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.