of Rhodes. Spurious works Andronicus.

The American journal of obstetrics and diseases of women and children online

. (page 43 of 109)
Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 43 of 109)
Font size
QR-code for this ebook


and does her beneficent work without recognition; only in the
more severe cases or those in which she is handicapped by the
existence of other maladies or unusual weaknesses does she
require our aid. In giving our aid, this natural power of resist-
ance to disease, the vis medicairix naturcB of the older writers,
should be kept constantly in view.

Most important is nutrition, the persistent administration
of food which requires little digestive effort on the part of the
stomach, such as the freshly expressed juice of beef, the animal
broths, peptonized milk, etc. Among the foods, also, must be
reckoned alcohol, which experience has taught the profession
to regard as one of the most satisfactory agents that can be
employed in sepsis. Besides acting as a food, it is thought
to promote the migration of phagocytes, and to stimulate all
the defensive forces of the system to greater activity. Pos-
sibly it may act also as a bactericide. Whisky, which is the
cheapest and most easily obtained form of alcohol, is gener-
ally employed, but it seems to me that absolute alcohol is

3



Digitized by VjOOQIC



418 pinkham: the treatment of septic abortion.

better, on account of its tastelessness, the ease with which it
can be disguised, and the greater precision possible in its dosage.
While alcohol is of great value, there is a limit to the amount
which can be taken to advantage. Overdoses of this, as with
other remedies, may do harm. In most cases a drachm of abso-
lute alcohol, equivalent to two drachms of whisky, once in two
to four hours, would be as much as the patient should take.
Among other supporting remedies strychnine or, better still,
the tincture of nux vomica in small and frequently repeated
doses (five minims every two hours or so), and quinine are to be
mentioned with approval.

The principles of treatment which I have thus outlined may be
summed up as follows:

1. To remove the foci of infection, so far as they can be
reached; and

2. To establish adequate drainage. In this connection, the
use of the sharp curette and the avoidance of packing are points
to be emphasized.

3. To neutralize the eflFects of the toxins produced by the
infecting organisms, and to destroy those organisms that have
escaped into the blood or are planted in the tissues beyond the
reach of surgical measures of treatment: Salt solution, anti-
toxin, bacterin, colloidal silver, etc.

4. To sustain the vital forces of the system and aid nature
in her work of defense by proper nutrition and supporting
remedies.

ethical considerations.

In view of the fact that nearly all cases of septic abortion
are also cases of criminal abortion, a brief discussion of some
of the ethical principles involved in the subject may not be con-
sidered out of place at this time.

It is under the stress of such a condition as sepsis following
abortion that the physician can impress upon the mind of his
patient the great danger attending a forcible interruption of
pregnancy and the moral turpitude of the act. If the woman
lives after such an ordeal, the attempt will probably be her last.
But the great majority of women are never on the verge of dis-
solution from such a cause, and all those that come under our
influence we should teach by all the means in our power what it
means to violate the sacred laws of our being in so flagrant a
manner. There are many women who do not know the great



Digitized by VjOOQIC



pinkham: the treatment of septic abortion. 419

seriousness of this ojffense. They believe that up to a certain
stage in its development the fetus has no standing as a human
being, and that they have a perfect right to destroy it if they
choose. They see the apathy toward induced abortion on the
part of their neighbors, physicans, and the world at large, and
are led to think lightly of the oflfense. If told that causing a
miscarriage intentionally, even by such means as the use of
herb teas, cathartics, or violent exertion with that purpose in
view, is a violation of the law, to be punished on conviction by
confinement in the state prison, they would pay little heed to the
declaration, for they know that the law is seldom enforced —
never, it may be said, when a woman herself commits the crime.
Many women are ignorant of the morbidity almost sure to fol-
low an induced abortion, and they do not realize the tremen-
dous danger of mortal infection, nor the liability to sterility
or habit abortion, if they survive. All these facts and considera-
tions should be constantly held up before the woman by her
physician, for, possessing such knowledge, a certain percentage
of women would unquestionably hesitate, especially in the
face of possible death, prolonged invalidism, sterility, or habit
abortion.

These remarks apply chiefly to married women. With the
unmarried woman, the situation is different. The sense of
personal disgrace which she feels, and the worry which comes
from fear the that her wrong-doing may become known, tell
strongly against any attempt to convince her that the better way
is. to bear her disgrace and give birth to the child. If public
opinion were not so unreasonably harsh and so unjust toward
those unfortunate women who become mothers outside of the
pale of matrimony, the cases of criminal abortion in the commu-
nity would be materially lessened. As a class, these unmarried
mothers are not so bad as they seem. Morally, they are far
superior to those women of society who, while liolding their
proud heads high, and associating with the elite, either murder
their children before they are born or neglect them shamefully
afterward.

There are two other points in the ethical consideration of this
subject which seem to me to be important : The first is the neces-
sity or advisability of publicity in the management in cases of
criminal abortion. For his own protection, the physican should
refuse to keep anything secret. If he cannot take the case to a
public hospital, where everything must become known, he should



Digitized by VjOOQIC



420 pinkham: the treatment of septic abortion.

associate with himself some other reputable physician, or refuse
to have anything to do with the case. It might be advisable
even to report the facts of the case to the prosecuting authorities
of the town or city. This would give him complete protection.
Good legal authority has declared that if the physician does not
do this, but maintains secrecy in the treatment, he becomes
particeps criminis, and subjects himself to a possible prosecution.
In many cases there are strong motives for maintaining secrecy,
either for the purpose of shielding the woman from disgrace or
for protecting a fellow-practitioner, whether he be the family
physician or some abortionist. It is to be assumed that every
educated and skillful physician is proof against any temptation
to commit the crime we are considering.

The famous dress suit case which happened in Boston a few
years ago illustrates the risks which a physician runs who attempts
to treat one of these criminal abortion cases secretly. A young
doctor was called at night by a colleague and friend to operate
on a girl who was suffering from septic infection following an
abortion, which had been, as was afterward proved, induced
in one of the notorious abortionist dens of the city. After
demurring for a while, he consented to operate and to keep the
whole affair a secret. A few days later, the dismembered body
of this young girl was found in the waters of Boston Harbor,
packed in two dress suit cases. The doctor and his associate
were arrested with others, and tried as accomplices in the crime.
While the principals were convicted, he and his confr^e were
acquitted, but the stigma was so great that both these doctors
were dropped from the Massachusetts Medical Society. One of
them soon died, while the other left the city. Assuming that
these young doctors were innocent of wrong intent, the course
which they pursued was extremely injudicious, to say the least.

The second point that I would make, is the importance of
extreme care in making the diagnosis of criminal abortion,
especially if the reputation of any other person is involved.
Although the symptoms and the ascertained facts of the case
may point to criminal abortion, it might be possible to make
a serious mistake, as was done in 1892 in the well-known case
of Dr. Reid, who suffered untold mortification following the
hasty assumption on the part of an interne at Bellevue Hospital.
Dr. Reid was exonerated and commended, but every man
might not be so successful in refuting a careless statement.

41 East Forty-first Street.



Digitized by VjOOQIC



pool: inevitable and incx)mplete abortion. 421



THE TREATMENT OF INEVITABLE AND
INCOMPLETE ABORTION.*

BY
WILLIAM P. POOL, A. M., M. D.,

Brooklyn. N. Y.

It is of importance in undertaking the treatment of abortion
to learn first whether it be threatened and possibly preventable,
or inevitable, or incomplete. In the early months the symptoms
of these conditions are sometimes so nearly identical that ac-
curate differential diagnosis is difficult.

The one constant sign is hemorrhage. Pain, cervical dilatation,
appearance of the separated ovum at the outlet, or extrusion
of part of the uterine contents are signs not always in evidence.
Hemorrhage, even though profuse, cannot be depended upon
as pathognomonic of inevitable abortion, for bleeding may
occur from time to time throughout pregnancy without inter-
fering with it. However, its long continuance must be regarded
as significant and may demand emptying the uterus even when
development of the ovum has not ceased. Pain is a variable
symptom and may be due to other causes. A patulous os usually
means the loss of the ovum, but such has been known to con-
tract and pregnancy has gone on without event. The expulsion
of part of the uterine contents is practically a certain sign of
abortion, yet Charpentier and Playfair have reported cases in
which particles of decidua were expelled without interrupting
pregnancy. When the ovum can be felt through a partially
dilated cervix, evidence of abortion is almost conclusive. But
if, in the presence of one or more of these signs, there still be a
doubt of the possibility of saving the pregnancy, valuable in-
formation may be had from bimanual examination of the uterus.
This, if its contents be still intact and in sitUy gives to the
touch a sense of resiliency which is peculiar to the pregnant state,
and which is better appreciated by experience than description.
If the ovum be dislodged or broken up the uterus is found to be
doughy, or intermittently contracting, or in tetanic spasm.

When it is certain that abortion is progressive and inevitable
there are two indications to be met: i. Emptying the uterus
by the means of least danger and traumatism to the patient.
2. The restoration of the pelvic organs to their normal condition.

♦ Read before the New York Obstetrical Society, December 14, 1908.



Digitized by VjOOQ IC



422 pool: inevitable and incomplete abortion.

The dangers to be avoided are chiefly hemorrhage, infection,
and subinvolution and subsequent displacement of the uterus.

Upon these facts all are agreed, but there is a diflFerence of
opinioil as to the methods best calculated to attain the desired
results. Whether it is better to follow an expectant plan in
the hope that spontaneous evacuation will occur, or to institute
radical treatment at once and remove the uterine contents by
operation, is still a disputed question. Peterson refers to what
he calls the normal mechanism of abortion, consisting in the
complete expulsion of the ovum after a short labor, and argues
that as it is the generally accepted rule in labor at term that
no operation to hasten delivery is permissible except in the
presence of certain well-defined indications, so in normal spon-
taneous abortion there is no reason why the same rule should not
apply. That all obstetric operations, whether at term or before,
increase the morbidity and mortality of the puerperium. Other
writers, Lusk, Winckle, and Boldt concur in this opinion, and
would delay any surgical interference until some indication, such
as hemorrhage or infection compels it, believing* that as a general
principle these cases do better when left to nature; that those
who have not been subjected to a forcible removal of the uterine
contents are in the end in just as good health as those who have
undergone operation; that retention of the decidua has little
or no influence upon convalescence; that endometritis, chronic
congestion, and displacement are not more frequent sequelae;
and that subsequent functions, menstruation and child-bearing
are not more likely to be interfered with. Their position is
further supported by pointing to the possible dangers of intra-
uterine instrumentation or manipulation.

On the other hand, it is held that when abortion cannot be
prevented the patient is in constant danger from hemorrhage
and sepsis so long as the products of conception remain in the
uterus, and that on this account alone immediate intervention
should be practiced. Further, it is believed that involution is
more prompt and complete if a thorough emptying of the uterus
of the ovum and all the decidua be accomplished at once; that
menstrual disturbances and chronic lesions of the uterus and ad-
nexa are less liable; that following sterility is not so frequent,
and the risk of abortion in a subsequent pregnancy not so great.
After contrasting the results of active and expectant treatment
in a series of 242 cases, Edgar has stated the belief that early
curettage is less dangerous than abortion and its sequelae, and



Digitized by VjOOQIC



pool: inevitable and incomplete abortion. 423

that hemorrhage and liability to infection are much less in the
former than in the latter. Garrigues has said : ** If left to itself,
or improperly treated, abortion is a dangerous accident which
often ends fatally, usually from the occurrence of hemorrhage
or septicemia. More women die from abortion than from
childbirth, even if the bungling operations of professional abor-
tionists be not considered." Diihrsen and Fehling also have
advocated immediate intervention.

Can abortion ever be regarded as a normal act? Can the
rules which obtain in the evacuation of the uterus at term be
equally applied to it in the early months? An examination of
the conditions in these two periods must be convincing of the
imperfect provision made by nature for casting oflf the uterine
contents in early pregnancy, even if repeated experiences have
not demonstrated the fact. The softer consistence and greater •
fragility of the ovum, the greater adhesion of the decidua, the
comparative hardness of the cervix, and the deficiency in con-
tractile power of the uterus, all predispose to imperfect abortion
and the retention of a part at least of the ovum or its envelopes
for an indefinite period. While it is true that nature is com-
petent in many instances of spontaneous abortion to complete
the act without intervention and without serious danger; yet
in no case can such a result be confidently expected..

In the first month of pregnancy abortion often occurs with-
being brought to medical attention, and may even escape the
knowledge of the patient. A missed period which is followed
later by a more profuse flow with little or no pain is frequently
regarded as a delayed menstruation and ascribed to some other
cause. Many such cases recover promptly and without com-
plication, as, owing to the small size of the ovum and the slight
changes in the uterus, hemorrhage is not great and involution
takes place readily. The only treatment usually required in
these very early cases is rest for a few days, and no more radical
measures need be employed unless bleeding be persistent. This
exceptionally may continue as a result of chronic hyperemia
and fungous overgrowth of the endometrium, when thorough
dilatation and curettage is indicated.

From this time forward the symptoms are more pronounced
and the dangers greater. Although hemorrhage is rarely severe
enough in the first three months to be a menace to life, still it is
not infrequently so profuse at the outset as to cause faintness
and loss of consciousness, and until the uterus is emptied, it is a



Digitized by VjOOQIC



424 pool: inevitable and incomplete abortion.

constant danger. So long as the detached or loosened ovum
remains in the uterus infection constantly threatens. There is
no question but that fever, rise in pulse rate, pelvic pain and
tenderness, which symptoms mean that infection has begim,
are indications demanding interference. Why is it not reason-
able to anticipate these conditions, and, by resorting to early
intervention, remove their cause, rather than to accept the risks
of operation at a later time when the patient may already be
depleted by hemorrhage or the field invaded by infection?
There are certain contraindications to immediate active treat-
ment. The spontaneous expulsion of the ovum entire, together
with the decidua, followed by cessation of hemorrhage and
prompt retraction of the uterus, show that abortion is already
complete and no local treatment is necessary. A careful exami-
nation of all clots and expelled particles should be made when
possible, to determine if this be the case. Also, when abortion
is inevitable but the cervix still remains so hard and undilated
that it will not permit the easy passage of a well-developed
fetus, it is best to wait, in the absence of signs of sepsis or alarm-
ing hemorrhage, till softening and relaxation of the cervix can
be brought about. This is materially aided, and at the same
time hemorrhage is temporarily controlled by a firm cervical and
vaginal tampon. A narrow strip of moist sterile gauze is in-
troduced into the cervix and the canal packed solidly. A wider
strip of the same material is then carried into the vagina and
placed round and round the cervix until the ca\'ity is filled.
The pressure and irritation of these tampons stimulate uterine
contractions, help to soften and dilate the cervix, and make
subsequent removal of the uterine contents quicker and easier.
The gauze should be removed in from twelve to twenty-four
hours, during which time the patient should be under intelligent
observation lest bleeding continue, in which case further delay
is not justifiable. If after twenty-four hours the cervix be still
insufficiently dilated it is usually not wise to wait longer, as
spontaneous progress is likely to be very slow or lacking.

Absolute rest and other measures which may have been em-
ployed in the hope of preventing abortion are no longer neces-
sary. Drugs which have been given to lessen sensibility and
allay contractions are now harmful and serve only to delay. In
their place, if medication be used at all, should be given some-
thing to stimulate muscular action, e.g., ergot and strychnia.
The lower bowel should be thoroughly cleared, and rectal irri-



Digitized by VjOOQIC



POOL: INEVITABLE AND INCOMPLETE ABORTION. 425

gation with normal salt solution at a temperature of 120° has
proved a good uterine stimulant.

When the cervix has well dilated and the ovum has been
partly expelled or presents to the examining finger in the lower
part of the uterus, with or without serious hemorrhage or signs
of sepsis, the best procedure is curettage. Removal of the
ovum with the finger or with a forceps may be accomplished,
but it is not a sure method of emptying the uterus of all its con-
tents. The forceps will almost certainly leave something be-
hind, and the gloved finger (the only sort that should be intro-
duced into the uterus), while it is an excellent palpator, is a poor
curette. Scraping the interior of the uterus with the bare finger
nail is an unclean and unsurgical procedure and cannot be too
strongly condemned. As the decidua vera separates from above
downward, the curette is the only instrument that can properly
insure its complete removal, but in conjunction with the curette
the finger may be used to explore the uterine cavity for remain-
ing particles of placenta or decidua. This examination is facili-
tated by forcing the uterus downward by suprapubic pressure
so that the whole cavity may be reached.

It is best to make a thorough preparation, and to approach
this operation with all the care that should be used in any surgi-
cal case. An anesthetic is desirable, as with improper equip-
ment and a resisting patient, it is often impossible to be sure
that the work is done completely. A large-size sharp curette
is best in the majority of cases, though it is an instrument to
be used with much care, and is contraindicated in some condi-
tions. It should not be used when there is any suspicion of
infection, particularly if this be of the streptococcic variety, as
tearing away the endometrium and opening the way for lym-
phatic involvement in the deeper structures may do much more
harm that leaving behind a part of the adherent decidua. In
induced abortions, where septic organisms may have been
carried into the uterus by unskilled instrumentation, this possi-
bility should be especially borne in mind, and in such cases
a dull curette is the safer instrument. A gauze sponge on a
Keith forceps serves well to detach fragments in some cases
and is a safe instrument in the presence of active sepsis. Curet-
tage may be followed by a douche of hot sterile salt solution,
though this is not usually necessary. It helps to check hemor-
rhage if this be persistent, but is contraindicated if there be in-
fection. Antiseptics are of doubtful value in the uterine cavity.



Digitized by VjOOQIC



426 pool: inevitable and incomplete abortion.

and may be positively harmful. A uterine pack is not used
except to control hemorrhage, as it is more likely to interfere
with, than promote drainage. It does serve one purpose: that
of carrying with it, upon its removal, small particles which have
escaped the curette and the finger. However, these are usually
cast off in the lochia without trouble.

Abortion is said to be incomplete when any portion of the
ovum or decidua remains within the uterus. It may be incom-
plete from the start as when there is a sudden loss of amniotic
fluid with or without the fetus, or it may become incomplete
by the expulsion of a part of the uterine contents during contrac-
tions. The symptoms at the outset often do not differ materi-
ally from those of inevitable abortion, but there are certain
characteristics by which it may usually be recognized. Frag-
ments of the ovum may be discovered in the vagina during ex-
amination; hemorrhage is continuous; the uterus is boggy and
the cervix patulous; the discharge becomes putrid and offensive.
Long-continued bleeding after a supposed complete abortion
should always lead to the suspicion that the uterus is not entirely
empty.

When a part of the ovum is lost the uterus has not the same
power of casting off the remainder that it has of expelling the
ovum intact. Its contractions are less vigorous, it is depleted
by hemorrhage, and may be further weakened by septic inva-
sion. Exceptionally the uterus may retain a part of its contents
for a long period without ill effects. The writer has seen one
case in which a three months' placenta remained in the uterus
for four months after a supposed complete abortion. There was
no abnormal sign during this time but amenorrhea. More
frequently, however, an incomplete abortion that begins as a
clean case will develop septic symptoms unless treatment is
instituted promptly. Owing to the inability of nature to take
care of herself under such conditions, early active treatment is
demanded in all cases of incomplete abortion. Drugs or
tamponing the cervix and vagina are of no avail, and the only
means of anticipating and avoiding the dangers of this state and
its far-reaching sequelae are by the immediate removal of the re-
mains from the uterus. Imperfect dilatation should not now be
regarded as a contraindication to operating at once, as in the
presence of a macerated ovum, valuable time may be lost while
attempting to bring about natural softening and relaxation of
the cervix. Here, too, preparation should be made with complete



Digitized by VjOOQIC



pool: inevitable and incomplete abortion. 427

surgical care, and an anesthetic administered. If the cervix will
admit the finger, it is well to palpate the uterine cavity first, to
determine how much material it contains and upon what part of
the wall it is adherent. Such knowledge is a valuable guide in



Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 43 of 109)