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SEPTIC ABORTION*

0. A. CANNON, M.B., F.A.C.S.

Hamilton, Ontario

AN abortion is the interruption of pregnancybefore the child is viable. The term pre-

mature labour should be used to designate thoseinstances where pregnancy terminates beforematurity but after the child has a chance to live.In scientific description it is better to discontinuethe use of the term "miscarriage," which is usedby the laity to apply to the interruption of preg-nancy at any period before full term.A septic abortion will have the same suggestive

clinical manifestations as an a-septic one, with theaddition of the findings associated with an infect-ive process. At times this infective process mayarrest or modify the symptoms which we considerto be the characteristic phenomena of abortion.Then, again, evidence of contamination mayappear at any stage of the abortion process andeven after its completion, depending upon thetime infecting organisms entered the body andalso upon the dormant period of these organisms.

Causation. Abortion is brought about bycauses associated with either the foetus or themother. Disease or malformation of the foetusor its appendages may result in its expulsion. Inthe mother, syphilis or other infectious disease,toxwemia of pregnancy or toxwemia from anaxsthesia,alcohol and drugs; mental disturbance, aborti-facients, local pelvic disease, particularly chronicendometritis and malpositions of the uterus, areall possible and frequent causes of abortion. Thegreatest etiological factor is, however, criminalinterference either by the pregnant woman her-self or by the abortionist. Of fifty-one women at-tended by me during abortion, twenty-two admit-ted criminal interference. This percentage offorty-three would have been materially increasedif all the patients had been equally frank.The process may be rendered septic in two ways,

speaking very broadly: the infection may have itsorigin within the body of the patient, or on theother hand it may be introduced from without.*Polak (1) regards the uterus during involution asa wound. Certain it is that when the placenta

*Read before the Medical Societies of Perth and OxfordCounties, Lakeside, Ontario, June 29th, 1921.

or decidua separate from the uterus a wound isthe result. This wound is bathed in blood andforms at once a splendid culture medium as wellas an avenue of entrance for any bacteria whichmay reach this situation. It is possible that theorganisms may be carried in the blood from afocus of infection remote from the pelvis. Theteeth sockets, the tonsils, the accessory nasalsinuses, the gall bladder, may harbour bacteriawhich often escape into the blood stream. It ispossible that the puerperal wounds may thus beinfected endogenously. Every writer on thissubject suggests this method of infection, butsatisfactory clinical and laboratory proof is lack-ing. The role played by focal infection in theproduction of toxwemias of pregnancy has longbeen suspected. Recently Talbot (2) from aclinical study of the placenta finds evidence ofblood-borne infection in that organ. Rosenow(3) in his study of the elective localization of bac-teria in certain lesions found that when a preg-nant rabbit was used in the experiments the lesionswere produced in the feetus of the same characteras those in the parent rabbit. Infectious infarctsin the placenta and infections produced in thefeetus go a long way toward establishing the pos-sibility of the infection of puerperal wounds byblood-borne organisms. Further work along the.lines indicated by Rosenow (3) ,(4) will doubtlesssolve this problem. There is, however, a methodof autoinfection about which it is not necessary tospeculate. Latent or active infective processesmay be located within or in close proximity tothe genital tract. The vagina under ordinarycircumstances contains a varied bacterial florawhich although apparently innocent there, ifcarried to the fresh wounds above may set up aserious infection. Many suffer from leucorrheeafrom chronic infection of the cervical or vaginalmucosa, or of the deeper glandular elements ofthe cervix or vulva. The presence of the gonoc-cocus in the vagina is a more serious circum-stance. All are familiar with the tragic sequenceof events which frequently follow abortion orlabour in those who suffer from gonorrheea. If

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the patient's life is spared, years of suffering areprobably ahead of her, with sterility and muti-lating operations in addition. Certain authorsstress the importance of the male fluid in thevagina as an important factor in the causation ofinfection. Bathing has also been held responsiblefor the entrance of germs into the birth canal toinfect puerperal wounds.

Autoinfection is, doubtless, assisted by the gen-eral condition of the patient, she being oftenparticularly susceptible to infection from thesevere anamia and shock of the abortion or fromsome concurrent condition.The introduction of infected material from

without is, however, the cause in the great major-ity of cases. DeLee (5) considers it to be properin all cases of septic abortion to suppose that theabortionist has been at work. Most authoritiesagree that a very large proportion of these casesare due to the work of the abortionist or to thepatient herself. In the author's series of thirty-one cases which forms the basis of this study,fifteen of the patients admitted criminal inter-ference. The abortionist does not make adequatepreparation of the parts, the hands, or the con-trivances. The work must, perforce, be donesecretly, which presages the fact that the operationis undertaken without assistants or proper pre-paration. The abortionist must have no witness-es to his deed. Holmes of Chicago holds that allcriminal abortions should be treated as septicuntil the clinical course proves otherwise. The,abortionist is realizing the importance of asep-sis as is evidenced by the fact that of twenty-two cases of admitted criminal abortion in myseries, seven did not become septic.

Regrettable as it may seem, the physician ornurse may be the party responsible for the in-fection. Unclean hands, faultily prepared dress-ings, packing and instruments, or carelessness inthe toilet of the patient may be the causativefactor. In this connection the proximity of theorifice of the bowel must ever be regarded as apotential danger, and all means taken to preventmaterial from the bowel entering the genitaltract. This is perhaps more important in labourat maturity, where the advance of the presentingpart expresses from the bowel material which mayreach the inevitable wounds caused by the traumaof birth. Bonney (6) gives it as his opinion thattoo little attention is given in all obstetricalprocedures to the isolation of the anal regionfrom the field of operation, and perhaps too muchstress given to the possibility of infection from

without. An improper technique may be res-ponsible for the transplanting of bacteria from thevagina or vulva to a higher position in the genitaltract, where they have an opportunity to invade.In infected cases one should bear in mind thatthe patient may be infected by one organism inpure culture, and that in order to prevent amixed infection the preparation and techniquemust be just as thorough.Symptoms. Added to the phenomena of abor-

tion will, be noted a rise of temperature oftenpreceded by a quickening of the pulse. If allcases of abortion are put on a two-hour pulse andtemperature chart one is frequently able to dis-cover that all is not well with the patient longbefore she has symptoms. Throughout the diseasethe pulse is a more reliable guide to prognosisand treatment than the temperature. A risingpulse rate unless associated with a correspondingrise in temperature is an ominous sign. Thetemperature may rise to 105 or 107 and fall assuddenly. In other cases it may show a steadydaily rise; and in still others it may never goabove 101, even although some of such cases mayterminate fatally. The temperature does notindicate whether the infecting organism is abenign saprophyte or a virulent streptococcus.One's equanimity need not be much disturbed ifthe pulse rate remains low, even when the tem-perature is very erratic. Chills and chilliness areusual. Repetition of chills indicates fresh in-vasions. Pain is usually not complained of untilthe peritoneum is reached except in cases of acutecongestion of the pelvic organs. An increase inthe white blood count is usual, and Polak (7)uses this symptom as his indication for surgicalinterference. In the writer's series it was notedthat in four patients severely ill there was aleucopenia. One of these died.

Lochia. Over and over again it has been statedthat because there was no odour to the lochlia thatthere was no infection of the genital tract. As amatter of fact, in streptococcic infections it isextremely characteristic for the normal mustyodour to disappear. In sapremic infection thelochia is usually very offensive and profuse. Ascanty discharge without odour leads one tosuspect that he is dealing with a systemic invasionbv the streptococcus or other organism.

Diagnosis. The fact of a septic abortion isdetermined by exclusion as in the diagnosis ofany other pathological condition. Any one ofall the conditions manifested by a thermal coursemay either be the cause of the abortion or con-

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current with it. It is the height of folly toattempt any radical treatment until it is definitelyand positively determined that the illness is dueto infection within the pelvis. Holmes of Chicagostates that while on the abortion committee- ofthe Chicago Medical Society he had opportunityto observe many instances where cases came toautopsy with a diagnosis of death from puerpuralsepsis and in which the pathologist discovered noevidence of pelvic disease but did find such con-ditions as pneumonia, brain abscess. and acuteabdominal conditions. One should be loath todiscourage thoroughness in diagnosis, but littleif any good so far has resulted from the identityof the infecting organism. If the blood cultureshows a growth the prognosis is more serious, butwhatever germ is found the treatment remainsthe same, most authorities being frankly pessi-mistic in regard to vaccine or serum therapy inthis condition. One cannot help feeling that inthis direction lies truth; but let us leave it to thetrained path-finders to show us the way, and letus not follow the many "will o' the wisps" whichin such distracting profusion would lure us fromthe thoroughfares of sound therapeutics. Anadmission of gonorrheea or the possibility of in-fection by the gonococcus is however an indicationfor bacteriologic examination of the discharges,as the presence of this organism is a mandate toleave the woman severely alone as far as localtreatment is concerned.

Prognosis. Nature attempts and usually suc-ceeds in limiting the process by means of anenveloping reaction zone. This may vary froma superficial infiltration of the endometrium withwhite blood cells to a very extensive inflammatoryprocess deep in the tissues. When the infectingorganism is virulent there is apparently no timefor nature to complete her protecting wall. Insuch cases at post mortem there is often aston-ishingly little evidence of tissue reaction, and thenecrotic layer lining the uterus where the infectionentered may be entirely absent. This whitelining of the uterus is found in most cases of septicabortion and indicates nature's effort to repel theinvader at the threshold. Prognosis will be in-fluenced by the virulence of the infecting organismand by the dosage, the immunity, and generalhealth of the patient, and upon the treatment shereceives. It also seems logical to suppose that awoman whose pelvic organs were healthy prev-iously will do better than one who has chronicdisease there. That treatment avails much isdoubted; but let us at least refrain from increasing

the helpless woman's difficulties by ill-advisedinterference.

TREATMENT.

Prophylaxis. The best treatment of any con-dition is its prevention. Abortion can be pre-vented in most cases. To the public healthworker we freely offer our tribute of praise for hismagnificient accomplishments along many lines.The reduction of infant mortality, the control ofvenereal disease, the improved living conditionsin the homes of the people, and the reduction ofthe death rate from infectious diseases are resultsdue to the tireless efforts of the physicians chargedwith the administration of public health affairs.The prevention of abortion is a phase of theirwork which has as yet received very little seriousattention, and any activities undertaken have notbeen pushed with vigor. The birth rate would bevery materially increased if the slaughter of un-born children could be prevented. Many womenare losing their lives and many others becomingeconomic burdens through chronic invalidismfollowing abortion. DeLee (8) says that prog-nosis as to health is worse after abortion thanafter labour at term. To give a personal ex-perience, I have attended during a certainperiod three hundred and fourteen women inlabour at term, while during the same period Iwas called to fifty-one cases of abortion. Thusover fourteen per cent. of my cases aborted. Thisexperience will no doubt approximate that ofothers, and will give an idea of the serious loss oflife from this cause. A great deal can be done toprevent the condition and the following sugges-tions are put forward for consideration.The influence of wide publicity has long been

recognized as an effectual method of bringingabout reform. One need only refer to the cam-paign against venereal diseases which has madeeveryone acquainted with these conditions, andby public co-operation has enabled the healthauthorities to get them under control. A similarcampaign in which cold facts about this conditionare given the widest publicity, the statisticsquoted, the causes of abortion enumerated, andexpectant mothers counselled to put themselvesunder medical supervision at once, would mostsurely result in a marked reduction in the numberof cases. The mere publication of the CriminalCode of Canada as it pertains to abortion couldnot help but have a deterrent effect on thoseguilty of improper practices. Its penalties aregenerous. Life imprisonment is prescribed for

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one who administers drugs or uses means.to pro-duce an abortion. If the woman herself is guiltythe penalty is seven years' imprisonment. Themost significant section reads as follows: "Every-one is guilty of an indictable offence and liable toimprisonment for life who causes the death of anychild which has not become a human being insuch a manner that he would have been guilty ofmurder if such a child had been born." Themoral conscience of the public, including that ofsome physicians, needs educating, and it shouldbe some one's business to make it known thatfrom conception the unborn child is a humancreature whose destruction is the equivalent ofmurder. If the public were in possession of allthe facts they would join in hunting down criminalabortionists as they do in the case of other male-factors. At present they flourish and enjoy acertain immunity owing to the apathy of thepublic toward their crime.The medical profession has also a duty in this

connection. Evidence against the criminal abor-tionist is often obtained, and while the violationof the confidence of patients is not to be consideredit is possible by discreet communications to thelocal officers of justice to rid the community ofthe obnoxious person.The medical man himself should shun the very

appearance of evil. Sympathy with the unfor-tunate woman who for any reason finds the cir-cumstances of pregnancy a hardship should nevercause him to suggest that it were better that herpregnancy be terminated. She would probablyseize upon this suggestion and use it to salve herconscience in further search for help. A firm,tactful refusal from her family physician will inmost cases put the idea out of her head.To make it more difficult for a woman to operate

on herself it should be enacted that druggists arenot to sell without a physician's order such articlesas male catheters and sponge tents. Ergot,cotton root, and other emmenagogue compoundsshould similarly be withdrawn from sale exceptwhen prescribed. Slippery elm which was usedin two of my cases would make just as good tea ifthe druggists were required to cut it up into smallpieces before offering it for sale.The registration of the birth of a "child" at

any stage of pregnancy would have beneficialeffect. It would insure that proper statistics-were obtained and the seriousness of the loss oflife from this cause would be known. It wouldalso be a decided check on the criminal cases.The prenatal care received by most pregnant

women is practically valueless. Many do notsee the doctor until he comes to attend them inlabour. Others go to "engage" him and see himno more until labour. The doctor may ask forsamples of the urine, and he may not. A mater-nity engagement should be considered a seriousmatter. The patient's history should be carefully.taken and a complete physical examination madeon her first visit. The blood should be examinedin every case. The urine should be examined andthe blood pressure taken every two weeks through-out her pregnancy. The woman should be in-structed in the care of her body during her preg-nancy and should be taught to recognize theabnormal indications and to seek help when theyappear. All this will take time and to the busypractitioner it may not seem very necessary. Thesatisfaction of preventing one abortion or of savingone woman from eclampsia will amply repay onefor much routine work. An engine driver whorefused to watch for his signals would not be con-sidered a safe man to pilot the engine, and anobstetrician who does not watch his patient care-fully for the onset of difficulty is likewise unfit forhis work. Then again, the public are slowl1rbecoming educated to the importance of prenatalcare, and the practitioner who fails to satisfyin this regard will be passed by in favour of hismore conscientious brother. Of course it isunderstood that this prenatal care must be prop-erly recompensed, and for those who cannot payfor the service, prenatal clinics should be estab-lished in every centre where this care can beobtained without cost.

Treatment. The treatment of septic abortionmay be: (1) Radical-operative; (2) Conserva-tive-expectant. In increasing numbers theleading authorities in obstetrics are becomingexponents of the latter method. He who wouldcurette, douche, or practice any of the methods ofintra-uterine therapy as a routine will lose morepatients than he who treats his patients purelyexpectantly. Williams (9) one of the earliestadvocates of conservative treatment, had a mor-tality of 4.35 per cent. in 1899, while his contem-poraries were treating their patients actively witha mortality as high as 30 per cent. Hillis (10)reports an interesting study at Cook CountyHospital, Chicago. In order to test the efficacyof the two methods of treatment and to reach adefinite conclusion, a clinical test was made.Women brought to the hospital suffering fromseptic abortion and with a temperature of over100 were assigned alternately to active and to

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conservative treatment. Tholist were immediately curettedas follows:

No. of cases............

Days of fever...........Average days of fever....Total days in hospital....Average days in hospital..Complications.........Deaths .................

Percentage mortality.

In my series of thirty-onetion, one only was treated actidied. In her case criminal i

mitted, and after a long perio(ment the uterus was curettectinuance of a fairly brisktemperature before operation100 but did not continuevomited occasionally. Thehave been used. Packing v

the uterus without as muchhours after operation she hacan acute rise of temperaturedays with acute bacteremia.treated expectantly recoverecexception of one who develolgitis and in whose case a histoobtained.

Operative treatment by c

moval, tamponade, and douopen to the same objectiormore often than not failing toof conception, and is in itselfThe curette is especially harmif a thorough curettage of thever done. Its configuratioiimpossible for the scrapingthan half the surface. It is

tidles may be removed, but ii

be sure that the uterus is emMany authors report cases

has gone to term after what

thorough curettage of the ul

ago I was associated with a skcase of pernicious vomiting ol

ruption of pregnancy was th(

My colleague dilated and pacpatient did not abort. She

ized and curetted. It waEproducts of conception were

Some days later she passed a

ose on the active Besides being an ineffectual instrument it is aL. The figures were dangerous one. Perforations are frequent with

its use. The soft friable uterine wall may giveway under the gentlest movements of the curette.

100A 100. The most formidable objection to its use in cases

810. 350. of septic abortion is that even with the dullest8.1 3.5 instrument and the softest strokes new wounds

are made and the spread of the infective process

13.28 8.48 is likely to result. DeLee says "My experience193 4 has taught me that the traumatism of curettage,191 digital or instrumental, may be fatal-a super-3.1 ficial and not dangerous infection being converted3. 1. into one with strong invasive qualities." If the

cases of septic abor- symptoms are due to infected uterine contents,vely and this patient nature can usually be relied upon to empty thenterference was ad- uterus -in due course. Their retention in thed of expectant treat- uterus can do no harm. The organisms in the1 owing to the con- mass may be leading what is practically a sapro-haemorrhage. Her phitic existence. To employ an instrument to

L did not rise above remove them may give these organisms an oppor-normal. She also tunity to actively invade. Fothergill (11) speakscurette should not of using the curette before the pathogenic organ-vould have emptied isms have entered the blood stream. If the in-danger. Thirty-six fection is due to a virulent organism it is far1 a severe chill with beyond the reach of the curette by the time

She died in four symptoms appear.The thirty cases The following is the treatment suggested: The

A promptly with the patient is put to bed in the Fowler position, seatedped a double salpin- upon a sling pillow. She is better in a hospital,ry of gonorrheea was where she can receive skilled care and be shielded

from visitors and annoyances. She should be puturettage, digital re- on a two-hour pulse-temperature chart. Waterches is in each case and nourishing fluid diet should be given in

i. It is ineffectual abundance. The bowels are opened by enemataremove the products and gentle laxatives. An ice bag is placed over

E a source of danger. the lower abdomen. If fluid is not taken freelytful and it is doubtful by mouth glucose or saline solution is given pere uterine cavity was rectum; or if not tolerated there, by subcutaneous* is such that it is injection. Appropriate stimulation is given ifedge to cover more required. Ergot or pituitin are used to keep thetrue that gross par- uterus in contraction. This probably blockstisnever possible to lymphatic channels. Quinine is often useful topty. remove retained products of conception. Afterin which pregnancy the temperature has been normal for five full dayswas thought to be a and the uterus is not empty, the contents shouldterus. A few weeks be removed. The patiernt's return to health isilful obstetrician in a thus expedited.f pregnancy. Inter- Should haemorrhage have to be reckoned withe decision of counsel. during the course of septic abortion, the followingked with gauze. The procedure is recommended: With the patientwas again antsthet- prepared for operation, with plenty of assistantss thought that the and if possible without anawsthetic, pass the largestremoved completely. sized tubular cervical speculum that can be gotlarge decidual mass. in and through it pack weak iodoform gauze with

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blunt dressing forceps. Then about the cervixpack sterile cotton layer upon layer until thevagina is full. In twenty-four hours the packingis removed and with it is usually found the pro-ducts of conception.

REFERENCES

1.-POLAK, J. 0. Pathology of Common PuerperalLesions: Amer. Jour. Obstet and Gynac., 1, 547, March, 19212.-TALBOT, J. E. A Clinical Study of the Placenta:

Surg., Gynac. and Obstet., vol. 32, 552.3.-RoSENOw, E. C. Studies in Elective Localization:

Jour. Dent. Research, vol. 1, No. 3, September, 1919.

4.-RoSENOW, E. C. Focal Infection and Elective Local-ization of Bacteria: Surg., Gynac. and Obstet., vol. 33, 19.5.-DE LEE, J. B. Principles and Practice cf Obstetrics,third edition, p. 438.6.-BONEY, V. Brit. Med. Jour., 1920, ii, 263.7.-POLAK, J. 0. Indications for Operation in Spreading

Peritonitis of Post-Abortal and Post-Partal Origin. Trans.Amer. Gynec. Soc., 1920.8.-DE LEE, J. B. Prin. and Prac. of Obstet., 3rd edition

p. 438.9.-WILLIAMS, Amer. Jour. Obstet., September, 1899.10.-HILLIS, D. S. The Treatment of Abortion: Surg.,Gynec. and Obstet., December, 1920.11.-FOTHERGILL, W. E.: Lancet, 1921, C.C. 59.

OBSERVATIONS ON THE VALUE OF LUMBAR PUNCTURE

A. HOWARD MACCORDICK, M.D.

Physician to the Out-Patient Department, Montreal General Hospital. Pathologist to the

Western Hospital.

LUMBAR puncture has long been recognizedas a measure not only of great diagnostic

value, but also of considerable therapeutic benefit.The information derived from the examinationof the spinal fluid, and the relief experienced onits removal, is, we believe, greatest in the acuteinflammatory conditions, such as septic menin-gitis and epidemic cerebro-spinal meningitis. Tothese we may add also the tuberculous meningitis.Our present laboratory methods enable us in theseacute conditions to make a diagnosis so easilythat it would seem little could be added from thelaboratory standpoint.The varied characteristics, however, of the

spinal fluid in certain more or less obscure cerebro-spinal conditions and their relation to the bloodfindings in the same patients, seem to be sufficientexcuse for the presentation of a few figures,gathered from the study of 130 examinations ofthe spinal fluid made in connection with the workof the medical departments of the MontrealGeaeral Hospital and the Western Hospital duringthe past four and a half years.Laboratory methods for estimating increase in

the number of white cells, or increase in theamount of globulin, have become very accurate,and have enabled us to detect the slightest evi-dence of acute or chronic inflammatory reaction.

Add to these tests the serological reactions, andwe have further enhanced our methods of diag-nosis. In spite of all our tests, however, theclinician may at times find great difficulty inarriving at a definite conclusion in cases showingsymptoms of lesions of the central nervoussystem or cord, in fact at times he may not onlybe helped little, but may actually be misled bythe laboratory findings.

This study has been confined to conditions, forthe most part, purely medical, or cases met within the medical wards and outdoor clinics. Itconsists of observations on the spinal fluid findingsin cerebral hawmorrhage, cerebral thrombosis,cerebral lues, encephalitis lithargica, poliomy-elitis, brain tumour, brain abscess, tabes dorsalis,myelitis and so-called meningismus. The findingshave been of interest not only from a medical anda scientific point of view but also from a medico-legal aspect. Several cases have come underobservation in which a definite diagnosis wasnecessary, in that men have taken actions in lawcourts to recover damages for disabilities whichthey attributed to accident. Others have arisenin which the obligation to pay insurance wasquestioned by the company.Here may be cited two illustrative cases:R. S., male, age 38, employed as a laborer, fe

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