Coition during pregnancy is unnatural because it necessarily fails of the end of coition, which is procreation. Curiously, too, all the lower animals instinctively appear to avoid this act during pregnancy. Men should be told that marriage has restraints as well as celibacy. Women are reminded of the law of the debitum, but not of the occasions when they are even obliged to deny it. If a man cannot keep continent in the presence of his pregnant wife, let him live in another part of the house. Regard for the woman is lacking in many ways. Young girls often marry without having the faintest notion of sexual life, and they are panic-stricken when assaulted. I have known two who were frightened into insanity. Priests should tell young married men that they are human beings, not animals; that they should act like rational beings when they are first married; and that after the wife has become pregnant the husband should not be the cause of abortion in the first three months, nor of puerperal sepsis in the last three months. Priestley,[88] in 2325 pregnancies, found one abortion in every four pregnancies; Guillemot and Devilliers in France, Hirst in Philadelphia, and others report the same proportion. These are natural, not criminal, abortions. If, then, in normal pregnancies about one child in five is lost before birth, husbands should be taught a continence which would to some degree avert this calamity. Superfetation has occurred by coition during pregnancy, and this results commonly in abortion and the death of both fetuses.
Premature labor in cases where the child is viable is produced by the same agencies that interrupt gestation in the early months. Obstetricians think that syphilis is the commonest cause of premature labor, and they estimate that from 50 to 80 per cent. of these premature births are due to syphilis. In a series of 705 fetal deaths in Johns Hopkins Hospital, 26.4 per cent. were due to syphilis. After syphilis the cause of premature labor next in frequency is nephritis with placental hemorrhages and infarcts. Twins are not seldom delivered prematurely because of lack of room in the uterus. For the same reason any tumor of the uterus or abdomen may cause an abortion.
When successive pregnancies are interrupted prematurely the abortion is said to be habitual, and again the commonest cause is syphilis. In this disease, as the virulence of the infection decreases, the gestation is prolonged until a child is born infected with congenital syphilis. This child commonly dies, and later a child strong enough to live appears. Correct treatment of the parents will avert this slaughter of the innocents. Sometimes the syphilis is latent so far as clinical symptoms are concerned, but we may find a positive Wassermann reaction. Hubert reported[89] that 8.8 per cent. of 8652 patients in a clinic at Munich where all were subjected to the Wassermann test had latent syphilis, and in 52 per cent. of these cases in men, and 75 per cent. in women, the infection was altogether unknown to the patients.
Chronic endometritis, where there is no syphilis, will permit habitual abortion, and each abortion makes the condition worse. Nephritis, diabetes, and other constitutional diseases cause habitual abortion.
In the first two months of gestation the decidual fold which holds the ovum against the uterine wall is thick, vascular, and friable. The contracting uterus in abortion expels the decidua with considerable difficulty, but the ovum containing the fetus may slip out easily and be lost. A fetus two months old is about three-fourths of an inch in length. If a physician, nurse, or other person finds the ovum, no matter how small it is, they should open it at once with a scalpel or scissors and baptize the fetus conditionally, even if no sign of life is perceptible. If the fetus is unmistakably dead—a diagnosis not easily made—there is no use in attempting baptism; but always give the fetus the benefit of the doubt. In the first six or eight weeks the whole ovum is usually born developed in decidual tissue; sometimes the ovum will slip out of the decidua and be covered only with shaggy villi, suggestive of a chestnut burr.
During the third and fourth months there may be (1) an abortion of the whole ovum; or (2) the membranes may rupture, the fetus be expelled, and the secundines remain in the uterus, and these may have to be removed by instrument or finger; or (3) the decidua reflexa and the chorion may split and let out the fetus into the amniotic sac: here again the remaining secundines, if they do not come away spontaneously, must be removed. Abortion after the fifth month is like a regular labor at term, but not so energetic.
An abortion may be threatened, inevitable, or incomplete. In each of these conditions there is uterine pain and hemorrhage. In inevitable and incomplete abortions we find softening and dilatation of the cervix, and a presentation or expulsion of part or all of the ovum.
In pregnancy uterine hemorrhage and uterine pain are symptoms of a threatened abortion, but not certain symptoms. Fromme found that 17.9 per cent. of 157 women who had these signs in the early months went on to term. If the fact of pregnancy is not known it is not always easy to differentiate a threatened abortion from other uterine conditions, like chronic metritis, ectopic gestation, a fibroid or other tumor, hemorrhage from cervical erosions or varices, or malposition of the uterus. If the abortion is inevitable the diagnosis is made more readily. The cervix is then more or less dilated and the ovum is palpable. There is rather profuse hemorrhage, flooding, and painful uterine contractions are evident. The rupture of the bag of waters may be simulated by the escape of secretions in hydrorrhoea gravidarum, or the escape of waters may be a primary symptom of graviditas exochorialis. Hydrorrhoea gravidarum is an intermittent discharge of clear or bloody fluid from a catarrhal endometritis under the decidua. It occurs in anemic, weak women, especially multiparae. In graviditas exochorialis the fetus is left within the womb but outside the ruptured chorion, and it may remain there for some time.
When an abortion is incomplete it is absolutely necessary to learn whether the entire ovum and decidual tissue have been expelled or not. When a part or all of the dead ovum is retained the consequences are so grave that they may result in the death of the woman or cause chronic invalidism. Sepsis may result, a placental polyp may form, and even syncytioma malignum may start—this fatal tumor, however, is not so common after incomplete abortion as after hydatid mole formation.
The prognosis as regards health is worse after abortion than after normal pregnancy. The involution of the uterus is slower than in full-term cases, and if infection has occurred there is great likelihood of a chronic endometritis and metritis. The woman may be rendered sterile, or she may become a chronic invalid to be cured only by capital operations.