ABORTION. BY E. S. McKEE, M.D., Cincinnati, O. [Ueprinted from the American Journal of Obstetrics and Diseases of Women and Children, Vol. XXIV., No. 11, 1891.] NEW YORK : WILLIAM WOOD & COMPANY, PUBLISHERS, 56 & 58 Lafayette Place. 1891. ABOETION. BY If E. S. McKEE, M.D., Cincinnati, O, [Reprinted from the|AMERiCAN Journal op Obstetrics and Diseases op Women and Children, Yol. XXIV., No. 11, 1891.] NEW YORK : WILLIAM. kWOOD & COMPANY, PUBLISHERS, 56 & 58 Lafayette Place. 1891. ABORTION. It is not the object of this paper to cover tlie entire field included under the heading, but to merely touch upon some special points of the subject. The discussion is here limited, so far as possible, to the expulsion of the products of concep- tion during the first trimestrium, omitting the consideration of miscarriage and premature labor. The statistics of abortion, if reliable, give much informa- tion. The following figures probably come near tlie truth: 18.6 per cent of the whole number are habitual; uterine dis- eases account for 50 per cent: reflex causes, 21.528 per cent; syphilis affecting the fetus, retroflexion, salpingitis, and rheu- matism, each 7.143 per cent. Treatment is followed by cure in 78.477 per cent, the patients subsequently bearing healthy children ; while sterility results in 21.528 per cent, of which 14.286 per cent have incurable uterine affections or are past child-bearing, and 7.242 per cent remain healthy but sterile. Ninety per cent of child-bearing women abort once or oft- ener, and about one pregnancy in ten terminates abortively. During the years from 1867 to 1875, inclusive, New York City reported one hundred and ninety-seven deaths resulting from abortion—a number probably far short of the truth. During seven years the Rotunda Hospital, Dublin, only had one death from abortion. The causes producing abortions are extremely variable ; sometimes the least thing is operative, and again an injury of the greatest magnitude may be insufficient. The discordant professional opinions on the subject suggest the necessity of renewed researches. Conditions of maternal blood often play 4 McKEE : ABORTION. an important part in the causation of abortion. Powerful emotions, as loss of friends, fires, explosions, and accidents of various kinds, are thought to alter the blood and thus bring about this result. The condition of the blood which accom- phnies infectious disease is a frequent source. When quinine is given to pregnant women it should be combined with a small quantity of morphia, which will overcome the danger. It is doubtful if quinine will originate uterine contractions, but it will increase them if once created. The constant inha- lation of the odor of the cottonseed and plant, especially after being nipped by the frost, has been thought by some writers to cause abortion in women who are picking cotton. Others think the stooping position and the friction of the apronful of cotton on the distended abdomen the real cause. Chronic lead poisoning and cardiac insufficiency have been recently described as resulting in abortion, and the latter is cited by Thomas as a sufficient reason for its artificial production. The treatment is to relieve the heart by the recumbent pos- ture. Cigar making and occupations involving constant man- ipulation of tobacco apparently lead to abortion. “ Habitual ” abortion is an unscientific term, only applied to cases of repeated abortion for which we have no better name ; where, having excluded maternal, fetal, and uterine causes, we are at a loss for a befitting designation. We can sometimes only explain them on the theory of a hyperesthetic condition of the uterine system of nerves, though a careful study will usually reveal the predisposing factor. Criminal abortion is termed by our European relatives the American sin, which they think so common among our peo- ple as to deserve this appellation. The Americans speak with horror of the European percentage of illegitimate births. They reply that in this country we hide our sins by the de- struction of unborn babes. Physicians meet in practice wo- men who would scorn to speak evil against a neighbor, who are tender and kind, leaders in social and even religious life, who are above suspicion as to chastity, yet who do not hesi- tate to murder their own children, provided only they be small enough. They do this not only once but repeatedly ; and not only do they commit this crime, but talk about it very unconcernedly, or engage in disseminating a knowledge McKEE : ABORTION. 5 of tlie work among friends as earnestly as they would work for a supper for tlie benefit of a hospital, kindergarten, or the far-distant heathen. They would fear to reverse the hands of a watch, but would break the laws of Nature in their own human mechanism, a hundredfold more delicate, com- plicated, and precious. But criminal abortion is not all to be ascribed to sin alone, but partially to tender-heartedness. Many have been far more tempted by a woman’s tears to lend her the knowledge which would save her from disgrace, than by the large fee she offered. The indications for the induction of abortion are well pre- sented by Parvin.1 He finds it sometimes necessary in dis- eases of the kidneys, though prophylactic measures will gen- erally suffice. The same is true of chronic heart disease nd diseases of the respiratory organs. Chorea is an indica- tion in cases where the life of the mother is jeopardized and other remedies fail. Eclampsia is infrequently an indication. Cancer of the rectum is occasionally so, as is also mammary cancer and severe cases of rheumatism. When the true conjugate of the pelvis is not less than seven centimetres, Yon Brelnn, by dieting the mother so as to prevent the formation of adipose tissue in the child, has avoided the necessity of inducing premature labor. The induction of abortion has changed somewhat in method during recent years. Among the instruments recom- mended are Hegar’s dilator, followed by a tampon saturated with a four-per-cent solution of salicylic acid. An improve- ment on Tarnier’s elastic balloon consists of a pear-shaped rubber ball, which when reduced to a small size is introduced into the uterine cavity and inflated. When pains commence it is slowly expelled in its distended state, and the fetus soon follows. Iodoform tampons are claimed to bring about the same result more safely and quickly than the sponge tent. Puncture of the membranes is sure but slow, inconvenient, and dangerous. The bougie is not entirely safe and not always sure. The average time of bringing on pains by the bougie is much greater than after puncture. Galvanism is recommended as sure and safe. The diagnosis of inevitable abortion is ever desirable, but 1 “ Annual of the Universal Medical Sciences,” i., 7, 1891. 6 McKEE : ABORTION. unfortunately the signs are not always sure indications. Hem- orrhage may continue for a considerable time and return at frequent intervals, yet the pregnancy may go on to term. Marked softening and dilatation of the cervix are generally followed by expulsion of the ovum, but not always. Three authors report cases where portions of the uterine contents were expelled and abortion did not follow. Given ruptured membranes, a persistent hemorrhage, dilated os, ovum dead and presenting, portions expelled, abortion is inevitable. Ho class of cases cause ns more anxiety and doubt than do abortions. Our masters lead us different paths ; and if we go to the learned societies and listen to their discussions, we are surprised at the diversity of opinion. As there is no fixed plan of treatment, the practitioner can follow almost any course which strikes his fancy, and find respectable authority to confirm him. The radical and the conservative methods in the treatment of the retention of the placenta and mem- branes have their advocates in every country. It is seriously considered by some that the safety of the patient and the comfort of the physician are best served by the immediate removal of the secundines after the expulsion of the ovum, in every case where it can be done without force sufficient to injure the woman. The curette in skilful hands and with a proper patient is a means of good after abortion, yet under other circumstances it is an instrument of danger. In the text books we find remarkable unanimity in recom- mendation of the expectant plan, while the recent contribu- tions to medical literature favor immediate removal. Care- ful consideration of the facts and circumstances of each case will result in a more intelligent conduct than the observation of any dogmatic rule. All will accord that the early removal of the secundines is desirable, but the question arises, When is it best ? Abortion is not physiological, as delivery at term, but is a pathological process—a premature death, a breaking up and tearing away, an abnormal condition. The dangers from septicemia and hemorrhage, the local inflammations, the or- ganic changes, the subinvolutions and septicemia arising from decidual retentions, render early, prompt, and thorough removal a matter of paramount importance. Safety, speed, McKEE : ABORTION. 7 and completeness are tlie principal questions for considera- tion. Are we doing the proper thing when we sit and wait for the onset of sepsis before removing the remains ? Im- mediate action may avoid the danger of septicemia and save the life of the patient. The so-called expectant plan is an easy way, and, thanks to Nature, is successful in a great ma- jority of cases; but why wait for dangerous symptoms before active interference, which may then be too late? After radi- cal treatment the patient is less liable to be troubled with subinvolution, hypertrophy, and displacement of the womb. The method is generally easy, and, if carefully done, is safe. Intravaginal injections of hot bichloride solutions should pre- cede, and intra-uterine follow, this treatment. I have had some noteworthy results in repeated abortions from the use of chlorate of potash, recommended by Shoe- maker in his new edition. In one case, where the patient had aborted ten times while married to two different hus- bands, fifteen grains of chlorate of potassium were given three times a day, also tinctura ferri chloridi, and two children were brought to term and born alive. No cause could be found in this case, but from the history and the time of the occurrence fatty degeneration of the placenta was suspected. The use of this remedy was first suggested by Sir James Y. Simpson, who employed it on the theory that an abundance of oxygen wTas supplied to the fetus by this means through the placental tufts. He gave it because of disease of the placenta, but also believed that it was a means of arterializing the blood. He was led to the use of this remedy by the experiments of Davy and Stephens, who found that an alkaline salt, when brought into contact with the blood, gave it an arterial appearance. From the large amount of oxygen contained in each atom of the chlorate of potash, Simpson argued that the maternal blood would be better oxygenated, and the child’s respiration be thereby im- proved, by its administration. Anemic patients improve in color under this drug. Alkalies are promoters of waste and assist the removal of inflammatory products. Patients who had not gained under tonics and nutrients will improve in weight and strength upon the withdrawal of these remedies, waste producers, provided their use has not been too long 8 McKEE : ABOKTION. continued. It is a well-recognized fact that there is an exces- sive accumulation of carbonic acid in the presence of inflam- matory changes of tissue. In the presence of carbonic acid nascent oxygen is formed from chlorate of potash, which may show how the inflammation is relieved and oxygen furnished the fetus. It is claimed on good authority that the chlorate of potash does not part with any great amount of oxygen at the body temperature, yet there remains the fact that, by increasing the alkalinity of the blood, its oxidizing function is augmented. Whatever its modus operandi, whether as a tonic or by its decomposition in the blood, thus directly fur- nishing an increased quantity of oxygen to the fetus through the placental tufts, or whether it puts the blood in such a state that it is able to carry an increased supply of oxygen, the clinical fact stands that it has a direct beneficial effect in properly selected cases, i.e., where there is fatty degeneration of the placenta. A very necessary method of treatment is absolute rest at the time for the recurrence of menstruation. This rest should continue as long or longer than the menses were wont to last; and complete rest in bed is sometimes necessary during the second, third, and fourth months. The local treatment and cure of chronic uterine disease is very essential, as this and its consequences are a very frequent cause of abortion. In these cases mercury seems to have a beneficial effect, even in non-specific cases. The viburnum prunifolium, here as elsewhere, proves a very efficient uterine sedative. The un- fortunate physician who is called to attend these doubtful, confusing, and tormenting cases should derive a large amount of comfort from the fact that gentlemen who have had quite an extensive practice in this line state that they have never lost a case from hemorrhage. Great care should be exercised to avoid rupture of the membranes, as the expulsion of the ovum en bloc is particularly desirable. Early aseptic precau- tions are advisable, preferably the intra-uterine injections of hot solutions of bichloride of mercury. The folly of defer- ring these precautions until the substance in utero begins to putrefy is attested by numerous deaths. Iodoform in suppo- sitories doubtless has the effect of preventing further decom- position. The faradie current is of considerable value in cases McK.EE : ABORTION. 9 of uterine inertia. It produces and intensifies contractions, checks hemorrhage, lessens suffering, and hastens delivery. A mild current is all that is necessary, the main thing being its intermittency. In fact, a strong current is rather to be avoided, as it is prone to produce a spasm of the muscular tissue. To prevent abortion use opium hypodermically by mouth or rectum to quiet nerves, muscles, and mind. Preparations containing viburnum prunifolium have done good work in allaying uterine contractions. Tampons will often dilate the cervix and hasten delivery, but are in many ways unsatisfac- tory and unsafe. They should consist of iodoform gauze, or absorbent cotton balls soaked in an antiseptic solution, re- newed about every six or twelve hours, and the patient care- fully watched. I do not use ergot until the uterus is empty. I prefer to dilate the cervix with Palmer’s steel dilators, and for removing the contents use my finger. Where this, Na- ture’s excellent instrument, fails, Reamy’s placental forceps will be found to act very nicely, having as recommendations simplicity, safety, and efficiency.