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 {507}
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 {508} 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.
If the os is dilated, the finger should be introduced--if necessary the
hand--into the vagina, which can easily be done if the fundus be
approximated by the other hand; better still, to use the curette, and I
would advise the large blade of my instrument; the small one can at all
times be passed into the cavity of the uterus during or immediately
after abortion, and usually the larger one also. This examination, if
with the scoop, consequent upon dilatation, should be followed by an
antiseptic injection, but I would unquestionably advocate a correct
diagnosis, whatever means may be necessary to obtain it, as appearances
are so deceptive. We need but recall those by no means rare cases which
to all appearances are those of completed abortion, yet the patient
does not perfectly regain health and strength, and if an examination is
made the os is found patulous and membranes or parts of the ovum are
retained. If examination and dilatation be neglected, a coming
menstrual period will discharge the disintegrating mass, or local and
constitutional disturbances, even septicæmia, may be looked for.
PROGNOSIS.--As to prognosis, it is the mother whom we must consider,
the dangers present and future, the attachment and dimensions of the
ovum, and the possibility of continued gestation. The prognosis of
traumatic or criminal abortion is worse than that of the spontaneous
form, the result of natural causes, because it is inaugurated by shock,
by injury, and inflammatory conditions which are aggravated by the
congestion and contraction accompanying the expulsion, for which the
tissues are entirely unprepared; whilst in natural, spontaneous
abortion, usually the result of some morbid condition, some disease of
the system, a cachexia, uterine disturbance, or death of the embryo and
ovum has preceded, and a retrograde metamorphosis to a certain extent
has been inaugurated; some preparation at least has been made for the
coming expulsion; hence the separation is more natural, less violent,
less liable to be followed by evil results.
The prognosis is invariably favorable if proper medical aid is summoned
in the early stages, but actually it varies greatly, as does the course
of abortion--whether completed in a reasonable time or of longer
duration, more favorable in the former, less propitious in the latter;
if hemorrhage has been profuse or comparatively slight, but of long
duration, anæmia is liable to result: if expulsion is long protracted,
the dangers of subinvolution, metritis, and perimetritis are great: if
the expulsive pains cease before the complete expulsion of ovum or
membranes, retention, putrefaction, and sepsis may be inaugurated, and
subinvolution, endocervicitis, and endometritis will follow.
{509} The embryo is scarce to be considered: it may be saved if the
hemorrhage has not been too severe and accompanied by pain, if the ovum
does not protrude into the cervix. The inflammation which usually
accompanies traumatic or criminal abortion greatly aggravates the
prognosis, but, however good it may be in individual cases, the result
will depend greatly upon the after-treatment, upon the time allowed for
proper involution, and upon the assistance given it. Though the
prognosis at the time of abortion may be a most favorable one for the
mother, the result is seriously affected by the care taken during the
period of involution, the after-treatment, which is by far more
important than generally supposed.
TREATMENT.--The successful treatment of abortion requires knowledge,
judgment, and resolution on the part of the practitioner, and in
importance it is equivalent at least to the management of labor at
term. Two lives may even be at stake, though the opportunity of saving
the embryo is, as a rule, afforded only during the period of
prophylactic and preventive treatment, as vitality is ordinarily
destroyed in the embryo when abortion, as the result of natural causes,
is once inaugurated: the life of the mother is not in question, as it
is in labor at term, but her health is even more endangered. Attention
is now forcibly called to the subject by earnest discussions between
the adherents of the expectant and those of the progressive method of
treatment, but mainly to the treatment of actual abortion; prevention
and after-treatment have been neglected. Important as is the method of
treatment employed in case of retention of membranes or ovum, the
necessity for such interference, especially the frequency of abortion,
would be greatly diminished if the family physician were thoroughly
imbued with the importance of the subject and could impress the same
upon his patients. If the dangers arising from such premature
interruption of gestation were appreciated by the laity and medical
attention summoned in the early stages, the management of abortion
would become more simple and more successful, and the cases of
retention which cause such suffering and injury to women would be far
less frequent.
Before entering upon the treatment proper it may be well to review
briefly the necessary adjuncts, as proper preparation will aid
materially the course to be adopted.
Preparations Necessary with Regard to the Patient.--Many of the
preparations necessary in the lying-in chamber are desirable in cases
of abortion as well. Attention should be paid to the bowels, as a
costive condition will interfere to some extent with the manipulations
as well as a rapid and favorable course of expulsion and involution; at
best, it is liable to make the patient uncomfortable. The bladder
should be evacuated, especially before active measures are resorted to,
and the patient should be so clad in night-gown and sacque, with long
hose and drawers, that she may be moved and manipulated without
exposure.
The bed should be prepared with rubber cloth and quilts, and sufficient
quilts, cloths, and towels should be on hand; a bed-pan is desirable,
and also a fountain or bulb syringe; the bed should be so placed that
the physician may be at the right hand of the patient, and convenient
to the light when she is placed in Sims's position of the dorsal
decubitus for operative interference.
{510} Antisepsis.--Cleanliness and antisepsis should be observed in the
management of abortion as strictly as in that of labor or in surgical
operations, as sepsis, either in the form of acute infection or an
insidious undermining of the constitution, is among the more frequent
of the dangerous consequences which follow in the wake of abortion.
Circumstances permitting, it is desirable that carbolated vaseline or
vaseline with iodoform, carbolated or some similarly prepared soap, be
on hand, and also permanganate of potassium, carbolic or boracic acid,
and iodoform. I am in the habit of prescribing carbolic acid for the
convenience of use: carbolic acid 2 ounces, alcohol 1 ounce, with 7 of
glycerin, which is as concentrated as may be well used (1 to 5, or 20
per cent.), and a proportion readily diluted to 2½ or 5 per cent.
Before and after examinations the hand should be washed in carbolated
water or some such disinfectant--permanganate of potassium, corrosive
sublimate, or boracic acid--as it appears desirable to use. If carbolic
acid is used, the parts should be cleansed with a 2 or 3 per cent.
solution. After interference or repeated examinations the vaginal
douche should be used, certainly after completion before leaving the
patient. If instrumental interference be necessary, and the ovum or
membranes forcibly removed, the cavity of the uterus should be washed
with hot water, from 115° to 125° F., containing 5 per cent. of
carbolic acid, the hot water serving styptic purposes. This may
suffice, but it is frequently desirable to mop the cavity with the
above-named solution or even the pure liquid after more active
interference, especially if some disintegration has taken place and is
indicated by odor.
After the use of tampons the vagina should be washed with a 2 or 3 per
cent. solution, or 1:2000, of corrosive sublimate; and it is even well
that the cotton, before being introduced, should be anointed with
either carbolized vaseline or carbolized oil (carbolic acid 2 drachms,
olive oil 3 ounces). Iodoform serves an excellent purpose for
disinfection of tampons, especially such as are packed into or against
the cervix, and as an application to the cavity after the removal of
the putrid contents following the hot douche. Borated cotton, or even
ordinary cotton or prepared tow, should be on hand to use during the
after-treatment in place of cloths for the purpose of receiving the
discharge: it is warm, soft, forms a good filter, and can be thrown
away or burnt when soiled, whilst the cloths ordinarily used, and often
very offensive, are kept for the wash.
Medication.--The most important of all the remedies is opium; in
preventive treatment it may be called a specific. It is far preferable
to the hypodermic injection of morphine, serving to relax and quiet the
uterine muscle and to lessen hemorrhage; for the latter purpose it is
often combined with acetate of lead--from ¼ to 1 grain of opium mixed
with ½ to 1 grain of acetate of lead, to be given at a dose and
repeated when necessary. Ipecacuanha combined with opium acts well in
relaxing the tension.
Viburnum prunifolium has long been used as a uterine sedative in these
cases in those States where the plant is endogenous, and its use has
been widely disseminated since it has found so able an advocate in
Jenks. The preparations are not all equally effective, but in the early
stages the fluid extract given in teaspoonful doses, according to the
amount of hemorrhage and pain either hourly or every two or three
hours, has a most {511} decided effect in allaying threatened abortion,
in checking hemorrhage, and in quieting pains. It seems to be a uterine
sedative. Several ounces may be taken, and successful cases are
reported where the pending expulsion was averted and gestation
continued to a successful termination after four ounces had been used.
Digitalis combined with acetate of lead also deserves recommendation as
an effective remedy in the early stages. Quinine may be given to
stimulate the system and further uterine contraction, and is invaluable
in an asthenic condition or if disintegrating shreds be present.
Nervines, valerian, asafoetida, valerianate of ammonia, bromide of
potassium, are of great service throughout the entire course of
abortion, as the patient is usually in a nervous almost febrile state.
Alone they may serve to allay the irritating symptoms in the early
stages, and answer well in preventing the disagreeable effects of
opium. Asafoetida may be given by injection or in pills, from ½ to 2
grains at a dose.
Clysmata tend to irritate, and should not be used as long as we may
hope to prevent threatened abortion. Such remedies as are indicated in
the treatment of this condition, especially opium and nervines, must
nevertheless at times be given by injection, as the stomach may refuse
to receive and retain them in the irritated condition which accompanies
this state. The clysms should always be warmed, of body temperature:
two tablespoonfuls of milk of asafoetida or gum arabic form an
excellent vehicle, though water or milk thickened with flour or starch,
which is always on hand, will do quite well.
Should it be necessary to move the bowels, castor oil is one of the
best remedies, whilst cathartics, especially aloes and similar drugs,
must be avoided as long as there is hope of preserving the ovum: they
certainly further expulsion. Ergot should not be used until after the
uterine cavity is emptied, and is decidedly contraindicated whilst the
ovum or any of its parts remain adherent in utero. The dangers arising
from the use of ergot in the early stages, whilst the ovum is still
intact, are rupture of the membranes and forcible contraction, which
always prolongs expulsion of the ovum or its membranes; the circular
fibres, which predominate, are stimulated most forcibly to action, more
particularly so under the conditions which usually exist in abortion:
the muscle of the uterine body is hindered in its contraction by the
adhesions of ovum and decidua, especially if these membranes are
infiltrated; and, moreover, in cases of abortion the tissues of the
womb itself are often more or less diseased; the lower portion of the
uterus and cervix alone is free to act, the circular fibres of the
internal os contract most readily under the influence of ergot, whilst
the activity of the fundus is interfered with; thus closing of the
outlet and incarceration of the membranes are liable to result. This
popular and dangerous drug must not be given until the tissues are
expelled, or, if desirable by reason of excessive hemorrhage, its use
may be resorted to under one condition: if the membranes are detached,
not only free in the uterine cavity, but entering that of the cervix;
they may be found massed together firmly, by compression of the uterine
walls, into a conical or pyriform mass; and when this has to a great
extent passed the internal os ergot may be given. This drug, so
dangerous in obstetric practice, is still used with altogether too much
freedom in this country, and it would be far better to do without it
than to {512} continue the prevalent abuse. I have insisted that this
drug must not be given in labors or abortion until the contents of the
uterine cavity have been removed. Although but one of our prominent
obstetricians approved of the position I took in 1883, and I was then
freely attacked, I now urge the point more earnestly, and the doctrine
is more commonly accepted: in Germany such men as Martin, Spiegelberg,
and others have succeeded in doing away with this dangerous remedy
altogether in the institutions under their care, restricting its use to
the non-gravid uterus.
As a styptic, hot water, carbolized, serves the best purpose: in the
early stages as vaginal douche, in the later as an intra-uterine
injection at 120°, it is an invaluable remedy, preferable to other
styptics, as it cleanses and removes the coagula. When the cavity has
been emptied, especially after the forcible removal of the membranes,
it is well to apply carbolic acid to the surface; and it is better for
this purpose than tincture of iodine or perchloride of iron, either of
which is only to be used in case that hemorrhage does not yield to the
before-mentioned remedies.
Anæsthetics.--Though bromide of potash, morphine, or opium may suffice
for the relief of the pain in ordinary cases, the use of an anæsthetic
is not only desirable, but necessary, if more active measures are
resorted to. For purposes of rapid dilatation and the removal of an
adherent ovum or membranes anæsthesia is almost indispensable; without
this the suffering of the already nervous, debilitated patient is
excessive; the uterine and abdominal muscles are tense, and operations
thus greatly impeded. An anæsthetic should be given in a rapid
dilatation on account of the pain, as well as the greater facility of
operating; and it is most necessary in an attempt at expression, as, if
made without an anæsthetic, the abdominal muscles are so tense that the
uterus cannot be well manipulated from without. I myself prefer
chloroform.
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 {513} 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.