A system of practical medicine. By American authors. Vol. 4

by Unknown

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.