1922 V-12

THE CANADIAN MEDICAL ASSOCIATION JOURNAL 163

SEPTIC ABORTION* 0. A. CANNON, M.B., F.A.C.S. Hamilton, Ontario AN abortion is the interruption of pregnancy or decidua separate from the a wound is before the child is viable. The term pre- the result. This wound is bathed in blood and mature labour should be used to designate those forms at once a splendid culture medium as well instances where pregnancy terminates before as an avenue of entrance for any bacteria which maturity but after the child has a chance to live. may reach this situation. It is possible that the In scientific description it is better to discontinue organisms may be carried in the blood from a the use of the term "," which is used focus of remote from the pelvis. The by the laity to apply to the interruption of preg- teeth sockets, the tonsils, the accessory nasal nancy at any period before full term. sinuses, the gall bladder, may harbour bacteria A septic abortion will have the same suggestive which often escape into the blood stream. It is clinical manifestations as an a-septic one, with the possible that the puerperal wounds may thus be addition of the findings associated with an infect- infected endogenously. Every writer on this ive process. At times this infective process may subject suggests this method of infection, but arrest or modify the symptoms which we consider satisfactory clinical and laboratory proof is lack- to be the characteristic phenomena of abortion. ing. The role played by focal infection in the Then, again, evidence of contamination may production of toxwemias of pregnancy has long appear at any stage of the abortion process and been suspected. Recently Talbot (2) from a even after its completion, depending upon the clinical study of the placenta finds evidence of time infecting organisms entered the body and blood-borne infection in that organ. Rosenow also upon the dormant period of these organisms. (3) in his study of the elective localization of bac- Causation. Abortion is brought about by teria in certain lesions found that when a preg- causes associated with either the foetus or the nant rabbit was used in the experiments the lesions mother. Disease or malformation of the foetus were produced in the feetus of the same character or its appendages may result in its expulsion. In as those in the parent rabbit. Infectious infarcts the mother, syphilis or other infectious disease, in the placenta and produced in the toxwemia of pregnancy or toxwemia from anaxsthesia, feetus go a long way toward establishing the pos- alcohol and drugs; mental disturbance, aborti- sibility of the infection of puerperal wounds by facients, local pelvic disease, particularly chronic blood-borne organisms. Further work along the endometritis and malpositions of the uterus, are .lines indicated by Rosenow (3) ,(4) will doubtless all possible and frequent causes of abortion. The solve this problem. There is, however, a method greatest etiological factor is, however, criminal of autoinfection about which it is not necessary to interference either by the pregnant woman her- speculate. Latent or active infective processes self or by the abortionist. Of fifty-one women at- may be located within or in close proximity to tended by me during abortion, twenty-two admit- the genital tract. The vagina under ordinary ted criminal interference. This percentage of circumstances contains a varied bacterial flora forty-three would have been materially increased which although apparently innocent there, if if all the patients had been equally frank. carried to the fresh wounds above may set up a The process may be rendered septic in two ways, serious infection. Many suffer from leucorrheea speaking very broadly: the infection may have its from chronic infection of the cervical or vaginal origin within the body of the patient, or on the mucosa, or of the deeper glandular elements of other hand it may be introduced from without. the cervix or vulva. The presence of the gonoc- *Polak (1) regards the uterus during involution as cocus in the vagina is a more serious circum- a wound. Certain it is that when the placenta stance. All are familiar with the tragic sequence or *Read before the Medical Societies of Perth and Oxford of events which frequently follow abortion Counties, Lakeside, Ontario, June 29th, 1921. labour in those who suffer from gonorrheea. If

history-of-obgyn.com obgynhistory.net 164 THE CANADIAN MEDICAL ASSOCIATION JOURNAL

the patient's life is spared, years of suffering are without. An improper technique may be res- probably ahead of her, with sterility and muti- ponsible for the transplanting of bacteria from the lating operations in addition. Certain authors vagina or vulva to a higher position in the genital stress the importance of the male fluid in the tract, where they have an opportunity to invade. vagina as an important factor in the causation of In infected cases one should bear in mind that infection. Bathing has also been held responsible the patient may be infected by one organism in for the entrance of germs into the birth canal to pure culture, and that in order to prevent a infect puerperal wounds. mixed infection the preparation and technique Autoinfection is, doubtless, assisted by the gen- must be just as thorough. eral condition of the patient, she being often Symptoms. Added to the phenomena of abor- particularly susceptible to infection from the tion will, be noted a rise of temperature often severe anamia and shock of the abortion or from preceded by a quickening of the pulse. If all some concurrent condition. cases of abortion are put on a two-hour pulse and The introduction of infected material from temperature chart one is frequently able to dis- without is, however, the cause in the great major- cover that all is not well with the patient long ity of cases. DeLee (5) considers it to be proper before she has symptoms. Throughout the disease in all cases of septic abortion to suppose that the the pulse is a more reliable guide to prognosis abortionist has been at work. Most authorities and treatment than the temperature. A rising agree that a very large proportion of these cases pulse rate unless associated with a corresponding are due to the work of the abortionist or to the rise in temperature is an ominous sign. The patient herself. In the author's series of thirty- temperature may rise to 105 or 107 and fall as one cases which forms the basis of this study, suddenly. In other cases it may show a steady fifteen of the patients admitted criminal inter- daily rise; and in still others it may never go ference. The abortionist does not make adequate above 101, even although some of such cases may preparation of the parts, the hands, or the con- terminate fatally. The temperature does not trivances. The work must, perforce, be done indicate whether the infecting organism is a secretly, which presages the fact that the operation benign saprophyte or a virulent streptococcus. is undertaken without assistants or proper pre- One's equanimity need not be much disturbed if paration. The abortionist must have no witness- the pulse rate remains low, even when the tem- es to his deed. Holmes of Chicago holds that all perature is very erratic. Chills and chilliness are criminal abortions should be treated as septic usual. Repetition of chills indicates fresh in- until the clinical course proves otherwise. The vasions. Pain is usually not complained of until ,abortionist is realizing the importance of asep- the peritoneum is reached except in cases of acute sis as is evidenced by the fact that of twenty- congestion of the pelvic organs. An increase in two cases of admitted criminal abortion in my the white blood count is usual, and Polak (7) series, seven did not become septic. uses this symptom as his indication for surgical Regrettable as it may seem, the physician or interference. In the writer's series it was noted nurse may be the party responsible for the in- that in four patients severely ill there was a fection. Unclean hands, faultily prepared dress- leucopenia. One of these died. ings, packing and instruments, or carelessness in Lochia. Over and over again it has been stated the toilet of the patient may be the causative that because there was no odour to the lochlia that factor. In this connection the proximity of the there was no infection of the genital tract. As a orifice of the bowel must ever be regarded as a matter of fact, in streptococcic infections it is potential danger, and all means taken to prevent extremely characteristic for the normal musty material from the bowel entering the genital odour to disappear. In sapremic infection the tract. This is perhaps more important in labour lochia is usually very offensive and profuse. A at maturity, where the advance of the presenting scanty discharge without odour leads one to part expresses from the bowel material which may suspect that he is dealing with a systemic invasion reach the inevitable wounds caused by the trauma bv the streptococcus or other organism. of birth. Bonney (6) gives it as his opinion that Diagnosis. The fact of a septic abortion is too little attention is given in all obstetrical determined by exclusion as in the diagnosis of procedures to the isolation of the anal region any other pathological condition. Any one of from the field of operation, and perhaps too much all the conditions manifested by a thermal course stress given to the possibility of infection from may either be the cause of the abortion or con-

history-of-obgyn.com obgynhistory.net THE CANADIAN MEDICAL ASSOCIATION JOURNAL 165 current with it. It is the height of folly to the helpless woman's difficulties by ill-advised attempt any radical treatment until it is definitely interference. and positively determined that the illness is due TREATMENT. to infection within the pelvis. Holmes of Chicago states that while on the abortion committee- of Prophylaxis. The best treatment of any con- the Chicago Medical Society he had opportunity dition is its prevention. Abortion can be pre- to observe many instances where cases came to vented in most cases. To the public health autopsy with a diagnosis of death from puerpural worker we freely offer our tribute of praise for his and in which the pathologist discovered no magnificient accomplishments along many lines. evidence of pelvic disease but did find such con- The reduction of infant mortality, the control of ditions as pneumonia, brain abscess. and acute venereal disease, the improved living conditions abdominal conditions. One should be loath to in the homes of the people, and the reduction of discourage thoroughness in diagnosis, but little the death rate from infectious diseases are results if any good so far has resulted from the identity due to the tireless efforts of the physicians charged of the infecting organism. If the blood culture with the administration of public health affairs. shows a growth the prognosis is more serious, but The prevention of abortion is a phase of their whatever germ is found the treatment remains work which has as yet received very little serious the same, most authorities being frankly pessi- attention, and any activities undertaken have not mistic in regard to vaccine or serum therapy in been pushed with vigor. The birth rate would be this condition. One cannot help feeling that in very materially increased if the slaughter of un- this direction lies truth; but let us leave it to the born children could be prevented. Many women trained path-finders to show us the way, and let are losing their lives and many others becoming us not follow the many "will o' the wisps" which economic burdens through chronic invalidism in such distracting profusion would lure us from following abortion. DeLee (8) says that prog- the thoroughfares of sound therapeutics. An nosis as to health is worse after abortion than admission of gonorrheea or the possibility of in- after labour at term. To give a personal ex- fection by the gonococcus is however an indication perience, I have attended during a certain for bacteriologic examination of the discharges, period three hundred and fourteen women in as the presence of this organism is a mandate to labour at term, while during the same period I leave the woman severely alone as far as local was called to fifty-one cases of abortion. Thus treatment is concerned. over fourteen per cent. of my cases aborted. This Prognosis. Nature attempts and usually suc- experience will no doubt approximate that of ceeds in limiting the process by means of an others, and will give an idea of the serious loss of enveloping reaction zone. This may vary from life from this cause. A great deal can be done to a superficial infiltration of the endometrium with prevent the condition and the following sugges- white blood cells to a very extensive inflammatory tions are put forward for consideration. process deep in the tissues. When the infecting The influence of wide publicity has long been organism is virulent there is apparently no time recognized as an effectual method of bringing for nature to complete her protecting wall. In about reform. One need only refer to the cam- such cases at post mortem there is often aston- paign against venereal diseases which has made ishingly little evidence of tissue reaction, and the everyone acquainted with these conditions, and necrotic layer lining the uterus where the infection by public co-operation has enabled the health entered may be entirely absent. This white authorities to get them under control. A similar lining of the uterus is found in most cases of septic campaign in which cold facts about this condition abortion and indicates nature's effort to repel the are given the widest publicity, the statistics invader at the threshold. Prognosis will be in- quoted, the causes of abortion enumerated, and fluenced by the virulence of the infecting organism expectant mothers counselled to put themselves and by the dosage, the immunity, and general under medical supervision at once, would most health of the patient, and upon the treatment she surely result in a marked reduction in the number receives. It also seems logical to suppose that a of cases. The mere publication of the Criminal woman whose pelvic organs were healthy prev- Code of Canada as it pertains to abortion could iously will do better than one who has chronic not help but have a deterrent effect on those disease there. That treatment avails much is guilty of improper practices. Its penalties are doubted; but let us at least refrain from increasing generous. Life imprisonment is prescribed for

history-of-obgyn.com obgynhistory.net 166 THE CANADIAN MEDICAL ASSOCIATION JOURNAL one who administers drugs or uses means.to pro- women is practically valueless. Many do not duce an abortion. If the woman herself is guilty see the doctor until he comes to attend them in the penalty is seven years' imprisonment. The labour. Others go to "engage" him and see him most significant section reads as follows: "Every- no more until labour. The doctor may ask for one is guilty of an indictable offence and liable to samples of the urine, and he may not. A mater- imprisonment for life who causes the death of any nity engagement should be considered a serious child which has not become a human being in matter. The patient's history should be carefully. such a manner that he would have been guilty of taken and a complete physical examination made murder if such a child had been born." The on her first visit. The blood should be examined moral conscience of the public, including that of in every case. The urine should be examined and some physicians, needs educating, and it should the blood pressure taken every two weeks through- be some one's business to make it known that out her pregnancy. The woman should be in- from conception the unborn child is a human structed in the care of her body during her preg- creature whose destruction is the equivalent of nancy and should be taught to recognize the murder. If the public were in possession of all abnormal indications and to seek help when they the facts they would join in hunting down criminal appear. All this will take time and to the busy abortionists as they do in the case of other male- practitioner it may not seem very necessary. The factors. At present they flourish and enjoy a satisfaction of preventing one abortion or of saving certain immunity owing to the apathy of the one woman from eclampsia will amply repay one public toward their crime. for much routine work. An engine driver who The medical profession has also a duty in this refused to watch for his signals would not be con- connection. Evidence against the criminal abor- sidered a safe man to pilot the engine, and an tionist is often obtained, and while the violation obstetrician who does not watch his patient care- of the confidence of patients is not to be considered fully for the onset of difficulty is likewise unfit for it is possible by discreet communications to the his work. Then again, the public are slowl1r local officers of justice to rid the community of becoming educated to the importance of prenatal the obnoxious person. care, and the practitioner who fails to satisfy The medical man himself should shun the very in this regard will be passed by in favour of his appearance of evil. Sympathy with the unfor- more conscientious brother. Of course it is tunate woman who for any reason finds the cir- understood that this prenatal care must be prop- cumstances of pregnancy a hardship should never erly recompensed, and for those who cannot pay cause him to suggest that it were better that her for the service, prenatal clinics should be estab- pregnancy be terminated. She would probably lished in every centre where this care can be seize upon this suggestion and use it to salve her obtained without cost. conscience in further search for help. A firm, Treatment. The treatment of septic abortion tactful refusal from her family physician will in may be: (1) Radical-operative; (2) Conserva- most cases put the idea out of her head. tive-expectant. In increasing numbers the To make it more difficult for a woman to operate leading authorities in obstetrics are becoming on herself it should be enacted that druggists are exponents of the latter method. He who would not to sell without a physician's order such articles curette, douche, or practice any of the methods of as male catheters and sponge tents. Ergot, intra-uterine therapy as a routine will lose more cotton root, and other emmenagogue compounds patients than he who treats his patients purely should similarly be withdrawn from sale except expectantly. Williams (9) one of the earliest when prescribed. Slippery elm which was used advocates of conservative treatment, had a mor- in two of my cases would make just as good tea if tality of 4.35 per cent. in 1899, while his contem- the druggists were required to cut it up into small poraries were treating their patients actively with pieces before offering it for sale. a mortality as high as 30 per cent. Hillis (10) The registration of the birth of a "child" at reports an interesting study at Cook County any stage of pregnancy would have beneficial Hospital, Chicago. In order to test the efficacy effect. It would insure that proper statistics- of the two methods of treatment and to reach a were obtained and the seriousness of the loss of definite conclusion, a clinical test was made. life from this cause would be known. It would Women brought to the hospital suffering from also be a decided check on the criminal cases. septic abortion and with a temperature of over The prenatal care received by most pregnant 100 were assigned alternately to active and to

history-of-obgyn.com obgynhistory.net THE CANADIAN MEDICAL ASSOCIATION JOURNAL 167

conservative treatment. Thoose on the active Besides being an ineffectual instrument it is a list were immediately curettedL. The figures were dangerous one. Perforations are frequent with as follows: its use. The soft friable uterine wall may give way under the gentlest movements of the curette. The most to its use in cases No. of cases...... 100A 100. formidable objection Days of ...... 810. 350. of septic abortion is that even with the dullest 8.1 3.5 instrument and the softest strokes new wounds Average days of fever.... are made and the spread of the infective process Total days in hospital.... 13.28 8.48 is likely to result. DeLee says "My experience Average days in hospital.. 193 4 has taught me that the traumatism of curettage, Complications...... 191 digital or instrumental, may be fatal-a super- Deaths ...... 3.1 ficial and not dangerous infection being converted Percentage mortality. 3. 1. into one with strong invasive qualities." If the In my series of thirty-one cases of septic abor- symptoms are due to infected uterine contents, tion, one only was treated actively and this patient nature can usually be relied upon to empty the died. In her case criminal interference was ad- uterus -in due course. Their retention in the mitted, and after a long perio(d of expectant treat- uterus can do no harm. The organisms in the ment the uterus was curettec1 owing to the con- mass may be leading what is practically a sapro- tinuance of a fairly brisk haemorrhage. Her phitic existence. To employ an instrument to temperature before operationL did not rise above remove them may give these organisms an oppor- 100 but did not continue normal. She also tunity to actively invade. Fothergill (11) speaks vomited occasionally. The curette should not of using the curette before the pathogenic organ- have been used. Packing vvould have emptied isms have entered the blood stream. If the in- the uterus without as much danger. Thirty-six fection is due to a virulent organism it is far hours after operation she hac1 a severe chill with beyond the reach of the curette by the time an acute rise of temperature She died in four symptoms appear. days with acute bacteremia. The thirty cases The following is the treatment suggested: The treated expectantly recoverecA promptly with the patient is put to bed in the Fowler position, seated exception of one who develolped a double salpin- upon a sling pillow. She is better in a hospital, gitis and in whose case a histo ry of gonorrheea was where she can receive skilled care and be shielded obtained. from visitors and annoyances. She should be put Operative treatment by curettage, digital re- on a two-hour pulse-temperature chart. Water moval, tamponade, and douches is in each case and nourishing fluid diet should be given in open to the same objectiori. It is ineffectual abundance. The bowels are opened by enemata more often than not failing to remove the products and gentle laxatives. An ice bag is placed over of conception, and is in itselfE a source of danger. the lower abdomen. If fluid is not taken freely The curette is especially harmtful and it is doubtful by mouth glucose or saline solution is given per if a thorough curettage of th e uterine cavity was rectum; or if not tolerated there, by subcutaneous ever done. Its configuratioi* is such that it is injection. Appropriate stimulation is given if impossible for the scraping edge to cover more required. Ergot or pituitin are used to keep the than half the surface. It is true that gross par- uterus in contraction. This probably blocks tidles may be removed, but iitisnever possible to lymphatic channels. Quinine is often useful to be sure that the uterus is empty. remove retained products of conception. After Many authors report cases in which pregnancy the temperature has been normal for five full days has gone to term after what was thought to be a and the uterus is not empty, the contents should thorough curettage of the ulterus. A few weeks be removed. The patiernt's return to health is ago I was associated with a skilful obstetrician in a thus expedited. case of pernicious vomiting olf pregnancy. Inter- Should haemorrhage have to be reckoned with ruption of pregnancy was th( e decision of counsel. during the course of septic abortion, the following My colleague dilated and packed with gauze. The procedure is recommended: With the patient patient did not abort. She was again antsthet- prepared for operation, with plenty of assistants ized and curetted. It waEs thought that the and if possible without anawsthetic, pass the largest products of conception were removed completely. sized tubular cervical speculum that can be got Some days later she passed a large decidual mass. in and through it pack weak iodoform gauze with

history-of-obgyn.com obgynhistory.net 168 THE CANADIAN MEDICAL ASSOCIATION JOURNAL

blunt dressing forceps. Then about the cervix 4.-RoSENOW, E. C. Focal Infection and Elective Local- pack sterile cotton layer upon layer until the ization of Bacteria: Surg., Gynac. and Obstet., vol. 33, 19. 5.-DE LEE, J. B. Principles and Practice cf Obstetrics, vagina is full. In twenty-four hours the packing third edition, p. 438. is removed and with it is usually found the pro- 6.-BONEY, V. Brit. Med. Jour., 1920, ii, 263. ducts of conception. 7.-POLAK, J. 0. Indications for Operation in Spreading Peritonitis of Post-Abortal and Post-Partal Origin. Trans. REFERENCES Amer. Gynec. Soc., 1920. 8.-DE LEE, J. B. Prin. and Prac. of Obstet., 3rd edition 1.-POLAK, J. 0. Pathology of Common Puerperal p. 438. Lesions: Amer. Jour. Obstet and Gynac., 1, 547, March, 1921 9.-WILLIAMS, Amer. Jour. Obstet., September, 1899. 2.-TALBOT, J. E. A Clinical Study of the Placenta: Surg., Gynac. and Obstet., vol. 32, 552. 10.-HILLIS, D. S. The Treatment of Abortion: Surg., 3.-RoSENOw, E. C. Studies in Elective Localization: Gynec. and Obstet., December, 1920. Jour. Dent. Research, vol. 1, No. 3, September, 1919. 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 recognized Add to these tests the serological reactions, and as a measure not only of great diagnostic we have further enhanced our methods of diag- value, but also of considerable therapeutic benefit. nosis. In spite of all our tests, however, the The information derived from the examination clinician may at times find great difficulty in of the spinal fluid, and the relief experienced on arriving at a definite conclusion in cases showing its removal, is, we believe, greatest in the acute symptoms of lesions of the central nervous inflammatory conditions, such as septic menin- system or cord, in fact at times he may not only gitis and epidemic cerebro-spinal meningitis. To be helped little, but may actually be misled by these we may add also the tuberculous meningitis. the laboratory findings. Our present laboratory methods enable us in these This study has been confined to conditions, for acute conditions to make a diagnosis so easily the most part, purely medical, or cases met with that it would seem little could be added from the in the medical wards and outdoor clinics. It laboratory standpoint. consists of observations on the spinal fluid findings The varied characteristics, however, of the in cerebral hawmorrhage, cerebral thrombosis, spinal fluid in certain more or less obscure cerebro- cerebral lues, encephalitis lithargica, poliomy- spinal conditions and their relation to the blood elitis, brain tumour, brain abscess, tabes dorsalis, findings in the same patients, seem to be sufficient myelitis and so-called meningismus. The findings excuse for the presentation of a few figures, have been of interest not only from a medical and gathered from the study of 130 examinations of a scientific point of view but also from a medico- the spinal fluid made in connection with the work legal aspect. Several cases have come under of the medical departments of the Montreal observation in which a definite diagnosis was Geaeral Hospital and the Western Hospital during necessary, in that men have taken actions in law the past four and a half years. courts to recover damages for disabilities which Laboratory methods for estimating increase in they attributed to accident. Others have arisen the number of white cells, or increase in the in which the obligation to pay insurance was amount of globulin, have become very accurate, questioned by the company. and have enabled us to detect the slightest evi- Here may be cited two illustrative cases: dence of acute or chronic inflammatory reaction. R. S., male, age 38, employed as a laborer, fe

history-of-obgyn.com obgynhistory.net