Chronic endometritis, or inflammation of the lining membrane of the uterine cavity, is the commonest maternal cause of abortion, especially of habitual abortion. In this condition hemorrhages in the decidua, or uterine fold that holds the fetus, kill the fetus, or force the ovum off the uterine wall, or excite expulsive uterine contractions. Without hemorrhage endometritis prevents a firm fixation of the ovum, or it may bring about a malposition of the placenta, called placenta praevia. Endometritis at the decidua may cause hydrorrhoea gravidarum, and the accumulated serous secretions from this source are likely to start uterine contraction. Chronic metritis, or inflammation of the deeper tissues of the uterus, is commonly found with endometritis, and it prevents the expansion of the uterine muscle. This condition is more likely to cause abortion than endometritis alone.
Acute gonorrhea, inflammations of the Fallopian tubes, and appendicitis sometimes interrupt pregnancy. Other causes are malformations and diseases of the uterus, infantilism, fibroids, polyps, uterine horns, lacerations and amputation of the cervix, and retroversions and retroflexions of the uterus. At times a replacement of the uterus will avert an abortion.
When the mother has an infectious disease like typhoid, smallpox, cholera, or typhus, the infection may reach the fetus and kill it, or may cause an endometritis with a hemorrhagic tendency. Maternal sepsis may kill the fetus directly or secondarily, and this is true also of maternal syphilis. A sudden rise in temperature may excite expulsive uterine contraction. In pneumonia the excess of carbon dioxide in the blood may bring on abortion. Like pneumonia, anesthesia may kill the fetus if kept up for a long time, or if marked by cyanosis. Prolonged nitrous-oxide anesthesia is especially dangerous to a fetus, but a brief nitrous-oxide anesthesia for the extraction of a tooth may not bring on abortion. The worst tooth stump can be extracted painlessly after local injection of novocain, with no danger to the fetus. The gums remain somewhat sore for a day or two after novocain infiltration, but this inconvenience is a much less evil than total anesthesia, even when there is no pregnancy. It is probable that total anesthesia is morally unjustifiable for the extraction of a single tooth if the tooth is not wedged in.
Violence, accidental or intentional, is a frequent primary or secondary cause of abortion. Sometimes a slight jar, a misstep on a stairway, a nervous shock, a jump from a carriage-step, lifting weights, running sewing-machines, sea-bathing, a rough automobile ride, will bring on an abortion where there is a predisposition. Often in healthy women, on the other hand, extreme violence does not interrupt pregnancy. Surgical operations are classed here with violence. In a neurotic woman a slight operation on an organ not directly connected with the uterus will start expulsive contractions. Again, 66 per cent. of operations on ovarian tumors during pregnancy have left the uterus undisturbed. De Lee says he has removed fibroids from the pregnant uterus, once even exposing the chorion, and has amputated the cervix of a gravid uterus, without interrupting pregnancy. Several cases have occurred where both ovaries have been removed during pregnancy without abortion. The breast has been amputated and a kidney removed from a pregnant woman[79] without disturbing the pregnancy. Wiener[80] did eleven operations for ovarian tumors during pregnancy with only two abortions. Von Holst[81] removed a myoma weighing two and a half pounds from the uterus at the seventh month of gestation without abortion. Davis of Birmingham, Alabama, reported[82] that a woman three and a half months pregnant was shot in the abdomen. The rifle bullet made twenty-five perforations in her intestines. She was taken eighty-five miles, and then Davis cut out five feet of the intestine. She recovered and gave birth to a living child at term.
Double ovariotomy brings on abortion in the early months of pregnancy oftener than in the later, probably from the loss of the corpus luteum, which, it appears, is necessary for the growth of the uterus. Appendicitis and appendectomy are especially likely to interrupt gestation, apparently as a result of infection and because pregnant women are prone to defer operation. The traumatism of criminal abortion, punctures and lacerations from bougies and curettes, and the exhibition of drugs like ergot and cantharides, are sources and results of abortion. Drugs will not empty the uterus unless they are given in poisonous doses which endanger the woman's life.
In the father, syphilis, tuberculosis, general paresis, general debility from alcoholism, unchastity, and senility, and septic conditions of the generative tract, may cause abortion. Many men who work with lead, phosphorus, mercury, or X-rays are sterile, and before they become totally sterile their condition appears to cause debility in the fetus which leads to abortion. In paternal lead poisoning there is a reduction of about 20 per cent. in the weight of the infants at birth, and a general weakness and retardation of the child. The children of lead-poisoned fathers are frequently permanently under weight.
Coition during gestation is a cause of abortion, and the fault here, as a rule, lies with the husband. St. Thomas[83] said: "St. Jerome protests against the sexual approach of the husband to his gravid wife, not that in this condition such an act is always a mortal sin, unless there is probable danger of abortion." St. Alphonsus[84] says if there is danger of abortion the use of the debitum is a grave sin. In n. 924 he again teaches that while it is true that if by the use of the debitum the life or formation of the fetus is endangered or checked the right to the use of the debitum is, in such circumstances, lost, yet he thinks that in pregnancy there is little danger of abortion from this cause, especially near term.
Sabetti-Barrett[85] says the wife is excused from the debitum conjugale if the husband is drunk, or if there is a rational dread of grave injury, or grave danger to health. Genicot[86] thinks that in pregnancy it "can scarcely be shown that there is a notable danger of abortion." Lehmkuhl[87] holds that a married person is not obliged to grant the debitum if there is great danger of abortion; but, he adds, "Even then, if there is a grave danger of incontinence I do not think it certain that there is an absolute obligation to abstain."
Unlike Lehmkuhl, moralists agree that if there is real danger of abortion from marital congress, such an act is illicit, but they are inclined to think that there is little or no danger of abortion, especially at the end of gestation. Authorities on obstetrics, on the contrary, say that one of the causes of abortion in the early months of pregnancy is marital congress; and one of the sources of sepsis in women, which may result in the death of both mother and child, is certainly congress at the end of gestation. This causation of abortion is found especially in neurotic irritable women, in such as have diseases of the generative tract, or a tendency to habitual abortion. Whenever a woman shows any tendency to bleeding during gestation the use of the debitum is undoubtedly contraindicated, because of the proximate danger of both abortion and septic infection. Toward the end of pregnancy the danger from sexual commerce is the risk of infecting the woman's vagina with bacteria which may bring on sepsis through the abrasions incident to parturition. The staphylococcus pyogenes albus, a dangerous septic microörganism, exists as a saprophyte in 50 per cent. of male urethras, and the bacillus coli communis is another source of infection from the father during pregnancy. De Lee saw two cases of sepsis that killed both mother and child from such an infection shortly before term. If a physician now examines a woman before delivery without using all the precautions known to prevent sepsis, such as wearing a sterile rubber glove, he is guilty of malpractice; yet certain moralists are inclined to let a husband do what he likes. Moralists talk about the fetus as protected in the membranes. That is nonsense, because it has no relevancy to the question. It can have the slight relevancy of untruth when the woman is rendered septic, because then the membranes are no protection at all.
The mortality statistics of the United States Census Bureau show that a little more than 42 per cent. of the infants who died in the registration area in 1911 did not last throughout the first month of extrauterine life, and of these babies almost seven-tenths died of prenatal and delivery abnormalities. In 1912, in the registration area, which then took in 63.2 per cent. of our population, the total death-rate of infants under a year old was 9035, and of these 3905 died of puerperal infection. In the entire country a very conservative estimate of the annual number of deaths of infants from puerperal sepsis is 5000; and about 15,000 women die here yearly from this etiology alone. Of course most of these deaths are caused by unclean midwives and quacks, but a large number of them are brought about by incontinent husbands. Invalidism from puerperal sepsis happens many times 15,000. Moreover, one-third of all the blindness in the world is caused by septic infection of the eyes at birth and virtually all this septic infection of the eyes is carried in by diseased husbands, although not necessarily by coitus during gestation.