The third and most effective method of illegal abortion was the use of instrumentation. The exact instrumental procedure that was employed depended on whether the abortionists were physicians, midwifes, nurses, or lay persons and their training, experience, and skill. Criminal abortion by instrumental means generally was of three types: douching, syringing, and direct instrumentation.
In induction by douching, a stream of water, hot or cold, with or without an irritant soap or antiseptic solution (Lysol®), was injected forcefully into the vagina at the external cervical os. More-experienced abortionists placed the nozzle of the tubing directly into the cervical canal. The successful abortion depended on the injected fluid's separating the fetal membrane and placenta from the uterine wall attachments. While the mechanical action could be produced just by the injection of ordinary water, most often a soapy solution composed of tap water and household soap was used. Lysol was also frequently used. The water was usually delivered by a household enema can or bag with attached rubber tubing and a long, slender, hard nozzle.
Because of the small cervical opening, failures using douching fluids were unusually high in the primigravida. The injected fluid would enter the vagina, but not the cervical canal. Abortion by douching was often self-induced, and was more common among multiparous women.
Abortion by syringing essentially used the same principle as that of douching. A large-capacity syringe or douche syringe was used, with the nozzle inserted into the cervix. Again, this was a favorite self-induced method of abortion.
Deaths due to abortion by douching or syringing were caused by:
• Cardiac arrhythmia
• Perforation of the uterus or vagina (rare)
Insertion of the douching or syringe nozzle into the cervix, combined with the rapid forceful injection of fluids or the rapid separation of the placenta from the uterine wall apparently produces a vagal reaction, with a cardiac arrhythmia and death. A number of these deaths were witnessed by relatives of the deceased. The patient died immediately upon insertion of the syringe or tubing into the cervical os and injecting of the fluid.
Sepsis was secondary to the nonsterile nature of the method of induced abortion. A corrosive endometritis caused by the fluid was common. On occasion, the soapy solution or solution containing Lysol would enter the uterine veins, initiating a hemolytic anemia, hemoglobinemia, and hemo-globinuric nephrosis, with uremia and death.
Air embolism could occur two ways. First is when air became trapped in the rubber tubing and was forcefully injected into the uterine cavity and into torn veins. Second, in the process of separating the fetal membranes from the uterine wall, veins were torn through which air from the atmosphere could be sucked in. While most deaths caused by air embolism occur within a few minutes of the procedure, in some cases, there have been delays of hours. One hypothesis for this delay is that the injected irritating fluid that caused separation and tearing also caused severe contraction of the uterus. Subsequently, as the uterus relaxed, the air then was able to enter the circulation.
The third method of inducing criminal abortion by instrumental means is induction by instruments. This was usually not self-induced, though in some instances women, especially multiparous women, were able to do so using knitting needles and coat hangers. Essentially, this method is a variation on dilatation and uterine curettage. Catheters, soft or hard, and other instruments were used to dilate the cervical os or at least to pass through the cervical os into the uterine cavity. The experienced non-physicians would typically insert a soft or hard catheter into the cervix and uterus. A cervical packing or tampon was then placed immediately adjacent to the cervix to hold the catheter in place and absorb any blood that might flow from the cervix or uterus during the woman's journey home. The woman was then instructed to go home and expect painful forceful uterine contractions and vaginal bleeding within 24 h, but not later than 48 h. This would indicate expulsion of the fetus and placenta. If the inserted catheter had perforated or ruptured the fetal membrane, causing loss of amniotic fluid and immediate contraction, the fetus and placenta would be expelled within hours. The woman was often instructed that, if she bled profusely, she was to dispose of the catheter and vaginal packing, go to the nearest doctor or hospital and tell them that she had severe vaginal bleeding. She would then attempt to pass this off as a spontaneous abortion. (Anyone working the emergency room of a large county hospital in urban areas noticed that there was an unusually large number of "spontaneous abortions" on Thursday and Friday nights, This was because hospitalization in such cases was only for three days. Thus, a woman having a "spontaneous abortion" on a Thursday night lost only one day of work, Friday, while the woman having one on Friday night lost only Monday.)
Deaths from instrumentation were caused by:
• Primary cardiac arrest caused by a vagal reaction produced by forceful dilation of the cervix and/or insertion of a catheter or sound into the uterus
• Complications of anesthesia
• Sepsis caused by perforation of the uterus, cervix, or vagina
• Thrombotic embolus
Sepsis was the most common cause of death by instrumental abortion (Figure 20.3).
One of the authors (DD) had the opportunity to autopsy or supervise the autopsies of 105 cases of criminal abortion in Brooklyn, New York, from 1960 to 1973. The causes of death in these 105 cases were:
• Deaths caused by abortifacients: 4
a. Deaths caused by douching: 22
b. Sudden cardiac deaths: 10
c. Air embolism: 3
• Deaths caused by instrumentation: 9
a. Postabortal sepsis following insertion of catheter into uterus: 8
b. Postabortal sepsis following insertion of wire coat hanger into uterus: 1
• Deaths caused by postabortal sepsis — method of abortion unknown: 60
• Deaths caused by postabortal hemorrhage — method of abortion unknown: 10
Of the four deaths caused by abortifacients, one was caused by potassium permanganate, two by quinine, and in one, the substance was unknown. The woman who took the potassium permanganate inserted the pills into the cervix and subsequently aborted. She developed methemo-globinemia, hemolytic anemia, methemoglobinuric nephrosis, and uremia. Those who took the quinine died from quinine overdoses. In the fourth case, an unknown number of pills were taken to induce abortion. The victim subsequently developed postabortal sepsis, subacute bacterial endocarditis and sepsis, and died. The 70 cases in which the method of abortion was unknown were, in virtually all instances, thought to be caused by instrumentation.
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