Chapter II: The Peculiarities of Certain Accidental Acute and Chronic Diseases (6)

TREATMENT.--The successful treatment of abortion requires knowledge, judgment, and resolution on the part of the practitioner, and in importance it is equivalent at least to the management of labor at term. Two lives may even be at stake, though the opportunity of saving the embryo is, as a rule, afforded only during the period of prophylactic and preventive treatment, as vitality is ordinarily destroyed in the embryo when abortion, as the result of natural causes, is once inaugurated: the life of the mother is not in question, as it is in labor at term, but her health is even more endangered. Attention is now forcibly called to the subject by earnest discussions between the adherents of the expectant and those of the progressive method of treatment, but mainly to the treatment of actual abortion; prevention and after-treatment have been neglected. Important as is the method of treatment employed in case of retention of membranes or ovum, the necessity for such interference, especially the frequency of abortion, would be greatly diminished if the family physician were thoroughly imbued with the importance of the subject and could impress the same upon his patients. If the dangers arising from such premature interruption of gestation were appreciated by the laity and medical attention summoned in the early stages, the management of abortion would become more simple and more successful, and the cases of retention which cause such suffering and injury to women would be far less frequent.

Before entering upon the treatment proper it may be well to review briefly the necessary adjuncts, as proper preparation will aid materially the course to be adopted.

Preparations Necessary with Regard to the Patient.--Many of the preparations necessary in the lying-in chamber are desirable in cases of abortion as well. Attention should be paid to the bowels, as a costive condition will interfere to some extent with the manipulations as well as a rapid and favorable course of expulsion and involution; at best, it is liable to make the patient uncomfortable. The bladder should be evacuated, especially before active measures are resorted to, and the patient should be so clad in night-gown and sacque, with long hose and drawers, that she may be moved and manipulated without exposure.

The bed should be prepared with rubber cloth and quilts, and sufficient quilts, cloths, and towels should be on hand; a bed-pan is desirable, and also a fountain or bulb syringe; the bed should be so placed that the physician may be at the right hand of the patient, and convenient to the light when she is placed in Sims's position of the dorsal decubitus for operative interference.

{510} Antisepsis.--Cleanliness and antisepsis should be observed in the management of abortion as strictly as in that of labor or in surgical operations, as sepsis, either in the form of acute infection or an insidious undermining of the constitution, is among the more frequent of the dangerous consequences which follow in the wake of abortion. Circumstances permitting, it is desirable that carbolated vaseline or vaseline with iodoform, carbolated or some similarly prepared soap, be on hand, and also permanganate of potassium, carbolic or boracic acid, and iodoform. I am in the habit of prescribing carbolic acid for the convenience of use: carbolic acid 2 ounces, alcohol 1 ounce, with 7 of glycerin, which is as concentrated as may be well used (1 to 5, or 20 per cent.), and a proportion readily diluted to 2½ or 5 per cent.

Before and after examinations the hand should be washed in carbolated water or some such disinfectant--permanganate of potassium, corrosive sublimate, or boracic acid--as it appears desirable to use. If carbolic acid is used, the parts should be cleansed with a 2 or 3 per cent. solution. After interference or repeated examinations the vaginal douche should be used, certainly after completion before leaving the patient. If instrumental interference be necessary, and the ovum or membranes forcibly removed, the cavity of the uterus should be washed with hot water, from 115° to 125° F., containing 5 per cent. of carbolic acid, the hot water serving styptic purposes. This may suffice, but it is frequently desirable to mop the cavity with the above-named solution or even the pure liquid after more active interference, especially if some disintegration has taken place and is indicated by odor.

After the use of tampons the vagina should be washed with a 2 or 3 per cent. solution, or 1:2000, of corrosive sublimate; and it is even well that the cotton, before being introduced, should be anointed with either carbolized vaseline or carbolized oil (carbolic acid 2 drachms, olive oil 3 ounces). Iodoform serves an excellent purpose for disinfection of tampons, especially such as are packed into or against the cervix, and as an application to the cavity after the removal of the putrid contents following the hot douche. Borated cotton, or even ordinary cotton or prepared tow, should be on hand to use during the after-treatment in place of cloths for the purpose of receiving the discharge: it is warm, soft, forms a good filter, and can be thrown away or burnt when soiled, whilst the cloths ordinarily used, and often very offensive, are kept for the wash.

Medication.--The most important of all the remedies is opium; in preventive treatment it may be called a specific. It is far preferable to the hypodermic injection of morphine, serving to relax and quiet the uterine muscle and to lessen hemorrhage; for the latter purpose it is often combined with acetate of lead--from ¼ to 1 grain of opium mixed with ½ to 1 grain of acetate of lead, to be given at a dose and repeated when necessary. Ipecacuanha combined with opium acts well in relaxing the tension.

Viburnum prunifolium has long been used as a uterine sedative in these cases in those States where the plant is endogenous, and its use has been widely disseminated since it has found so able an advocate in Jenks. The preparations are not all equally effective, but in the early stages the fluid extract given in teaspoonful doses, according to the amount of hemorrhage and pain either hourly or every two or three hours, has a most {511} decided effect in allaying threatened abortion, in checking hemorrhage, and in quieting pains. It seems to be a uterine sedative. Several ounces may be taken, and successful cases are reported where the pending expulsion was averted and gestation continued to a successful termination after four ounces had been used. Digitalis combined with acetate of lead also deserves recommendation as an effective remedy in the early stages. Quinine may be given to stimulate the system and further uterine contraction, and is invaluable in an asthenic condition or if disintegrating shreds be present.

Nervines, valerian, asafoetida, valerianate of ammonia, bromide of potassium, are of great service throughout the entire course of abortion, as the patient is usually in a nervous almost febrile state. Alone they may serve to allay the irritating symptoms in the early stages, and answer well in preventing the disagreeable effects of opium. Asafoetida may be given by injection or in pills, from ½ to 2 grains at a dose.

Clysmata tend to irritate, and should not be used as long as we may hope to prevent threatened abortion. Such remedies as are indicated in the treatment of this condition, especially opium and nervines, must nevertheless at times be given by injection, as the stomach may refuse to receive and retain them in the irritated condition which accompanies this state. The clysms should always be warmed, of body temperature: two tablespoonfuls of milk of asafoetida or gum arabic form an excellent vehicle, though water or milk thickened with flour or starch, which is always on hand, will do quite well.

Should it be necessary to move the bowels, castor oil is one of the best remedies, whilst cathartics, especially aloes and similar drugs, must be avoided as long as there is hope of preserving the ovum: they certainly further expulsion. Ergot should not be used until after the uterine cavity is emptied, and is decidedly contraindicated whilst the ovum or any of its parts remain adherent in utero. The dangers arising from the use of ergot in the early stages, whilst the ovum is still intact, are rupture of the membranes and forcible contraction, which always prolongs expulsion of the ovum or its membranes; the circular fibres, which predominate, are stimulated most forcibly to action, more particularly so under the conditions which usually exist in abortion: the muscle of the uterine body is hindered in its contraction by the adhesions of ovum and decidua, especially if these membranes are infiltrated; and, moreover, in cases of abortion the tissues of the womb itself are often more or less diseased; the lower portion of the uterus and cervix alone is free to act, the circular fibres of the internal os contract most readily under the influence of ergot, whilst the activity of the fundus is interfered with; thus closing of the outlet and incarceration of the membranes are liable to result. This popular and dangerous drug must not be given until the tissues are expelled, or, if desirable by reason of excessive hemorrhage, its use may be resorted to under one condition: if the membranes are detached, not only free in the uterine cavity, but entering that of the cervix; they may be found massed together firmly, by compression of the uterine walls, into a conical or pyriform mass; and when this has to a great extent passed the internal os ergot may be given. This drug, so dangerous in obstetric practice, is still used with altogether too much freedom in this country, and it would be far better to do without it than to {512} continue the prevalent abuse. I have insisted that this drug must not be given in labors or abortion until the contents of the uterine cavity have been removed. Although but one of our prominent obstetricians approved of the position I took in 1883, and I was then freely attacked, I now urge the point more earnestly, and the doctrine is more commonly accepted: in Germany such men as Martin, Spiegelberg, and others have succeeded in doing away with this dangerous remedy altogether in the institutions under their care, restricting its use to the non-gravid uterus.

As a styptic, hot water, carbolized, serves the best purpose: in the early stages as vaginal douche, in the later as an intra-uterine injection at 120°, it is an invaluable remedy, preferable to other styptics, as it cleanses and removes the coagula. When the cavity has been emptied, especially after the forcible removal of the membranes, it is well to apply carbolic acid to the surface; and it is better for this purpose than tincture of iodine or perchloride of iron, either of which is only to be used in case that hemorrhage does not yield to the before-mentioned remedies.

Anæsthetics.--Though bromide of potash, morphine, or opium may suffice for the relief of the pain in ordinary cases, the use of an anæsthetic is not only desirable, but necessary, if more active measures are resorted to. For purposes of rapid dilatation and the removal of an adherent ovum or membranes anæsthesia is almost indispensable; without this the suffering of the already nervous, debilitated patient is excessive; the uterine and abdominal muscles are tense, and operations thus greatly impeded. An anæsthetic should be given in a rapid dilatation on account of the pain, as well as the greater facility of operating; and it is most necessary in an attempt at expression, as, if made without an anæsthetic, the abdominal muscles are so tense that the uterus cannot be well manipulated from without. I myself prefer chloroform.

Instruments.--A speculum, a dull curette, a sharp scoop, a vulsellum forceps, and uterine dressing-forceps are essentially necessary. Any speculum may be used. The best is Sims's if the semi-prone position be used, or Simon's in the dorsal decubitus. The Schroeder's or my forceps is necessary to steady and bring down the uterus for the introduction of tent or finger and the use of the scoop or the application of styptics. This is in the main the American bullet-forceps, an instrument far superior to the sharp vulsellum which is so popular. The curette I would most recommend is my own modification of Récamier's instrument of pliable metal, one blade resembling that of Récamier's, but curved somewhat more like the uterine sound--sharp upon one side, dull upon the other--to be used for the purpose of severing the ovum or membranes in the line of their adhesion: this is so narrow that it can be introduced into the os even after contraction if this be not almost tetanic, as after the giving of ergot. The other blade is larger, broad and flat, more spoon-like, to be used in case of moderate dilatation of the os, both, however, being for the purpose of severing the adhesions and leaving the ovum intact. The broad blade serves as a lever to remove the ovum or membranes when detached. But if the membranes be ruptured, it is of service in separating these from the uterine wall, leaving them as complete as possible, which will always facilitate removal or expulsion. The irritation caused by the severing of the adhesions with this instrument frequently suffices to inaugurate uterine contraction; and ovum or {513} membranes, being once liberated, are then compressed by the uterine muscle into one mass, thus affording a resistance which the uterus is enabled to grasp and expel. This method I believe to be far more rational than the removal of the membranes with the sharp instrument: it furthers the process of nature more strictly, separating rather than cutting away the tissues, as does the latter. The sharp scoop is an instrument which is only to be used for firm adhesions in secondary cases, where the progress of abortion has temporarily ceased and the membranes have become more firmly attached, especially where disintegration of such adherent parts has taken place to some extent; it is necessary and cannot be dispensed with where remnants have been retained for months and have become firmly attached, simulating polypoid growths. I object to the use of the sharp scoop in recent cases, because it is preferable to follow the line of demarcation indicated by nature, and separate the membranes or the ovum, if still entire, in this strait; whilst the sharp scoop removes them piecemeal, cutting deep into the mucosa at one place, and possibly leaving pieces of embryonic tissue in another.

Dressing-Forceps.--These are serviceable for the introduction and 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.

A closed internal os may usually be looked upon as evidence that the {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.