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.