Book - Contributions to Embryology Carnegie Institution No.56-18

From Embryology

Chapter 18. Some Aspects of Abortion

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Mall FP. and Meyer AW. Studies on abortuses: a survey of pathologic ova in the Carnegie Embryological Collection. (1921) Contrib. Embryol., Carnegie Inst. Wash. Publ. 275, 12: 1-364.

In this historic 1921 pathology paper, figures and plates of abnormal embryos are not suitable for young students.

1921 Carnegie Collection - Abnormal: Preface | 1 Collection origin | 2 Care and utilization | 3 Classification | 4 Pathologic analysis | 5 Size | 6 Sex incidence | 7 Localized anomalies | 8 Hydatiform uterine | 9 Hydatiform tubal | Chapter 10 Alleged superfetation | 11 Ovarian Pregnancy | 12 Lysis and resorption | 13 Postmortem intrauterine | 14 Hofbauer cells | 15 Villi | 16 Villous nodules | 17 Syphilitic changes | 18 Aspects | Bibliography | Figures | Contribution No.56 | Contributions Series | Embryology History

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The word abortion is here used in the general sense of an interruption of gestation, regardless of the time or the cause.


In considering the possible reasons for the interruption of gestation, one must not only distinguish between the alleged and the real causes, but must also bear in mind the fact that we still speak of the occurrence of spontaneous and habitual abortion. It is scarcely necessary to emphasize that there can, of course, be no such thing as spontaneous abortion, for no gestation can be presumed to be interrupted without a cause, whatever its nature. This is self-evident, and I gladly would let the matter pass without comment were it not for the fact that the conclusion that a certain abortion was spontaneous often ends further inquiry.


Hegar (1904) directed especial attention to the presence of pathologic changes in the conceptus as a cause of abortion, thus clearly recognizing that the difficulty may not lie in the maternal organism, although it must not be forgotten that many of the so-called pathologic changes present in conceptuses nevertheless may be due to adverse influences, somatic and maternal rather than germinal in origin. However, since the presence of anomalies in the fetus usually is determined by inspection of the gross specimen, it is evident that only the presence of external deformities generally is noted. But from dissecting-room experience alone we know that pronounced anomalies commonly are present internally without having become evident externally. This may be true of such extreme anomalies as situs viscerum inversus even, and when one considers how much more disadvantageous for the development of the cyema such a condition must be than such minor things as polydactyly and brachydactyly, hare-lip, cleft palate, or club-foot and hand, it becomes apparent that internal must far more frequently be the cause of fetal death than the external anomalies. The latter have long been recognized as probable causes of fetal death and the subsequent termination of gestation merely because they are so evident. It is true that external not infrequently are associated with internal anomalies, but the effect of the latter upon the life of the cyema probably has been underestimated largely because they can be revealed only by painstaking examination. However, the frequent presence of marked internal anomalies in the bodies of individuals who have passed middle life, or even the proverbial threescore and ten, also indicates that the r61e of external anomalies in the termination of gestation probably has been overestimated. For aside from such major defects as the various forms of cranio-rachischisis, it is difficult to see how minor external anomalies, such as polydactyly or brachydactyly, hyperphalangism, cleft palate, or hare-lip or anarthroses and synarthroses, in themselves can lead to the death of the fetus and hence to the interruption of pregnancy. The same thing is true of anomalous renal development, except in so far, perhaps, as it is extremely pronounced or associated with anomalies in the organs of internal secretion. Cardiac anomalies, especially septal defects, and internal hydrocephalus, on the other hand, probably would very seriously affect the further development of the cyema, even if not evident externally.


It is strange that we know so little regarding the anomalous development of the chorion as a factor in the termination of pregnancy. That the cause for the latter not infrequently may be sought in the ovum or spermatazoon one can scarcely doubt, for otherwise one would have to assume that the human reproductive cells are characterized by a unique immunity and perfection. That this is not the case has been abundantly shown for the human spermatazoon, but we are still quite ignorant concerning the occurrence of pathologic unfertilized ova. Jones (1897), however, came to the conclusion that they were common, and Detleftsen (1914) reported that abnormal ovaries commonly occur in guinea-pig hybrids that is, crosses between the domestic and the wild cavy species. Furthermore, Huber (1915) found abnormal fertilized ova which disintegrate even before implantation in the rat.


Crosti (1896) believed that abortion in the first 8 or 10 weeks is always due to defects inherent in the ovum, and Szasz (1903) stated that fetuses from the early months of gestation may show malformations not found in the later months. If this be true, then it demonstrates what one would seem to be able safely to assume, that the existence of some fetal anomalies makes continued development impossible. Such anomalies, hence, never should be met in the newborn, but should be found in the early fetus only. This conclusion of Szasz would also seem to be justified if fetal anomalies were more common in the earlier than in the later months of pregnancy. This was the conclusion reached by Mall (1917), who found that localized anomalies are twelve times as common in abortuses as are monsters among fetuses at term. But since not only acardiac monsters, but also small nodules, such as reported by Slemons (1917 a ) under the caption "Fetus amorphous anideus," may sometimes survive until term, it is difficult to substantiate the assertion of Szasz at present, except perhaps indirectly by the greater infrequency of anomalies at term and by the occurrence of such heretofore unknown specimens as No. 1843 (Meyer, 1919 e ), in which survival was manifestly impossible. Such vesicles as this, wholly devoid of a cyema, apparently never can continue to develop for any length of time, and, as far as I can learn, never have been observed before; for the large hydatiform degenerations, composed of portions of a chorionic vesicle and villi only, really belong in another category.


No one will doubt that the presence of certain developmental anomalies tends to fetal death and hence also to early abortion, but until more material is available it will be impossible to make reliable statistical deductions and determine the relative frequency with which various anomalies occur in the different months of pregnancy or even at the time of birth. However, there is no doubt that small primary nodular forms, which are true developmental anomalies, such as those shown in figures 205 and 206 (plate 18, Chap. XIII), are far more frequent among young than among older specimens in the Carnegie Collection. This, however, does not wholly confirm the statement of Szasz, though it is in entire accord with Mall's conclusion. If one considers the external form and the structure of these small masses, one feels quite certain that some of them belong in the category of rare, full-term specimens such as that reported by Siemens. Few of these probably survive till term on account of an insufficient blood-supply, and the occasional survival of one in association with a normal, full-term fetus is an extremely interesting occurrence.


One need only to regard the question of abortion historically and recall the practices of primitive races to be reminded of the fact that in such a matter as this human custom, conduct, and frailty play a very large role. Nor need attention be directed to the practices of primitive or uncivilized peoples alone, even if Robinson's (1919) estimate that 1,000,000 criminal abortions are performed annually in the United States can not be accepted without question. Since the number of annual births in the United States, estimated on the basis of the registration area, is only about 2,400,000, this would imply that 1 criminal abortion is performed for every 2.4 births. Or, to put it another way, if somewhat less than 40 per cent of all pregnancies terminate prematurely, as Pearson (1897) estimated, then, according to Robinson, 1 out of every 4 pregnancies is terminated criminally. But the highest estimates of the ratio of abortions to pregnancies are those of Taussig (1910) and myself. Those of Taussig were based upon the experience at a St. Louis gynecological clinic, and mine upon about 700 selected histories from the Carnegie Embryological Collection. From these data it seems that there is 1 abortion to about 1.7 to 2.3 pregnancies. Hence, if we accept Robinson's estimate of the incidence of criminal abortion in the United States as 1 to every 2.4 births, it would follow that in the women considered by Taussig or myself about 70 per cent of all pregnancies which terminated prematurely were terminated criminally! Furthermore, upon the basis of Pearson's estimate of prenatal mortality, the criminally induced actually would exceed the abortions due to all other causes by over one-half, while upon the basis of Mall's earlier estimate of a prenatal mortality of about 20 per cent, the criminal abortions in the United States, as estimated by Robinson, actually would exceed the grand total of abortions from all causes by 200,000 cases annually!


It is regrettable that we are left partly to surmise regarding the exact incidence of prenatal death. Ahlfeld (1898) estimated that there is 1 abortion for every 4 or 5 normal births. This would be 1 to every 5 or 6 pregnancies. A. Hegar (1863) estimated that 1 out of 8 or 10 pregnancies ends prematurely. Michailoff (1897), as reported by Chazan (1904), gave a frequency of 10.18 per cent, and Keyssner (1895) a frequency of 15.1 per cent, or 1 abortion to every 5 or 6 births, an estimate confirmed also by Williams (1917). According to Lechler (1883) and Chazan (1904), this was also the figure reached by Busch and Moser (1840), upon theoretical grounds alone.


Stumpf (1892) found 1 abortion for every 3.56 pregnancies, a mortality of 28 per cent, and Keyssner still less, or 1 abortion in 9 pregnancies, or a mortality of but 11 per cent.


Since the causes responsible for postnatal mortality differ so widely from those which operate before birth, it is wholly unlikely that a curve of postnatal mortality, if extended through prenatal life back to conception, as done by Busch and Moser and by Pearson, would tell the truth. Indeed, it could do so only by the merest chance, for the curve of postnatal mortality is based upon a totally different set of conditions. Besides, it undoubtedly is true that the rate of mortality varies from month to month in prenatal much as it does from decade to decade in postnatal life, although probably in a totally different way. It could fail to do so only if a perfect uniformity of conditions obtained throughout the period of gestation. Since this is not the case, the curve of postnatal mortality is of course based upon a totally different set of conditions.


Upon theoretical grounds, Pearson (1897) decided for a mortality of 37.6 per cent, or 1 abortion in every 2.7 pregnancies, an estimate which Mall (1917 C ) regarded as too low. This opinion of Mall would seem to be confirmed by Taussig (1910), who, from data obtained in 201 gynecological dispensary patients, concluded that there was 1 abortion to every 2.3 pregnancies, a mortality of 43.4 per cent; and also by the present series of almost 700 cases, which indicates a prenatal mortality of 58 per cent.


If we take the statement of certain social workers or propagandists, who allege that a conservative statement of the total number of criminal abortions annually performed in the United States is 250,000, then on the basis of Pearson, 1 in every 6, and on the basis of Mall's earlier estimate, 1 in every 3 interrupted pregnancies, is terminated criminally. However, Taussig (1910), on the basis of histories obtained from 293 patients at the St. Louis gynecological dispensary, reported that only 36 out of 371, or approximately 10 per cent, of the abortions in these women were admittedly mechanical. The histories in the Carnegie Collection present similar evidence, but these percentages undoubtedly are too low.


It should not be overlooked, however, that the surprisingly high percentages of prenatal mortality in the above women undoubtedly do not represent the actual life conditions of the whole population. They merely represent the conditions in women who have aborted. How much the inclusion of all those women who never had aborted would have lowered these percentages it is impossible to say, but one scarcely can doubt that the lowering would be considerable. After a fuller consideration of the literature, Schultz, page 183, estimated the prenatal mortality among the general population at 22.0 per cent, a figure somewhat higher than Mall's earlier but considerably below his later estimate.


Since the women in the present series do not constitute a dispensary group, but very largely also represent cases in private practice, one can not contemplate the amazing prenatal mortality in these women without the profoundest concern, not alone because of its significance upon the birth-rate, but also because of its relation to the wellbeing of these women and the effect of such practices upon public morals. Nor can one be quite certain that the indicated antenatal mortality is on the decrease or that it is high in these women alone, for Malins (1903), for example, believed that abortion is more common among the economically more fortunate classes. This opinion seems to be shared also by others. Nothing even remotely like it seems to be known in the case of the domestic animals, except in such conditions as contagious abortion. Aside from this affection, abortion in some domestic animals seems to be a rather rare phenomenon, having occurred, according to Malins, only 131 times in a series of pregnancies which resulted in 3,710 living colts. This is a ratio of only 1 abortion in every 29.1 pregnancies, or less than one-seventeenth the frequency found in the women in the present series.


But it is very clear that we lack sufficient data upon which to base reliable opinions regarding these matters. Social workers undoubtedly far overestimate the prevalence of criminal abortion, though it should at once be admitted that professional obstetricians very likely underestimate its frequency, for their opinion is based upon a rather different experience. However, that the estimate of the former is entirely too high can be shown also by their estimate of the deaths due to abortion. It has been stated publicly, for example, by enthusiasts for birth control that there are 8,000 deaths due to abortions, annually, in New York alone, and 50,000 in the entire country. Since the total number of deaths from all causes among all women between the ages of 15 and 40, regardless of whether they are child-bearing women or not, as estimated on the basis of the registration area according to the United States census for 1916, was only 139,642, one-third of all deaths in women of these ages would, according to these advocates, be due to criminal abortion!


No mention was made of the occurrence of previous abortions in 11.4 per cent of the 697 selected cases of abortion in which the clinical histories were quite complete and apparently reliable. This small percentage stands in marked contrast to the findings of Malins (1903), who stated that 63.4 per cent of the women in a selected series of 2,000 hospital and private cases had not aborted before, and that of the childless 3.2 per cent had aborted. Only 3 cases among the 697 were specifically stated to have suffered no previous abortions. In the rest of the 11.4 per cent the matter was not mentioned. Only 1 of these 3 women had borne children, and the remaining 2 were recorded as having had neither previous abortions nor children.


Malins, who found 14.2 per cent sterile women in a series of 2,000 selected private and hospital cases, stated that 3.1 per cent of these had aborted, but had had no children. Although it is not recorded in 78 cases that the women had either had children or abortions, one can not assume that they had neither, else the percentage of primiparae would be 11.4 as compared to 4.86 per cent in the series of Franz (1898). Graefe (1896) found only 2 out of 38 cases in primipars, a percentage of 5.5 per cent, and stated that Litthauer found only one such case. However, such small groups as these really can not contribute anything of statistical value, except when combined. Out of Hellier's series of 1,800 married women belonging to the laboring classes, 184, or over 10 per cent, never had been pregnant before, and 1,616, or 89.7 per cent, had one or more abortions. The latter was true of 92.9 per cent of the cases in the Carnegie series, and although repeated abortion occurred in a considerable percentage of these women, only 5.6 per cent had aborted more than 5 times.


The above 78 cases also represent the women in this series of 697 cases who may not have aborted previously. However, all of them had aborted once, or they would not be represented in the Carnegie Collection. The only exceptions to this statement may be a few instances of spurious pregnancy in which hemorrhage or membranous dysmenorrhea may have been taken for genuine evidence of pregnancy because of an irregularity in the menstrual history.


A single previous abortion had occurred in 56.6 per cent of 608 cases, and two previous abortions in 22.9 per cent. About 79 per cent of these women, as contrasted to the 66 per cent of Stumpf's series of 446 cases, had aborted once or twice previously, and 69.1 per cent once or twice only. Hence the great majority of the specimens in the present series came from cases of first and second abortions, as indicated in table 13. However, one should, I presume, recall in this connection that it always is easy for a woman to say that she has aborted onjy once or not at all. Yet the records probably are not very defective in this regard, for, as will appear later, most of the women were relatively young.


As shown in table 14, 394 out of 692 women, or 56.9 per cent, aborted before the beginning of the fourth month of gestation. Hence it is evident that most of the conceptuses from this series are small. Only 3 cases aborted during the last 2 months and 78.6 per cent before the beginning of the fifth month. The marked increase in the frequency of abortion from the first to the second month, as well as the marked decrease from the sixth to the seventh month, is not without significance. The same factor probably is at least partially responsible for both. Knowledge confirmatory of the fact that she is pregnant would come to a woman with the advent of the second month, while the viability of the fetus would act as a deterrent to interference with the gestation especially after the fifth month.


Only 33.4 per cent of the women of this series aborted in the third month, as compared to 59 per cent in the series of Diihrssen (1887), and to 42.7 per cent of Franz's (1898) cases, taken only, however, from the first 7 months of gestation. However, since only 3 of the present series of 692 cases aborted during the last 2 months, and only 14 during the last 3 months, it is quite immaterial whether or not the cases in this series from the last 3 months are included, for 98.2 per cent aborted before the seventh month. Although Franz stated that only 15.45 per cent of the cases collected by him had aborted before the twenty-eighth week, the summary given at the end of his paper would seem to make this percentage 76.9, which compares fairly well with the 98.2 per cent found in this series.


That no existing collection of specimens or of histories correctly represents the actual facts in the world at large would seem to be indicated by a comparison of the results obtained by different investigators, as given in table 15. With the exception of the results of Stumpf and myself, and some of those of Lechler for the third, fifth, sixth, and seventh months, the divergencies are striking probably irreconcilable and suggest that a far larger series of cases than that dealt with at present is necessary before any results closely approximating the truth can be obtained. The only regard in which the findings of Franz, Hellier, Stumpf, and myself are in surprising agreement is the average number of pregnancies to abortions per woman. This was 4.77 in Franz's, 4.59 in Hellier's, 4.15 in Stumpf's, and 4.58 in the present series. Hellier's group came largely from the laboring classes of Leeds. The Carnegie series comprises women from widely different stations in life and from widely scattered communities, and those of Franz and Stumpf came from different regions of the European continent. Since these four series included 3,762 women, it would seem that one can assume that the average of these groups, or 4.54 full-term pregnancies per abortion, probably approaches the truth very closely indeed. This truly remarkable agreement found in women from three countries also seems to imply that the proportion of births and abortions per woman is largely, if not wholly, independent of nationality and environment.


A very large proportion of the women in the histories of whom the matter was recorded were childless. This, as shown in table 16, was true of 143 out of 585 cases, or of 24.4 per cent. Hellier found the childless to form only 1.3 per cent of his series of 1,800 gynecological cases from among the working classes of Leeds. Approximately the same percentage of the present series as was childless had but a single child. A somewhat smaller number had two children, the childless and those who had one and two children forming 67.1 per cent of the whole group. Yet one woman had borne 14 and another 16 times.


Franz found that primiparae formed only 4.86 per cent of his series of 844 cases, but if we could assume that all the cases in the Carnegie series which were reported as childless actually were primiparae, then the percentage of the latter in this collection would be 24.7. However, since such a marked discrepancy exists between the percentage recorded by Franz and the latter figure, it is more than likely that a considerable number of the women recorded as childless in this series were not primiparae after all. This is indicated also by the fact that only 78 out of 697 women, or 11.2 per cent, of which number the 585 included in table 16 form a part, were unrecorded as to offspring or previous abortions. Only 2 additional cases were recorded as not having suffered an abortion previously. Consequently only 80 out of these 697 women, or 12.9 per cent, apparently were in their first pregnancy.


Franz found abortion twice as common in multiparse as in nulliparse. From clinical cases Graefe (1896) concluded that women who had borne three times aborted most frequently, but he added that this finding was not confirmed in his private practice. Stumpf found the ratio of abortions to births 1 to 5.1 in primiparae, but only 1 to 2.21 in multiparae having up to and including 5 children, and 1 to 2.22 in multiparse having more than 5 children.


As shown in table 16, the average number of abortions per woman is practically the same in the childless and in those having had one child, but with the second child a rise of almost 16 per cent takes place, for the average number of abortions per woman changes from 2.5 to 2.9. Another smaller advance is shown to occur with the fourth child, although there are relatively slight fluctuations in women having had 4 to 7 children. Since the number of women having borne 8, 9, and 10 children was so small, no conclusions could be drawn regarding them.


In all groups except the first two, composed of women having none or but one child, the average number of abortions lies between 2.9 and 3.6 per woman. Moreover, this ratio is practically the same in the groups having borne 2, 4, and even 6 children, but since the total number of cases involved in this table is only 585, the number in each group is necessarily small, being over 100 in the first three groups only.


Upon comparing the total number of previous abortions suffered by 697 women with the total number of children borne by them, we find that there was 0.84 previous abortion for every child. However, if the 697 abortions represented by the specimens which brought these women to our notice be included, then the ratio becomes 1.3 instead of 0.84 abortion per child; yet Malins, on the basis of 2,000 selected private and hospital cases, found but 1 abortion to every 5 children. A similar proportion is recorded also by Hellier, who, on the basis of 6,974 births and 1,288 abortions in 1,800 married women, found one abortion for every 5.5 children. Keyssner (1895), on the basis of 9,381 births and 1,194 abortions, found a ratio of but 1 abortion to every 8 births. Although the statistics of Keyssner were taken from the clinics, polyclinics, and gynecological journals, and those of Malins from selected private and hospital cases, one is at a loss to explain the great disparity between them and those in the present series.


In this series of 697 women with 1,351 children and 1,843 abortions, there were 1.3 abortions for every child or 1 abortion for every 1.7 pregnancies. This result differs somewhat from that recorded by Taussig for the cases in the St. Louis Gynecological Clinic, which was 1 abortion for every 2.3 pregnancies. The lack of correspondence between the estimate made by Taussig and that in the present series is not surprising, for the Carnegie series is fairly representative, being composed to a considerable extent of material obtained from the general practitioner. However, it is surprising to find that this ratio of children to abortions is lower in these women than in the cases from a dispensary, unless we accept the opinion of those who hold that abortion is more common among the economically more favored classes.


The relative constancy in the ratio of abortions to children in families with 3 to 7 children seems to imply that whatever the factors responsible for the interruption of pregnancy, they act with unexpected regularity in women of widely differing ages and with decidedly different reproductive histories. This would seem to imply that in these women there is no tendency to limit the family to any particular number of children through interference with the gestation, for were such the case abortion should be more frequent in connection with the particular number to which it is attempted to restrict the size of the family. This could fail to be true only if we could assume that this supposed limitation in the size of the family were due to causes other than interference with the gestation.


Only 29.1 per cent of the 607 women whose ages were given were less than 25 years old, but, as shown in table 17, 56.1 per cent were less than 30 and 77.4 per cent less than 35 years. In the series of Stumpf this was true of 23.3, 51.7, and 71.8 per cent, respectively. Upon considering the relation of the different age groups as shown in table 18, nothing unusual appears. The average number of abortions per child is highest in the 15 to 19 year group, in which it is 4.8. In the 20 to 24 year group it has dropped to 1.6, and then, as might be expected, a gradual decrease, both in the number of children and of abortions, is noticeable in each half-decade from 15 to 50 years, where it is 0.14.


The number of abortions per woman ranges from 1.1 in the 15 to 19 year group to 2.7 in the 40 to 44 year group. There is a decided drop in this average in the 45 to 49 year group, but since this group contains only 3 cases, it must be disregarded. In the 15 to 19 and 20 to 24 year groups, the average number of abortions per woman exceeds the average number of children, but after that the reverse is true, these ratios being almost equal in the 25 to 29 and 30 to 34 year groups. The greatest disproportion between abortions and children is reached in the 40 to 44 year group, in which the ratio is 2.08 children for every abortion.


Taussig found 870 full-term births in 293 women, the average number of children per woman being considerably higher, or 2.9, instead of 1.9 as in this series. The average number of abortions in 201 women was 1.8, instead of 2.6 as in this series. Hellier (1901) found that 1,800 selected married women had borne 6,974 children, or an average of 3.87 each, and in Franz's series of 4,255 women, the average number of children per woman was still higher, or 4.77, as compared with 1.9 of the present series of 697 women.


The series of 446 cases of Stumpf form a striking contrast to the present one, for, although the actual number of cases of pregnancy in essentially the above age groups ranges from 89 in the group over 40 to 365 in the 26 to 30 year group, the ratio of abortions per pregnancy differed markedly, as an inspection of table 18 will show. Aside from the entire lack of correspondence between the two sets of percentages shown there, especially as far as women below 20 are concerned, in whom the difference is practically 1,600 per cent, Stumpf found two maxima of abortions to births, instead of a gradual decline as in the Carnegie series. Stumpf 's first maximum occurred between 26 and 30, and the second after 40. It also is peculiar that although Stumpf 's ratios are 200 to 1,600 per cent below mine in women below the age of 40 years, they are 200 per cent higher than mine after this age. Since the discrepancies are so great, it is very likely that a number of unknown factors are involved. Hence it is hardly worth while to try to reconcile the remarkable difference.


The 21 admittedly unmarried women in this series had 25 abortions, or 1.2 abortions per woman, and 11 children, or 0.5 child each. Both of these figures are below the average for the professedly married women, yet, as might be surmised, the ratio of abortions to children is considerably higher in this group of the unmarried than in the case of all groups of the married except the 15 to 19 year group. It is 2.2 abortions per child. Since the average number of abortions per child in the 15 to 19 year group of professedly married women is more than twice as high as in the small group of the unmarried, it would seem that there is something in the marital relationship of women of these years, or in the attitude toward abortion on the part of the married, which is responsible for this difference. However, until a far larger group can be obtained, such a surmise remains unsupported.


In contrasting the number of abortions per woman in 344 women giving birth to conceptuses classed as normal with those suffered by 264 women who aborted conceptuses classed as pathologic, we find (table 19) that the former had sustained an average of 1.7 abortions and the latter only 1.79, or practically the same number. However, upon referring to table 20, it will be seen that a slight tendency to earlier abortion of pathologic conceptuses is indicated. Yet table 21 indicates that abortion of a conceptus classed as pathologic strangely enough seems to have had no discernible effect in reducing the number of children per woman. This is, of course, contrary to what one should expect, and undoubtedly contrary also to the facts. The 256 women giving birth to conceptuses classed as pathologic really had more children on an average than the 337 who had aborted conceptuses classed as normal, for women giving birth to conceptuses classed as pathologic had an average of 2.3 children, but those aborting conceptuses classed as normal only 2.1 children. Hence, one would seem to be led to the startling and impossible conclusion that pathogenicity of the conceptus, whatever its cause, does not reduce, but enhances, fertility!


It may be recalled in this connection that Hellier found that 96.5 per cent of the 1,800 married women who had abortions "almost up to the maximum" nevertheless later bore one or more children. But the explanation for the above anomalous and self-contradictory result probably lies in the fact that many conceptuses classed as pathologic very likely are merely macerated normal specimens, the form of which was changed during long retention.


The women aborting conceptuses classed as pathologic aborted somewhat earlier, for 86.7 per cent of them had done so before the beginning of the fifth month of gestation, as compared with 76.5 per cent of those who aborted specimens classed as normal. Since the groups in table 20 contain 402 normal and 290 pathologic cases, this difference in percentages of early abortions might seem to imply that conceptuses classed as pathologic actually had developed under unfavorable conditions, died, and were aborted sooner. Since, as previously stated, most of these are young, while those classed as normal are relatively older, one may assume that young conceptuses are retained relatively longer after death than older ones. This conclusion is borne out also upon comparing the menstrual with the estimated or anatomic ages of specimens grouped as normal and pathologic. From such a comparison it is evident that the specimens classed as pathologic were retained relatively longer after death than those classed as normal, and that had they been aborted as soon after their death as were those classed as normal, a still larger percentage of them would have been aborted before the fifth menstrual month than actually was the case.


From table 22 we learn that 50 per cent of the women aborting conceptuses classed as pathologic and 60.9 per cent of those aborting conceptuses classed as normal were below 30 years. Hence the women aborting conceptuses classed as pathologic would seem to have been somewhat older.


Upon contrasting the conditions in the small group of negro women, as revealed in tables 18 to 22, with those in whites, one is not justified in drawing any definite conclusion regarding the possibility of racial differences, because the group of negro women is so small; but nevertheless it strikes one's attention that self-induction of abortion is unrecorded among them. Psychic and accidental mechanical causes also are unrecorded. Therapeutic intervention occurred in only 1.3 per cent of the colored women, but in 6.6 per cent of the white. As shown in table 18, families with single children seem to be rarer among these negro women, but the average number of children was less, a fact in agreement with the statement in our last national census to the effect that, with the exception of the cities of Baltimore and Washington, the average family among negroes in cities of a population of 10,000 and over is somewhat smaller than that among whites.


Abortions among the negro women also seemed to fall somewhat later in gestation than among the white, only 65.4 per cent of them aborting before the fifth month, as contrasted with 79.7 per cent of the white women. The negro women, however, did not differ materially in age-grouping, as shown in table 22.


Could one take the figures deduced from the records of specimens classed as pathologic at their face value, one would be justified in concluding that but a very small percentage of the abortions here concerned were due to interference on the part of the patient. It also must be remembered that a smaller proportion of abortuses classed as pathologic than of those grouped as normal probably result from interference by the patient. This follows from the inference that a normal gestation may be presumed to continue uninterrupted in its development far more frequently than a pathologic one, a conclusion reached also by Giacomini and by Mall.


As shown in table 23, abortion was recorded as self-induced in approximately 34 per cent of 198 histories selected from the Carnegie Collection, in which other causes than disease are mentioned. But these percentages do not truly represent the situation, for such interference no doubt occurred in a far larger percentage of cases, for the simple reason that physicians are disinclined to record and report, and patients still more disinclined to state, such a fact. That the alleged causes are not always the true ones is a matter of common knowledge.


The interference was alleged to have been medicinal in only two of these cases. In the rest it was said to have been mechanical. This was true of 68 out of 90 cases in which the termination of the gestation was alleged to have been due to medicinal, accidental, or psychic causes or to mechanical interference on the part of the patient. This is a percentage of 70.8. Associated diseases were mentioned in only 54 out of 252 cases, or in 21.4 per cent. The abortion was recorded as having been spontaneous in 2 cases only, although no cause was recorded in 463 of the 697 cases. Therapeutic abortions formed 24.7 per cent of those in which a cause was assigned.


A comparison of the part played by various alleged causes of abortion as recorded in histories classed as normal and pathologic is given in table 24. What particularly strikes one's attention is the fact that tumors and displacements of the uterus are recorded more frequently as a cause of abortion among specimens classed as normal and self-induction more frequently among the pathologic cases. In a higher percentage of these the presence of associated diseases was mentioned, however, and miscellaneous and psychic causes also were recorded. Interference might be presumed to occur more frequently in cases involving pathologic conditions, yet it is recorded more frequently in connection with conceptuses classed as normal. It is not unlikely that the explanation given for the apparent increase in fertility with the increase in frequency of abortion applies also to this contradictory result. However, therapeutic intervention was somewhat more common among the pathologic in a somewhat larger percentage of which no cause for the termination of the gestation was assigned". The latter was the case in 76.6 per cent of 264 pathologic and in 63.3 per cent of 344 normal cases out of a total of 608. Miscellaneous causes, such as exertion, purgative drugs, coitus, etc., were assigned as frequently in the one as in the other class of cases, but the total number in each group is so small that these percentages probably are not very reliable.


That the abortion was inevitable in many, even if not in the majority, of the so-called spontaneous or habitual cases, is corroborated by the fact that most of the abortuses in the pathologic division are young, by far the greater majority of the older. fetuses falling among the normal. Moreover, many of the larger conceptuses also are received fresh, and in the case of those which were received as the result of such complications of pregnancy as toxemia, pernicious vomiting, placenta prsevia, febrile conditions, and other similar causes, these causes are recorded.


There often is no way of accounting for the termination of the so-called spontaneous cases from an examination of the conceptuses alone. However, it was very interesting to frequently find that the chorionic vesicle and the decidua had undergone pronounced changes in the case of abortions which were reported as spontaneous. Many of these fell into the first four groups of Mall's classification and showed the presence of hydatiform degeneration, thus contradicting the statement of Hegar (1904) that hydatiform moles almost invariably occur only later in pregnancy, and confirming the statement of Solowij (1899), who claimed that clinical experience teaches that hydatiform moles are aborted in toto only in the first months of pregnancy.


Indeed, pathologic conditions of the chorion and decidua seem to be especially frequent causes for the termination of pregnancy during the early months, although one must recall that decidual and possibly chorionic changes may be the consequence of previous interference alone. It may long remain impossible to determine the true or original cause of antenatal death, for the secondary or immediate cause may completely mislead one. Hegar (1902) concluded that the cause of abortion not infrequently lies in the decidua alone, and that the death of the cyema usually can be shown to be due to degenerate changes in the villi. He came to this conclusion because he found no evidence of pathologic changes in the chorions of some abortuses. That endometritis and other uterine conditions pre-existent to the implantation may be responsible, especially for early abortions, one can not doubt, for the changes in the endometrium and decidua frequently seem to be so profound.


Certain alleged minor causes to which recourse is had by patients recur so frequently in the histories that this fact alone suggests that they probably are not the true or ultimate causes. Among such causes, a slip or a slight fall on the stairs and minor psychic disturbances may be cited. That psychic disturbances may interrupt gestation seems quite likely, but they probably merely are the immediate, not the ultimate, cause of the abortion. They could be regarded as the ultimate cause only if the conceptus is aborted well preserved, for otherwise one would have to assume that psychic causes can produce uterine contractions sufficiently severe to cause the death of the conceptus, and that later, after the conceptus has become macerated, recurring similar psychic disturbances finally effect the expulsion of the macerated specimen.


Since infectious diseases no doubt very often are the immediate rather than the ultimate cause of abortion, as Harris (1919) found in the case of influenza, it undoubtedly may be assumed that many of the abortions caused by such and similar complications would have occurred later. They remind one of the defective fruit which persists insecurely upon the tree until a sudden gust of wind showers it to the ground. The findings of Harris regarding the effects of influenza and pneumonia upon gestation, seem to be confirmed also by the small series of cases of abortion among the present series in which the abortion was attributed to an infectious disease. But in considering the alleged causes of abortion, one must bear in mind that when a woman knows of a plausible exonerating reason for the termination of the gestation she has every incentive to state it. That this is the case is indicated by the various strange and, to the initiated, highly improbable or even impossible reasons often assigned for the interruption of a pregnancy.


Associated constitutional or venereal diseases were recorded in only 76 out of 697 selected histories. In 463 of these 697 cases the cause of abortion was not given. In 52 out of the 76 cases in which associated diseases were present, other causes for the termination of pregnancy also were recorded. Hence the suggestion that the associated diseases probably were merely the immediate or incidental causes in these cases seems decidedly probable.


What strikes one's attention in the perusal of some of the histories is the long period during which many of these young conceptuses really were in process of abortion, as indicated not only by the anatomic as contrasted with the menstrual age, but also by the repeated hemorrhages. Since in most of these cases the abortion probably was inevitable from the beginning, it would seem that the conclusion of Giacomini, reached also by Mall, that one should not temporize with such cases, but promptly relieve the patient of an abnormal, dead or dying conceptus, would seem to be justified. That some general practitioners apparently are beginning to realize this situation is instanced by Dr. Bacon, who, in connection with a recent specimen donated to the collection, wrote: "This makes the second or third case in which I have apparently delayed an abortion and, when the gestation finally was ended, was rewarded with an abnormal child for my pains. I wonder if it really pays humanity?" However, the practitioner no doubt meets with great and often insuperable difficulties in determining the exact status of affairs, and in the present state of our knowledge he must temporize so as not to be led into unjustifiable procedures. There is no doubt, however, that conservative symptomatic treatment, no matter how unavoidable because of our inability to determine the condition of the conceptus, often is directly opposed to the best interests of the patient.


No case confirmatory of that reported by Jackson (1838) came to my attention among those in the Carnegie Collection. It seems strange that one of a pair of human twins can be aborted weeks or even months before term and the other continue in uninterrupted development to the end of normal gestation. Moreover, since the authenticity of Jackson's case rests solely upon the statement of "a very intelligent lady" who was "too intelligent to be deceived and too honest to deceive," one scarcely can feel convinced by it alone. However, Jackson stated that Nancrede had observed a similar case in which one fetus was aborted at 4^ months and the other went to term, and Fuertes (1879) reported such an instance as one of superfetation. In this case a woman of 27 years gave birth to a male child on March 13 and to a female on July 27. The former, which lived only 15 days, was regarded as having been born in the seventh month of pregnancy, and the latter at full term. Bonnar (1865) also reported a series of cases of this sort in connection with a review of the question of superfetation. It is true that the alleged denouement in dystocia and also in cases of interrupted labor seems to suggest that even vigorous contractions of the uterus are not inconsistent with retention of attachment by the placenta, but expulsion of one with retention of the other fetus for some months afterward would seem to fall into a somewhat different category.


In examining the histories one is impressed by the frequent cases of so-called habitual abortion. These sometimes begin with the married life of a young woman and continue more or less interruptedly throughout her child-bearing period. This is illustrated by the cases in which a birth at term was followed by several abortions, and by another birth at term and again by abortions. Regarding some of these cases, it is clearly stated that the patients took steps to terminate the unwelcome pregnancies, and in others the histories concerned mothers who had given birth to 6 or more, even up to 13 children, and then suffered one or more successive abortions, without a history of previous abortions. This is illustrated by the following seven cases, for example, in which the women had borne 6, 8, 9, 10, 11, 12, and 13 children, respectively. The first woman had experienced 4 successive abortions, the following 5 one abortion each, and the last, 3 successive abortions. In some of these cases it is fairly evident that weariness with such heavy burdens of child-bearing probably was responsible for the termination of pregnancy, while in others abortion may have resulted from exhaustion due to a large series of quickly succeeding gestations, and in still others to pathologic or other causes. Experience with higher domestic animals, too, would seem to suggest that abortion not infrequently follows too closely repeated pregnancies, especially under the stress of advancing years.


If the condition of the uterine mucosa at the time of implantation of the impregnated ovum may show variations in structure at all comparable to those seen in deciduse accompanying abortuses, then it is easily conceivable that the fate of the conceptus may be determined by the structure of the implantation site. Not infrequently a small area of the decidua about an abortus shows all the transitions shown in figures 75, 76, 77 (plate 6, Chap. IV), and 135 (plate 13, Chap. IX). The first figure shows the fine, clear, large, potygonal decidual cells, practically wholly infiltrated, and hence presents a rather homogeneous appearance. Figure 76 shows considerable infiltration and autolysis, and also marked change from the usual polygonal cell found present in the post-menstruum by Hitschmann and Adler (1908) to a fibroblast form. In figure 78 (plate 6, Chap. IV) the normal decidual cells have become still more elongated, and in figure 135 the decidua is represented by a decidedly fibrous mass totally different from what it once was. I do not know how far these changes of fibrosis of the decidua may have progressed before implantation occurred, but if the changes in the mucosa are at all pronounced, one scarcely can believe that they can fail to profoundly affect the nutrition and growth of the conceptus.


It may be urged that fibrosis of the decidua is but an effect of the death and retention of the conceptus rather than an indication of the pathologic conditions pre-existent in the mucosa. However, the many instances of abortuses in which the decidua is very degenerate and also infiltrated would seem to argue against such an assumption. Besides, many of the decidua? found surrounding retained specimens do not show comparable changes. Moreover, Orloff (1896), Iwanoff (1898), and L. Fraenkel (1903, 1910 b ) found that restoration of the mucosa may begin before the conceptus is expelled from the uterus. This fact also seems to suggest that fibrosis probably is pathologic in significance. Moreover, in the few cases of partial regeneration of the mucosa which came to my attention, the decidua was not in the fibrous state shown in figure 135. Infiltration of the decidua no doubt more frequently might arise after death of the conceptus, but that it frequently is present long before this time would seem to be indicated also by the fact that the presence of fibrosis does not seem to bear any definite relation to the duration of the retention, and that the condition of the mucosa before implantation can markedly influence the course of gestation is indicated also by the findings of Punto (1906) in cases of pregnancy complicated by myomata.


Table 13. Total number of cases (608), grouped according to the number of previous abortions

Number of abortions.


Total.


1


2


3


4


5


6


7


8


9


10


11


12


13



178 137 16 12


75 56

4 4


31 33

2


8 11

4 2


12 5


5

1

1


1


2


2


1


1


2


317 243 27 21 P th 1 1 H


1


1


Total

343


139


66


25


17


7


1


3


3


1


1


2

TABLE 14. Total number of cases (692), grouped according to the time of last abortion in months

Month of gestation.

Total.

1


2


3


4


5


6


7


8


9


10


14 7 1 1

75 57 4 4

103 112

8 8

95 45 8 2

36 17 9

1

29 13 3 4


13

8


3

7


1

369 268 33 22


2

1


1

Total

23

140 231

150

63

49


22


11


1


2


TABLE 15. Comparative time of abortion

Author.

No. of cases.

Month of gestation.


1


2


3


4


5


6


7


8


9


10


Franz


824 26 500 620 692 446


p. ct. 0.12


p. ct. 33.1


p. ct. 43.6


p. ct. 16.0 3.7 7.4 12.5 21.6 7.6


p. ct. 4.4 14.8 1.0 10.8 9.0 9.3


p. ct. 2.5


p. ct.


p. ct.


p. ct.


p. ct.


Graefe


7.4


18.6


11.1

Kneiss (Tausaig)


1.2 0.8 3.3


44.4 12.8 20.2 9.8


14.6 52.0 33.3 30.8




Lechler


5.0 7.0 7.1


7.0 3.1 3.3


1.6 11.0


0.14 13.6


0.29 7.1

Stumpf . . .

Average


1.36 2,636


24.1 2,982


34.9 2,982


1L.5 3,007


8.2 3.007


5.4 2,482


5.2

1,683


10.4 1,163


8.28 1,163


3.7 1,138


No. of cases


3,007


TABLE 16. Total number of cases (585), grouped according to the number of children

No. of children.


No. of

cases.


No. of abortions.


Average No. of abortions per woman.


No. of children.


No. of cases.


No. of abortions.


Average No. of abortions per woman.


143


359


2.5


7


18


65


3.6


1


142


364


2.5


8


4


9


4.7


2


108


323


2.9


9


7


24


3.4


3


64


212


3.3


10


4


21


5.2


4


40


125


3.1


6


36


122


3.5


Total. .


585


1093



6


12


37


3.0


TABLE 17. Total number of cases (607), grouped according to the age of the mother

Age of mother (years).


Total.


15 to 19


20 to 24


25 to 29


30 to 34


35 to 39


40 to 44


45 to 49


Normal white


21 9 4 2


80 49

4

8


91 63 9 1


60 66

7 6


44 37 4

1


18 28

1 1



314 244 29 20



2



Pathologic colored .... . .


1


Total


36


141


164


129


86


48


3


TABLE 18. Ratio of abortions to children in the various age-groups. Total number of cases, 576

Average



Average


Ratio of average


Stumpf (446 cases).



No. of


No. of


No. of


No. of


No. of abortions


cases.


abortions


cases.


children


to average No.

per woman.



per woman.


of children.


Age.


Average No.


15-19


29


1.1


20


0.23


4.8


Before 21


0.30


20-24


134


1.4


133


0.84


1.6


21-25


0.31


25-29


161


1.7


156


1.9


0.89


26-30


0.45


30-34


124


2.2


123


2.6


0.84


31-35


0.36


35-39


80


2.2


78


3.4


0.64


36-40


0.37


40-44


45


2.7


44


5.6


0.48


40 +


0.75


45-49


3


1.0


3


7.0


0.14


TABLE 19. Total number of cases (608), grouped according to the number of abortions, race, and the nature of the conceptus

No. of abortions.


Total.


1


2


3


4


6


6


7


8


9


10


11


12


13



194 149


79 60


33 33


12 13


12 6


6

1



2

1


2

1


1


1


2



344 264


Pathologic. . . . Total .... White


1







343


139


66


25


17


7


1


3


3


1


1


2



608



315

28


131

8


64 2


19 6


17


5 2


1


2 1


2 1


1


1


2



560

48



Total








343


139


68


25


17


7


1


3


3


1


1


2



608



TABLE 20. Total number of cases (692), grouped according to time of abortion by months, race, and nature of the conceptus

Month of gestation.


Total.


1


2


3


4


5


6


7


8


9


10



15 8


79 61


111 120


103 47


45 18


32 17


13 9


3

8


1



402 290



2


Total



23


140


231


150


63


49


22


11


1


2


692


White


21 2


132

8


215 16


140 10


53 10


42

7


21 1


10

1


1


2


637 55



Total




23


140


231


150


63


49


22


11


1


2


692


TABLE 21 Abortions grouped according to the number of children, race, and the nature of the conceptus

(Total number of cases, 593.)



No. of children.


Total.



1


2


3


4


6


6


7


8


9


10


11


12


13


14


15


16



79 68


91

50


58 51


39 26


24 17


17 19


8 4


9 9


2 2


2

5


3 2


3

1


1



1




337

256



1




1


Total






147


141


109


65


41


36


12


18


4


7


5


4


1


1


1



1


593


White


133 14


134

7


102 7


61 4


40 1


35

1


9 3


15 3


4


5 2


3

2


3 1


1


1


1



1


548 45



Total







147


141


109


65


41


36


12


18


4


7


5


4


1


1


1



1


593

TABLE 22. Abortions grouped according to the age of the mother, race, and the nature of the conceptus

(Total number of cases, 607.)



Age of mother (years).


Total.


15-19


20-24


25-29


30-34


35-39


40-44


45-49



25 11


84 57


100 64


67 62


48 38


19 29



343 264


Pathologic


3


Total


36


141


164


129


86


48


3


607

558 49


White


30 6


129 12


154 10


116 13


81 5


46

2


2 1


Colored . ....


Total


36


141


164


129


86


48


3


607


TABLE 23. Total number of cases (697), grouped according to the causes of abortion

Cause of abortion.


Total.


Unrecorded.


Spontaneous.


Selfinduced.


Therapeutic.


Accid. Mech.


Psychic.


Assoc. disease.


Tumor and malposition.


Miscellaneous.


Normal white


233 189 25 16


1

1


48 20


31 12 6

1


9 3


6 5


25 24 1 4


18 10 4 1


17 7 1 1


387 271 36 23


Pathologic white


Normal colored


Pathologic colored Total



463


2


68


49


12


10


54


33


26


717 20


Less duplicates ....


Total cases



697




TABLE 24. Causes of abortion (252 cases)

Alleged causes of abortion.


Pathologic (88 cases).


Normal (164 caaes).


Self-induced


p. ct.

on o


p, ct. oo 7


Therapeutic


21 O


U7


Tumor and malposition


12 5


IQ 4


Associated disease


Q1 Q


1C Q


Miscellaneous. Psychic \.


Accid. mech. . J


The cause was unrecorded in 76.6 per cent of 264 pathologic and in 63.3 per cent of 344 normal cases out of a total of 608.



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Mall FP. and Meyer AW. Studies on abortuses: a survey of pathologic ova in the Carnegie Embryological Collection. (1921) Contrib. Embryol., Carnegie Inst. Wash. Publ. 275, 12: 1-364.

In this historic 1921 pathology paper, figures and plates of abnormal embryos are not suitable for young students.

1921 Carnegie Collection - Abnormal: Preface | 1 Collection origin | 2 Care and utilization | 3 Classification | 4 Pathologic analysis | 5 Size | 6 Sex incidence | 7 Localized anomalies | 8 Hydatiform uterine | 9 Hydatiform tubal | Chapter 10 Alleged superfetation | 11 Ovarian Pregnancy | 12 Lysis and resorption | 13 Postmortem intrauterine | 14 Hofbauer cells | 15 Villi | 16 Villous nodules | 17 Syphilitic changes | 18 Aspects | Bibliography | Figures | Contribution No.56 | Contributions Series | Embryology History

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