{520} retained masses, whether ovum or membranes, are adherent, though
in case of sepsis more or less dilatation exists; yet in the latter
case the indications afforded by those symptoms are of little
importance, as the constitutional symptoms, with the character and odor
of the discharge, clearly indicate the existing conditions, and
consequently show the course to be pursued. No question exists as to
the necessity of immediate delivery in these cases, but as to the
manner of treatment in retention of ovum or membranes not
disintegrating there is a wide difference of opinion: able men are
still inclined to urge a reliance upon nature, yet it is a dangerous
course for the practitioner to pursue: successful as it may prove in
many cases, it is certainly fatal in some, and but too often followed
by the insidious consequences so frequent in its tracks.
Labor at term may be left far more readily to the powers of nature than
abortion: the former is a physiological process, the latter
pathological. The expulsion of the ovum at term has been preceded by
preparatory changes in maternal and foetal parts; the separation of the
membranes is facilitated by the fatty degeneration of decidua serotina
and vera; the hypertrophied uterine muscle is strained to its utmost,
its fibres increased and strengthened for the ordeal, but in the early
months no such conditions exist. Though expulsion has been anticipated
and the preceding hemorrhage frequently serves to separate the
structures, and development ceases with the death of the embryo, a
retrograde metamorphosis is inaugurated only in certain cases, and then
incomplete, and the frequency of intermittent abortion which we find in
cases left to nature is evidence of incompetency to fulfil the task
attempted: hemorrhage, more or less protracted, and contraction of the
uterus cease; the ovum has been partially separated; its growth is
checked, and then a retrograde metamorphosis is inaugurated in the
tissues which have been in so active a state of development; this
continues until a recurring menstrual period or excessive exercise
brings about a renewal of the expulsive effort; and if sepsis has not
taken place we usually find that the ovum is expelled with rapidity.
When the attempt was first made, it proved ineffectual and the effort
ceased; the tissues were impaired in their nutrition, underwent a fatty
degeneration tending toward disintegration, and the second attempt of
nature, with the parts properly prepared, terminates rapidly and
effectually. Though the tendency of the profession at large seems
toward a more expectant plan, guided by able authorities--such as
Parvin, who urges attention to the old-time remedies, rest, time, and
laudanum; and Leishman, who advocates this treatment when hemorrhage
has stopped and the os is closed, perhaps aiding nature by the use of
ergot--I would advise more active interference. It is indeed true that
the ovum or some of its parts may remain in utero for months and then
be expelled by a healthy effort of nature, without injury to the
patient; but this is not the rule. I have seen such cases, but mostly
the health of the patient is affected; even if more active symptoms,
such as hemorrhage and sepsis, do not appear, subinvolution certainly
follows. In cases less severe the patient is nervous, restless, suffers
from insomnia, uterine colic, and occasional oozing; perhaps there is
an offensive discharge,--all symptoms which are not sufficient to cause
great anxiety, but we may with certainty expect them to result in
serious inflammations of the uterus and surrounding tissues--metritis,
thrombosis, cellulitis, {521} endometritis, peritonitis; hence why
should we wait? Why allow these dangerous membranes to remain, as
claimed by some, "as long as no injurious effects appear"? Why wait for
these more threatening symptoms when evil results are almost certain to
follow upon the retention of such masses, even though hemorrhage and
sepsis be at the time wanting? I have removed thoroughly healthy,
semi-organized remnants as late as the fifth month after partial
expulsion of the ovum; the patients were suffering no very serious
inconvenience at the time, nor did any grave consequences directly
follow; yet it would have been far better for them had decided steps
been taken at the time of the inaugural flow; they were forced to seek
advice in some instances by reason of uterine pains and oozing, in
others by profuse and sudden hemorrhage; and, though decided injuries
were not at the time evident, subinvolution and uterine displacement
were certainly threatened.
Various periods are mentioned as preferable for interference. Some say
that there is no need for alarm if the placenta remains in utero for
twenty-four or forty-eight hours, provided the patient be under
observation; but the os is liable to contract, always within a week,
sometimes within forty-eight hours, after preliminary hemorrhage, and
it certainly is unreasonable to allow complete contraction of the os
and thorough cessation of the efforts of nature to take place, with the
probability of evil results before us. If the physician is called at a
time when the course of abortion seems retrogressive, the os closing,
and he is uncertain as to the complete emptying of the uterine cavity,
he should satisfy himself of the existing condition; and there is no
reason whatever to the contrary in the present era of antiseptic
gynecology. He should explore the uterine cavity, determine the state
of affairs, and act accordingly. The proper course is clearly
indicated: retained tissues should be removed, though it is difficult
to formulate precisely the conditions by which action should be guided.
The circumstances permitting of interference and removal are a patulous
os, an open cervical canal, and detachment of ovum or membranes: these
existing, removal is easily accomplished, and should be undertaken even
though no threatening symptoms be present. The indications which at all
times determine and obligate immediate removal are--a putrid discharge,
hemorrhage and constitutional symptoms, debility, fever or sepsis; then
immediate removal is necessary at all hazards.
Though it does not appear advisable to remove the ovum, as urged by
Fehling, at once, if the tampon fails after ten or twelve hours' trial,
the physician must not wait until threatening local or constitutional
symptoms appear, as various evils develop insidiously long before
removal is so loudly called for. There are no conditions which could,
by any possibility, contraindicate immediate interference if the
indications above mentioned exist--not even inflammations, pelvic
cellulitis, or fixation of the uterus, as is claimed by some. The
limits of active interference being given by the above indications, the
practitioner must determine by the greatly-varying symptoms of the
individual case, as he does upon the proper time of applying the
forceps in labor at term. If parts of the ovum remain in utero, they
should be removed as irritating and dangerous; and a patulous os must
necessarily lead the practitioner to infer the presence of such a mass;
yet this is not a constant symptom: if the os is closed and {522} the
presence of membranes presumptive, he should dilate and satisfy himself
as to the true state of affairs, dilatation with antiseptic precautions
being entirely harmless. If remnants are found, the first step to their
removal has already been accomplished in the diagnostic dilatation.
This is best attained with the patient in complete narcosis and in
proper position. The dorsal decubitus and Simon's speculum are
preferable to the left-lateral semi-prone position, as we are better
able to manipulate the uterus both externally and internally,
especially to control the fundus. If the os be not too firmly
contracted, the finger may be introduced when anæsthesia is
established, and sufficient dilatation thus accomplished, or the scoop
may be at once used without further preparation. If time is no object,
the uterus is best dilated with a tupelo or carbolized sponge tent;
where immediate action is indicated, the finger or steel dilator is
best. Molesworth's instrument, even if ready for immediate action, is
liable to dilate within the cervical and uterine cavity, remaining
contracted at the point of greatest importance, the internal os.
Incision with the knife, the splitting open of the cervix, is now
recommended by German authors.
The tampon can be of service only where a larger mass is retained, not
if the membranes alone remain. The use of the tent for the purpose of
dilating is of advantage if introduced well into the uterine cavity,
stimulating the muscle, so that expulsion frequently follows
dilatation; but even then the curette should be used--the dull
instrument--for a careful examination of the cavity. I have already
stated the conditions indicating a resort to the sharp scoop, the
Simon's or Sims's, or the dull curette, such as Munde's or my own. The
wire loop of Thomas is too weak, and serves more for the removal of
already loose masses than for the separation of the tissues, which I
consider by far the most important. Where possible, it is always
preferable to use the dull instrument for purposes of separation; and
there is no better than Récamier's old instrument, or, in case of a
large cavity, the broad blade of my own; both may be used without
dilatation if the contraction of the os is not excessive. If firmer
masses are found, as is frequently the case when the placental remnants
have been retained for several months, Simon's sharp scoop is
indicated, and the smaller size can be used without previous
dilatation; the speculum is not necessary, but desirable, but for the
effective handling of the instrument it is best that the patient be
placed in the lithotomy position, upon the edge of the bed, the hips
elevated, with a rubber cloth underneath. It is all-important that the
movement of the scoop should be thoroughly controlled by the unengaged
hand grasping the uterine fundus: this will serve to fix the organ well
and prevent its escaping the instrument. Where the fundus is out of
reach, as in retro-displacement, the Schroeder forceps, which is always
of great service in bringing the uterus within reach, must be used. In
case Récamier's or my own instrument is used, it is curved to adapt
itself to the cavity, and, with one edge pressing firmly against the
uterine wall toward the point of attachment of the membrane, it is
carried around the entire space, so as to separate such adhesions as
may exist, and the released membranes are then forced or pressed out
with the instrument. In case the sharp spoon is used, it must be
handled with great care, pressing firmly against, but not too deeply
into, the uterine wall, and carried in {523} regular parallel strokes
from the fundus toward the internal os. After such manipulation the
cavity should be well washed out with hot water containing from 2 to 5
per cent. of carbolic acid, bichloride of mercury, borax, or
permanganate of potash, either with the ordinary syringe or Bozeman's
catheter; after this the entire inner surface of the uterus is touched
with carbolic acid, a little cotton wrapped upon the end of an
applicator and saturated with the solution answering the purpose very
well.
Hot water and carbolic acid usually suffice to thoroughly contract the
organ; should this not be the case, should a flabby, atonic condition
exist, it is well to place a tampon of iron cotton in the cavity. The
applicator is loosely wrapped with cotton of sufficient thickness to
fill the cavity; this is steeped in Monsel's solution or the
perchloride of iron, the superabundant fluid expressed, and then
introduced. Contraction is sure to follow, and the tampon is left in
place for three or four days, when it will either be expelled by the
action of the uterus or it will be found, coated with healthy pus,
barely held in the grasp of the muscle, and can be removed by the
slightest traction: no effort should be made, as it will remain firmly
fixed until a healthy granulating surface is established. It may be
kept in place by a tampon of cotton carbolated, or, better still,
prepared with iodoform, which is always a desirable application after
interference. Ergot should then invariably be given, either by
hypodermic injection or per os--if the stomach is in good condition, a
teaspoonful of the fluid extract every three hours during the first
day.
Putrid discharge and septic symptoms unquestionably indicate immediate
interference; the method, however, remains the same. In case of
beginning putrid discharge without constitutional symptoms, the dull
curette is greatly to be preferred to separate the sloughing tissue
from the healthy uterine structure without injuring the latter; whilst
if the uterine structure itself is affected, it is necessary to resort
to the sharp spoon to thoroughly remove all that is diseased.
Constitutional treatment must, of course, follow the local measures
above advocated. The danger of the sharp instrument, under these
circumstances, is in the possibility of lacerating healthy tissues and
opening new ways for infection. It can only be used if all diseased
tissue is thoroughly removed and the operation followed by
cauterization with pure carbolic acid and intra-uterine injection, that
all remaining particles, however small, may be washed away.
An active general treatment must accompany these local measures, but
upon this I will not dwell, as it is the same which must be followed in
all cases of septic poisoning. Quinine is the main stay, and in
addition to the remedies in general use ergot is here indicated to
further contraction and expulsion of offensive particles and close the
capillary and lymphatic canals to the possibility of infection.
AFTER-TREATMENT.--It cannot be too often repeated that the danger
resulting from abortion is not the immediate or primary one, but the
secondary, even in case of profuse hemorrhage; it is that of anæmia, of
general debility, a slow getting up. After abortion we have conditions
analogous to those of the puerperium, the dangers of infection, of
septicæmia, the greater liability of the system to surrounding
influences, {524} epidemic, infectious, malarial; but even greater than
after labor at term is that of incomplete involution with its chain of
insidious consequences. In the main, the danger of abortion lies in the
lightness of the affection and the indifference to after-treatment.
Involution is more questionable than after labor at term, and yet time
and opportunity are rarely given nature to accomplish this process of
restitution. If the abortion is passed easily, the patient rarely keeps
her bed, pays little or no attention to the occurrence, certainly none
to her getting up, and subinvolution, by far the most frequent sequence
to abortion, follows. Abortion is altogether the most prolific cause of
uterine disease, in consequence of the indifference with which it is
treated, not only by the patient, but by her physician. With the
expulsion of the ovum and the cessation of hemorrhage the case is
considered finished; even if a physician is called, proper time is not
given for restitution of the parts. Although by far less is to be
accomplished by the retrograde metamorphosis than after labor at full
term, the parts being not so fully developed, they are not so
thoroughly prepared for this restitution: retrograde metamorphosis has
not been initiated with the inauguration of the abortion, as it has
with the inauguration of labor at term. In the latter fatty
degeneration is in progress; the tissues are prepared for the
restorative process which is to follow: not so in case of abortion;
hence nature must be assisted, must be allowed to perform those
functions which are necessary to a healthy restoration of the sexual
organs.
In the great mass of cases it is not strictly medical attention which
is necessary, medical treatment, but mere ordinary care, precaution,
and cleanliness on the part of the patient herself, so as to assist the
efforts of nature: a week's rest in bed with healthy nutritious diet
should be accorded every woman who has aborted, and this must be
followed by at least one more week of quiet and confinement to the
room, and not until a month after the accident has occurred should the
patient resume her ordinary vocations.
I will not enter into the details of the after-treatment, as it is
identical with that after labor at term. No decided treatment is called
for unless demanded by symptoms peculiar to individual cases, yet
ergot, quinine, and tonics are in place, and the same antiseptic
precautions must be observed which are so highly appreciated in the
lying-in room.
The patient must be kept in a recumbent position, the room quiet, and
visitors excluded; a bed-pan must be used; the food must be easily
digestible and nutritious; prepared tow or salicylated or borated
cotton should be used in preference to the old-fashioned cloth to
receive the discharge, and this must be changed with sufficient
frequency: the parts must be washed with a lukewarm antiseptic wash,
and vaginal injections of the same given as cleanliness demands, at
least once a day; these should be hot (110°-120°) to further
contraction. Corrosive sublimate 1:2000, carbolic acid 2:100, or
boracic acid or borate of soda, serves a good purpose; intra-uterine
injections are called for only in case of putrid or offensive
discharge.
After the third or fourth day it is well to add an astringent, such as
alum or tannin, to the hot vaginal douche, a teaspoonful to the quart,
beginning with less, as some are very sensitive to these remedies, and
increasing the strength if desirable.
{525} Iron and chinine are serviceable in aiding the system to regain
its tone and in guarding against zymotic and malarial influences, to
which it is more subject in this weakened condition. Ergot is here in
its proper place: a three-grain pill of the aqueous extract should be
given, at least during the first week, three times a day; I prefer this
to the fluid extract in common use, which is nauseating to many. This
drug, so much abused during progressing abortion and in labor before
the contents of the uterus are expelled, answers an excellent purpose
at this stage, and, together with the hot, astringent douche, may be
relied upon to prevent subinvolution.
I can but repeat that the after-treatment should be that of the
lying-in room after labor at term, modified according to circumstances,
but never to be neglected, not even after the most simple cases. We
must remember that it is indifference under these circumstances,
under-estimation of the accident, which leads to years of suffering, by
which subinvolution so insidiously destroys a vigorous constitution.
Rest, peace of mind, and quiet of body should, together with antiseptic
precautions and tonic treatment, follow every abortion, intensified
according to the severity of the accident. The two most important, and
at the same time most neglected, features in the after-treatment of
abortion, both of which are called for in even the most ordinary cases,
are rest and cleanliness--rest, quiet of body and mind, to afford the
proper conditions for the efforts of nature toward restitution and
involution; cleanliness, antisepsis, to prevent external interference
with this process and to guard the lacerated cavity of the womb, which
offers so ready a receptacle for septic elements, against the dangers
which threaten from without and so frequently bring about the
rapidly-fatal termination of an apparently simple abortion.
{526}
{527}
DISEASES OF THE MUSCULAR SYSTEM.
MYALGIA.
PROGRESSIVE MUSCULAR ATROPHY.
PSEUDO-HYPERTROPHIC PARALYSIS.
{528}
{529}
MYALGIA.
BY JAMES C. WILSON, M.D.
DEFINITION.--An affection of the voluntary muscles, of which the chief,
and often the only, symptom is pain on movement.
SYNONYMS.--Myalgia as a general term has few synonyms. It is sometimes
called myodynia. This affection has no essential relation to rheumatism
or the rheumatic diathesis; therefore the common use of the term
muscular rheumatism as a synonym for myalgia is an error. This error
has occasioned much confusion of thought and mistaken medication, and
tends to maintain the obscurity which overhangs the subject of the
so-called and often miscalled rheumatic affections in general. That
true rheumatic processes may extend from serous or fibrous structures
to contiguous muscular masses has, in the absence of demonstration,
been assumed by many writers of authority, but that acute or subacute
rheumatism, with its recognized characters, ever manifests itself
primarily or exclusively as an inflammation of muscle-substance is an
assumption wholly without clinical or pathological support.
The term myo-rheumatism is as inapplicable as muscular rheumatism, and
lacks the sanction of usage. Myositis is a term used to describe (1) an
acute inflammation of muscle, often traumatic, and commonly attended by
suppuration, and (2) a chronic indurating inflammatory process, not
infrequently due to syphilis. Neither of these conditions resembles the
affection under consideration in its clinical aspects, nor is allied to
it pathologically.
As manifested in particular muscles or groups of muscles myalgia has
been described under the terms cephalodynia, torticollis (myalgia
cervicalis), pleurodynia (m. pectoralis seu intercostalis), lumbago (m.
lumbalis), dorsodynia, omodynia, scapulodynia (m. dorsalis), etc.
This affection must, in the present state of our knowledge, be
classified with the diseases of nutrition in the more narrow sense. It
is not a diathetic disease.
HISTORICAL CONSIDERATIONS.--To Inman[1] of Liverpool is due the credit
of having first pointed out the frequency of this malady and the ease
with which it may be mistaken for other and much more serious
diseases--an error in diagnosis which has been followed by serious
results, especially in the case of nervous and self-centred females and
other hypochondriacal persons. It cannot, however, be denied that this
author, carried away by his enthusiasm, exaggerated the importance of
this local {530} affection at the expense of undervaluing the frequency
and significance of other painful disorders which have their origin in
the nervous system. To Inman we also owe the term myalgia, which has
the positive merit of embodying the idea of pain as the chief symptom
of the disorder and the muscles as its seat, and the not inferior
negative merit of implying no erroneous theory as to its nature and
cause.
[Footnote 1: Thomas Inman, M.D., _Certain Painful Muscular Affections_,
1856; _Spinal Irritation Explained_, 1858; _On Myalgia, its Nature,
Causes, and Treatment_, 1860.]
This affection is described in few even among the recent textbooks; in
others it receives merely incidental mention; in the majority of them
it is passed over in silence. Yet it is obvious that the descriptions
of muscular rheumatism, which are rarely omitted, are based upon and
refer to cases of various kinds which for the most part are not
rheumatic at all, and very frequently are examples of true myalgia.
ETIOLOGY.--(_A_) Predisposing Influences.--Myalgia is "essentially pain
produced in a muscle which is obliged to work when its structure is
imperfectly nourished or impaired by disease." Hence all influences
which unfavorably affect the nutrition of the muscles, all diseases
which directly affect the integrity of their structure, predispose them
to this affection. The defect in nutrition may be only relative to the
amount of work the muscle is called upon to do, or there may be
absolute malnutrition, implicating the whole body. The muscle may be
impaired by a local disease which affects it alone, or it may share in
morbid processes which also involve other and distant structures.