576THE CANADIAN MEDIcAL AsSocIATIoN JOURNAL [Nov. 1931~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
A CONSERVATIVE TREATMENT OF INCOMPLETE ABORTIONBy MURRAY BLAIR, M.D., C.M.,
Department of Gynccotogy and Obstetrics, Vancouver General Hospital,Vancouver
CURRENT medical literature abounds in therare and unusual in medicine, at the
expense of the commonplace every-day prob-lems with which the general practitioner mustgrapple. Among the commonplace problemsare there two commoner conditions to be metthan gonorrhoea and abortion? And yet howoften do we meet them in our medical reading?The object of this paper is to bring up againthe subject of abortion, chiefly from the stand-point of treatment. The treatment here de-scribed is that used in our cases admitted tothe Vancouver General Ho'spital during thepast six months (January 1 to June 30, 1931).A good many years ago the profession be-
came impressed with the conservative treat-ment of abortion as compared with the earlierand more radical methods of treatment. Muchhas been written about that protective zone oflymphocytes which lies in the basal structuresof the endometrium and which if broken downby any form of trauma allows free access ofthe potentially infective areas to the maternalcirculation. It is felt that if such a mentalpicture is kept before us probably the uteruswill receive more of that respect which isrightfully its due.A study of the records of cases in the
gynEecological service of the Vancouver GeneralHospital from January 1 to June 30, 1931,shows that 41 cases of abortion were admitted.These were classified as follows: complete, 10;incomplete, 28; threatened, 3.By complete abortion we mean those cases
who were admitted as inevitable abortions,and who after admission succeeded in com-pletely emptying their own uteri or for somereason had therapeutic abortions performed.All 10 cases ran an afebrile and uneventfulconvalescence.' By incomplete abortion wemean those cases who were admitted with ahistory of amenorrheea, followed by bleeding,intermittent pain, and the passage of clots ormasses of some sort before admission. By
threatened abortion we mean those cases whocame in showing the classical signs of impend-ing abortion, but whose crises were avertedand who were discharged as normal cases ofpregnancy.The treatment of complete and threatened
abortion is carried out in this clinic on thesame conservative lines as that of incompleteabortion. The detail of treatment is, however,not within the scope of this paper.
GENERAL TREATMENTIncomplete abortion should be treated as an
open wound and given the same care and con-sideration. Each patient with abortion admittedunder the staff of the Vancouver General Hos-pital is put to bed, and an ice bag applied tothe lower abdomien for the purpose of improv-ing and keeping up uterine tone. If there bebleeding, we may or may not elevate the footof the bed, but it is doubtful if posture in bedhas any influence on uterine bleeding. If thebleeding is marked, pituitrin 0.5 to 1 c.c. maybe given. In our series it is surprising howvery seldom it was found necessary to resort toan oxytocic.As soon as possible every patient with incom-
plete abortion is placed on an examining table,a vaginal speculum inserted and, with a goodlight the vagina and cervix inspected. Thisprocedure is carried out under strictly asepticconditions. It is the only procedure in ourwhole routine which might be considered asbordering on the radical, rather than the con-servative, in treatment. One or two experienceshowever, have shown us that fragments of theproducts of gestation may lie, completelyseparated from the maternal wall, in the cervix,or even in the vagina. These fragments, beingforeign bodies, can be readily removed withsponge forceps, but if left in situ, may or maynot be expelled. If not, they must be absorbedand the process of absorption may lead tosepsis. We believe that a goodly number of
[Nov. 1931'576 THE CANADIAN MEDicAL AssoCIATION JOURNAL
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cases have been saved from the category of"septic abortion" by this simple procedure.No bimanual examination is made, nor anymanipulation of the uterus that might in anyway even remotely suggest trauma.Having satisfied ourselves that those pro-
ducts of gestation remaining to make theabortion incomplete are inside the uterus, thefollowing routine treatment is instituted. Acomplete history is taken, a catheterized speci-men of urine sent to laboratory, a Wassermanntest is made, a complete blood count and theblood pressure is taken. The nursing treatmentconsists of absolute bed-rest, an ice-bag to thelower abdomen, plenty of fluids, a well roundedsupportive diet, a heavy Russian oil, ounces 1/2three times a day, to be cut down if necessary,but if not enough to be followed up with asoap-suds enema every 48 hours. Should thetemperature and pulse remain within reason-able bounds, the patient is left strictly aloneand permitted to empty her own uterus in herown way. This, we believe, the overwhelming,majority are quite capable of doing. At leastso it has been found in our series.
HAEMORRHAGEThe old adage, "An empty uterus never
bleeds", might imply that a uterus onlypartially emptied bleeds freely. The initialfear of abortion is the fear of heemorrhage, andit is because of this that so many activemeasures are taken by many men. The routineuse of pituitrin, ergot, vaginal or even uterinepacking, intrauterine douches, curettage, etc.,are all introduced to offset the risk of im-mediate heemorrhage or subsequent infection.Our experience is that hawmorrhage from incom-plete abortion is by no means common.Threatened abortion of course demands ourstrictest watching because of the tendency to-wards sudden and vicious hemorrhage, butthreatened abortion is not considered in thispaper.
OXYTOCICSOxytocics are not given as a routine. The
reason is that they were not found necessaryto prevent bleeding and we have found themunsatisfactory as a method of completelyemptying the already partially emptied uterus.
TRAUMAUterine or vaginal packing was not resorted
to in our service. As a routine we consider itbad practice. Too little, we feel, has beenwritten about trauma in the presence of incom-plete abortion. The whole idea in our conserva-tive treatment is to keep infection fromspreading to the cellular tissues beyond theuterine wall. And how does post-partum in-fection spread? By means of lymphatics andby surface continuity, as does gonorrhoea inthe endometrium? No. The intrauterine in-fection accompanying abortion to a great,extent extends directly through the walls ofthe uterus to the cellular tissues beyond. Nodoubt the added risk accompanying curettagecomes far more from trauma than from the riskof carrying in infection. Trauma to uterinemusculature under such conditions breaks downthe protective leucocytic barrier around theinfected placental site and takes from themuscle something of its power to inhibit themigration of infective bacteria or their toxins.It is felt that the trauma to the uterine wallfrom packing, even vaginal packing, is veryreal and so to be avoided. Emergency hmemor-rhage is, of course, another matter, so obviousas to need no comment. Emergency, likenecessity, knows no law.The practice of many men to use the ex-
amining finger as a curette and to sweep out allparticles of the gestation still attached to theuterus is doubtless satisfactory from the stand-point of immediate results. It is, however,added trauma, no matter how gently the pro-cedure be carried out, and therefore, in ouropinion, better left undone. In view of this itis hardly necessary to comment on our attitudeconcerning curettage in the treatment of thiscondition. The exigencies of staff practicemay, however, be such as to make is impracticalto keep intractable cases in hospital indefinite-ly. Such a reason for performing a curettageis theoretically weak, but, practically, may atleast elicit sympathy. We curetted one caseof incomplete abortion in this group of casesfor the above reason.
INFECTED ABORTIONOne of the barometers of the financial condi-
tions in a community is, I think, the number ofabortions admitted to that community's hos.
BLAm: INcompimm ABoRTioN 577Nov. 1931]
pital. Especially is this so with regard to thenumber of criminal abortions. We have takenas a definition of criminal abortion only thosecases induced by the local application of anoutside agency, whether done by an abortionistor by the patient. Our experience seems toshow that self-induced abortions brought on bydrugs, exhaustion, and other agents cause littleor no more trouble than the innocent accidentalabortion. Either, of course, may cause a truepost-abortal sepsis. The number of abortionsadmittedly criminally induced, whether self-induced or by an abortionist, constitutes anextraordinary percentage of the whole. Ourdefinition of criminal induction does not in-clude that vast field of inductions caused bydrugs, such as castor oil, quinine, and manyproprietary preparations containing ergot orits derivatives. We have listed as criminallyinduced only those cases in which actual inter-ference had taken place via the vaginal route.Of these there were 16. Only 2 were admitted-ly brought on by the services of an abortionist.The great majority of criminally induced wereapparently self-inductions.. One reason, webelieve, is because this city is, on the whole,fairly free from such practitioners, and theother and best reason is that those people whoattend the free clinics of a general hospitalca