and precede the expulsion of the ovum develop with the growth of the
latter and its encroachment upon the cervix; although they vary as
strikingly as do the symptoms of pregnancy, yet we may say that the
larger the ovum, the greater the foetal and placental circulation, the
more marked must be the effect of their cessation; the larger the
uterus and ovum, the more distinct this feeling of fulness, of pelvic
dragging, which accompanies the descent of the gravid organ previous to
expulsion of the ovum. The larger the ovum, the more distinct the pains
which accompany beginning separation, the more the encroachment upon
the cervix, the greater the dilatation which gives rise to the earlier
symptoms. These symptoms, however, vary so greatly, and are so often
altogether wanting, that they are hardly to be considered, especially
during the period in which abortions are by far the most common, in the
third and fourth month; and as, in all but traumatic and criminal
abortions, the disappearance of such symptoms of pregnancy as have
existed {500} is indicative of coming abortion, the death of embryo and
ovum often precedes expulsion for a considerable period of time, and
the symptoms of pregnancy consequently cease. Symptoms of pelvic
congestion, bearing-down pains, pressure upon rectum and bladder, are
among those frequently preceding abortion. At times we see a rigor,
feverishness, rapid pulse, nervous disturbances, lack of appetite,
anæmia, fulness of the head, also palpitation, cold extremities, heavy,
uneasy feeling at the pubes and coccyx, lumbar pains, and vesical
tenesmus--symptoms which are all unusual, with the exception of the
latter. The descent of the enlarged and congested uterus in the pelvis,
which always precedes the expulsion of any body from its cavity,
frequently causes dragging pains in the pelvis, a fulness, heaviness
with pressure upon the bladder and rectum, and an uneasiness at the
pubes and coccyx or lumbar and vesical tenesmus. Later, the death of
the ovum and foetus will cause more striking symptoms; the cessation of
pregnancy will be more marked in mammary changes, but reliable symptoms
are rare at all times, and usually wanting in the earlier months.
SYMPTOMS OF ABORTION.--Early abortion is frequently ignored, the
symptoms greatly resembling those of profuse and painful menstruation.
The course of abortion is inaugurated by hemorrhage, occasionally
ceasing: sometimes there is very little pain: again it is quite severe;
but the period of expulsion is well characterized; when completed the
pain ceases, and with it the hemorrhage. Often the ovum is passed
without the knowledge of the mother, even when accompanied by pain, as
it is at this time more like that of a dysmenorrhoea.
Abortion in the Third and Fourth Month.--Spontaneous, Non-criminal
Abortion.--At this period the ovum usually passes en masse;
occasionally, and more often as the fifth month is approached, the
membranes are ruptured in the course of its expulsion.
Normal Course.--We have already delineated the normal course of
abortion at this period. The death of the embryo has usually preceded,
often for weeks, and is characterized by the feeling of pelvic
congestion, gastric and vesical irritation, weariness, weakness, and
increase of uterine and vaginal secretion; the membranes have developed
more or less; expulsion is inaugurated by hemorrhage. If the cause be
more violent, the flow of blood is free. Usually there is but a slight
oozing, which ceases at times, but gradually increases; the suffering
which accompanies uterine contraction is present. Separation of the
decidua and dilatation of the cervix are indicated by pain, which is
intensified in case of uterine disease, so often present as the cause
of abortion: the ovum is expelled as a pyriform mass, its apex imbedded
in clotted blood, the inverted decidua adherent to its larger upper
pole. If hemorrhage has taken place in the decidua, or the abortion be
due to disease of this membrane, it is the most prominent feature and
envelops the expelled ovum like a rigid mantle. In traumatic abortion
it usually follows; ordinarily the membrane in part or in shreds is
expelled with or very soon after the ovum.
Traumatic and Criminal Abortion.--Traumatic, especially criminal,
instrumental, abortion varies in its symptoms, so well characterized by
Van de Warker, from the spontaneous occurrence. The latter is
inaugurated by hemorrhage; constitutional symptoms are wanting, and if
they {501} occur usually follow upon injudicious interference. In the
former constitutional disturbances are present from the first; so also
pains with inflammatory symptoms, mostly in the hypogastric region,
abdominal tenderness: the pains of dilatation may even precede
hemorrhage, whilst in spontaneous abortion they follow, often after
days. The pulse is accelerated from 100 to 120 as a result of the
primary insult; tenderness of the sensitive and congested uterus and
cervix is rarely wanting; it is, in fact, characterized by Van de
Warker as the one almost invariable symptom; vaginal hyperæsthesia,
heat, and tenderness of the os are natural results. We have no history
of previous accidental or spontaneous abortion: preliminary symptoms
are wanting; the occurrence, on the contrary, is inaugurated by
violence and shock; constitutional disturbance and hemorrhage follow.
The consequences also are liable to be more severe, in accordance with
the insults offered.
Recurring Abortion.--Morbid conditions, which interfere with the
development of the ovum and lead to abortion, tend greatly to produce
similar results if conception again takes place; hence we not
infrequently find the repeated occurrence of abortion in a patient once
afflicted; and this was formerly looked upon as a habit and known as
habitual abortion--a term which must yield to the more correct repeated
or recurring abortion, as no such habit exists: it is the continuance
of the same cause which brings about a recurrence of the accident in
repeated pregnancies. The cause being the same, the results are
similar: the abortion will recur at about the same period if conception
again take place; if due to a disease of the uterine mucosa, an early
interruption is to be expected. The death of the foetus is usually the
indirect cause of the abortion, and always precedes it: in these cases,
in most instances, it is due to syphilis; at times to other cachectic
conditions of the mother or an affection of the uterus or its mucosa.
The development of the ovum continues for some time until abortion
takes place, and this occurs, if due to changes in the mucosa or
decidua, in the first months; if the result of anæmia or cachectic
conditions of the mother, of syphilis, in the sixth or seventh month,
or toward term. The death of the embryo is followed by retrograde
metamorphosis, thrombosis of placental or uterine vessels, and
expulsion from one to three weeks later.[5]
[Footnote 5: Geonbert, _Thèse de Paris_. 1878.]
Plethora as well as anæmia may cause this occurrence; thus Campbell
relates a case of seventeen successive abortions occurring in an
extremely plethoric person, who was finally enabled to bear a child to
term by repeated venesections made monthly; and others record cases of
a similar nature: lack of nutrition, anæmic conditions, brought about a
remarkable increase in the number of abortions during the siege of
Paris and in the succeeding year of want. Chronic endometritis with
cystic formations has been repeatedly recognized as leading to
recurring abortion; so also laceration of the cervix in case conception
does take place. The continuation of the same cause should lead to its
recognition, as in most cases it is amenable to treatment; syphilis,
inflammation of the endometrium, and laceration of the cervix, among
the most frequent causes of such repetition, are the very diseases most
thoroughly under our control, so that in the present advanced stage of
our knowledge we should no longer hear of such a condition as recurring
abortion. Ruge of Berlin {502} considers syphilis as the cause of death
of the foetus in 83 per cent. of such cases.
VARIATIONS.--A cessation of the symptoms not infrequently occurs:
either with or without treatment the oozing may stop; even if
hemorrhage and pains have existed all symptoms may cease. Large clots
of blood have been expelled, the patient rests quietly in her bed, and
gradually becomes easier; contractions and hemorrhage cease altogether,
and she recovers, regains her vigor, and begins to move about. At the
time of the following menstrual period the same cycle is repeated, and
not until then is the ovum expelled. If the membranes are delicate,
these may be ruptured by uterine contraction or by artificial or
mechanical interference, and with the collapse of the ovum or the
expulsion of its greater mass irritation is lessened and the symptoms
subside. Exercise or the congestion and irritation consequent upon the
return of the menstrual period will again arouse uterine activity, and
the remnants are then expelled, a month or two after the inaugural
hemorrhage.
These are conditions which are very frequent when the expulsion is left
to nature or the aid of the midwife is sought, but they are with equal
frequency produced by unskilful interference. The efforts of the
physician are not unfrequently directed to a lessening of the
hemorrhage, regardless of the existing conditions: applications are
made to the abdomen and ergot is given, both methods of treatment which
tend to stimulate uterine contraction; the more powerful circular
fibres predominate and contract, the os is closed, the symptoms cease,
and the conditions above mentioned are produced. Abortion is prevented
for the time being, and sooner or later the patient is astonished by a
return, which is, however, accompanied by less hemorrhage and more
active labor-pains with a more rapid expulsion. If styptic injections
are made into the uterine cavity or pieces of the ovum removed with the
uterine dressing-forceps, a similar effect is produced, though the
result is a more unfavorable one, as parts of the ovum are removed, and
the collapsed membranes and shreds which remain are liable to prolong
and aggravate the case, as they do not irritate the uterus and
stimulate it to healthy action like the intact ovum.
The interval between the period of expulsion and the inaugural
hemorrhage is often one of complete rest and health, more usually one
of occasional oozing and malaise. As a consequence, we must have
putrefaction and sepsis or the development of placental polypi and
hemorrhage. Air is often admitted, either during the efforts at removal
or later; if the cervix is not fully contracted, the secretions are
more copious and liable to putrefy with the retained shreds. The
symptoms are, however, unlike those of septic infection after labor at
term, on account of the comparatively intact surface, the absence of
the large uterine sinuses: they are insidious, not intense and
acute--lack of appetite, weakness, slight increase of pulse and
temperature--so that assistance may not be sought until increased
suffering, putrid discharge, and high fever necessitate interference.
This putrefaction is more liable to take place when the greater mass of
the ovum has been expelled and parts alone remain, but will also occur
when the entire mass is retained. Even without active interference the
symptoms may subside as the disintegrating masses pass away as a putrid
discharge, intercurrent hemorrhages at times carrying away larger
shreds.
{503} The so-called placental polypi result from the retention of parts
of the ovum, especially of the placental portion, chorion, or decidua
serotina, which, enveloped in fibrinous coagula, are entered by the
proliferating vessels of the surrounding tissue. Such growths,
sometimes of the size of a hazelnut or walnut, even to that of a small
egg, may be unnoticed for months, but sooner or later give rise to
oozing and hemorrhage, and in more fortunate cases are finally
expelled. The expulsion of these retained membranes is inaugurated by
hemorrhage, which may be preceded by more or less oozing: it is rapid
in its course, accompanied by that pain which characterizes the last
stage of abortion, and terminates with the appearance of the corpus
delicti. It is merely the final scene of the abortion, which was but
partially completed weeks or months ago, and the task is greatly
simplified. Dilatation of the cervix and separation of the tissues were
accomplished in the first stages, and during the interval of rest
nature has been quietly making the necessary preparations to facilitate
and complete the task undertaken, precisely as during the last months
of gestation. Consequently, this expulsion is rapidly accomplished:
pain and hemorrhage, even if severe for a time, are not of long
duration. I have such a mass--which upon section reveals distinctly the
villi of the chorion--which was cast off with all the symptoms of
abortion four months after the occurrence of the inaugural hemorrhage
and partial expulsion. More frequently I have been called to remove
these masses, which have given rise to constant oozing and actual
hemorrhages, two and three months after the occurrence of abortion, the
adhesion to the uterine wall being so firm that the sharp scoop was
called for, and sometimes I have been obliged to remove them piecemeal
like a small uterine fibroid.
Late Abortion.--All abortions in the fifth and sixth month approximate
in their symptoms those of labor at term; the membranes are ruptured,
the ovum is never expelled in toto; the foetus may either precede the
placenta or be expelled with it. It is at this period also that the
hydatiform mole usually passes away, though it may be retained for a
much longer period of time, even beyond the duration of normal
pregnancy, the symptoms resembling those of abortion in the third or
fourth month. After complete expulsion of the ovum and membranes more
active hemorrhage and pain cease, the uterus contracts, but a slight
oozing follows, and this becomes more pale and gradually merges into a
serous flow.
DURATION.--The course of abortion varies greatly in its duration, and
is usually prolonged, death of the ovum frequently occurring weeks
before active symptoms are inaugurated, and even these may be slow in
developing: a slight and often interrupted oozing may precede a more
profuse flow and the dilatation of the cervix, or, as we have seen, the
symptoms may cease for weeks and months even after they have been fully
inaugurated; again, the ovum may be expelled in part and the remnants
be retained for months--four months being the extent of time in which I
have seen such retention terminate in expulsion without interference.
By the formation of placental polypi the period may be protracted
indefinitely.
The question how long abortion may be delayed, for what length of time
the membranes may be retained, is far more important than is {504}
generally supposed, both from a social and medico-legal standpoint, and
is by no means thoroughly understood. I have recently seen a mole
formation, the infiltrated foetal membranes, and part of the decidua
which had been retained nearly four years--three years and nine
months.[6] For four consecutive years the foolish woman, who had
brought about abortion and expulsion of the embryo, suffered from
occasional menorrhagia, and nausea and vomiting like that which had
existed in the first months of pregnancy, until the annoyance became
unbearable and medical advice was sought. An examination revealed an
enlarged anteflexed uterus, from which a peculiar compressed and
elongated mole was removed, after which the symptoms ceased. The case
is moreover peculiar, as several of the symptoms were those of
pregnancy, which do not generally continue after death of the embryo.
[Footnote 6: Ovum retained nearly four years, E. C. Gehrung, _Weekly
Medical Review_, St. Louis, April 25, 1885.]
For a term of three years a twin embryo has been retained, causing
violent epileptiform attacks, always most severe during the menstrual
period, which first appeared four weeks after the last labor and
continued, to the great detriment of the patient, until the macerated
embryo was removed, when recovery took place. This was most probably a
twin intramural pregnancy, the twin developing in the tubo-uterine
cavity being retained after the expulsion of the one properly located,
and then gradually forced into the more commodious uterine cavity.[7]
These cases indicate the extent of this still unsettled question.
[Footnote 7: C. K. Patterson, _Weekly Medical Review_, June 13, 1885.]
TERMINATION.--Dangers of Abortion.--Though fatal results are rare and,
when occurring, due to sepsis rather than to hemorrhage, much of female
suffering is traceable to this accident, the pathological interruption
of pregnancy. Uterine and pelvic disease, especially subinvolution and
consequent displacement, diseases of the endometrium and cervical
tissue, result from abortion; sterility as well--all diseases which
leave their traces indelibly marked upon the system of woman. They are
not the direct or necessary consequences of abortion, but rather the
results of the underrating of this most decidedly pathological
occurrence--an underrating which is unfortunately prevalent among the
profession and universal among the laity.
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 {505} 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 {506} 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.