79. Causes of spontaneous abortion.-The causes of spontaneous abortion may be looked for in the father in some cases; usually where he has some chronic disease, or chronic intoxication. In the mother, similarly, the chronic diseases lead to abortion, but many other causes also play an important part. All sicknesses of the mother increase the liability to abortion in proportion to the severity of the infection. And the local pelvic conditions are even more significant; especially disease, or displacement, or malformation of the uterus. Moreover, there are a certain number of cases where abortion comes on after such slight cause that they have been designated as due to an "irritable uterus." In that class are included the cases in which abortion follows some most inadequate cause. Brouardel2 refers to two such cases in the practice of M. Tarnier, one of the most distinguished obstetricians of France, where a simple pelvic examination unintentionally produced abortion. Additional causes of abortion must be sought in the fetus and its membranes; its disease or maldevelopment or malposition. Death of the fetus is always expected to be followed by its expulsion. 80. Signs of spontaneous abortion. The signs of a spontaneous abortion are, first, those of the cause of the abortion; and second, those of recent delivery, as detailed in chapter II., on the DIAGNOSIS OF PREVIOUS PREGNANCY.3 81. Causes of induced abortion, in general.-In the cases of induced abortion we have three classes of causes: 1, drugs; 2, general mechanical means; and 3, local mechanical means. 82. Use of drugs in general.— Many drugs have been used for the production of abortion, but practically all without success. Only one or two have produced the abortion without causing the death of the woman from the effects of the drug. Those generally used belong to the classes of irritants, purges, or emmenagogues. 83. Irritants. Of the irritants cantharides is the only one much used, and its effect on the uterus is probably merely secondary to its irritation of the entire genito-urinary tract. 84. Purges. Of the purges, those having a drastic effect, such as aloes, jalap, croton oil, and elaterium, may produce abortion by a secondary effect upon the uterus, but both of these classes of drugs act upon the uterus only after marked effects upon the other pelvic organs, and usually only after endangering the life of the mother. Tarnier et Brouardel, Inculpation d'Avortement, etc., Annal. d'Hyg., 1881, V., 304. VOL. III. MED. JUR.-4. See § 26, ante. Brouardel takes up this subject in considerable detail, and gives references to a number of cases where these drugs have been used for the purposes of criminal abortion; among them he cites two cases in which aloes given during pregnancy, in the usual therapeutic doses for catharsis, produced abortion. 85. Emmenagogues. The third class of drugs, emmenagogues, is that perhaps most commonly used, and comprises ergot, rue, savine, tansy, yew, parsley, and the root of the common cotton. With the exception of ergot none of them have been known to produce abortion without either death, or, at least, the symptoms of intense poisoning in the mother. Many cases are on record of deaths from the taking of these drugs for their supposed effect upon the uterus.5 86. Ergot.- Ergot is the only drug which has been used successfully for the production of abortion, and many times when it has been tried it has been found wanting. However, Wood says that Youatt states, that in a large experience upon many animals he has never known the drug to fail. Stillé says that Diez, Oslere, Percy, and Laurent, found it to cause abortion in guinea-pigs, sows, rabbits, cows, and cats. M. Bodin has reported an epidemic of abortion occurring among cows near Trois Croix, which he attributes to feeding upon ergotized grasses. As for its effect upon the pregnant woman, while its action may be uncertain, still we have the evidence of a number of authorities that it does produce abortion. Thus, Mr. Whitehead (who by no means favors the view of its specific character) states, that in a case under his care, where, owing to deformity of the pelvis, it was necessary to get rid of the fetus in the fifth month of pregnancy, the ergot alone was employed, and at first with desired effect. It was given in three successive pregnancies, and in each instance labor-pains came on after eight or ten doses had been administered, and expulsion was effected by the end of the third day. Tried in a fourth pregnancy in the same person, it failed completely. Hofmann has collected the experience of others, with this substance: Out of forty-seven cases of premature labor in which the ergot was employed, it produced abortion without the necessity of, or the employment of, other means, in Brouardel, L'Avortement, p. 127. H. C. Wood, Therapeutics, 9th ed., 1894, p. 875. 'Stille, Therapeutics, 2d ed., Vol. II., p. 585. Bodin, Journ. des Connaissances Méd., 1842. 'On the Causes and Treatment of Abortion and Sterility, Am. Ed., 1848. thirty-two; while, in the remaining fifteen cases, it was given in addition to other means." Dr. Ramsbotham says: "Egomet ipse tamen permuta vidi exempla, in quibus partus prematurus inductus fuit septimo vel octavo graviditatis mense peracto, solo secalis cornuti usu, ovuli membranis integris servatis, ore uteri occluso neque digito, neque ullo alio modo ad patefactionem excitato." The same author has recently published a valuable paper on the induction of premature labor by the ergot, in which, we think, the reader will find conclusive evidence of the specific power of this drug. Premature labor was artificially induced by it in three successive pregnancies in one patient. A table of fifty-five cases is given in which it was successfully used.12 Dr. Churchill says: "Ergot of rye is now pretty generally supposed to have the power of originating uterine contractions." 13 To these we may add the statement of Brouardel11 from Krause of eighty cases in which ergot was used to induce abortion, in only eighteen of which it was ineffectual, but in three of which it caused death. Brouardel concludes from his studies that ergot is useless in the early months, and also in the majority of cases if labor has not set in; but grants it the ability to produce abortion in the smaller number of cases. Much of the difference of opinion as to the uterine effect of ergot depends, no doubt, upon the inertness of the samples of the drug used. It is well established, also, that independently of its effects upon uterine contractions, ergot affects the life of the fetus by depressing its heart's action, so tending also to the production of abortion. This slowing of the heart's action of the fetus, from 140 to 80 or 50, as well as the slowing of the heart's action of the inother, associated with gastrointestinal irritation, is characteristic of the action of ergot,15 though a positive diagnosis of ergot poisoning would involve the finding of the ergot in the intestinal tract. - 87. General mechanical means.- The general mechanical means which may produce abortion are: baths, hot or cold, sometimes sitz baths, sometimes general; general bloodletting; traumatism to any part of the body; exertion carried on to fatigue; and abdominal compression. The results of these factors is extremely variable. 87a. Baths, bleeding. The baths, as a rule, are ineffectual, even the mustard bath proving useless in the majority of cases. Bleeding seldom has a tendency to produce abortion. In fact it is a remedy well Bd. 23. Neue Zeitschrift f. Geburtskunde, "Parturition, London, 1841. Appendix. p. 639. "Med. Times, Jan., 1854. "Syst. of Midwifery, p. 279. See also Shapter, Prov. Med. Journ., April, 1844. 14 L'Avortement, Brouardel, Paris, 1901, p. 147. 15 Brouardel. L'Avortement, p. 149. recognized as of therapeutic value to ward off a threatened abortion. On the other hand, when pushed to the point of producing syncope, it may interfere with the pregnancy. M. Depaul relates an instance in his own practice where a woman apparently suffering from headache, in two successive pregnancies applied to him for the purpose of being bled. He afterwards discovered that the bleedings in these two instances, and on one previous occasion, had led to the destruction of the fetus.16 87b. Traumatisms and operations. The effects of general traumatism are extremely varying. In some cases where we can obtain a history of merely a misstep or slight stumble, abortion has followed promptly. In other cases where marked traumatisms have been sustained, either accidentally or with the intent of producing abortion, the pregnancy has gone on smoothly to its normal termination. Mauriceau17 reports the cases of a fall from a third story window upon a stone pavement without interfering with the pregnancy. Mr. Whitehead mentions the case of a woman who, in the fourth month of pregnancy, received a severe blow on the skull with a hatchet, resulting in a fracture of the skull, for which she was under treatment for nine weeks. She was delivered of a healthy child at full term. Brilland Langardiére18 reports the case of a woman who, in the attempt to bring on abortion, was carried on horseback over the fields at full gallop, and then thrown to the ground; and this maneuver repeated several times, along with other proceedings, without producing the desired effect. Hofmann19 reports the case of a woman who was placed upon the ground and beaten on the abdomen till she fainted, but the pregnancy continued uninterrupted. Again, sometimes surgical operations are needed in the course of the pregnancy; and amputations of the cervix of the uterus for cancer, ovariotomy, and the reinoval of fibroid tumors from the uterus itself have been performed without interfering with the pregnancy.20 As to the abdominal compression, if it is of marked degree, and continued several days and nights continuously, it may produce abortion. And in Sweden, where the massage treatment is so much in vogue, there is a class of abortionists calling themselves "Bauchpressers," who guarantee to empty the pregnant uterus by massage for fifteen or twenty minutes every day. 16 Traité d'Auscultation Obstétricale, p. 270. 17 198. Obstétriques, etc., Paris, 1717, II., De l'avortement provoqué, etc., 1862. p. 179. 10 Nouveaux Eléments de Méd. Lég., 1881, p. 165. 20 Verneuil, Revue de Méd., 1877, pp. 493, 588. 88. Local mechanical means. The local procedures used to produce abortion are by all odds the most effectual. Among the various maneuvers of this class may be mentioned the vaginal douche, which usually has little effect, but may produce abortion; coitus, which certainly seems to be the cause of a certain number of miscar riages; and the wearing of a pessary, which possibly causes miscarriage in some cases. The foregoing may be accidentally used, or, at least, without the intention of producing an interference with the course of the pregnancy; but the uterine manipulations to be next described can scarcely be applied to a uterus in which the diagnosis of pregnancy is evident without the intent being equally evident. These are the dilatation of the cervix of the uterus, the rupture of the membranes, either with the finger or with some instrument; and the separation of the membranes from the uterine walls by any means, whether finger, douche, air injection, or instrument. These are the methods regularly used by physicians for the induction of labor for medical reasons, and are known to have that effect. In the hands of the ignorant they are often unsuccessful and associated with severe injuries, frequently costing the woman her life. In the hands of the skilled obstetrician at times they need to be repeated before bringing the desired result, and some of them are even then not devoid of dangers. Although the application of such means to the cervix or uterus usually indicates the intervention of a second person, yet, in some cases, the woman herself has succeeded in applying them.21 89. Signs of induced abortion in fetus.-The signs of induced abortion, in addition to those found in spontaneous abortion cases, include the evidences of the method used, as shown by the fetus or the mother. In the fetus drugs generally leave no trace. 22 The general mechanical means show merely the effects of the traumatism as transmitted through the sac of amniotic fluid, so that it would take a peculiar traumatism to leave any mark upon the fetus without producing a penetrating wound of the abdomen and uterus. Likewise, it is seldom possible to find any trace on the fetus of the local measures employed, though a certain number of cases have been recorded of injury to the fetus in utero. It has been held that during the first three months a spontaneous abortion regularly shows the discharge of the ovum "Such a case is reported by Dr. Le Blond, Ann. d'Hyg. Publ. et de Méd. Lég., 1884, XI., 520, and Charpentier, P. 524. Chloral, chloroform, opium, and digitalis all show their effects on the fetus; potassium iodid has been demonstrated in the meconium of the fetus in cases where the mothers have been taking these drugs. See Friedrich's Blätt. f. gerichtl. Med. 1892, XLIII., 165. |