Abortion

ABORTION. Contents: I. Artificial abortion as a socio-domestic phenomenon............ 40 II. Abortion as a medical phenomenon.... 48 III. Abortion from a forensic medical perspective.................. 55 Abortion is defined as the premature termination of pregnancy, either artificially or spontaneously, during the first 7 lunar months or 28 weeks. I. Artificial abortion as a socio-domestic phenomenon. Artificial abortion has been known throughout human history. Although no data on abortion among primitive peoples has been preserved, its existence can be inferred from the fact that abortions are still performed among peoples at a primitive stage of development: among Eskimos, natives of New Zealand, New Caledonia, Samoa, Tahiti, Fiji, Solomon and Canary Islands, and among Kaffirs of South Africa. They perform abortion due to lack of nutrition or conditions of nomadic life (Eskimos). In ancient Greece, abortion was widely used for socio-economic reasons and to regulate population size (Plato, Aristotle). In the Hippocratic Oath, artificial abortion is mentioned as a crime, although Hippocrates himself lists means to produce abortion in his writings. In ancient Rome, abortion became even more widespread; it is mentioned in the satires of Juvenal, Ovid, Seneca's letters to his mother, and other writers. In neither Greece nor Rome was value placed on the fetus in the mother's womb, and therefore no repressive measures were taken against abortion. Only among Jews was the production of abortion considered infanticide, with corresponding punishment. Abortion remained unpunished also in the first centuries after the emergence of Christianity, but even then proposals were put forward to consider the fetus after 40 days as animated, and from the time of the Sixth Ecumenical Council, the destruction of an animated fetus is punished by death. The Code of Charles V (1533), Emperor of the Holy Roman Empire and King of Spain, already punished with death both the one who caused a miscarriage and the woman who performed an artificial abortion on herself. The influence of the church and its view of abortion as murder had the strongest effect on the legislation of European countries, which in the Middle Ages applied extreme punishments for the production of abortion, up to the death penalty. Only with the development of the humanitarian movement and the creation of new social relations did proposals begin to emerge for the mitigation of punishment for abortion. The book by Beccaria (in 1764) 'On Crimes and Punishments' appeared, where it is indicated that one must take into account the difficult situation of a woman deciding on abortion, and preventive measures are recommended, such as the organization of shelters, assistance to 'fallen' women, etc. In Prussia, from 1794, abortion was punished only by imprisonment from 6 to 10 years, and if it was performed without the mother's knowledge - from 10 years to life imprisonment; according to the Bavarian law - by confinement in a workhouse from 4 to 8 years. In France, during the time of the French Revolution (from 1791 to 1810), a woman who performed an abortion on herself was completely exempt from criminal liability, while accomplices were punished with imprisonment up to 20 years. But the Napoleonic Penal Code (1810), which is still in force, punishes more severely. The old Russian Code of Punishments considered the destruction of the fetus as murder (Articles 1461-1463). Thus, according to Article 1461- 'whoever, without the knowledge and consent of a woman, intentionally by any means causes the expulsion of the fetus, is punished by hard labor from 4 to 6 years; but if at the same time the woman is caused serious injury - then by hard labor from 6 to 8 years, and if death - then from 8 to 10 years.'- The one who caused the expulsion of the fetus with the knowledge and consent of the pregnant woman was punished, under Article 1462, by corrective imprisonment in separate departments from 5 to 6 years, and the pregnant woman herself - by imprisonment from 4 to 5 years with deprivation of all special rights. The punishments determined by Articles 1461 and 1462 were increased by one degree if a doctor, midwife, obstetrician, pharmacist, or one previously guilty of the same crime was involved in the crime. The Criminal Code of 1903 already reduced the severity of punishment. Thus, under Article 465: 'a mother guilty of killing her fetus is punished by confinement in a corrective institution for a term not exceeding three years', and Article 466: 'one guilty of killing the fetus of a pregnant woman is punished by confinement in a corrective institution'. Thus, in relation to abortion, one can note a period of impunity (up to the 15th-16th centuries), then a period of harshest repression (until the end of the 17th century), and finally some mitigation of punishment (in the 19th century). Most laws of Western European states on abortion to this day are constructed almost analogously to the cited Articles 465-466 of Russian legislation. Nevertheless, bourgeois states, based on private property sanctified by the church, and needing a reserve army of the unemployed and a human reserve in case of war, left rather severe punishments for abortion in their legislation. But despite punitive measures, the number of abortions has been rapidly increasing since the 80-90s of the last century. The increase in the number of abortions can be judged 1) by the decline in birth rate, 2) by the increase in the number of persons charged and convicted of abortion, and mainly 3) by the increase in admissions of women to hospitals with abortion initiated outside. The decline in birth rate in Germany is expressed in the following figures: per 1,000 population, the birth rate was in 1880-40; in 1890-37; in 1900-36; in 1910-30 and in 1924-already 26. The decline in birth rate is most sharply manifested in France: already in 1901 it was equal to 22; in 1910 - 19.7 and in 1924 - 19.6, and the natural increase in population was either insignificant or gave a negative value. The number of persons convicted of abortion in Germany rose from 243 people in 1885 to 949 in 1911, 1,467 in 1913 and 5,296 in 1924. (In the USSR, in 1926, 66 men and 805 women were convicted of abortion, mainly midwives). The punitive system for abortion, the bourgeoisie directs exclusively against working women and peasant women. Thus, in Austria, out of 100 women convicted of abortion, 92% were insolvent; professional abortionists rarely end up in the dock. Admitted to hospitals with abortion initiated outside in Germany (Latzko, materials from Vienna clinics): in 1898-18.9% of all admissions; in 1908-32.7%, in 1913-57.2%. According to Hamburg statistics, after the war, the number of these admissions reached 60-70%. Per 100 abortions, Bentin considers 89% artificial; according to Nuremberg statistics-66%; according to Hamburg-70%. According to Sandhorn, the number of abortions increased from 8-10 per 100 births in 1890 to 15 in 1910 and reached 25 in 1924. According to Bentin's data, 240,000 abortions were performed in Germany in 1911; in 1923-500,000 (Heynemann's data) and in 1924-875,750 (Liepmann), of which 70-80% of these abortions were criminal (Schoffer, Nuremberg, Bumm). For Berlin, Roesle considers 23,000 artificial abortions annually, and Freudenberg indicates that in Berlin the number of abortions increased from 10 (1909) to 40 (1921) per 100 births. Lacassagne determines the number of artificial abortions (before the war) in Paris at 70,000 annually, in all France-from 450,000 to 500,000. Delèri believes that 35-40% of all pregnancies in France are terminated artificially. In 1905, in the Strasbourg clinic, 10.5%, in 1906-12.7%, in 1907-14.4% of admissions were with miscarriage. In the Lepeshin maternity hospital in Moscow, admissions with abortion were in 1908-3.4%, 1909-5.3%, 1910-6.7%, 1911-11.6%, 1913-13.5% in relation to all admissions. In the Timister hospital (for postpartum diseases) in 1910-17.9%, 1911-20%, 1913-30.9%. In Leningrad, from 1904 to 1909, the number of miscarriages increased in maternity institutions from 10% to 17%, and by 1910 in gynecological departments - even to 33% in relation to all admissions. According to Borkhov's data, in Leningrad in 1914, 4,734 were admitted with abortion, in Moscow in the same year-5,537. The dynamics of abortion in Moscow and its frequency are visible from the following data (see table on the next page). Years

3.8

4.6

6.4

6.8

9.3

10.2

18.7

21.6

19.2

19.5

31.4

35.4

35.2

34.2

33.5

32.2

31.0

30.6

25.6

30.1

29.3

31.0

1.3

1.6

2.2

2.3

2.9

3.2

5.7

5.5

5.5

5.7

9.7

36.7

36.8

36.4

35.8

35.1

34.2

36.3

31.1

35.6

35.0

40.7

It must be noted that before 1920, only complicated abortions that were completed in hospitals were registered. The actual figures were undoubtedly higher. At present, it can be assumed that in Moscow, almost 90% of abortions are performed in hospitals. All the data presented above prove the continuous growth of abortions over the last 50 years. The main cause of this social phenomenon was the lack of material means for supporting offspring. The growing participation of women in industry also played a significant role. Since the introduction of machinery, capitalists have been able to use unskilled labor force—children and, especially, women—who are paid less, which led to the rapid growth of the female proletariat, which in the present day in Germany and France has reached 10,000,000. In the textile industry of Germany, women were employed in 1907—21.6% of all employed in this production, in 1912—29.9%, in 1913—31.2%, in 1923—34.6%, in 1924—35.3%. In the USSR, in the textile industry, women make up 55% of the total number of workers. Meanwhile, the participation of women in production in a capitalist state inevitably leads them to a deep contradiction with the function of motherhood: a woman, in order to preserve her earnings, more and more often resorts to abortion. In the USSR, the involvement of women in industry, contributing to their economic emancipation, is at the same time supplemented by the broadest system for the protection of women's labor and the protection of motherhood and infancy. But however far legislation and practical measures to ensure the normal upbringing of a child may go in this regard, they can only partially alleviate the acuteness of the issue of abortion. Women's desire to take a more active part in public life inevitably leads to a desire to limit childbirth. In the last decades before the war, and in bourgeois states even now, the working class is waging a stubborn struggle for the legalization of abortions, attracting in this struggle a number of representatives of the liberal intelligentsia. Thus, in Germany even before the war, a number of prominent criminologists spoke out in favor of abolishing the criminalization of abortion. To their voice, under the tsarist government, the XII Pirogov Congress and the X Congress of the Russian section of criminologists also joined. The struggle of the working class, in turn, led to a great softening of the punishment for abortion. Abortions in the USSR. From the very first days of the October Revolution in the USSR, the criminalization of the production of abortions was actually abolished, which was subsequently formalized by the following resolution of the Commissariats of Justice and Health of November 18, 1920 (in the Ukrainian SSR—July 5, 1923): 'In the last decades, both in the West and among us, the number of women resorting to the termination of their pregnancy is increasing. The legislation of all countries fights this evil by means of punishments for both the woman who decides on a miscarriage and for the doctor who performs it. Without bringing positive results, this method of fighting has driven the operation underground and made the woman a victim of greedy and often ignorant abortionists, who have made a business out of this secret operation. As a result, up to 50% of women become ill from infection and up to 4% of them die. The Workers' and Peasants' Government takes into account all the harm of this phenomenon for the collective. By means of agitation against abortions among the masses of the working female population, it fights this evil, and by introducing the socialist system and widely implementing the principles of Protection of Motherhood and Infancy, it foresees the gradual disappearance of this phenomenon. But, as long as the moral remnants of the past and the heavy economic conditions of the present still force some women to decide on this operation, the People's Commissariat of Health and the People's Commissariat of Justice, protecting the health of women and the interests of the race from ignorant and greedy charlatans and considering the method of repression in this area absolutely ineffective, resolve: 1) The free and free production of this operation is permitted in the setting of Soviet hospitals, where its maximum harmlessness is ensured. 2) The production of this operation is absolutely prohibited to anyone other than a doctor. 3) Those guilty of performing this operation—a midwife or a traditional birth attendant—are deprived of the right to practice and are brought before the people's court. 4) A doctor who performs the operation of fruit expulsion in his private practice for greedy purposes is answerable before the People's Court. People's Commissar of Health N. Semashko, People's Commissar of Justice Kursky'. The legalization of abortions sharply increased the hospital attendance of women who previously resorted to the services of private abortionists for this purpose. The number of registered abortions therefore began to grow rapidly. That this growth is indeed mainly explained by the extraction of abortions from the underground is proven by the stability of the birth rate indicator in the USSR. Thus, the birth rate coefficient in the USSR: in 1911—43.8; in 1923—42.2; in 1924—42.9; in 1925—44.2 and in 1926—43.8. On the other hand, the number of women admitted to hospitals with an abortion started outside is decreasing. According to the data of the People's Commissariat of Health, in 20 provinces in 1923—42%; in 1924—37% and in 1925—28.8% in relation to the total number of abortions. An even sharper decrease in underground abortions in Moscow, going parallel with the growth of beds for abortions: in 1923—57.9%; 1924—43.2%; in 1925 already only 15.5% and in 1926—12.2%. Although the number of underground abortions is decreasing, and although abortions are even in the underground are performed with greater precautions, they are still fatal to women's health. Thus, it turns out that the termination of pregnancy is performed (data for Moscow for 1925 in %): in the 1st month 1.5, in the 2nd month 81.7, in the 3rd month 16.4, beyond the 3rd month in hospitals

0.4 Outside hospitals (clandestinely).... 0.6 48.1 33.9 17.4 Thus, 17.4% of clandestine abortions are performed after three months, i.e. at the moment most dangerous for the female organism. For performing clandestine abortions, various sharp-pointed objects are used: probes, awls, spindles, etc. By resolution of the People's Commissariats of Health and Justice of November 3, 1924, it was proposed that local commissions be organized to issue permits for free abortions in hospitals with the establishment of priority, namely: 1) unemployed single women, 2) single working women with one child, 3) employed mothers of many children, 4) wives of workers with many children, 5) all other categories of insured women, and 6) other female citizens. Social indications for abortion, according to the People's Commissariat of Health, are large families (presence of 3-4 children) and lack of support. The degree of these is judged by the commission. Due to the shortage of hospital beds, women who received a refusal from the commission were forced to turn to the few private clinics, and more often to doctors, midwives, and other individuals still engaged in clandestine abortions. Therefore, most provincial health departments in the last 2-3 years, in order to extract the maximum number of abortions from the underground, have introduced paid beds for persons not meeting social indications that give the right to receive a free bed for abortion. "Abortion" commissions were not organized in rural areas, and peasant women had to travel to district cities to obtain permission for abortion. This had a negative effect on the fight against clandestine abortions among peasant women. Therefore, by circular of March 17, 1925, the People's Commissariat of Health granted district physicians the right to independently decide on the performance of abortion in the presence of medical and social indications. The 1920 resolution on the legalization of abortion made it possible to study socio-medical data on women seeking abortions. From July 1924, mandatory registration on "abortion cards" was established for all women who received permission from commissions for abortion. This same "card" must also be filled out for women admitted to hospital in a state of miscarriage (extra-hospital abortion) and in private clinics. The study of these cards began the statistical study of the abortion problem. Number of Abortions. Among industrial groups, 3,011 Ivanovo-Voznesensk textile workers were investigated. It turned out that among them, per 100 pregnancies from 1900 to 1913, 5 ended in miscarriages; from 1914 to 1916 - 9; 1917-1919 - 15; 1920-1922 - 23; 1923-1924 - 29. It is characteristic that among them before 1917, over 50% of children died annually, in 1918 only 38%, in 1919 - 32%, in 1921 - 25%, in 1922 - 30%, in 1924 - 17%, i.e. simultaneously with the increase in the number of miscarriages, there was a decrease in child mortality. Data for 1924-25 have also been compiled for 20 provinces. The frequency of abortion is calculated at 5 to 6 per 1,000 population in rural areas, or about 13% in relation to the annual number of births; in Moscow - 9.7 and in Leningrad - 12.0 per 1,000 population, or 43.2 per 100 births in Leningrad and 31.4 in Moscow (for 1925). Although the number of abortions is increasing, "a significant portion of the visible increase in the number of abortions must be attributed to the improvement in statistical registration of abortions and to the spread among the population of information about the possibility of hospital performance of the operation" (Paevsky). The frequency of abortion is affected by the instability of marital relations. Thus, in Leningrad in 1925, per 100 births from registered marriages, there were 31.5% of all abortions, per 100 births from unregistered marriages - 47.2%. The number of abortions in unregistered marriages is also influenced by casual sexual relations, which is confirmed by the fact that in 1925 in Leningrad and Moscow among women with registered marriages, the first pregnancy is terminated by abortion: in Leningrad - 4.2%, in Moscow - 5.6% (of all abortions), while among unregistered: in Leningrad - 29%, in Moscow - 19.5%. - A factor influencing the frequency of abortion is also alcoholism. The consumption of alcoholic beverages leads to a greater number of accidental pregnancies and therefore greater demand for abortion services. Thus, per 1,000 pregnancies among Ivanovo-Voznesensk textile workers, there were abortions: among non-drinkers - 33, among alcohol consumers - 39. The influence on the frequency of abortion is also exerted by literacy, which increases the cultural demands of women and their desire to participate in public life. This is confirmed by a study of the same Ivanovo-Voznesensk workers (Department for the Protection of Motherhood and Infancy), where per 1,000 pregnancies, there were 55 abortions among literate women, and 23 among illiterate. The age of women terminating pregnancy in cities (data for 1925) shows that the largest group (about 65%) among them are women under 30 years of age. Moscow.. 0.2

31.5

3.8 Leningrad 0.2

31.6

3.9 The group of persons not in registered marriages shows a significantly greater participation of young ages (under 30 years) - 74.6% (in registered marriage - 61.7%). As for social status, the majority of women who had abortions were engaged in hired labor, followed by students, the unemployed, wives of military personnel, and wives of workers and employees. Thus, according to data from the Department for the Protection of Motherhood and Infancy, per 1,000 working women and female employees - there are 25 abortions, per 1,000 wives of workers and employees - 19 abortions. The motives for abortion in cities are, mainly, lack of material resources related to housing need (the majority of women who had abortions live in one room with four or more people): in Moscow - 53.7%, in Leningrad - 62.6% of the total of all motives; poor health: Moscow - 12.7% and Leningrad - 12.3%; presence of an infant - 11.9% and 8.8%; desire to hide pregnancy - 0.6% and 0.4%; unwillingness to have a child and other reasons - 21.1% and 15.9%. - In rural areas, complete registration of abortions has not yet been achieved. Therefore, the state of the issue in the countryside can only be judged by relative indicators. Among the motives, compared to the city, poor health is twice as often a reason for abortion - 30%, and the number of abortions due to the desire to hide pregnancy increases 4 times (1.6%-2.9% in cities, 7.3% in rural areas); the presence of infants is less often a reason for abortion in the village (4.8% compared to 12.7% in cities). The desire to hide pregnancy occurs only in 0.6% of the total of all motives among registered marriages and 40 times more in unregistered marriages - 26.0%. This shows the strong influence of old living conditions. Compared to cities (Moscow, Leningrad), in rural areas abortions are performed at a later age, namely: after 30 years in Moscow and Leningrad - 35% of all women who had abortions, in rural areas - 48.4%. The majority of women who had abortions in cities have one to two children: Moscow - 57%, Leningrad - 59% (1925), in rural areas the majority of women who had abortions have four or more. Per 100 abortions, there were only 29.2 repeat abortions in villages; in cities - 42. Consequently, in villages pregnancy is terminated less frequently than in cities. Almost no one seeks to have the following national minorities undergo abortion: Kalmyk women, Mordovian women, Tatar women, Bashkir women, Kirghiz women, Buryat women, and to some extent German women. All these nationalities (except German women) are Muslim women; the absence of abortion among them can be explained mainly by religious beliefs, according to which infertility among Muslims is considered a disgrace and even serves as a reason for divorce. Thus, at present there exist two systems for resolving the abortion problem, around which in bourgeois states an acute discussion is still being conducted among doctors and criminologists: 1) legalization and 2) repressive policy. Obviously, repressions cannot stop the growth in the number of abortions; so, in 1924 in both Leningrad and Berlin there were 5 to 6 abortions per 1,000 population. But repressions absolutely unfavorably affect the morbidity resulting from abortion. In bourgeois states, abortion is entirely in the hands of "abortionists," very often not even specialists. Liepmann cites 226 cases of perforation in clandestine abortions, mostly ending in death. In Berlin (according to Bumm's data), out of 100 women who had abortions and were admitted to hospitals, 50 had elevated temperature; of these, 36 were seriously ill, 4 died. Annually in Germany, 75,000 women contract sepsis and up to 7,000 women in the prime of their age die (according to Hansberg and Grotjahn). According to Roesle, all cases of sepsis after abortions and births in Berlin in 1922 (per 1,000 births) resulted in 13 deaths; in 1923 - 14; in 1924 - 11; from the same cause in Leningrad per 1,000 births and abortions died in 1922 - 3.92; in 1923 - 3.55, in 1924 - 2.76, in 1925 - 2.45. Liepmann considers (probably exaggerated) for all of Germany in 1924 - 43,782 deaths after abortion. According to data from the Department for the Protection of Motherhood and Infancy, artificial abortions performed in the USSR in a hospital setting resulted in no deaths. All this confirms the correctness of Soviet policy on the issue of abortion. Only a fundamental restructuring of the economic foundations of society will make it possible to effectively fight abortion. At present, in Soviet practice, we are striving to further reduce the number of clandestine abortions, and by disseminating contraceptive means, we are seeking to achieve the greatest possible reduction OF THEIR TOTAL NUMBER.

A. Gene.

II. Abortion as a medical phenomenon. Cases of A. should be divided into 1) A. in the proper sense of the word (before 16 weeks) and 2) "immature births"-partus im-maturus (between 16 and 28 weeks). Such a division is important from a clinical standpoint: only after 16 weeks can one speak of labor periods and the labor mechanism. General etiology. The causes of A. are endogenous (internal) and exogenous (external). Endogenous causes: 1) primary insufficiency of viability of the ovum as a result of biologically inadequate parental sex cells (damage to them under the influence of various industrial poisons, alcohol, morphine, various infectious diseases and exhausting factors); 2) abnormalities of the internal secretion of the ovary (and other glands)-in the sense of hypofunction of the corpus luteum, the hormones of which apparently promote nidation (implantation) of the ovum and its further firm attachment to the uterus (placentation); these abnormalities are one of the main causes of "habitual abortion"; 3) various developmental abnormalities of the sexual organs (hypoplasia, hypofunction of them) and, in particular, underdevelopment of the uterus in connection with infantilism. This includes those cases of very early habitual abortion, often occurring unnoticed, which are observed in primigravidas; 4) inflammatory and hyperplastic processes in the deciduous tissue, especially in connection with increased cytolytic properties of the villous epithelium, hemorrhages and disturbance of nutrition of the ovum (often gonorrheal endometritis plays a role here); 5) factors mechanically impeding the growth of the pregnant uterus-abnormalities of its position, inflammatory adhesions, neoplasms in the small pelvis, etc.; 6) all general acute infections; the producing factors here are a) elevated temperature causing uterine contractions, b) harmful effect of toxins on the fetus, c) spread of infection to the mucous membranes of the genital canal and the resulting hemorrhages into them, d) direct infection of the fetus through the mother's blood; 7) chronic infections and, above all, syphilis (damage to the placenta by spirochetes), with pregnancy usually not interrupted before the fourth month, and severe forms of tuberculosis; 8) severe diseases of internal organs and metabolic diseases, such as decompensated heart defects (due to insufficient oxidation of blood and hemorrhages into the fetal membranes and placenta), chronic nephritis (due to white infarcts of the placenta and possible premature separation of it), diabetes, etc.-Exogenous causes: 1) chronic intoxications, primarily by industrial poisons (phosphorus, lead, mercury), as well as accidental poisoning by medicinal substances taken in toxic doses; 2) physical and psychic trauma; the significance of both should not be overestimated, since the resistance of a pregnant woman to any trauma is very great. As factors predisposing to A., one can name too frequent and vigorous coitus in the first months of pregnancy, especially on days corresponding to menstrual periods, as well as rapid succession of one pregnancy after another. The very essence of the action of many of the above factors of early interruption of pregnancy amounts either to 1) primary death of the ovum, or 2) secondary death of it due to complete disruption of its connection with the uterine walls, occurring as a result of strong contractions. The ovum may also die due to various diseases of the fetal membranes-for example, due to insufficient development of vessels in the chorionic villi, then due to degeneration of the entire ovum (hydatidiform mole), and later due to entanglement and twisting of the umbilical cord. Death of the fetus is usually the immediate cause of A., since the dead fetus, as a foreign body (except in cases of missed abortion), causes strong uterine contractions until it is completely expelled. Course of A. There are cases when the phenomena of an already begun A. (bleeding, painful contractions, some dilation of the cervix) gradually subside; the partially separated ovum is retained in the uterus, and pregnancy continues to develop (threatened abortion). When A. is already in progress (incipient abortion), in order to act correctly, the physician needs to remember the following. In the first weeks and months of pregnancy the fetus is still so small, its consistency so soft, that it cannot be taken into account as an object of expulsion requiring the so-called special labor mechanism. Nevertheless, even here a certain regularity is observed, manifesting itself in two essentially different modifications: 1) the entire ovum separates completely from the uterine walls and is expelled outward together with the shed membrane in the form of a kind of triangular sac corresponding to the shape of the uterine cavity. Sometimes separation first occurs in the area of dec. basalis: then the ovum, whose connection with the sources of nutrition is thereby disrupted, causes uterine contractions; the fetus, covered by the capsular membrane, goes first, pulling after it the true shed membrane. If the ovum, having already passed through the entire cervix, encounters resistance at the external os of the uterus (which is less yielding in a nulliparous woman), a strong dilation of the cervix occurs (cervical abortion). In any case, in all these cases the ovum is expelled, sooner or later, completely (complete, one-stage A.); 2) often already in the second half of the 3rd month (rarely earlier), the expulsion of the ovum occurs in a different way: under the influence of uterine contractions, a rupture of deciduae capsularis occurs; the fetus, covered by the amnion and chorion, is expelled from the uterus, while the shed membrane either is discharged later by itself or is retained for a long time. Along with decid. capsularis, sometimes a rupture of the chorion and amnion or only one of them can occur. The fetus may come out without membranes-in these cases we are dealing with incomplete or two-stage A. From a clinical standpoint it is very important to distinguish between these two types of A., because the membranes retained in the uterus hinder its involution, maintain persistent bleeding and require operative intervention for removal of the retained pieces.-Complications. 1. In incomplete A., parts of the placenta are often retained, especially in the tubal angles of the uterus, where its connection with the uterine walls is stronger. The rough surface of the placental tissue easily causes clotting of the blood in contact with it; the resulting blood clots, settling on its surface, layer on top of each other and gradually form an increasingly larger firmly attached growth, which, undergoing organization in the outer layers, turns into a dense formation (placental polyp). 2. Sometimes the course of A. takes a prolonged character (protracted A.): due to more or less severe hemorrhages in the uterine cavity, often lasting for whole weeks, the ovum itself becomes saturated with blood, and after absorption of the embryo, it all turns into an amorphous mass of clotted blood with included remains of the egg membranes (blood clot). Later, with gradual leaching of Hb, this formation turns into a fleshy clot. This is more often observed with unskillful and incomplete attempts at expulsion, i.e., in criminal abortion. Every incomplete A. is naturally associated with the danger of infection, especially if A. was induced artificially without observing necessary precautions, or if its treatment was carried out without sufficient asepsis. In some cases, which are as it were an exception to the general rule, the dead fetus, being already a foreign body, does not cause uterine contractions (the contractions and bleeding that appeared soon cease) and is retained in it for a long time, sometimes for a whole month (missed abortion). In these cases, the amniotic fluid is gradually absorbed, the entire egg cavity collapses, the fetus and its membranes become wrinkled, and only the placenta continues to be supplied with blood for some time, but finally it also undergoes degeneration. Only then, in the end, the spontaneous expulsion of the retained ovum occurs. If the retention continues, operative intervention is required. The dead fetus, retained for a long time in the uterus, in the absence of infection, may undergo maceration, which is a purely aseptic process. The epidermis of the fetus lifts up in the form of blisters, which then burst on their own: later autolysis occurs, and in particular hemolysis, leading to a blood-colored staining of the amniotic fluid, umbilical cord, and the entire skin of the fetus (foetus sanguinolentus). The macerated fetus has no odor. If infection has penetrated into the retained ovum, putrefactive decay of the fetus occurs, with a foul odor developing and gases forming in such quantity that on percussion of the uterus a tympanic sound is obtained (tympania uteri).

In very rare cases, mummification of the retained fetus is observed, the amniotic fluid is completely absorbed, the fetus shrivels and turns into the so-called foetus compressus s. papyraceus, or, even more rarely, petrification occurs, i.e., the deposition of lime salts in it (lythopedion). Treatment of A. If the egg with all its membranes has been expelled naturally and completely, and there is no significant bleeding or temperature fluctuations, then there is usually no need for so-called treatment. From this, the indications for medical intervention naturally follow: 1) severe bleeding, 2) incomplete expulsion of the egg. In connection with the latter, repeated bleeding and infection of the retained remnants are always possible. Both can only be prevented and stopped by immediate and thorough emptying of the uterus, which is indicated here from both a preventive and purely therapeutic point of view, even with only a suspicion of retention of parts of the egg. Fever in connection with A. can be of various origins: 1. Sometimes it appears not immediately, for example, during a prolonged spontaneous abortion. Its source is toxins released by saprophytes penetrating into the uterine cavity and causing putrefactive decay of the ovum. Such fever is usually stopped immediately by curettage. Sometimes a single shaking chill and an increase in temperature (to 40°) are observed in this case; this is a reaction to the enhanced penetration of toxins into the blood caused by the operation: with a good pulse, it is not dangerous (putrefactive, purulent A.). 2. Much more serious are those cases where the fever is caused by tissue infection caused by pus-forming microbes. In these cases, it often appears already at the very beginning of the abortion, when the cervical os is almost completely closed, and the bleeding is either insignificant or there is none at all. Such data almost always give grounds to suspect the involvement of inexperienced and dirty hands trying to terminate the pregnancy (septic A.). It is difficult to draw a strict line between these two types of febrile A. from an etiological point of view, since in cases of purulent A., tissue infection caused by anaerobic bacteria can also play a role. How to proceed in these latter cases is still a controversial question. According to Winter's opinion, another guiding criterion here can be bacteriological control, i.e., - in the presence of hemolytic streptococci, intervention is impossible due to the danger of breaking through the protective leukocyte barrier; expectant therapy (ergotin, ice, general strengthening treatment, etc.) is more appropriate here. However, as experience shows, hemolysis itself by no means can be a reliable criterion; moreover, severe bleeding can sometimes force the doctor to operate; statistics have shown that there is no significant difference in the comparative mortality figures between expectant and active treatment. Most therefore prefer - to prevent the spread of infection - operative intervention, i.e., curettage of the uterine cavity contents. If the infection has spread to the Fallopian tubes or the uterine connective tissue, then, whether anything remains in the uterus or not, operation is absolutely contraindicated due to the undeniable danger of general infection. The clinical experience of many obstetricians has shown that timely and carefully performed operative intervention (curettage) in an abortion with fever (with the aforementioned reservation) is quite appropriate. General prerequisites and technical instructions for active therapy of early A. The most important prerequisite is sufficient patency of the cervical canal (it must be passable for a finger; if this condition is not met, it needs to be created). To open the cervical canal, tamponade of the uterus and vagina, expansion of the canal with laminaria, or Hegar's metal dilators are recommended. In A. not later than the 3rd month, at present, Hegar's metal dilators (with half-numbers) are almost everywhere the most reliable method. At the same time, preliminary accurate determination of the size of the uterus and its position is of essential importance. Dilators should be inserted approximately up to No. 12, but in primigravidas - only up to No. 10, to avoid possible ruptures of the cervix, bleeding, and infection. Emptying of the uterine cavity can be done either with a finger or with instruments. The instrumental method, usually performed without anesthesia, is safer in terms of infection transmission in experienced hands. The curet should be sufficiently large. As for the abortus forceps, this instrument in inexperienced hands can cause various injuries up to uterine perforation, and therefore it cannot be recommended to beginners. The cornual forceps should be considered completely inappropriate and absolutely unacceptable. With sequential treatment and in non-febrile A. cases, when the curettage operation has been performed thoroughly and the uterus contracts quickly, one can do without any tampons, douches, irrigations, being satisfied with daily cleaning of the external genital parts. The patient is discharged from the institution, if there are no complications, on the 4th-7th day. Of course, the regeneration of the uterine mucosa and the reverse development of the entire sexual apparatus require considerable time. In any case, a woman can be considered fully capable of work no earlier than 2 weeks after the operation. Technical errors and complications during the curettage operation performed on a pregnant uterus are as follows: 1) during cervical dilation and curettage, the operator, out of fear of uterine perforation, sometimes does not penetrate sufficiently into its cavity, removes only a small part of the shedding membrane, and pregnancy may remain undisturbed; 2) out of fear of the onset of severe bleeding, the operator does not complete the operation, hastily tampons the uterus, knowingly leaving parts of the ovum in it - counting on their spontaneous separation in the future; as a result, bleeding and subsequent infection may occur; thus, a picture of septic A. arises, with sometimes arising dilemma - to wait or to operate a second time; 3) too vigorous curettage, involving the deep layers of the shedding membrane and even the muscular wall of the uterus, can subsequently lead to partial adhesions or even - to complete obliteration of its cavity. The main danger is the possibility of uterine perforation. Technical errors that can lead to this serious complication are as follows: 1) the operator's lack of a clear understanding of spatial relationships, i.e., of the limit of manipulations with the instrument that can be allowed in this case; 2) too rough dilation, when the dilator, inserted with a certain force, suddenly overcoming the obstacle in the internal os, can immediately penetrate to the bottom of the uterus and injure it; 3) careless, too rapid manipulations with the curet or curette when the os is not sufficiently dilated; 4) incorrect use of the abortus forceps, consisting in the operator forgetting the valuable rule - to grasp with this instrument the contents of the uterus only when it is completely separated from the walls. If the doctor has performed a perforation, he should immediately recognize this complication, which, if not recognized in time, threatens the woman's death. It is best to follow the following rule here - even with only a probability of perforation, one should act as if it were actually established. If the instrument penetrated into the uterus deeper than could be expected, taking into account the established dimensions of the uterine cavity before the operation, then perforation can be suspected with great probability. However, it must be remembered that sometimes, due to the sudden relaxation of the uterine musculature (under the influence of prolonged or very strong mechanical irritation of it), the instrument can pass very deeply without causing perforation; such cases have been established with certainty both experimentally and clinically; however, in practice they are very rare; moreover, clinically they are difficult to differentiate from actual perforation. Once perforation is recognized or even only suspected, then, regardless of at what stage of the complication occurred, further manipulations must be stopped. Uterine perforation, of course, is associated with the danger of bleeding, damage to abdominal organs (especially - the intestine) and infection - up to septic peritonitis with a fatal outcome. The prognosis is always serious, even with timely recognized perforation; it is even more serious if significant parts of the ovum, preventing uterine contraction and reduction of the perforation opening, remained in it at the moment of perforation. The danger of peritonitis is always great due to the free communication of the uterine cavity, usually already non-aseptic, with the abdominal cavity. Therefore, in doubtful, from an aseptic point of view, cases or in the presence of severe trauma, immediate laparotomy is most rational, which makes it possible to provide the necessary assistance.

If the uterus is not removed and the perforation has healed on its own, then during subsequent deliveries, a rupture along the old scar is possible. On the other hand, it should be noted that in a number of cases of uncomplicated perforation, expectant treatment (rest, ice, narcotics) gives quite good results. Artificial Abortion (abortus artificialis) is usually performed no later than the 3rd month of pregnancy, both for socio-domestic and purely medical indications. The most important diseases that may require termination of pregnancy are as follows: toxicoses of pregnancy (in their severe forms), tuberculosis of the larynx and lungs (progressive forms), decompensated heart defects and generally serious disorders of its function, severe kidney diseases, Basedow's disease, diabetes, tetany, osteomalacia, epilepsy, chorea of pregnancy, polyneuritis, otosclerosis, psychoses, severe diseases of the central nervous system, leukemia, malignant anemia. As for the technique of performing artificial Abortion, it does not present any particular features compared to what has already been said regarding the active therapy of Abortion in general. If it is necessary to evacuate the pregnant uterus (whether under conditions of a spontaneous, or clandestinely initiated, or artificially induced Abortion in a hospital setting) after the 3rd month of pregnancy, then the scraping operation is technically already difficult and dangerous and therefore unacceptable. At this time, the following operations may be considered (see Obstetric operations): hysterotomy, vaginal cesarean section or so-called 'small' abdominal cesarean section (the latter, if necessary, with simultaneous sterilization). e. Kurdliopskii.