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withdrawn grasping simply what is seized between its blades.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 {514}
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 {515} 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 {516} 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.
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 {517}
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,
{518} 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
{519} 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.
TREATMENT IN CASES OF RETENTION OF OVUM OR MEMBRANES.--These are by far
the more trying conditions, and, unfortunately, the ones to which the
physician is most frequently called. Aid is not summoned at an earlier
stage on account of that dangerous underrating of abortion or for fear
of unnecessary expense, and the position of the practitioner is made a
trying one, as he is ignorant of the state of the case. Clots of blood
have passed, but as to the precise conditions he is left in doubt;
whether the membranes have ruptured, whether the ovum is expelled in
whole or in part, he is not told. He may find the os closed; the size
of the uterus reveals but little, as in many cases, at least those of
spontaneous abortion, development is retarded; it is smaller than would
be supposed at that period of gestation. It is only in case the uterus
corresponds at least approximately in size to the time, or if the os be
sufficiently dilated, that he can at once decide positively as to the
presence of ovum or membranes.