ABORTION.
BY GEORGE J. ENGELMANN, M.D.
DEFINITION.—Abortion, the mishap of popular parlance, the fausse couche of the French, is the premature interruption of intra-uterine pregnancy, the expulsion of the non-viable ovum, whether the result of natural causes or criminal interference.
SYNONYMS.—Common as the accident unfortunately is, the nomenclature, both popular and scientific, is somewhat indistinct, the terms abortion and miscarriage being used in a variety of ways, so that the physician is liable to be misunderstood by his professional brethren and in danger of causing serious offence to his patients. A strict definition of the terms is hence of importance, and in order not to add to the confusion we can do no better than adopt the one now adhered to by the authorities of the day. Abortion and miscarriage are strictly synonymous, notwithstanding the popular belief that the term abortion is restricted to the criminal interruption of pregnancy, whilst miscarriage is supposed to designate the accident resulting from natural causes. Again, some make a difference in time between abortion and miscarriage—abortion being the expulsion of the ovum in the first four months of pregnancy; miscarriage, or the partus immaturus, in the next three months, from the fourth to the seventh; and the partus prematurus from the seventh to the ninth month.
CLASSIFICATION.—We might, indeed, in regard to importance, cause, and course of expulsion, designate four different periods of gestation—the first two during the continuance of the chorion frondosum, and the last two during the period of placental development: the first during the first two months of pregnancy, before sufficient adhesions have formed; the second, still during the period of the chorion frondosum, until it begins to disappear, from the second to the fourth month; the third, in the early stages of placental development, before the term of foetal viability, from the fourth to the seventh month; and the fourth, which is everywhere recognized as the partus prematurus—premature delivery—from the seventh to the ninth month, when the placenta is fully developed with firm adhesions and the child viable.
For practical reasons and simplicity's sake we will distinguish only between abortion and premature labor—miscarriage, abortion, abortus, being the expulsion of a non-viable foetus, of the ovum before the time of complete placental development, in the first seven months of pregnancy; and premature labor, the interruption of pregnancy in the last two months, from the seventh to the ninth, when the foetus is viable and formation and attachment of the placenta has been completed. These two classes naturally blend, but are strikingly different in cause, symptoms, and treatment if we consider the type about which they are grouped—abortion proper as most frequent in the third and fourth month, and premature labor in the seventh and eighth. It is abortion or miscarriage of which we shall treat in this article, more especially its characteristic form before the formation of the placenta, whilst we shall touch but lightly upon those forms which approximate premature labor and come within the sphere of the obstetrician; that is, abortion in the sixth or seventh month, when the placenta is more fully developed.
FREQUENCY.—With regard to the frequency with which this accident occurs, we can but form an estimate, as there are but few of the pathological conditions to which the human constitution is subject in regard to which we are more at fault as to statistics: neither the case-book of the physician nor the hospital or post-mortem record permits of more than an indefinite approximation as to the frequency of its occurrence. During the first six or eight weeks of gestation, certainly the first four, the patient herself is often ignorant of her condition, and the ovum passes off amid a more profuse menstruation, with only the symptoms of simple menorrhagia; the same may be true at later periods by reason of coexisting conditions. Some knowingly conceal the fact; many, knowing it, call no assistance; others have midwives, the physician seeing only the more threatening cases; and but few enter the hospital, where our most reliable statistics are gathered.
All points considered, it has been stated that to every 5.5 labors at term we will find 1 case of premature expulsion of the ovum (Busch and Moser). Whitehead asserts that 90 per cent. of married women abort, or that 37 out of 100, somewhat over one-third, of all mothers abort at least once before their thirtieth year. Hegar estimates 1 abortion in the early months to 8 or 10 labors at term, which harmonizes very well with the figures given by Busch and Moser. Multigravidæ abort more often than primigravidæ, although there are certain causes peculiar to primigravidæ which tend to abortion, such as the indiscretions of early married life: uterine disease, perimetritis, and endometritis, on the other hand, are more common in multigravidæ, and, again, the number of multigravidæ is by far greater than that of primigravidæ.
These estimates are all somewhat general, but even if exact statistics could be gathered as to any one locality, they would not hold good in others—true of one region, they would not be so of another. Climate, habits of life, and morals of the community very greatly affect the completion and interruption of pregnancy.
IMPORTANCE.—Frequent as the occurrence of abortion is—common almost as childbirth—its importance is universally underrated. Many of the ills to which women are subject result directly or indirectly from this accident, or, we may justly say, from an undervaluation of its importance. If not criminal or traumatic, it is the result of pathological changes either in the maternal system, in the sexual organs, or in the ovum itself; labor is brought about amid these conditions at a time when neither ovum nor uterus is properly prepared, as in labor at term, and under these conditions, especially in a diseased system or diseased uterus, involution will not so readily take place. Morbid conditions of the sexual organs follow, and affect the health of the patient more or less, though death but rarely results, either directly or indirectly. These evils are more commonly the consequence of mismanaged abortion and neglected after-treatment than of the accident itself; hence the result depends rather upon a thorough appreciation of the importance of this condition by both patient and physician, especially the general practitioner, the family physician; if assistance is sought, it is he who is called, and not the specialist—not the gynecologist or the obstetrician. It is the physician conversant with the family secrets whose aid is sought in this matter, which is considered by the mother rather as a delicate and disagreeable than an important affair.
Women should be given to understand more thoroughly the serious results which so often follow neglected abortion or abortions which, for the very reason of their being rapid and favorable in their course, are neglected as to after-treatment. Women must be impressed with the necessity of proper attention during the progress of miscarriage from its very initiation, and the even greater care that is necessary after the ovum is expelled and all is supposed to be over, and involution of the uterus at this period must be guided and guarded as after expulsion at term.
Much suffering would be avoided if women were taught to consider abortion as a disease, a pathological condition, demanding immediate and active attention, and not simply as a disagreeable and disgraceful accident, to be concealed if possible. The patient would then no longer endeavor to worry through without assistance or call in nurse or midwife; and, thoroughly knowing the possible dangers, they would be more cautious, and the frequency of criminal abortions would also decrease: these, above all, cause injury to health, because medical attendance is avoided if at all possible, and care likewise, as the patient is anxious to conceal her indisposition. Then also the practitioner must bear in mind the great importance of this accident, both that he may anticipate and prevent it, and if inaugurated he may guide it to a rapid and successful termination and guard his patient throughout the period of involution. Great temporary pain, and often lifelong suffering, will thus be prevented.
A thorough knowledge of abortion, of its causes, course, and treatment, is equally necessary to the physician, that he may guard his own honor and that of the profession: an abortion, due to uterine disease or malnutrition of the ovum, occurring during some period of medical attendance is often blamed upon the physician by those anxious for offspring, whilst, on the other hand, that large and shrewd class who are seeking to avoid childbirth not infrequently resort to the trick of urging certain methods of treatment during early pregnancy, with the hope that the physician himself may thus induce abortion, or he is called, with all appearance of innocence, by the criminal who has interrupted gestation to complete the abortion once commenced. His own reputation and that of his profession is then at stake: to guard this and to preserve the health of the mother entrusted to his care he must be conversant with the pathological conditions involved and the importance which attaches to them.
Woman requires skilled aid in labor, the physiological termination of pregnancy; more necessary still is this in the premature pathological interruption of this condition, in abortion! The attendant is often responsible for two lives, as in labor, although under the conditions usually existing medical aid is not summoned until the life of the embryo is already destroyed—a most urgent argument in favor of timely medical advice and of close attention to prevention, a proper management of the pregnant state, and the treatment of threatening abortion, as at this time both lives may still be saved. This accident, so frequent in its occurrence, so disastrous to the health of woman, is important in all its phases, not only in the stage of expulsion and retention, to which attention has been directed on account of the surgical interest, but as well in its incipience, the time of prevention, and its after-treatment; abortion demands, and is worthy of, the most careful study and the best efforts of the physician.
HISTORY.—The history of abortion, it has often been stated, is the history of civilization, but I would rather say that it is the history of races—of their rise and fall. Abortion in consequence of natural causes, as well as criminal, is now, and has at all times been, practised among savage as well as civilized peoples, and develops with the progress of civilization, with the deterioration and fall of races, civilized and savage, as shown by history ancient and modern.
Abortion consequent upon natural causes is by far less frequent among a vigorous and healthy people still struggling for supremacy, full of youth and strength, than among nations who have reached the height of power, who have been enfeebled by indolence and the luxuries of civilization, by vice and fashion. Of criminal abortion this is naturally true to a far greater extent, yet this is common and customary among many primitive, semi-civilized peoples. As nations advance they become debilitated and demoralized amid the brilliancy and luxuriousness of their surroundings, and they rapidly retrograde toward the very worst vices of primitive humanity: they are thus undermined, and succumb to the attacks of their more vigorous neighbors, and magnificent empires are overthrown and extinguished by the youthful vigor of a hardy, simple people. The more civilization progresses, the greater the apparent abhorrence of the crime of abortion, the more numerous the laws enacted to guard against it, the more frequent does the crime become; and, strange though it may seem, it is nowhere punished. Abortionists everywhere are known; in the larger cities of this continent as well as Europe they achieve a widespread fame, are well known, and yet rarely if ever convicted. It is a notorious fact in our community that these worst of criminals almost invariably escape, and even in the states of Germany, where the laws are strict and rigidly enforced, where the crime of abortion is punished by imprisonment of from five to twenty years, that eminent teacher of medical jurisprudence, J. L. Casper, says that "Of all the many accused, never a one was condemned, and in no one case was the crime proven." They are sheltered by the words of the law and the sympathy of the community, which, notwithstanding the abhorrence expressed, still accompanies these criminals, though not to so great an extent as it does those equally forlorn women who are guilty of killing the child when born; for, as Hodge truly says, "There is no class of criminals who meet with so much sympathy as women guilty of foeticide." Greece and Rome when at the height of their power favored by their laws, and almost openly advocated, abortion, whilst among the ancient Germans it was one of the crimes most deeply despised and most severely punished—just as it was condemned by the laws of the Goths. How different is it now among the races sprung from these proud conquerors of Rome, now that they have reached the very acme of their career! The more civilized, the more powerful they become, the more does this crime develop, as in Germany and France, where it is practised upon a most extensive scale, and yet, as we have seen, the criminals escape, notwithstanding the most rigorous laws. Condemned from the bench and the pulpit, the crime still progresses. There is the poor girl who has yielded her honor for the sake of bread for herself or those dependent upon her; there is the lady of fashion, by far more culpable, who cannot give up the time she owes to society to the cares of maternity; or the society belle, who would resort to any and every measure that she may escape maternity for the sake of retaining her beauty and the freshness of her charms, a slender waist and a well-shaped breast; others resort to it that their round of pleasure may not be disturbed. Many an unborn child is executed upon the plea of limited resources, that the family cannot continue to live in their accustomed luxury if an additional member should appear.
Neither the laws of God nor man will affect the hearts of women thus brutalized: it is the physician alone who can interfere; it is to him they come most often; it is he, the trusted family friend, who will do more than judge or priest to change this unfortunate condition of affairs. In crowded countries abortion is looked upon as a necessity of nations, just as it is here considered a necessity in a family too numerous; hence in China, Japan, and Hindostan it is common; in Arabia and in New Caledonia it is produced on account of the scarcity of nourishment and the difficulty of raising children. Among some crude people it is not the wish of the individual, but the law of the land, which determines the course of gestation; so upon the island of Formosa a woman is not allowed to bear a child before her thirty-sixth year, and priestesses fulfil a social law by kicking the belly of the woman who becomes pregnant before the proper age, lest the population grow too large for the resources of the island. So it is among other islanders also—upon the Sandwich Islands, the South Sea Islands, whose population was reduced from two hundred thousand to seven or eight thousand in the course of thirty years. Upon Tahiti and King's Mills Islands it is equally common. Upon the latter a more generous feeling prevails, and the woman is at least allowed to have a family of three, but not beyond that; and upon the Feejee Islands one of every two conceptions is supposed to be destroyed before the period of gestation is completed.1 So also among the New Zealanders, the Hottentots, and the inhabitants of Madagascar. By the Icelanders this crime is committed as an heirloom left by their Norwegian ancestors.
1 Trader, Criminal Abortion.
Not alone upon the islands, but among the inhabitants of states not overcrowded like China and Japan, abortion is legalized; so in Paraguay and La Plata, where it is caused in every family after the birth of two living children. Some of the African negroes produce abortion on account of limitation of resources; among the Buddhists, otherwise so humane in their laws, it is frequent—a wonderful disharmony between the conduct of individuals and the dictates of their political and religious laws.
Wherever celibacy is demanded crime and abortion result, as among the Buddhists, whose laws condemn large numbers of vigorous subjects to this existence; and in our own civilization we see the same inevitable result in many of the most closely-populated Catholic countries. Thus abortion is frequent among the Anamites and among the Kambysians, who marry late and are frequently obliged to produce abortion before the time of marriage. Among the Brahmans it is a common practice, induced by religious and political arrangements, the direct result of a law which encourages sexual excesses, and frequently of the restrictions placed upon the needs of woman (widows are condemned by law to eternal celibacy); yet this terrible crime is looked upon as most harmless by the people of India, the destruction of a child that has not seen day being, according to their view, less of an evil than the dishonor of a woman. In Turkey it is so common that a certain price is paid for abortion and another for infanticide, and the law is indulgent to the crime, as it can be paid for cheaply. The cost of removing a non-viable foetus, or even an embryo, is equivalent to a tenth of the price paid for the murder of an infant.
The methods by which expulsion is accomplished are everywhere the same among people civilized and savage, ancient and modern—local and general. Among the local measures external violence is the most simple, as among the Tasmanians, who practise abortion by striking the belly, just as it is done by the priestesses of Formosa; and this is quite common in our day and in our communities. The introduction of instruments and implements into the womb is more intricate, but likewise common; the knitting-needle is a favorite resort in our country, and among primitive peoples a similar practice is resorted to; thus some of the negroes of Africa introduce the sprouting stem of a plant into the uterine cavity. Venesection, the drawing of blood from the vulva, anus, and foot, was often resorted to for the purpose of producing abortion.
Among the more common remedies used in former times are emetics, which are still very often resorted to, cantharides, emmenagogues, sabin, snakeroot, and the famous pennyroyal; so also ergot; the compound cathartic pill of the United States Pharmacopoeia is a favorite remedy,—all of which maim or kill the patient as often as they produce abortion. In New Caledonia a decoction of red-bud and banana-peel or green fruit is taken boiling: in China aperient medicines are publicly advertised for sale, and aphrodisiacs under the name of remedies to free the stomach and give back virginity. Certain negro tribes bring on abortion by manipulation of the abdomen and the use of purgative substances, such as the bark of the koche and sonnaly, which are also used to facilitate labor. Pen-tsae enumerates a large number of remedies as accelerators of abortion or purgatives according to the dose; many of them have a very doubtful action, however. The natives of India most commonly use the black annin, vulgarly called black anise or fourspice; fifteen grammes is an emmenagogue and larger doses produce abortion. The Arab women seek to produce sterility and escape the annoyance of numerous pregnancies, and imagine that they can arrive at that end by drinking a solution of sal soda, a decoction of peach-leaves, and the sap of the male fig tree.
Among peoples savage and civilized, for good reasons and bad, villains sufficient are found to do the bidding of thoughtless and misguided women; the remedies used, internal and external, local and general, are very often so violent as to be followed by the death of the victim. The plea of limited resources, of the inability of supporting a large family, is one common to people of all races in all stages of civilization: permitted by the unwritten law among some, it is practised with equal frequency by others, though strictly condemned. As we have stated, among many of the American nations it is legalized.
Again, there have been people at all times who have scorned the crime, but this is only among those pure, primitive, and still-developing peoples, as, for instance, the ancient Goths and Germans; and the Noxes of South America, as well as some of the negroes of Africa, even permit the husband without hesitation to kill his wife if she should abort. It is among those of the primitive peoples where the blessing of offspring is held in high esteem that the crime of abortion is most condemned and most rare. With the progress of civilization and religion, of refinement and knowledge, this crime, strange as it may seem, rapidly develops. It is not among the low and ignorant—it is among the educated and refined, among the wealthy—that it is most common; and the plea given in excuse of this crime is one most especially urged by the educated and refined, by the devout Christian, that the embryo is not an animated being, not an individual existence—that it does not attain the dignity of a living being until the time of quickening, until the middle of pregnancy. Religious and scientific reasoning is brought to bear in support of this theory in excuse of the many refined criminals; and it is this very point which the physician must urge: that the ovum, the embryo, from the moment of conception is an animated being, an individual existence with a life of its own. Important as the treatment of abortion, in consequence of natural causes, is, its prevention, and, above all, the prevention of criminal abortion, is still more so; and it is this which lies in the hands of the physician, whose most forcible argument must be in the evident and glaring crime which is committed by the destruction of a living being, as is the embryo from the moment of conception, not to forget the injury resulting to the mother. The former appeals to the moral, the latter to the physical, elements of womanly nature.
Whilst abortion, in consequence of natural causes, is a condition more dangerous than labor at term, the interruption of pregnancy by forcible means—criminal abortion—must necessarily be more grave in its consequences. The interference is often a violent one; the aborting woman is in mental distress, unable to seek the necessary comfort or attention; she is oppressed by the crime in her inner conscience; under unfavorable conditions, physical and mental, for the suffering which is most likely to follow.
With the progress in the practice of medical science the art of the abortionist keeps pace, and in civilized communities of to-day one cause of this growing frequency is in the increased numbers and the increased skill of practitioners ready to pander to all the whims of their degenerated customers: but the greater should be the efforts of honorable physicians to dispel the false illusions by which women seem to justify their doings, and to erase this darkest of all thoughts that lurks amid the noblest sentiments in woman's mind. A strong effort was made not long ago by the American Medical Association to urge the importance of this matter upon the profession, resulting from the earnest efforts of that honored obstetrician Hugh L. Hodge, which culminated in a report of the Committee on Criminal Abortion, read before the American Medical Association in 1871, and a number of papers written upon the subject at that time, prominent among which I would mention those of Van de Warker, Tabor Johnson, and John W. Trader. The wave has swept by: what has been accomplished may be gleaned from the police records of our cities.
PHYSIOLOGY OF EARLY PREGNANCY.—For an understanding of the pathological conditions which determine, precede, and accompany this accident a knowledge of the physiological state is as important as normal anatomy is to the pathologist. But as this subject is treated of in full in other articles, we will confine ourselves to a few of the leading features which are most important for purposes of diagnosis and treatment.
The changes, local and general, resulting from the physiological state of pregnancy are extremely variable, often approximating or simulating pathological conditions, so that we must differentiate and discriminate between such as pertain to the normal condition and such as indicate pathological changes and threatening danger. This is necessary, as prevention is, above all, important, it being often possible thus to save two lives with by far less danger and suffering to the mother than is to be expected from the treatment of abortion once inaugurated after the time of possible prevention has passed. Moreover, a correct post-abortum diagnosis is important for the future welfare of the patient, if not from a medico-legal point of view; and this is equally impossible without a knowledge of the physiological condition. This will enable us to determine whether the ovum expelled is healthy or not—whether the causes are traumatic or criminal, or whether the abortion is due to pathological changes; which, again, must guide us in treatment.
Abortion is the expulsion of an ovum the product of a conception, and can only occur during the period of menstrual life, as conception, the impregnation of the female ovule by the male semen, is the consequence of fruitful intercourse, liable to take place at any time during the period of womanhood, the thirty years of female menstrual life from puberty—the appearance of the catamenia—to the time of their cessation. Its occurrence is followed by intense physiological activity of the maternal organism, lasting throughout gestation to the time of its natural termination with the expulsion of the fully-developed ovum at term at the end of the tenth lunar month. This is made evident by striking changes in the entire system, but especially in the sexual organs, which in the earlier period of pregnancy are entirely progressive, developmental, whilst in the later months, toward term, the character is changed to that of a retrograde metamorphosis, preparatory to the separation and expulsion of the ovum and final restitution of the organs. This hyper-activity inaugurated by impregnation becomes evident by marked changes in the system of the mother, in the sexual organs, and in the ovum itself.
Changes in the Maternal System.—These are most peculiar and varied, differing in repeated pregnancies in the same patient, sometimes entirely absent, at others most distressing, even fatal; sometimes appearing at one period, sometimes at another. Healthy, robust women may suffer throughout the entire period of gestation, whilst those at other times ailing are well only in this condition. The most marked of these symptoms are the hystero-neuroses, disturbances of the entire nervous system, central and peripheral; mental depression, more rarely excitement; gastric disturbances, nausea and vomiting; increased activity, renal and pulmonary, consequent upon changes in the circulation; discoloration of the skin upon the forehead, the linea alba, and areola; oedema and varicosities of the veins upon the lower extremities. All these, and many others still more erratic, may accompany the normal physiological condition.
Changes in the Uterus and Pelvic Viscera.—Whilst the ovum develops in the uterus, this organ, its appendages, and the viscera surrounding it, enclosed together within the pelvic cavity, undergo the most marked changes. The early months of pregnancy are those of greatest physiological activity in the uterine muscle, the period of its hypertrophy. This is inaugurated from the very moment of conception, at first increasing, then gradually lessening, until within the last months, when it becomes passive, the rapidly-growing ovum merely distending the hypertrophied uterus, apparently increasing in size, but merely distended by its contents, as a rubber bag would be. In the earlier months the growth of the uterus is entirely due to muscular development—after the fifth month to distension. The individual muscular cells attain enormous growth, and a large number of pre-existing embryonic cells are developed; so also in the interlacing connective tissue. The blood-vessels as well as the lymphatics increase in size and length; the arteries become tortuous; the capillary circulation is to a great extent supplanted by sinuses.
Weighing in its normal condition, when at rest, little above an ounce, the uterus attains within the first four or five months a weight almost fifteen times greater. Remaining the first four months within the pelvic cavity, the increase in size is not of that diagnostic importance which it attains in the later months, when it is to be felt beneath the abdominal walls, though at the end of this period it is distinctly perceived above the symphysis; about the fifth month, between navel and symphysis; and at the sixth month, at the height of the navel. At the end of the third month the uterus is some 4½ to 5 inches in length, by 4 in breadth and 3 in thickness; at the end of the fourth month, 5½ to 6 inches in length, by 5 in breadth and 4 in thickness; at the end of the fifth month, 6 to 7 inches in length, 5½ in breadth, and 5 in thickness; at the end of the sixth month it is some 8 to 9 inches in length.
The changes which take place in the cervix are a merely passive accompaniment of the uterine hypertrophy, it being enlarged more especially by reason of the succulence of its tissues consequent upon the congestion and activity of the body. It is somewhat enlarged in all its dimensions, thickened, and elongated, soft, velvety to the touch, appearing, however, somewhat shortened by reason of the hypertrophy of the vaginal attachment—a condition that approximates rather that of the vagina and external sexual organs than that of the uterus, softened, succulent, somewhat hypertrophied, congested, of a deeper bluish-red wine color, its cavity occluded by thick tenacious mucus, as the secretions of the mucous membrane of the vagina and external sexual organs are also augmented. In the first and second months the uterus is retroverted, the cervix seems to descend as the enlarged organ, by reason of its weight, settles in the pelvis, the fundus sinking down in the hollow of the sacrum, the cervix consequently pointing more forward; as the organ increases in size and rises above the brim in its endeavor to escape the confining space of the pelvic cavity, the enlarged fundus, meeting with the resistance of the promontory, seeks the point of least resistance, and the uterus begins to assume that position of anteversion which continues to become more marked as pregnancy progresses: the cervix points backward into the hollow of the sacrum, and rises gradually (as the fundus increases in size and withdraws from the pelvic cavity).
The Uterine Mucosa.—This structure is as interesting as it is important. The wonderful changes which it undergoes go hand in hand with the various changes and stages of female life: it is the nidus for the reception of the impregnated ovum; it serves to shelter and nourish the delicate ovum, and if diseased, affording insufficient nutrition, leads to the death and expulsion of the embryo. Its shreds when expelled are of diagnostic importance, and in early abortions its massive thick tissues, changed by disease, often cause greater trouble than the ovum itself, forming, alone or with the membranes proper of the ovum, what is so commonly but erroneously called the placenta in abortion. The membrane which lines the cavity proper of the uterus, passing at the internal os into the mucous membrane of the cervical canal, is characterized by the absence of even the slightest trace of submucous or areolar tissue—by its peculiar substratum of connective tissue abounding in cells and tubular glands. It is closely and inseparably attached to the muscular coat. In a state of rest it is a little over 0.04 inch in thickness at the fundus,2 and the anterior and posterior walls diminishing toward the sides, the cervical and tuber ostea. It is traversed by a series of tubular glands, wavy in their upper part, bifurcated toward their base, running more or less parallel to each other. In this membrane, so important for the preservation and development of the ovum, the physiological activity of the system is inaugurated, and seems to centre during the first week of gestation. With the impregnation of the ovule the uterine mucosa, its earliest shelter, begins to hypertrophy: the rapid development which now takes place is owing to the proliferation of the cells of the stroma and the enlargement of the individual cells of all kinds, including those of the glands themselves, as well as the increase of the succulent homogeneous and cellular substance. The glands throughout their greatest extent are enlarged: the increase in thickness is more especially due to the hypertrophy of the superficial layer, the upper half, in which the stroma appears less compact, growing far above the original gland-openings, circumvallating the enlarged ostea, and thus causing those funnel-shaped depressions which give the membrane its sieve-like, cribriform appearance when seen from above. In the third month of pregnancy the mucous membrane attains its greatest thickness, forming a soft succulent lining to the uterine cavity, by its distension closing the various ostea. It is then as much as 0.236 inch in thickness in the anterior and posterior walls, lessening toward the ostea, and begins to present the characteristic layers which become so distinct in the later months—a dense upper and a very loose lower one, comparable to a lax meshwork. Its growth now ceases, and as the uterine cavity increases in size and the ovum in growth, it is distended to cover the rapidly-expanding surface, and becomes thinner and thinner, the upper dense layer remaining as such, whilst the glandular sinuses of the lower layer of the membrane are stretched transversely until they become mere flat meshes like a network stretched along the surface of the womb.
2 Engelmann Mucous Membranes of the Uterus.
The impregnated ovum, as it rapidly enlarges during the first two or three weeks, becomes imbedded in the thickened succulent decidua; and we may compare this to the sinking of a bullet into soft dough: the soft mass of the dough yields to the weight of the superimposed body, and gradually closes over it, so the tissue of these overlapping folds soon unites, completely surrounding the ovum, the nidus thus formed, in which the ovum settles, being usually in the upper portion of the fundus upon the posterior wall of the right side. We now distinguish in the mucous membrane of the uterus three parts: the decidua vera, the greater part of the membrane lining the cavity of the womb where it is not in contact with the ovum; the decidua serotina, which is that part directly beneath the ovum, between it and the uterine wall, which is in connection with the tufts of the chorion, later in part develops to form the placenta; and the decidua reflexa, that part of the mucosa which overlaps and has overgrown the ovum. This membrane is little known and rarely recognized, though always present. It is of no practical importance; a delicate membrane even at the time when it is the great safeguard of the tender ovum, serving to protect it and hold it within the soft bed formed by the decidua serotina; this function of the reflexa continues until the third month, when the ovum has developed sufficiently to occupy the entire uterine cavity and is everywhere in contact with its walls. The thin tissues of the reflexa become more transparent and delicate as they are distended and compressed between ovum and decidua vera, which now with the muscular wall of the uterus surround the ovum and continue the previous function of the reflexa.
The Development of the Ovum.—Practically, we may distinguish two periods in the development of the ovum: the first, that in which we are here interested, before the development of the placenta, where it is a cyst-like body surrounded by the shaggy chorion, the chorion velosum; and after the development of the placenta, after the fourth or fifth month, when the foetus is more fully developed and the ovum is covered with the smooth chorion, the chorion levæ.
The period scientifically the first, and the most interesting stage of development, during the first three or four weeks, when segmentation takes place and the form is moulded, we shall in no way consider. The ovum may then be cast off, perhaps at a succeeding monthly period, unbeknown to any one, perhaps not even to the unconscious mother: certainly the services of an accoucheur are not called for. In the third or fourth week it is a delicate cyst-like body of the size of a hazel-nut, some half an inch in diameter, surrounded by its translucent chorion, and is crushed in the passages or disappears amid the clots of blood of an apparently profuse menstrual flow. The following periods of development are, however, of practical importance, as they will serve diagnostic purposes, as well as an understanding of the appearance of the ovum and the symptoms accompanying miscarriage.
The ovum during the first months of pregnancy is an oval cyst-like body surrounded by the chorion, the shaggy tufts of which give it a characteristic readily-recognized appearance. Enclosed within is the delicate transparent amnion, and the embryo, attached to the navel-string, floating in the clear liquor. At six weeks the size of the ovum is likened to that of a pigeon's egg; at eight or nine weeks to that of a hen's egg, perhaps 1½ inches in length; at the twelfth week, to that of a goose-egg, some 4 inches in length. In the second month the ovum forms a bulging prominence in the uterine cavity, usually toward the fundus, and reveals all the parts recognized at term with the exception of the placenta and the still distinct umbilical vesicle: its surface is covered by the tufts of the chorion and surrounded by the decidua reflexa. In the third month it is so far developed as to completely occupy the uterine cavity, as yet but slightly adherent, approximated, a part of it agglutinated to the uterine mucosa, to the decidua serotina, the greater mass of the chorion being in no way adherent to the surrounding reflexa. The tufts of the chorion begin to sprout and develop more fully at its point of contact with the uterine wall above the decidua serotina, whilst upon the remaining and greater portion of its surface their growth ceases, and as the membrane distends the delicate filaments gradually disappear. At the end of the third month, in the fourth month, the tufts of the chorion have sufficiently developed in its adherent portion to form the rudimentary placenta, and at the end of the fourth month this is developed still more—has become more dense and large, whilst the remaining portion of the membrane appears smooth and barely shows a few scanty remnants of the once-shaggy tufts.
The growth of the ovum now rapidly outstrips that of the uterine cavity; the membranes are pressed more firmly against its walls, approximated to the decidua vera, but not by any means agglutinated. In the sixth month the placenta has been thoroughly formed—it has become dense and large, the foetal membranes beginning to agglutinate to the uterine wall, and the conditions existing at term are rapidly approached. The embryonic tissues are supplied with the necessary nutriment by endosmosis from the surrounding maternal structures during the first months; the entire surface of the chorion absorbs, whilst this function is delegated to the proliferating villi as they develop and agglutinate with the decidua serotina, foreshadowing the activity of the placenta by which the foetus is nourished to term.
Practically, the most important period in the development of the ovum is the one most dangerous to its existence—in the third and fourth month, that period of intense activity of chorion and decidua, the time of the formation of the placenta, when hemorrhage is likely to occur from the congestion of the vessels so necessary to the nutrition of the rapidly-growing and delicate tissues. Nutriment is no longer merely absorbed by the succulent embryonic cells of the ovum from the tissue in which they are in contact, but the embryo is forced to seek sustenance through those now fully-developed tufts of the chorion—from the proper site, the decidua serotina and the surrounding vessels—directly from the uterine structures. If hemorrhage interferes or disease prevails, the healthy growth of the ovum is checked, and a morbid development ensues, to result sooner or later in death of the embryo and expulsion.
The embryo in the early months of pregnancy is small as compared to the size of the sac, the membranes, liquor amnii, and navel-string; at the end of the fourth week the embryo measures from 1/3 to ¼ of an inch in length; at the end of the eighth week, from ¾ to 1 inch: the arms and legs become visible, the umbilical vesicle, though reduced in size, still exists; the small body with large upper extremity is pendent from the short, thick navel-string. At the end of the twelfth week the embryo measures from 2 to 3 inches in length; fingers and toes can be distinctly seen; mouth and nose are also recognizable. At the end of the sixteenth week, the fourth month, the embryo measures some 4 to 5 inches in length; sex can be distinguished; the head assumes shape, but it is still immense in size, perhaps an inch in length; the features of the face are all formed. At the end of the twentieth week, the fifth month, there is no longer doubt as to sex; the nails, which were previously visible, have become distinct; the soft, woolly lanugo begins to develop; hair may be noticed upon the head; motion, inaugurated weeks before, is felt by the mother. Toward the end of the sixth month, in the twenty-fourth week, the embryo is some 12 inches in length. As has been before stated, with the cessation of the development of individual organs and parts growth in size becomes more rapid. As this was less in the earlier months, it is now very marked. With the seventh month, as the foetus becomes viable, it is some 12 to 14 inches in length, weighing 2 to 3 pounds; the body is covered with lanugo; the hair on the head becomes quite marked; the papular membrane disappears.
It is well to bear in mind the leading features in the development of the uterus, decidua, and the ovum, and more particularly its membranes, as a guide in the treatment, that we may recognize the parts expelled and know what remains to be removed—as an aid in diagnosis, that we may properly judge the conditions, whether healthy or morbid, and post-abortum, when we may be forced to determine by the corpus delicti, as the all-important evidence in criminal cases, as to the duration of pregnancy and the causes which led to its termination.
ETIOLOGY.—Causes of Abortion.—Interesting as the etiology of disease is to the inquiring mind, to the progressive physician it is of great practical importance as well; and this is eminently true of the causes leading to abortion. More so of (A) spontaneous or accidental abortion, though by no means to be neglected in (B) criminal abortion. Etiology is important in both, as it is a knowledge of cause alone which can lead to prevention, that most valuable of all methods of treatment, and in criminal abortion to detection, thus indirectly to the prevention of recurrence.
A. Accidental or Spontaneous Abortion, or Abortion as the Result of Natural Causes.—The etiology of non-criminal abortion is indispensable to the practitioner, as it is this alone which will enable him to prevent its occurrence and recurrence, thus leading to the preservation of the lives of mother and child, doing away with the danger and suffering of actual treatment, and frequently serving as a guide in the latter. We will meet with some difficulties in our endeavor to analyze these causes, as they are so varied in their nature and differ so greatly in the medium through which they act. There are causes predisposing and exciting, local and general, internal and external, and causes which depend upon father, mother, and ovum. The direct dependence of treatment upon the exciting causes seems to necessitate a simple and practical delineation of the etiology of abortion. A direct reference of the cause to the offending organ is understood most readily, and will point most directly to the necessary measure of relief; hence we will consider such causes as spring from or act through mother and child—more properly, the maternal system and its individual organs on the one hand, and the ovum and its parts upon the other. We cannot, however, pass by these without giving a thought to such causes to which great importance is attached by many, and which it is best to consider separately.
Predisposing Causes.—Almost all abnormal conditions, whether pertaining to the system or external to it, are more or less predisposing causes, whilst direct exciting causes are few; they may or may not be followed by the premature interruption of gestation; they tend to death and expulsion of the ovum, making it likely to occur whenever the exciting cause arises. We may say all those by which the occurrence of abortion is favored are predisposing causes: they are conditions under which we may expect its occurrence; and, knowing them, it is the duty of the physician to guard his patient. The classification is indefinite. Thus Naegele considers as predisposing causes anæmia, congestion local and general of the maternal system, neurotic influences; and as exciting causes—1st, those which tend to sever the amnion from the surrounding uterine structures; 2d, those which cause malnutrition, disease, and death of the embryo or foetus; 3d, those which directly arouse uterine contraction. Others consider diseases acute and chronic on the part of the mother, local and general, as well as diseases on the part of the father, predisposing causes, whilst traumatism and neurotic influences are considered as exciting causes. All are classifications based upon no strict foundation. I wish, however, to call attention to certain conditions which I look upon as predisposing to abortion: that is, a pregnant woman while under the influence of such condition, such cause, is more liable to abort upon the occurrence of some directly exciting cause. The existence of one or more predisposing causes does not necessitate abortion; pregnancy may continue without interruption if exposed to any of the conditions which we will term as exciting causes.
First. Climate.—We find abortion, both accidental and criminal, prevalent in certain countries and in certain districts, dependent upon climate—in the deltas and valleys subject to malaria, upon barren soil where food is wanting or where the work of woman is particularly laborious.
Secondly. Number and character of the population: this mishap is most common in large cities, where morals are lax, where the ill-fed poor are crowded into tenement-houses and the rich live in the whirl of social dissipation, or in thickly-settled regions where there is an intermingling of sexes, where women are neglected and ill-fed. I may here add an observation which truly shows the difference of locality. Both Playfair and Philippeaux3 claim that abortion is especially prevalent in the country. This may be true of the rural districts of England, France, and Germany, especially the latter military government, where it is in the country that young, able-bodied women do the hardest and most of the work, as is seen when passing through these regions in harvest-time. In America the very opposite is true, as in the country here abortion is most rare.
3 Annals Gynécologie, 1881.
Third. Certain periods in woman's life eminently predispose to abortion. There are those important epochs in woman's life during which her nervous system undergoes a severe strain wrought by those changes which are all-important to her existence. These are, first, in early married life, when intense hyperæsthesia exists due to changes wrought in the sexual system: the young wife is, moreover, exposed to injurious external influences, certain forms of traumatism; and secondly, toward the approach of the menopause, as the activity of sexual function and the uterine organ diminishes and the nervous system is undergoing those changes with periods of intense neurotic excitement which accompany the menopause. Finally, we may look upon the morbid conditions of the system, all unfavorable changes in the surroundings, as predisposing causes.
Exciting Causes.—We have seen that Naegele considers malnutrition and all causes which lead to separation of the ovum from its surroundings, and even uterine contractions, as exciting causes, whilst Spiegelborg considers hemorrhage so much so that to him the history of hemorrhage during gestation is the history of abortion. As exciting causes I consider uterine contractions and such conditions as directly lead to hemorrhage in the uterine or foetal membranes; but I cannot class either as exciting causes direct and primarily, both being merely sequents dependent upon some more remote cause. The varied importance of predisposing and exciting causes will be best appreciated if we but recollect the ordeals which a healthy woman may undergo—the direct exciting causes which may act upon her—and yet abortion not occur, provided no predisposing causes exist. Thus we have the well-authenticated statement of a pregnant woman being run over, the wheels of a physician's carriage passing directly over the abdomen, and yet abortion not following. I myself know of the attempts of a husband to produce abortion upon a willing wife by beating the abdomen, finally stamping and sitting down upon it, and yet not succeeding. I have the statement of a reliable physician as to the continuation of intra-uterine application of iodine and astringents to the cavity of a uterus supposed to be diseased, which proved to be pregnant, until the fourth month, and yet abortion not following. We know how women with criminal intent produce local injuries, even such as result in death, whilst the ovum remains undisturbed. These are cases in which no predisposing cause existed. On the other hand, the careless washing of the feet in cold water, a single effort at the wash-tub, a rapid drive, fright, a piece of bad news, coitus, the slightest nervous or physical disturbance, may produce abortion where predisposing cause sufficient does exist. We will here classify the exciting causes of abortion, in reference to the consequent treatment and the possibility of prevention, as maternal and foetal, dependent upon, acting by means of, the maternal system and organs or those of the ovum. Those dependent upon the mother are amenable to preventive treatment; not so those dependent upon the ovum.
A. Causes of spontaneous or non-criminal abortion:
1. Causes due to pathological changes in the maternal system, general and local. These are by far most important to the practitioner, as they are amenable to treatment. His attention should most especially be directed to—
a. General causes acting through the system. These are—
(1) Diseases acute and chronic;
(2) Causes acting through the nervous system, neurotic;
(3) Physical or traumatic;
And (4) I shall classify what I might term social causes, such as result from custom and fashion, which form an important element in the etiology of abortion, and one more particularly open to and demanding prevention.
b. Local causes on the part of the uterus and its adnexa.
2. Causes on the part of the ovum.
1. Causes Maternal.—These may be general or local. General causes, arising either in the maternal system or exterior to it, but acting upon it, may be either physical or nervous, arising from diseased morbid conditions of the maternal system.
a. General causes acting through or resulting from changes within the maternal system.
The premature interruption of pregnancy may frequently be traced to disturbance of the maternal system or external influences which act upon it, either directly by traumatism or indirectly through the nervous system, and the uterus, hypersensitive in this state of intense physiological activity, responds. It is the point of least resistance to which the shock is conducted; as the electric current invariably passes through the best conductor in a network of wires to the point of greatest attraction, so shock follows the course of the uterine nerves, at the time most tense, and the explosion follows in that organ.
(1) Disease, acute and chronic, on the part of mother and father interferes with the nutrition and development of the ovum—on the part of the father, through the semen; on the part of the mother, by malnutrition of the growing germ.
Acute Diseases.—A vitiated condition of the blood, as well as the increase of temperature, local and general, which accompanies constitutional disturbance, affects nutrition and development of the ovum. Zymotic infectious diseases, as well as those accompanied by congestion of the pelvic viscera, are most liable to affect gestation: the excessively high temperature of the nutrient fluid and of the surrounding viscera, if not direct infection of the germ, leads to death of the embryo and consequent abortion in the course of zymotic disease. The localization of the morbid affection in the vicinity of the uterus affects the existence of the embryo by reason of the consequent congestion and irritation, as well as by depletion of the system, as in dysentery; direct infection, as in variola or scarlatina. This delicate existence is threatened in various ways by traumatic injury, as may occur in eclampsia. Fortunately, abortion in the course of disease is not the rule, but the exception, and usually accompanies morbid conditions of the system only if most intense or if predisposing causes exist; yet gestation is at all periods endangered by intercurrent disease in the early as well as the later stages. It is in the later stages only that the existence of direct infection can be determined, and, though perhaps not common, well-authenticated cases are recorded: I have myself delivered a mother, just recovering from a severe case of variola, of a seventh-month foetus covered with a typical eruption. That abortion occurs in the course of malarial fever is well known in the valleys and deltas of our great rivers, and it has been most erroneously ascribed by some to the energetic medication which is called for. If the disease attacks pregnant women, its continuance, but not the medication, may lead to abortion: it is not quinine given upon correct indications—it is the existing disease—which causes the accident, and must hence be checked as speedily as possible; it is the uterus which shelters the developing ovum, congested, hyperæsthetic, which is at the time the centre of physiological activity, and, we may say, the most sensitive portion of the body, most easily affected by an accidentally existing disease, as the non-pregnant woman, one more sensitive or feeble, always suffers most during an accidentally existing disease in that organ which is habitually most sensitive or weak or at the time under an unusual strain; if throat, lungs, or heart is weakened, it is that part which suffers most in the acme of malarial fever; if a woman is exposed to cold during the menstrual period, the pelvic viscera will respond most readily.
Chronic diseases affect growth and development of the ovum by reason of malnutrition, local and general anæmia. As has before been stated, the impregnation of even a healthy ovule by diseased semen or the semen of a diseased father may result in morbid development, which sooner or later ends in expulsion of the affected ovum. Of the diseases on the part of the father it is more especially—and I may say almost alone—syphilis which exerts a direct influence upon the ovum. Debility of the system is more likely to result in sterility, whilst the ovum, if impregnation takes place by such semen, remains healthy though feeble, and the traces are indelibly marked upon the offspring. The use of liquor, like the morphine habit, may lead to sterility, but not to abortion; though the offspring of a phthisical father rarely escapes, the disease is inherited, but does not develop during the early stages of gestation, and does not affect the ovum in its growth.
Chronic diseases on the part of the mother would seem as if readily leading to abortion, though the result is comparatively a rare one. The diseased, badly-nourished, often anæmic system offers an unfavorable nidus for the rapidly-developing ovum, which is so much in need of healthy and abundant nutrition; but as the feeble, sickly mother often has an abundance of healthy milk for the new-born child, a healthy physiological activity seeming to exist in those parts in the time of functional activity, so may the ovum find a sufficiency whilst other parts are affected. The intense activity existing in the uterus attracts an abundance of the circulating fluid; women low with chronic diseases, phthisis, or cancerous growths, often in the last stages, will bear children, yet they are fortunately not so free to conceive, and if impregnation does occur the healthy growth of the ovum is soon interrupted.
The causes which lead to an enfeebled condition of the system may lead to abortion, whether it be an anæmia, the result of disease or lack of food, of the mode of life, or the locality in which the sufferer lives—of poisonous gases or poisons of other kinds slowly admitted to the system. These poisons, however, whether acute or chronic in the mother, may directly affect the foetus. Lead and noxious gases, like the infection of variola or smallpox, are examples of the latter; more rapidly-acting poisons, like strychnia, opium, carbonic oxide gas, and syphilis, of the former.
Death of the foetus and abortion may result as a consequence of syphilis on the part of either father or mother, or of primary infection during gestation, and are liable to occur at the same period in successive pregnancies; if in the later stages of gestation, the ovum, especially the foetus, bears its characteristic marks. The effects of treatment and improvement are readily visible: abortion is more and more delayed; if the afflicted parent but slowly improves, abortion will occur at a later period during each subsequent gestation until a foetus is carried to term, but stillborn—the next living, perhaps, for a brief period. If vigorous treatment be applied in the early stages, abortion may cease altogether. The results of disease can be more readily seen in the foetus than in other parts of the ovum. The gummata of the placenta, the syphilitic indurations, are difficult to distinguish from other conditions, and appear only at later stages. The syphilitic pemphigus, when occurring upon the foetus, is characteristic, but the mucous membranes are most liable to show its traces. The gummata in the large viscera are frequent, especially in the lungs and liver; but most typical is the osteo-myelitis in the long bones, between epiphysis and diaphysis, a pale-red line in the earlier stages, resulting in a thickening of the parts at later periods.
(2) Causes acting through the Nervous System.—During pregnancy, that stage of intense uterine activity, of gestation and increased growth, we find an increased nervous excitability, motor and vaso-motor, the nerves responding violently to slight causes which would arouse no reaction during the normal condition. There is an increased reflex activity which may lead to a disturbance in the circulation or in the nutrition of the ovum, or to uterine contraction upon some slight excitement. This condition varies exceedingly, the causes which excite these reactions and the extent of the reaction excited differing greatly in degree. Uterine hemorrhage, contractions, and expulsion of the ovum in consequence of neurotic influences are more likely by far to occur during the existence of predisposing causes. Fright, a nervous shock of any kind which in no way affects healthy gestation in a healthy woman, will result in abortion in a person afflicted with uterine disease or in a system otherwise weakened.
The frequent occurrence of abortion in early married life and toward the menopause is mainly referable to nervous influences. Marriage is a period in woman's life comparable to puberty and the menopause—a period of heightened nervous excitability: a change takes place in all the modes of life, and, in addition to the many other causes which at that time unite to interfere with conception, increased nervous excitability is one of the most important, as it is toward the climacterium. We shall consider this period more particularly under the head of Social Causes. As the change of life is approached, the activity of the sexual organs, their nutrition, the blood-supply, and especially the healthy activity of the mucous membrane, are lessened, and hence the growth of the ovum is endangered; but the condition of the nervous system at this period certainly has an equally powerful influence in producing the tendency to abortion. During this hyperæsthesia an existing predisposing cause or some slight additional excitement will arouse the vigorous action of the tensely-strung vaso-motor nerves; coitus even at these periods may be looked upon as dangerous to continued gestation. It is not alone the traumatic influences which must be considered, but the effect upon the nervous system as well, especially the vaso-motor nerves, in the state of intense excitement which accompanies the sexual orgasm. During these periods of increased nervous tension during pregnancy coition is more liable to produce abortion than at other times. It is in the coming together of numerous causes that one more intense than the others, though harmless alone, will be followed by sudden response.
Much has been said as to the injurious effect of coition during pregnancy. Those who look to physical causes as mainly tending to abortion claim the injurious effect to be purely physical, traumatic; whilst others, and I believe more justly, claim that the influence is strictly neurotic. Parvin says that coition is so frequent a cause that he blames upon this half the cases which are termed spontaneous abortions; certainly it has a most unfortunate effect, so that we frequently see the expulsion of a healthy ovum from the second to the fourth month in young women recently married, mainly in the higher walks of life and among delicately organized women, who are more intensely sensitive to the great change which they have undergone. I have repeatedly had occasion to see these unfortunate cases, and almost look for the occurrence of an abortion within the first six or eight months after marriage in the bride of fashionable society. Though the statement of Parvin may seem somewhat forcible, the fact is not to be ignored: the ovum expelled in such an abortion gives evidence of being of healthy growth, so that the cause must not be sought for in malnutrition or local disease. The laws of many peoples are as strict in regard to coition during pregnancy as they are about the care of menstruating women: by some it is forbidden; among the ancient Mexicans it was regulated, it being ordained that sexual intercourse should be exercised to a moderate extent during pregnancy in order that the healthy development might be furthered and strength given to the child. The injurious effect of coition is everywhere acknowledged, and, I can say, not unjustly. Total abstinence was looked upon by the Mexicans and other peoples as likewise harmful.
The changes wrought in the nervous and physical condition of women after marriage and toward the menopause are such that the menstrual periodicity is interfered with, dysmenorrhoea sometimes existing, at times menorrhagia, so that the expulsion of an ovum of from eight to ten weeks is ignored, passing away with the clots of a profuse menstrual flow: it is often not even known to the mother, being considered by herself and family as merely a profuse flow; the accompanying pains are often no greater than those of the dysmenorrhoea common at such times; no precautious are taken, and thus the foundation is often laid for uterine disease.
We know that the emotions—fright, fear, joy—may check the menstrual flow or produce menorrhagia; in the gravid uterus hemorrhage may be caused or contractions aroused, and abortion results. In a misled girl or a young married woman the fear of pregnancy may frequently cause cessation of the menstrual flow: the effect of the mind and nervous system upon these organs is equally evident in the cessation of the menses when pregnancy is longed for, though it does not exist: I have even known of the summoning of midwife and physician by an aged bride with distended abdomen (gastric hystero-neurosis) who longed for pregnancy and thought she felt uterine contraction and the inauguration of labor. As the emotions affect the general health, the ovum may likewise suffer as a part of the maternal system; but when they are sudden, such as by fright or shock, the effect upon the vaso-motor centres by reflex action is so forcible that the uterine vessels are paralyzed, dilated, and hemorrhage follows; or a tetanic contraction of the vessels may result, and then the nutrition of the embryo is checked.
The evil effect of nursing during pregnancy is due in part to the withdrawal of nutrition from the ovum, but in part to the contraction of the uterus and its vessels, which may result as a reflex symptom from the irritation of the nipples, and thus cause abortion. The frequent occurrence of abortion upon ships at sea is due in part to traumatic influence, the vomiting of sea-sickness; in part it is neurotic, due to the changed mode of life, the leaving of a home by the emigrant for foreign lands, just as the menstrual flow is stopped for months and months in the immigrant girl upon her first arrival in a strange country.
(3) Traumatic influences are comparatively rare as a cause of natural spontaneous abortion; and it is true of these as of every other cause that it depends upon existing conditions whether abortion will result or not. The pounding of the belly is an ordinary method of producing abortion among primitive peoples: a fall, a jump from a wagon, may disturb the progress of gestation, while traumatism far more violent may not affect it, as in the case of the woman in the later months of pregnancy over whose abdomen the wheels of a physician's carriage passed without causing any injury whatever.
In the earlier months, while the ovum is still sheltered in the pelvic cavity, injuries are still less liable to cause abortion. I have myself seen a pregnant woman severely bruised about the lower bowels and go to term. I have been told by reliable physicians that local treatment of uterine disease has been continued by reason of the non-cessation of the menses to the third and fourth month, when pregnancy was discovered, and yet abortion did not follow, though I regret to say that quite a number of cases have come to my knowledge where the treatment of supposed uterine disease, especially of uterine tumor—pregnancy in fact—was suddenly terminated by the appearance of the corpus delicti, a four or five months' embryo. The intensity of the resistance is well illustrated in a case which it was my good fortune to see in consultation, where the most brutal local treatment had been resorted to for three or four months and abortion did not occur; the patient had left her persecutor and travelled hundreds of miles to seek treatment. The manipulations had been so violent as to produce metritis and cellulitis, yet the growth of the ovum continued, as demonstrated by the healthy foetus of five months which was at last expelled. I have but recently examined a lady who has been treated locally for uterine disease, and found her in the beginning of the third month of pregnancy, so far undisturbed.
We may well place the uterine sound and applicator among the traumatic causes. The physician himself, especially the gynecologist, has been sought out by women to aid in relieving them from the product of conception, and it is through sound or applicator that he is expected to accomplish the work. Among the many devices to which women—and, I am sorry to say, those in the most fortunate circumstances, in the best walks of life—resort to attain this end is one which certainly shows knowledge and shrewd calculation, but most villainous intent, which is not unfrequently practised, and against which it is well for the physician to be on his guard. It is that of forcing the attendant to uterine examination and treatment upon the plea of disease, well knowing that the germ must thus be destroyed. The woman calls upon a physician—in preference upon some specialist not attending in her family—upon the plea of uterine suffering, well knowing, either from personal experience or the gossip so common among ladies, some of the more common symptoms of this disease—backache, pains in the side, nervousness, weakness, menstrual suffering. She relates her case; upon questioning states that the period is just passed; and, though the examination may reveal nothing, though no application may be made, she well knows the uterine sound will be used. That is what she desires. If an application of iodine or nitrate of silver follows, all the better. Though for reasons far more important the physician should listen to the history of a patient with distrust, and rely must thoroughly upon his own examination, this course is especially indicated in gynecological cases without distinct sign of disease; and these very cases again point to the importance of a careful bimanual examination, and a resort to all other methods before the sound is used; and that in case of an enlargement of the uterus, discoloration of the cervix and vagina, we should under no circumstances introduce an instrument into the cavity unless it is established with absolute certainty that the congestion and increased size are due to pathological and not physiological causes.
Social Causes.—I wish to call attention more particularly to some of the abuses of modern life which not unfrequently interfere with gestation. These exist among all classes of society, high and low: among the poor they are unfortunately forced; among the wealthy they are the result of devotion to fashion and society. As we have seen that in the Old World abortion is common in the rural districts, it is an evidence of hard labor, especially in the field, at the wash-tub, and labor by which the abdomen is compressed, the abdominal muscles freely exercised. It is not only physical labor, but exposure to cold and wet, cold feet, which are to blame; in those more fortunately situated tight lacing, dancing, and consequent colds have a like injurious influence.
I would again allude to the newly-married, who are so subject to the lighter forms of traumatism, the always greater frequency of coition, the congestion and mechanical insult, the bridal trip being especially injurious. During this period of hyperæsthesia it is too great a strain upon the body as well as upon the nervous system: the young husband, unacquainted with woman's strength and needs, is always liable to judge her powers by his own. Railroad travel, the fatigues of sight-seeing, pleasures, theatre, and the dance, are all borne by the patient bride, anxious to please the groom: upon returning home the cares of the new house, excessive social duties, all combine to undermine the strength of a delicate woman in her first gestation. Enfeebled, often depressed by reason of gestation or nervous changes, excessive pleasures are forced upon her by reason of her condition—i.e. bride—and abortion follows; and, we may say, follows in consequence of traumatism. In other walks of life we find other conditions, still with the same unfortunate developments—excessive labor and pleasure during this period, when rest and care are so necessary. It is in young married women partly the pleasures of society, partly the unaccustomed duties imposed, which lead to injury. Ignorant of their condition, ignorant of the care necessary, even when aware of injury unwilling to acknowledge it, desiring to bear up, to show no weakness, they lay the foundation of much future suffering. The cause of so much uterine and pelvic disease in the unmarried, in the society girl, exists to the same extent in the newly-married, only that the injuries caused are far greater in the first period of married life, as the strain both of body and mind is increased in this most susceptible condition.
Local Causes.—Though the local causes on the part of the mother which lead to abortion, diseases of the uterus, especially of its mucous membrane, are equally frequent and equally amenable to treatment, they are of less practical interest to the general practitioner. Diseases of the uterus itself are not so important etiologically as those of its lining membrane: uterine tumors, unless of enormous size, usually admit of the completion of gestation; flexions and versions rarely interfere with the development of the ovum; a prolapsed uterus may bear the foetus to term unless the adhesions are unyielding and impregnation is impossible, because the uterus as it develops with the growth of the ovum rises beyond the confines of the pelvic cavity, and the displacement is thus remedied. Anteflexions and anteversions are always rectified; retroversions in rare cases only lead to abortion; adherent retroflexions are most to be dreaded; when the uterine body, bound down to the pelvic floor, expands within the cavity to such a size as to make escape through the brim impossible, abortion must necessarily follow. Deep lacerations of the cervix make conception improbable and interfere with gestation; cervical catarrh in no way affects its progress. Those morbid conditions of the uterine tissues which are unaccompanied by disease of its mucous membrane rarely lead to abortion.
Uterine contractions due to reflex nervous excitability are perhaps the most common of all these causes, yet here the uterus primarily is not at fault. A state of intense excitability is very often due to general causes, to intense febrile action, to congestion or anæmia; high or low temperature, whether due to external or internal causes, and irritation of the surrounding parts,—all of which conditions tend to increased contractility. Such diseases of the uterus as cause induration of the walls may lead to abortion, like the incarceration of the organ in the pelvic cavity, by reason of prevented distension.
Uterine Mucosa, Decidua.—Of far greater consequence than the conditions existing in the muscular tissue of the uterine wall upon the vitality and development of the ovum are those of the uterine mucosa in its state of physiological hypertrophy as the decidua of pregnancy. This soft, succulent tissue, rich in lymphatics and blood-vessels, is the nidus in which the ovum rests, its immediate protecting shelter, and the source from which nutrition is derived; hence morbid changes of this structure react promptly and forcibly upon the ovum—most so in the earliest stages, when it is altogether dependent upon this structure; less so as gestation progresses. As the ovum grows it becomes more resistant, its tissues more dense, and the source of nourishment is gradually changed to the large uterine sinuses at the placental site. Moreover, the decidua after the third and fourth month, when it has served its term, performed its function, gradually diminishes in thickness, until toward term retrograde metamorphosis is initiated preparatory to the expulsion of this structure, at that time merely forming a line of demarcation in the lax meshwork in its lower layer between the healthy tissue which remains and those structures which are passed off in labor. An inactivity of the mucous membrane, an imperfect development of the deciduous structure due to disease of the mucosa, is a frequent source of abortion. In chronic disease of the uterus or its lining membrane this rapid and healthy development of the decidua after conception is prevented, the delicate membranes of the ovum do not absorb the necessary nutrition, the development of the embryo is checked, morbid conditions of the ovum follow, and abortion results, especially at that time of active development, the period of placental formation. The decidua vera is the least important part of this structure, serving nutritive purposes only in the very first weeks at the site of placental formation, and sheltering the delicate ovum in the nest formed by its soft tissue: it is the decidua serotina, and especially that membrane which holds the ovum in place, the decidua reflexa, which claims attention. But morbid conditions of the vera, the greater part of the mucous membrane, are naturally accompanied by imperfect development of serotina and reflexa, and hence the imperfect imbedding and nutrition of the ovum.
Hypertrophy or excessive morbid development of the decidua may accompany acute infectious diseases, as we find similar conditions in other organs of the body, especially in the larger viscera. These changes, morbid in their character, interfere with development as do the atrophic forms. These hypertrophies may, however, exist independent in their nature, due to local disease of the uterus and its parts, as in chronic endometritis, where in place of the succulent deciduous structure we find an induration and a proliferation of the active tissue usually throughout the entire membrane, rarely localized, of a polypoid form: the chronic catarrhal affections are accompanied by an increase of secretion, morbid in character, which is liable to interfere with the development of the germ. Moreover, hemorrhage more readily occurs under these pathological conditions, usually secondary in character, brought about by minor insults, trivial causes, which would not affect healthy tissues. These hemorrhages, all-important in the early stages, affect development less and less as gestation advances, the importance of the decidua lessening and its functions being superseded. Where a slight extravasation of blood within the deciduous structure may lead to separation and expulsion of the ovum in the first and second months, larger hemorrhages are often without consequence when occurring within the same tissues in the fifth or sixth.
2. The Ovum.—Pathological changes of the ovum itself, of the embryo, of the surrounding membranes are less frequent as primary causes of abortion, and they are of less importance to the practitioner as being in no way amenable to treatment. When they do occur they usually lead to expulsion in the earlier months.
Those conditions liable to lead to abortion are especially diseases of the chorion, placenta, and umbilical cord, rarely of the amnion, the embryo itself, or the amniotic fluid.
Chorion and Placenta.—The chorion being the nutritive organ, supplying the means of communication between mother and child in the earlier stages by the villi over its entire surface, later by the placenta, must necessarily determine the progress or cessation of foetal development by the conditions existing within its own tissues. One of the most striking and notable changes to which it is subject is the hydatiform degeneration of the villi, leading to a formation of the grape mole or hydatiform mole. This is a cystic degeneration of the terminal sprouts, an hypertrophy of the germinal tissue, the young connective-tissue cells, which usually begins at a very early stage: the vascular development is interfered with, the nutritive material is directed to the morbid activity of the chorion, which in its exuberant growth, usually inaugurated in the first weeks, destroys that of the other structures; the delicate tissues of the embryo are soon absorbed, and even the amniotic sac may disappear, the within-lying cavity, which always remains in every malformation as an unmistakable trace of the ovum—a characteristic which serves at once to mark the product of conception. A mole of this kind usually attains the size of an apple, but may grow to that of a child's head, and the period to which it is carried is much longer than that of the mola carnosa—usually five to seven months, sometimes eight or ten. The appearance is that of a conglomeration of cysts, usually the size of a currant or gooseberry, though they are often from that of a pinhead upward, connected everywhere by thin connective-tissue strands; they consist of a delicate transparent membrane enclosing a pale, colorless fluid: in the earlier stages the amnion with its cavity remains, but with the development of the growth that is destroyed, and the appearance of the hydatiform mole as a product of conception even becomes unrecognizable when no longer surrounded by the decidua; as in cases of excessive development, the morbidly-enlarged villi may even break through the decidua vera in their growth, and we find a dense mass consisting of a conglomerate of small cysts united by connective-tissue shreds enclosed in the cavity of the uterus.
Hemorrhage.—In the third or fourth month, at the time of most active development of the villi at the placental site, primary hemorrhage may occur, due to the active vascular development, and thus lead to abortion, but this is rare; frequent as hemorrhage is, it is almost invariably to be traced to some cause.
The Placenta.—In later stages, when the greater part of the chorion appears as a more firm, non-vascular membrane, that part which in connection with the decidua serotina is developed to the placental formation is the most vulnerable point, as it is the connecting link between the foetus and the maternal tissues, and the one source of nutrition. Hemorrhage in this structure, whether in its maternal or foetal portion, if excessive, must lead to a cessation of development, to abortion. Slight hemorrhages, such as must have proved fatal in the earlier stages, no longer interfere with the growth of the ovum, but are absorbed or remain as small hemorrhagic spots, the tufts or cotyledons in which they have occurred appearing as a hard whitish mass of connective tissue. If the hemorrhage is more profuse or widespread, it may lead to abortion directly or to inanition—to death of the foetus, and secondarily to abortion. Inflammation may occur throughout the entire placental site or localized, as in all other points in the connective tissue of the structure, accompanied by vascular development in the first place, followed by induration and shrinkage; frequently remaining as small irregular or conical indurations between the villi or cotyledons, leading to abortion, either by the tendency to hemorrhage thereby excited or the death of the foetus if sufficient of the tissue is destroyed to cause inanition.
Fatty degeneration occasionally results in consequence of insufficient nutrition due to hemorrhage, or after death of the foetus preparatory to premature expulsion—a morbid approximation to the condition upon its maternal surface and in the decidua serotina at term.
Syphilis.—The changes in the chorion and placental tissue accompanying syphilitic disease are rarely the direct cause of abortion or premature expulsion of the ovum; as a rule, they are mere local manifestations of the morbid condition existing in all the foetal structures, and frequently in those of the mother. In the early months, during the period of the chorion frondosum, abortion results from insufficiency of the nutriment absorbed by the indurated villi of the chorion, lacking in vascularity and in succulent embryonic tissue; the structures are more dense, the villi hypertrophied, in the more aggravated cases the vessels entirely obliterated, whilst after the formation of the placenta in later months the existence of syphilis is made evident by appearances similar to those which accompany other chronic inflammatory conditions. The appearance presented by a syphilitic placenta is usually that of cellular hypertrophy, the centre in a state of whitish induration or fatty degeneration according to the stage of the disease. But it is hardly possible to diagnose syphilis with certainty from the appearance of the placenta alone, nor is the placenta usually affected to such an extent as to appear as the prime cause of foetal death. The placenta is usually large as compared to the size of the child, in appearance similar to other inflammatory conditions presented by the placenta, the growth of the foetus being interfered with, whilst that of the placental structure continues until the retrograde metamorphosis is sufficient to result in expulsion. The placenta in a syphilitic foetus is larger than ordinary, 1 to 4, whilst usually 1 to 6. Gummata are rare, so also tumors of the placenta. A myxoma developing from the embryonic tissue is occasionally found. If the foetal portion of the placenta alone is affected, or in the earlier stages the chorion and the decidua healthy, we may with safety infer syphilis on the part of the father alone previous to impregnation.
The Amnion.—The amnion, which serves merely as a container for the preserving fluid, is wanting in vascularity, and consequently but little subject to morbid changes. The only pathological condition which we find in this structure is an inflammatory development, the formation of amniotic bands stretching across this delicate sheath or from some portion of it to the foetus, crippling or cutting its membranes in such a way as to interfere with gestation. Nor does an abundance or want of amniotic fluid affect the development of the embryo or ovum during the earlier stages. It is no more a cause of abortion than the slight changes occasionally found in the amnion itself.
The Umbilical Cord.—The navel-string, however—the sheath stretching from amnion to foetus, enclosing the umbilical vessels—is subject to quite a number of changes, frequently the cause of abortion, occasionally mere results of other complications. Excessive or insufficient length of the cord, which may seriously complicate labor at term, in no way affects the development of the ovum; in the third or fourth month the length of the cord is naturally much greater than that of the embryo, and the resulting coils and knots seem in no way to endanger its existence. Knotting of the navel-string may lead to death of the foetus, but only in the last months, rarely at earlier periods. Stenosis of one or the other of the vessels sometimes occurs, leading to the death of the embryo and consequent abortion: a condition which I have found remarkably frequent is that of torsion of a very long and thin cord in the third and fourth months; but this torsion of the cord seems so frequent in abortion that it must appear as a consequence, movement of the dead foetus apparently leading to a twisting during inactivity of the tissue. A very striking condition of the cord has frequently attracted my attention—lack of embryonic tissue, the gelatin of Wharton, with excessive torsion; the cord flat, thin, in parts thread-like, and usually very much twisted; the embryo retarded in development as compared to the size of the ovum, no other cause being at the same time discernible, neither disease of the uterus nor affection of the system. The torsion is secondary, often wanting, the cord being very thin and thread-like in places, consisting of the amniotic sheath and the vessels, obliterated entirely or in part. Torsion I believe to be secondary, as I have noticed these excessively twisted cords otherwise healthy in cases of abortion; but this peculiar state, which I cannot term otherwise than atrophy of the cord, appears as a frequent primary cause of abortion in the second to the fourth month; torsion and knots may occur at later periods. Ruge of Berlin,4 who has investigated this subject, thinks that stenosis of the cord in the vicinity of the umbilical insertion is rarely the primary cause of abortion, though often a secondary, resulting from motion and traction on the inactive, dead vessels; whilst Leopold seems to look upon it as the primary cause.
4 Zeitschrift für Gynäcol. u. Geburtsh., vol. i. 1, p. 57.
I have endeavored to call attention to the various conditions which may lead to abortion, but it is almost impossible to place an estimate upon their relative importance. Whilst uterine contractions, hemorrhage, and abortion may result in one case from a slight nervous excitement, a trifling annoyance, the most violent nervous irritation will in no way affect another; whilst a fall, a jump from a buggy, may lead to a mishap in one patient, the crushing of the abdomen beneath its wheels will not affect another; a trifling fever may appear as the cause in one, and again the most severe pneumonia or typhoid condition will not impair development in another; the child may be carried to term by a mother in the last stages of consumption, whilst a very trifling affection may lead to abortion at other times. So it is with remedies taken internally, though as a rule they have but little effect: a violent aperient may cause abortion, and again, as in one instance which I recall, a woman in the fourth month of pregnancy died rapidly of dysentery resulting from the taking of cathartic pills to produce abortion, and the post-mortem revealed a perfectly healthy ovum in a healthy uterus, whilst the dysentery consequent upon the remedy killed the mother. The careful introduction of a sound into the gravid uterus has led to a separation of the ovum, to hemorrhage, and to abortion, whilst a knitting-needle has been passed into the uterine cavity and through the womb, causing the death of the criminal mother, without in any way disturbing the ovum. The uterus has been regularly treated for supposed disease for three and five months by internal applications, and gestation has progressed. So it is with all these cases: at one time, especially with pre-existing disposition, a slight interference may result in the cessation of development, and at another the most violent insults in no way disturb gestation.
B. Causes of Criminal Abortion.—The causes proper of criminal abortion are immorality among all classes, high and low—among the wealthy fashion, the pleasures of society, and the desire to limit the number of children—a common cause, strange to say, mostly among those very people who can actually afford the expense. The cause direct, the means by which the crime is accomplished, should be known to the practitioner in order that he may detect the deception which is so frequently practised upon him—that he may prevent it if possible, and at least not, by reason of ignorance, be made particeps criminis.
The means resorted to are either external or internal, traumatic and instrumental, or by medication.
Traumatic.—When produced by the patient herself it is either by violent exercise, running up and down stairs, walking and dancing, occasionally by pressure upon the abdomen or by the use of the knitting-needle, catheter, or similar instrument. The more expert or daring only attempt to enter the uterine cavity, as the organ itself may be pierced; if the catheter is successfully introduced, the attachment of the ovum is severed, and with the knitting-needle the sac is punctured.
These attempts are usually made in the second or third month at the second or third missed period. There is, however, a class of experts among the most elegant who have attained such remarkable dexterity as invariably to introduce the instrument successfully into the uterine cavity; and these are in the habit of regularly practising this dangerous experiment when the first days of the expected period have passed without the coming of the flow.
The abortionist either injects fluid into the uterus or introduces a probe or catheter into the cavity. Customs vary in different countries; so Van de Warker states that in France puncture of the membranes is fashionable, whilst here a syringe or sound is used.
Among the most common—and perhaps most harmless—means is the hot foot- and hip-bath, the "sitz-bath," often with the addition of mustard: this, as well as the steaming of the parts by sitting over a chamber filled with hot chamomile tea, is the first step taken by the nervous wife when the menstrual flow has failed to appear sharp on time and she still lives in hopes that it is but a cold which has interfered with the regularity of its return. Even physicians, respectable men in good practice, who may not venture upon bolder measures and wish to keep their conscience clear, are known to advocate this course, though they well know what such a cold means.
Medication is perhaps more commonly attempted, but less successfully, notwithstanding the injuries caused to the system. To follow Van de Warker's thorough study, the remedies used are mainly of two classes—those which act directly, the emmenagogues, oxytoxics, and reflex abortifacients. Notwithstanding the firm popular belief in their efficiency, they are less harmful to the ovum than to the system of the mother, and, as Van Warker says, there is more science and skill used than is generally supposed in the various pills and teas, which are less simple, but no less common, than the foot-baths and the gin-bottle. Ergot is almost sure to be called upon to perform its office. Its action is very uncertain, but if persistently used is readily recognized by its effect upon the vascular and nervous system—uterine or ovarian pains and depressed action of the heart where in spontaneous abortion an acceleration is to be expected; the temperature is lowered, and the sphygmograph shows a remarkably flattened apex with an almost senile pulse. Cotton-root is also commonly used, especially in the South, and is marked by its narcotic action.
Among those termed reflex abortifacients, acting more indirectly by their effect upon surrounding organs, we may notice cathartics, principal among them aloes, which, notwithstanding its purgative action, does not appear to deplete the circulation, but, on the contrary, results in pelvic congestion; but even its excessive use need not in any way affect gestation. I have seen a patient dying amid the resulting dysenteric symptoms, frequent, scanty, and bloody evacuations, accompanied by excessive tenesmus, inflammatory conditions, and abdominal pain, though the uterus did not react and the ovum remained intact. The odor of the drug is imparted, it is said, so intensely to the evacuations that it is unmistakably noticed.
Juniper and black hellebore, the latter especially endangering the life of the patient, are both toxic in their effects. The painful fluid evacuations, accompanied by bearing down, tenderness of the abdomen, pain and sickness at the stomach, dry throat, would characterize the former; the odor the latter, as well as the flushed appearance of the face, with heaviness and pain in the head and frequent micturition. But one of the first and most common remedies to which the desperate woman resorts when she finds a day of the menstrual period passing by without the appearance of the flow is tansy, which seems to act by reason of the uterine congestion which it causes. Though undoubtedly effective at times, it will, like all other drugs thus used, more often cause injury, and even the death of the mother, without disturbing gestation. "Disturbance of the nervous system, profuse salivation, immobility and dilatation of the pupils, and severe strangury," are noted as the symptoms of such poisoning. Hardly less popular is the still more dangerous cantharides.
The female pills and various mixtures more or less openly sold by druggists are, according to the researches of Van de Warker, composed of one or more of the above-mentioned ingredients, and the immense quantities disposed of show how truly abortion is called the crime of the period. Knowledge of the remedies used for these purposes will aid the physician in arriving at a correct diagnosis and enable him to save the child and guard his patient.
PATHOLOGY AND MORBID ANATOMY.—I have endeavored to describe with some accuracy the appearance of the healthy ovum, the sac, and surrounding structures during the various periods of early pregnancy, as it is the comparison with these which will enable the practitioner to distinguish between spontaneous and criminal abortion, enable him to determine the duration of pregnancy, guide him as to the cause, and thus serve to facilitate treatment and perhaps to prevent recurrence. Knowing what has been expelled, whether it is ovum and decidua entire or only in part, the line of action is evident. In all abortions due to an immediate and active exciting cause, whether criminal or resulting from shock or accidental trauma, the ovum is healthy, normal in all its parts, size and development of the embryo corresponding to the period of pregnancy at which the accident occurred; whilst in spontaneous abortions due to accidental causes more or less marked changes exist: the development of the embryo especially is retarded; its life has been destroyed, and growth has ceased, whilst the morbid development of the membranes continues, so that the mass expelled presents more or less of a mole formation—comparatively solid, with thick walls formed by the foetal membranes infiltrated with blood, the cavity often compressed by the surrounding extravasation, the embryo comparatively small or disintegrated in whole or in part.
The ovum is usually separated in its upper portion by hemorrhage, which comes from that point at which the vessels are most fully developed, the future placental site, though still agglutinated. With the inauguration of uterine contractions separation takes place at its lower pole by dilatation of the os, and retraction of the uterine walls from the ovum proper surrounded by the reflexa; as the abortion progresses, the muscular fibres of the fundus force it down into the dilating cervix through the still partially adherent decidua, and the intact ovum is expelled, the inverted decidua following it as the membranes do the placenta in labor at term. Yet these conditions vary greatly with the existing morbid changes.
In traumatic or criminal abortion the perfectly-formed ovum, the delicate cystic body surrounded by its shaggy chorion, is first expelled, to be followed by the decidua, usually—when in a healthy state—first by its anterior and then by its posterior half; whilst if the abortion has been inaugurated by some slowly-acting cause the decidua is hardened, infiltrated with compressed and clotted blood, the small ovum forming merely a part of the solid mass; and thus a firm oval body, coated with blood upon its rough, irregular exterior, appears.
Up to the third month the ovum is, as a rule, expelled as a whole, often even in the fourth. Later, unless decided pathological changes have taken place, the membranes are mostly ruptured and the embryo separately expelled, as in labor at term. In later months this is always the case, and the progress of abortion is greatly impaired by the adherent tissues: the mass of the ovum, which serves so much to excite uterine contractions and promote expulsion, is destroyed by the collapse of the amniotic sac, and separation and expulsion of the membranes are hindered by reason of the smaller amount of resistance offered. Hemorrhage is most likely to occur in the villi of the chorion, between its tissues and the surrounding decidua; if occurring in the latter structure, it appears thick, hard, infiltrated with blood, and no longer presents that soft, succulent appearance, but is firm and brittle.
The ovum as expelled presents three typical forms: First, as above stated, in accidentally-occurring traumatic or criminal abortion we find a healthy ovum with its shaggy chorion, and the inverted decidua attached or soon following, usually in two sections; most common, however, and almost without exception in spontaneous non-criminal abortion, is the mole formation, rarely the hydatiform mole, which has been described, and results only from the peculiar pathological condition of the chorion. The common form is the flesh mole, the mola carnosa, characteristic in appearance, resembling a polypoid growth, a reddish oval or rather pyriform mass with shreds of tissue (the decidua) adherent to its larger upper extremity, darker clots at the elongated lower pole. Upon section the walls show a brittle reddish structure, that of compressed and inspissated coagula, and in the centre a cavity containing fluid and detritus, if not the embryo, lined with a delicate membrane, amnion or amnion and chorion: the shape of the cavity is rather irregular by reason of the bulging protuberances formed by the contraction of the inspissated mass of blood extravasated between or within the tissues. These moles have very much the appearance of uterine polypi, and are often considered as such by physicians who pride themselves greatly upon curing their patients of tumors and the accompanying hemorrhage by a few doses of ergot. Though the macroscopic resemblance is such as to be quite deceptive, the mole upon section will always reveal a cavity, even if very small, containing fluid; and this cavity reveals the above-described characteristic slight bulging protuberances lined with a delicate membrane; whilst the microscopic examination shows the firm walls to consist of nothing but blood-corpuscles: the outer covering, often thoroughly infiltrated with blood, consists of the decidua serotina and reflexa, with more or less of the infiltrated shreds of the vera usually pendent from its upper extremity; when floated in water and cleansed, the outer or uterine surface of these shreds is ragged, rough, often appearing somewhat like the villi of the chorion, hence looked upon as placenta; this peculiar appearance is caused by the torn tissue in the line of demarcation in the lower or central meshy layer of the decidua vera, where it is separated from the lowest layer which remains adherent to the uterine wall. The inner surface toward the ovum will show a slightly wavy, cribriform appearance, the openings of the ducts appearing as fine depressions in the surface. (It must be remembered that this smooth inner surface is in the expelled specimen generally the outer one, as the decidua follows the ovum mostly as the membranes do the placenta at term—inverted.) If the disturbance causing the abortion has been of rapid progress, the cavity is large, the embryo approximating in development the period of expulsion; whilst if the changes have taken place slowly, the walls are thick, the cavity small, and the embryo may appear merely as a small mass pendent from the navel-string, or may have entirely disappeared, and can be traced only by the fine detritus in the amniotic fluid, the cord itself perhaps only in part remaining, and even this may have disappeared. The cavity will always be found toward the pendent pole of the decidua reflexa, as the extravasation takes place mainly in the serotina, giving it the appearance of a thick mass of clotted, compressed blood, and forcing the cavity toward the opposite extremity. These moles are usually more elongated and pyriform, one or two inches in diameter at their upper or larger extremity, three or four inches in length, with a greatly elongated and narrowed lower end, which has been so formed by being first wedged into the slowly-distending cervix.
Such is the appearance in those cases of slow progress in which death of the embryo has probably occurred at an early stage and hemorrhage has been the exciting factor, whether due to disease of the mother or other causes that may have destroyed the vitality of the germ. When resulting from disease of the mucous membrane, especially endometritis or catarrhal affections, it is a more oval tough mass, the main part of which is formed by the thickened and indurated vera; and if this be opened the ovum, in a very early stage of development, will be found within.
The uterus itself presents very much the appearance of the organ after labor; the external os, however, closes more rapidly, less rarely showing the funnel-shaped appearance of the puerperium; the cervix, though somewhat enlarged, is normal in appearance; the cavity is lined by the lower layer of the decidua, soft shreds covered with coagula; but it is lacking in the placental site and the putrid thrombi visible in labor at term.
Involution is slow if we take into consideration the slight distension of the uterus as compared to the process after delivery at term. The organ is in a state of healthy development, not prepared for the following retrograde metamorphosis, unless the expulsion of the ovum has been due to local disease, when some retrograde changes may have been inaugurated; if it results from constitutional causes, the existing depression naturally interferes with restitution. If shreds of tissue, parts of ovum, or decidua remain, absorption or expulsion is retarded. As a morbid or atonic condition so often exists, at least in abortion consequent upon natural causes, subinvolution or inflammatory conditions of the organ itself or the surrounding tissues are hence a frequent sequence.
SYMPTOMATOLOGY.—It will be remembered that abortion is more likely to occur among multigravidæ on account of the greater frequency of disease, especially pelvic affections; that it is most likely to accompany the periodic congestion which recurs at the time of expected menstruation; that it is more frequent in early married life, on account of the greater liability to traumatic injury and the existing nervous disturbance, and toward the menopause in that state of nervous and physical disturbance and lessening uterine activity. The third or fourth month of gestation is the dangerous period, as it is one of change of nutrition for the ovum, of the highest development of the decidua, and intense activity and congestion of the chorion, the rapidly-sprouting vessels finding but little resistance in the embryonic structures of the villi which surround them. Chronic disease of the mother is more likely to interfere with gestation at a later period; and, when knowingly undertaken with criminal intent, the time of choice is either the first month, when the first indications of pregnancy become evident and the menstrual period does not appear at the usual time, or more commonly at the time for reappearance of the third menstrual flow, when the fact of conception has been established to a certainty, and the conscious mother, firm in the belief of the nonviability of the embryo before the fourth month, thinks it harmless to rid herself of the ovum, which she considers a mere growth without life or soul, while she would shrink from destroying what, at a later period, she calls a living being.
SYMPTOMS AND COURSE OF ABORTION.—General Remarks: Preliminary Symptoms.—1. Course of early abortion, first two months.
2. Abortion at the time most common, the third or fourth month: a, spontaneous; b, criminal and traumatic.
3. Later abortion—in the fifth and sixth months—and hydatiform mole.
The expulsion of the ovum during all periods of pregnancy is characterized by two inevitable symptoms—hemorrhage and pain. It is the time of appearance as well as the relative intensity of these symptoms by which the period of gestation at which the expulsion takes place is at once indicated. In early abortion the hemorrhage is excessive and precedes the pain, the pain being comparatively slight; in labor at term pain is the prominent symptom and precedes the comparatively slight hemorrhage, which does not appear until the pain has almost ceased, and labor is completed after the expulsion of the placenta. Expulsion of the ovum in intervening periods is marked by an approximation of symptoms, though the existing conditions which characterize individual cases greatly modify this typical course.
I have, for the sake of conveniently grouping the symptoms, accepted three periods which serve well to characterize the course which abortion is wont to take in the progressive months of pregnancy. Hemorrhage and pain are the never-failing symptoms—hemorrhage due to the separation of the membranes; pain in the earlier months is due to the dilatation of the rigid, unprepared cervix, which greatly preponderates over the pain which accompanies the expulsion of the comparatively small mass through the once-dilated passage. In the later months, the cervix being gradually prepared, the pain is almost altogether due to the increased effort which is necessary to expel the large mass of the ovum.
1. Early Abortion.—In the first and second months the ovum is small, the vascular development trifling; the decidua preponderates, being greatest in mass and in extent of its vessels; hence this is the most important part. The hemorrhage is considerable, due to the separation of the vascular and hypertrophied mucous membrane, the decidua. The ovum is very small and expelled with comparatively slight pain, the symptoms often resembling those of membranous dysmenorrhoea; no great dilatation of the os is even necessary.
2. In the third and fourth month, the period at which abortion both spontaneous and criminal is most common, the placental formation is inaugurated by the growth of the vascular tufts of the chorion; and it is now that the ovum in toto—or we may perhaps say the membranes, as they are by far the greater part of the ovum—assumes the most important rôle. The abortion is still inaugurated by hemorrhage due to the separation of the vessels, but the pain is greater, as the cervix must dilate more to admit the passage of this larger mass, and an expulsive effort as well is necessary to force the mass out. The greatest amount of pain is caused by the dilatation of the rigid, unyielding cervix, which fortunately remains in this undilatable state until after the period of viability of the foetus, and serves to a great extent as a check upon its more frequent expulsion.
3. Late Abortions.—Now the ovum and foetus are of pre-eminent importance; though the parts are still unprepared, hemorrhage continues to be the preliminary symptom, yet pain follows rapidly upon the inaugural flow, because the ovum is now so large that it cannot descend without dilatation: it must have advanced before abortion can progress to any extent, and the expulsive pains assume greater prominence on account of the increased size of the ovum; the symptoms of labor at term are approximated, and, as the placental formation is developed in the sixth month, pains may at times precede, certainly rapidly follow upon, the preliminary hemorrhage. It is now the placenta which plays the most important part, as in labor at term it is the foetus which is all-determining, upon which all the efforts of expulsion are centred; the membranes, amnion and chorion, are secondary, and the decidua, which was so important a feature in the first months, has by this time entirely disappeared as a factor in the act. The remaining shreds are partially adherent to the ovum, and in part passed slowly off with the lochial flow. Thus we see how the symptoms, at extreme periods so varying, approximate and interlace, and the various organs gradually yield in importance to newly-developing structures.
In the first period, then, the decidua is all-important, whilst the small and yielding ovum causes but little disturbance, not to mention the embryo. In the second period the membranes of the ovum are more important, and together form what is most erroneously termed the placenta in abortion. Then, as the placenta develops, this with the membranes predominates; finally, in labor at term the decidua, first all-important, has vanished as a factor of consequence, and the embryo, in the first stage a minimum, assumes such dimensions as to concentrate upon itself every effort of the obstetrician.
Pain, especially in the earlier months, is liable to be more excessive in primigravidæ, as the external os is closed, the cervix rigid, the time necessary for the expulsion of the ovum greater. In multigravidæ, with ordinarily more yielding and relaxed cervical tissues, the effort of the uterine muscle is concentrated upon the expulsion of the ovum from the cavity proper; and when it once passes the internal os a path is opened, and little or no force but that of gravity is often necessary to complete expulsion, whilst the cervical canal and external os offer formidable opposition in primigravidæ to the forcing out of the ovum, even though it has passed the os internum. A wide range of varying conditions naturally exists, due to the very different states of the cervical tissues: they may be relaxed in primigravidæ or firm and unyielding in multigravidæ, though the opposite is true in typical cases.
PRELIMINARY SYMPTOMS.—The symptoms which accompany death of the embryo and precede the expulsion of the ovum develop with the growth of the latter and its encroachment upon the cervix; although they vary as strikingly as do the symptoms of pregnancy, yet we may say that the larger the ovum, the greater the foetal and placental circulation, the more marked must be the effect of their cessation; the larger the uterus and ovum, the more distinct this feeling of fulness, of pelvic dragging, which accompanies the descent of the gravid organ previous to expulsion of the ovum. The larger the ovum, the more distinct the pains which accompany beginning separation, the more the encroachment upon the cervix, the greater the dilatation which gives rise to the earlier symptoms. These symptoms, however, vary so greatly, and are so often altogether wanting, that they are hardly to be considered, especially during the period in which abortions are by far the most common, in the third and fourth month; and as, in all but traumatic and criminal abortions, the disappearance of such symptoms of pregnancy as have existed is indicative of coming abortion, the death of embryo and ovum often precedes expulsion for a considerable period of time, and the symptoms of pregnancy consequently cease. Symptoms of pelvic congestion, bearing-down pains, pressure upon rectum and bladder, are among those frequently preceding abortion. At times we see a rigor, feverishness, rapid pulse, nervous disturbances, lack of appetite, anæmia, fulness of the head, also palpitation, cold extremities, heavy, uneasy feeling at the pubes and coccyx, lumbar pains, and vesical tenesmus—symptoms which are all unusual, with the exception of the latter. The descent of the enlarged and congested uterus in the pelvis, which always precedes the expulsion of any body from its cavity, frequently causes dragging pains in the pelvis, a fulness, heaviness with pressure upon the bladder and rectum, and an uneasiness at the pubes and coccyx or lumbar and vesical tenesmus. Later, the death of the ovum and foetus will cause more striking symptoms; the cessation of pregnancy will be more marked in mammary changes, but reliable symptoms are rare at all times, and usually wanting in the earlier months.
SYMPTOMS OF ABORTION.—Early abortion is frequently ignored, the symptoms greatly resembling those of profuse and painful menstruation. The course of abortion is inaugurated by hemorrhage, occasionally ceasing: sometimes there is very little pain: again it is quite severe; but the period of expulsion is well characterized; when completed the pain ceases, and with it the hemorrhage. Often the ovum is passed without the knowledge of the mother, even when accompanied by pain, as it is at this time more like that of a dysmenorrhoea.
Abortion in the Third and Fourth Month.—Spontaneous, Non-criminal Abortion.—At this period the ovum usually passes en masse; occasionally, and more often as the fifth month is approached, the membranes are ruptured in the course of its expulsion.
Normal Course.—We have already delineated the normal course of abortion at this period. The death of the embryo has usually preceded, often for weeks, and is characterized by the feeling of pelvic congestion, gastric and vesical irritation, weariness, weakness, and increase of uterine and vaginal secretion; the membranes have developed more or less; expulsion is inaugurated by hemorrhage. If the cause be more violent, the flow of blood is free. Usually there is but a slight oozing, which ceases at times, but gradually increases; the suffering which accompanies uterine contraction is present. Separation of the decidua and dilatation of the cervix are indicated by pain, which is intensified in case of uterine disease, so often present as the cause of abortion: the ovum is expelled as a pyriform mass, its apex imbedded in clotted blood, the inverted decidua adherent to its larger upper pole. If hemorrhage has taken place in the decidua, or the abortion be due to disease of this membrane, it is the most prominent feature and envelops the expelled ovum like a rigid mantle. In traumatic abortion it usually follows; ordinarily the membrane in part or in shreds is expelled with or very soon after the ovum.
Traumatic and Criminal Abortion.—Traumatic, especially criminal, instrumental, abortion varies in its symptoms, so well characterized by Van de Warker, from the spontaneous occurrence. The latter is inaugurated by hemorrhage; constitutional symptoms are wanting, and if they occur usually follow upon injudicious interference. In the former constitutional disturbances are present from the first; so also pains with inflammatory symptoms, mostly in the hypogastric region, abdominal tenderness: the pains of dilatation may even precede hemorrhage, whilst in spontaneous abortion they follow, often after days. The pulse is accelerated from 100 to 120 as a result of the primary insult; tenderness of the sensitive and congested uterus and cervix is rarely wanting; it is, in fact, characterized by Van de Warker as the one almost invariable symptom; vaginal hyperæsthesia, heat, and tenderness of the os are natural results. We have no history of previous accidental or spontaneous abortion: preliminary symptoms are wanting; the occurrence, on the contrary, is inaugurated by violence and shock; constitutional disturbance and hemorrhage follow. The consequences also are liable to be more severe, in accordance with the insults offered.
Recurring Abortion.—Morbid conditions, which interfere with the development of the ovum and lead to abortion, tend greatly to produce similar results if conception again takes place; hence we not infrequently find the repeated occurrence of abortion in a patient once afflicted; and this was formerly looked upon as a habit and known as habitual abortion—a term which must yield to the more correct repeated or recurring abortion, as no such habit exists: it is the continuance of the same cause which brings about a recurrence of the accident in repeated pregnancies. The cause being the same, the results are similar: the abortion will recur at about the same period if conception again take place; if due to a disease of the uterine mucosa, an early interruption is to be expected. The death of the foetus is usually the indirect cause of the abortion, and always precedes it: in these cases, in most instances, it is due to syphilis; at times to other cachectic conditions of the mother or an affection of the uterus or its mucosa. The development of the ovum continues for some time until abortion takes place, and this occurs, if due to changes in the mucosa or decidua, in the first months; if the result of anæmia or cachectic conditions of the mother, of syphilis, in the sixth or seventh month, or toward term. The death of the embryo is followed by retrograde metamorphosis, thrombosis of placental or uterine vessels, and expulsion from one to three weeks later.5
5 Geonbert, Thèse de Paris. 1878.
Plethora as well as anæmia may cause this occurrence; thus Campbell relates a case of seventeen successive abortions occurring in an extremely plethoric person, who was finally enabled to bear a child to term by repeated venesections made monthly; and others record cases of a similar nature: lack of nutrition, anæmic conditions, brought about a remarkable increase in the number of abortions during the siege of Paris and in the succeeding year of want. Chronic endometritis with cystic formations has been repeatedly recognized as leading to recurring abortion; so also laceration of the cervix in case conception does take place. The continuation of the same cause should lead to its recognition, as in most cases it is amenable to treatment; syphilis, inflammation of the endometrium, and laceration of the cervix, among the most frequent causes of such repetition, are the very diseases most thoroughly under our control, so that in the present advanced stage of our knowledge we should no longer hear of such a condition as recurring abortion. Ruge of Berlin considers syphilis as the cause of death of the foetus in 83 per cent. of such cases.
VARIATIONS.—A cessation of the symptoms not infrequently occurs: either with or without treatment the oozing may stop; even if hemorrhage and pains have existed all symptoms may cease. Large clots of blood have been expelled, the patient rests quietly in her bed, and gradually becomes easier; contractions and hemorrhage cease altogether, and she recovers, regains her vigor, and begins to move about. At the time of the following menstrual period the same cycle is repeated, and not until then is the ovum expelled. If the membranes are delicate, these may be ruptured by uterine contraction or by artificial or mechanical interference, and with the collapse of the ovum or the expulsion of its greater mass irritation is lessened and the symptoms subside. Exercise or the congestion and irritation consequent upon the return of the menstrual period will again arouse uterine activity, and the remnants are then expelled, a month or two after the inaugural hemorrhage.
These are conditions which are very frequent when the expulsion is left to nature or the aid of the midwife is sought, but they are with equal frequency produced by unskilful interference. The efforts of the physician are not unfrequently directed to a lessening of the hemorrhage, regardless of the existing conditions: applications are made to the abdomen and ergot is given, both methods of treatment which tend to stimulate uterine contraction; the more powerful circular fibres predominate and contract, the os is closed, the symptoms cease, and the conditions above mentioned are produced. Abortion is prevented for the time being, and sooner or later the patient is astonished by a return, which is, however, accompanied by less hemorrhage and more active labor-pains with a more rapid expulsion. If styptic injections are made into the uterine cavity or pieces of the ovum removed with the uterine dressing-forceps, a similar effect is produced, though the result is a more unfavorable one, as parts of the ovum are removed, and the collapsed membranes and shreds which remain are liable to prolong and aggravate the case, as they do not irritate the uterus and stimulate it to healthy action like the intact ovum.
The interval between the period of expulsion and the inaugural hemorrhage is often one of complete rest and health, more usually one of occasional oozing and malaise. As a consequence, we must have putrefaction and sepsis or the development of placental polypi and hemorrhage. Air is often admitted, either during the efforts at removal or later; if the cervix is not fully contracted, the secretions are more copious and liable to putrefy with the retained shreds. The symptoms are, however, unlike those of septic infection after labor at term, on account of the comparatively intact surface, the absence of the large uterine sinuses: they are insidious, not intense and acute—lack of appetite, weakness, slight increase of pulse and temperature—so that assistance may not be sought until increased suffering, putrid discharge, and high fever necessitate interference. This putrefaction is more liable to take place when the greater mass of the ovum has been expelled and parts alone remain, but will also occur when the entire mass is retained. Even without active interference the symptoms may subside as the disintegrating masses pass away as a putrid discharge, intercurrent hemorrhages at times carrying away larger shreds.
The so-called placental polypi result from the retention of parts of the ovum, especially of the placental portion, chorion, or decidua serotina, which, enveloped in fibrinous coagula, are entered by the proliferating vessels of the surrounding tissue. Such growths, sometimes of the size of a hazelnut or walnut, even to that of a small egg, may be unnoticed for months, but sooner or later give rise to oozing and hemorrhage, and in more fortunate cases are finally expelled. The expulsion of these retained membranes is inaugurated by hemorrhage, which may be preceded by more or less oozing: it is rapid in its course, accompanied by that pain which characterizes the last stage of abortion, and terminates with the appearance of the corpus delicti. It is merely the final scene of the abortion, which was but partially completed weeks or months ago, and the task is greatly simplified. Dilatation of the cervix and separation of the tissues were accomplished in the first stages, and during the interval of rest nature has been quietly making the necessary preparations to facilitate and complete the task undertaken, precisely as during the last months of gestation. Consequently, this expulsion is rapidly accomplished: pain and hemorrhage, even if severe for a time, are not of long duration. I have such a mass—which upon section reveals distinctly the villi of the chorion—which was cast off with all the symptoms of abortion four months after the occurrence of the inaugural hemorrhage and partial expulsion. More frequently I have been called to remove these masses, which have given rise to constant oozing and actual hemorrhages, two and three months after the occurrence of abortion, the adhesion to the uterine wall being so firm that the sharp scoop was called for, and sometimes I have been obliged to remove them piecemeal like a small uterine fibroid.
Late Abortion.—All abortions in the fifth and sixth month approximate in their symptoms those of labor at term; the membranes are ruptured, the ovum is never expelled in toto; the foetus may either precede the placenta or be expelled with it. It is at this period also that the hydatiform mole usually passes away, though it may be retained for a much longer period of time, even beyond the duration of normal pregnancy, the symptoms resembling those of abortion in the third or fourth month. After complete expulsion of the ovum and membranes more active hemorrhage and pain cease, the uterus contracts, but a slight oozing follows, and this becomes more pale and gradually merges into a serous flow.
DURATION.—The course of abortion varies greatly in its duration, and is usually prolonged, death of the ovum frequently occurring weeks before active symptoms are inaugurated, and even these may be slow in developing: a slight and often interrupted oozing may precede a more profuse flow and the dilatation of the cervix, or, as we have seen, the symptoms may cease for weeks and months even after they have been fully inaugurated; again, the ovum may be expelled in part and the remnants be retained for months—four months being the extent of time in which I have seen such retention terminate in expulsion without interference. By the formation of placental polypi the period may be protracted indefinitely.
The question how long abortion may be delayed, for what length of time the membranes may be retained, is far more important than is generally supposed, both from a social and medico-legal standpoint, and is by no means thoroughly understood. I have recently seen a mole formation, the infiltrated foetal membranes, and part of the decidua which had been retained nearly four years—three years and nine months.6 For four consecutive years the foolish woman, who had brought about abortion and expulsion of the embryo, suffered from occasional menorrhagia, and nausea and vomiting like that which had existed in the first months of pregnancy, until the annoyance became unbearable and medical advice was sought. An examination revealed an enlarged anteflexed uterus, from which a peculiar compressed and elongated mole was removed, after which the symptoms ceased. The case is moreover peculiar, as several of the symptoms were those of pregnancy, which do not generally continue after death of the embryo.
6 Ovum retained nearly four years, E. C. Gehrung, Weekly Medical Review, St. Louis, April 25, 1885.
For a term of three years a twin embryo has been retained, causing violent epileptiform attacks, always most severe during the menstrual period, which first appeared four weeks after the last labor and continued, to the great detriment of the patient, until the macerated embryo was removed, when recovery took place. This was most probably a twin intramural pregnancy, the twin developing in the tubo-uterine cavity being retained after the expulsion of the one properly located, and then gradually forced into the more commodious uterine cavity.7 These cases indicate the extent of this still unsettled question.
7 C. K. Patterson, Weekly Medical Review, June 13, 1885.
TERMINATION.—Dangers of Abortion.—Though fatal results are rare and, when occurring, due to sepsis rather than to hemorrhage, much of female suffering is traceable to this accident, the pathological interruption of pregnancy. Uterine and pelvic disease, especially subinvolution and consequent displacement, diseases of the endometrium and cervical tissue, result from abortion; sterility as well—all diseases which leave their traces indelibly marked upon the system of woman. They are not the direct or necessary consequences of abortion, but rather the results of the underrating of this most decidedly pathological occurrence—an underrating which is unfortunately prevalent among the profession and universal among the laity.
The direct consequences of hemorrhage are rarely severe: if harm ensues from loss of blood, it is not from profuse hemorrhage, but from long-continued oozing, generally that which accompanies the oozing following incarceration in the efforts at delivery, by which the system is depleted, and so weakened that years of care may be necessary for perfect restitution: evil results are much more liable to follow upon ill-timed or injudicious interference, the removal of part of the ovum or the checking of hemorrhage, the closing of the os by cold applications or ergot; equally serious consequences arise from sepsis if putrefaction of the parts retained takes place. The indirect results are even more common, and I cannot too often repeat that these, as well as the before-mentioned direct results, are due to a misapprehension of the existing condition—to an underrating of the importance of abortion. It is looked upon by women as no more than a profuse menstruation; some follow their daily vocations, bearing the suffering, or they may remain in bed during the most profuse flow and the greatest agony, but with the expulsion of the ovum or after a day's rest they resume their daily toils and pleasures. Frequently the midwife or nurse is called, and thus after-treatment neglected; and even the physician too often discharges his patient after a few days' confinement.
The worst consequences follow upon comparatively rapid and easy abortions, which are treated lightly, even by the practitioner; and should he by chance take the proper view of the case, the patient herself is unwilling to observe the necessary care. If she is prudent, she awaits the cessation of the discharge; daily work is then resumed by some, the usual round of pleasures by others. Gradually annoying symptoms appear, local or general; health fails; backaches, dragging-down pains, appear after so long a period that so slight a matter as the abortion, which has occurred months before, is never thought of as the cause of the suffering, and subinvolution is thus the most common result. As in all but traumatic and criminal abortions pathological conditions precede, especially of the pelvic viscera, it is often a diseased organ in which the abortion takes place, and restitution will only be accomplished by time and care, rest and proper treatment.
Subinvolution, chronic uterine lesion, and sterility are a common result of the first abortion in young married women, and in most instances it is the neglect of after-treatment to which these results must be ascribed; it is the underrating of abortion by the laity, and even by the profession; and as natural, healthy labor with too rapid getting up is liable to result in evil consequences slowly developing, so it is true to a far greater extent of simple abortion. The usual termination is in subinvolution, chronic cervicitis, and endometritis.
It is the duty of the physician to impress upon his patient the fact that equal if not greater care is necessary in the management of the pathological condition, of the early termination of pregnancy, than of normal labor at term, and that abortion is to be compared to a severe labor rather than to a simple menstruation. Were the physician summoned at once, much evil would be prevented. But if called at all, it is only when hemorrhage and pain become alarming; yet I am sorry to say that I have seen those who have suffered most, ruined in health and sterile, women in the best walks of life, who have closely followed the advice of able physicians, who skilfully managed the existing trouble, but undervalued the consequences—not giving the necessary time for involution, comparatively slow at this period when the system is so unprepared for a process to which its course is slowly shaped as term approaches.
DIAGNOSIS.—It is of importance to know, when called to a patient, first whether abortion is threatening or actually inaugurated—that is, whether the patient is pregnant, and whether the existing symptoms are those of abortion or of dysmenorrhoea; secondly, whether the abortion can be prevented, and if not, what treatment is to be pursued; and thirdly, whether the abortion is completed?
1. Does pregnancy exist and is abortion inaugurated? or are the symptoms those of dysmenorrhoea, metritis, or uterine tumor? The existence of pregnancy is a condition often difficult to discover, especially in unmarried women intent upon deceit, or in cases where the patient is herself in ignorance and no cessation of the menstrual flow has occurred. The symptoms of pregnancy must be carefully inquired into, as well as the condition of the patient, local and general, during the previous months and previous pregnancy. Dysmenorrhoea, menorrhagia, and membranaceous dysmenorrhoea may simulate abortion; but the pain in dysmenorrhoea is relieved by the discharge, whilst this is not the case in the pain of abortion: on the contrary, as the flow increases, with the dilatation of the cervix and the separation of the ovum, the pain increases; shreds of membrane accompany the discharge of dysmenorrhoea, whilst in the case of abortion the membranes follow the ovum when pain and discharge have almost ceased. In dysmenorrhoea the pain is ovarian, more violent, and aggravated with the cessation of the discharge, whilst in abortion it is uterine, more particularly referable to the cervix in the period of dilatation and to the fundus in that of expulsion, and lessens or ceases with the cessation of the discharge. The hemorrhage due to fibroids and polypi may greatly resemble that of abortion, especially if mole formations occur, but the pregnant and aborting uterus is greater in size than the congested menstrual organ. In the abortion of a comparatively healthy ovum the uterus approximates in size the period of gestation; the ovum as it descends during the pain becomes more broad, round, and tense, whilst in the case of a growth or clot the part which is forced down during a pain is more pointed at its presenting extremity than in the interval. In most cases of abortion, however, the uterus is rather smaller than it should be at the period of pregnancy at which the interruption occurs, and as the membranes are infiltrated with blood a mole formation is approximated; the ovum is more pyriform, pointed in shape; the apex imbedded in clots of blood, so that it resembles in feel, as it descends during the pain, a clot or polypus. The pregnant uterus, however, is more soft and elastic than the diseased organ.
2. Can abortion be prevented? The presence of an ovum being determined, our attention must next be directed to the possibility of its preservation. The distension of the os, especially the amount of hemorrhage, must guide the practitioner in seeking an answer to this important inquiry, upon which treatment must depend. The amount of hemorrhage is indicative of the separation of the ovum, but a slight flow continued for days is by no means as dangerous to gestation as a profuse instantaneous discharge. The os may be dilated, but if the hemorrhage is slight and the ovum out of reach, the progress of abortion may yet be prevented even after pains have been inaugurated, the first pains being those of dilatation. The appearance of rhythmical pains, indicative of expulsive contractions, leaves little hopes for the practitioner to check the course inaugurated. Even if the ovum can be felt, abortion may still be prevented, but if it protrude through the gaping os, little is to be expected, though even under these circumstances prevention is still said to be possible if the hemorrhage has not been severe. But if the liquor amnii has passed, there is no possibility of saving the ovum at any time, though it is claimed that even this can be done if pain or hemorrhage alone exists and the latter be not too severe. Even if the separation has not progressed so far that abortion is inevitable, the question must arise whether it be judicious to attempt prevention or whether abortion should be furthered. This depends upon the condition of the embryo, whether it is destroyed or not; if no previous abortions have occurred, and no known cause, especially predisposing or local, exist, if the size of the uterus corresponds to the period of pregnancy, and there are no symptoms of mechanical interference or trauma, an effort should be made to preserve the ovum; but if there be cause sufficient to account for its death, if the uterus be more hard and round, wanting in the elastic oval of normal gestation, if it be smaller than usual at the period of gestation at which the interruption has occurred, death of the embryo and ovum may be supposed, and, notwithstanding the possibility of prevention, abortion should be hastened and completed, the ovum and membranes expelled.
3. Is abortion completed? Difficult as it often is to answer the question whether the ovum has been expelled, it is almost impossible to say whether the abortion has been fully completed, whether the last remnants of tissue have been evacuated. If the physician has been present or the clots have been saved from the time of the inaugural hemorrhage, it may be easy to determine the condition of affairs; but, unfortunately, these are usually thrown away, and the attendant comes at a late period, at one of suffering and exhaustion, when masses of blood, quantities of clots, with whatever of the ovum they may contain, have been removed. If present, he should crumble each clot and float the coagula in water. Fibrin and blood will soon wash away, and the shreds of tissue become separated and remain floating in the fluid.
An examination of all pieces that have passed will readily reveal the existing stage; but ordinarily the physician has no such clue. The hemorrhage has ceased, the uterus is firmly contracted, the os is closed, and the diagnosis is exceedingly difficult, but it must be determined. If left to nature, time will disclose the true condition of affairs: if the ovum has been expelled, the uterus will rapidly diminish in size, the appearance of the discharge will change—it will become more thin and pale; but if the uterus remains firmly contracted, and does not diminish in size, it is probable that the membranes are retained, and the renewal of exertion, of work, or of a succeeding menstrual period—if not the first, the second—will bring about a recurrence of the hemorrhage and the completion of abortion. If the uterus remains large, hard, globular, it is probable that the ovum, or at least the greater part of the membranes, remains in the cavity.
Unless the hemorrhage has ceased and the os be closed for some time previous to the coming of the physician, he will find the uterus low in the pelvis, the os still yielding, except when ergot has been given or ice applied, and by the introduction of the finger into the uterus the condition of the cavity will be determined: this will in all cases be readily accomplished by pressing with one hand firmly upon the fundus and examining with one or two fingers of the other; if not easily done in this way, the entire hand should be introduced into the vagina; the uterine cavity may then be thoroughly swept with the examining finger; but, though this will reveal an enclosed ovum, the membranes can by no means be detected with ease, and will often escape observation; hence the dull curette is in place: it will sever such tissues as may still be adherent. All excellent instrument, especially if the os be small, is the Récamier curette, or the modification which I have devised for the purpose. Should any doubt exist, dilatation should be at once resorted to for curative as well as diagnostic purposes; a rapid dilatation is in place—not instrumental, but by the tupelo or sea-tangle: this affords positive knowledge of the state of the case, and the cavity can then be thoroughly cleansed. Even the sponge tent is harmless if the abortion is completed, as the cervix is still dilatable and yielding, easily expanded. At all events, the diagnosis is unquestioned and the treatment clear. This is by far better than the expectant plan, which is most commonly followed for fear of interference, allowing the patient to continue perhaps for a month or more in ignorance of her condition—allowing her to resume her labors, exposed to sepsis, hemorrhage, and, in the most favorable case, expulsion of the ovum at any time.
If the os is dilated, the finger should be introduced—if necessary the hand—into the vagina, which can easily be done if the fundus be approximated by the other hand; better still, to use the curette, and I would advise the large blade of my instrument; the small one can at all times be passed into the cavity of the uterus during or immediately after abortion, and usually the larger one also. This examination, if with the scoop, consequent upon dilatation, should be followed by an antiseptic injection, but I would unquestionably advocate a correct diagnosis, whatever means may be necessary to obtain it, as appearances are so deceptive. We need but recall those by no means rare cases which to all appearances are those of completed abortion, yet the patient does not perfectly regain health and strength, and if an examination is made the os is found patulous and membranes or parts of the ovum are retained. If examination and dilatation be neglected, a coming menstrual period will discharge the disintegrating mass, or local and constitutional disturbances, even septicæmia, may be looked for.
PROGNOSIS.—As to prognosis, it is the mother whom we must consider, the dangers present and future, the attachment and dimensions of the ovum, and the possibility of continued gestation. The prognosis of traumatic or criminal abortion is worse than that of the spontaneous form, the result of natural causes, because it is inaugurated by shock, by injury, and inflammatory conditions which are aggravated by the congestion and contraction accompanying the expulsion, for which the tissues are entirely unprepared; whilst in natural, spontaneous abortion, usually the result of some morbid condition, some disease of the system, a cachexia, uterine disturbance, or death of the embryo and ovum has preceded, and a retrograde metamorphosis to a certain extent has been inaugurated; some preparation at least has been made for the coming expulsion; hence the separation is more natural, less violent, less liable to be followed by evil results.
The prognosis is invariably favorable if proper medical aid is summoned in the early stages, but actually it varies greatly, as does the course of abortion—whether completed in a reasonable time or of longer duration, more favorable in the former, less propitious in the latter; if hemorrhage has been profuse or comparatively slight, but of long duration, anæmia is liable to result: if expulsion is long protracted, the dangers of subinvolution, metritis, and perimetritis are great: if the expulsive pains cease before the complete expulsion of ovum or membranes, retention, putrefaction, and sepsis may be inaugurated, and subinvolution, endocervicitis, and endometritis will follow.
The embryo is scarce to be considered: it may be saved if the hemorrhage has not been too severe and accompanied by pain, if the ovum does not protrude into the cervix. The inflammation which usually accompanies traumatic or criminal abortion greatly aggravates the prognosis, but, however good it may be in individual cases, the result will depend greatly upon the after-treatment, upon the time allowed for proper involution, and upon the assistance given it. Though the prognosis at the time of abortion may be a most favorable one for the mother, the result is seriously affected by the care taken during the period of involution, the after-treatment, which is by far more important than generally supposed.
TREATMENT.—The successful treatment of abortion requires knowledge, judgment, and resolution on the part of the practitioner, and in importance it is equivalent at least to the management of labor at term. Two lives may even be at stake, though the opportunity of saving the embryo is, as a rule, afforded only during the period of prophylactic and preventive treatment, as vitality is ordinarily destroyed in the embryo when abortion, as the result of natural causes, is once inaugurated: the life of the mother is not in question, as it is in labor at term, but her health is even more endangered. Attention is now forcibly called to the subject by earnest discussions between the adherents of the expectant and those of the progressive method of treatment, but mainly to the treatment of actual abortion; prevention and after-treatment have been neglected. Important as is the method of treatment employed in case of retention of membranes or ovum, the necessity for such interference, especially the frequency of abortion, would be greatly diminished if the family physician were thoroughly imbued with the importance of the subject and could impress the same upon his patients. If the dangers arising from such premature interruption of gestation were appreciated by the laity and medical attention summoned in the early stages, the management of abortion would become more simple and more successful, and the cases of retention which cause such suffering and injury to women would be far less frequent.
Before entering upon the treatment proper it may be well to review briefly the necessary adjuncts, as proper preparation will aid materially the course to be adopted.
Preparations Necessary with Regard to the Patient.—Many of the preparations necessary in the lying-in chamber are desirable in cases of abortion as well. Attention should be paid to the bowels, as a costive condition will interfere to some extent with the manipulations as well as a rapid and favorable course of expulsion and involution; at best, it is liable to make the patient uncomfortable. The bladder should be evacuated, especially before active measures are resorted to, and the patient should be so clad in night-gown and sacque, with long hose and drawers, that she may be moved and manipulated without exposure.
The bed should be prepared with rubber cloth and quilts, and sufficient quilts, cloths, and towels should be on hand; a bed-pan is desirable, and also a fountain or bulb syringe; the bed should be so placed that the physician may be at the right hand of the patient, and convenient to the light when she is placed in Sims's position of the dorsal decubitus for operative interference.
Antisepsis.—Cleanliness and antisepsis should be observed in the management of abortion as strictly as in that of labor or in surgical operations, as sepsis, either in the form of acute infection or an insidious undermining of the constitution, is among the more frequent of the dangerous consequences which follow in the wake of abortion. Circumstances permitting, it is desirable that carbolated vaseline or vaseline with iodoform, carbolated or some similarly prepared soap, be on hand, and also permanganate of potassium, carbolic or boracic acid, and iodoform. I am in the habit of prescribing carbolic acid for the convenience of use: carbolic acid 2 ounces, alcohol 1 ounce, with 7 of glycerin, which is as concentrated as may be well used (1 to 5, or 20 per cent.), and a proportion readily diluted to 2½ or 5 per cent.
Before and after examinations the hand should be washed in carbolated water or some such disinfectant—permanganate of potassium, corrosive sublimate, or boracic acid—as it appears desirable to use. If carbolic acid is used, the parts should be cleansed with a 2 or 3 per cent. solution. After interference or repeated examinations the vaginal douche should be used, certainly after completion before leaving the patient. If instrumental interference be necessary, and the ovum or membranes forcibly removed, the cavity of the uterus should be washed with hot water, from 115° to 125° F., containing 5 per cent. of carbolic acid, the hot water serving styptic purposes. This may suffice, but it is frequently desirable to mop the cavity with the above-named solution or even the pure liquid after more active interference, especially if some disintegration has taken place and is indicated by odor.
After the use of tampons the vagina should be washed with a 2 or 3 per cent. solution, or 1:2000, of corrosive sublimate; and it is even well that the cotton, before being introduced, should be anointed with either carbolized vaseline or carbolized oil (carbolic acid 2 drachms, olive oil 3 ounces). Iodoform serves an excellent purpose for disinfection of tampons, especially such as are packed into or against the cervix, and as an application to the cavity after the removal of the putrid contents following the hot douche. Borated cotton, or even ordinary cotton or prepared tow, should be on hand to use during the after-treatment in place of cloths for the purpose of receiving the discharge: it is warm, soft, forms a good filter, and can be thrown away or burnt when soiled, whilst the cloths ordinarily used, and often very offensive, are kept for the wash.
Medication.—The most important of all the remedies is opium; in preventive treatment it may be called a specific. It is far preferable to the hypodermic injection of morphine, serving to relax and quiet the uterine muscle and to lessen hemorrhage; for the latter purpose it is often combined with acetate of lead—from ¼ to 1 grain of opium mixed with ½ to 1 grain of acetate of lead, to be given at a dose and repeated when necessary. Ipecacuanha combined with opium acts well in relaxing the tension.
Viburnum prunifolium has long been used as a uterine sedative in these cases in those States where the plant is endogenous, and its use has been widely disseminated since it has found so able an advocate in Jenks. The preparations are not all equally effective, but in the early stages the fluid extract given in teaspoonful doses, according to the amount of hemorrhage and pain either hourly or every two or three hours, has a most decided effect in allaying threatened abortion, in checking hemorrhage, and in quieting pains. It seems to be a uterine sedative. Several ounces may be taken, and successful cases are reported where the pending expulsion was averted and gestation continued to a successful termination after four ounces had been used. Digitalis combined with acetate of lead also deserves recommendation as an effective remedy in the early stages. Quinine may be given to stimulate the system and further uterine contraction, and is invaluable in an asthenic condition or if disintegrating shreds be present.
Nervines, valerian, asafoetida, valerianate of ammonia, bromide of potassium, are of great service throughout the entire course of abortion, as the patient is usually in a nervous almost febrile state. Alone they may serve to allay the irritating symptoms in the early stages, and answer well in preventing the disagreeable effects of opium. Asafoetida may be given by injection or in pills, from ½ to 2 grains at a dose.
Clysmata tend to irritate, and should not be used as long as we may hope to prevent threatened abortion. Such remedies as are indicated in the treatment of this condition, especially opium and nervines, must nevertheless at times be given by injection, as the stomach may refuse to receive and retain them in the irritated condition which accompanies this state. The clysms should always be warmed, of body temperature: two tablespoonfuls of milk of asafoetida or gum arabic form an excellent vehicle, though water or milk thickened with flour or starch, which is always on hand, will do quite well.
Should it be necessary to move the bowels, castor oil is one of the best remedies, whilst cathartics, especially aloes and similar drugs, must be avoided as long as there is hope of preserving the ovum: they certainly further expulsion. Ergot should not be used until after the uterine cavity is emptied, and is decidedly contraindicated whilst the ovum or any of its parts remain adherent in utero. The dangers arising from the use of ergot in the early stages, whilst the ovum is still intact, are rupture of the membranes and forcible contraction, which always prolongs expulsion of the ovum or its membranes; the circular fibres, which predominate, are stimulated most forcibly to action, more particularly so under the conditions which usually exist in abortion: the muscle of the uterine body is hindered in its contraction by the adhesions of ovum and decidua, especially if these membranes are infiltrated; and, moreover, in cases of abortion the tissues of the womb itself are often more or less diseased; the lower portion of the uterus and cervix alone is free to act, the circular fibres of the internal os contract most readily under the influence of ergot, whilst the activity of the fundus is interfered with; thus closing of the outlet and incarceration of the membranes are liable to result. This popular and dangerous drug must not be given until the tissues are expelled, or, if desirable by reason of excessive hemorrhage, its use may be resorted to under one condition: if the membranes are detached, not only free in the uterine cavity, but entering that of the cervix; they may be found massed together firmly, by compression of the uterine walls, into a conical or pyriform mass; and when this has to a great extent passed the internal os ergot may be given. This drug, so dangerous in obstetric practice, is still used with altogether too much freedom in this country, and it would be far better to do without it than to continue the prevalent abuse. I have insisted that this drug must not be given in labors or abortion until the contents of the uterine cavity have been removed. Although but one of our prominent obstetricians approved of the position I took in 1883, and I was then freely attacked, I now urge the point more earnestly, and the doctrine is more commonly accepted: in Germany such men as Martin, Spiegelberg, and others have succeeded in doing away with this dangerous remedy altogether in the institutions under their care, restricting its use to the non-gravid uterus.
As a styptic, hot water, carbolized, serves the best purpose: in the early stages as vaginal douche, in the later as an intra-uterine injection at 120°, it is an invaluable remedy, preferable to other styptics, as it cleanses and removes the coagula. When the cavity has been emptied, especially after the forcible removal of the membranes, it is well to apply carbolic acid to the surface; and it is better for this purpose than tincture of iodine or perchloride of iron, either of which is only to be used in case that hemorrhage does not yield to the before-mentioned remedies.
Anæsthetics.—Though bromide of potash, morphine, or opium may suffice for the relief of the pain in ordinary cases, the use of an anæsthetic is not only desirable, but necessary, if more active measures are resorted to. For purposes of rapid dilatation and the removal of an adherent ovum or membranes anæsthesia is almost indispensable; without this the suffering of the already nervous, debilitated patient is excessive; the uterine and abdominal muscles are tense, and operations thus greatly impeded. An anæsthetic should be given in a rapid dilatation on account of the pain, as well as the greater facility of operating; and it is most necessary in an attempt at expression, as, if made without an anæsthetic, the abdominal muscles are so tense that the uterus cannot be well manipulated from without. I myself prefer chloroform.
Instruments.—A speculum, a dull curette, a sharp scoop, a vulsellum forceps, and uterine dressing-forceps are essentially necessary. Any speculum may be used. The best is Sims's if the semi-prone position be used, or Simon's in the dorsal decubitus. The Schroeder's or my forceps is necessary to steady and bring down the uterus for the introduction of tent or finger and the use of the scoop or the application of styptics. This is in the main the American bullet-forceps, an instrument far superior to the sharp vulsellum which is so popular. The curette I would most recommend is my own modification of Récamier's instrument of pliable metal, one blade resembling that of Récamier's, but curved somewhat more like the uterine sound—sharp upon one side, dull upon the other—to be used for the purpose of severing the ovum or membranes in the line of their adhesion: this is so narrow that it can be introduced into the os even after contraction if this be not almost tetanic, as after the giving of ergot. The other blade is larger, broad and flat, more spoon-like, to be used in case of moderate dilatation of the os, both, however, being for the purpose of severing the adhesions and leaving the ovum intact. The broad blade serves as a lever to remove the ovum or membranes when detached. But if the membranes be ruptured, it is of service in separating these from the uterine wall, leaving them as complete as possible, which will always facilitate removal or expulsion. The irritation caused by the severing of the adhesions with this instrument frequently suffices to inaugurate uterine contraction; and ovum or membranes, being once liberated, are then compressed by the uterine muscle into one mass, thus affording a resistance which the uterus is enabled to grasp and expel. This method I believe to be far more rational than the removal of the membranes with the sharp instrument: it furthers the process of nature more strictly, separating rather than cutting away the tissues, as does the latter. The sharp scoop is an instrument which is only to be used for firm adhesions in secondary cases, where the progress of abortion has temporarily ceased and the membranes have become more firmly attached, especially where disintegration of such adherent parts has taken place to some extent; it is necessary and cannot be dispensed with where remnants have been retained for months and have become firmly attached, simulating polypoid growths. I object to the use of the sharp scoop in recent cases, because it is preferable to follow the line of demarcation indicated by nature, and separate the membranes or the ovum, if still entire, in this strait; whilst the sharp scoop removes them piecemeal, cutting deep into the mucosa at one place, and possibly leaving pieces of embryonic tissue in another.
Dressing-Forceps.—These are serviceable for the introduction and removal of tampons, the cleansing of the uterine cavity, and the removal of a detached ovum when in the cervical canal or almost extruded; but the very common habit of seizing the ovum with this instrument as soon as the apex appears is a most pernicious one: the membranes are ruptured, the continuity destroyed, the mass collapses, and the resistance offered to the contracting muscle as well as the dilating wedge is thus destroyed, and the course of abortion greatly prolonged. No narrow grasping instruments should ever be used to make forcible traction upon the ovum; the tissues, if healthy, are very often delicate, and if degenerated into mole formations, infiltrated with blood, brittle, breaking beneath the instrument, which is always withdrawn grasping simply what is seized between its blades. I know of none of the many ovum-forceps which I can recommend.
Position of the Patient.—For purposes of instrumental interference the patient may be placed on side or back, in the left-lateral, semi-prone position if Sims's speculum be used; I prefer the dorsal decubitus, using Simon's speculum. The bivalve specula might be used if short, like the operating speculum of Albert Smith, but they are not to be recommended, on account of their small diameter and their usually too great length, by which they push the uterus away. The organ should be approximated as nearly as possible to the vulva and finger by the instrument, and this is best done either by a short, broad Sims's or Simon's speculum. Simon's speculum in the dorsal decubitus has among its other advantages that of greater convenience for the purpose of injections. The patient is transversely brought on the bed, with the hips upon the edge, elevated by a folded blanket or hard cushion; the legs are flexed, the feet placed upon two chairs; an oil cloth directly under the parts is folded into a slop-jar standing underneath, so as to receive all refuse matter, which enables the physician to use the douche freely. Bozeman's catheter, with double current for intra-uterine injection, is a very convenient and valuable instrument, though not an absolutely necessary addition to the armamentarium.
The use of gynecological instruments is even more important in abortion than in labor at term: it is by far more convenient to introduce the tent or dilator, and even to use the scoop through the speculum, than blindly with the aid of the finger, guided only by the hand on the fundus. Knife and scissors, needle and thread, may be of use in difficult cases, or in case of a firmly-contracted os with putrefaction of the membranes, for rapid dilatation. German authorities advocate incision with a knife in preference to rapid dilatation where it must be done quickly for purposes of immediate evacuation; should this be resorted to, it is very necessary that after abortion is completed the parts should be again carefully united by close sutures—a method which is only to be recommended to the expert in extreme cases. The Récamier or my own curette can be used effectively without dilatation in ordinary cases, even if the os is somewhat contracted; there is so much relaxation that these instruments can be readily introduced, the os being dilated during the act; and if the sharp instrument be used the particles cut are carried out by the spoon, the douche taking away the remnants. With my own instrument I am in the habit of separating the adhesions and removing the mass more, as with a lever, especially if the ovum be intact. The large blade of the spoon is used to press the ovum down into the hollow of the sacrum, very much as the placenta at term is removed.
PROPHYLAXIS.—In primigravidæ the physician should urge careful attention to all conditions that may further a healthy state. As indicated by the physiology of early pregnancy, this lies mainly in a proper preparation for the changes wrought by the physiological activity of the sexual organs; free scope must be given for their development, and this guarded against all injuries, nervous and traumatic: the congested developing parts and the sensitive, tensely-strung nervous system must be protected against insult; a healthy condition of the system must be established, and possibly existing predisposing causes counteracted.
Young married women, above all, are liable to injury from coition, from over-exertion in this period, from amusement or labor, as well as from the demands of fashion. It is the mother, and more often the family physician, who must see that a free and healthy development is permitted: let it be remembered that the close-fitting corset, the heavy dresses suspended from the hips, exertion whether for pleasure or work, frequent intercourse, as well as mental condition, all affect the fate of the ovum. The menstrual congestion, recurring with greater or less periodicity at the usual time of the flow, is a period of especial danger at which still greater care is necessary. As a rule, we can only say that a strict attention to dietetic laws, which should be observed in every gestation, is of the greatest prophylactic importance. In the case of multigravidæ, especially such as have previously aborted, the same rules must be observed, and, in addition, especial attention must be paid to the removal of such causes as may have resulted in previous abortions. The proper prevention, however, lies in treatment of these conditions before the occurrence of conception: as we have seen, these may be either plethora, anæmia, most usually syphilis or uterine disease, and a lacerated cervix, endometritis, pelvic cellulitis, or retroflexion. The treatment of such morbid conditions should be inaugurated as soon after recovery from an abortion as possible, and continued, in case of constitutional disturbance, after conception has again occurred. Though the avoidance of excessive exercise and perfect quiet are desirable, especially during the menstrual congestion and at that period of gestation when abortion has previously occurred, it is ridiculous to confine the patient to bed at this time, without further treatment, with a view of preventing the recurrence of abortion by rest alone. This is a common practice, and can result in good only in isolated cases; it usually annoys and weakens the patient; and it is high time that this antiquated doctrine should be exploded, and that the attending physician take sufficient interest in his patient to urge examination and local treatment by the specialist if he himself cannot detect and relieve the trouble which has caused, and will continue to cause, such serious disturbance. It is a paramount duty of the physician to inquire into the cause of the previous abortion and to prevent recurrence by its removal: if he himself should have attended her, he should examine the ovum most carefully, and later the patient as regards her constitution and the condition of the uterus and pelvic viscera. If the abortion be due to syphilis of mother or father, this must be treated, an existing disease relieved, a retroflexion of the uterus replaced, a lacerated cervix repaired, or the disease of the endometrium overcome; but the confining to bed of the patient during the period of danger, or even during the many months of pregnancy, will aid but little: this is advisable only when the symptoms of threatening abortion again appear. Moderate exercise is conducive to health, and hence to the development of the ovum, and only in rare cases can abortion be prevented by rest alone: confinement to bed may be resorted to as our only means if we are in a state of ignorance, where the original cause has not been detected or treatment is at the time impossible; and this is partially true in pregnancy of a uterus with a lacerated cervix which has not been repaired. An inflamed or irritated cervix is open to treatment, and even a lacerated cervix can be improved during the existence of gestation.
Preventive Treatment.—If symptoms of threatening abortion, or such as resemble them—oozing, hemorrhage, uterine pain—appear in the pregnant woman, however questionable the diagnosis, the treatment must invariably be directed toward the prevention of threatened abortion. If the symptoms are indistinct, the oozing may be merely that of a congested or eroded cervix during the menstrual period or the existing pains—a reflex symptom due to other causes—and should be treated; but then in addition the necessary means must be at once adopted to prevent threatened abortion; and if we are ignorant of the condition of the ovum, whether healthy with a living embryo or pathologically changed, treatment must be directed toward its preservation until absolute knowledge to the contrary is obtained; and this is, above all, necessary in the earlier months, when it is almost impossible to determine as to its condition. Every effort must be made to preserve the ovum as if healthy; and if it be so, success is by far more likely to crown the efforts of the physician, whilst he will strive in vain if it be a healthy effort of the uterus to rid itself of a dead embryo and the diseased membrane surrounding it. Perfect quiet, mental and physical, rest of body and mind, is necessary; the patient is put to bed and kept quiet, excitement and irritation prevented; no coffee, tea, or stimulants should be given, but acids, cool drinks, sour lemonade, aromatic sulphuric acid, opium alone or in combination with other remedies according to the conditions, are in place. If hemorrhage is profuse, we should further vascular contraction sufficiently to check the flow with chinine, ipecacuanha, or, best, viburnum prunifolium, the fluid extract in teaspoon doses, if very profuse every hour, otherwise every two or three hours; digitalis may be added in case of nervous excitement, which is often intense; so also bromide of potassium, valerian, or asafoetida. Ergot and cold applications to the abdomen must be avoided; the latter are frequently resorted to, as they tend to allay hemorrhage, but at the same time they stimulate uterine contractions too freely. No unnecessary examination must be made, and the patient must be kept in perfect repose until the symptoms have completely disappeared.
TREATMENT OF ABORTION WHICH IS FULLY INAUGURATED AND PROGRESSING.—If all means to overcome the existing conditions and check threatening abortion have failed, if the pains continue, the os dilates, or hemorrhage becomes profuse, the treatment is radically changed. Before this period it was directed to the preservation of the ovum, whilst the object is now to complete delivery. The practitioner must now endeavor to check hemorrhage, allay suffering, and above all empty the uterus at the earliest possible time, and to this latter end all his efforts should be directed. By accomplishing this all other symptoms will be most satisfactorily and perfectly relieved; and though time and patience are remedies which cannot be dispensed with even in this stage, more active interference and local measures are now indicated, which, it will be remembered, were to be avoided if prevention seemed still possible.
The progress of dilatation and separation is often slow, and during this stage one precaution must be observed: whatever measures be adopted, the membranes must be preserved intact. We must avoid all interference with the foetal sac; after this is ruptured the hemorrhage is liable to become more profuse, as an additional source of bleeding is added by the collapse of the ovum, which causes a diminution of the intra-uterine pressure. The succulent and vascular tissues are no longer compressed between the resistant mass of the ovum and the uterine walls, and ooze freely into the cavity; moreover, the resistance and irritation previously existing, whilst the ovum was unbroken, is removed, and uterine contractions, the expulsive efforts, are diminished or cease entirely.
The prominent indication for interference is given by hemorrhage, and such means must be adopted to check this as will at the same time promote the expulsion of the ovum.
Pain.—Opium must now be most sparingly used. Complete relief of pain is not desirable in this stage; uterine contractions, the dilatation of the cervix, should be furthered; nervous irritation and excessive suffering may be relieved by nervines—valerianate of ammonia, bromide of potash, perhaps a hypodermic injection of morphine; regular pains indicative of uterine contraction must not be interfered with under any circumstances.
Hemorrhage.—The treatment previously inaugurated—rest, quiet, cold iced drinks—may be continued, but in addition more active measures must be employed: our main resort in this stage is in local measures, mainly in the tampon. Ergot must not be given, as it may lead to rupture of the membranes or incarceration of the ovum, or both.
The tampon is all-important in the management of this stage of abortion, as opium is in the first and the curette in that of retention; according to the method of its use it will serve a variety of purposes, and by skilful manipulation the object desired can be attained with a fair degree of certainty. The cervical tampon is preferable if the os is contracted and the cervix not dilating; pledgets of cotton have been used to plug the cervical canal, but the tent is far preferable; tupelo or slippery elm should be used. In cases where rapid dilatation as well as relief of hemorrhage is desired the sponge tent may be resorted to, but is, as a rule, to be avoided on account of the dangers of infection and the liability of adhesion of particles of soft tissues with which it comes in contact within the cavity. The tupelo is preferable to sea-tangle, as it may be had in more serviceable size and shape; the slippery elm is most excellent, is everywhere within reach, especially of the country practitioner, and has no superior: when cut in proper size, the edges slightly smoothed, and placed for a moment in warm water, it is soon covered with mucoid exudation, which makes its introduction extremely easy, and its presence within the uterine cavity decidedly less harmful than any other substance: it will readily find its way between the membranes, and a number of tents can be placed side by side, so that the disadvantages of inferior distension are equalized.
The tent is best introduced through the speculum, the cervix being fixed by a tenaculum, Engelmann or Schroeder forceps, and a tampon of salicylated or carbolized cotton placed in the vagina for the purpose of retention as well as disinfection. Care must always be taken that the tent be of sufficient length and passed well into the uterine cavity, to within a half inch of the fundus, as it will then serve not only to compress the bleeding vessels and dilate the cervical canal, but to separate the ovum and stimulate uterine contraction. When the tent or cervical tampon is used the vaginal tampon is unnecessary; each has its proper office to perform.
The Vaginal Tampon.—The vaginal tampon is preferable where the os is patulous and the cervix dilating; if small, packed merely in the cul-de-sac and directly about the cervix, it irritates but little; tents should be thus used if it be desirable to check hemorrhage and the possibility of prevention still exists. If larger and the vagina is more thoroughly packed, it is a violent excitor of uterine contractions, and is used in part for this purpose. The rubber bag or colpeurynter, even when filled with hot or cold water, is of little service in checking hemorrhage, though it serves to stimulate uterine contractions; hence it is of no value in those cases where the vaginal tampon is usually called for. The best method of checking hemorrhage and furthering separation and expulsion of the ovum, when intact, is the thorough packing of the cul-de-sac and larger part of the vagina with balls of cotton; wads of the size of a walnut should be made, and strong thread or string should be tied to each to facilitate removal: clots should be removed and the vagina cleansed with an antiseptic injection of 2 or 3 per cent. of carbolized water preparatory to their introduction. If convenient, salicylated or carbolated cotton should be used; the ordinary cotton wadding or cotton wool may be taken, but then it is desirable to soak at least the first which are introduced in carbolized water, 5 per cent., or carbolized oil, 10 per cent.
Tampons are best placed with the aid of Sims's or Simon's speculum, though the bivalve may also be used. If no instrument is at hand, the vagina may be distended by the fingers, which are so introduced that they separate the parts thoroughly and press down the perineum; the prepared tampons are now seized with the dressing-forceps and securely packed in the cul-de-sac and against the cervix, so that it is firmly surrounded by a compact plug; then the entire vaginal canal is similarly packed to the vulva. Hemorrhage is perfectly checked if the tampon be properly applied; if not, it ceases for a time until the cotton or other material used has been saturated, and then continues as before. If the desired object be attained, the pains will become more severe and rapid and the tampon will be expelled: upon examination the ovum will be found in the vagina or at least within the cervix, and is easily removed. It is stated that the tampon should not be left in place over twenty-four hours: this is certainly the limit, as, saturated with blood and secretions, it is liable to putrefy and thus lead to more unpleasant results. Twelve hours is, as a rule, ample time. If the vagina has been properly packed, hemorrhage is stopped and uterine contractions aroused which should be sufficient to cause dilatation and separation of the ovum. If the desired result be not accomplished at this time, it is best to remove the tampon, and, according to circumstances, introduce another or resort to other measures. After removal of tampons the vagina should always be cleansed by a disinfectant injection. If the os be found closed and uterine contractions have ceased—which is very rarely the case when the vagina has been properly packed—no further measures should be resorted to, as the continuance of gestation may be hoped for.
In case of very profuse hemorrhage the tent or vaginal tampon is necessary, but the hot antiseptic douche is but little inferior as a hæmostatic and excitor of uterine contractions. If carbolic acid is used, 2 or 3 per cent. may be added of corrosive sublimate, 1:2000, and the temperature of the water should be at least from 115° to 125° F.—if gauged by the hand, so hot that the fingers can hardly be kept in the water, at least not without moving them about. The external parts, especially the perineum, must be coated with lard, as they are particularly sensitive and liable to be scorched (vaseline washes off too easily). Emetics or purgatives, though still occasionally recommended, must not be given with a view of promoting separation or expulsion of the ovum.
Removal of the Ovum.—The tampon has been expelled by uterine contractions, and the ovum, as before stated, will probably be found within the vagina or separated and easy of removal. Should the tampon, however, have been previously removed by reason of insufficient action, the hot antiseptic douche may be tried and the vagina again packed.
Constitutional symptoms, excessive suffering, nervousness, debility, rise of pulse or temperature, necessitate immediate removal of the ovum. Under ordinary circumstances this is allowable only if the os be patulous, the cervical canal sufficiently dilated, and the ovum detached; and if the above preliminary steps have been taken, this will usually be the case in an abortion during the first three months. If the cervix permits of the introduction of the finger, a satisfactory examination may then be made if the patient be placed in the proper position, with the hips elevated, the limbs flexed, and the uterus approximated to the examining finger by pressure upon the fundus with the other hand. If this be not possible by reason of thick abdominal walls, the fixation of the cervix with Engelmann or Schroeder forceps is called for. Expression is then preferable to extraction. The dressing-forceps, and even the ovum-forceps, are of but little service for this purpose unless the os be dilated and the ovum completely detached, as they are liable to rupture the sac, and thus increase the difficulty of extraction. The broad, blunt blade of my curette, Récamier's instrument, or Munde's, should be passed into the uterine cavity and swept around the entire circumference of the ovum: the uterine sound properly bent may be used for the same purpose, and if liberated it may be removed by using my instrument as a lever, placing it beneath the ovum in case of retroflexion of the uterus, and anteriorly in anteflexion, and pressing it down toward the pelvic outlet. Expression by hand is still recommended, and is very efficient in relaxed or thin abdominal walls, where both hands may be readily used for manipulation. The fingers are pressed against the uterine fundus—anteriorly in case of anterior displacement, posteriorly if the uterus is retroflexed or retroverted—whilst firm counter-pressure is made by the other hand upon the abdominal walls; the ovum being thus, as it were, squeezed out.
In later months greater dilatation is necessary, the importance of preserving the ovum intact is augmented, and the greatest care must be taken that efforts at expression are not made whilst the ovum is still adherent. I have found great difficulty in detaching the membranes, even when the canal is permeable, with the finger, as has been recommended; and it is for this purpose especially that I have found the large blade of my instrument so valuable. It is readily introduced, pliable, so that it may be bent and properly adapted, and the point of attachment being found it can be passed about the entire ovum in the same plane, loosening without rupturing; and the irritation caused by this manoeuvre is often sufficient to stimulate contractions, so that expulsion will follow. In fact, I consider this of less importance than separation, retention being mostly due to adhesions, especially at the point of placental formation. Once separated, it is a foreign body and an irritant, which is readily expelled. Nature thus teaches us the course which we must follow, to complete separation and dilatation before attempting removal.
TREATMENT IN CASES OF RETENTION OF OVUM OR MEMBRANES.—These are by far the more trying conditions, and, unfortunately, the ones to which the physician is most frequently called. Aid is not summoned at an earlier stage on account of that dangerous underrating of abortion or for fear of unnecessary expense, and the position of the practitioner is made a trying one, as he is ignorant of the state of the case. Clots of blood have passed, but as to the precise conditions he is left in doubt; whether the membranes have ruptured, whether the ovum is expelled in whole or in part, he is not told. He may find the os closed; the size of the uterus reveals but little, as in many cases, at least those of spontaneous abortion, development is retarded; it is smaller than would be supposed at that period of gestation. It is only in case the uterus corresponds at least approximately in size to the time, or if the os be sufficiently dilated, that he can at once decide positively as to the presence of ovum or membranes.
A closed internal os may usually be looked upon as evidence that the retained masses, whether ovum or membranes, are adherent, though in case of sepsis more or less dilatation exists; yet in the latter case the indications afforded by those symptoms are of little importance, as the constitutional symptoms, with the character and odor of the discharge, clearly indicate the existing conditions, and consequently show the course to be pursued. No question exists as to the necessity of immediate delivery in these cases, but as to the manner of treatment in retention of ovum or membranes not disintegrating there is a wide difference of opinion: able men are still inclined to urge a reliance upon nature, yet it is a dangerous course for the practitioner to pursue: successful as it may prove in many cases, it is certainly fatal in some, and but too often followed by the insidious consequences so frequent in its tracks.
Labor at term may be left far more readily to the powers of nature than abortion: the former is a physiological process, the latter pathological. The expulsion of the ovum at term has been preceded by preparatory changes in maternal and foetal parts; the separation of the membranes is facilitated by the fatty degeneration of decidua serotina and vera; the hypertrophied uterine muscle is strained to its utmost, its fibres increased and strengthened for the ordeal, but in the early months no such conditions exist. Though expulsion has been anticipated and the preceding hemorrhage frequently serves to separate the structures, and development ceases with the death of the embryo, a retrograde metamorphosis is inaugurated only in certain cases, and then incomplete, and the frequency of intermittent abortion which we find in cases left to nature is evidence of incompetency to fulfil the task attempted: hemorrhage, more or less protracted, and contraction of the uterus cease; the ovum has been partially separated; its growth is checked, and then a retrograde metamorphosis is inaugurated in the tissues which have been in so active a state of development; this continues until a recurring menstrual period or excessive exercise brings about a renewal of the expulsive effort; and if sepsis has not taken place we usually find that the ovum is expelled with rapidity. When the attempt was first made, it proved ineffectual and the effort ceased; the tissues were impaired in their nutrition, underwent a fatty degeneration tending toward disintegration, and the second attempt of nature, with the parts properly prepared, terminates rapidly and effectually. Though the tendency of the profession at large seems toward a more expectant plan, guided by able authorities—such as Parvin, who urges attention to the old-time remedies, rest, time, and laudanum; and Leishman, who advocates this treatment when hemorrhage has stopped and the os is closed, perhaps aiding nature by the use of ergot—I would advise more active interference. It is indeed true that the ovum or some of its parts may remain in utero for months and then be expelled by a healthy effort of nature, without injury to the patient; but this is not the rule. I have seen such cases, but mostly the health of the patient is affected; even if more active symptoms, such as hemorrhage and sepsis, do not appear, subinvolution certainly follows. In cases less severe the patient is nervous, restless, suffers from insomnia, uterine colic, and occasional oozing; perhaps there is an offensive discharge,—all symptoms which are not sufficient to cause great anxiety, but we may with certainty expect them to result in serious inflammations of the uterus and surrounding tissues—metritis, thrombosis, cellulitis, endometritis, peritonitis; hence why should we wait? Why allow these dangerous membranes to remain, as claimed by some, "as long as no injurious effects appear"? Why wait for these more threatening symptoms when evil results are almost certain to follow upon the retention of such masses, even though hemorrhage and sepsis be at the time wanting? I have removed thoroughly healthy, semi-organized remnants as late as the fifth month after partial expulsion of the ovum; the patients were suffering no very serious inconvenience at the time, nor did any grave consequences directly follow; yet it would have been far better for them had decided steps been taken at the time of the inaugural flow; they were forced to seek advice in some instances by reason of uterine pains and oozing, in others by profuse and sudden hemorrhage; and, though decided injuries were not at the time evident, subinvolution and uterine displacement were certainly threatened.
Various periods are mentioned as preferable for interference. Some say that there is no need for alarm if the placenta remains in utero for twenty-four or forty-eight hours, provided the patient be under observation; but the os is liable to contract, always within a week, sometimes within forty-eight hours, after preliminary hemorrhage, and it certainly is unreasonable to allow complete contraction of the os and thorough cessation of the efforts of nature to take place, with the probability of evil results before us. If the physician is called at a time when the course of abortion seems retrogressive, the os closing, and he is uncertain as to the complete emptying of the uterine cavity, he should satisfy himself of the existing condition; and there is no reason whatever to the contrary in the present era of antiseptic gynecology. He should explore the uterine cavity, determine the state of affairs, and act accordingly. The proper course is clearly indicated: retained tissues should be removed, though it is difficult to formulate precisely the conditions by which action should be guided.
The circumstances permitting of interference and removal are a patulous os, an open cervical canal, and detachment of ovum or membranes: these existing, removal is easily accomplished, and should be undertaken even though no threatening symptoms be present. The indications which at all times determine and obligate immediate removal are—a putrid discharge, hemorrhage and constitutional symptoms, debility, fever or sepsis; then immediate removal is necessary at all hazards.
Though it does not appear advisable to remove the ovum, as urged by Fehling, at once, if the tampon fails after ten or twelve hours' trial, the physician must not wait until threatening local or constitutional symptoms appear, as various evils develop insidiously long before removal is so loudly called for. There are no conditions which could, by any possibility, contraindicate immediate interference if the indications above mentioned exist—not even inflammations, pelvic cellulitis, or fixation of the uterus, as is claimed by some. The limits of active interference being given by the above indications, the practitioner must determine by the greatly-varying symptoms of the individual case, as he does upon the proper time of applying the forceps in labor at term. If parts of the ovum remain in utero, they should be removed as irritating and dangerous; and a patulous os must necessarily lead the practitioner to infer the presence of such a mass; yet this is not a constant symptom: if the os is closed and the presence of membranes presumptive, he should dilate and satisfy himself as to the true state of affairs, dilatation with antiseptic precautions being entirely harmless. If remnants are found, the first step to their removal has already been accomplished in the diagnostic dilatation. This is best attained with the patient in complete narcosis and in proper position. The dorsal decubitus and Simon's speculum are preferable to the left-lateral semi-prone position, as we are better able to manipulate the uterus both externally and internally, especially to control the fundus. If the os be not too firmly contracted, the finger may be introduced when anæsthesia is established, and sufficient dilatation thus accomplished, or the scoop may be at once used without further preparation. If time is no object, the uterus is best dilated with a tupelo or carbolized sponge tent; where immediate action is indicated, the finger or steel dilator is best. Molesworth's instrument, even if ready for immediate action, is liable to dilate within the cervical and uterine cavity, remaining contracted at the point of greatest importance, the internal os. Incision with the knife, the splitting open of the cervix, is now recommended by German authors.
The tampon can be of service only where a larger mass is retained, not if the membranes alone remain. The use of the tent for the purpose of dilating is of advantage if introduced well into the uterine cavity, stimulating the muscle, so that expulsion frequently follows dilatation; but even then the curette should be used—the dull instrument—for a careful examination of the cavity. I have already stated the conditions indicating a resort to the sharp scoop, the Simon's or Sims's, or the dull curette, such as Munde's or my own. The wire loop of Thomas is too weak, and serves more for the removal of already loose masses than for the separation of the tissues, which I consider by far the most important. Where possible, it is always preferable to use the dull instrument for purposes of separation; and there is no better than Récamier's old instrument, or, in case of a large cavity, the broad blade of my own; both may be used without dilatation if the contraction of the os is not excessive. If firmer masses are found, as is frequently the case when the placental remnants have been retained for several months, Simon's sharp scoop is indicated, and the smaller size can be used without previous dilatation; the speculum is not necessary, but desirable, but for the effective handling of the instrument it is best that the patient be placed in the lithotomy position, upon the edge of the bed, the hips elevated, with a rubber cloth underneath. It is all-important that the movement of the scoop should be thoroughly controlled by the unengaged hand grasping the uterine fundus: this will serve to fix the organ well and prevent its escaping the instrument. Where the fundus is out of reach, as in retro-displacement, the Schroeder forceps, which is always of great service in bringing the uterus within reach, must be used. In case Récamier's or my own instrument is used, it is curved to adapt itself to the cavity, and, with one edge pressing firmly against the uterine wall toward the point of attachment of the membrane, it is carried around the entire space, so as to separate such adhesions as may exist, and the released membranes are then forced or pressed out with the instrument. In case the sharp spoon is used, it must be handled with great care, pressing firmly against, but not too deeply into, the uterine wall, and carried in regular parallel strokes from the fundus toward the internal os. After such manipulation the cavity should be well washed out with hot water containing from 2 to 5 per cent. of carbolic acid, bichloride of mercury, borax, or permanganate of potash, either with the ordinary syringe or Bozeman's catheter; after this the entire inner surface of the uterus is touched with carbolic acid, a little cotton wrapped upon the end of an applicator and saturated with the solution answering the purpose very well.
Hot water and carbolic acid usually suffice to thoroughly contract the organ; should this not be the case, should a flabby, atonic condition exist, it is well to place a tampon of iron cotton in the cavity. The applicator is loosely wrapped with cotton of sufficient thickness to fill the cavity; this is steeped in Monsel's solution or the perchloride of iron, the superabundant fluid expressed, and then introduced. Contraction is sure to follow, and the tampon is left in place for three or four days, when it will either be expelled by the action of the uterus or it will be found, coated with healthy pus, barely held in the grasp of the muscle, and can be removed by the slightest traction: no effort should be made, as it will remain firmly fixed until a healthy granulating surface is established. It may be kept in place by a tampon of cotton carbolated, or, better still, prepared with iodoform, which is always a desirable application after interference. Ergot should then invariably be given, either by hypodermic injection or per os—if the stomach is in good condition, a teaspoonful of the fluid extract every three hours during the first day.
Putrid discharge and septic symptoms unquestionably indicate immediate interference; the method, however, remains the same. In case of beginning putrid discharge without constitutional symptoms, the dull curette is greatly to be preferred to separate the sloughing tissue from the healthy uterine structure without injuring the latter; whilst if the uterine structure itself is affected, it is necessary to resort to the sharp spoon to thoroughly remove all that is diseased.
Constitutional treatment must, of course, follow the local measures above advocated. The danger of the sharp instrument, under these circumstances, is in the possibility of lacerating healthy tissues and opening new ways for infection. It can only be used if all diseased tissue is thoroughly removed and the operation followed by cauterization with pure carbolic acid and intra-uterine injection, that all remaining particles, however small, may be washed away.
An active general treatment must accompany these local measures, but upon this I will not dwell, as it is the same which must be followed in all cases of septic poisoning. Quinine is the main stay, and in addition to the remedies in general use ergot is here indicated to further contraction and expulsion of offensive particles and close the capillary and lymphatic canals to the possibility of infection.
AFTER-TREATMENT.—It cannot be too often repeated that the danger resulting from abortion is not the immediate or primary one, but the secondary, even in case of profuse hemorrhage; it is that of anæmia, of general debility, a slow getting up. After abortion we have conditions analogous to those of the puerperium, the dangers of infection, of septicæmia, the greater liability of the system to surrounding influences, epidemic, infectious, malarial; but even greater than after labor at term is that of incomplete involution with its chain of insidious consequences. In the main, the danger of abortion lies in the lightness of the affection and the indifference to after-treatment. Involution is more questionable than after labor at term, and yet time and opportunity are rarely given nature to accomplish this process of restitution. If the abortion is passed easily, the patient rarely keeps her bed, pays little or no attention to the occurrence, certainly none to her getting up, and subinvolution, by far the most frequent sequence to abortion, follows. Abortion is altogether the most prolific cause of uterine disease, in consequence of the indifference with which it is treated, not only by the patient, but by her physician. With the expulsion of the ovum and the cessation of hemorrhage the case is considered finished; even if a physician is called, proper time is not given for restitution of the parts. Although by far less is to be accomplished by the retrograde metamorphosis than after labor at full term, the parts being not so fully developed, they are not so thoroughly prepared for this restitution: retrograde metamorphosis has not been initiated with the inauguration of the abortion, as it has with the inauguration of labor at term. In the latter fatty degeneration is in progress; the tissues are prepared for the restorative process which is to follow: not so in case of abortion; hence nature must be assisted, must be allowed to perform those functions which are necessary to a healthy restoration of the sexual organs.
In the great mass of cases it is not strictly medical attention which is necessary, medical treatment, but mere ordinary care, precaution, and cleanliness on the part of the patient herself, so as to assist the efforts of nature: a week's rest in bed with healthy nutritious diet should be accorded every woman who has aborted, and this must be followed by at least one more week of quiet and confinement to the room, and not until a month after the accident has occurred should the patient resume her ordinary vocations.
I will not enter into the details of the after-treatment, as it is identical with that after labor at term. No decided treatment is called for unless demanded by symptoms peculiar to individual cases, yet ergot, quinine, and tonics are in place, and the same antiseptic precautions must be observed which are so highly appreciated in the lying-in room.
The patient must be kept in a recumbent position, the room quiet, and visitors excluded; a bed-pan must be used; the food must be easily digestible and nutritious; prepared tow or salicylated or borated cotton should be used in preference to the old-fashioned cloth to receive the discharge, and this must be changed with sufficient frequency: the parts must be washed with a lukewarm antiseptic wash, and vaginal injections of the same given as cleanliness demands, at least once a day; these should be hot (110°-120°) to further contraction. Corrosive sublimate 1:2000, carbolic acid 2:100, or boracic acid or borate of soda, serves a good purpose; intra-uterine injections are called for only in case of putrid or offensive discharge.
After the third or fourth day it is well to add an astringent, such as alum or tannin, to the hot vaginal douche, a teaspoonful to the quart, beginning with less, as some are very sensitive to these remedies, and increasing the strength if desirable.
Iron and chinine are serviceable in aiding the system to regain its tone and in guarding against zymotic and malarial influences, to which it is more subject in this weakened condition. Ergot is here in its proper place: a three-grain pill of the aqueous extract should be given, at least during the first week, three times a day; I prefer this to the fluid extract in common use, which is nauseating to many. This drug, so much abused during progressing abortion and in labor before the contents of the uterus are expelled, answers an excellent purpose at this stage, and, together with the hot, astringent douche, may be relied upon to prevent subinvolution.
I can but repeat that the after-treatment should be that of the lying-in room after labor at term, modified according to circumstances, but never to be neglected, not even after the most simple cases. We must remember that it is indifference under these circumstances, under-estimation of the accident, which leads to years of suffering, by which subinvolution so insidiously destroys a vigorous constitution.
Rest, peace of mind, and quiet of body should, together with antiseptic precautions and tonic treatment, follow every abortion, intensified according to the severity of the accident. The two most important, and at the same time most neglected, features in the after-treatment of abortion, both of which are called for in even the most ordinary cases, are rest and cleanliness—rest, quiet of body and mind, to afford the proper conditions for the efforts of nature toward restitution and involution; cleanliness, antisepsis, to prevent external interference with this process and to guard the lacerated cavity of the womb, which offers so ready a receptacle for septic elements, against the dangers which threaten from without and so frequently bring about the rapidly-fatal termination of an apparently simple abortion.