward the opposite extremity. These moles are
usually more elongated and pyriform, one or two inches in diameter at
their upper or larger extremity, three or four inches in length, with a
greatly elongated and narrowed lower end, which has been so formed by
being first wedged into the slowly-distending cervix.
Such is the appearance in those cases of slow progress in which death
of the embryo has probably occurred at an early stage and hemorrhage
{497} has been the exciting factor, whether due to disease of the
mother or other causes that may have destroyed the vitality of the
germ. When resulting from disease of the mucous membrane, especially
endometritis or catarrhal affections, it is a more oval tough mass, the
main part of which is formed by the thickened and indurated vera; and
if this be opened the ovum, in a very early stage of development, will
be found within.
The uterus itself presents very much the appearance of the organ after
labor; the external os, however, closes more rapidly, less rarely
showing the funnel-shaped appearance of the puerperium; the cervix,
though somewhat enlarged, is normal in appearance; the cavity is lined
by the lower layer of the decidua, soft shreds covered with coagula;
but it is lacking in the placental site and the putrid thrombi visible
in labor at term.
Involution is slow if we take into consideration the slight distension
of the uterus as compared to the process after delivery at term. The
organ is in a state of healthy development, not prepared for the
following retrograde metamorphosis, unless the expulsion of the ovum
has been due to local disease, when some retrograde changes may have
been inaugurated; if it results from constitutional causes, the
existing depression naturally interferes with restitution. If shreds of
tissue, parts of ovum, or decidua remain, absorption or expulsion is
retarded. As a morbid or atonic condition so often exists, at least in
abortion consequent upon natural causes, subinvolution or inflammatory
conditions of the organ itself or the surrounding tissues are hence a
frequent sequence.
SYMPTOMATOLOGY.--It will be remembered that abortion is more likely to
occur among multigravidæ on account of the greater frequency of
disease, especially pelvic affections; that it is most likely to
accompany the periodic congestion which recurs at the time of expected
menstruation; that it is more frequent in early married life, on
account of the greater liability to traumatic injury and the existing
nervous disturbance, and toward the menopause in that state of nervous
and physical disturbance and lessening uterine activity. The third or
fourth month of gestation is the dangerous period, as it is one of
change of nutrition for the ovum, of the highest development of the
decidua, and intense activity and congestion of the chorion, the
rapidly-sprouting vessels finding but little resistance in the
embryonic structures of the villi which surround them. Chronic disease
of the mother is more likely to interfere with gestation at a later
period; and, when knowingly undertaken with criminal intent, the time
of choice is either the first month, when the first indications of
pregnancy become evident and the menstrual period does not appear at
the usual time, or more commonly at the time for reappearance of the
third menstrual flow, when the fact of conception has been established
to a certainty, and the conscious mother, firm in the belief of the
nonviability of the embryo before the fourth month, thinks it harmless
to rid herself of the ovum, which she considers a mere growth without
life or soul, while she would shrink from destroying what, at a later
period, she calls a living being.
SYMPTOMS AND COURSE OF ABORTION.--General Remarks: Preliminary
Symptoms.--1. Course of early abortion, first two months.
2. Abortion at the time most common, the third or fourth month: _a_,
spontaneous; _b_, criminal and traumatic.
{498} 3. Later abortion--in the fifth and sixth months--and hydatiform
mole.
The expulsion of the ovum during all periods of pregnancy is
characterized by two inevitable symptoms--hemorrhage and pain. It is
the time of appearance as well as the relative intensity of these
symptoms by which the period of gestation at which the expulsion takes
place is at once indicated. In early abortion the hemorrhage is
excessive and precedes the pain, the pain being comparatively slight;
in labor at term pain is the prominent symptom and precedes the
comparatively slight hemorrhage, which does not appear until the pain
has almost ceased, and labor is completed after the expulsion of the
placenta. Expulsion of the ovum in intervening periods is marked by an
approximation of symptoms, though the existing conditions which
characterize individual cases greatly modify this typical course.
I have, for the sake of conveniently grouping the symptoms, accepted
three periods which serve well to characterize the course which
abortion is wont to take in the progressive months of pregnancy.
Hemorrhage and pain are the never-failing symptoms--hemorrhage due to
the separation of the membranes; pain in the earlier months is due to
the dilatation of the rigid, unprepared cervix, which greatly
preponderates over the pain which accompanies the expulsion of the
comparatively small mass through the once-dilated passage. In the later
months, the cervix being gradually prepared, the pain is almost
altogether due to the increased effort which is necessary to expel the
large mass of the ovum.
1. Early Abortion.--In the first and second months the ovum is small,
the vascular development trifling; the decidua preponderates, being
greatest in mass and in extent of its vessels; hence this is the most
important part. The hemorrhage is considerable, due to the separation
of the vascular and hypertrophied mucous membrane, the decidua. The
ovum is very small and expelled with comparatively slight pain, the
symptoms often resembling those of membranous dysmenorrhoea; no great
dilatation of the os is even necessary.
2. In the third and fourth month, the period at which abortion both
spontaneous and criminal is most common, the placental formation is
inaugurated by the growth of the vascular tufts of the chorion; and it
is now that the ovum in toto--or we may perhaps say the membranes, as
they are by far the greater part of the ovum--assumes the most
important rôle. The abortion is still inaugurated by hemorrhage due to
the separation of the vessels, but the pain is greater, as the cervix
must dilate more to admit the passage of this larger mass, and an
expulsive effort as well is necessary to force the mass out. The
greatest amount of pain is caused by the dilatation of the rigid,
unyielding cervix, which fortunately remains in this undilatable state
until after the period of viability of the foetus, and serves to a
great extent as a check upon its more frequent expulsion.
3. Late Abortions.--Now the ovum and foetus are of pre-eminent
importance; though the parts are still unprepared, hemorrhage continues
to be the preliminary symptom, yet pain follows rapidly upon the
inaugural flow, because the ovum is now so large that it cannot descend
without dilatation: it must have advanced before abortion can progress
to any extent, and the expulsive pains assume greater prominence on
account of {499} the increased size of the ovum; the symptoms of labor
at term are approximated, and, as the placental formation is developed
in the sixth month, pains may at times precede, certainly rapidly
follow upon, the preliminary hemorrhage. It is now the placenta which
plays the most important part, as in labor at term it is the foetus
which is all-determining, upon which all the efforts of expulsion are
centred; the membranes, amnion and chorion, are secondary, and the
decidua, which was so important a feature in the first months, has by
this time entirely disappeared as a factor in the act. The remaining
shreds are partially adherent to the ovum, and in part passed slowly
off with the lochial flow. Thus we see how the symptoms, at extreme
periods so varying, approximate and interlace, and the various organs
gradually yield in importance to newly-developing structures.
In the first period, then, the decidua is all-important, whilst the
small and yielding ovum causes but little disturbance, not to mention
the embryo. In the second period the membranes of the ovum are more
important, and together form what is most erroneously termed the
placenta in abortion. Then, as the placenta develops, this with the
membranes predominates; finally, in labor at term the decidua, first
all-important, has vanished as a factor of consequence, and the embryo,
in the first stage a minimum, assumes such dimensions as to concentrate
upon itself every effort of the obstetrician.
Pain, especially in the earlier months, is liable to be more excessive
in primigravidæ, as the external os is closed, the cervix rigid, the
time necessary for the expulsion of the ovum greater. In multigravidæ,
with ordinarily more yielding and relaxed cervical tissues, the effort
of the uterine muscle is concentrated upon the expulsion of the ovum
from the cavity proper; and when it once passes the internal os a path
is opened, and little or no force but that of gravity is often
necessary to complete expulsion, whilst the cervical canal and external
os offer formidable opposition in primigravidæ to the forcing out of
the ovum, even though it has passed the os internum. A wide range of
varying conditions naturally exists, due to the very different states
of the cervical tissues: they may be relaxed in primigravidæ or firm
and unyielding in multigravidæ, though the opposite is true in typical
cases.