IV.—The Inherent Dangers of Abortion to a Woman's Health and to her Life.
IV.—The Inherent Dangers of Abortion to a Woman's Health and to her Life.
It is generally supposed, not merely that a woman can wilfully throw off the product of conception without guilt or moral harm, but that she can do it with positive or comparative impunity as regards her own health. This is a very grievous and most fatal error, and I do not hesitate to assert, from extended observation, that, despite apparent and isolated instances to the contrary—
1. A larger proportion of women die during or in consequence of an abortion, than during or in consequence of childbed at the full term of pregnancy;
2. A very much larger proportion of women become confirmed invalids, perhaps for life; and,
3. The tendency to serious and often fatal organic disease, as cancer, is rendered much greater at the so-called turn of life, which has very generally, and not without good reason, been considered as especially the critical period of a woman's existence.
These, as I have said, are conclusions that cannot be gainsaid, as they are based on facts; and that these facts are merely what ought, in the very nature of things, to occur, can readily enough be shown.
1. Nature does all her work, of whatever character it may be, in accordance with certain simple and general laws, any infringement of which must necessarily cause derangement, disaster, or ruin.
In the present instance, it has been ascertained, by careful dissections and microscopic study, that the woman's general system, both as a whole and as regards each individual organ and its tissues, is slowly and gradually prepared for the great change which naturally occurs at the end of nine months' gestation; and that if this change is by any means prematurely induced, whether by accident or design, it finds the system unprepared. Not even do I except from this law the earlier months of pregnancy, when it is thought by so many that abortion can be brought on without any physical shock.
During pregnancy all the vital energies of the mother are devoted to a single end: the protection and nourishment of the child. Such wise provision is made for its security, such intimate vascular connection is established between the fœtal circulation and the blood-vessels of the mother, that its premature rupture is usually attended by profuse hemorrhage, often fatal, often persistent to a greater or less degree for many months after the act has been completed, and always attended with more or less shock to the maternal system, even though the full effect of this is not noticed for years.
In birth at the full period, it is found that what is called by pathologists fatty degeneration of the tissues, occurs both in the walls of the mother's womb, and in the placenta or after-birth, by which attachment is kept up with the child. This change, in all other instances a diseased process, is here an essential and healthy one. By it the occurrence of labor at its normal period is to a certain extent determined; by it is provision made against an inordinate discharge of blood during the separation and escape of the after-birth, and by it is the return of the uterus to the comparatively insignificant size, that is natural to it when unimpregnated, insured. Any deviation from this process at the full term, which prevents the whole chain of events now enumerated from being completed, lays the foundation of, and causes a wide range of uterine accidents and disease, displacements of various kinds, falling of the womb downwards or forwards or backwards, with the long list of neuralgic pains in the back, groins, thighs, and elsewhere that they occasion; constant and inordinate leucorrhœa; sympathetic attacks of ovarian irritation, running even into dropsy, &c., &c. These are only a portion of the results that might be enumerated.
Now, while all this is true of any interference with the natural process at the full time, it is just as true, and if anything more certain, when pregnancy has been prematurely terminated; and out of many hundred invalid women, whose cases I have critically examined, in a very large proportion I have traced these symptoms, to the mental conviction of the patient, as well as to my own, directly back to an induced abortion.
Again—not merely does nature prepare the appendages of the child and the womb of its mother for the separation that in due time is to ensue between them, it also provides an additional means of insuring its successful accomplishment through the action that takes place in the woman's breasts, namely, the secretion of the milk. Though the escape of this fluid does not ordinarily occur in any quantity until some little time after birth has been effected, yet the changes that ensue have gradually been progressing for days, or weeks, or even months; for, as is well known, in some women the lacteal secretion is present before birth, at times even during a large part of pregnancy, and in all women there is doubtless a decided tendency of the circulation towards the breasts, prior to the birth of the child, just as there has been so extreme a tendency of the circulation for so long a time towards the womb. It is indeed to take the place of the latter that the former is established, and to prevent the evil consequences that might otherwise ensue. The sympathy between the mammary glands and the uterus is now well established; it is shown in many different ways: in some women the application of the child to the breasts is immediately followed by after-pains, and in others these pains, which are usually but contractions of the womb to expel any clots that may have accumulated, are attended by a freer secretion or discharge of the milk. It is not uncommon, when the monthly discharge is scanty or suddenly checked, for the breasts to become enlarged and painful, as is so often the case soon after impregnation, while, on the other hand, one of the most efficient means we have of establishing the periodical flow, when suppressed, is by the application of sinapisms to the surface of the breasts. In view of these facts it will readily be understood why it is that women who make good nurses are so much less likely than others to suffer from the various disorders of the womb, and why they are also less likely to rapidly conceive, and why, moreover, too long lactation should not be indulged in for either of these so desirable ends. The demands of fashion shorten or prevent nursing, the demands of fashion often forbid a woman from bearing children; but whether this is attained by the prevention of impregnation, or by the induction of miscarriage, it is almost inevitably attended, as is to a certain extent the sudden cessation of suckling, by a grievous shock to the mother's system, that sooner or later undermines her health, if even it does not directly induce her death.
I have asserted that dangers attend the occurrence of abortion which directly threaten a mother's life. This is true of all miscarriages, whether accidental or otherwise; but these dangers are enhanced when the act is intentional. When caused by an accident, the disturbance is often of a secondary character, the vitality of the ovum being destroyed, or the activity of the maternal circulation checked, before the separation of the two beings from each other finally takes place. But in a forced abortion there is no such preservative action; the separation is immediate if produced by instruments, which often besides do grievous damage to the tissues of the mother with which they are brought into contact, lacerating them, and often inducing subsequent sloughing or mortification; or, if the act is effected by medicines, it is usually in consequence of violent purgation or vomiting, which of themselves often occasion local inflammation of the stomach or intestines, and death. Add to this that even though the occurrence of any such feeling may be denied, there is probably always a certain measure of compunction for the deed in the woman's heart—a touch of pity for the little being about to be sacrificed—a trace of regret for the child that, if born, would have proved so dear—a trace of shame at casting from her the pledge of a husband's or lover's affection—a trace of remorse for what she knows to be a wrong, no matter to what small extent, or how justifiable, it may seem to herself, and we have an explanation of the additional element in these intentional abortions, which increases the evil effect upon the mother, not as regards her bodily health alone, but in some sad cases to the extent even of utterly overthrowing her reason.
The causes of an immediately or secondarily fatal result of labor at the full period are few; in abortion nearly every one of these is present, with the addition of others peculiar to the sudden and untimely interruption of a natural process, and the death of the product of conception. There is the same or greater physical shock, the same or greater liability to hemorrhage, the same and much greater liability to subsequent uterine or ovarian disease. To these elements we must add another, and by no means an unimportant one; a degree of mental disturbance, often profound, from disappointment or fear, that to the same extent may be said rarely to exist in labors at the full period.[12]
Viewing this subject in a medical light, we find that death, however frequent, is by no means the most common or the worst result of the attempts at criminal abortion. This statement applies not to the mother alone, but, in a degree, to the child.
We shall perceive that many of the measures resorted to are by no means certain of success, often indeed decidedly inefficacious in causing the immediate expulsion of the fœtus from the womb; though almost always producing more or less severe local or general injury to the mother, and often, directly or by sympathy, to the child.
The membranes or placenta may be but partially detached, and the ovum may be retained. This does not necessarily occasion degeneration, as into a mole, or hydatids, or entire arrest of development. The latter may be partial, as under many forms, from some cause or another, does constantly occur; if from an unsuccessful attempt at abortion, would this be confessed, or indeed always suggest itself to the mother's own mind? Fractures of the fœtal limbs, prior to birth, are often reported, unattributable in any way to the funis, which may amputate, indeed, but seldom break a limb. A fall or a blow is recollected; perhaps it was accidental, perhaps not, for resort to these for criminal purposes is very common. In precisely the same manner may injury be occasioned to the nervous system of the fœtus, as in a hydrocephalic case long under the writer's own observation, where the cause and effect were plainly evident. Intrauterine convulsions have been reported; as induced by external violence they are probably not uncommon, and the disease thus begun may eventuate in epilepsy, paralysis, or idiocy.
To the mother there may happen correspondingly frequent and serious results. Not alone death, immediate or subsequent, may occur from metritis, hemorrhage, peritonitic, or phlebitic inflammation, from almost every cause possibly attending not merely labor at the full period, comparatively safe, but miscarriage increased and multiplied by ignorance, by wounds, and violence; but if life still remain, it is too often rendered worse than death.
The results of abortion from natural causes, as obstetric disease, separate or in common, of mother, fœtus, or membranes, or from a morbid habit consequent on its repetition, are much worse than those following the average of labors at the full period. If the abortion be from accident, from external violence, mental shock, great constitutional disturbance from disease or poison, or even necessarily induced by the skilful physician in early pregnancy, the risks are worse. But if, taking into account the patient's constitution, her previous health, and the period of gestation, the abortion has been criminal, these risks are infinitely increased. Those who escape them are few.
In thirty-four cases of criminal abortion reported by Tardieu, where the history was known, twenty-two were followed, as a consequence, by death, and only twelve were not. In fifteen cases necessarily induced by physicians, not one was fatal.
It is a mistake to suppose, with Devergie, that death must be immediate, and owing only to the causes just mentioned. The rapidity of death, even where directly the consequence, greatly varies; though generally taking place almost at once if there be hemorrhage, it may be delayed even for hours where there has been great laceration of the uterus, its surrounding tissues, and even of the intestines; if metro-peritonitis ensue, the patient may survive for from one to four days, even, indeed, to seven and ten. But there are other fatal cases, where on autopsy there is revealed no appreciable lesion, death, the penalty of unwarrantably interfering with nature, being occasioned by syncope, by excess of pain, or by moral shock from the thought of the crime.
That abortions, even when criminally induced, may sometimes be safely borne by the system, is of little avail to disprove the evidence of numberless cases to the contrary. We have instanced death. Pelvic cellulitis, on the other hand, fistulæ, vesical, uterine, or between the organs alluded to; adhesions of the os or vagina, rendering liable subsequent rupture of the womb, during labor or from retained menses, or, in the latter case, discharge of the secretion through a Fallopian tube, and consequent peritonitis; diseases and degenerations, inflammatory or malignant, of both uterus and ovary; of this long and fearful list, each, too frequently incurable, may be the direct and evident consequence, to one patient or another, of an intentional and unjustifiable abortion.
We have seen that, in some instances, the thought of the crime, coming upon the mind at a time when the physical system is weak and prostrated, is sufficient to occasion death. The same tremendous idea, so laden with the consciousness of guilt against God, humanity, and even mere natural instinct, is undoubtedly able, where not affecting life, to produce insanity. This it may do either by its first and sudden occurrence to the mind, or, subsequently, by those long and unavailing regrets, that remorse, if conscience exist, is sure to bring. Were we wrong in considering death the preferable alternative?[13]
To the above remarks it might truthfully be added, that not only is the fœtus endangered by the attempt at abortion, and the mother's health, but that the stamp of disease thus impressed is very apt to be perceived upon any children she may subsequently bear. Not only do women become sterile in consequence of a miscarriage, and then, longing for offspring, find themselves permanently incapacitated for conception, but, in other cases, impregnation, or rather the attachment of the ovum to the uterus, being but imperfectly effected, or the mother's system being so insidiously undermined, the children that are subsequently brought forth are unhealthy, deformed, or diseased. This matter of conception and gestation, after a miscarriage, has of late been made the subject of special study, and there is little doubt that from this, as the primal origin, arises much of the nervous, mental, and organic derangement and deficiency that, occurring in children, cuts short or embitters their lives.
It may be alleged by those who, sceptical or not sceptical as to these conclusions, have reason, nevertheless, to desire to throw discredit upon them, that the weekly or annual bills of mortality, the mortuary statistics, do not show such direct influence from the crime of abortion as I have claimed exists.
On the other hand, it must not be forgotten that in these cases there is always present every reason for concealment. In the earlier months of pregnancy it is very difficult to prove, in the living subject, that pregnancy has occurred. Such a conclusion being arrived at, before the sound of the fœtal heart can be heard, for this is the only sign that is positively certain, by merely circumstantial and probable evidence, which becomes of weight only as it is accumulated and found corroborative. In the dead subject, the victim of an abortion in the earlier months, the case is often equally obscure, or at least doubtful, unless the product of conception has not yet escaped, or, having been thrown off, has been detected or preserved. When found, it of course proves pregnancy, whether the parent be living or dead; that is, in the former instance, if its discharge can be traced directly to the woman in question, and to no other, and correlative circumstances may show that an abortion has occurred; but this may have been accidental and guiltless. Where the act has been committed by an accomplice, the proofs of such commission and of the intent, though this is generally implied by the act itself, are by no means always forthcoming. Where the abortion has been induced by the woman herself, as is now so frequently the case, certainty upon the point becomes far more difficult. The only positive evidence by which to judge of the real frequency of the crime isconfession, and it is from the confessions of many hundreds of women, in all classes of society, married and unmarried, rich and poor, otherwise good, bad, or indifferent, that physicians have obtained their knowledge of the true frequency of the crime.
The confidential relations in which the physician stands to his patient; the understanding that nothing can wring from him her disclosures, save the direct commands of the law, so unlikely in any given case to become cognizant of its existence, elicits from a woman in almost every instance, especially if she believes herself in peril of death, a frank statement of the means by which she has been brought low; for it is evident that upon such knowledge must depend the measures of relief to which the physician may resort. Could the test of confession be always applied, as is, however, manifestly impossible, so many women die during or in consequence of an abortion, without the attendance of a physician and without making any sign, it would be found that many of the cases now reported upon our bills of mortality as deaths from hemorrhage, from menorrhagia, from dysentery, from peritonitis, from inflammation of the bowels or of the womb, from obscure tumor, or from uterine cancer, would be found in reality to be deaths from intentional abortion. At first sight, it would seem impossible that such grossly erroneous opinions as the above could be rendered; but their likelihood is readily perceived when it is recollected how often, when the best medical skill has been secured, attending circumstances are such as to excite little or no suspicion of the true state of the case, and a physical examination of the patient is therefore neglected. Women are still allowed to die of ovarian or of other tumors that might be easily and successfully removed, and, in default of a proper examination, are sometimes mistakenly pronounced instances of disease of the liver or of ordinary abdominal dropsy, and as such are buried. If such and similar errors can occur in chronic cases, where time and opportunity have permitted the most thorough examination and study, still more likely are they to take place during the hurry and anxieties of an acute and alarming attack, where the conscience and shame of the patient are alike interested in causing or keeping up a deception.
It will have been seen, then, not merely that an induced abortion may be attended with great immediate danger to the mother, but that in reality it is very often fatal, either from the so-called shock to her system, or from hemorrhage, or from immediately ensuing peritonitis.
2. Should the woman survive these immediate consequences, no matter how excellently she may have seemed to rally, she is by no means safe as to her subsequent health. There are a host of diseases, some of them very dangerous, to which she is directly liable.
The product of conception is not always entirely gotten rid of. If a fragment remains, no matter how trifling in size, it may serve as the channel of the most severe and constant hemorrhagic discharge. Of this, examples are by no means infrequent; the flux lasting at times for very many months, and, if the cause is not finally detected and removed, hurrying the patient to her grave.
The product of conception is sometimes retained entire, after its detachment from the uterine walls has been supposed wholly effected. It may be carried for many years, always acting as a foreign body; at times occasioning extreme irritation, shown perhaps only by distant and otherwise inexplicable symptoms, or it may lie dormant for a time without apparent trouble—finally making itself known by some sudden explosion of disease, whether by purulent absorption and general pyæmia; by ulceration and discharge of fœtal debris, through the intestines, bladder, or even abdominal integuments; or, by metritic inflammation, followed by sympathetic or consequent fatal peritonitis.
The patient, after an abortion, is very liable to one or another of the forms of uterine displacement, which are now known to lie at the foundation of so very large a proportion of the lame backs, formerly supposed consequent on spinal irritation; of the painfully neuralgic breasts, so often suggestive of incipient cancer; of the disabled limbs, pronounced affected with sciatica, cramps, or even paralysis; of the impatient bladders, from whose irritability or incontinence the kidneys are supposed diseased; of the obscure abdominal aches and pains, which unjustly condemn so many a liver and so many an ovary; of the constipation from mere mechanical pressure, which is so often thought to argue stoppage from stricture or other organic disease; of the severe and intractable headaches that, resisting all and every form of direct or constitutional treatment, are supposed to indicate an incurable affection of the brain; of the easily deranged stomachs, that are so suggestive of ulceration or of malignant degeneration; of the general hypochondria and despondency, that of the most gentle, even almost angelic, dispositions make the shrew and virago, and of the purest and most innocent produce, in her own conceit, the worst of sinners, even at times effecting suicide. Who that has suffered will think this picture overdrawn? Who that has practised will not recognize in displacements, the key by which these riddles may be solved?
Their mode of causation is plain. After an abortion, just as after labor at the full term, the womb is more weighty than natural—its walls thicker and heavier than usual, alike by the excess of blood they contain, and by the increased deposition of muscular fibre. After childbed, it has been shown that this increase is normally lessened by certain physiological processes attending the natural completion of that function. After an abortion, these processes are absent or are but imperfectly performed. It is notorious that during the slight increase of weight from simple congestion that occurs at the regular monthly periods, women are very liable to displacement on any effort, extreme or slight, whether riding on horseback, gently lifting, or even straining at stool; during or after an abortion, the risk is very greatly increased.
With equal justice could I refer to the chances of trouble that otherwise accompany the premature ending of pregnancy. In many instances, I have now been summoned to attend, and frequently to operate upon, the consequences of local uterine or vaginal inflammation or of laceration, for both of these results may ensue where the womb has not been prepared to evacuate itself by the normal closure of pregnancy—and this, whether or not instruments may have been employed. Adhesions of varying situation and extent are not uncommon as the result of an abortion. They may be slight, and merely tilt or draw the womb to one side, giving rise only to severe local or distant neuralgias, and rendering the occurrence of a subsequent pregnancy somewhat dangerous; they may be more decided, and as bridles or septa partially close the canal of the vagina, rendering menstruation and conjugal intercourse alike difficult and painful; they may be so complete as entirely to obliterate the mouth of the womb or of the external passage, in these instances preventing the escape of the menses, and rendering an operation necessary to avoid a rupture that might perhaps be fatal. Should it be the outer entrance that is occluded, the woman is of course entirely shut off from her husband's embrace; an effect that, however grateful to many an invalid, her shame would hardly be willing to accept as the consequence of disease.
These that I have mentioned are but a tithe of the pathological effects daily revealed to physicians, as in consequence of an intentional abortion. They are, however, sufficient for our purpose.
3. But not only is a woman in peril both as to life and health, alike at the time of an abortion and for months or years subsequently. She may seem to herself and to others successfully to have escaped these dangers, and yet when she has reached the critical turn of life, succumb.
At this eventful period, when the fountains of youth dry up, and the scanty circulation is turned from its accustomed channel, the woman ceases from the periodical discharges, which in health and with care are the secret of her beauty, her attractions, her charms. At its occurrence not merely is a change produced in the system generally, but the womb, no longer required, becomes atrophied and dwindles into insignificance. It may have had impressed upon it, years and years back, the stamp of derangement, till now not rendered effective; for, as in other portions of the body, a part once weakened may retain itself in tolerably good condition until some accident or other change develops or awakens the seed of disease. Thus it is that an ancient hypertrophy, or a chronic irritation, may become scirrhous and degenerate into undoubted carcinoma, or chronic menorrhagia or uterine leucorrhœa become intractable hemorrhage, or a latent fibroid deposit develop into an irrepressible, and, perhaps, irremediable tumor.
Little the comfort for a woman to have had her own way against the dictates of her conscience, the advice, perhaps, of her physician, if to the dangers she must directly incur, she must add the looking forward through all the rest of her life to possible disease, invalidism or death as the direct consequence of her folly; no wonder if she should consider prevention better than such cure as this, and yet the prevention of pregnancy, by whatever means it may be sought, by cold vaginal injections, or by incomplete or impeded sexual intercourse, is alike destructive to sensual enjoyment and to the woman's health; her only safeguard is either to restrict approach to a portion of the menstrual interval, or to refrain from it altogether.
Not merely are certain of the measures to which I have alluded detrimental to the health of the woman, they are so to both parties engaged, and it is to their frequent employment, freely confessed as this is to the physician, that much of the ill health of the community, both of men and women is to be attributed. Though they may seem sanctioned by the rites of marriage, they are in some respects worse for the physical health, I might almost say for the moral health likewise, than illicit intercourse or even prostitution, for they bring both parties down to all the evils and dangers, mental and physical, of self-abuse.