In inevitable abortion after the third month it may be very difficult to get the embryo out. The cervix, in primiparae especially, may be long, thick, and hard. If the fetus is dead, it may then be removed by morcellement—i. e., by cutting and breaking it into pieces, and then taking out these pieces with an ovum or stone forceps. Sometimes, though rarely, the operator may find it impossible to get the entire fetus away. Then the uterus is packed with weak iodine gauze, and after twenty-four hours the fetal remains are expelled.
In every abortion the presence or absence of extrauterine pregnancy is to be made out. If there is an extrauterine pregnancy, curettage will cause rupture of the sac.
When the interior of the aborting uterus has become septic the old treatment was to empty the uterus at once, but now the treatment is expectant, because the traumatism of the curetting makes the sepsis worse. The commonest and worst infections are of the streptococcus putridus, a pus staphylococcus, and the bacterium coli communis. Curettage lets these microörganisms enter the circulation. The cause of this condition is often unskilful attempts at artificial abortion. When the womb contains decomposing material bleeding usually obliges tamponing, and thus often the uterine contents come away in twenty-four hours with the gauze. If there is no hemorrhage there should be no tamponing: it is then better to get dilatation by packing and drain the uterus with gauze. The curette should not be used at all.
Where there is habitual abortion the cause must be found. During gestation syphilis and displacements of the uterus, as causes, may be treated. Endometritis can be cured only when the uterus is empty. Rest in bed at the time when these abortions usually occur, and at the time when menstruation customarily appears, is required. Treatment of the husband is often necessary, as he is virtually always the source of luetic infection.
Attention or inattention to the mother's own hygiene during pregnancy has great effect on the fetus, and care of hygiene may avert abortion. The woman's dress should be simple and warm enough to prevent congestion from changes in temperature. Congestions are likely to affect the kidneys, and care of the renal function is always one of the most important facts connected with pregnancy. No circular constrictions of the trunk by lacing or stiff corsets should be attempted. The corset forces the uterus and child downward into the pelvis and against the lower abdominal wall, causing congestion of the pelvic veins and strain on the abdominal muscles. Tight corsets, preventing the expansion of the uterus and the growth of the fetus, may cause mutilations like club-foot and wry-neck, or even kill the child. The woman who would "preserve her figure" by corsets, to the mutilation, weakening, or killing of her unborn infant, and this is an every-day evil, is either a criminal fool or an unmitigated scoundrel. Tight lacing to conceal pregnancy is a method of murder. High-heeled shoes are somewhat injurious because of the constrained position into which they throw the woman. X-ray photographing of pregnant women is very likely to cause abortion.
The woman's diet should be simple. She must abstain from all alcoholic liquors even if she has been accustomed to their use at meals. She should not overeat on the supposition that she has to feed two persons. Some popular books advise a special diet to reduce the bone-salts and thus get a smaller baby and one more easily delivered. Such advice is criminal. The constipation of pregnancy is not to be treated by strong cathartics like Epsom salt. The kidneys are to be watched; therefore the urine should be examined every three weeks up to the seventh month, then oftener. If there is any suspicion of toxemia or nephritis, the urine should be examined daily. Obstetricians who have any regard for their own conscience and reputation will have nothing to do with a woman who refuses to take this precaution.
Physical exercise should be gentle—say, walking, up to two miles in the daytime. The vast majority of women are too lazy to take physical exercise as a hygienic duty at any time, and during pregnancy their aversion to all effort to overcome indolence is so great they make even themselves believe they cannot. Just as most professional men think they think, most women think they work. There are thousands of women who have servants, yet make not only their families and friends but themselves believe they are worked to death, and their work is the spreading of four or five beds, and the ordering of groceries over the telephone. When these women are pregnant they quit even the bed-making.
Cold and hot baths, Turkish and Russian baths, hot sitz-baths and ocean bathing are not permissible during gestation. Tepid baths and spongings are to be substituted. Near term the bath-tub is not safe because of danger of uterine infection from unclean water. Then shower-baths are better, but these are dangerous if the woman must step over an enameled bath-tub side to take them, because she may slip and fall. Vaginal douches are not to be used in pregnancy except in certain diseased conditions, under the direction of a competent physician.
Therapeutic abortion and therapeutic induction of premature labor are employed in five chief groups of conditions: (1) contracted pelvis; (2) diseases caused by pregnancy; (3) diseases coincident with pregnancy; (4) habitual death of the child after viability but before term; (5) prolonged pregnancy. There is no such act as therapeutic abortion of an inviable child; all abortions of inviable children, when direct, are criminal, and nothing criminal is therapeutic. The consideration of narrow pelvis, and the diseases caused by pregnancy and coincident therewith, will be treated in detail.
When the child dies after viability but before term the cause is most commonly syphilis. In such cases a Wassermann reaction should be made from both parents; and even if it is negative, and no other definite cause for the fetal death can be found, syphilitic treatment should be tried on the father and mother. Bright's disease, even when scarcely diagnosable, anemia, diabetes, adiposity, and hypothyroidism are other lethal causes of habitually still-born infants. Not seldom the cause is in the husband. If he is an alcoholic (and two or three drinks of whiskey a day make any man an alcoholic), if he is especially susceptible to the toxin of tobacco (and tobacco alone may render some men not only sterile but impotent), if he is a worker in poisonous metals, an X-ray operator, a user of narcotics, exhausted with overwork and worry, affected with weakening systemic disease, his germ-cells are unfit for their function. Such men are not technically sterile, but they are practically sterile.