usually masked by the appearance of the accompanying chronic metritis.
Intrapelvic pains, disturbance of the menstrual function,
extra-menstrual hemorrhages, the presence of a more or less profuse
leucorrhoea, are signs which urgently indicate bimanual palpation.
The catarrhal secretion from the utricular glands may be imprisoned
within the uterine cavity by a functional or organic stricture of the
internal os, resulting in periodic discharges of a thin, translucent
alkaline fluid, readily distinguishable from the thick, tenacious
cervical mucus. In certain cases, particularly in old women, the
blenorrhoeal secretion may be permanently retained within the uterine
cavity, constituting the condition hydrometra.
The introduction of a small sharp spoon within the cavity of the uterus
will enable the observer to remove sufficient tissue for microscopical
examination without entailing the slightest injury on the patient. A
positive diagnosis can be made in this way, and a rational therapy
instituted.
Digital and specular examinations disclose the condition of the vaginal
portion of the cervix. The amount and physical characters of the
cervical secretions are items of important diagnostic moment. In
suspicious cases of cervical erosion a small bit of tissue may be cut
away from the surface and subjected to microscopical examination.
Secondary disturbances in connection with the gastro-intestinal canal
and nervous system occur in chronic inflammations of the endometrium,
as in the case of chronic uterine infarct.
PROGNOSIS.--Chronic inflammations of the corporeal and cervical mucous
membrane seldom threaten life directly. The continuous loss of blood
and serum, however, may produce a condition of profound anæmia and
render the individual more susceptible to intercurrent disease.
Then the hyperplastic condition of the endometrium is always an
occasion for anxiety. The relation between polypoid and fungoid growths
of the corporeal mucous membrane, erosions of the vaginal portion of
the cervix, and malignant new formations is not settled. The
possibility of malignant residua, however, must be admitted.
Sterility, acute and chronic decidual inflammations, adherent placenta,
disturbances in the involution of the puerperal uterus, and the
like--direct results of chronic endometritic inflammation--are
conditions which confer an unfavorable element upon the prognosis.
Finally, while it is possible to effect a material amelioration of all
the symptoms by a judicious general and local treatment, a complete
restitutio ad integrum is seldom or never achieved. Recidiva are always
liable to occur.
TREATMENT.--Prophylaxis.--The remarks made with reference to the
prevention of chronic uterine infarct apply with equal force to the
prophylaxis of chronic corporeal and cervical endometritis.
{465} Curative.--Of chief importance, in the very large majority of
cases, is the subject of general treatment. Many cases of chronic
catarrhal endometritis are improved by the regulation of the functions
of the gastro-intestinal canal, skin, kidneys, and hæmatopoietic
viscera in the absence of all local treatment. This statement holds
true with particular force when scrofulosis, tuberculosis, syphilis,
and the like are chief etiological factors.
Local Treatment.--The methods of local treatment at the present time
are infinitely various. For convenience of description they may be
collected under three headings:[42]
I. The washing out of the uterine cavity;
II. The cauterization of the uterine cavity;
III. The curettement of the uterine mucous membrane.
[Footnote 42: H. Fritsch, _op. cit._, 1885, p. 419.]
To Schultze, in particular, are we indebted for methods of washing out
the cavity of the uterus. The cervical canal is dilated by means of the
finger, tents, or metallic instruments, and the mucous membrane lining
the cavity of the uterus is cleansed with dilute solutions of carbolic
acid, boric acid, bichloride of mercury, and other solvent and
antiseptic fluids.
Cauterization is usually effected at the present time by the
application of pure tincture of iodine, iodine with glycerin, or
carbolic acid, to the endometrium. Bandl's canulæ for the washing out
of the uterine cavity with solutions of alum and cupric sulphate are
valuable instruments in this connection. The application of the solid
stick of nitrate of silver and intra-uterine injections of liquor ferri
are gradually passing into disuse.
The curettement of the diseased endometrium has been rapidly gaining
ground within recent years, and now constitutes the most reliable
method of treatment in obstinate cases in which local interference is
indicated at all. Martin, Düvelius, and other clinicians have
abundantly established the fact that, after the mechanical removal of
the old diseased mucous membrane, a new endometrium of relatively
normal functional activity is formed.
The number of operative procedures for the relief of chronic
endocervicitis is enormous. In the majority of cases occurring among
multiparæ it will be found that the condition is aggravated, if not
caused, by cervical laceration with ectropium. Under these
circumstances, and under the indications and conditions insisted upon
by the author of the procedure, Emmet's operation will alleviate, if it
does not cure, the pathological state of the mucous membrane.
{466}
{467}
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 {468} 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 {469} 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
{470} 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 {471} 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.
[Footnote 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
{472} 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.