Chapter II: The Peculiarities of Certain Accidental Acute and Chronic Diseases (5)

These attempts are usually made in the second or third month at the second or third missed period. There is, however, a class of experts among the most elegant who have attained such remarkable dexterity as invariably to introduce the instrument successfully into the uterine cavity; and these are in the habit of regularly practising this dangerous experiment when the first days of the expected period have passed without the coming of the flow.

The abortionist either injects fluid into the uterus or introduces a probe or catheter into the cavity. Customs vary in different countries; so Van de Warker states that in France puncture of the membranes is fashionable, whilst here a syringe or sound is used.

Among the most common--and perhaps most harmless--means is the hot foot- and hip-bath, the "sitz-bath," often with the addition of mustard: this, as well as the steaming of the parts by sitting over a chamber filled with hot chamomile tea, is the first step taken by the nervous wife when the menstrual flow has failed to appear sharp on time and she still lives in hopes that it is but a cold which has interfered with the regularity of its return. Even physicians, respectable men in good practice, who may not venture upon bolder measures and wish to keep their conscience clear, are known to advocate this course, though they well know what such a cold means.

Medication is perhaps more commonly attempted, but less successfully, notwithstanding the injuries caused to the system. To follow Van de Warker's thorough study, the remedies used are mainly of two classes--those which act directly, the emmenagogues, oxytoxics, and reflex {494} abortifacients. Notwithstanding the firm popular belief in their efficiency, they are less harmful to the ovum than to the system of the mother, and, as Van Warker says, there is more science and skill used than is generally supposed in the various pills and teas, which are less simple, but no less common, than the foot-baths and the gin-bottle. Ergot is almost sure to be called upon to perform its office. Its action is very uncertain, but if persistently used is readily recognized by its effect upon the vascular and nervous system--uterine or ovarian pains and depressed action of the heart where in spontaneous abortion an acceleration is to be expected; the temperature is lowered, and the sphygmograph shows a remarkably flattened apex with an almost senile pulse. Cotton-root is also commonly used, especially in the South, and is marked by its narcotic action.

Among those termed reflex abortifacients, acting more indirectly by their effect upon surrounding organs, we may notice cathartics, principal among them aloes, which, notwithstanding its purgative action, does not appear to deplete the circulation, but, on the contrary, results in pelvic congestion; but even its excessive use need not in any way affect gestation. I have seen a patient dying amid the resulting dysenteric symptoms, frequent, scanty, and bloody evacuations, accompanied by excessive tenesmus, inflammatory conditions, and abdominal pain, though the uterus did not react and the ovum remained intact. The odor of the drug is imparted, it is said, so intensely to the evacuations that it is unmistakably noticed.

Juniper and black hellebore, the latter especially endangering the life of the patient, are both toxic in their effects. The painful fluid evacuations, accompanied by bearing down, tenderness of the abdomen, pain and sickness at the stomach, dry throat, would characterize the former; the odor the latter, as well as the flushed appearance of the face, with heaviness and pain in the head and frequent micturition. But one of the first and most common remedies to which the desperate woman resorts when she finds a day of the menstrual period passing by without the appearance of the flow is tansy, which seems to act by reason of the uterine congestion which it causes. Though undoubtedly effective at times, it will, like all other drugs thus used, more often cause injury, and even the death of the mother, without disturbing gestation. "Disturbance of the nervous system, profuse salivation, immobility and dilatation of the pupils, and severe strangury," are noted as the symptoms of such poisoning. Hardly less popular is the still more dangerous cantharides.

The female pills and various mixtures more or less openly sold by druggists are, according to the researches of Van de Warker, composed of one or more of the above-mentioned ingredients, and the immense quantities disposed of show how truly abortion is called the crime of the period. Knowledge of the remedies used for these purposes will aid the physician in arriving at a correct diagnosis and enable him to save the child and guard his patient.

PATHOLOGY AND MORBID ANATOMY.--I have endeavored to describe with some accuracy the appearance of the healthy ovum, the sac, and surrounding structures during the various periods of early pregnancy, as it is the comparison with these which will enable the practitioner to distinguish between spontaneous and criminal abortion, enable him to determine the duration of pregnancy, guide him as to the cause, and thus serve to {495} facilitate treatment and perhaps to prevent recurrence. Knowing what has been expelled, whether it is ovum and decidua entire or only in part, the line of action is evident. In all abortions due to an immediate and active exciting cause, whether criminal or resulting from shock or accidental trauma, the ovum is healthy, normal in all its parts, size and development of the embryo corresponding to the period of pregnancy at which the accident occurred; whilst in spontaneous abortions due to accidental causes more or less marked changes exist: the development of the embryo especially is retarded; its life has been destroyed, and growth has ceased, whilst the morbid development of the membranes continues, so that the mass expelled presents more or less of a mole formation--comparatively solid, with thick walls formed by the foetal membranes infiltrated with blood, the cavity often compressed by the surrounding extravasation, the embryo comparatively small or disintegrated in whole or in part.

The ovum is usually separated in its upper portion by hemorrhage, which comes from that point at which the vessels are most fully developed, the future placental site, though still agglutinated. With the inauguration of uterine contractions separation takes place at its lower pole by dilatation of the os, and retraction of the uterine walls from the ovum proper surrounded by the reflexa; as the abortion progresses, the muscular fibres of the fundus force it down into the dilating cervix through the still partially adherent decidua, and the intact ovum is expelled, the inverted decidua following it as the membranes do the placenta in labor at term. Yet these conditions vary greatly with the existing morbid changes.

In traumatic or criminal abortion the perfectly-formed ovum, the delicate cystic body surrounded by its shaggy chorion, is first expelled, to be followed by the decidua, usually--when in a healthy state--first by its anterior and then by its posterior half; whilst if the abortion has been inaugurated by some slowly-acting cause the decidua is hardened, infiltrated with compressed and clotted blood, the small ovum forming merely a part of the solid mass; and thus a firm oval body, coated with blood upon its rough, irregular exterior, appears.

Up to the third month the ovum is, as a rule, expelled as a whole, often even in the fourth. Later, unless decided pathological changes have taken place, the membranes are mostly ruptured and the embryo separately expelled, as in labor at term. In later months this is always the case, and the progress of abortion is greatly impaired by the adherent tissues: the mass of the ovum, which serves so much to excite uterine contractions and promote expulsion, is destroyed by the collapse of the amniotic sac, and separation and expulsion of the membranes are hindered by reason of the smaller amount of resistance offered. Hemorrhage is most likely to occur in the villi of the chorion, between its tissues and the surrounding decidua; if occurring in the latter structure, it appears thick, hard, infiltrated with blood, and no longer presents that soft, succulent appearance, but is firm and brittle.

The ovum as expelled presents three typical forms: First, as above stated, in accidentally-occurring traumatic or criminal abortion we find a healthy ovum with its shaggy chorion, and the inverted decidua attached or soon following, usually in two sections; most common, however, and almost without exception in spontaneous non-criminal abortion, is the {496} mole formation, rarely the hydatiform mole, which has been described, and results only from the peculiar pathological condition of the chorion. The common form is the flesh mole, the mola carnosa, characteristic in appearance, resembling a polypoid growth, a reddish oval or rather pyriform mass with shreds of tissue (the decidua) adherent to its larger upper extremity, darker clots at the elongated lower pole. Upon section the walls show a brittle reddish structure, that of compressed and inspissated coagula, and in the centre a cavity containing fluid and detritus, if not the embryo, lined with a delicate membrane, amnion or amnion and chorion: the shape of the cavity is rather irregular by reason of the bulging protuberances formed by the contraction of the inspissated mass of blood extravasated between or within the tissues. These moles have very much the appearance of uterine polypi, and are often considered as such by physicians who pride themselves greatly upon curing their patients of tumors and the accompanying hemorrhage by a few doses of ergot. Though the macroscopic resemblance is such as to be quite deceptive, the mole upon section will always reveal a cavity, even if very small, containing fluid; and this cavity reveals the above-described characteristic slight bulging protuberances lined with a delicate membrane; whilst the microscopic examination shows the firm walls to consist of nothing but blood-corpuscles: the outer covering, often thoroughly infiltrated with blood, consists of the decidua serotina and reflexa, with more or less of the infiltrated shreds of the vera usually pendent from its upper extremity; when floated in water and cleansed, the outer or uterine surface of these shreds is ragged, rough, often appearing somewhat like the villi of the chorion, hence looked upon as placenta; this peculiar appearance is caused by the torn tissue in the line of demarcation in the lower or central meshy layer of the decidua vera, where it is separated from the lowest layer which remains adherent to the uterine wall. The inner surface toward the ovum will show a slightly wavy, cribriform appearance, the openings of the ducts appearing as fine depressions in the surface. (It must be remembered that this smooth inner surface is in the expelled specimen generally the outer one, as the decidua follows the ovum mostly as the membranes do the placenta at term--inverted.) If the disturbance causing the abortion has been of rapid progress, the cavity is large, the embryo approximating in development the period of expulsion; whilst if the changes have taken place slowly, the walls are thick, the cavity small, and the embryo may appear merely as a small mass pendent from the navel-string, or may have entirely disappeared, and can be traced only by the fine detritus in the amniotic fluid, the cord itself perhaps only in part remaining, and even this may have disappeared. The cavity will always be found toward the pendent pole of the decidua reflexa, as the extravasation takes place mainly in the serotina, giving it the appearance of a thick mass of clotted, compressed blood, and forcing the cavity toward the opposite extremity. These moles are usually more elongated and pyriform, one or two inches in diameter at their upper or larger extremity, three or four inches in length, with a greatly elongated and narrowed lower end, which has been so formed by being first wedged into the slowly-distending cervix.

Such is the appearance in those cases of slow progress in which death of the embryo has probably occurred at an early stage and hemorrhage {497} has been the exciting factor, whether due to disease of the mother or other causes that may have destroyed the vitality of the germ. When resulting from disease of the mucous membrane, especially endometritis or catarrhal affections, it is a more oval tough mass, the main part of which is formed by the thickened and indurated vera; and if this be opened the ovum, in a very early stage of development, will be found within.

The uterus itself presents very much the appearance of the organ after labor; the external os, however, closes more rapidly, less rarely showing the funnel-shaped appearance of the puerperium; the cervix, though somewhat enlarged, is normal in appearance; the cavity is lined by the lower layer of the decidua, soft shreds covered with coagula; but it is lacking in the placental site and the putrid thrombi visible in labor at term.

Involution is slow if we take into consideration the slight distension of the uterus as compared to the process after delivery at term. The organ is in a state of healthy development, not prepared for the following retrograde metamorphosis, unless the expulsion of the ovum has been due to local disease, when some retrograde changes may have been inaugurated; if it results from constitutional causes, the existing depression naturally interferes with restitution. If shreds of tissue, parts of ovum, or decidua remain, absorption or expulsion is retarded. As a morbid or atonic condition so often exists, at least in abortion consequent upon natural causes, subinvolution or inflammatory conditions of the organ itself or the surrounding tissues are hence a frequent sequence.

SYMPTOMATOLOGY.--It will be remembered that abortion is more likely to occur among multigravidæ on account of the greater frequency of disease, especially pelvic affections; that it is most likely to accompany the periodic congestion which recurs at the time of expected menstruation; that it is more frequent in early married life, on account of the greater liability to traumatic injury and the existing nervous disturbance, and toward the menopause in that state of nervous and physical disturbance and lessening uterine activity. The third or fourth month of gestation is the dangerous period, as it is one of change of nutrition for the ovum, of the highest development of the decidua, and intense activity and congestion of the chorion, the rapidly-sprouting vessels finding but little resistance in the embryonic structures of the villi which surround them. Chronic disease of the mother is more likely to interfere with gestation at a later period; and, when knowingly undertaken with criminal intent, the time of choice is either the first month, when the first indications of pregnancy become evident and the menstrual period does not appear at the usual time, or more commonly at the time for reappearance of the third menstrual flow, when the fact of conception has been established to a certainty, and the conscious mother, firm in the belief of the nonviability of the embryo before the fourth month, thinks it harmless to rid herself of the ovum, which she considers a mere growth without life or soul, while she would shrink from destroying what, at a later period, she calls a living being.

SYMPTOMS AND COURSE OF ABORTION.--General Remarks: Preliminary Symptoms.--1. Course of early abortion, first two months.

2. Abortion at the time most common, the third or fourth month: _a_, spontaneous; _b_, criminal and traumatic.

{498} 3. Later abortion--in the fifth and sixth months--and hydatiform mole.

The expulsion of the ovum during all periods of pregnancy is characterized by two inevitable symptoms--hemorrhage and pain. It is the time of appearance as well as the relative intensity of these symptoms by which the period of gestation at which the expulsion takes place is at once indicated. In early abortion the hemorrhage is excessive and precedes the pain, the pain being comparatively slight; in labor at term pain is the prominent symptom and precedes the comparatively slight hemorrhage, which does not appear until the pain has almost ceased, and labor is completed after the expulsion of the placenta. Expulsion of the ovum in intervening periods is marked by an approximation of symptoms, though the existing conditions which characterize individual cases greatly modify this typical course.

I have, for the sake of conveniently grouping the symptoms, accepted three periods which serve well to characterize the course which abortion is wont to take in the progressive months of pregnancy. Hemorrhage and pain are the never-failing symptoms--hemorrhage due to the separation of the membranes; pain in the earlier months is due to the dilatation of the rigid, unprepared cervix, which greatly preponderates over the pain which accompanies the expulsion of the comparatively small mass through the once-dilated passage. In the later months, the cervix being gradually prepared, the pain is almost altogether due to the increased effort which is necessary to expel the large mass of the ovum.

1. Early Abortion.--In the first and second months the ovum is small, the vascular development trifling; the decidua preponderates, being greatest in mass and in extent of its vessels; hence this is the most important part. The hemorrhage is considerable, due to the separation of the vascular and hypertrophied mucous membrane, the decidua. The ovum is very small and expelled with comparatively slight pain, the symptoms often resembling those of membranous dysmenorrhoea; no great dilatation of the os is even necessary.

2. In the third and fourth month, the period at which abortion both spontaneous and criminal is most common, the placental formation is inaugurated by the growth of the vascular tufts of the chorion; and it is now that the ovum in toto--or we may perhaps say the membranes, as they are by far the greater part of the ovum--assumes the most important rôle. The abortion is still inaugurated by hemorrhage due to the separation of the vessels, but the pain is greater, as the cervix must dilate more to admit the passage of this larger mass, and an expulsive effort as well is necessary to force the mass out. The greatest amount of pain is caused by the dilatation of the rigid, unyielding cervix, which fortunately remains in this undilatable state until after the period of viability of the foetus, and serves to a great extent as a check upon its more frequent expulsion.

3. Late Abortions.--Now the ovum and foetus are of pre-eminent importance; though the parts are still unprepared, hemorrhage continues to be the preliminary symptom, yet pain follows rapidly upon the inaugural flow, because the ovum is now so large that it cannot descend without dilatation: it must have advanced before abortion can progress to any extent, and the expulsive pains assume greater prominence on account of {499} the increased size of the ovum; the symptoms of labor at term are approximated, and, as the placental formation is developed in the sixth month, pains may at times precede, certainly rapidly follow upon, the preliminary hemorrhage. It is now the placenta which plays the most important part, as in labor at term it is the foetus which is all-determining, upon which all the efforts of expulsion are centred; the membranes, amnion and chorion, are secondary, and the decidua, which was so important a feature in the first months, has by this time entirely disappeared as a factor in the act. The remaining shreds are partially adherent to the ovum, and in part passed slowly off with the lochial flow. Thus we see how the symptoms, at extreme periods so varying, approximate and interlace, and the various organs gradually yield in importance to newly-developing structures.

In the first period, then, the decidua is all-important, whilst the small and yielding ovum causes but little disturbance, not to mention the embryo. In the second period the membranes of the ovum are more important, and together form what is most erroneously termed the placenta in abortion. Then, as the placenta develops, this with the membranes predominates; finally, in labor at term the decidua, first all-important, has vanished as a factor of consequence, and the embryo, in the first stage a minimum, assumes such dimensions as to concentrate upon itself every effort of the obstetrician.

Pain, especially in the earlier months, is liable to be more excessive in primigravidæ, as the external os is closed, the cervix rigid, the time necessary for the expulsion of the ovum greater. In multigravidæ, with ordinarily more yielding and relaxed cervical tissues, the effort of the uterine muscle is concentrated upon the expulsion of the ovum from the cavity proper; and when it once passes the internal os a path is opened, and little or no force but that of gravity is often necessary to complete expulsion, whilst the cervical canal and external os offer formidable opposition in primigravidæ to the forcing out of the ovum, even though it has passed the os internum. A wide range of varying conditions naturally exists, due to the very different states of the cervical tissues: they may be relaxed in primigravidæ or firm and unyielding in multigravidæ, though the opposite is true in typical cases.

PRELIMINARY SYMPTOMS.--The symptoms which accompany death of the embryo 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.

2. Can abortion be prevented? The presence of an ovum being determined, 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.