Letter C (part 1 of 3)
Case No. 2.--Miss ----, æt. twenty-two, a brunette of French parentage, came to the clinic for the purpose of having removed from the vagina a tumor of a year's growth, which she said was still rapidly growing, making it difficult and painful for her to walk or engage in any pursuit. The tumor of which she spoke is the one represented by Fig. 31. The operation for the removal of the tumor simply consisted in excising the entire mass and putting a ligature around the base of the hypertrophied clitoris. Three days after a hard-rubber vaginal dilator was inserted, and ordered to be worn most of the time until the parts were healed.
In the first case here reported there was no evidence of any syphilitic taint, but the woman lived in a markedly malarial district. In the last one there were indications of a syphilitic taint. A microscopic examination of the tumor of each case plainly showed its pachydermatous character. Both women were very dark brunettes, each having a coarse, tawny skin, and neither was over-cleanly in her habits.
An important indication relating to operative treatment in this locality is the use of the galvano- or thermo-cautery, particularly the latter, owing to the great vascularity of the parts and the lack of points upon which to exercise counter-pressure to control hemorrhage.
Hæmatoma.
DEFINITION.--Hæmatoma of the vulva is also designated as thrombus or pudendal hæmatocele. This affection consists of an effusion of blood in subcutaneous or submucous cellular tissue of the vulvo-vaginal region; the effusion occurs usually in one labium or in the cellular tissue surrounding the vaginal walls, and, later becoming coagulated, forms a tumor which may vary in size. The tumors sometimes attain the size of a foetal head.
ETIOLOGY.--Hæmatoma generally occurs during pregnancy or during labor, usually from some injury, but rarely spontaneously or in the non-pregnant. Muscular effort during childbirth, blows, kicks, falls, the passage of the foetal head, or anything which can obstruct the return of venous blood or produce rupture of the veins, may be a cause.
SYMPTOMATOLOGY.--The patient will have a feeling of discomfort, later pain of a throbbing character, and often difficult urination on account of the tumor encroaching upon the urethra. If the tumor is very large she will experience some degree of faintness.
DIAGNOSIS.--The sudden appearance of the tumor with the symptoms alluded to usually renders diagnosis an easy task. The affections which may possibly be confounded with this are abscess of the labia, inflammation or cysts of the glands of Bartholini, and pudendal hernia.
TREATMENT.--If the effusion should be small and the symptoms light, but little is demanded except quiet and cooling lotions, like the lead-and-opium wash. If there is effusion in the labia and there are indications of suppuration, it should be treated as phlegmonous inflammation by hot poultices, etc.[20]
[Footnote 20: Vide Phlegmonous Inflammation of the Labia, p. 391.]
{402} It is sometimes necessary during labor, in order to complete it, that a free incision is made in the tumor and the clot turned out with the fingers. This same treatment is often requisite when the tumor is very large and there are good reasons for believing that it will not undergo absorption. It is generally advisable to pursue the same course if a thrombus has existed for some time and there are no signs of absorption or suppuration, by reason of the continued discomfort and pain to which the patient is subject.
After the clot is removed there is often a renewal of the bleeding, in which case the cavity should be plugged with lint or surgical cotton and pressure applied by means of vaginal tampons and external bandages. Sometimes it is requisite to saturate lint or cotton with liquid persulphate of iron, and finally pack the cavity with it in order to check the bleeding. If there is no hemorrhage after the evacuation of one of these tumors, then there is no need of packing or making use of styptics, but it is necessary to prevent phlegmonous inflammation or septicæmia. For this purpose iodoform or carbolic acid should be used and a free outlet provided for the discharge of pus. Washing out the cavity with a weak solution of the permanganate of potassium[21] also serves a good purpose.
[Footnote 21: The author usually directs that from 4 to 8 grains of this salt shall be added to each pint of warm water when it is to be used as an injection or wash.]
Cancer of the Vulva.
Cancer is not a common disease of the vulva, yet as a primary affection it attacks this locality more frequently than the vagina.
Epithelioma is the most common form, and generally appears in the outset near the clitoris or on one labium as a small hard and warty growth, which at first itches and later smarts, but is not painful.
After an indefinite length of time the growth, which has increased somewhat in size, becomes painful, ulcerated, and there is more or less of an offensive ichorous discharge. If the disease pursues its natural course, the ulceration will rapidly extend until neighboring tissue becomes involved; the inguinal glands become affected, and after the characteristic cachexia becomes apparent there is no known remedy or means of treatment that can prevent the progress of the disease to a fatal termination.
If the clitoris becomes affected with this form of malignant disease, it can be detected earlier than epithelioma of any other portion of the organs of generation on account of its more external position, its greater sensitiveness, and the increasing pain which the affection and its enlargement produce.
TREATMENT.--If the disease is detected sufficiently early, an entire removal of all the affected parts, including a wide margin of healthy tissue, will generally effect a cure; but postponement until neighboring parts, more particularly the lymphatic glands, are implicated leaves little or no hope of cure through any mode of treatment. Carcinoma of the vulva is generally an extension of the same disease from the uterus or the inguinal glands, and rarely occurs as a primary affection.
{403} Urethral Caruncle.
This painful affection, commonly included by medical authors as among diseases of the vulva, will be very briefly considered.
DEFINITION.--The most common neoplasm to which the urethra is subject is known as urethral caruncle, vascular tumor, or irritable vascular excrescence of the urethra. These growths consist of all excrescences located at the mouth of the urethra, and sometimes extending within the canal for a short distance. They are of a deep-red color, soft and friable, sometimes regular in shape, but more frequently irregular, and then resemble a small cockscomb. They vary in size from the head of a pin to a raspberry, occasionally attaining that of a walnut.
ETIOLOGY.--No definite cause can be given for the development of urethral caruncle. These growths occur among married and single, old and young.
SYMPTOMS.--The first symptom generally is that the patient experiences a severe smarting pain during or immediately after voiding urine. Pain is also caused by walking, pressure, friction, or even the slightest contact of clothing. Also sleep is frequently disturbed in consequence of slight movements of the body. Coition not only causes a severe pain, but, owing to the friable and vascular character of the growth, it often causes a flow of blood, which leads the subject to believe she has cancer or some other serious disorder. In addition to the foregoing symptoms the patient usually becomes fretful, nervous, hysterical, and melancholy. The severity of one's suffering when thus affected is very much out of proportion to the size of the growths giving rise to it.
Occasionally there will be a feeling of weight and pain in the pelvic region, extending down the thighs. There will also be a muco-purulent discharge from the urethra.
PATHOLOGY.--Urethral caruncles may be briefly defined as consisting of "dilated capillaries in connective tissue, the whole being covered with squamous epithelium."[22]
[Footnote 22: Hart and Barbour.]
DIAGNOSIS.--(This has been given in part under head of Symptoms.) If there is protrusion of any portion of the caruncle the diagnosis is easy. Yet a prolapse of the urethral mucous membrane or of the urethra may be mistaken for a vascular tumor, but there will not be the characteristic pain attending either of these conditions that invariably accompanies caruncle of the urethra.
Syphilitic growths are sometimes located here, but they are wart-like and painless, and generally have companions in the same neighborhood.
By placing the patient on her back in the lithotomy position and carefully inspecting the parts a diagnosis is by no means difficult. When the growths are within the meatus slight dilatation may be requisite to see them, for which purpose a pair of ordinary dressing-forceps will usually suffice.
TREATMENT.--Owing to the liability of the recurrence of caruncles their simple removal by a cutting instrument will not, as a rule, suffice. Various modes of treatment have been recommended, but the most efficacious can be very briefly stated as follows: The patient being anæsthetized and placed on her back, the growths are then removed and their bases {404} thoroughly cauterized by Paquelin's thermo-cautery at a dull heat; if of a large size it is a better plan to first remove them by scissors and then apply the cautery. If a thermo- or galvanic cautery is not at hand, a knitting-needle heated in the flame of a spirit-lamp will serve a good purpose.
Atresia.
Although the subject is referred to here in its regular order, yet for the greater convenience of the reader vulvar atresia has been included by the author in the preceding section on Diseases of the Vagina (see p. 373).
Eruptions.
The skin and mucous membrane of the vulva may develop eruptions common to such tissues in other parts of the body. Those most often found are eczema, erythema, herpes, and acne. They are not distinguished from eruptions located elsewhere, except it may be their greater obstinacy in responding to treatment.
{405}
DISORDERS OF PREGNANCY.
BY W. W. JAGGARD, A.M., M.D.
"Gestation," says Mauriceau, "is a disease of nine months' duration." Robert Barnes[1] more truthfully remarks: "Since in pregnancy every organ and the whole organism are specially weighted, undergoing extraordinary developmental and functional activity, so any defect or fault inherited or acquired, however latent, will be liable to be evolved or intensified under the trial. Hence pregnancy is the great test of bodily soundness." The pregnant woman is liable to many disorders which can be distinctly traced to the existence of pregnancy. The study of the natural history of gestation renders it highly probable that these disorders are merely pathological exaggerations of physiological functions. Then, pregnancy confers upon the individual no immunity from the diseases to which the non-pregnant woman is liable. But certain acute and chronic diseases, sustaining the relation of accidental complications, are variously modified in their course and effects by pregnancy, and accordingly are of interest to the general practitioner.
[Footnote 1: Obstetric Medicine and Surgery, 1884, London, p. 205.]
For convenience of discussion the disorders of pregnancy may be classified under two headings: I. The Pathological Exaggerations of Physiological Processes; and II. The Peculiarities of Certain Accidental Acute and Chronic Diseases occurring in the Course of Pregnancy.
* * * * *
I. THE PATHOLOGICAL EXAGGERATIONS OF PHYSIOLOGICAL PROCESSES.
It is always difficult, frequently impossible, to draw the boundary-line at which normal functional activity becomes pathological. As remarked by Spiegelberg, all the diagnostic penetration of the physician is demanded to recognize this transition. Then, a high exercise of judgment is necessary to determine when to preserve a wise and masterly inactivity, when to adopt measures of active interference.
Alterations in the Constitution of the Blood.
CHLOROSIS AND HYDRÆMIA.
Recent investigations show that qualitative and quantitative changes occur in the constitution of the blood of the normal pregnant woman. The {406} red corpuscles, albumen, and iron diminish, while the white corpuscles, fibrin, and aqueous elements increase. Virchow describes this increase in the number of white corpuscles as a physiological leucocytosis dependent upon the growth of the lymph-vessels and corresponding hypertrophic changes in the pelvic and lumbar lymphatic glands. The total blood-mass is also increased--a change especially notable in the second half of pregnancy. When the number of red blood-corpuscles is abnormally diminished the woman becomes chlorotic. If, in addition, the albumen is abnormally diminished, hydræmia results. Chlorosis and hydræmia can only be regarded as independent affections in the absence of cardiac and renal lesions. They are seldom traceable to pregnancy in the absence of individual predisposition. Effusions into the subcutaneous connective tissue, pleural and peritoneal cavities, are liable to occur. Sudden exudations into the pleural cavity are particularly dangerous, while effusions into the subcutaneous tissue of the abdomen, vulva, and lower extremities are annoying and may interrupt pregnancy.
TREATMENT.--The indications for treatment are obvious. The quality of the blood must be improved, elimination of the aqueous elements attempted, and local disturbances alleviated. Nutritious food, iron in combination with non-irritant diuretics, fulfil the first two indications. Blaud's pill, which Niemeyer and Spiegelberg extol so highly, is an excellent tonic preparation. Basham's iron mixture is admirable in its effects.
PROGRESSIVE PERNICIOUS ANÆMIA.
Gusserow[2] was the first to observe and describe a peculiar form of progressive pernicious anæmia occurring during gestation. The disease is of rare occurrence, and nothing is known as to its etiology. Chlorosis and hydræmia, however, may be mentioned as predisposing causes.
[Footnote 2: Arch. f. Gyn., ii. p. 218.]
PATHOLOGY.--The alterations in the constitution of the blood are identical with those in anæmia and hydræmia, and produce similar effects. Evidences of fatty degeneration are found in the musculature of the heart, intima of the arteries, and portions of the capillary walls; retinal hemorrhages are constant lesions. The number of white corpuscles is not increased, and signs of leukæmia--splenic tumor, swelling of the lymphatic glands--are wanting. The condition is that of oligæmia or oligocythosis.
The prodromal symptoms occur during the first half of pregnancy, are obscure, and cannot be distinguished from the effects of chlorosis and hydræmia. After the disease has passed through its incipient stages, food, iron, and tonics seem to have no influence upon its course. During the second half of pregnancy abortion or premature labor usually occurs spontaneously. Under these conditions the shock and hemorrhage resulting from parturition are sufficient to cause a lethal issue in many cases.
PROGNOSIS.--Graefe[3] has collected 25 cases of this rare affection: 1 case recovered, 2 cases were discharged improved; the others died before or shortly after labor. The prognosis is obviously grave.
[Footnote 3: Diss., Halle, 1880.]
TREATMENT.--As food, iron, and tonics have little or no effect upon the disease after it has passed through its incipient stages, therapeutic resources are limited. The evacuation of the uterine cavity, as shown by {407} Graefe's cases, exercises a favorable influence upon the course of the affection. Gusserow advises the artificial interruption of pregnancy whenever grave symptoms occur, and the weight of professional opinion is very decidedly in favor of such a course. Negative results have attended all efforts at transfusion.
HÆMOPHILIA.
Kehrer[4] has recently called attention to the apparent influence of pregnancy in the development of the hemorrhagic diathesis. This influence, however, is seldom observed, and then only in cases of distinct, individual predisposition.
[Footnote 4: Arch. f. Gyn., x. p. 201.]
TREATMENT.--The induction of premature labor, or, at times, of abortion, is indicated.
PLETHORA.
The experiments and observations of Spiegelberg[5] and Gscheidlen prove the possibility of the occurrence of plethora during gestation. Actual increase of the red corpuscles, albumen, and iron in the blood is observed during the second half of pregnancy, and then only under the most favorable conditions. As described by Spiegelberg, the symptoms are--mammary and cerebral congestions, palpitation, vertigo, constipation, hepatic torpor.
[Footnote 5: Lehrbuch d. Geburtshülfe, Lahr, 1882, p. 58.]
TREATMENT.--Restricted diet, muscular exercise, and an occasional saline purge will relieve the troublesome symptoms. Spiegelberg is convinced of the value of bleeding in selected cases.
Circulatory Disturbances.
Among the circulatory disturbances due to pregnancy, mechanical oedema and the varices of the pelvis and lower extremities deserve attention.
De Cristoforis of Milan describes a mechanical inferior venous hyperæmia, the result of the pressure of the gravid uterus on the iliac veins. The mechanical oedema of the abdominal walls, vulva, and lower extremities, intensified by chlorosis and hydræmia, is usually associated with venous ectasis. The oedema may become so excessive that locomotion is rendered difficult, while the labia are enormously distended and the subcutaneous tissue of the abdominal walls becomes pendulous. Toward the end of pregnancy, when the uterus sinks into the pelvic cavity, the oedema and varices frequently abate.
Active measures for the relief of the symptoms produced by oedema are frequently indicated. Threatened gangrene of the skin from hyper-distension may render puncture of the hydropsical regions necessary. It is quite possible to interrupt pregnancy by this little operation, especially if the labia are punctured. Elevation of the lower extremities, rest in the horizontal position, elastic bandages and stockings, local hot packs, mild diuretics, usually fulfil all indications for treatment.
Varices are observed more frequently among multiparæ, but may occur in primiparæ. They are usually developed during the second half {408} of pregnancy. The principal trunk of the saphena is first involved, and subsequently the lateral branches. Congeries of veins are observed on the inner sides of the legs and thighs, especially in the vicinity of the knees. The iliac veins may become dilated, as shown by the condition of the vulvar veins and the occurrence of hemorrhoids. Varices incommode the patient, but seldom cause serious disturbances. Sometimes, however, their tunics are lacerated, and serious even fatal hemorrhage may result. Spiegelberg[6] records four cases of fatal hemorrhage from the rupture of varices in pregnancy. Then there is always the danger of phlebitis and the processes of thrombosis and embolism, even when the loss of blood is insignificant.
[Footnote 6: Lehrbuch d. Geburtshülfe, Lahr, 1882, p. 235.]
TREATMENT.--The regular and gentle evacuation of the bowels will frequently relieve the distressing symptoms due to hemorrhoids. Fordyce Barker points out the fact that aloes is not contraindicated by pregnancy. A pill containing a grain or a grain and a half of powdered aloes, with a quarter of a grain of extract of nux vomica, is a very good remedy. Frequent hot fomentations in conjunction with narcotic ointments will relieve the pain from the congestion of the piles. Attempts at reduction must be instituted with extreme care. It is usually impossible to completely cure the condition during pregnancy, and there is danger of interrupting gestation. Elevation of the lower extremities and equable compression by an elastic bandage or rubber stocking relieve the symptoms caused by varices of the saphena. P. Ruge[7] and A. Martin have seen favorable results from the hypodermatic injection of ergotin.
[Footnote 7: Berl. Beitr. z. Geb. u. Gyn., Bd. iii. p. 7.]
Disorders of the Alimentary Canal.
THE UNCONTROLLABLE VOMITING OF PREGNANCY.
Nausea, even vomiting, in the morning, before or shortly after meals, during the early months of gestation, is so common and devoid of injurious effect that it is regarded as physiological. Robert Barnes views it as a normal means of discharging superfluous nervous energy. The uncontrollable vomiting of pregnancy, in which the stomach retains absolutely nothing, is a grave disorder. The patient vomits glairy mucus, clear or colored by the bile. Ultimately the vomit is mixed with blood. Violent retching, intense nausea, pyrosis, and hiccough are constant and distressing symptoms. The woman becomes emaciated. The buccal cavity is dry, the tongue red and shining, the teeth and gums covered with sordes, the breath horribly fetid, the skin dry and harsh. Salivation is frequently observed. Constipation and extreme thirst usually coexist. The epigastrium is tender upon pressure. The woman becomes restless and irritable from loss of sleep and painful efforts at vomiting. A fever of typhoid type is developed, with a quick, rapid, thready pulse. The urine is sparingly secreted, concentrated, and contains albumen and tube-casts. Jaundice is frequently noticed. Extreme marasmus supervenes, and the woman succumbs to some intercurrent disease or dies of exhaustion in muttering delirium. Phthisis and diarrhoea are intercurrent affections which may hasten the lethal issue.
{409} Between the slight nausea upon rising in the morning and the state of extreme marasmus thus briefly sketched every degree of pathological variation may be observed.
It is a remarkable fact that the incessant vomiting, retching, and hiccough seldom interrupt pregnancy until near its end. The muscular effort and loss of blood at this time may precipitate the fatal termination.
Occasionally, spontaneous abortion or premature labor occurs before the patient's condition is desperate. Under these circumstances the severe symptoms may disappear immediately. The same sudden cessation of the vomiting is frequently observed after quickening, rapid excentric hypertrophy of the uterus, and death of the foetus.
The COURSE of the disorder is chronic. Cases terminate by recovery or death in from two to three months. Alarming symptoms are usually developed from the second to the sixth month--very seldom during the seventh and eighth months.
Fortunately, the uncontrollable vomiting of pregnancy is a rare affection. So few cases are recorded in German medical literature that Hohl[8] has denied the existence of the condition. Carl Braun[9] in a fabulous experience of over one hundred and fifty thousand obstetrical cases has never seen a fatal case.
[Footnote 8: Grundriss d. Geburtshülfe, Kleinwächter, 1881, p. 197.]
[Footnote 9: Lehrb. d. Gynaekologie, Wien, 1881, p. 842.]
PATHOLOGY AND ETIOLOGY.--As the essential predisposing cause of this disorder it is necessary to bear in mind the increased functional activity of the nervous system in general, and of the spinal cord in particular, during pregnancy. Increased reflex mobility is apparent in all the so-called sympathetic affections.
Peripheral irritants are not wanting. The growing ovum stretches the uterine fibres, and consequently irritates the uterine nerves. Bretonneau adduces many facts in favor of this theory. Vomiting is severer in first pregnancies, and occurs during the first half of pregnancy. Vomiting is observed in connection with passive distension of the uterus caused by the unusually rapid growth of the ovum, as in hydramnion and multiple pregnancy. Immediate cessation of all symptoms is frequently noted after quickening, rapid excentric hypertrophy of the uterus, death of the foetus, evacuation of the uterine contents. Henry Bennet directs attention to the importance of congestions, inflammations, and lacerations of the cervix uteri as etiological factors. Graily Hewitt maintains that uterine displacements, with or without incarceration, producing irritation of the uterine nerves, are potent causes. The round gastric ulcer, chronic catarrhal gastritis, are sufficient causes in many cases.
Diseases of the endometrium, decidua, foetal envelopes, or of the foetus itself may supply adequate excentric irritants.
Frerichs has pointed out the connection of hyperemesis with the renal insufficiency of Bright's disease. Kiwisch finds a sufficient cause in the relation between the hyperæsthetic gastric nerves and the hydræmic condition of the blood of the pregnant woman. Lebert and Rosenthal are of the opinion that hyperemesis is symptomatic of extreme general inanition of nervous tissue. Numerous other theories more or less ingenious, and adequately explanatory of certain cases, exist in the literature of the subject. Notwithstanding the extent and accuracy of etiological research {410} into the uncontrollable vomiting of pregnancy, a large class of cases remains in which no organic change capable of objective demonstration can be found.
DIAGNOSIS.--The diagnosis of the uncontrollable vomiting of pregnancy is not so easy as at first apparent. Guéniot[10] pertinently calls attention to three distinct elements: (1) The diagnosis of pregnancy; (2) the diagnosis of the adjuvant or determining cause of hyperemesis; (3) the differential diagnosis between the uncontrollable vomiting of pregnancy and obstinate vomiting from some other cause entirely independent of the pregnant condition.
[Footnote 10: Thèse Agrégation, Paris, 1863.]
Experienced clinicians have committed mistakes, particularly in the third element. Trousseau once made the diagnosis of uncontrollable vomiting of pregnancy in a case in which the autopsy revealed cancer of the stomach. This case was observed by Depaul. Charpentier[11] reports a serious error in diagnosis made by Beau. The case was diagnosticated as hyperemesis of pregnancy. The autopsy showed that the obstinate vomiting was probably due to tuberculous meningitis.
[Footnote 11: Traité pratique des Accouchements, Paris, 1883, t. i. p. 621.]
PROGNOSIS.--Severe vomiting in pregnancy is always ground for anxiety, and the prognosis must always be guarded. The majority of cases terminate in recovery without the interruption of pregnancy. Guéniot records 118 cases: of these, 46 died; of the 72 survivals, 42 recovered after the spontaneous or artificial evacuation of the uterine contents. Recovery usually, though not always, rapidly follows the cessation of pregnancy. The prognosis is absolutely unfavorable after the appearance of fever and typhoid symptoms.
TREATMENT.--The treatment of hyperemesis may be effective. Its efficiency, however, depends largely upon the accurate recognition of the adjuvant and determining causes. A rational therapeusis must consist in the elimination of these etiological factors. The treatment naturally resolves itself into (1) hygienic; (2) medical; (3) gynæcological; (4) obstetrical.
Hygienic.--The hygienic treatment is of avail in the minor degrees of the disorder, although not without influence in the more serious cases. Diet is of primary importance. Let the patient breakfast upon a small cup of strong coffee or tea, half a cup of milk and lime-water, a morsel of cracker or toast early in the morning, in bed, and lie quietly for one or two hours following the meal. Small quantities of easily-digestible food at short intervals will be tolerated when the patient has given up all pretence at keeping to regular meals. Liquid foods, as sparkling koumiss, egg-albumen in water, iced milk with lime- or soda-water, commend themselves. Absolute dietetic rules, however, cannot be maintained. The stomach of the pregnant woman is proverbially capricious and fanciful. Charpentier narrates the history of a case suggestive in connection with this subject. The patient, four months advanced in pregnancy, in a critical condition from uncontrollable vomiting, came under the care of Beau in the Hôpital de la Charité. One day she asked for Bordeaux crawfishes. Beau granted her request. On the first day two crawfishes were retained; on the second, six; on the third, crawfishes ad libitum, bouillon, and milk. Within six days {411} the vomiting disappeared. Cazeaux and Guéniot cite cases in which ham and paté de foie gras were retained after the rejection of easily-digestible foods. It is necessary to respect these caprices and fancies.
When everything is rejected absolute stomach-rest is indicated. Then nutrient enemata may be tried. Of the great value of rectal alimentation under these conditions there can be no doubt. Henry F. Campbell of Georgia relates the history of a case in which he nourished the patient for fifty-two days by the rectum alone. There is danger, however, of irritating the rectum and causing diarrhoea--a peculiarly unfavorable complication at this time; and this fact must be clearly borne in mind. Of the various nutrient enemata, peptonized milk, cream, defibrinated blood, Leube's beef-and-pancreas mixture, eggs, and beef-tea containing albumens are among the best. From four to six ounces should be exhibited not more frequently than once every six hours.
Inunctions of oil are of undoubted value. Absolute moral and physical rest frequently exercises a favorable influence. Seyfert advised his patients to go home on a visit to their mothers, and return to the conditions to which they were accustomed prior to marriage. Coitus may be a disturbing factor. Rest in the horizontal decubitus exercises as favorable an influence as in sea-sickness.
Medical.--There are few drugs in the Pharmacopoeia which have not been vaunted as specifics by some and found utterly worthless by others. This fact indicates, as remarked by Schroeder, that all remedies are unreliable, and that spontaneous cures frequently occur. Various effervescent liquids, as dry champagne, carbonic-acid water containing one drachm of potassium bromide to the siphon, are sometimes grateful. Subnitrate of bismuth and the antacids are of great value in cases of excessive gastric acidity. Oxalate of cerium, a much-vaunted remedy, is of very little value. Small doses of the tincture of nux vomica are useful in cases of gastric catarrh. The various local anæsthetics are of great importance. Small doses of creasote, carbolic acid, tincture of aconite-root, hydrocyanic acid, and the volatile oils have been used with varying degrees of success. Of this class of remedies cocaine hydrochlorate deserves especial attention. On a priori grounds there is much in its favor. Clinical experience with the drug is not such as to warrant very positive deductions. W. Otto[12] has employed cocaine in sea-sickness, especially in pregnant women, with favorable results. Manassein[13] reports several cases of hyperemesis of pregnancy cured by its exhibition. The subject is certainly worthy of thorough investigation. G. Gaertner of Vienna states that 0.1 cocainum muriaticum has no toxic effect upon adults. Doses of 0.015-0.02 of the solution (cocain. muriat. sol. Merck, 1.0; aq. destill. 9.0) may be given to an adult three times daily without fear of toxæmia. Goodell recommends drop doses of wine of ipecacuanha and tincture of belladonna, repeated every fifteen minutes.
[Footnote 12: Berl. klin. Woch., 1885, No. 43.]
[Footnote 13: Ibid., 1885, No. 35.]
Of all medical agents, however, opium, the bromides, and chloral are the most reliable. A clyster containing thirty or forty drops of the deodorized tincture, or a half-grain suppository of the aqueous extract of opium, sometimes produces a happy effect. Hypodermatic injections of morphine will frequently allay the distressing symptoms after the failure of other measures. In the German hospitals large doses of the bromides {412} and chloral are exhibited per rectum with gratifying success in many cases.
Flying blisters, the ether spray, and the faradic current applied to the pit of the stomach may give relief in the milder forms of the disorder.
Gynæcological.--Under the gynæcological treatment of hyperemesis quite a number of important operative procedures are included: 1. If bimanual examination reveals a displacement of the uterus capable of producing symptoms, the organ must be replaced if possible, and retained in position by a properly fitting pessary. 2. Henry Bennet suggested the cauterization of the cervix in all cases, basing his therapy upon his peculiar views of the pathology of the condition. Welponer, Sims, and Jones recommend the application of a 10 per cent. solution of argentic nitrate to the vaginal portion of the cervix in all cases, irrespective of the condition of the cervical tissues, when other means have proved useless. Carl Braun[14] bears testimony as to the value of this procedure. 3. As an ultimate resource before artificially interrupting gestation, the plan of dilating the os externum and cervix uteri with the index finger should be tried. Copeman[15] of Norwich, England, desirous of inducing abortion in the case of a patient afflicted with hyperemesis, pushed his finger through the cervical canal to the membranes and attempted to puncture the amnion with a sound. Failing to accomplish his purpose, he went home for assistance, and returned at the expiration of two hours. To his surprise, the uncontrollable vomiting had ceased. Since 1875, when he published the results of this experience, cases have accumulated proving the great value of this method. W. Gill Wylie[16] of New York has devised a steel dilator to substitute the finger. When the os externum is at all patulous, the index finger is the safest and most efficient dilator. The method is a purely empirical one, does not always secure the desired result, and frequently causes abortion or premature labor. Still, as the ultimate gynæcological resort it has important functions.
[Footnote 14: Lehrb. d. g. Gynaekoloqie, 1881, p. 841.]
[Footnote 15: Brit. Med. Journal, 1875, 1879.]
[Footnote 16: N. Y. Med. Record, Dec. 6, 1884.]
Obstetrical.--The evacuation of the uterine contents, if effected before the development of the febrile stage, is usually followed by immediate disappearance of all distressing symptoms. In the large majority of cases, however, the same end may be secured by a judicious combination of the hygienic, medical, and gynæcological methods of treatment to which attention has been directed. The weight of professional opinion is decidedly opposed to the procedure. For practical purposes the induction of premature labor may be excluded from consideration. The woman usually recovers or dies before the period of foetal viability. Carl Braun[17] gives expression to the very general professional conviction upon this subject in the following words: "I myself have never observed a lethal issue in consequence of the uncontrollable vomiting of pregnancy, lay the greatest weight upon the expectant management and more modern medicamentation, and am of the opinion that after a conscientious estimate of all considerations and contraindications, artificial abortion can be omitted, notwithstanding its permissibility from a scientific point of view when extreme danger to maternal life has been determined by several physicians."
[Footnote 17: Lehr. d. g. Gynaekologie, 1881, p. 842.]
{413} PTYALISM.
The excessive secretion of saliva is a rare disorder of pregnancy. At all times distressing, it may seriously endanger the patient's life when the quantity of fluid amounts to several quarts per diem. The parotid and submaxillary glands are swollen and tender. The buccal mucous membrane is red and tumid. The absence of fetor serves to distinguish the salivation of pregnancy from the ptyalism of mercurial poisoning. A generous diet and the free exhibition of iron mitigate in some degree the distressing symptoms. Dewees recommends a strictly animal diet. Astringent mouth-washes, small doses of potassium iodide, and subcutaneous injections of atropine over the submaxillary glands are indicated, but seldom influence the condition.
TOOTHACHE.
Toothache in pregnancy may be a purely functional disorder. In the majority of cases, however, actual caries is present. During gestation the secretions of the buccal cavity are sometimes altered, and become sufficiently acid to dissolve the lime salts out of the enamel. Again, when for any reason an insufficient quantity of lime salts is ingested with the food, the foetus is supplied with ossific materials derived in part from the maternal teeth. The condition of pregnancy is not infrequently detected in the dentist's chair from these changes. Popular recognition of these dental changes gave origin to the familiar saw, "For every child a tooth." The indications for treatment are obvious. Quinine and local anæsthetics relieve the symptoms of the functional forms of the disorder. Caries may be prevented, to a certain degree, by extreme attention to the teeth and secretions of the buccal cavity and a free, generous mixed diet. Doubtless, the popular belief, that an absolute fruit diet will limit the deposition of ossific material in the foetal skeleton and render labor easier, is responsible for much of the caries observed in American women. It is needless to say that such a belief is utterly without foundation in fact. When structural changes in the teeth have occurred the decalcified dentine should be excavated, and temporary fillings of oxyphosphates or gutta-percha inserted. This little operation can be performed rapidly, without pain or fatigue, and preserves the contour of the teeth.
CONSTIPATION.
Constipation is a usual, sometimes a troublesome, attendant upon gestation. The etiological factors are mechanical interference of the gravid uterus with intestinal peristalsis, defective innervation of the bowels, and alterations in the intestinal secretions. When the rectum becomes filled with scybalous masses the condition predisposes to abortion or premature labor. Diet is of primary importance in securing regular evacuations of the bowels. Fresh fruits, brown bread, oatmeal porridge are useful to this end. Enemata have obvious advantages over all drugs. In the selection of aperient remedies care must be taken to choose laxatives and avoid drastic cathartics. The compound licorice powder and confection of senna of the U. S. Pharmacopoeia, Hunyadi, Friederichshalle, and Pullna mineral waters, may be included in the list.
{414} DIARRHOEA.
Diarrhoea is a less frequent but more dangerous disorder during pregnancy than constipation. In the early and latter months of gestation diarrhoea is liable to occur from mechanical compression of the rectum by the gravid uterus. Dysentery, with tormina and tenesmus, is a particularly unfavorable complication. The dangers are apparent. Not only is the blood impoverished, but abortion or premature labor may be induced. Every diarrhoea occurring during pregnancy demands immediate attention. Small doses of argentic nitrate in combination with opium, in pill form, are useful in mild cases of diarrhoea, while the deodorized tincture of opium in starch-water enemata is indicated in dysentery.
Diseases of the Liver.
In normal pregnancy the functions of the liver in the secretion of bile and the excretion of cholesterin are not materially modified. The case is different with the glycogenic function. Blot in 1856 detected the presence of glycogen in the urine of nearly half the pregnant women examined. He concluded that this glycosuria was physiological. Tarnier in 1857 called attention to certain structural changes in the liver occurring during normal gestation. The liver is enlarged in volume, and a peculiar fatty infiltration within the lobule is perceptible. De Sinéty confirmed Tarnier's observations, finding the fatty infiltration within the centre of the lobule, seldom near the periphery. Robert Barnes and Ewart have added corroboratory testimony. Tarnier ascribes the physiological glycosuria announced by Blot to the fatty infiltration observed by himself. Each of these three functions of the liver, the secretion of bile, the excretion of cholesterin, and the glycogenic function, may undergo pathological exaggeration during pregnancy.
ICTERUS.
Icterus is observed with relative infrequency during gestation. Two distinct forms are recognized--simple jaundice, with bright-yellow coloration of conjunctivæ and skin, without fever and cerebral symptoms; and malignant jaundice, with dull-yellow coloration of conjunctivæ and skin, with fever and cerebral symptoms.
Simple Jaundice.--Simple icterus may occur at any time during pregnancy, runs its usual course, and exercises, as a rule, no serious influence upon the maternal health. The effect upon the foetus is grave. If the icterus is intense and lasts for a considerable period of time, the foetus dies and gestation is interrupted. All the foetal tissues are found to be stained with the biliary coloring matters--a condition termed by Lobstein cirrhonosis.
ETIOLOGY.--The causes of simple jaundice in pregnancy are identical with those which produce the condition in the non-gravid state, and are frequently obscure. It is in a high degree probable that pressure from the gravid uterus is without influence, since the symptom may appear at any time during gestation. The pathological condition usually present is catarrh of the mucous membrane of the duct or of the duodenum in the vicinity of the orifice, causing a narrowing of its lumen.
{415} SYMPTOMS.--The conjunctivæ, skin, and urine are colored bright yellow, and there is entire absence of febrile and cerebral symptoms.
The PROGNOSIS and TREATMENT, so far as the mother is concerned, are the same as in the non-pregnant state. In view of the possible causative relation between simple and malignant icterus, and the injurious effect upon the foetus, medical treatment should be instituted at once. Restricted diet, mercurials or ipecacuanha, followed by saline cathartics, are the more important measures. Artificial abortion or the induction of premature labor has no effect upon the condition. This operative procedure is indicated in the interest of the child, however, when the icterus is intensive, of long duration, the foetus living and viable, the frequency of the foetal heart-beats diminished, and there is reason to fear its death. Carl Braun recognizes very distinctly the force of this indication.
Malignant Icterus.--Malignant icterus, due to the acute yellow atrophy of the liver of the pregnant woman (Rokitansky), is a very rare disease. Carl Braun has observed the condition only once in twenty-eight thousand cases from 1857 to 1863.
ETIOLOGY AND PATHOLOGY.--Very little is known as to the causes of acute yellow atrophy of the liver. Virchow ascribes one case coming under his own observation to compression of the lower half of the liver and gall-bladder by the growing uterus. The rarity of the affection and its occurrence irrespective of the time of pregnancy prove the limited operation of this etiological factor. It is in a high degree probable that the disease may have its starting-point in simple catarrhal icterus.
The liver is ochre-colored, shrunken to one half its volume, and flaccid. On section no signs of lobular structure are visible. Microscopical examination reveals total destruction of the acini and hepatic cells. In the place of the glandular elements, fat-globules, fine granular detritus, crystals of leucin and tyrosin are noted. The spleen is enlarged and the kidneys show acute inflammatory changes. Extensive ecchymoses are observed under the skin, pericardium, and gastric mucous membrane.
SYMPTOMS.--The prodromal symptoms of acute yellow atrophy of the liver are usually overlooked. A trivial jaundice with slight elevation of temperature may precede by several days the development of cerebral symptoms. Difficulty in speech, headache, disorders of the senses followed by delirium, convulsions (cholæmic eclampsia), and coma are the more important symptoms of cerebral origin. The pulse is remarkably frequent and small. The temperature is at first elevated several degrees, but becomes subnormal prior to death. The urine is sparingly secreted, highly colored by the bile-pigments, and contains albumen, tube-casts, leucin, tyrosin, and cholesterin. Urea, uric acid, and the urates are diminished. The combination of symptoms points to the retention within the system of the waste products usually excreted by the liver and kidneys. Ultimately, a condition of complete hepatic and renal insufficiency obtains.
DIAGNOSIS.--The dull yellow color of the skin and conjunctivæ, with fever and cerebral symptoms, is a sign of greatest diagnostic value. Physical exploration reveals tenderness on pressure over the hepatic region, and rapidly diminishing area of hepatic dulness on percussion. Care must be taken to exclude acute phosphorus-poisoning--a toxæmia {416} simulating very closely acute yellow atrophy, and repeatedly confounded with that affection.
PROGNOSIS.--No case of recovery has been recorded up to the present time. The disease pursues a rapidly fatal course, terminating within a few days after the development of the icterus.
TREATMENT.--Therapeutic measures must be addressed to prophylaxis. It is necessary to regard simple icterus as a possible prodrome of the malignant form of the disorder.
DIABETES MELLITUS.
The most superficial discussion of the disorders of pregnancy would not be complete without some mention of diabetes. The existence of physiological glycosuria during pregnancy and lactation has been demonstrated. Bernard has shown that sugar appears in the placenta of calves at an early period, attains its maximum in the third or fourth month, and when the glycogenic function of the foetal liver is established entirely disappears. The relation between physiological glycosuria and that pathological exaggeration of a normal process, diabetes mellitus, is very obscure. It is, however, a clinical fact that diabetes mellitus occurs more frequently in the pregnant than in the non-gravid woman. Diabetic women are less apt to conceive. When conception does occur, pregnancy is liable to interruption from the death of the foetus. Under these circumstances glucose is found in the amniotic liquor and foetal urine. A case related by Bennewitz and cited by Matthews Duncan indicates that diabetes mellitus may be developed during successive pregnancies, and entirely disappear during the intervals. The influence of pregnancy in developing a latent diabetic tendency may be accepted as established. A clinical observation of some importance is that diabetic coma is seldom developed.
PROGNOSIS.--Matthews Duncan[18] has collected the histories of 22 pregnancies in fifteen women varying in age from twenty-one to thirty-eight years: 4 of the 22 pregnancies terminated fatally by collapse, rather than by coma. The majority of the children died during pregnancy after attaining to the age of viability. Two children were feeble at birth, and died a few hours later. One infant was diabetic.
[Footnote 18: Obstet. Trans., vol. xxiv. p. 256.]
TREATMENT.--The hygienic and medical treatment of diabetes mellitus occurring during pregnancy does not differ from the therapy in the non-gravid state. There is great diversity of opinion upon the subject of the induction of premature labor. On a priori grounds it would seem to be indicated in the interest both of the mother and the child in the graver cases. In the entire absence of authoritative clinical experience, however, the operation must be resorted to with an extreme degree of caution.
Diseases of the Kidneys.
Albumen is found in the urine of from 3 to 5 per cent. of all pregnant women.[19] In parturient women albuminuria is of much more frequent occurrence. Leube's researches indicate the existence of physiological {417} albuminuria in the pregnant as in the non-gravid state. It is a matter of great practical difficulty to determine the limits of this normal functional activity. In a large proportion of cases the boundary-line between health and disease is passed. The physiological function undergoes pathological exaggeration, and various forms of nephritis are produced.
[Footnote 19: Schroeder, Lehrb. d. Geburtshülfe, Bonn, 1884, p. 373.]
ETIOLOGY AND PATHOLOGY.--The types of renal disease to which pregnancy stands in more or less direct causal relation are numerous.
1. Leyden describes a condition, the kidney of pregnancy, which may be regarded as the intermediate stage between health and disease. The amount of albumen is increased; hyaline and granular casts, with renal epithelium, showing fatty changes, appear in the urine. This fatty degeneration of the cells covering the glomeruli and lining the uriniferous tubules is not of an inflammatory nature. Anasarca of the lower extremities is usually present. The condition may last for an indefinite period of time without causing serious symptoms. With the expiration of the term of pregnancy it may disappear, leaving no trace of its former existence. On the other hand, the kidney of pregnancy may be the starting-point of some serious renal lesion.
2. Latent chronic interstitial nephritis, chronic tubal nephritis, and lardaceous degeneration of the kidney are usually influenced unfavorably by pregnancy, and, in turn, may lead to the interruption of that state. Chronic interstitial nephritis and chronic tubal nephritis may have their origin in the kidney of pregnancy. The cirrhotic kidney is distinguished from the other forms by the abundant aqueous urine, containing comparatively little albumen--none at all at times--cardiac hypertrophy, and hard pulse. In the differential diagnosis of chronic tubal nephritis and the kidney of pregnancy chief reliance must be placed upon the history of the case and the course of the affection. Albuminuria is a very inconstant symptom of the lardaceous kidney, especially in the beginning and ultimate stages of the disease.
3. Mixed types of chronic Bright's disease are frequently observed. Thus, the interstitial and tubal forms of the disease may be combined. Lardaceous degeneration may be present with either form, and fatty changes are common in all the types of Bright's disease. Eclampsia is of relatively infrequent occurrence in chronic Bright's disease, although anasarca and its consequences may cause the interruption of pregnancy.
4. Acute Bright's disease is one of the most serious disorders occurring in the course of pregnancy. The urine is diminished in quantity, and contains a large amount of albumen, tube-casts, and red blood-corpuscles. Eclampsia is of frequent occurrence, and usually induces abortion or premature labor.
The causes of renal disease and of its symptom albuminuria are not always evident. In the kidney of pregnancy there is no inflammatory change. The cells covering the glomeruli and the glandular cells lining the uriniferous tubules undergo fatty degeneration, and are cast off as the result of anæmia.
In the acute and chronic forms of renal inflammation there is a variety of probable etiological factors. Mechanical pressure from the gravid uterus may impede the return of venous blood and determine congestion of the kidneys. This explanation is rendered more probable by the fact {418} that albumen usually appears in the urine after the fifth month, when the uterus has attained considerable size. Albuminuria is of comparatively more frequent occurrence in primiparæ with tense abdominal walls. It is frequently observed in cases of large ovarian cysts and uterine fibroids. The increased functional activity of the organs, the elevation of blood-pressure, the alterations in the constitution of the blood, are doubtless potential factors. When any latent tendency to Bright's disease exists, exposure to cold and impeded cutaneous functional activity are more likely to develop the disease in the pregnant than in the non-gravid state. Compression of the ureters is regarded by Halbertsma as a cause of great importance.
SYMPTOMS.--The symptoms of Bright's disease in pregnancy are neither uniform nor constantly present. Anasarca frequently directs attention to the patient's condition long before the appearance of more significant signs. Oedematous swellings of the face, hands, arms, feet, legs, and labia majora are always suspicious, and should lead to an examination of the urine. These oedematous swellings are wandering--appear when the patient is lying down, and disappear when she rises and walks about. Sometimes, toward the end of pregnancy, they become less marked, not infrequently entirely disappearing, while the albuminuria is increasing. The skin covering the oedematous portions of the body is dry, of a chalkish-white appearance, and the surface temperature is depressed.
Anomalous nervous phenomena, such as headache, vertigo, dimness of vision, spots before the eyes, ringing in the ears, sudden deafness, obstinate nausea and vomiting, sleeplessness, neuralgia, are often observed, and should always excite suspicion. These various nervous symptoms may be viewed as produced by the retention within the blood of certain substances normally excreted by the kidneys.
Convulsions, due to renal insufficiency, may occur during pregnancy, but are observed more frequently during parturition and the puerperium.
Attention has already been called to the characters of the urine. It is necessary to remember that in the granular, contracted kidney and lardaceous degeneration albuminuria may escape observation.
Bright's disease strongly predisposes to abortion or premature labor.
PROGNOSIS.--Any organic disease of the kidneys is serious. When the disease is extensive and involves both organs the prognosis is especially unfavorable. Accurate conclusions as to the dangers of Bright's disease during pregnancy are not justified by the present state of our knowledge. It is only possible to say, in a general way, that the prospect of recovery is less favorable than in the non-gravid state. Owing to the strong predisposition to abortion and premature labor, the chances of the foetus surviving pregnancy are relatively slight. Even if the child is not prematurely expelled from the uterus, it usually succumbs to the influence of the excrementitious products retained within the maternal blood.
TREATMENT.--In view of the serious complications arising in pregnancy from interference with the functions of the kidneys, the absolute necessity of chemical examination of the urine at regular intervals in every case, especially during the latter half of gestation, is apparent. When pathological albuminuria is present, rational therapy will be directed to the removal of the cause. Evacuation of the uterine contents is the only mode of removing the pressure from the gravid uterus, but {419} we have a variety of expedients, hygienic and medical, which must be invoked before resorting to such a radical procedure.
Hygienic.--The diet should be restricted, as far as possible, to milk, and nitrogenous articles of food must be forbidden. The functional activity of the skin can be maintained by frequent baths in lukewarm water. Vapor baths are of still greater value. Hot-water baths are employed on an extensive scale in the obstetrical clinics of the Vienna General Hospital. Carl Braun, Josef Spaeth, and Gustav Braun give testimony to their efficacy. Indeed, in Vienna chief reliance is placed upon the hot-water bath as a prophylactic and remedial agent. Breus[20] has recently described the method usually practised. The patient is placed in a bath-tub filled with water at a temperature slightly above 99° F. The tub is then covered with a heavy blanket, leaving the face free, and the temperature of the water is gradually elevated to 110° or 112° F. She remains in the bath thirty minutes. A towel wrung out of ice-water and placed upon the head relieves any distressing cephalic sensations. While in the bath the patient drinks large quantities of water. Upon emerging from the bath she is covered with a warm sheet and enveloped in an upper and lower layer of thick blankets, so that only the face is exposed. Within a very few minutes free perspiration is observed. The sweating is continued for two or three hours. According to the gravity of the case the hot-water bath may be repeated once daily for an indefinite period. The relief of all threatening symptoms under this simple plan of treatment alone is surprising. Sometimes the hot-water bath acts as an efficient excitant of uterine contractions, and premature labor is induced. A. Sippel[21] calls attention to this fact, and proposes hot-water baths as a harmless method of induction of premature labor. Although such an event is not undesirable, it is unusual, and occurs only when the temperature of the water reaches a great elevation or the baths are frequently repeated, or, finally, when there is a very decided predisposition to the interruption of pregnancy. The lateral or latero-prone posture during sleep serves to relieve in some degree the kidneys of the pressure from the gravid uterus, and should be advised.
[Footnote 20: Arch. f. Gynaek., vol. xix. p. 219.]
[Footnote 21: Centralb. f. Gynaek., No. 44, 1885, p. 693.]
Medical.--The exhibition of non-irritating diuretics, such as the acetate and bitartrate of potassium, in large quantities of water, causes an increased secretion of urine and lessens the congestion of the renal vessels. Among the mineral waters Bilin, Giesshübel, Preblau, Selters, and Vichy deserve commendation. Benzoic acid, in conformity with Frerichs' suggestion, is employed in Vienna. The tincture of the chloride of iron, alone or in combination with small doses of tincture of digitalis, is an efficient diuretic, and at the same time an excellent tonic.
Cathartics which produce large, watery stools without much irritation supplement the action of diuretics. The compound powder of jalap and the saline purges fulfil this indication. Care must be taken, however, to avoid the drastic effects of too large a dose.
Jaborandi and pilocarpine have been, and are at the present time, extensively used to aid in the elimination by the skin of retained excrementitious matters. The weight of authority is decidedly against the exhibition of this remedy. At best, it is uncertain in its action. It is a cardiac depressant, and frequently stands in a causal relation to {420} pulmonary oedema. For these reasons the drug has been condemned in unequivocal terms by Carl Braun and Fordyce Barker. The same effect, with less risk, can be produced by the hot-water baths.
Local Treatment.--In the acute forms of Bright's disease various modes of counter-irritation are useful. Wet and dry cups and leeches applied to the loins are indicated. Frerichs recommends pills of the extract of aloes and tannin with the view of restoring the normal tonus to the blood-vessel walls.
By a judicious combination of these varied therapeutic resources, hygienic and medical, threatening symptoms may be averted. Cure of Bright's disease, acute or chronic, is seldom if ever achieved during pregnancy. Not unfrequently, however, notwithstanding all efforts, the amount of albumen steadily increases, hydræmia becomes more pronounced, hydropsies appear with threatening cerebral, cardiac, or pulmonary symptoms. More active treatment is demanded, and the subject of the induction of premature labor must be seriously considered. Without entering into a detailed discussion of the arguments for and against the artificial premature interruption of pregnancy under these conditions, let it suffice to say that clinical experience furnishes overpowering evidence in favor of the operation. The weight of professional opinion is also very decidedly in favor of the artificial induction of premature labor. In the selection of the method for the induction of premature labor it is well to bear in mind the possible excitant effect on uterine contractions of hot-water baths, as pointed out by A. Sippel.[22]
[Footnote 22: Centralb. f. Gynaek., No. 44, 1885, p. 693.]
Skin Diseases.
Diseases of the skin occur with comparative frequency during pregnancy. Latent diatheses are roused into activity. The graver forms of skin disease usually disappear during or shortly after the puerperium. These facts point to some causal relation between the diseases and gestation. Under the increased activity of the glandular system the growth of hair may be stimulated, giving origin to a condition termed by dermatologists hirsuties gestationis. Slocum[23] relates the history of a case in which a woman in successive pregnancies grew a full beard. Anomalous deposits of pigment, constituting the condition known as chloasma uterinum, are observed, more especially among pregnant women exposed to sunlight. Chloasma is interesting from a diagnostic point of view, since it is liable to be confounded with pityriasis versicolor, an affection of frequent occurrence during pregnancy. The red nose of acne rosacea may be one of the first signs of pregnancy. General pruritus, a rare affection, belongs to the class of idio-neuroses (Hebra). Spiegelberg relates the history of a case of general pruritus occurring in an old primipara. The affection made its appearance in the second month, and continued without material abatement of symptoms throughout the period of gestation. Pruritus of the vulva is a common disorder of pregnancy. It is usually symptomatic of eczema, some inflammatory condition of the genitalia, or diabetes mellitus. The treatment must be directed to the removal of the cause. Vaginal douches containing vegetable or mineral astringents will {421} afford relief when the itching is due to acrid vaginal secretions. Dilute solutions of corrosive sublimate in water or alcohol (1:100 or 200), followed by compresses saturated with tar-water, are recommended very highly by Spiegelberg.
[Footnote 23: New York Medical Record, 1875.]
Pregnancy cannot be regarded as a cause of psoriasis. When that affection exists, however, it is usually aggravated. The elder Hebra[24] in 1872 described a rare form of skin disease occurring in the course of pregnancy which he called herpes impetiginiformis, and of which he encountered five cases. Grouped vesicles upon inflamed bases appear about the genitalia, and subsequently diffuse themselves by successive crops over the body. Great prostration, rigors, and intense fever accompany the eruption. Four of the five cases terminated fatally. Milton and Duncan Bulkley a few months later described a rare skin affection peculiar to pregnancy which they designated herpes gestationis. Erythema, papules, vesicles, and bullæ are developed. Vesicles predominate, appear on the lower extremities, subsequently spreading over the body. Intense itching and burning attend the vesicles. Urticaria, neuralgia, and other neurotic troubles accompany the affection. The disease appears early in pregnancy, continues until after delivery, and is apt to recur with succeeding pregnancies. The constitutional symptoms are much less severe than in the condition described by Hebra. At the meeting of the American Dermatological Society, 1885, L. A. Duhring[25] called attention to the relation of impetigo herpetiformis, herpes gestationis, pemphigus, and certain other forms of disease to dermatitis herpetiformis. Attention was briefly directed to the identity of the impetigo herpetiformls of Hebra with dermatitis herpetiformis. Herpes gestationis was a misnomer, the affection being found in men as well as in women. The disease was the vesicular variety of dermatitis herpetiformis. The peculiar forms of pemphigus observed during pregnancy, not of syphilitic origin, may be viewed as examples of the same disease. Duhring thinks that "we stand on the threshold of our knowledge of the disease."
[Footnote 24: Wiener Med. Woch., No. 48, 1872.]
[Footnote 25: Journal of Cutaneous, etc. Dis., October, 1885, p. 317.]
Neuroses.
Of all the neuroses occurring in the course of pregnancy, puerperal eclampsia is of chief clinical importance. Puerperal convulsions, however, occur more frequently during labor and the lying-in period than during gestation. For this reason the subject is usually discussed in connection with the pathology of the puerperium. The various psychoses are referred for a similar reason to the same chapter.
TETANUS.
Tetanus, a rare affection, especially in women, is occasionally observed in pregnancy. It occurs with greatest relative frequency in hot climates after abortion and the removal of placental or decidual remains. Sir James Y. Simpson collected 28 cases which sustained some relation to abortion or labor. Mr. Waring[26] has collected 232 cases occurring in a tropical climate.
[Footnote 26: Indian Annals, 1855.]
{422} The PROGNOSIS is unfavorable. Of Sir James Y. Simpson's 28 cases, only 6 recovered; 2 cases observed by Wiltshire terminated unfavorably.
In the entire absence of knowledge of the pathology of the disease, TREATMENT is empirical. Chloroform, the narcotics, curare, and nitrite of amyl are the remedial agents usually employed.
CHOREA.
Chorea occurs in pregnancy as an accidental complication or as the direct result of that state. It is a rare disorder of pregnancy. Spiegelberg has observed 3 cases; Barnes has collected 56 cases; Fehling[27] brings the number up to 68; altogether, 84 cases are on record.
[Footnote 27: Lehrb. d. Geburtshülfe, 1882, p. 239.]
ETIOLOGY.--The investigations of Robert Barnes show that where chorea arises in pregnancy in the large majority of cases there is a history of chorea in childhood, acquired predisposition prior to pregnancy, or hereditary "nervous diathesis predisposing to chorea." The connection between rheumatism, endocarditis, and chorea is a well-established fact. The precise nature of this relation is unknown. Hughlings Jackson has constructed the theory of "embolism of the small branches of the middle cerebral artery supplying the structures near the corpus striatum." Robert Barnes[28] calls attention to the following facts, which invalidate this ingenious theory: "(1) The frequent recovery of choreic patients; (2) the occasional immediate cessation of choreic fits upon delivery; (3) the progressive character of the disease during pregnancy, convulsions increasing in severity, and the gradual development of mania in some cases; (4) the fact that embolism is rare during pregnancy." In the absence of any definite cause, Spiegelberg refers a large number of these cases to the class of reflex neuroses. All the elements essential to a reflex neurosis are present. We have (1) a predisposition to chorea, inherited or acquired; (2) inanition of the central nervous system incident to the hydræmic state of the blood in pregnancy; (3) various potential peripheral irritants in connection with the sexual organs. Intense emotions, terror and the like, may act as exciting causes.
[Footnote 28: Obstetric Medicine and Surgery, London, 1884, p. 379.]
COURSE AND SYMPTOMS.--Chorea usually makes its appearance in the course of the first half of pregnancy, and continues until the beginning of labor. Sometimes choreic attacks are witnessed during parturition. In only 3 out of the 84 recorded cases the disease continued after the puerperium. Primiparæ are more frequently affected than multiparæ. The disease is liable to recur with succeeding pregnancies, entirely disappearing in the intervals. The choreic movements are the same as in the non-gravid woman affected with the disease. They are usually bilateral. As in chorea in the non-gravid state, transitory albuminuria and glycosuria may be observed. The increase of urates and phosphates in the urine is interpreted as the result of nervous excitement and muscular activity. Pregnancy is interrupted in about one-half the cases. The child may be born alive and affected with the disease.
PROGNOSIS.--Out of the 84 cases, 23 terminated fatally as the result of complications. Mania, loss of memory, grave cerebral and spinal lesions are occasionally traceable to the chorea of pregnancy. The {423} prognosis with reference to the child is unfavorable, from the tendency to the premature interruption of pregnancy.
TREATMENT.--The palliative treatment of chorea occurring in pregnancy is unsatisfactory in the extreme. All the specifics of greater or less value in the non-gravid state are frequently without influence during gestation. The diet must be nutritious and easily digestible. Large doses of iron and quinine are indicated. As in other convulsive disorders, during the paroxysms chief reliance is placed upon anæsthetics, subcutaneous injections of morphine, potassium bromide, and chloral. Charcot recommends the exhibition of large doses of bromide of potassium through a considerable period of time. Clifford Albutt extols succus conii. In over one-half the recorded cases the most judicious combinations of hygienic and medical therapeutic resources have proved of no avail. In view of the prognosis, the induction of premature labor is usually indicated, in the interest of both the mother and child, at an early stage of the disease. Sometimes the question of the artificial induction of abortion comes up for consideration. In view of the grave cerebral and spinal lesions which may result from the affection, the mother is justly entitled to the benefit of the doubt. It may not be amiss to add that this indication for the induction of abortion is not generally recognized.
EPILEPSY.
Epilepsy is usually an accidental complication of pregnancy. Spiegelberg[29] is responsible for the observation that in chronic epilepsy pregnancy sometimes modifies the course of the affection in a favorable manner. The seizures occur less frequently and are not so violent in character. Acute epilepsy may be developed as the result of pregnancy when a latent predisposition, inherited or acquired, exists. The epileptogenous zone in acute epilepsy comprehends the distribution of the ischiatic nerve. Acute epilepsy disappears with the cessation of pregnancy, but is apt to recur with succeeding gestations.
[Footnote 29: Lehrb. d. Geburtshülfe, 1882, p. 241.]
The occurrence of acute or chronic epilepsy during pregnancy is of great diagnostic interest from the resemblance of the epileptic seizures to the convulsions produced by renal inadequacy. The urine secreted during or after an epileptic fit is usually free from albumen. In the severest forms of puerperal eclampsia the urine may also be entirely free from albumen and tube-casts. In the ultimate stages of amyloid degeneration[30] and atrophy of the kidney, the most formidable forms of Bright's disease, albumen may not appear in the urine.
[Footnote 30: Carl Braun, Lehrb. d. g. Gynaek., 1881, p. 827.]
The DIAGNOSIS is usually cleared up by the history of the case and the course of the affection.
The PROGNOSIS with reference to mother and child is favorable. Epilepsy rarely leads to the premature interruption of pregnancy.
The TREATMENT is the same as in the non-gravid state.
Disorders of the Special Senses.
Disorders of the special senses usually occur in the course of pregnancy as symptoms of acute or chronic Bright's disease. Amblyopia, amaurosis, {424} ringing in the ears, sudden deafness, loss of taste and smell, may be developed under the influence of renal inadequacy before or after the occurrence of puerperal convulsions. Apart from the disorders of the special senses dependent upon lesions of the kidney, disturbances of vision are of chief clinical interest.
Amblyopia, hemeralopia, and color-blindness are occasionally observed as the result of nutritive disturbances in the retina. Nyctalopia, Spiegelberg says, is not recorded in the literature of the subject.
The PROGNOSIS is favorable as a rule. The disorders of vision usually disappear during the puerperium, and evince no tendency to recurrence.
Generous diet, iron, and a tonic plan of treatment are indicated.
* * * * *
II. THE PECULIARITIES OF CERTAIN ACCIDENTAL ACUTE AND CHRONIC DISEASES OCCURRING IN THE COURSE OF PREGNANCY.
The older obstetricians believed not only that pregnant women possessed a certain immunity from accidental diseases, but also that the course of such affections was favorably modified by gestation. Modern research has demonstrated the groundless nature of this belief. It is an established fact that pregnancy confers upon the individual no immunity from the disorders to which the non-gravid woman is liable. Moreover, such accessory diseases are usually aggravated by pregnancy, and, in turn, exercise an unfavorable influence upon gestation, frequently leading to its interruption.
Acute Infectious Diseases.
Of all the so-called accessory diseases occurring in the course of pregnancy, the acute infectious diseases are of the gravest clinical significance. These diseases are peculiarly dangerous complications for two reasons:
I. They have a marked tendency to cause the death of the foetus and the interruption of pregnancy, when the loss of blood and the muscular exertion consequent upon the expulsion of the product of conception from the uterine cavity seriously imperil the mother's life.
II. Hemorrhagic endometritis, caused in part by changes in the constitution of the blood, is not an uncommon symptom in the course of acute infectious diseases in the non-gravid state. In pregnancy this symptom is of more constant occurrence, just as it is of graver prognostic moment, both with reference to the mother and to the child.
I. The death of the foetus and the interruption of pregnancy may result from the operation of a variety of etiological factors.
1. The foetus usually dies in consequence of the elevation of maternal temperature. The case is a veritable example of that condition which H. C. Wood of Philadelphia terms heat-stroke. The normal foetal temperature is slightly more elevated than the maternal. The foetus in its membranes, surrounded by maternal tissues, must possess at least the {425} same temperature as the maternal body. But it has its own heat-producing apparatus in addition. A very slight elevation of the maternal temperature produces a disproportionate rise in the temperature of the foetal body. Kaminsky[31] has shown that an elevation of maternal temperature to 104° F. imperils foetal life. Increased frequency of the pulsation of the foetal heart and abnormally active foetal movements are followed by diminished cardiac and muscular activity, and the foetus dies. The autopsy reveals the characteristic lesions of heat-stroke.
[Footnote 31: Moskauer Med. Z., 1867, Nos. 13-19.]
2. Runge[32] has demonstrated the occurrence of foetal death from asphyxia when the maternal blood-pressure is seriously lowered. This lowering of the maternal blood-pressure occurs as the result of diminution in the force and frequency of the heart's action observed in the course of acute infectious diseases or from the sudden loss of blood. Asphyxia may also be caused by structural changes in the epithelium covering the foetal placenta, due to the state of the maternal blood.
[Footnote 32: Arch f. Gyn., Bd. xii. p. 16.]
3. The foetus may perish in consequence of infection with the specific poison of the acute disorder. Death as the result of acute infection has been observed in variola and relapsing fever.
4. Pregnancy may be interrupted, independently of the condition of the foetus, as the result of the thermic irritation of the uterine muscular fibre by the maternal blood. Spiegelberg on a priori grounds asserted the possibility of this event. Runge[33] has since demonstrated by experimental methods its actual occurrence.
[Footnote 33: Volkmann's Sammlung, No. 174; Arch. f. Gyn., Bd. xii. p. 16.]
II. Hemorrhagic endometritis in the course of acute infectious diseases complicating pregnancy has been demonstrated by Slavjansky's[34] researches. In cholera this symptom is observed with relative frequency. Following hemorrhage into the decidua, according to the time, extent, and site, pregnancy may be immediately interrupted, or secondarily as the result of the pathological changes in the placenta or membranes induced by the extravasated blood. The hemorrhage may be so severe as to jeopardize the life of the mother.
[Footnote 34: Arch. f. Gyn., iv. p. 285.]
Of the eruptive fevers, smallpox, scarlet fever, and measles are of especial clinical interest. Smallpox is observed most frequently. The eruptive fevers usually occur early in pregnancy, but the disposition to the severer forms and the mortality, as remarked by Spiegelberg, grow with the duration of gestation.
SMALLPOX.
A mutually unfavorable relation exists between smallpox and pregnancy. A distinct tendency to the hemorrhagic form of the disease is notable. Pregnancy frequently terminates in abortion or premature labor under circumstances which seriously imperil the mother's life from loss of blood. When the disease pursues its course without interrupting pregnancy, the effect upon the foetus is interesting and instructive. The child may be born alive with characteristic variolous cicatrices or in the eruptive stage. Usually the eruption appears from eight to ten days after birth. Very rarely the child may escape infection altogether. The foetus may be infected in utero, while the mother {426} remains apparently unaffected. Fumée of Montpellier narrates the history of a remarkable case of twin pregnancy. Only one of the children showed variolous pustules.
During smallpox epidemics abortions and premature labors, accompanied by abnormally severe hemorrhages, are frequently observed when no exanthem or other sign of the disease is noticeable in the mother. The healthy child of a mother affected with variola in the course of pregnancy is usually insusceptible to vaccinia for a long time after birth.
In the event of a smallpox epidemic the vaccination or revaccination of pregnant women is advisable. The effect of the vaccination of the pregnant woman upon the foetus is still a subject of controversy. Thorburn in 1870 successfully vaccinated a number of pregnant women, and found no insusceptibility in their children. Behm[35] vaccinated 33 women pregnant in the eighth, ninth, and tenth months. The vaccination was completely successful in 22 cases, partially in 7, and failed in 4. Of the 33 children, 25 were successfully vaccinated. In 8 cases vaccination was not attended with success. Failure was ascribed in 7 cases to bad lymph, leaving only 1 case of presumed protection from intra-uterine vaccination. Bollinger and Burckhardt, supported by the results of Rickett and Roloffs in the inoculation of sheep, maintain that over one-half the infants are protected from vaccinia and smallpox by the vaccination of the mother during pregnancy.
[Footnote 35: Centralbl. f. Gynaek., 1882.]
MEASLES.
Rubeola, of infrequent occurrence in the adult generally, is a very rare complication of pregnancy. It is of serious prognostic moment, from the tendency to the hemorrhagic form of the disease, and pneumonia.
SCARLET FEVER.
Scarlatina, like measles, occurs infrequently in the course of pregnancy. Olshausen has collected 7 cases. Pregnancy was interrupted in 4 out of these 7 cases, probably as the result of the elevation of maternal temperature. The renal complications also add an unfavorable element to the prognosis.
TYPHOID FEVER.
Typhoid fever occurs with greatest frequency during the early months of gestation. It is a very rare complication of the puerperium. Pregnancy is usually interrupted. Abortion rather than premature labor is observed. This tendency to the interruption of gestation is more marked than in any of the acute infectious diseases with the possible exception of smallpox. Of 98 cases collected by Kaminsky, interruption of pregnancy occurred in 63; Zülzer reports 14 interruptions of pregnancy in 24 cases; Scanzoni, 6 out of 10 cases. In about 63 per cent. of the cases collected by these observers pregnancy was interrupted. The causes of abortion or premature labor in typhoid fever are found in the elevation of maternal temperature, the hemorrhagic endometritis, and perforation (Kleinwächter). The transmission of the infection from mother to child is a disputed point. The prognosis depends largely upon the stage of the disease in which the interruption of pregnancy occurs. If abortion or {427} premature labor occurs early in the course of the disease, before the mother is exhausted, the outlook is naturally more favorable.
RELAPSING FEVER.
Murchison states very positively that pregnancy is invariably interrupted by the occurrence of relapsing fever. Recent investigations, however, indicate that this assertion is entirely too general. Weber[36] has collected 63 cases of pregnancy complicated by this disease. Pregnancy was interrupted in 23 cases, or 36.5 per cent. Hemorrhagic endometritis is of less frequent occurrence than in typhoid fever. In two cases (Wyss-Ebstein and Albrecht) spirilla were found in the foetal blood, indicating the infection of the child by the mother.
[Footnote 36: Berlin. klin. Woch., vii., 1870, p. 22.]
TYPHUS FEVER.
Typhus fever manifests much less tendency to the production of hemorrhagic endometritis than typhoid and relapsing fevers. The interruption of pregnancy is the exception rather than the rule. When abortion or premature labor occurs, it is usually caused by the elevation of the maternal temperature. There is no evidence pointing to the infection of the child with the specific poison of the disease.
MALARIAL FEVER.
The popular belief that pregnant women enjoy a certain[37] immunity from malarial fever seems to have some foundation in fact. This apparent immunity may be due in part to the environment and freedom from exposure to the malarial poison--in part to the condition of pregnancy. In latent, chronic malarial poisoning gestation may be the cause of the explosion or acute exacerbation of the affection. The course and symptoms of malarial fever are materially modified by the coexistence of pregnancy. The attacks lose something of their rhythmical character. Chills are of irregular occurrence, and the fever assumes a remittent or continued type. In the latter months of gestation acute attacks of malarial fever are especially distressing to the patient.
[Footnote 37: Ritter, Virchow's Archiv, 1867.]
The interruption of pregnancy is not an uncommon event. Göth has recently reported 46 cases, in 19 of which either abortion or premature labor took place. When pregnancy is interrupted hemorrhage is apt to be profuse.
The communication of the disease to the foetus is a well-authenticated clinical fact. Hubbard reports an interesting case of intra-uterine malarial fever. Autopsies of infants born of mothers affected with acute or chronic malarial poisoning reveal the characteristic lesions of that pathological condition. Malarial paroxysms are usually suspended during labor, but may reappear during the lying-in period. Very rarely the fever assumes a pernicious type, and then may stand in a certain causal relation to the essential anæmia of pregnancy, of which mention has already been made.
In the TREATMENT of malarial poisoning during pregnancy large doses of quinine are indicated. Spiegelberg points out the important fact that, owing to the impairment of the digestive and assimilative functions, only {428} a portion of the quinine is absorbed. There is no ground for fearing any untoward effect from quinine. The researches of Chiara of Milan and numerous other observers prove that even the largest therapeutic doses of quinine are not abortifacient in malarial fever or in health.
CHOLERA.
Pregnant women evince no proclivity to, nor immunity from, cholera. As in variola, the disposition to, and mortality of, the disease grow with the duration of gestation. The prospect of recovery is especially unfavorable during the sixth and seventh months. Pregnancy is usually interrupted when the woman survives the terribly rapid course of the disease. Many women die with the product of conception in the cavity of the uterus. Exceptionally, in the lighter forms of the disease recovery may occur without the interruption of gestation. The causes of premature labor or abortion may be found in the constant hemorrhagic endometritis and the changes in the pressure and constitution of the maternal blood. As the result of the operation of the two latter factors, asphyxia is usually produced. Buhl, Gütterbock, and others are of the opinion that the disease may be communicated by the mother to the foetus.
Pregnancy undoubtedly exercises an unfavorable influence on the course of the disease, chiefly from the tendency to uterine hemorrhage. Pregnancy is interrupted in over 50 per cent. of the cases. Premature labor is observed more frequently than abortion. The prognosis with reference to the life of the child is absolutely unfavorable.
In very exceptional cases the evacuation of the uterine cavity has seemed to exercise a favorable influence on the course of the disease. Upon this ground the induction of abortion or premature labor has been seriously proposed. The operation, after an extended trial, has fallen into deserved disrepute.
SYPHILIS.
Syphilis is a frequent complication of pregnancy. Sigmund[38] has observed and described the characters of syphilis contracted at the beginning or during the course of gestation. The duration of the stage of incubation is abbreviated. Two weeks is the rule, six weeks the exception. The initial lesions are characterized by an unusual degree of intensity, occasionally involving the vulva, vagina, cervix, nates, and inner surfaces of the thighs. The intensity of the initial lesions is due to the anatomical relations of the genitalia in the pregnant woman and the increased nutritive activity of the parts. The symptoms are marked local reaction, reddening and excoriation of the skin and mucous membrane, swelling, oedema, eczema, follicular abscesses, and necrosis of the connective tissue. Induration is not a characteristic of chancre situated about the genitalia of the pregnant woman. Phagedenic ulceration sometimes attacks the chancre, and then the case may be mistaken for one of phagedenic chancroid. The secondary symptoms are unusually mild. Condylomata appear about the genitalia, and psoriasis is noticeable on the palms of the hands and soles of the feet. Glandular infiltration follows slowly, and alopecia, iritis, laryngitis, and the skin manifestations are observed with comparative infrequency.
[Footnote 38: Wien. Med. Presse, 1873, No. 1, xiv.]
{429} Constitutional Syphilis.--The influence of constitutional syphilis upon the foetus is marked, and always unfavorable. The foetus may be infected through the medium of the spermatic fluid, the ovum, and by the mother after conception. From an enormous number of carefully-recorded observations it is possible to deduce the following conclusions with reference to the modes of infection and the effect upon the product of conception:
1. When the mother is perfectly healthy, but the father is affected with constitutional syphilis, the foetus is infected by the diseased spermatozoids. The intensity of the foetal disease will depend upon the degree of latency and age of the paternal affection. This mode of infection is observed in the severer forms of hereditary syphilis. Usually the mother is not infected. Occasionally the disease is communicated to her by the foetus in the mode termed by the French syphilographers choc en rétour.
2. When the mother has had constitutional symptoms prior to conception the ovum is infected before its fertilization. The child usually dies in utero, and is expelled in a state of maceration.
3. When the mother is infected during the act of coitus it was formerly believed that the foetus could only be syphilized during its passage through the parturient canal. Sigmund and Vajda have shown that even under these circumstances the infection may be communicated by the mother to the foetus in the course of pregnancy. If the father is affected with constitutional syphilis when the mother acquires the initial lesion, the result sketched in the first proposition follows.
4. Infection of the foetus may occur during its passage through the parturient canal. Weil[39] records a case of this nature.
[Footnote 39: Deutsch. Zeitsch. f. prakt. Med., 1877, No. 42.]
5. When both parents are affected with constitutional syphilis the disease will be communicated to the foetus. The intensity of the foetal syphilis will depend upon the degree of latency and age of the parental affection. When both parents have passed through the tertiary forms an apparently healthy child may be born. Evidences of hereditary syphilis, however, are usually developed before puberty.
According to the intensity of the poison the foetus dies in utero, causing the interruption of pregnancy; is born alive, with manifestations of hereditary syphilis, seldom acquired; or may give evidence of the inheritance of the disease after a variable interval of from weeks to months.
TREATMENT.--Fortunately, syphilis as a complication of pregnancy is a very tractable affection. The interruption of pregnancy may be prevented and the effect of the syphilitic poison upon the foetus favorably modified in the large majority of cases by appropriate specific treatment. Mercurial inunctions are preferable to the exhibition of the remedy by the mouth. Iodide of potassium must be used with care, on account of its tendency to provoke uterine contractions.
Attention must be paid to local primary or secondary lesions, since the child may be infected during its passage through the parturient canal.
Cardiac Diseases.
The mutually unfavorable relations between acute and chronic cardiac diseases and pregnancy depend largely upon the seat and character of the affection.
{430} ACUTE ENDOCARDITIS,
occurring in the course of gestation, evinces a distinct tendency to the malignant, ulcerative form. This disposition is much more marked during the puerperium. The dangers of the detachment of particles of valvular vegetations, giving origin to the processes of thrombosis and embolism, are obvious.
The PROGNOSIS of acute endocarditis during pregnancy and the puerperium is much more unfavorable than in the non-gravid state.
CHRONIC HEART DISEASES.
The mode in which pregnancy, parturition, and puerperium exert an unfavorable influence on chronic heart diseases is still the subject of controversy. Spiegelberg accounts for the disastrous results attending aortic insufficiency observed in the second half of pregnancy on the ground of the inadequacy of the compensatory hypertrophy of the left ventricle. The intercalation of the placental circulation, the increase of the total blood-mass, the increase in arterial tension, throw an extra amount of work upon the left heart, which it is not able to perform. Irregular heart-action and dyspnoea, sometimes leading to the interruption of pregnancy, are the results.
After labor the placental circulation is eliminated, arterial blood-pressure is lowered, venous blood-pressure is elevated, and the right heart is threatened. In case of mitral insufficiency and dilatation of the left ventricle, without compensatory hypertrophy of the right heart, the effect of these sudden variations in vascular tension is obviously serious. Dyspnoea, pulmonary catarrh, general oedema, albuminuria, ascites, pleural effusions, occur. Fritsch[40] is of the opinion that these phenomena, sometimes observed in the course of mitral disease after labor, are due to the sinking of intra-abdominal pressure, the accumulation of blood in the great abdominal vessels, and cardiac paralysis from insufficient blood-supply.
[Footnote 40: Arch. f. Gyn., viii. p. 373; x. p. 270.]
During parturition Spiegelberg[41] thinks the chief danger in all forms of valvular defects consists in pulmonary oedema as the result of circulatory disturbances.
[Footnote 41: Lehrbuch d. Geburtshülfe, 1882, p. 248.]
Löhlein and Kleinwächter[42] believe that the chief danger of chronic valvular disease occurs during the puerperium, and lies in the tendency to the recurrence of endocarditis.
[Footnote 42: Kleinwächter's Grundriss d. Geburtshülfe, 1881, p. 190.]
TREATMENT.--The treatment of acute and chronic heart disease is not materially modified by the coexistence of pregnancy.[43] In threatened asphyxia the induction of premature labor is indicated in the interest of the child. During labor the timely performance of version or application of the forceps lessens the bearing-down efforts, and may prevent alarming complications.
[Footnote 43: Carl Braun, Lehrb. d. g. Gynaek., 1881, p. 708.]
Diseases of the Lungs.
ACUTE LOBAR PNEUMONIA.
This is a rare affection in women at all times, and is a very infrequent complication of pregnancy. Occurring with greatest relative frequency {431} in the early months of pregnancy, the unfavorable character of the prognosis grows with the duration of pregnancy. Interruption of pregnancy may occur as the result of a variety of causative agencies. The elevation of maternal temperature, insufficient oxygenation of the maternal blood, placental anæmia from inadequate supply of blood to the left heart, are of chief etiological moment.
The PROGNOSIS with reference to mother and child is always grave.
The TREATMENT is that of pneumonitis in the non-gravid state. Parturition exerts a prejudicial influence by overtaxing the failing heart-power and increasing the hydræmia. The induction of premature labor is therefore strongly contraindicated. In the event of labor every effort must be made by operative procedure to save the mother's strength.
ACUTE PLEURITIS
is nearly as fatal a complication of pregnancy as pneumonitis, and for the same reason. The danger is especially great during labor.
CHRONIC PLEURISY, EMPHYSEMA, AND EMPYEMA
are dangerous complications of pregnancy, limiting respiratory space and producing cardiac complications. The induction of premature labor may be indicated by these conditions in the interest of mother and child.
PULMONARY TUBERCULOSIS.
Pregnancy exerts a prejudicial influence on hereditary or acquired tuberculosis as a rule. Latent tendencies to the disease are developed, and the progress of the existing affection is hastened. These effects upon the course of phthisis, Lusk says, are most frequently observed between the ages of twenty and thirty years, although of not infrequent occurrence between the ages of thirty and forty years. To these general propositions there are occasional rare exceptions. The disease is sometimes--very rarely--observed to make no progress during gestation and the patient may decidedly improve during the lying-in period. The puerperal phases, says Spiegelberg, exercise such varied influences upon the development and course of tuberculosis that it is an imperative necessity to individualize in every case.
When the disease progresses during pregnancy, abortion or premature labor may take place, or the woman may die undelivered. Infants born of tuberculous mothers are usually weak and sickly, and perish during the first months of life.
For these reasons it is an established rule in practice to inform women of the tuberculous diathesis of the dangers entailed by the marital relation. A woman affected with tuberculosis ought never to nurse her own child. As a rule, however, there is seldom any necessity for such a warning, as the function of lactation is rarely established under these conditions.
{432}
FUNCTIONAL DISORDERS IN CONNECTION WITH THE MENOPAUSE.
BY W. W. JAGGARD, A.M., M.D.
DEFINITION AND TERMINOLOGY.--The time of life in a woman when the natural cessation of ovulation and menstruation occurs has received a variety of appellations more or less descriptive of the phenomena which are supposed to precede, attend, and follow that event. Change of life, Turn of life, Critical time, Climacteric, in English; Das klimacterium, Das aufhören menstrualer Ausscheidung, Das aufhören der Weiblichen Reinigung, in German; Ménopause, Âge de retour, Âge critique, Temps critique, in French; Cessatio mensium, Climacterium, in Latin; Menolipsis, in Greek,--are terms used to mark out a certain period of time commencing with the functional and organic disorders connected with the cessation of ovulation and menstruation in a causal relation, and terminating with the permanent resettlement of health.
DATE OF CESSATION OF MENSTRUATION, AND DURATION OF THE CHANGE OF LIFE.--The function of ovulation, as far as we know, ceases with the discontinuance of menstruation, although immature ova still exist in the ovaries. The date of natural cessation of menstruation and ovulation is variable in different women. It is difficult to determine an average date, because the menopause may be gradually ushered in, and then women are apt to interpret any genital hemorrhage as menstruation. In certain cases the menstrual flow may cease between the ages of thirty and forty years, or even at an earlier period. On the other hand, the function has been noted by competent observers[1] to continue up to and beyond the sixtieth year. According to tradition, Cornelia, the mother of the Gracchi, was confined in her seventieth year. Parvin[2] has recently called attention to another historical instance of alleged late menstruation, recorded in a note to the fifty-sixth chapter of the Decline and Fall of the Roman Empire. On the authority of D'Herbelot's great work, Bibliothèque orientale, 1777, Gibbon mentions the case of Asima, the mother of Abdallah. When the tidings of the death of her son were borne to Asima her menses reappeared at the age of ninety as the physical effect of her grief. The historian informs us that the flow proved fatal in five days. These anomalous cases of so-called protracted menstruation are frequently examples of pathological hemorrhages dependent upon structural changes, sometimes of a malignant character. Even admitting the {433} possibility of the condition of extremely protracted menstruation, such cases, as remarked by Playfair, like examples of unusually precocious menstruation, cannot be regarded as having any bearing on the general rule.
[Footnote 1: Tilt, The Change of Life, 4th ed., 1882, p. 24.]
[Footnote 2: The Medical News 26th Sept., 1885, p. 352.]
The periodic discharge of blood from the uterus usually ceases between the ages of forty and fifty years. Raciborski[3] concludes, from the observation of a large number of cases, that the average date of cessation is the forty-sixth year. This estimate is confirmed by the observations of Brierre de Boismont, Guy, and Tilt. The average date of cessation in 1082 cases,[4] collected by these three observers, was forty-five years and nine months.
[Footnote 3: Traité de la Menstruation, Paris, 1868.]
[Footnote 4: Tilt, The Change of Life, 4th ed., 1882, p. 22.]
Climate, race, and the various accidental circumstances which exercise such potent influence upon the establishment of the functions of ovulation and menstruation have measurably less effect upon their cessation. Mayer[5] attaches some importance to social condition as determining the date of cessation. From the observation of a large number of cases belonging to the higher classes he determines the average age to be 47.138 years. It is a popular belief that the period of menstrual life is a constant number of years, usually from thirty to thirty-five; that is to say, if a woman commences to menstruate when very young, cessation will occur at an earlier age than in a woman who begins to menstruate later in life. Cazeaux, Raciborski, Frank, Dusourd, and Tilt, supported by Guy's[6] analysis of 1500 cases, are of the opinion, on the contrary, that the duration of menstruation is longest in women who have menstruated earliest. In the words of Négrier,[7] "It seems well proved that the ovarian function, creative of germs, is prolonged in life in direct ratio of the volume of the ovaries and of the precocity of ovulation; thus the girl nubile at twelve will continue menstruating until fifty or even fifty-five; whilst the girl who did not menstruate until eighteen or twenty--a fact which reveals feeble development and small energy of the organs--will cease to menstruate at forty, an early age."[8] Cessation occurs later in women who have passed through repeated normal pregnancies than in virgins or sterile females. Cohnstein[9] observed the longest duration of menstruation in women who had menstruated early, married, and borne more than three children, suckled their offspring, and were normally confined for the last time between the ages of thirty-eight and forty-two years. An interesting opinion with reference to the relation between longevity and the date of cessation was expressed by Robert Cowie at the Paris Medical Congress in 1867. According to Cowie, there is a direct and constant relation between longevity and protracted menstruation. A woman who menstruates up to an advanced period of life has more chances of attaining extreme old age than one whose menstrual function has ceased earlier. Cowie derives this opinion from the observation of numerous cases of longevity and coincident protracted menstruation which occurred in the Shetland Islands.
[Footnote 5: Schroeder, Handbuch der Krankheiten der Weiblichen Geschlechtsorgane, 1881, p. 321.]
[Footnote 6: Medical Times and Gazette, 1845.]
[Footnote 7: Barnes, Diseases of Women, 1878, p. 194.]
[Footnote 8: T. Gallard, Pathologie des Ovaires, Paris, 1885, p. 114.]
[Footnote 9: Deutsche Klinik, 1873, No. 5.]
Among the pathological factors which determine the early occurrence {434} of cessation, puerperal atrophy of the uterus, syphilis--especially the graver forms--and chronic alcoholism deserve particular attention (Lancereaux).
The average date of cessation of menstruation may be regarded as the fixed time from which to estimate the duration of the pre-cessation and post-cessation periods of the menopause. The duration of the pre-cessation period--or the dodging-time, as it is popularly termed--is subject to many and extreme variations. Tilt[10] places the limits of normal variation between a few months and six or seven years. The average length of the dodging-time in 275 cases Tilt estimates at two years and three months. The same observer claims to have seen cases of morbid prolongation of the pre-cessation period through ten and even twelve years. Equally variable and indefinite, in point of duration, is the post-cessation period. From the study of his 500 cases, Tilt concludes that cessation of menstruation divides involution into two periods of nearly equal length when no disease of the uterus or adnexa is present. In 383 cases, three or four years after cessation all functional disorders due to the menopause disappeared. But the length of the post-cessation period, as in the case of the dodging-time, is liable to abnormal protraction. Tilt is very positive in the assertion that disturbances directly traceable to the menopause may continue ten or twelve years after cessation of menstruation. The statistical evidence adduced by Tilt in support of his peculiar views as to the possible protraction of the pre-cessation and post-cessation periods (twenty to twenty-four years) may well be questioned. His analysis of cases does not indicate rigid scrutiny. The line between merely coincident phenomena and disorders which are directly traceable to the menopause is nowhere clearly and distinctly drawn. Robert Barnes[11] is of the opinion that the average duration of the change of life, comprehending the pre-cessation and post-cessation periods, is from two to three years--an estimate more in accord with the experience of the majority of clinicians.
[Footnote 10: The Change of Life, 4th ed., p. 46 et seq.]
[Footnote 11: Diseases of Women, 1878, p. 287.]
THE NATURAL HISTORY OF THE CHANGE OF LIFE.--In order to gain an adequate conception of the dynamic disorders in connection with the menopause, it is necessary to bear clearly and distinctly in mind the alterations in functional activity of a purely physiological character which attend that event. Many of the so-called functional disorders of the change of life are merely physiological processes consequent upon the transition from active ovario-uterine life to sexual decrepitude. There is nothing remarkable in the fact that the cessation of menstruation and ovulation, after functional activity of an average period of time varying from thirty to thirty-five years, is sometimes attended by a series of disturbances of a local and constitutional character. The changes of functional activity under these conditions are in analogy to the course and constitution of nature as observed in connection with dentition, puberty, and other epochs in human life.
The physiology of the menopause is a subject extremely difficult of investigation. The reasons are obvious. Our knowledge of the nature and significance of the function of ovulation and menstruation is very defective. The phenomena in connection with the change of life are numerous and complex. All interpretations of the appearances are peculiarly liable to fallacies and unavoidable sources of error. Correction {435} and confirmation by anatomical research are usually impossible. Then the number of recorded cases in which the phenomena have been rigidly analyzed is very limited. But, despite the difficult nature of the subject and the poverty of the literature, a solid nucleus of acquired truth exists. Familiarity with these definitely established facts will clear up many obscure points in the pathology of the menopause.
RESPIRATORY CHANGES. The researches of Andral and Gavarret[12] indicate that the quantity of carbonic acid exhaled by the lungs during the second infancy (eight years to puberty) is increased in man and woman. With the establishment of menstruation the quantity of carbonic acid exhaled by the female becomes constant, and persists in this state throughout her menstrual life. During the pre-cessation period the quantity of carbonic acid exhaled by the lungs is rapidly augmented, attaining its maximum about the time of cessation. During the post-cessation period the quantity gradually diminishes until the resettlement of health is effected. After this period it remains relatively constant. In the male, on the other hand, the quantity of carbonic acid exhaled increases up to the thirtieth year, and then progressively diminishes until the end of life.
[Footnote 12: "Recherches sur la quantité d'Acide carbonique exhalé par les Poumons dans l'Éspèce humaine," Annales de Chimie et de Physique, 3^e Série, t. viii.]
During pregnancy the amount of carbonic acid exhaled is approximately the same as at the time of cessation.
Aran[13] recognizes in this augmented excretion of carbonic acid during the change of life a critical or compensating discharge--a waste-gate or outlet, to use the figurative expressions of Tilt and Barnes, for the energy set free in the system by the more or less suddenly suppressed functions of ovulation and menstruation. Gallard,[14] on the other hand, has pointedly called attention to the fact that the menstrual blood carries out of the system a quantity of carbonic acid which during pregnancy and change of life is excreted by the lungs--that, accordingly, the increased exhalation of carbonic acid during the climacterium cannot be regarded in the light of a critical discharge.
[Footnote 13: Leçons cliniques sur les Maladies de l'Utérus et de ses Annexes, Paris, 1858-60, p. 284.]
[Footnote 14: T. Gallard, Pathologie des Ovaires, p. 87, Paris, 1885.]
ALTERATIONS IN THE FUNCTIONS OF THE SKIN.--It is a matter of common observation that the functions of the skin are profoundly influenced in many cases by the changes consequent upon the menopause. Tilt records 300 cases of more or less profuse perspiration, occurring in 500 women, due in some degree at least to the change of life. This estimate is probably exaggerated. A variety of agents influences the total amount of perspiration, as well as the relation between sensible and insensible perspiration, at all periods of life. The dryness, temperature, and amount of movement of the surrounding atmosphere, nature and quantity of food taken and liquid drank, exercise, mental condition, medicines, poisons, diseases, and the relative activity of the other excreting organs (e.g. the kidneys), are factors which deserve due consideration before attributing all increased activity of the sudoriparous glands about the forty-fifth year to the effects of the change of life. In the tables mentioned no distinction is drawn between mere coincidence and causal relation.
{436} The perspirations due to the change of life may have prodromal signs. These symptoms are--sensations of cold, shivering, chills, sinking or faintness referred to the pit of the stomach. Usually, however, they are not attended by any premonitory phenomena. They are frequently accompanied by dilatations of the skin blood-vessels, corresponding to definite areas of distribution of the vaso-motor nerves, which are popularly known as flushes. When the perspirations following the dilatations of the skin blood-vessels are insensible, women are in the habit of terming the symptoms dry flushes. The number and duration, as well as the time of occurrence, of these sweats and flushes are various in different women. Tilt has observed them to occur as often as five or six times in an hour, and last from two to fifteen minutes. They are usually noticed during the daytime. The regions involved are, in the order of frequency, face, chest, lower portions of the trunk, upper and lower extremities. Very seldom the entire skin surface is affected. In point of intensity the heightened activity of the sudoriparous glands varies from a gentle perspiration to a drenching sweat.
The function of these perspirations and flushes cannot be regarded as definitely settled. The popular opinion is that they constitute an important outlet for the actual energy liberated by the cessation of ovulation and menstruation. Tilt, adopting the popular view, thinks that the relief obtained by increased perspiration is the most important and habitual safety-valve of the system during the change of life. There are certain a priori considerations which render this hypothesis in some degree probable.
The quantity of matter which leaves the human body by the skin, per hour, is considerable. Seguin[15] has estimated it at eleven grains, while the quantity excreted by the lungs is seven grains. It is possible to isolate three factors which directly influence the secretion of sweat: (1) The skin, apart from its glandular apparatus, is a simple animal membrane, and permits a relatively small quantity of water to transude through the portions intervening between the mouths of the glands. As pointed out by Erismann,[16] this function of the skin is a subordinate one. The simple transudation of water is greater through those portions of the skin abundantly supplied with glands than through those in which they are sparsely distributed. (2) Vascular dilatation accompanies, and at least aids, the secreting activity of the cutaneous surface. Bernard's experiments on the division of the cervical sympathetic and clinical observation abundantly demonstrate the operation of this etiological factor. (3) Independently of vascular supply, it is in a high degree probable that there are special nerves directly controlling the activity of the sudoriparous glands. Stimulation of the sciatic nerve causes an increase in perspiration in the toes of the dog, without any concomitant hyperæmia, as shown by the experiments of Kendal and Luchsinger.[17] In a word, the skin is adequate to the regulation of aberrations in nerve-force and blood-supply and to the restoration of equilibrium. If superfluous actual energy is liberated by the cessation of the monthly ovarian stimulus and determination of blood to the uterus, it is not improbable that the perspirations and flushes of the menopause may constitute an efficient means of discharge.
[Footnote 15: Ann. de Chim., xc. pp. 52, 403.]
[Footnote 16: Zeitschrift f. Biol., xi. p. 1.]
[Footnote 17: Pflüger's Archiv, xiii., 1876, p. 212.]
{437} ALTERATIONS IN THE SECRETION BY THE KIDNEYS.--In many cases of the menopause important changes occur in the urine. The secretion becomes turbid and the quantity of sediments is large. These sediments usually consist of the inorganic salts. The phosphates, carbonates, and sulphates are increased, while no change is observed in the quantity of sodium chloride. The quantity of nitrogenous crystalline bodies is apparently not influenced in the great majority of cases. Occasionally the quantity of uric acid is increased,[18] and gives origin to many distressing symptoms. In the absence of accurate data respecting the changes in the constitution of the urine it is useless to speculate about the significance of the occasional increase in the quantity of inorganic salts and uric acid. Doubtless the functional activity of the skin and lungs, diseases of the genito-urinary tract, and diet play an important part in the production of the alterations in the chemical constituents of the excretion. It cannot, however, be denied that the menstrual flow performs some office as an emunctory, and it is not at all improbable that its cessation throws additional work on the kidneys.
[Footnote 18: Barnes, Diseases of Women, 1878, p. 285.]
ALTERATIONS OF NUTRITION.--Of the various alterations of nutrition consequent upon the change of life, obesity is of greatest clinical interest. It is a matter of common observation that women frequently grow fat coincidently with the cessation of menstruation. Out of 383 cases collected by Tilt, 121 women grew stouter within five years after cessation; 3 women became suddenly fat when the menstrual flow ceased to recur. Barnes, Baillie, Fothergill, and numerous other clinicians abundantly confirm this observation. Adipose tissue is usually deposited in the omentum, abdominal walls, breasts, face, and limbs.
The nature of the relation between the formation of fat and the change of life is obscure. In the attempt to ascribe due influence to the menopause in the production of adipose tissue it must not be forgotten that in males the maximum of weight is attained, according to Quetelet, about the fortieth year. But the accumulation of fat in many of the lower animals after the extirpation of the ovaries, and the frequent occurrence of obesity in women after normal ovariotomy and the Porro-Müller operation of Cæsarean section (Braun, Spaeth), indicate that in some cases, at least, there is a necessary relation between the two phenomena. The generally received view is that the formation of adipose tissue is an outlet for the more or less sudden aberrations in nerve-force and blood-supply following cessation. The weight of probable evidence is very decidedly in favor of this opinion. Physiology teaches that fat fluctuates in bulk more than any other tissue in the body. As remarked by Foster,[19] a large amount of adipose tissue may disappear within a very short space of time, or the quantity in a body may be multiplied many times within an equally short time. Although the direct influence of trophic nerves on metabolic activity has not been demonstrated, there is still evidence of a high order in favor of such a view.
[Footnote 19: M. Foster, Physiology.]
The Mammary Glands.--Apart from the enlargement of the mammary gland from the deposition of adipose tissue, the organ may be the seat of active secretory changes. Tilt observed this phenomenon in 15 out of his 500 cases. The breasts increase in size and become tender. Blue veins are visible through the skin, and changes resembling in kind {438} those of pregnancy may be observed about the nipples and areolæ. A milky fluid is sometimes secreted. Semple has described a case in which a monthly discharge of blood continued for five years after cessation. Tilt has published a case in which a painless exudation of red serum, lasting for several days, recurred every three weeks.
In view of the intimate connection between the ovaries and uterus and mammary glands at other periods of life, it is in a high degree probable that many cases of active nutritive disturbances in the mammary glands, occurring about the forty-fifth year, are directly due to cessation. The exact nervous mechanism has not been fully worked out. These nutritive disturbances are probably physiological, and partake of the nature of the so-called critical discharges.
HEMORRHAGES AND MUCOUS AND SEROUS DISCHARGES.--Vicarious hemorrhages are occasionally though rarely observed in connection with the change of life. These more or less regular discharges of blood occur from a great variety of sites. The region is usually so located that the external escape of blood can easily be effected. The more usual forms of vicarious hemorrhage are hæmatemesis, epistaxis, hæmoptysis, and bleeding from hemorrhoids. General hæmatidrosis, bleeding from the nipples, intestinal hemorrhage, bleeding from the alveoli of the teeth, and subcutaneous ecchymoses are more uncommon types. Every case of suspected vicarious hemorrhage deserves most rigid scrutiny. The condition is such a rare one, and so many local causes sufficient to explain the phenomena frequently exist, that a certain amount of scepticism in the concrete case is perfectly justifiable.
The nervous mechanism of these hemorrhages, so far as it has been worked out, may be stated in a very few words. The cessation of menstruation causes an increase in vascular tension, and consequent irritation of the vaso-motor centres. Various local hæmostases result, which cause the symptoms of suffusion of the face, tinnitus, headache, giddiness, etc. In a limited number of cases these local congestions are relieved by the escape of blood. Vicarious hemorrhages seldom lose their physiological character.
Metrorrhagia is a less uncommon event than vicarious hemorrhage during the climacteric. Uterine hemorrhage is regarded as a critical discharge due to the changes brought about by the menopause, when it occurs, in the absence of local disease or constitutional vice, in connection with the perspirations, flushes, obesity, nervous phenomena, and other signs of cessation. In point of time these uterine hemorrhages, or floodings, usually occur after cessation. The causes of the floodings of the menopause are not at all evident. Barnes[20] is of the opinion that they are ultimately referable to imperfect functional activity of the liver and kidneys. Local congestions occur, vascular tension is increased, the heart and blood-vessels are engorged, and a disposition to uterine hemorrhage is created. In many cases flooding seems to exert a salutary influence upon the health of the individual. J. Frank says he has observed cases of critical floodings after cessation in which checking the bleeding caused apoplexy. Tilt[21] confirms this opinion by the citation of two cases. Not infrequently, however, metrorrhagia during the change of life exceeds physiological limits and endangers the life of the individual. In the {439} large majority of cases flooding after cessation is always a cause for anxiety, and constitutes an urgent indication for a physical examination. By careful indagation it is usually possible to eliminate cases of metrorrhagia due to carcinoma, fibroids, and diseases of the endometrium.
[Footnote 20: Diseases of Women, p. 283.]
[Footnote 21: Change of Life, p. 197.]
Leucorrhoea.--Closely allied in function to the floodings of the menopause is the profuse flow of mucus, unmixed with pus, from the cervix and vagina. This phenomenon is of frequent occurrence in connection with the other signs of the change of life. In the absence of local disease and constitutional vice it may be regarded as a critical discharge, an effort of nature to relieve pelvic congestion.[22]
[Footnote 22: Emmet, Gynæcology, 1884, p. 184.]
Diarrhoea.--The recurrence of a profuse serous diarrhoea at more or less regular intervals during the change of life is common. Gendrin, Brierre de Boismont, and Chambon regard diarrhoea as habitual at this time. It acquires particular prominence as a symptom in the absence of the other critical discharges already mentioned. Indeed, it may constitute the only sign of the menopause apart from cessation of the menstrual flow. Care must be exercised, however, to differentiate in the concrete case between the purely functional serous diarrhoea of the change of life and those forms of the affection which depend upon local or general causes.
The explanation of the serous diarrhoea of the menopause, viewed as a critical discharge, is simple when the intimate connection between the pelvic circulation and that of the mesentery is considered.[23]
[Footnote 23: Ibid.]
FUNCTIONAL DISORDERS IN CONNECTION WITH THE MENOPAUSE.--Vague, indefinite, and speculative as our conception of the physiology of the climacterium is, the deficiency of precise knowledge becomes more apparent when we come to consider the functional disorders of cessation. Many women pass through the change of life without the slightest disturbance of normal functional activity. In such women menstruation has usually been established at an early age and without local or general disorders. Moreover, all traces of disease of the uterus and adnexa are usually absent. Again, it is not an uncommon observation to see hysterical women, afflicted for years with uterine disease, begin to improve in health at an early stage of the pre-cessation period. These facts indicate that the change of life does not necessarily involve morbid phenomena.
In the large majority of cases, however, various functional and organic disorders are observed during this period of life. Under these circumstances it becomes a matter of extreme difficulty to distinguish between accidental complications, dependent upon collateral disease and pathological conditions of the pelvic viscera, and those disorders which stand in some causal nexus with the change of life. The scanty literature of the subject is to a great extent a mass of confused generalizations, in which the distinction between the relation of cause and effect and mere coincidence in point of time is seldom adequately drawn. Tilt's meritorious treatise is not free from this defect. In Table xxi., among the morbid liabilities at the change of life in five hundred women, heart disease, rheumatism, erysipelas, hysteria, epilepsy, cancer of the womb, ovarian tumors, and more than one hundred and fifty other pathological states are mentioned! Any paper on the subject at the present time, to perform a {440} serviceable office, must direct attention to the obscure, confused, inadequate state of knowledge rather than aid in the perpetuation of error by the description of purely hypothetical forms of disease. The comparatively few functional disorders which stand in direct pathological connection with the change of life are, in the large majority of cases, examples of pathological exaggerations of physiological processes. Under these conditions it requires an unusual degree of diagnostic skill and penetration to draw the boundary-line between health and disease. Then in the matter of treatment, as remarked by Spiegelberg, it requires tact to determine how long a purely expectant attitude should be maintained and the time when active interference should be instituted.
The woman passing through the change of life possesses no immunity from accidental diseases. But some of these accidental diseases may be modified in symptoms and course by the changes consequent upon the climacterium.
DISORDERS OF THE ALIMENTARY CANAL.--Salivation.--Ptyalism has been observed by Bouchut and other observers to occur in connection with the other symptoms of the change of life. It is a phenomenon of infrequent occurrence. In the absence of any other adequate explanation it may be regarded as an example of sympathetic irritation strictly analogous to the salivation sometimes observed in pregnancy.
The milder degrees of this affection deserve slight attention. When, however, the flow of saliva is so great as to incommode the individual or seriously endanger her health, active treatment must be instituted. Chalybeate tonics, quinine, hypodermatic injections of atropia over the glands--especially the submaxillary--and iodide of potassium, are among the more reliable remedies. Astringent mouth-washes are grateful and relieve the congestion of the mucous membrane.
Constipation.--The habit of constipation, although not induced, may be aggravated, during the change of life. Interference with the action of the voluntary muscles and intestinal peristalsis by the deposition of adipose tissue in the abdominal walls and omentum, diminution of the intestinal secretions as the result of profuse perspirations and critical discharges, are etiological factors frequently referable to the menopause. Alterations in the innervation of the intestinal walls are probably productive of conditions which tend to constipation. The nature of the changes in the functions of the abdominal sympathetic nervous system during the menopause is a matter of pure speculation. There are many a priori considerations, however, which render probable the view that the constipation in connection with the menopause is, in some degree at least, a visceral neurosis. The prominence of the symptoms, enteralgia and flatulence, lends additional probability to this opinion. The treatment of constipation in connection with the menopause is a subject of the greatest practical importance. Many of the obscure nervous symptoms, distressing perspirations, and critical discharges may be relieved, if not prevented, by attention to the regular daily evacuation of the bowels. The specific hygienic and medical means to be used to secure this end are fully discussed in other portions of this work.
Diarrhoea.--Diarrhoea referable to the menopause and regarded simply as a critical discharge, sometimes, though rarely, passes beyond physiological limits and demands active remedial treatment. This statement {441} holds true especially in cases of chronic diarrhoea aggravated by cessation. It is frequently a matter of extreme difficulty to draw the boundary-line between the physiological process and its pathological exaggeration. Careful attention to the symptoms, however, will usually disclose the fact whether or no the frequent alvine dejections conduce to the patient's well-being. Sometimes the stools are very profuse, and threaten life from the loss of large quantities of serum. Entorrhagia and colic are frequently observed under these circumstances. Rest, restricted diet, opium, the vegetable and mineral astringents, usually suffice to fulfil all the indications.
DISORDERS OF THE LIVER.--Many eminent clinicians unite in the opinion that functional derangements of the liver are peculiarly liable to occur during the change of life. Sir J. Y. Simpson, Robert Barnes, Tilt, Gardanne, Gendrin, Meissner, and Otterburg may be mentioned among the observers who hold that there is some direct relation between certain dynamic disorders of the liver and the menopause. There are also many a priori considerations in favor of this view. Habitual or long-continued constipation--a condition frequently observed in connection with the change of life--interferes materially with the secretion and excretion of bile. Barnes ascribes to the menstrual flow an excretory function. In the absence of this emunctory an increased amount of work is thrown on the liver and other secretory organs. The portal venous system is engorged. Under these circumstances disorders are apt to arise as the result of increased functional activity in an organ which may be undergoing organic change.
Well-pronounced jaundice, however, is of infrequent occurrence during this period in the absence of more potent factors than those just mentioned. It is not more justifiable to speak of the icterus of the menopause than of the icterus of menstruation. Flint[24] has justly said that the occurrence of jaundice at the menstrual periods is too infrequent to suppose that there is any direct pathological connection, as implied in the term icterus menstrualis proposed by Senator.
[Footnote 24: Practice of Medicine, 1881, p. 637.]
On the other hand, that condition vaguely described as biliousness, implying the constitutional effects of chronic hepatic hyperæmia, has been noted by many clinical observers. The derangement referred to is aptly described in the words of B. Lane and quoted by Tilt:[25] "Nothing can be more common than to find severe biliary derangement occurring at or about the period of menstrual cessation; and, looking at the great physiological change which then takes place in connection with hepatic development, it is naturally to be expected. A woman will complain of being bilious; there may be a bitter taste in the mouth, a burning in the throat, frontal headache, nausea, and even vomiting, the urine high-colored, the bile abounding in the alvine dejections, and perhaps causing heat and a stinging sensation in the rectum; the tongue furred, a biliary tinge pervading the cutaneous surface." The propriety of ascribing the symptoms so graphically described in these words to excess, deficiency, or vitiation of the biliary secretion, in the entire absence of precise knowledge, may well be questioned. Tilt is of the opinion that the gastro-intestinal disorders produced by functional disturbances of the liver during the menopause are peculiarly obstinate in their resistance to {442} treatment. Many other clinicians bear testimony to the truth of this statement. This fact increases the importance of the subject of treatment. As this matter is very fully discussed in other parts of this work, it is only necessary to call attention at this time to the importance of directing the therapy to the gastro-intestinal disorders, such as the accompanying subacute gastro-duodenitis and constipation, rather than to the hepatic viscus itself.
[Footnote 25: The Change of Life, 4th ed., p. 227, 1882.]
Incidentally, it may be remarked that gall-stones are apt to give origin to distressing symptoms during the menopause. The causes in operation are substantially the same as those already mentioned in connection with the functional disorders of the liver.
CLIMACTERIC NEUROSES.--Incidental mention has been made, in the discussion of the physiology of the menopause, of functional changes in the nervous system, as involved in the perspirations, flushes, hemorrhages, and other so-called critical discharges. Knowledge at the present time of the physiological changes undergone by the nervous system during the menopause is limited to these few general statements, all of which are not yet definitely established facts. The field has always been a fascinating one to the medical writer, probably because, in the utter absence of precise information, the widest play is given to the most vivid and fertile imagination. The literature of the subject abounds in vague terms, figurative expressions, and rhetorical forms. Numerous ingenious and interesting speculations may be found in the writings of systematic authors from Gardanne[26] to Barnes and Tilt.
[Footnote 26: Aris aux Femmes entrant dans l'Âqe critique, 1816.]
Tilt, following in the wake of the French writers, asserts that the nervous system is in a state of irritability or nervocism. This assertion conveys no information, as irritability may be the expression of weakness as well as of strength. The system is said to be in a condition of nervous plethora. We have seen that the rôle of plethora in recent pathology is insignificant. Cohnheim denies its existence altogether, except as a transitory state. Even admitting the existence of that state, what evidence is there that nerve-force accumulates in the body under the same conditions as the blood?
We have no desire to minify the importance of the physiological and pathological changes in the nervous system connected with the menopause. In comparison with these alterations the other phenomena of the menopause are insignificant. In the absence of precise knowledge, however, it is useless to devote time and attention to empty speculation.
In no part of the subject of climacteric neuroses are notions more obscure or information less precise than in connection with the diseases of the sympathetic or ganglionic nervous system. Under the term gangliapathy Tilt[27] has grouped a number of symptoms frequently observed during the menopause, which have their origin in a condition of "more or less debility associated with paralysis, hyperæsthesia, or dysæsthesia of the central ganglia of the sympathetic system." Gangliapathy includes the functional disorders described by other observers under the terms cardialgia, gastralgia, gastrodynia, and the like.
[Footnote 27: The Change of Life, 4th ed., p. 109, 1882.]
But it is impossible to view affections of the sympathetic apart from disorders of the general nervous system. It is impossible to distinguish {443} the conditions described by Tilt as ganglionic shock, paralysis, hyperæsthesia, and dysæsthesia from abdominal neuralgias and many of the functional and organic diseases of the abdominal viscera. Finally, the connection of these various disorders, entirely irrespective of names, with the change of life has never been demonstrated, nor even rendered in a high degree probable.
Cerebral Hyperæmia.--The older authors dwell with especial emphasis upon hyperæmia of the brain as an important functional disorder in connection with the change of life. The condition is supposed to be apt to occur, in the absence of perspirations, flushes, and the other so-called critical discharges, as the result of plethora. Headache, tinnitus aurium, dizziness, heaviness, drowsiness, suffusion of the face and neck, bounding pulse, are among the symptoms which have been referred to the lighter forms of cerebral hyperæmia. Few systematic writers, however, sustain Dusourd in his assertion that apoplexy and the severer forms of hyperæmia of the brain are frequently caused by the cessation of menstruation.
Under the impression that plethora actually caused cerebral hyperæmia and the symptoms mentioned, and doubtless influenced by the teachings of Broussais (1844), Tissot, Hufeland, and Meissner advocated bleeding in the treatment of climacteric neuroses. Fordyce Barker and Tilt may be mentioned among modern clinicians who retain the old opinion as to the nature and treatment of this condition.
Cohnheim,[28] representing the modern school of pathologists, says "that except as a transitory state polyæmia does not occur under any circumstances." In recent pathology the various appearances of plethora are regarded as caused chiefly by dilatations of the skin blood-vessels, and not by an increase in the total blood-mass. The changes in the character of the pulses are referred to alterations in the vessels or their innervation. Even admitting the existence of the so-called plethora universalis, it does not follow that headache, dizziness, tinnitus aurium, and the like are due to cerebral hyperæmia. Andral has well said that these symptoms might with equal justice be ascribed to qualitative changes in the constitution of the blood.
[Footnote 28: Pepper, System of Medicine, Vol. III. p. 886.]
Whatever view may be accepted as to the pathology of cerebral hyperæmia, and as to the necessary connection with the change of life, two important facts derived from experimental physiology deserve careful consideration before bleeding is performed for the relief of the symptoms mentioned:[29] (1) A high blood-pressure does not imply an augmentation of the total blood-mass. A large quantity of blood may be injected into the vessels without any considerable elevation of pressure. (2) Bleeding does not directly lower blood-pressure unless the quantity of blood removed be dangerously large.
[Footnote 29: M. Foster, Physiology.]
In the lighter cases the so-called derivative treatment fulfils all the indications. Hot, irritating foot-baths, purgatives, saline diuretics, are indicated for the relief of distressing symptoms. Diet, exercise, frequent bathing, and other hygienic resources exercise a most important prophylactic function.
Hysteria.--The occurrence of hysteria during the menopause, as at other periods of life, is a well-established fact. Whether or no there is {444} any direct pathological connection of cause and effect between the change of life and the disorder is a question which has been the subject of much controversy, and at the present time is unsettled. Gardanne, Dubois, D'Amiens, Vigaroux, and Beclard think the relation one of coincidence; Charcot, Tilt, F. Hoffman, Pujol, and Meissner are of the opinion that the climacteric may stand in a causal relation. Tilt's tabulated cases bearing upon this subject show nothing more than the coincidence of the two conditions, and contribute nothing to the solution of the problem. There are important considerations which favor the view that while the menopause may influence hysteria favorably or unfavorably, it is only in exceptional cases that the climacteric is the immediate cause of the affection. While hysteria may occur at any time of life, it is most frequently observed between the ages of fifteen and twenty years. It is in a high degree probable that a woman who has arrived at her forty-fifth year without hysterical manifestations will not be molested during the change of life. It is not an uncommon observation to see hysterical woman rapidly regaining health during the pre-cessation period, and making complete recoveries before the permanent resettlement of health.
Hysteria during the menopause does not differ as to symptoms from the affection at other periods of life. It retains its protean character. Almost all the described forms of nervous disease may be accurately simulated. The severer forms of the disorder are paroxysms characterized by convulsions, coma more or less complete, or delirium. Coma enters to a greater or less degree into the paroxysms characterized by convulsions. Lypothæmia--a term used by the older writers to signify an hysterical semi-unconsciousness with feeble pulse and widely-dilated pupils--is frequently observed. This condition, as well as a state termed pseudo-narcotism by Tilt, may be regarded as a lighter form of coma.
Functional paralyses and pareses of motion or sensation, or both, are occasionally observed. Paraplegia is of relatively frequent occurrence. Not infrequently this condition is of reflex origin, the eccentric irritant residing in the uterus and adnexa or the gastro-intestinal canal. Hemiplegia and general paralysis are observed less frequently.
In the differential diagnosis it is necessary to exclude epilepsy and eclampsia, although it is well to bear in mind the fact that both these conditions may coexist.
The treatment of climacteric hysteria differs in no essential particular from that of the same disorder at other periods of life. The practitioner, however, has the comfortable knowledge that with the resettlement of health all symptoms, in the absence of local disease, will probably disappear.
It may not be amiss, in passing, to notice the value as a palliative measure of that old and well-tried remedy, the hot-water enema containing asafoetida. One to two ounces of the tincture of asafoetida in one quart of hot water, carried well up into the colon, is usually productive of excellent results, moral and physical.
Climacteric Pseudocyesis.--False or spurious pregnancy is a neurosis of not infrequent occurrence at or about cessation. It may justly be regarded as one of the mimetic forms of hysteria. The symptoms which give origin to the illusion may be observed in young, unmarried women or long after the cessation of ovulation and menstruation. In {445} the large proportion of cases, however, the phenomenon is noticed at or about the climacteric. The subjective and objective signs of this curious condition may simulate pregnancy very closely. The breasts are swollen and tender, and a milky fluid may exude from the nipple. Nausea and vomiting in the morning and the various sympathetic disorders of pregnancy may be feigned. The abdomen may become enormously distended from the deposition of adipose tissue in the abdominal walls and omentum and the flatulent distension of the intestines. Foetal movements are simulated by intestinal peristalsis and irregular contractions of the abdominal muscles. The ensemble of symptoms may be very deceptive, as shown by the famous case of Joanna Southcott. Crichton Browne[30] relates the history of an illustrative case which came under his observation in the West Riding Asylum. A woman long past the menopause claimed to be two months advanced in pregnancy. At the end of seven months she informed her friends that she was about to be confined. Accordingly she went to bed, and the process of simulated parturition lasted four days, terminating with a bloody discharge from the vagina.
[Footnote 30: British Medical Journal, 1841.]
The differential diagnosis is easy. The mammary changes, upon close examination, will be found to differ from those of pregnancy. Inspection, palpation, percussion, and auscultation will disclose the fact that the woman is only big with fat and wind, as Barnes puts it. Anæsthesia will facilitate the examination. Bimanual examination usually reveals the characteristic senile changes in the uterus or a pathological enlargement differing essentially from the gravid organ.
The so-called phantom tumors sometimes observed during the menopause are closely analogous to spurious pregnancies.
Epilepsy.--Epilepsy is a relatively uncommon disorder during the menopause. The present state of our knowledge indicates that the climacteric cannot be regarded as a distinct cause of the disease in the absence of previous epileptic seizures or inherited predisposition. Out of 200 cases of epilepsy occurring during the climacteric, observed by Jewell of Chicago, not a single case could be traced by the most rigid analysis to the change of life. Considering the rôle the sympathetic nerve plays in the etiology of epilepsy, it would not seem improbable, on a priori grounds, that the disease should be aggravated at the menopause. Evidence derived from clinical observation, however, is entirely inadequate to settle this question.
Insanity.--Various opinions are held as to the relation between the menopause and insanity. Mania, monomania, dementia, and even idiocy, are among the forms of mental alienation which have been attributed to climacteric influences.
Monomania.--There is much probable evidence in support of the view that the change of life may stand in a direct causal relation to monomania. On the other hand, no proof exists sufficient to establish a necessary pathological connection between cessation and mania, dementia, or idiocy.
Gardanne, Dubois d'Amiens, and Chambon have called attention to the occurrence of melancholia and hypochondriasis at this period. This opinion is confirmed by the results of Battey's operation in the hands of Lawson Tait, Bantock, Thornton, and other operators of large {446} experience. In many of the cases of artificial induction of the menopause melancholia has been observed as a most distressing sequela. However, in connection with Battey's operation there are numerous and important considerations which must be carefully weighed in order to distinguish between a relation of cause and effect and mere coincidence. The number of women operated upon is now large, and some of the cases of melancholia following ovarian extirpation are probably examples of the return of a disease of earlier life or of the influence of heredity. Then, the fact of disqualification for maternal duties supplies in many cases an adequate psychological cause for more or less complete mental alienation. The important effects of chronic hepatic hyperæmia and the coexisting gastro-intestinal catarrh--conditions so frequently present at cessation--must not be forgotten when disorders of the intellect are referred to the cessation of the ovarian stimulus.
The positive diagnosis of climacteric melancholia and hypochondriasis is always difficult, frequently impossible. After the careful exclusion of all other possible causes, it may be assumed with a certain degree of probability that the intellectual disorder is due to the change of life.
The prognosis of climacteric melancholia and hypochondriasis is not necessarily unfavorable. In a large proportion of cases sanity returns with the re-establishment of health. The treatment, in the absence of a positive diagnosis, must be expectant. Effort must be addressed to the removal of any possible cause. Hygienic measures fulfil all the indications for treatment in the disorder when it is caused by the change of life. Opium and alcohol must be employed with extreme care in view of the great danger of the formation of obstinate habits.
Uncontrollable impulses and perversions of moral instincts are frequently observed during the climacterium, as at other periods of life. There is no reliable statistical evidence sufficient to establish a necessary pathological connection between cessation and uncontrollable peevishness, impulse to deceive, suicidal impulse, nymphomania, dipsomania, kleptomania, and the like. Nor is it possible to assert that these various disorders are of more frequent occurrence during the menopause than at other periods of life.
{447}
DISEASES OF THE PARENCHYMA OF THE UTERUS; METRITIS AND ENDOMETRITIS.
BY W. W. JAGGARD, A.M., M.D.
Acute Metritis.
The occurrence of an acute inflammation of the parenchyma of the non-gravid uterus has been denied by many systematic writers. Wenzel[1] says the condition is a figment of the imagination; Duparcque is sceptical; Klob[2] up to 1864 had never seen a case in which a positive diagnosis was possible. Emmet[3] writes in the last edition of his valuable book, "Inflammation of the uterine body never occurs except after parturition."
[Footnote 1: Krankheiten des Uterus, p. 42.]
[Footnote 2: Pathol. Anatomie der Weibl. Sexualorgane.]
[Footnote 3: Gynæcology, 1884, p. 31.]
Comparatively recent investigations, however, have established the fact of occurrence beyond doubt or question. While a relatively uncommon condition, many facts with reference to its causation, pathological anatomy, and clinical course are definitely known.
ETIOLOGY.--Disturbances in connection with menstruation play a rôle of great importance in the production of acute inflammation of the uterine parenchyma. The rapid cooling off of extensive areas of the skin surface, as in wetting the feet in cold water, severe exertion, or the cold-water vaginal douche, may transform the normal menstrual congestion into an acute inflammation. The retention of menstrual blood within the uterine cavity, the result of organic stenoses, flexions, or tumors, occasionally gives origin to acute septic metritis. The inflammatory process frequently extends from the endometrium to the muscular substance. Gonorrhoeal endometritis is of chief clinical significance in this connection. Duparcque's observations, confirmed in 1872 by Noeggerath, have recently attracted a great deal of attention. Säuger's statement at Magdeburg, that one-ninth of all gynæcological cases are of gonorrhoeal origin, created some surprise at the time. In the light of the recent investigations of Schroeder, Bumm,[4] Lomer,[5] Oppenheimer,[6] and others, it is not considered an exaggeration, although it is still unsettled whether or no the gonococcus of Neisser is the agent of infection.
[Footnote 4: Arch. f. Gyn., xxiii. 3.]
[Footnote 5: Deutsch. Med. Wochenschrift, 22d Oct., 1885.]
[Footnote 6: Arch. f. Gyn., xxv. 1.]
Under the heading of traumatism a great number and variety of etiological factors are included. Operations on the cervix, curetting the uterine cavity, and other minor gynæcological procedures, in the absence {448} of careful antisepsis, may cause traumatic inflammation in the vicinity of the wound, which may involve the entire organ. An ill-fitting pessary, especially the intra-uterine stem, cauterization of the cervix or endometrium with the solid stick of nitrate of silver, intra-uterine injections, the careless passage of the sound, inordinate sexual indulgence,--are all potential causes. Bloeschke[7] relates the history of a case in which a piece of straw penetrated the cervix of a peasant-woman working in the fields. An acute metritis was the result.
[Footnote 7: Säxinger, Prager Vierteljahrschrift, 1866, i. p. 130.]
Finally, acute inflammations of the muscularis may be lighted up in the vicinity of new growths, as in the case of carcinoma of the cervix or mural fibroids. Such inflammations, however, as remarked by Schroeder, possess only a secondary significance.
PATHOLOGICAL ANATOMY.--The uterus, of a bluish-red color, is enlarged, especially in its upper two-thirds, to the size of a goose's egg, and is thickened in its antero-posterior diameter. Its walls, filled with venous and arterial blood, are soft and succulent from the transudation of serum. The bundles of muscular fibres are swollen, and the inter-muscular tissue is infiltrated with white blood-corpuscles and a few pus-corpuscles. Extravasations of blood, sometimes larger, sometimes smaller, are usually observed in the connective tissue. These changes are most marked in the innermost layers, where there is a greater abundance of connective tissue, and the inflammatory process is propagated toward the periphery. The endometrium, pelvic peritoneum, and connective tissue are usually involved. The tubes and ovaries are less frequently affected except in the case of gonorrhoeal infection.
SYMPTOMS.--The attack is usually ushered in by a chill, followed by elevation of bodily temperature--a symptom which is apt to persist throughout the course of the disorder. Pain, referred to the lower portion of the abdomen and sacral region, is constant. The sensation may be dull, gnawing, or boring, like the pains in the first stage of labor or abortion, or sharp and lancinating. Tenderness on pressure, indicating involvement of the perimetrium, is marked. The pain is increased in intensity by standing, walking, coughing, straining at stool, or any act which causes an elevation of intra-abdominal pressure. Distressing symptoms arise in connection with the bladder and rectum. Urination is frequent and painful, while the secretion may contain blood. Griping pains are felt along the colon and rectum; the sensation of fulness or the presence of a foreign body excites a frequent or constant desire to defecate, and the act is accompanied with straining.
When acute metritis is caused by wetting the feet in cold water during the period, the menstrual flow may be suddenly arrested, to return after a variable interval. In very rare cases menstruation is permanently suppressed, and even atrophy of the uterus may result. In other cases profuse menorrhagia may occur. Not infrequently this copious hemorrhage is physiological, relieving as it does the congestion of the organ.
Various sympathetic disturbances, as nausea and even vomiting, are occasionally observed.
Acute metritis is frequently complicated by inflammation of the endometrium, pelvic peritoneum, and connective tissue. Under these circumstances the symptoms peculiar to inflammation of the muscular substance {449} are masked. Acute metritis may terminate (1) in resolution, with gradual resorption of the exudation and return of the organ to its normal relations. (2) New connective tissue may be formed, giving origin to induration of tissue and permanent increase in size--the chronic uterine infarct of Kiwisch. The acute inflammation has become chronic. While admitting the possibility of this mode of termination, A. Martin[8] is of the opinion that a causal nexus is only demonstrable in isolated cases. (3) A very rare mode of termination is suppuration and the formation of abscesses in the muscular tissue. In these cases it is necessary, as pointed out by A. Martin,[9] to exclude myomata, which have undergone suppuration in the process of retrograde metamorphosis.
[Footnote 8: Pathologie und Therapie der Frauenkrankheiten, 1885, p. 181.]
[Footnote 9: Ibid.]
DIAGNOSIS.--The more or less sudden occurrence of a chill, fever, and localized pain and tenderness urgently indicates a careful examination of the pelvic viscera by bimanual palpation. The uterus is exquisitely painful upon the slightest touch, even in the absence of any exudate. The organ is enlarged, especially in its upper two-thirds, and thickened in its antero-posterior diameter. The uterus is softened, resembling in its consistence the organ in the early months of pregnancy. During the stage of active hyperæmia the secretions are diminished in amount; at a later period profuse leucorrhoea, especially in the absence of menorrhagia, is a prominent symptom. The diagnosis of abscess in the uterine walls is difficult, if not impossible, when the collection of pus is small. The gradual enlargement of the uterus, the presence of fluctuation, the indications of pointing, and the constitutional symptoms are usually sufficient to establish the diagnosis when the pus-cavity has attained a considerable size.
PROGNOSIS.--Under appropriate treatment the prognosis of acute metritis is not unfavorable. It must, however, always be guarded, as it will be governed to a great degree by the causation, clinical course, and complications. Acute metritis from wetting the feet in cold water during the period and the like usually terminates in resolution. It is necessary to bear in mind the fact that in rare cases the function of menstruation may be permanently arrested, and even atrophy of the uterus induced. In acute metritis from traumatism the danger of general sepsis constitutes the unfavorable prognostic element. In gonorrhoeal infection the tendency to involvement of the tubes and peritoneum is great; moreover, the condition is apt to recur. In all forms of the disorder the relation to chronic uterine infarct deserves consideration. Finally, death may result from the rupture of an abscess, located in the uterine walls, into the abdominal cavity.[10] Fortunately, these abscesses usually open into the uterine cavity, rectum, or through the abdominal parietes.
[Footnote 10: Scanzoni, Krankh. d. Weibl. Sexualorg., iv. Aufl. Bd. i., p. 203; Lados, Gaz. médic. de Paris, 1839, p. 605.]
TREATMENT.--In general terms, the treatment may be described as vigorously antiphlogistic.
Chrobak[11] has pointed out in a detailed manner the absolute necessity of the most rigid attention to antisepsis in all the minor as well as the major operative procedures in gynæcology. The prophylaxis, a subject {450} of vital importance, is limited, so far as the general practitioner is concerned, to the enforcement of absolute cleanliness in all manipulations of the female genito-urinary tract.
[Footnote 11: "Untersuchung. der Weibl. Genitalia und Allgem. gyn. Therapie," Deutsche Chirurgie, Lief. 54.]
Absolute rest in bed in the dorsal decubitus, with the pelvis elevated or depressed according to the patient's sensations, is a matter of primary importance. Pain demands for its relief the free use of morphine hypodermatically or opium per rectum. Chloral is a valuable adjuvant.
In the absence of menorrhagia free and repeated scarifications of the cervix are indicated to deplete the uterus. Twelve to twenty leeches applied to the abdomen above the symphysis will measurably relieve the congestion of the perimetrium. At a later stage, when the disorder does not occur at a menstrual epoch, mediate cold-water irrigation, by means of Leiter's modification of Petitgard's tubes, over the hypogastric region is an invaluable therapeutic resource. When the affection occurs during the period, hot compresses applied to the abdomen, hot sitz-baths, and even hot-water vaginal injections, are grateful.
The rectum and sigmoid flexure frequently require evacuation. A simple warm- or hot-water enema will usually secure this result. Occasionally a dose of castor oil is indicated, but drastic cathartics are distinctly contraindicated.
When the acute metritis is caused by traumatism, as in the case of operations on the cervix and curetting of the endometrium, the wounded surfaces demand attention. Under these conditions the neck of the uterus and the uterine cavity require careful antiseptic local treatment.
Abscesses in the uterine walls rarely indicate operative interference, except in case of pointing in the direction of the abdominal cavity. When incision is indicated the pus-cavity is usually large and superficial, and its evacuation involves no especial difficulty.
The treatment of the later stages of acute metritis will be considered in connection with the subject of Chronic Metritis.
Chronic Metritis.
SYNONYMS.--Chronic uterine infarct (Kiwisch); Diffuse connective-tissue hyperplasia of the entire uterus (Klob, C. Braun, Wedl); Induration of the uterus (Wenzel); Engorgement (Lisfranc); Hysteritis, Phlegmasie rouge (Duparcque); Congestion ou engorgement hypertrophique métrite (Becquerel); Interstitial metritis (De Sinéty); Congestive hypertrophy (Emmet); Areolar hyperplasia, Diffuse interstitial hypertrophy, Sclerosis uteri (Thomas, Skene); Subinvolution, Irritable uterus (Hodge).
In the absence of exact knowledge with reference to the ultimate pathology of so-called chronic metritis, it is impossible to frame a definition which cannot be justly criticised. Schroeder's definition answers all practical purposes, and probably contains as few objectionable terms as any other in the literature of the subject.
DEFINITION.--Hyperplasia of the connective tissue of the uterus combined with increased sensibility.
ETIOLOGY.--1. Subinvolution of the puerperal uterus is a frequent cause of chronic metritis. But the number of etiological factors which {451} interfere directly and indirectly with the retrograde metamorphosis of the puerperal uterus is immense. Getting up too early from childbed, inability to suckle the child, too early sexual intercourse, retention within the uterine cavity of blood-clots or placental remains, acute inflammations of the uterus during the puerperium, retroversions and flexions of the puerperal uterus, severe exertion and the like,--are some of the more usual causes in this connection. Involution of the puerperal uterus is effected by contractions of the muscular walls, fatty metamorphosis of the uterine substance, and profuse secretion. Disturbance of any one of these processes may defer indefinitely the return of the organ to its normal relations. When pregnancy is prematurely interrupted the operation of each of these factors is materially modified. Uterine contractions are relatively feeble. The stimulus of a nursing child is also lacking. The albuminoids of the muscular protoplasm are not so readily converted into fat capable of easy resorption. A comparatively large quantity of decidua vera--even in the absence of portions of the foetal envelopes--is retained within the uterine cavity, and the secretory activity of the endometrium is seriously disturbed. Then, women are less careful after miscarriages than labor at term.
Laceration of the cervix uteri--an accident liable to occur in abortion as well as during confinement at term--if at all extensive, usually interferes with the retrograde metamorphosis of the uterus.
2. Continuous or repeated hyperæmia, active or passive, frequently exceeds physiological limits and leads to chronic metritis. Menstrual subinvolution, dysmenorrhoea from organic stenoses, flexions, changes in position with retained menstrual fluid, excessive venery, masturbation, conjugal onanism, chronic endometritis--especially gonorrhoeal--inflammations of the pelvic cellular tissue, chronic oöphoritis, new formations as in the case of carcinoma and myoma,--result in the production of active flexion and venous engorgement. The pernicious effects of conjugal onanism in the causation of chronic uterine infarct have been dwelt upon with particular fondness by Wenzel, Scanzoni, Emmet, Goodell, and numerous other ancient and modern gynæcologists of distinction. Van de Warker,[12] on the other hand, is of the decided opinion that the operation of this etiological factor has been exaggerated. His conclusions are based upon an incomplete gynæcological study of the Oneida Community. Onanism was practised on a colossal scale by this strange people for a number of years. Summing up the results of his imperfect investigations, Van de Warker says: "I can discover nothing but negative evidence relating to the effect of male continence upon the health of the community." It is quite possible that too much importance has also been attached to excessive venery. Fritsch[13] does not stand alone when he says, "I have examined puellæ publicæ for years, but have not gained the impression that metritis chronica is of frequent occurrence."
[Footnote 12: Ely Van de Warker, "A Gynecological Study of the Oneida Community," The American Journal of Obstetrics, etc., August, 1884.]
[Footnote 13: Heinrich Fritsch, Die Lageveränderungen und die Entzündungen der Gebärmutter, 1885, p. 318.]
3. Venous stasis from organic hepatic, cardiac, and pulmonary diseases doubtless predisposes to chronic inflammation of the metrium. {452} Constipation, usually habitual with invalids, and an over-distended bladder, are causes which are more frequently and directly operative in the production of vascular engorgement and displacements of the uterus.
4. Various operative procedures upon the cervix, ill-advised and frequently repeated intra-uterine applications, must be included in the list of causative agencies.
5. Chronic metritis is one mode of termination of acute inflammation of the uterine parenchyma. This method of origin, however, is seldom observed except after repeated attacks of acute inflammation, as in the case of gonorrhoeal infection.
The enumeration of possible causes might be indefinitely prolonged. Scanzoni's classical monograph on chronic metritis contains a much larger number. As remarked by Fritsch,[14] "In the elastic bands of his conception of the disease every catarrh, every affection of the uterus, fitted finally snugly into place." The more common efficient causes have been indicated.
[Footnote 14: Op. cit., p. 299.]
PATHOLOGICAL ANATOMY.--Modern pathological doctrines on chronic metritis are largely modifications of the opinions so ably advocated by Scanzoni[15] in 1863. Scanzoni, while fully recognizing the various forms of chronic uterine infarct, simplified the study of the subject by comprehending them all under two stages: I. the stage of infiltration; II. the stage of induration.
[Footnote 15: Die Chronische Metritis, Wien, 1863.]
I. In the first stage the uterine tissue is infiltrated with serum, blood, and fibrin (serös-blutige, serös-faserstoffige Infiltration). The organ is in a state of engorgement oedema, the consequence of active and passive hyperæmia. It is enlarged in volume, altered in shape, reddened and more or less sensitive on pressure, soft and doughy to the sense of touch. The uterus may remain in this condition, or, after a longer or shorter interval, pass over into the stage of induration. Long-continued venous hyperæmia leads with comparative infrequency to induration, although intercurrent inflammations, exudations, and new formations of tissue may produce that effect. This stage cannot be invariably viewed as of an inflammatory character. These enlargements of the uterus are frequently examples of the nutritive disturbances commonly observed in other organs in consequence of long-continued venous hyperæmia. The close correspondence of Scanzoni's stage of infiltration with Emmet's congestive hypertrophy is at once apparent.
II. In the stage of induration a luxuriant growth of connective tissue replaces the specific tissue-elements which are destroyed by a chronic inflammatory process. Early in this stage there may be an actual increase in size of the individual muscular elements. Ultimately, the hypertrophy disappears, the soft and succulent connective tissue becomes fibrillated, and the vessels are narrowed, sometimes obliterated, by its contraction. The uterus, though still enlarged and altered in shape, is of a pale color, anæmic, dry, tough, and hard. Ultimately, the uterus is reduced in size by the cicatricial contraction of the firm, fibrillar connective tissue. On section the tissue is white, of cartilaginous consistence, and the knife creaks as it divides the structures. Scanzoni's stage of induration is thus nearly identical with the areolar hyperplasia, diffuse interstitial hypertrophy, sclerosis uteri, of Thomas and Skene.
{453} Klob[16] a pupil of Rokitansky's, attributes the hyperplasia of connective tissue to nutritive disturbances, considers the terms chronic metritis and chronic infarct anatomically incorrect, and classes the condition among the new formations. Carl Braun[17] and Wedl in 1864 assumed the same position.
[Footnote 16: Jul. M. Klob, Pathologische Anatomie d. Weibl. Sexualorgane, Wien, 1864.]
[Footnote 17: Lehrbuch d. g. Gynaekologie, Wien, 1881, p. 351.]
Klebs[18] is of the opinion that, although the so-called chronic uterine infarct may be of inflammatory origin, in the majority of cases the clinical and anatomical demonstration is lacking. With Scanzoni and Virchow, he distinguishes two forms of the disease, the one consisting in hyperplasia of the muscular elements, the other in a similar change in the connective tissue.
[Footnote 18: Handbuch der Pathologischen Anatomie, Berlin, 1873, iv. p. 878.]
Birch-Hirschfeld[19] supports the doctrine of Scanzoni, that the stage of induration at least is of an inflammatory nature. The connective tissue is formed out of emigrated white blood-corpuscles. Hypertrophy of the muscular elements is also observed in certain cases.
[Footnote 19: Pathologische Anatomie, p. 1131.]
Fritsch[20] has materially strengthened the position of Scanzoni by his recent anatomical investigations. Mayrhofer[21] substantially reproduces Scanzoni's doctrines.
[Footnote 20: Op. cit., p. 309 et seq., Stuttgart, 1885.]
[Footnote 21: Entwicklungsfehler und Entzündungen des Uterus.]
Finally, the great majority of modern clinicians have accepted Scanzoni's teachings as originally uttered or as modified in non-essential details. Schroeder,[22] De Sinéty,[23] and A. Martin[24] are notable examples of the truth of this statement.
[Footnote 22: Carl Schroeder, Handbuch der Krankheiten d. Weibl. Geschlechtsorgane, Leipzig, 1881, p. 91.]
[Footnote 23: L. de Sinéty, Manuel practique de Gynécologie et des Maladies des Femmes, Paris, 1879.]
[Footnote 24: Op. cit., Wien, 1885, p. 185.]
The hyperplasia of the connective tissue may be diffuse or circumscribed. It may be limited in development to the collum or corpus uteri. The perimetrium is usually thickened, and other signs of chronic inflammation of that structure are usually present. Chronic endometritis is a constant accompaniment. The pelvic connective tissue is not commonly involved. The plexus pampiniformes and utero-vaginales frequently undergo varicose dilatation.
SYMPTOMS.--The onset of the disease is so insidious and protracted that it is difficult to determine the exact order of occurrence of the symptoms in point of time. Then the complications are so numerous and important that the symptoms of the chronic metritis are frequently masked. A sensation of weight, fulness, or pressure within the pelvis may direct the patient's attention to her condition. This sensation may increase to such a degree that the woman complains of heavy, dull, dragging pains, referred to the centre of the pelvis or the sacral region. Backache is a constant and distressing symptom. Pains radiating up over the abdominal parietes and down the thighs are frequently experienced. Coitus may be productive of acute distress. When the uterus is anteverted, pressing against the bladder, ischuria is the usual result. Constipation, usually present as one of the etiological factors, is aggravated by the retroversion or retroflexion of the top-heavy uterus. Under these {454} circumstances one or both ovaries may be drawn down along with the prolapsed, retroverted uterus, and add materially to the woman's discomfort. The act of defecation is painful; the woman avoids the water-closet, days and even weeks elapsing between evacuations.
Disturbances of the menstrual function are constant. All forms of dysmenorrhoea, including dysmenorrhoea membranacea, are liable to occur. Menstruation is usually profuse, giving origin to menorrhagia, which usually results in the production of an alarming degree of anæmia. The periods are irregular in recurrence and duration. The periodic discharge of blood may last from one to three weeks, and then cease, to reappear after a variable interval of from six to eight weeks. In other cases menstruation may last the usual length of time, but recur every two or three weeks. Amenorrhoea may be observed in the stage of induration.
Priestly,[25] Fasbender,[26] Fehling, and numerous other clinicians have called attention to intermenstrual pain (règles surnuméraires) as a tolerably constant symptom of chronic metritis. From fourteen to fifteen days after and before the regular time for menstruation vague intrapelvic pains are complained of, and the woman is of the opinion that the monthly flow of blood is about to begin. The pains, however, are not so severe, and do not last so long, as those of menstruation. Occasionally bloody mucus may escape from the vagina. Fehling ascribes this intermenstrual pain to the swelling of the mucous membrane preparatory to the next monthly discharge of blood. The symptom is not at all pathognomonic, as it occurs in connection with oöphoritis and other pathological conditions.
[Footnote 25: Brit. Med. Journ., 1872, p. 431.]
[Footnote 26: Zeitschrift f. Gebürtskulfe und Frauenkrankheiten, i. 1.]
As the result of the chronic endometritis, which usually follows parenchymatous inflammation, metrorrhagia is frequently observed. Leucorrhoea, more or less profuse, is a constant symptom. Opinions vary extremely as to the systemic reaction following chronic metritis. General failure of nutrition, functional disturbances of the gastro-intestinal canal, hysteria, headache,[27] facial neuralgia (Barnes), coccygodynia, vaginodynia, skin diseases, alopecia (Hebra), and a host of other affections, have been ascribed from time to time to the direct influence of chronic uterine infarct. Doubtless, the condition under discussion plays an important rôle in the production of these and other disorders. But the position is utterly untenable at the present day that chronic parenchymatous inflammation of the uterus is the efficient cause in the absence of all other etiological factors.[28]
[Footnote 27: Peaselee, "Uterine Headache," American Medical Monthly, 1860.]
[Footnote 28: Fritsch, op. cit., 1885, p. 323.]
Intercostal neuralgia and mastodynia, with swelling of the breasts and darkening of the areolæ, are phenomena of such constant occurrence in connection with chronic uterine infarct that a direct causal nexus is in a high degree probable. The investigations of Krause[29] have established the fact of anastomotic communication between the arteries supplying the mammary gland and those distributed to the uterus. The perforating branches of the internal mammary artery supply in part the mammary gland. The superior epigastric artery, one of the terminal branches of {455} the internal mammary, anastomoses with the inferior epigastric, which arises from the external iliac a few lines above Poupart's ligament. The inferior epigastric sends off a spermatic branch which passes along the round ligament and anastomoses with the ovarian artery derived from the aorta, and the uterine artery derived from the anterior trunk of the internal iliac. The nervous communication is effected through the sympathetic and spinal nerves. There is nothing remarkable, therefore, in the occurrence of intercostal neuralgia, mastodynia, and nutritive disturbances in the mammary gland as the result of chronic parenchymatous inflammation of the uterus. The intercostal neuralgia and mastodynia are examples of reflected neuroses the result of compression of nerve-fibres by the infiltration or of an ascending neuritis (Fritsch).
[Footnote 29: Specielle und Makroskopische Anatomie, Hannover, 1879.]
PHYSICAL SIGNS OF CHRONIC METRITIS.--Bimanual palpation prior to the stage of cicatricial contraction reveals alterations in size, shape, position, consistence, and sensibility of the uterus. Variations in size are extreme. Veit[30] has recorded a case in which the fundus extended two inches above the umbilicus. The uterus is usually thickened, especially in its antero-posterior diameter. As regards position, the organ may be prolapsed, elevated, or remain in situ. The consistence will depend upon the stage of the disease. During the stage of infiltration the organ is soft and imparts a doughy sensation to the examining finger. During an exacerbation of acute inflammation the vagina is hot and dry; the uterus is swollen with blood and very sensitive on pressure. During the intervals between exacerbations no change in sensibility is noticed. The sound demonstrates a varying degree of elongation of the uterine cavity. During the second stage, after cicatricial contraction of the connective-tissue elements, the uterus is relatively small, hard, and insensible.
[Footnote 30: Frauenkrankheiten, 2 Aufl. p. 367.]
The cervix is hard or soft according to the time of examination. In virgins or women who have not borne children enlargement is of relatively infrequent occurrence. In multiparæ, especially in cases of bilateral cervical laceration, the increase in volume is great. The mucous membrane of the cervical canal is everted and studded with minute cysts--distended follicles.
The influence of chronic metritis upon conception is not direct. When the endometrium is not seriously involved the condition seems to exercise no untoward influence. However, associated with chronic uterine infarct as complications we have endometritis, salpingitis, oöphoritis, perimetritis, and displacements, pathological states which may obviously cause sterility.
When conception does occur, abortion follows with relative frequency. The reason why is not clear. The chronic endometritis may interfere with the development of the decidua; the parenchyma may not be able to undergo evolution. When pregnancy reaches its normal termination, labor is not materially influenced by the pathological condition of the uterus, but complications are liable to occur during the puerperium. Postpartum hemorrhages which do not readily yield to ergot are observed as the result of the deficiency in muscular elements. The hyperplasia of the connective-tissue elements and destruction of the muscular tissue is a distinct predisposing cause of complete or incomplete uterine inversion. {456} Subinvolution is increased. Menstruation recurs soon after pregnancy, and the chronic metritis is aggravated.[31]
[Footnote 31: A. Martin, op. cit., Wien, 1885, p. 189.]
Occasionally, gestation, parturition, the puerperium, and lactation seem to exercise a favorable influence on the state of the parenchyma. In exceptional cases all traces of the original chronic metritis disappear with the puerperium. The connective-tissue hyperplasia may undergo the same involution to which the hypertrophied muscular tissue is subject. This favorable termination of the disease is seldom observed during the stage of induration.
TERMINATIONS.--I. Chronic metritis may terminate during the stage of infiltration in resolution. This mode of termination is rare. It is observed occasionally as the result of involution in the puerperal uterus. Judicious treatment in favorable cases may reduce the size of the uterus and relieve all distressing symptoms. Recidiva of the disease are liable to occur, however, and all traces of the former condition seldom disappear.
II. Usually, the condition persists, with acute exacerbations, through years, until cessation of menstruation and ovulation occurs. Under the influence of the change of life the symptoms may gradually disappear and the uterus may undergo senile atrophy. In some cases chronic uterine infarct seems to defer the climacteric changes. Finally, the disease may continue after the menopause, usually with abatement in the severity of the symptoms.
III. The morbid condition may terminate in induration. The uterus becomes comparatively small, hard, and insensible. Amenorrhoea may be the result. This process may be viewed as a relative cure, since it is attended, as a rule, with amelioration of all the troublesome symptoms.
DIFFERENTIAL DIAGNOSIS.--It is not always an easy matter to institute a differential diagnosis between chronic metritis and pregnancy and fibroid tumors by bimanual palpation. Alterations in the volume, form, position, consistence, and sensibility of the uterus occur in pregnancy as in chronic metritis. But in pregnancy the uterus, particularly in its vaginal portion, is softer; the organ is not so sensitive; the cyanotic hue of the vaginal mucous membrane is more marked; arterial pulsations in the vagina are more evident; the uterus enlarges more rapidly; finally, there is the history of the case. Pregnancy may occur, however, in a chronically inflamed uterus, and this fact must be borne in mind.
The alterations in the size of the uterus are usually circumscribed in fibroid tumors. One wall is thickened; the other retains its normal relations. In submucous fibroids the cervix is shortened; in chronic metritis it is usually enlarged. In both submucous and interstitial fibroids the cavity of the uterus is encroached upon--a fact to be determined by the use of the sound. The history of the case will throw some light upon the differential diagnosis. Frequently, however, it is impossible to exclude fibroids by any of the means already mentioned. Dilatation of the cervix, and the careful examination of the walls by the finger introduced into the uterine cavity, will clear up the diagnosis in the most obscure case.
PROGNOSIS.--The prognosis with reference to life is favorable. The duration of life however, may be abbreviated in exceptional cases by {457} disturbances of nutrition, anæmia the result of menorrhagia and metrorrhagia, extension of the inflammation to the peritoneum, and the like--conditions which predispose to some intercurrent affection.
Although the immediate danger of death is minimal, the woman is rendered wretched by the frequent exacerbations of acute inflammation and other symptoms already mentioned. The spontaneous disappearance of the affection with the puerperium or menopause is of such seldom occurrence as to have but slight bearing on the general rule.
Under judicious treatment disappearance of the more distressing symptoms may be confidently expected during the stage of infiltration. The outlook is especially favorable in cases of puerperal subinvolution in the absence of chronic inflammations of the endometrium and parametrium. A perfect restitution of the uterus to its normal condition is so seldom effected by any rational therapy that for practical purposes this desirable result may be excluded from consideration. Recidiva of the disease are liable to occur at any time.
TREATMENT.--Prophylaxis.--Very much can be done to prevent the occurrence of chronic metritis. A careful consideration of the etiology of the disease will at once suggest the principles of prophylactic treatment. The conduct of the second stage of labor, the puerperium, lactation, the hygiene of menstruation, are subjects especially significant in this connection. Antecedent acute metritis and endometritis under a rational therapy usually terminate in resolution, and their pernicious influences as etiological factors may be avoided, or at least modified, in the large majority of cases. The early rectification of uterine flexions and displacement is urgently indicated in view of the probable consequences.
Uncomplicated chronic metritis is such a rare affection that efforts at curative treatment are seldom addressed to the condition of the parenchyma, to the exclusion of the endometrium, perimetrium, and parametrium. Certain special indications, however, exist in the case of chronic uterine infarct, and the discussion of treatment is limited here to their consideration.
1. Local Treatment.--In view of the pathology of the condition, local treatment, especially in the first stage, is antiphlogistic.
Hot-Water Vaginal Douche.--The irrigation of the vagina with hot water, of different degrees of temperature according to the indications in the concrete case, deservedly occupies the high position in American gynæcological therapeutics which Emmet[32] in particular has assigned it. The smooth muscular fibres of the uterus are excited to contract, and the whole pelvic circulation is directly or indirectly influenced. During the stage of infiltration--Emmet's congestive hypertrophy--hot-water vaginal irrigation is simply an invaluable adjuvant. But to secure the maximum benefit from this remedy it must be rationally employed. With reference to posture, Emmet recommends the dorsal decubitus, with elevation of the hips, or, better, the genu-pectoral position. The temperature of the water should be rapidly elevated from blood-heat to 110° F., or to as high a degree as the patient can tolerate. The quantity of water will vary with the stage of the treatment and the improvement in health of the patient. It is customary to begin the irrigations with one to two {458} gallons of water, and to increase or decrease the quantity according to circumstances. Two irrigations per diem--one at night before going to bed, one in the morning upon rising--are usually sufficient. Fritsch[33] has tried on an extensive scale the plan of continuous vaginal irrigation with hot water through five and even ten hours, but has obtained better results with the simple periodic vaginal douche as recommended by Emmet.
[Footnote 32: Principles and Practice of Gynæcology, 3d ed. 1884, pp. 85, 113.]
[Footnote 33: Op. cit., 1885, p. 337.]
During the stage of induration, when the muscular elements have been destroyed and replaced by connective tissue, the beneficial effects of the hot-water douche are decidedly less evident. Nor is the plan applicable to all cases during the stage of congestive hypertrophy. General nervous excitement, insomnia, and even positive intrapelvic pain, sometimes, though rarely, may result. The range of therapeutic application of the hot-water vaginal douche is largely empirical.
Local Depletion.--The local bloodletting of from a drachm to one ounce of the fluid, repeated according to the indications every three or four days, ranks next to the hot-water vaginal douche in importance as an antiphlogistic agent. This plan of treatment is of especial value as an adjuvant during the stage of infiltration in cases of menorrhagia, metrorrhagia, exacerbations of acute inflammation, and the like. Local depletion, however, is a double-edged sword. It may cause an increased determination of blood to the uterus and aggravate the pathological condition already existing. This effect is observed when the bloodletting is practised at too short intervals.[34] Thus, frequent scarifications of the cervix constitute a most important therapeutic resource in the treatment of certain forms of atrophy of the uterus.
[Footnote 34: A. Martin, op. cit., 1885, p. 59.]
Local depletion of the cervix is effected by scarification, puncture, leeches, wet and dry cupping. Scarification and puncture have almost entirely superseded the other two methods.
Local depletion has fallen into a state of comparative disuse in America. In the Woman's Hospital of New York[35] it has almost completely passed out of vogue. In Germany, however, it constitutes the basis of all methods of treatment. Schroeder, A. Martin of Berlin, H. Fritsch of Breslau, Carl Braun, Spaeth, and Chrobals of Vienna unite in enthusiastic advocacy of its intelligent employment in suitable cases.
[Footnote 35: T. Gaillard Thomas, Diseases of Women, 5th ed., 1880, p. 334.]
Glycerin Tamponade.--Sims many years ago called attention to the employment of cotton tampons saturated with glycerin in the treatment of chronic metritis and kindred affections. In virtue of its avidity for water the glycerin tampon, when placed in the vagina, provokes a profuse aqueous discharge. The albuminoid constituents of the blood are not affected, while the capillaries are drained of their aqueous elements. Emmet[36] has substituted oakum for absorbent cotton. Oakum, when saturated with glycerin, becomes soft as a sponge, is perfectly antiseptic, and will remain odorless in the vagina a much longer time than cotton. Glycerin dissolves the salts more readily than water. Boric acid (1:10), potassium iodide (5:100), iodoform, chloral, and a variety of substances may be applied locally by means of this menstruum. Glycerin, employed in conjunction with hot-water vaginal irrigation and scarification, or used {459} alone in cases contraindicating these procedures, is an important addition to our therapeutic resources.
[Footnote 36: Gynæcology, 1884, p. 128.]
Local Alteratives.--Much importance is attached in the United States to the application of various alteratives to the vaginal portion and endometrium in cases of chronic uterine infarct. They may accomplish good results indirectly--for example, by curing the accompanying endometritis--but it is doubtful whether they have any direct effect in hastening the resorption of the infiltration.
The vaginal vault and intravaginal portion of the cervix are usually painted with the compound tincture of iodine; mercury, potassium iodide, iodoform, and other substances are introduced into the vagina by means of vaseline, gelatin, and cacao butter.
Operative Treatment.--1. Repair of Lacerations of the Cervix.--The importance of the repair of lacerations of the cervix for the cure of chronic uterine infarct and allied conditions was recognized by Emmet in 1862. In the autumn of 1862 he devised and performed the operation, which is now known the world over as Emmet's operation. This highly original and valuable surgical procedure has been but little modified in the years which have intervened since its first full description in 1869.
2. Amputation of the Collum Uteri.--Carl Braun[37] and Wedl in 1864 pointed out the fact that amputation of the neck of the chronically inflamed uterus is frequently followed by a more or less complete involution of the whole organ, resembling very closely the reductive metamorphosis of the puerperal uterus. August Martin in recent years has called attention to Braun's observation, and at the Naturforscherversammlung in Cassel described a series of seventy cases in which amputation of the collum uteri had been performed for the relief of chronic metritis. As an ultimate resort in extreme cases, amputation of the neck of the uterus is now a generally well-recognized operative procedure.[38]
[Footnote 37: Wiener Med. Jahrbücher, Wien, 1864.]
[Footnote 38: H. Fritsch, op. cit., 1885, p. 343.]
3. Castration.--At a comparatively recent date a determined effort has been made to include desperate cases of chronic metritis under the indications for the performance of oöphorectomy. Numerous and distinguished surgeons have taken this advanced position. But at the present time the cases in which the operation has been performed are too few in number and too recent to warrant positive deductions with reference to the effects of the operation.
2. General Treatment.--It is not possible to adequately discuss the subject of the general or constitutional treatment of chronic metritis in the limited space at our command. It is scarcely necessary to add that the subject is of vital importance, and more frequently neglected than the local treatment. The indications for therapeutic aid are usually apparent, and are not always peculiar to the condition. Attention has been directed, in other portions of this work, to the importance of the observation of hygienic laws, in the widest sense of that expression, with respect to diet, rest, clothing, recreation, personal cleanliness, temperance in sexual intercourse, and other bodily habits.
Habitual constipation, involving as it does engorgement of the portal system and pelvic veins, demands especial consideration. In the absence of regular daily alvine dejections the most elaborate plan of local and {460} constitutional treatment will fail to effect amelioration of symptoms. Diet, exercise, and the like are not sufficient, as a rule, to correct this most obstinate habit. Among remedial agents, senna, rhubarb, cascara sagrada, and the milder laxatives deserve particular mention. The compound licorice powder and confection of senna of the U. S. Pharmacopoeia are comparatively innocent in their effects, even when used through long periods of time. Aloes must be employed with a certain amount of caution. As pointed out by August Martin,[39] when there is a disposition to uterine hemorrhages the drug, in the exercise of its well-known influence on the pelvic circulation, may increase this tendency. Clysters may be employed to advantage in connection with hygienic and medical means.
[Footnote 39: Op. cit., p. 195.]
Ergot, hydrastis canadensis, potassium iodide, ammonium chloride, strychnia, are among the remedial agents which are supposed to have some direct effect upon the condition of the uterine parenchyma. Ergot may be exhibited by the mouth or hypodermatically. Squibb's fluid extract, while an active and tolerably agreeable preparation, is not as effective as the decoction employed on an extensive scale in many of the German hospitals, and the formula of which we append:
Rx. Secalis cornuti recent. pulver., 15.0 Alcohol., 5.0 Acidi sulphurici, 2.0 Aquæ, 500.0 Coque ad 200.0 Ne cola. Adde Syr. cinnamom., 30.0
Dose: Two to three teaspoonfuls, pro re nata. This unfiltered decoction is extremely distasteful, and its continued use is not without effect upon the gastric mucous membrane. It is, however, physiologically very active. Subcutaneous injections of Squibb's aqueous extract of ergot may be occasionally employed with benefit to keep up the impression of the remedy when exhibition per os is interrupted. Schatz speaks in high terms of the fluid extract of hydrastis canadensis in doses of fifteen to twenty drops two or three times daily.
All European writers ascribe an important influence to the numerous watering-places and baths of the Continent in the treatment of chronic uterine infarct. The rigid observance of hygienic rules, the imbibition of enormous quantities of water more or less impregnated with salines and carbonic acid, the frequent bathings, exercise, and recreation, undoubtedly effect amelioration of symptoms in many desperate cases.
Acute Endometritis.
ETIOLOGY.--An acute inflammation of the mucous membrane of the uterus is a rare affection before puberty. The acute infectious diseases play an important rôle in the production of the condition. The acute exanthems--smallpox, measles, scarlet fever, cholera, typhus, typhoid, and relapsing fever, certain forms of malarial fever--deserve mention in this connection. Probably owing to some change in the constitution {461} of the blood, these diseases predispose to the hemorrhagic form of acute endometritis. The rapid cooling off of extensive areas of the skin surface during menstruation frequently leads to an acute inflammation of the endometrium, with suppression of the flow as one of the first symptoms. Gonorrhoeal infection and sepsis are most important causative factors. Ill-advised therapeutic procedures, as in the case of acute metritis, must be included in the list of causative agencies. Finally, acute endometritis may be caused by various poisons. Among toxic agents which may give origin to the condition under discussion phosphorus is especially noteworthy.[40]
[Footnote 40: Hausmann, Berl. Beitr. z. Geb. u. Gyn., Bd. i. S. 265.]
PATHOLOGICAL ANATOMY.--The entire lining membrane of the uterine cavity may be involved in the inflammatory process; usually, the mucosa of the body and fundus is affected, the mucosa of the cervical canal remaining normal. The mucous membrane is of a dark-red color, swollen, softened, and presents a velvety appearance. Its connection with the muscularis is loosened, so that it can frequently be stripped off with the handle of a scalpel. Minute extravasations of blood are visible in the superficial layers and on the surface. The interglandular connective tissue is the seat of the inflammatory process. The glands are involved secondarily. The ciliated epithelium is destroyed and cast off at an early stage. The bloody discharge from the uterine cavity becomes serous, and finally purulent, during the progress of the condition. The cervical secretion becomes thin, turbid, and profuse.
The inflammatory process is seldom limited to the endometrium. It involves, as a rule, the tubal mucous membrane, the uterine parenchyma, and the perimetrium.
DIAGNOSIS.--The symptoms resemble closely in kind, but differ in degree from, the appearances in acute metritis. The uterus is smaller and not so painful on pressure. The endometrium is sensitive to the slightest touch--a fact elicited upon the passage of the sound. The characteristic symptom is the discharge from the uterine cavity of a more or less profuse secretion possessing the character already mentioned. An absolute differential diagnosis is impossible, nor is it necessary, seeing that the treatment of the two conditions is nearly identical.
PROGNOSIS.--Acute endometritis terminates in resolution or chronic inflammation. The latter mode of termination is of more frequent occurrence, particularly in the presence of gonorrhoea, sepsis, and the like as etiological factors. The disease endangers life when the peritoneum is involved by the propagation of the inflammatory process along the tubes or through the uterine parenchyma. Then the acute endometritis may be the starting-point of general septic infection through the media of the veins and lymphatic vessels.
TREATMENT.--Absolute rest in bed, the relief of pain by morphine, the evacuation of the bowels by enemata or mild laxatives, the free imbibition of bland mucilaginous fluids for the vesical tenesmus,--are measures which usually fulfil all indications for treatment. Even in the case of gonorrhoeal infections astringent applications to the endometrium are contraindicated. Usually, various complications mark the endometritis, the starting-point of the pathological condition, and these complications demand more active interference.
{462} Chronic Endometritis.
ETIOLOGY.--Attention has been called to the etiology of chronic metritis in a somewhat detailed manner. The limits of this paper will not admit of adequate mention even of the more common causative factors of chronic endometritis. All the conditions which determine an active fluxion or passive hyperæmia of the uterus may operate as causative factors. Hypersecretion of mucus is frequently observed in chlorotic, scrofulous, and tuberculous females. Syphilis and gonorrhoea are potential causative agents. Climate seems to exercise a more or less direct influence. Thus, we are informed by Schroeder[41] that chronic endometritis is observed with relative frequency in damp, cool regions, such as Holland, Belgium, and certain parts of England. Europeans who reside in hot climates--for example, the Englishwomen living in India--are said to be affected with leucorrhoea to a degree entirely out of proportion to local or constitutional causes.
[Footnote 41: Handbuch der Krankheiten der Weiblichen Geschlechtsorgane, 1881, p. 111.]
PATHOLOGICAL ANATOMY.--An analogy of striking character exists between the structural changes in chronic endometritis and chronic metritis. In chronic endometritis, as in chronic metritis, it is possible to clearly distinguish two stages in the inflammatory process. In the first, or stage of infiltration, a more or less acute inflammation is observed, which involves, primarily, the interglandular connective tissue; secondarily, the glands themselves. When the stage of infiltration does not terminate in resolution with the resorption of the exudate, the newly-formed connective-tissue elements contract, and the glands are to a greater or less degree obliterated.
1. Chronic Catarrhal Endometritis.--The endometrium during the first stage is swollen, vascular, soft, and succulent. Small extravasations of blood and pigmentary deposits from ecchymoses are observed in the interacinous connective tissue. The surface of the mucous membrane is smooth or roughened in spots. The orifices of the glands are visible. The mucous membrane of the cervix is infected, its transverse folds distended, the follicles filled with mucus, the canal plugged with tenacious turbid secretion; the vaginal portion is enlarged, spongy, and its mucous membrane exhibits hypertrophic changes in the papillary body. The os externum is frequently patulous. The uterine walls having undergone excentric hypertrophy, the cavity is usually enlarged, and contains a translucent alkaline secretion which resembles mucus.
Microscopical examination of the endometrium reveals a variety of structural changes. A luxuriant development of embryonal connective-tissue elements is observed with relative frequency in the interacinous connective tissue. Olshausen has applied the term chronic hyperplastic endometritis to this condition. The term chronic interstitial endometritis has been more generally accepted. While the newly-formed connective-tissue elements are soft and succulent, hemorrhages are frequent.
Changes in the glandular structures may become more prominent features than alterations in the connective tissue. The laminæ of the glands and the cells of the acini increase in size. The glands branch, frequently resulting in the production of a dendritic network. Schroeder and Carl Ruge have termed this glandular endometritis diffuse adenoma.
{463} The thickness of the mucous membrane may increase in spots from three or four millimeters to fourteen or fifteen millimeters, and there is produced a form of chronic endometritis which is known as fungoid or polypoid.
Under the name endometritis villosa Slavianski described in 1874 a condition of the uterine mucous membrane which consists in a papillary growth of the endometrium with myxomatous degeneration of the vessel tunics.
During the stage of induration the ciliated epithelium, destroyed and cast off during the stage of infiltration, is replaced by cells which resemble squamous epithelium. The utricular glands, with dilated cavities, are flattened out, entirely obliterated, or present the appearance of shallow crypts. The secretion is gradually diminished, until finally the endometrium is converted into a layer of connective tissue.
Under the names erosion, ulceration, granulation, and the like a variety of pathological conditions, entirely distinct from, sometimes in connection with, cervical laceration and ectropium, are included. The flattened epithelium covering the vaginal portion may be cast off, and replaced by the dark-red subjacent cylindrical epithelium, giving origin to the condition known as simple erosion. Occasionally, glandular canals, formed out of these cylindrical cells, and penetrating the mucous membrane in every direction, present the appearances of papillary erosion; and the condition has accordingly been termed by Carl Ruge papillary ulcer. Cervical secretions may stagnate in these glandular tubes, retention-cysts appear, and the condition technically termed follicular erosion results. In all forms of cervical erosion or laceration the secretions are increased in amount and altered in physical and chemical characters during the stage of infiltration. In a later stage of the disease the hyperplasia and subsequent contraction of the connective-tissue elements may result in the total obliteration of all traces of glandular structure. There is a certain amount of probable evidence in favor of the view that these changes in the cylindrical cells normally situated beneath the squamous epithelium covering the vaginal portion may terminate in malignant disease. These erosions, in the present state of our knowledge, must be viewed as symptomatic of chronic endocervicitis.
2. Dysmenorrhoea Membranacea.--The exfoliation and casting off of large pieces, or even of the superficial layers, of the entire endometrium during menstruation has been observed from the days of Morgagni up to the present time. Peter Frank pointed out the resemblance between this exfoliation and the membrana caduca. Simpson, recognizing the sieve-like perforations caused by the utricular glands, termed the condition exfoliation of the hypertrophic mucous membrane. Virchow erroneously termed the membrane decidua menstrualis. Olshausen, Wyder, and v. Recklinghausen (1877) have demonstrated the truth of Simpson's view, and have shown that the condition must be regarded as a symptom of a series of endometritic inflammatory processes. In all cases in which a decidual membrane is cast off the diagnosis of abortion must be made, whether the pregnancy be intra-uterine or extra-uterine.
Wyger has reported a case in which syphilis was regarded as an etiological factor. This observation has not been confirmed.
3. Chronic Croupous Inflammation of the Endometrium is sometimes observed in connection with carcinoma of the corpus. It may follow {464} gangrenous vaginitis in diphtheria and the acute infectious diseases. The interacinous connective tissue is infiltrated with fibrinous materials, and extravasations of blood are everywhere visible. The superficial layers of the mucous membrane become gangrenous, are cast off, and occasionally the entire intra-uterine expanse is converted into a wound surface.
DIAGNOSIS.--The symptoms of chronic endometritis and endocervicitis are usually masked by the appearance of the accompanying chronic metritis. Intrapelvic pains, disturbance of the menstrual function, extra-menstrual hemorrhages, the presence of a more or less profuse leucorrhoea, are signs which urgently indicate bimanual palpation.
The catarrhal secretion from the utricular glands may be imprisoned within the uterine cavity by a functional or organic stricture of the internal os, resulting in periodic discharges of a thin, translucent alkaline fluid, readily distinguishable from the thick, tenacious cervical mucus. In certain cases, particularly in old women, the blenorrhoeal secretion may be permanently retained within the uterine cavity, constituting the condition hydrometra.
The introduction of a small sharp spoon within the cavity of the uterus will enable the observer to remove sufficient tissue for microscopical examination without entailing the slightest injury on the patient. A positive diagnosis can be made in this way, and a rational therapy instituted.
Digital and specular examinations disclose the condition of the vaginal portion of the cervix. The amount and physical characters of the cervical secretions are items of important diagnostic moment. In suspicious cases of cervical erosion a small bit of tissue may be cut away from the surface and subjected to microscopical examination.
Secondary disturbances in connection with the gastro-intestinal canal and nervous system occur in chronic inflammations of the endometrium, as in the case of chronic uterine infarct.
PROGNOSIS.--Chronic inflammations of the corporeal and cervical mucous membrane seldom threaten life directly. The continuous loss of blood and serum, however, may produce a condition of profound anæmia and render the individual more susceptible to intercurrent disease.
Then the hyperplastic condition of the endometrium is always an occasion for anxiety. The relation between polypoid and fungoid growths of the corporeal mucous membrane, erosions of the vaginal portion of the cervix, and malignant new formations is not settled. The possibility of malignant residua, however, must be admitted.
Sterility, acute and chronic decidual inflammations, adherent placenta, disturbances in the involution of the puerperal uterus, and the like--direct results of chronic endometritic inflammation--are conditions which confer an unfavorable element upon the prognosis.
Finally, while it is possible to effect a material amelioration of all the symptoms by a judicious general and local treatment, a complete restitutio ad integrum is seldom or never achieved. Recidiva are always liable to occur.
TREATMENT.--Prophylaxis.--The remarks made with reference to the prevention of chronic uterine infarct apply with equal force to the prophylaxis of chronic corporeal and cervical endometritis.
{465} Curative.--Of chief importance, in the very large majority of cases, is the subject of general treatment. Many cases of chronic catarrhal endometritis are improved by the regulation of the functions of the gastro-intestinal canal, skin, kidneys, and hæmatopoietic viscera in the absence of all local treatment. This statement holds true with particular force when scrofulosis, tuberculosis, syphilis, and the like are chief etiological factors.
Local Treatment.--The methods of local treatment at the present time are infinitely various. For convenience of description they may be collected under three headings:[42]
I. The washing out of the uterine cavity; II. The cauterization of the uterine cavity; III. The curettement of the uterine mucous membrane.
[Footnote 42: H. Fritsch, op. cit., 1885, p. 419.]
To Schultze, in particular, are we indebted for methods of washing out the cavity of the uterus. The cervical canal is dilated by means of the finger, tents, or metallic instruments, and the mucous membrane lining the cavity of the uterus is cleansed with dilute solutions of carbolic acid, boric acid, bichloride of mercury, and other solvent and antiseptic fluids.
Cauterization is usually effected at the present time by the application of pure tincture of iodine, iodine with glycerin, or carbolic acid, to the endometrium. Bandl's canulæ for the washing out of the uterine cavity with solutions of alum and cupric sulphate are valuable instruments in this connection. The application of the solid stick of nitrate of silver and intra-uterine injections of liquor ferri are gradually passing into disuse.
The curettement of the diseased endometrium has been rapidly gaining ground within recent years, and now constitutes the most reliable method of treatment in obstinate cases in which local interference is indicated at all. Martin, Düvelius, and other clinicians have abundantly established the fact that, after the mechanical removal of the old diseased mucous membrane, a new endometrium of relatively normal functional activity is formed.
The number of operative procedures for the relief of chronic endocervicitis is enormous. In the majority of cases occurring among multiparæ it will be found that the condition is aggravated, if not caused, by cervical laceration with ectropium. Under these circumstances, and under the indications and conditions insisted upon by the author of the procedure, Emmet's operation will alleviate, if it does not cure, the pathological state of the mucous membrane.
{466}
{467}
ABORTION.
BY GEORGE J. ENGELMANN, M.D.
DEFINITION.--Abortion, the mishap of popular parlance, the fausse couche of the French, is the premature interruption of intra-uterine pregnancy, the expulsion of the non-viable ovum, whether the result of natural causes or criminal interference.
SYNONYMS.--Common as the accident unfortunately is, the nomenclature, both popular and scientific, is somewhat indistinct, the terms abortion and miscarriage being used in a variety of ways, so that the physician is liable to be misunderstood by his professional brethren and in danger of causing serious offence to his patients. A strict definition of the terms is hence of importance, and in order not to add to the confusion we can do no better than adopt the one now adhered to by the authorities of the day. Abortion and miscarriage are strictly synonymous, notwithstanding the popular belief that the term abortion is restricted to the criminal interruption of pregnancy, whilst miscarriage is supposed to designate the accident resulting from natural causes. Again, some make a difference in time between abortion and miscarriage--abortion being the expulsion of the ovum in the first four months of pregnancy; miscarriage, or the partus immaturus, in the next three months, from the fourth to the seventh; and the partus prematurus from the seventh to the ninth month.
CLASSIFICATION.--We might, indeed, in regard to importance, cause, and course of expulsion, designate four different periods of gestation--the first two during the continuance of the chorion frondosum, and the last two during the period of placental development: the first during the first two months of pregnancy, before sufficient adhesions have formed; the second, still during the period of the chorion frondosum, until it begins to disappear, from the second to the fourth month; the third, in the early stages of placental development, before the term of foetal viability, from the fourth to the seventh month; and the fourth, which is everywhere recognized as the partus prematurus--premature delivery--from the seventh to the ninth month, when the placenta is fully developed with firm adhesions and the child viable.
For practical reasons and simplicity's sake we will distinguish only between abortion and premature labor--miscarriage, abortion, abortus, being the expulsion of a non-viable foetus, of the ovum before the time of complete placental development, in the first seven months of pregnancy; and premature labor, the interruption of pregnancy in the last two months, from the seventh to the ninth, when the foetus is viable and {468} formation and attachment of the placenta has been completed. These two classes naturally blend, but are strikingly different in cause, symptoms, and treatment if we consider the type about which they are grouped--abortion proper as most frequent in the third and fourth month, and premature labor in the seventh and eighth. It is abortion or miscarriage of which we shall treat in this article, more especially its characteristic form before the formation of the placenta, whilst we shall touch but lightly upon those forms which approximate premature labor and come within the sphere of the obstetrician; that is, abortion in the sixth or seventh month, when the placenta is more fully developed.
FREQUENCY.--With regard to the frequency with which this accident occurs, we can but form an estimate, as there are but few of the pathological conditions to which the human constitution is subject in regard to which we are more at fault as to statistics: neither the case-book of the physician nor the hospital or post-mortem record permits of more than an indefinite approximation as to the frequency of its occurrence. During the first six or eight weeks of gestation, certainly the first four, the patient herself is often ignorant of her condition, and the ovum passes off amid a more profuse menstruation, with only the symptoms of simple menorrhagia; the same may be true at later periods by reason of coexisting conditions. Some knowingly conceal the fact; many, knowing it, call no assistance; others have midwives, the physician seeing only the more threatening cases; and but few enter the hospital, where our most reliable statistics are gathered.
All points considered, it has been stated that to every 5.5 labors at term we will find 1 case of premature expulsion of the ovum (Busch and Moser). Whitehead asserts that 90 per cent. of married women abort, or that 37 out of 100, somewhat over one-third, of all mothers abort at least once before their thirtieth year. Hegar estimates 1 abortion in the early months to 8 or 10 labors at term, which harmonizes very well with the figures given by Busch and Moser. Multigravidæ abort more often than primigravidæ, although there are certain causes peculiar to primigravidæ which tend to abortion, such as the indiscretions of early married life: uterine disease, perimetritis, and endometritis, on the other hand, are more common in multigravidæ, and, again, the number of multigravidæ is by far greater than that of primigravidæ.
These estimates are all somewhat general, but even if exact statistics could be gathered as to any one locality, they would not hold good in others--true of one region, they would not be so of another. Climate, habits of life, and morals of the community very greatly affect the completion and interruption of pregnancy.
IMPORTANCE.--Frequent as the occurrence of abortion is--common almost as childbirth--its importance is universally underrated. Many of the ills to which women are subject result directly or indirectly from this accident, or, we may justly say, from an undervaluation of its importance. If not criminal or traumatic, it is the result of pathological changes either in the maternal system, in the sexual organs, or in the ovum itself; labor is brought about amid these conditions at a time when neither ovum nor uterus is properly prepared, as in labor at term, and under these conditions, especially in a diseased system or diseased uterus, involution will not so readily take place. Morbid conditions of {469} the sexual organs follow, and affect the health of the patient more or less, though death but rarely results, either directly or indirectly. These evils are more commonly the consequence of mismanaged abortion and neglected after-treatment than of the accident itself; hence the result depends rather upon a thorough appreciation of the importance of this condition by both patient and physician, especially the general practitioner, the family physician; if assistance is sought, it is he who is called, and not the specialist--not the gynecologist or the obstetrician. It is the physician conversant with the family secrets whose aid is sought in this matter, which is considered by the mother rather as a delicate and disagreeable than an important affair.
Women should be given to understand more thoroughly the serious results which so often follow neglected abortion or abortions which, for the very reason of their being rapid and favorable in their course, are neglected as to after-treatment. Women must be impressed with the necessity of proper attention during the progress of miscarriage from its very initiation, and the even greater care that is necessary after the ovum is expelled and all is supposed to be over, and involution of the uterus at this period must be guided and guarded as after expulsion at term.
Much suffering would be avoided if women were taught to consider abortion as a disease, a pathological condition, demanding immediate and active attention, and not simply as a disagreeable and disgraceful accident, to be concealed if possible. The patient would then no longer endeavor to worry through without assistance or call in nurse or midwife; and, thoroughly knowing the possible dangers, they would be more cautious, and the frequency of criminal abortions would also decrease: these, above all, cause injury to health, because medical attendance is avoided if at all possible, and care likewise, as the patient is anxious to conceal her indisposition. Then also the practitioner must bear in mind the great importance of this accident, both that he may anticipate and prevent it, and if inaugurated he may guide it to a rapid and successful termination and guard his patient throughout the period of involution. Great temporary pain, and often lifelong suffering, will thus be prevented.
A thorough knowledge of abortion, of its causes, course, and treatment, is equally necessary to the physician, that he may guard his own honor and that of the profession: an abortion, due to uterine disease or malnutrition of the ovum, occurring during some period of medical attendance is often blamed upon the physician by those anxious for offspring, whilst, on the other hand, that large and shrewd class who are seeking to avoid childbirth not infrequently resort to the trick of urging certain methods of treatment during early pregnancy, with the hope that the physician himself may thus induce abortion, or he is called, with all appearance of innocence, by the criminal who has interrupted gestation to complete the abortion once commenced. His own reputation and that of his profession is then at stake: to guard this and to preserve the health of the mother entrusted to his care he must be conversant with the pathological conditions involved and the importance which attaches to them.
Woman requires skilled aid in labor, the physiological termination of pregnancy; more necessary still is this in the premature pathological interruption of this condition, in abortion! The attendant is often {470} responsible for two lives, as in labor, although under the conditions usually existing medical aid is not summoned until the life of the embryo is already destroyed--a most urgent argument in favor of timely medical advice and of close attention to prevention, a proper management of the pregnant state, and the treatment of threatening abortion, as at this time both lives may still be saved. This accident, so frequent in its occurrence, so disastrous to the health of woman, is important in all its phases, not only in the stage of expulsion and retention, to which attention has been directed on account of the surgical interest, but as well in its incipience, the time of prevention, and its after-treatment; abortion demands, and is worthy of, the most careful study and the best efforts of the physician.
HISTORY.--The history of abortion, it has often been stated, is the history of civilization, but I would rather say that it is the history of races--of their rise and fall. Abortion in consequence of natural causes, as well as criminal, is now, and has at all times been, practised among savage as well as civilized peoples, and develops with the progress of civilization, with the deterioration and fall of races, civilized and savage, as shown by history ancient and modern.
Abortion consequent upon natural causes is by far less frequent among a vigorous and healthy people still struggling for supremacy, full of youth and strength, than among nations who have reached the height of power, who have been enfeebled by indolence and the luxuries of civilization, by vice and fashion. Of criminal abortion this is naturally true to a far greater extent, yet this is common and customary among many primitive, semi-civilized peoples. As nations advance they become debilitated and demoralized amid the brilliancy and luxuriousness of their surroundings, and they rapidly retrograde toward the very worst vices of primitive humanity: they are thus undermined, and succumb to the attacks of their more vigorous neighbors, and magnificent empires are overthrown and extinguished by the youthful vigor of a hardy, simple people. The more civilization progresses, the greater the apparent abhorrence of the crime of abortion, the more numerous the laws enacted to guard against it, the more frequent does the crime become; and, strange though it may seem, it is nowhere punished. Abortionists everywhere are known; in the larger cities of this continent as well as Europe they achieve a widespread fame, are well known, and yet rarely if ever convicted. It is a notorious fact in our community that these worst of criminals almost invariably escape, and even in the states of Germany, where the laws are strict and rigidly enforced, where the crime of abortion is punished by imprisonment of from five to twenty years, that eminent teacher of medical jurisprudence, J. L. Casper, says that "Of all the many accused, never a one was condemned, and in no one case was the crime proven." They are sheltered by the words of the law and the sympathy of the community, which, notwithstanding the abhorrence expressed, still accompanies these criminals, though not to so great an extent as it does those equally forlorn women who are guilty of killing the child when born; for, as Hodge truly says, "There is no class of criminals who meet with so much sympathy as women guilty of foeticide." Greece and Rome when at the height of their power favored by their laws, and almost openly advocated, abortion, whilst among the ancient Germans it was {471} one of the crimes most deeply despised and most severely punished--just as it was condemned by the laws of the Goths. How different is it now among the races sprung from these proud conquerors of Rome, now that they have reached the very acme of their career! The more civilized, the more powerful they become, the more does this crime develop, as in Germany and France, where it is practised upon a most extensive scale, and yet, as we have seen, the criminals escape, notwithstanding the most rigorous laws. Condemned from the bench and the pulpit, the crime still progresses. There is the poor girl who has yielded her honor for the sake of bread for herself or those dependent upon her; there is the lady of fashion, by far more culpable, who cannot give up the time she owes to society to the cares of maternity; or the society belle, who would resort to any and every measure that she may escape maternity for the sake of retaining her beauty and the freshness of her charms, a slender waist and a well-shaped breast; others resort to it that their round of pleasure may not be disturbed. Many an unborn child is executed upon the plea of limited resources, that the family cannot continue to live in their accustomed luxury if an additional member should appear.
Neither the laws of God nor man will affect the hearts of women thus brutalized: it is the physician alone who can interfere; it is to him they come most often; it is he, the trusted family friend, who will do more than judge or priest to change this unfortunate condition of affairs. In crowded countries abortion is looked upon as a necessity of nations, just as it is here considered a necessity in a family too numerous; hence in China, Japan, and Hindostan it is common; in Arabia and in New Caledonia it is produced on account of the scarcity of nourishment and the difficulty of raising children. Among some crude people it is not the wish of the individual, but the law of the land, which determines the course of gestation; so upon the island of Formosa a woman is not allowed to bear a child before her thirty-sixth year, and priestesses fulfil a social law by kicking the belly of the woman who becomes pregnant before the proper age, lest the population grow too large for the resources of the island. So it is among other islanders also--upon the Sandwich Islands, the South Sea Islands, whose population was reduced from two hundred thousand to seven or eight thousand in the course of thirty years. Upon Tahiti and King's Mills Islands it is equally common. Upon the latter a more generous feeling prevails, and the woman is at least allowed to have a family of three, but not beyond that; and upon the Feejee Islands one of every two conceptions is supposed to be destroyed before the period of gestation is completed.[1] So also among the New Zealanders, the Hottentots, and the inhabitants of Madagascar. By the Icelanders this crime is committed as an heirloom left by their Norwegian ancestors.
[Footnote 1: Trader, Criminal Abortion.]
Not alone upon the islands, but among the inhabitants of states not overcrowded like China and Japan, abortion is legalized; so in Paraguay and La Plata, where it is caused in every family after the birth of two living children. Some of the African negroes produce abortion on account of limitation of resources; among the Buddhists, otherwise so humane in their laws, it is frequent--a wonderful disharmony between {472} the conduct of individuals and the dictates of their political and religious laws.
Wherever celibacy is demanded crime and abortion result, as among the Buddhists, whose laws condemn large numbers of vigorous subjects to this existence; and in our own civilization we see the same inevitable result in many of the most closely-populated Catholic countries. Thus abortion is frequent among the Anamites and among the Kambysians, who marry late and are frequently obliged to produce abortion before the time of marriage. Among the Brahmans it is a common practice, induced by religious and political arrangements, the direct result of a law which encourages sexual excesses, and frequently of the restrictions placed upon the needs of woman (widows are condemned by law to eternal celibacy); yet this terrible crime is looked upon as most harmless by the people of India, the destruction of a child that has not seen day being, according to their view, less of an evil than the dishonor of a woman. In Turkey it is so common that a certain price is paid for abortion and another for infanticide, and the law is indulgent to the crime, as it can be paid for cheaply. The cost of removing a non-viable foetus, or even an embryo, is equivalent to a tenth of the price paid for the murder of an infant.
The methods by which expulsion is accomplished are everywhere the same among people civilized and savage, ancient and modern--local and general. Among the local measures external violence is the most simple, as among the Tasmanians, who practise abortion by striking the belly, just as it is done by the priestesses of Formosa; and this is quite common in our day and in our communities. The introduction of instruments and implements into the womb is more intricate, but likewise common; the knitting-needle is a favorite resort in our country, and among primitive peoples a similar practice is resorted to; thus some of the negroes of Africa introduce the sprouting stem of a plant into the uterine cavity. Venesection, the drawing of blood from the vulva, anus, and foot, was often resorted to for the purpose of producing abortion.
Among the more common remedies used in former times are emetics, which are still very often resorted to, cantharides, emmenagogues, sabin, snakeroot, and the famous pennyroyal; so also ergot; the compound cathartic pill of the United States Pharmacopoeia is a favorite remedy,--all of which maim or kill the patient as often as they produce abortion. In New Caledonia a decoction of red-bud and banana-peel or green fruit is taken boiling: in China aperient medicines are publicly advertised for sale, and aphrodisiacs under the name of remedies to free the stomach and give back virginity. Certain negro tribes bring on abortion by manipulation of the abdomen and the use of purgative substances, such as the bark of the koche and sonnaly, which are also used to facilitate labor. Pen-tsae enumerates a large number of remedies as accelerators of abortion or purgatives according to the dose; many of them have a very doubtful action, however. The natives of India most commonly use the black annin, vulgarly called black anise or fourspice; fifteen grammes is an emmenagogue and larger doses produce abortion. The Arab women seek to produce sterility and escape the annoyance of numerous pregnancies, and imagine that they can arrive at that end by drinking a solution of sal soda, a decoction of peach-leaves, and the sap of the male fig tree.
{473} Among peoples savage and civilized, for good reasons and bad, villains sufficient are found to do the bidding of thoughtless and misguided women; the remedies used, internal and external, local and general, are very often so violent as to be followed by the death of the victim. The plea of limited resources, of the inability of supporting a large family, is one common to people of all races in all stages of civilization: permitted by the unwritten law among some, it is practised with equal frequency by others, though strictly condemned. As we have stated, among many of the American nations it is legalized.
Again, there have been people at all times who have scorned the crime, but this is only among those pure, primitive, and still-developing peoples, as, for instance, the ancient Goths and Germans; and the Noxes of South America, as well as some of the negroes of Africa, even permit the husband without hesitation to kill his wife if she should abort. It is among those of the primitive peoples where the blessing of offspring is held in high esteem that the crime of abortion is most condemned and most rare. With the progress of civilization and religion, of refinement and knowledge, this crime, strange as it may seem, rapidly develops. It is not among the low and ignorant--it is among the educated and refined, among the wealthy--that it is most common; and the plea given in excuse of this crime is one most especially urged by the educated and refined, by the devout Christian, that the embryo is not an animated being, not an individual existence--that it does not attain the dignity of a living being until the time of quickening, until the middle of pregnancy. Religious and scientific reasoning is brought to bear in support of this theory in excuse of the many refined criminals; and it is this very point which the physician must urge: that the ovum, the embryo, from the moment of conception is an animated being, an individual existence with a life of its own. Important as the treatment of abortion, in consequence of natural causes, is, its prevention, and, above all, the prevention of criminal abortion, is still more so; and it is this which lies in the hands of the physician, whose most forcible argument must be in the evident and glaring crime which is committed by the destruction of a living being, as is the embryo from the moment of conception, not to forget the injury resulting to the mother. The former appeals to the moral, the latter to the physical, elements of womanly nature.
Whilst abortion, in consequence of natural causes, is a condition more dangerous than labor at term, the interruption of pregnancy by forcible means--criminal abortion--must necessarily be more grave in its consequences. The interference is often a violent one; the aborting woman is in mental distress, unable to seek the necessary comfort or attention; she is oppressed by the crime in her inner conscience; under unfavorable conditions, physical and mental, for the suffering which is most likely to follow.
With the progress in the practice of medical science the art of the abortionist keeps pace, and in civilized communities of to-day one cause of this growing frequency is in the increased numbers and the increased skill of practitioners ready to pander to all the whims of their degenerated customers: but the greater should be the efforts of honorable physicians to dispel the false illusions by which women seem to justify their doings, and to erase this darkest of all thoughts that lurks amid the {474} noblest sentiments in woman's mind. A strong effort was made not long ago by the American Medical Association to urge the importance of this matter upon the profession, resulting from the earnest efforts of that honored obstetrician Hugh L. Hodge, which culminated in a report of the Committee on Criminal Abortion, read before the American Medical Association in 1871, and a number of papers written upon the subject at that time, prominent among which I would mention those of Van de Warker, Tabor Johnson, and John W. Trader. The wave has swept by: what has been accomplished may be gleaned from the police records of our cities.
PHYSIOLOGY OF EARLY PREGNANCY.--For an understanding of the pathological conditions which determine, precede, and accompany this accident a knowledge of the physiological state is as important as normal anatomy is to the pathologist. But as this subject is treated of in full in other articles, we will confine ourselves to a few of the leading features which are most important for purposes of diagnosis and treatment.
The changes, local and general, resulting from the physiological state of pregnancy are extremely variable, often approximating or simulating pathological conditions, so that we must differentiate and discriminate between such as pertain to the normal condition and such as indicate pathological changes and threatening danger. This is necessary, as prevention is, above all, important, it being often possible thus to save two lives with by far less danger and suffering to the mother than is to be expected from the treatment of abortion once inaugurated after the time of possible prevention has passed. Moreover, a correct post-abortum diagnosis is important for the future welfare of the patient, if not from a medico-legal point of view; and this is equally impossible without a knowledge of the physiological condition. This will enable us to determine whether the ovum expelled is healthy or not--whether the causes are traumatic or criminal, or whether the abortion is due to pathological changes; which, again, must guide us in treatment.
Abortion is the expulsion of an ovum the product of a conception, and can only occur during the period of menstrual life, as conception, the impregnation of the female ovule by the male semen, is the consequence of fruitful intercourse, liable to take place at any time during the period of womanhood, the thirty years of female menstrual life from puberty--the appearance of the catamenia--to the time of their cessation. Its occurrence is followed by intense physiological activity of the maternal organism, lasting throughout gestation to the time of its natural termination with the expulsion of the fully-developed ovum at term at the end of the tenth lunar month. This is made evident by striking changes in the entire system, but especially in the sexual organs, which in the earlier period of pregnancy are entirely progressive, developmental, whilst in the later months, toward term, the character is changed to that of a retrograde metamorphosis, preparatory to the separation and expulsion of the ovum and final restitution of the organs. This hyper-activity inaugurated by impregnation becomes evident by marked changes in the system of the mother, in the sexual organs, and in the ovum itself.
Changes in the Maternal System.--These are most peculiar and varied, differing in repeated pregnancies in the same patient, sometimes entirely absent, at others most distressing, even fatal; sometimes appearing at one {475} period, sometimes at another. Healthy, robust women may suffer throughout the entire period of gestation, whilst those at other times ailing are well only in this condition. The most marked of these symptoms are the hystero-neuroses, disturbances of the entire nervous system, central and peripheral; mental depression, more rarely excitement; gastric disturbances, nausea and vomiting; increased activity, renal and pulmonary, consequent upon changes in the circulation; discoloration of the skin upon the forehead, the linea alba, and areola; oedema and varicosities of the veins upon the lower extremities. All these, and many others still more erratic, may accompany the normal physiological condition.
Changes in the Uterus and Pelvic Viscera.--Whilst the ovum develops in the uterus, this organ, its appendages, and the viscera surrounding it, enclosed together within the pelvic cavity, undergo the most marked changes. The early months of pregnancy are those of greatest physiological activity in the uterine muscle, the period of its hypertrophy. This is inaugurated from the very moment of conception, at first increasing, then gradually lessening, until within the last months, when it becomes passive, the rapidly-growing ovum merely distending the hypertrophied uterus, apparently increasing in size, but merely distended by its contents, as a rubber bag would be. In the earlier months the growth of the uterus is entirely due to muscular development--after the fifth month to distension. The individual muscular cells attain enormous growth, and a large number of pre-existing embryonic cells are developed; so also in the interlacing connective tissue. The blood-vessels as well as the lymphatics increase in size and length; the arteries become tortuous; the capillary circulation is to a great extent supplanted by sinuses.
Weighing in its normal condition, when at rest, little above an ounce, the uterus attains within the first four or five months a weight almost fifteen times greater. Remaining the first four months within the pelvic cavity, the increase in size is not of that diagnostic importance which it attains in the later months, when it is to be felt beneath the abdominal walls, though at the end of this period it is distinctly perceived above the symphysis; about the fifth month, between navel and symphysis; and at the sixth month, at the height of the navel. At the end of the third month the uterus is some 4½ to 5 inches in length, by 4 in breadth and 3 in thickness; at the end of the fourth month, 5½ to 6 inches in length, by 5 in breadth and 4 in thickness; at the end of the fifth month, 6 to 7 inches in length, 5½ in breadth, and 5 in thickness; at the end of the sixth month it is some 8 to 9 inches in length.
The changes which take place in the cervix are a merely passive accompaniment of the uterine hypertrophy, it being enlarged more especially by reason of the succulence of its tissues consequent upon the congestion and activity of the body. It is somewhat enlarged in all its dimensions, thickened, and elongated, soft, velvety to the touch, appearing, however, somewhat shortened by reason of the hypertrophy of the vaginal attachment--a condition that approximates rather that of the vagina and external sexual organs than that of the uterus, softened, succulent, somewhat hypertrophied, congested, of a deeper bluish-red wine color, its cavity occluded by thick tenacious mucus, as the secretions of the mucous membrane of the vagina and external sexual organs are also augmented. In the first and second months the uterus is retroverted, the cervix seems to {476} descend as the enlarged organ, by reason of its weight, settles in the pelvis, the fundus sinking down in the hollow of the sacrum, the cervix consequently pointing more forward; as the organ increases in size and rises above the brim in its endeavor to escape the confining space of the pelvic cavity, the enlarged fundus, meeting with the resistance of the promontory, seeks the point of least resistance, and the uterus begins to assume that position of anteversion which continues to become more marked as pregnancy progresses: the cervix points backward into the hollow of the sacrum, and rises gradually (as the fundus increases in size and withdraws from the pelvic cavity).
The Uterine Mucosa.--This structure is as interesting as it is important. The wonderful changes which it undergoes go hand in hand with the various changes and stages of female life: it is the nidus for the reception of the impregnated ovum; it serves to shelter and nourish the delicate ovum, and if diseased, affording insufficient nutrition, leads to the death and expulsion of the embryo. Its shreds when expelled are of diagnostic importance, and in early abortions its massive thick tissues, changed by disease, often cause greater trouble than the ovum itself, forming, alone or with the membranes proper of the ovum, what is so commonly but erroneously called the placenta in abortion. The membrane which lines the cavity proper of the uterus, passing at the internal os into the mucous membrane of the cervical canal, is characterized by the absence of even the slightest trace of submucous or areolar tissue--by its peculiar substratum of connective tissue abounding in cells and tubular glands. It is closely and inseparably attached to the muscular coat. In a state of rest it is a little over 0.04 inch in thickness at the fundus,[2] and the anterior and posterior walls diminishing toward the sides, the cervical and tuber ostea. It is traversed by a series of tubular glands, wavy in their upper part, bifurcated toward their base, running more or less parallel to each other. In this membrane, so important for the preservation and development of the ovum, the physiological activity of the system is inaugurated, and seems to centre during the first week of gestation. With the impregnation of the ovule the uterine mucosa, its earliest shelter, begins to hypertrophy: the rapid development which now takes place is owing to the proliferation of the cells of the stroma and the enlargement of the individual cells of all kinds, including those of the glands themselves, as well as the increase of the succulent homogeneous and cellular substance. The glands throughout their greatest extent are enlarged: the increase in thickness is more especially due to the hypertrophy of the superficial layer, the upper half, in which the stroma appears less compact, growing far above the original gland-openings, circumvallating the enlarged ostea, and thus causing those funnel-shaped depressions which give the membrane its sieve-like, cribriform appearance when seen from above. In the third month of pregnancy the mucous membrane attains its greatest thickness, forming a soft succulent lining to the uterine cavity, by its distension closing the various ostea. It is then as much as 0.236 inch in thickness in the anterior and posterior walls, lessening toward the ostea, and begins to present the characteristic layers which become so distinct in the later months--a dense upper and a very loose lower one, comparable to a lax meshwork. Its growth now ceases, {477} and as the uterine cavity increases in size and the ovum in growth, it is distended to cover the rapidly-expanding surface, and becomes thinner and thinner, the upper dense layer remaining as such, whilst the glandular sinuses of the lower layer of the membrane are stretched transversely until they become mere flat meshes like a network stretched along the surface of the womb.
[Footnote 2: Engelmann Mucous Membranes of the Uterus.]
The impregnated ovum, as it rapidly enlarges during the first two or three weeks, becomes imbedded in the thickened succulent decidua; and we may compare this to the sinking of a bullet into soft dough: the soft mass of the dough yields to the weight of the superimposed body, and gradually closes over it, so the tissue of these overlapping folds soon unites, completely surrounding the ovum, the nidus thus formed, in which the ovum settles, being usually in the upper portion of the fundus upon the posterior wall of the right side. We now distinguish in the mucous membrane of the uterus three parts: the decidua vera, the greater part of the membrane lining the cavity of the womb where it is not in contact with the ovum; the decidua serotina, which is that part directly beneath the ovum, between it and the uterine wall, which is in connection with the tufts of the chorion, later in part develops to form the placenta; and the decidua reflexa, that part of the mucosa which overlaps and has overgrown the ovum. This membrane is little known and rarely recognized, though always present. It is of no practical importance; a delicate membrane even at the time when it is the great safeguard of the tender ovum, serving to protect it and hold it within the soft bed formed by the decidua serotina; this function of the reflexa continues until the third month, when the ovum has developed sufficiently to occupy the entire uterine cavity and is everywhere in contact with its walls. The thin tissues of the reflexa become more transparent and delicate as they are distended and compressed between ovum and decidua vera, which now with the muscular wall of the uterus surround the ovum and continue the previous function of the reflexa.
The Development of the Ovum.--Practically, we may distinguish two periods in the development of the ovum: the first, that in which we are here interested, before the development of the placenta, where it is a cyst-like body surrounded by the shaggy chorion, the chorion velosum; and after the development of the placenta, after the fourth or fifth month, when the foetus is more fully developed and the ovum is covered with the smooth chorion, the chorion levæ.
The period scientifically the first, and the most interesting stage of development, during the first three or four weeks, when segmentation takes place and the form is moulded, we shall in no way consider. The ovum may then be cast off, perhaps at a succeeding monthly period, unbeknown to any one, perhaps not even to the unconscious mother: certainly the services of an accoucheur are not called for. In the third or fourth week it is a delicate cyst-like body of the size of a hazel-nut, some half an inch in diameter, surrounded by its translucent chorion, and is crushed in the passages or disappears amid the clots of blood of an apparently profuse menstrual flow. The following periods of development are, however, of practical importance, as they will serve diagnostic purposes, as well as an understanding of the appearance of the ovum and the symptoms accompanying miscarriage.
{478} The ovum during the first months of pregnancy is an oval cyst-like body surrounded by the chorion, the shaggy tufts of which give it a characteristic readily-recognized appearance. Enclosed within is the delicate transparent amnion, and the embryo, attached to the navel-string, floating in the clear liquor. At six weeks the size of the ovum is likened to that of a pigeon's egg; at eight or nine weeks to that of a hen's egg, perhaps 1½ inches in length; at the twelfth week, to that of a goose-egg, some 4 inches in length. In the second month the ovum forms a bulging prominence in the uterine cavity, usually toward the fundus, and reveals all the parts recognized at term with the exception of the placenta and the still distinct umbilical vesicle: its surface is covered by the tufts of the chorion and surrounded by the decidua reflexa. In the third month it is so far developed as to completely occupy the uterine cavity, as yet but slightly adherent, approximated, a part of it agglutinated to the uterine mucosa, to the decidua serotina, the greater mass of the chorion being in no way adherent to the surrounding reflexa. The tufts of the chorion begin to sprout and develop more fully at its point of contact with the uterine wall above the decidua serotina, whilst upon the remaining and greater portion of its surface their growth ceases, and as the membrane distends the delicate filaments gradually disappear. At the end of the third month, in the fourth month, the tufts of the chorion have sufficiently developed in its adherent portion to form the rudimentary placenta, and at the end of the fourth month this is developed still more--has become more dense and large, whilst the remaining portion of the membrane appears smooth and barely shows a few scanty remnants of the once-shaggy tufts.
The growth of the ovum now rapidly outstrips that of the uterine cavity; the membranes are pressed more firmly against its walls, approximated to the decidua vera, but not by any means agglutinated. In the sixth month the placenta has been thoroughly formed--it has become dense and large, the foetal membranes beginning to agglutinate to the uterine wall, and the conditions existing at term are rapidly approached. The embryonic tissues are supplied with the necessary nutriment by endosmosis from the surrounding maternal structures during the first months; the entire surface of the chorion absorbs, whilst this function is delegated to the proliferating villi as they develop and agglutinate with the decidua serotina, foreshadowing the activity of the placenta by which the foetus is nourished to term.
Practically, the most important period in the development of the ovum is the one most dangerous to its existence--in the third and fourth month, that period of intense activity of chorion and decidua, the time of the formation of the placenta, when hemorrhage is likely to occur from the congestion of the vessels so necessary to the nutrition of the rapidly-growing and delicate tissues. Nutriment is no longer merely absorbed by the succulent embryonic cells of the ovum from the tissue in which they are in contact, but the embryo is forced to seek sustenance through those now fully-developed tufts of the chorion--from the proper site, the decidua serotina and the surrounding vessels--directly from the uterine structures. If hemorrhage interferes or disease prevails, the healthy growth of the ovum is checked, and a morbid development ensues, to result sooner or later in death of the embryo and expulsion.
{479} The embryo in the early months of pregnancy is small as compared to the size of the sac, the membranes, liquor amnii, and navel-string; at the end of the fourth week the embryo measures from 1/3 to 1/4 of an inch in length; at the end of the eighth week, from ¾ to 1 inch: the arms and legs become visible, the umbilical vesicle, though reduced in size, still exists; the small body with large upper extremity is pendent from the short, thick navel-string. At the end of the twelfth week the embryo measures from 2 to 3 inches in length; fingers and toes can be distinctly seen; mouth and nose are also recognizable. At the end of the sixteenth week, the fourth month, the embryo measures some 4 to 5 inches in length; sex can be distinguished; the head assumes shape, but it is still immense in size, perhaps an inch in length; the features of the face are all formed. At the end of the twentieth week, the fifth month, there is no longer doubt as to sex; the nails, which were previously visible, have become distinct; the soft, woolly lanugo begins to develop; hair may be noticed upon the head; motion, inaugurated weeks before, is felt by the mother. Toward the end of the sixth month, in the twenty-fourth week, the embryo is some 12 inches in length. As has been before stated, with the cessation of the development of individual organs and parts growth in size becomes more rapid. As this was less in the earlier months, it is now very marked. With the seventh month, as the foetus becomes viable, it is some 12 to 14 inches in length, weighing 2 to 3 pounds; the body is covered with lanugo; the hair on the head becomes quite marked; the papular membrane disappears.
It is well to bear in mind the leading features in the development of the uterus, decidua, and the ovum, and more particularly its membranes, as a guide in the treatment, that we may recognize the parts expelled and know what remains to be removed--as an aid in diagnosis, that we may properly judge the conditions, whether healthy or morbid, and post-abortum, when we may be forced to determine by the corpus delicti, as the all-important evidence in criminal cases, as to the duration of pregnancy and the causes which led to its termination.
ETIOLOGY.--Causes of Abortion.--Interesting as the etiology of disease is to the inquiring mind, to the progressive physician it is of great practical importance as well; and this is eminently true of the causes leading to abortion. More so of (A) spontaneous or accidental abortion, though by no means to be neglected in (B) criminal abortion. Etiology is important in both, as it is a knowledge of cause alone which can lead to prevention, that most valuable of all methods of treatment, and in criminal abortion to detection, thus indirectly to the prevention of recurrence.
A. Accidental or Spontaneous Abortion, or Abortion as the Result of Natural Causes.--The etiology of non-criminal abortion is indispensable to the practitioner, as it is this alone which will enable him to prevent its occurrence and recurrence, thus leading to the preservation of the lives of mother and child, doing away with the danger and suffering of actual treatment, and frequently serving as a guide in the latter. We will meet with some difficulties in our endeavor to analyze these causes, as they are so varied in their nature and differ so greatly in the medium through which they act. There are causes predisposing and exciting, local and general, internal and external, and causes which depend upon father, {480} mother, and ovum. The direct dependence of treatment upon the exciting causes seems to necessitate a simple and practical delineation of the etiology of abortion. A direct reference of the cause to the offending organ is understood most readily, and will point most directly to the necessary measure of relief; hence we will consider such causes as spring from or act through mother and child--more properly, the maternal system and its individual organs on the one hand, and the ovum and its parts upon the other. We cannot, however, pass by these without giving a thought to such causes to which great importance is attached by many, and which it is best to consider separately.
Predisposing Causes.--Almost all abnormal conditions, whether pertaining to the system or external to it, are more or less predisposing causes, whilst direct exciting causes are few; they may or may not be followed by the premature interruption of gestation; they tend to death and expulsion of the ovum, making it likely to occur whenever the exciting cause arises. We may say all those by which the occurrence of abortion is favored are predisposing causes: they are conditions under which we may expect its occurrence; and, knowing them, it is the duty of the physician to guard his patient. The classification is indefinite. Thus Naegele considers as predisposing causes anæmia, congestion local and general of the maternal system, neurotic influences; and as exciting causes--1st, those which tend to sever the amnion from the surrounding uterine structures; 2d, those which cause malnutrition, disease, and death of the embryo or foetus; 3d, those which directly arouse uterine contraction. Others consider diseases acute and chronic on the part of the mother, local and general, as well as diseases on the part of the father, predisposing causes, whilst traumatism and neurotic influences are considered as exciting causes. All are classifications based upon no strict foundation. I wish, however, to call attention to certain conditions which I look upon as predisposing to abortion: that is, a pregnant woman while under the influence of such condition, such cause, is more liable to abort upon the occurrence of some directly exciting cause. The existence of one or more predisposing causes does not necessitate abortion; pregnancy may continue without interruption if exposed to any of the conditions which we will term as exciting causes.
First. Climate.--We find abortion, both accidental and criminal, prevalent in certain countries and in certain districts, dependent upon climate--in the deltas and valleys subject to malaria, upon barren soil where food is wanting or where the work of woman is particularly laborious.
Secondly. Number and character of the population: this mishap is most common in large cities, where morals are lax, where the ill-fed poor are crowded into tenement-houses and the rich live in the whirl of social dissipation, or in thickly-settled regions where there is an intermingling of sexes, where women are neglected and ill-fed. I may here add an observation which truly shows the difference of locality. Both Playfair and Philippeaux[3] claim that abortion is especially prevalent in the country. This may be true of the rural districts of England, France, and Germany, especially the latter military government, where it is in the country that young, able-bodied women do the hardest and most of the work, as is seen when passing through these regions in harvest-time. In {481} America the very opposite is true, as in the country here abortion is most rare.
[Footnote 3: Annals Gynécologie, 1881.]
Third. Certain periods in woman's life eminently predispose to abortion. There are those important epochs in woman's life during which her nervous system undergoes a severe strain wrought by those changes which are all-important to her existence. These are, first, in early married life, when intense hyperæsthesia exists due to changes wrought in the sexual system: the young wife is, moreover, exposed to injurious external influences, certain forms of traumatism; and secondly, toward the approach of the menopause, as the activity of sexual function and the uterine organ diminishes and the nervous system is undergoing those changes with periods of intense neurotic excitement which accompany the menopause. Finally, we may look upon the morbid conditions of the system, all unfavorable changes in the surroundings, as predisposing causes.
Exciting Causes.--We have seen that Naegele considers malnutrition and all causes which lead to separation of the ovum from its surroundings, and even uterine contractions, as exciting causes, whilst Spiegelborg considers hemorrhage so much so that to him the history of hemorrhage during gestation is the history of abortion. As exciting causes I consider uterine contractions and such conditions as directly lead to hemorrhage in the uterine or foetal membranes; but I cannot class either as exciting causes direct and primarily, both being merely sequents dependent upon some more remote cause. The varied importance of predisposing and exciting causes will be best appreciated if we but recollect the ordeals which a healthy woman may undergo--the direct exciting causes which may act upon her--and yet abortion not occur, provided no predisposing causes exist. Thus we have the well-authenticated statement of a pregnant woman being run over, the wheels of a physician's carriage passing directly over the abdomen, and yet abortion not following. I myself know of the attempts of a husband to produce abortion upon a willing wife by beating the abdomen, finally stamping and sitting down upon it, and yet not succeeding. I have the statement of a reliable physician as to the continuation of intra-uterine application of iodine and astringents to the cavity of a uterus supposed to be diseased, which proved to be pregnant, until the fourth month, and yet abortion not following. We know how women with criminal intent produce local injuries, even such as result in death, whilst the ovum remains undisturbed. These are cases in which no predisposing cause existed. On the other hand, the careless washing of the feet in cold water, a single effort at the wash-tub, a rapid drive, fright, a piece of bad news, coitus, the slightest nervous or physical disturbance, may produce abortion where predisposing cause sufficient does exist. We will here classify the exciting causes of abortion, in reference to the consequent treatment and the possibility of prevention, as maternal and foetal, dependent upon, acting by means of, the maternal system and organs or those of the ovum. Those dependent upon the mother are amenable to preventive treatment; not so those dependent upon the ovum.
A. Causes of spontaneous or non-criminal abortion:
1. Causes due to pathological changes in the maternal system, general and local. These are by far most important to the practitioner, as they {482} are amenable to treatment. His attention should most especially be directed to--
a. General causes acting through the system. These are--
(1) Diseases acute and chronic;
(2) Causes acting through the nervous system, neurotic;
(3) Physical or traumatic;
And (4) I shall classify what I might term social causes, such as result from custom and fashion, which form an important element in the etiology of abortion, and one more particularly open to and demanding prevention.
b. Local causes on the part of the uterus and its adnexa.
2. Causes on the part of the ovum.
1. Causes Maternal.--These may be general or local. General causes, arising either in the maternal system or exterior to it, but acting upon it, may be either physical or nervous, arising from diseased morbid conditions of the maternal system.
a. General causes acting through or resulting from changes within the maternal system.
The premature interruption of pregnancy may frequently be traced to disturbance of the maternal system or external influences which act upon it, either directly by traumatism or indirectly through the nervous system, and the uterus, hypersensitive in this state of intense physiological activity, responds. It is the point of least resistance to which the shock is conducted; as the electric current invariably passes through the best conductor in a network of wires to the point of greatest attraction, so shock follows the course of the uterine nerves, at the time most tense, and the explosion follows in that organ.
(1) Disease, acute and chronic, on the part of mother and father interferes with the nutrition and development of the ovum--on the part of the father, through the semen; on the part of the mother, by malnutrition of the growing germ.
Acute Diseases.--A vitiated condition of the blood, as well as the increase of temperature, local and general, which accompanies constitutional disturbance, affects nutrition and development of the ovum. Zymotic infectious diseases, as well as those accompanied by congestion of the pelvic viscera, are most liable to affect gestation: the excessively high temperature of the nutrient fluid and of the surrounding viscera, if not direct infection of the germ, leads to death of the embryo and consequent abortion in the course of zymotic disease. The localization of the morbid affection in the vicinity of the uterus affects the existence of the embryo by reason of the consequent congestion and irritation, as well as by depletion of the system, as in dysentery; direct infection, as in variola or scarlatina. This delicate existence is threatened in various ways by traumatic injury, as may occur in eclampsia. Fortunately, abortion in the course of disease is not the rule, but the exception, and usually accompanies morbid conditions of the system only if most intense or if predisposing causes exist; yet gestation is at all periods endangered by intercurrent disease in the early as well as the later stages. It is in the later stages only that the existence of direct infection can be determined, and, though perhaps not common, well-authenticated cases are recorded: I have myself delivered a mother, just recovering from a severe case of {483} variola, of a seventh-month foetus covered with a typical eruption. That abortion occurs in the course of malarial fever is well known in the valleys and deltas of our great rivers, and it has been most erroneously ascribed by some to the energetic medication which is called for. If the disease attacks pregnant women, its continuance, but not the medication, may lead to abortion: it is not quinine given upon correct indications--it is the existing disease--which causes the accident, and must hence be checked as speedily as possible; it is the uterus which shelters the developing ovum, congested, hyperæsthetic, which is at the time the centre of physiological activity, and, we may say, the most sensitive portion of the body, most easily affected by an accidentally existing disease, as the non-pregnant woman, one more sensitive or feeble, always suffers most during an accidentally existing disease in that organ which is habitually most sensitive or weak or at the time under an unusual strain; if throat, lungs, or heart is weakened, it is that part which suffers most in the acme of malarial fever; if a woman is exposed to cold during the menstrual period, the pelvic viscera will respond most readily.
Chronic diseases affect growth and development of the ovum by reason of malnutrition, local and general anæmia. As has before been stated, the impregnation of even a healthy ovule by diseased semen or the semen of a diseased father may result in morbid development, which sooner or later ends in expulsion of the affected ovum. Of the diseases on the part of the father it is more especially--and I may say almost alone--syphilis which exerts a direct influence upon the ovum. Debility of the system is more likely to result in sterility, whilst the ovum, if impregnation takes place by such semen, remains healthy though feeble, and the traces are indelibly marked upon the offspring. The use of liquor, like the morphine habit, may lead to sterility, but not to abortion; though the offspring of a phthisical father rarely escapes, the disease is inherited, but does not develop during the early stages of gestation, and does not affect the ovum in its growth.
Chronic diseases on the part of the mother would seem as if readily leading to abortion, though the result is comparatively a rare one. The diseased, badly-nourished, often anæmic system offers an unfavorable nidus for the rapidly-developing ovum, which is so much in need of healthy and abundant nutrition; but as the feeble, sickly mother often has an abundance of healthy milk for the new-born child, a healthy physiological activity seeming to exist in those parts in the time of functional activity, so may the ovum find a sufficiency whilst other parts are affected. The intense activity existing in the uterus attracts an abundance of the circulating fluid; women low with chronic diseases, phthisis, or cancerous growths, often in the last stages, will bear children, yet they are fortunately not so free to conceive, and if impregnation does occur the healthy growth of the ovum is soon interrupted.
The causes which lead to an enfeebled condition of the system may lead to abortion, whether it be an anæmia, the result of disease or lack of food, of the mode of life, or the locality in which the sufferer lives--of poisonous gases or poisons of other kinds slowly admitted to the system. These poisons, however, whether acute or chronic in the mother, may directly affect the foetus. Lead and noxious gases, like the infection of variola or smallpox, are examples of the latter; more rapidly-acting {484} poisons, like strychnia, opium, carbonic oxide gas, and syphilis, of the former.
Death of the foetus and abortion may result as a consequence of syphilis on the part of either father or mother, or of primary infection during gestation, and are liable to occur at the same period in successive pregnancies; if in the later stages of gestation, the ovum, especially the foetus, bears its characteristic marks. The effects of treatment and improvement are readily visible: abortion is more and more delayed; if the afflicted parent but slowly improves, abortion will occur at a later period during each subsequent gestation until a foetus is carried to term, but stillborn--the next living, perhaps, for a brief period. If vigorous treatment be applied in the early stages, abortion may cease altogether. The results of disease can be more readily seen in the foetus than in other parts of the ovum. The gummata of the placenta, the syphilitic indurations, are difficult to distinguish from other conditions, and appear only at later stages. The syphilitic pemphigus, when occurring upon the foetus, is characteristic, but the mucous membranes are most liable to show its traces. The gummata in the large viscera are frequent, especially in the lungs and liver; but most typical is the osteo-myelitis in the long bones, between epiphysis and diaphysis, a pale-red line in the earlier stages, resulting in a thickening of the parts at later periods.
(2) Causes acting through the Nervous System.--During pregnancy, that stage of intense uterine activity, of gestation and increased growth, we find an increased nervous excitability, motor and vaso-motor, the nerves responding violently to slight causes which would arouse no reaction during the normal condition. There is an increased reflex activity which may lead to a disturbance in the circulation or in the nutrition of the ovum, or to uterine contraction upon some slight excitement. This condition varies exceedingly, the causes which excite these reactions and the extent of the reaction excited differing greatly in degree. Uterine hemorrhage, contractions, and expulsion of the ovum in consequence of neurotic influences are more likely by far to occur during the existence of predisposing causes. Fright, a nervous shock of any kind which in no way affects healthy gestation in a healthy woman, will result in abortion in a person afflicted with uterine disease or in a system otherwise weakened.
The frequent occurrence of abortion in early married life and toward the menopause is mainly referable to nervous influences. Marriage is a period in woman's life comparable to puberty and the menopause--a period of heightened nervous excitability: a change takes place in all the modes of life, and, in addition to the many other causes which at that time unite to interfere with conception, increased nervous excitability is one of the most important, as it is toward the climacterium. We shall consider this period more particularly under the head of Social Causes. As the change of life is approached, the activity of the sexual organs, their nutrition, the blood-supply, and especially the healthy activity of the mucous membrane, are lessened, and hence the growth of the ovum is endangered; but the condition of the nervous system at this period certainly has an equally powerful influence in producing the tendency to abortion. During this hyperæsthesia an existing predisposing cause or some slight additional excitement will arouse the vigorous action of the tensely-strung {485} vaso-motor nerves; coitus even at these periods may be looked upon as dangerous to continued gestation. It is not alone the traumatic influences which must be considered, but the effect upon the nervous system as well, especially the vaso-motor nerves, in the state of intense excitement which accompanies the sexual orgasm. During these periods of increased nervous tension during pregnancy coition is more liable to produce abortion than at other times. It is in the coming together of numerous causes that one more intense than the others, though harmless alone, will be followed by sudden response.
Much has been said as to the injurious effect of coition during pregnancy. Those who look to physical causes as mainly tending to abortion claim the injurious effect to be purely physical, traumatic; whilst others, and I believe more justly, claim that the influence is strictly neurotic. Parvin says that coition is so frequent a cause that he blames upon this half the cases which are termed spontaneous abortions; certainly it has a most unfortunate effect, so that we frequently see the expulsion of a healthy ovum from the second to the fourth month in young women recently married, mainly in the higher walks of life and among delicately organized women, who are more intensely sensitive to the great change which they have undergone. I have repeatedly had occasion to see these unfortunate cases, and almost look for the occurrence of an abortion within the first six or eight months after marriage in the bride of fashionable society. Though the statement of Parvin may seem somewhat forcible, the fact is not to be ignored: the ovum expelled in such an abortion gives evidence of being of healthy growth, so that the cause must not be sought for in malnutrition or local disease. The laws of many peoples are as strict in regard to coition during pregnancy as they are about the care of menstruating women: by some it is forbidden; among the ancient Mexicans it was regulated, it being ordained that sexual intercourse should be exercised to a moderate extent during pregnancy in order that the healthy development might be furthered and strength given to the child. The injurious effect of coition is everywhere acknowledged, and, I can say, not unjustly. Total abstinence was looked upon by the Mexicans and other peoples as likewise harmful.
The changes wrought in the nervous and physical condition of women after marriage and toward the menopause are such that the menstrual periodicity is interfered with, dysmenorrhoea sometimes existing, at times menorrhagia, so that the expulsion of an ovum of from eight to ten weeks is ignored, passing away with the clots of a profuse menstrual flow: it is often not even known to the mother, being considered by herself and family as merely a profuse flow; the accompanying pains are often no greater than those of the dysmenorrhoea common at such times; no precautious are taken, and thus the foundation is often laid for uterine disease.
We know that the emotions--fright, fear, joy--may check the menstrual flow or produce menorrhagia; in the gravid uterus hemorrhage may be caused or contractions aroused, and abortion results. In a misled girl or a young married woman the fear of pregnancy may frequently cause cessation of the menstrual flow: the effect of the mind and nervous system upon these organs is equally evident in the cessation of the menses when pregnancy is longed for, though it does not exist: I have even {486} known of the summoning of midwife and physician by an aged bride with distended abdomen (gastric hystero-neurosis) who longed for pregnancy and thought she felt uterine contraction and the inauguration of labor. As the emotions affect the general health, the ovum may likewise suffer as a part of the maternal system; but when they are sudden, such as by fright or shock, the effect upon the vaso-motor centres by reflex action is so forcible that the uterine vessels are paralyzed, dilated, and hemorrhage follows; or a tetanic contraction of the vessels may result, and then the nutrition of the embryo is checked.
The evil effect of nursing during pregnancy is due in part to the withdrawal of nutrition from the ovum, but in part to the contraction of the uterus and its vessels, which may result as a reflex symptom from the irritation of the nipples, and thus cause abortion. The frequent occurrence of abortion upon ships at sea is due in part to traumatic influence, the vomiting of sea-sickness; in part it is neurotic, due to the changed mode of life, the leaving of a home by the emigrant for foreign lands, just as the menstrual flow is stopped for months and months in the immigrant girl upon her first arrival in a strange country.
(3) Traumatic influences are comparatively rare as a cause of natural spontaneous abortion; and it is true of these as of every other cause that it depends upon existing conditions whether abortion will result or not. The pounding of the belly is an ordinary method of producing abortion among primitive peoples: a fall, a jump from a wagon, may disturb the progress of gestation, while traumatism far more violent may not affect it, as in the case of the woman in the later months of pregnancy over whose abdomen the wheels of a physician's carriage passed without causing any injury whatever.
In the earlier months, while the ovum is still sheltered in the pelvic cavity, injuries are still less liable to cause abortion. I have myself seen a pregnant woman severely bruised about the lower bowels and go to term. I have been told by reliable physicians that local treatment of uterine disease has been continued by reason of the non-cessation of the menses to the third and fourth month, when pregnancy was discovered, and yet abortion did not follow, though I regret to say that quite a number of cases have come to my knowledge where the treatment of supposed uterine disease, especially of uterine tumor--pregnancy in fact--was suddenly terminated by the appearance of the corpus delicti, a four or five months' embryo. The intensity of the resistance is well illustrated in a case which it was my good fortune to see in consultation, where the most brutal local treatment had been resorted to for three or four months and abortion did not occur; the patient had left her persecutor and travelled hundreds of miles to seek treatment. The manipulations had been so violent as to produce metritis and cellulitis, yet the growth of the ovum continued, as demonstrated by the healthy foetus of five months which was at last expelled. I have but recently examined a lady who has been treated locally for uterine disease, and found her in the beginning of the third month of pregnancy, so far undisturbed.
We may well place the uterine sound and applicator among the traumatic causes. The physician himself, especially the gynecologist, has been sought out by women to aid in relieving them from the product of conception, and it is through sound or applicator that {487} he is expected to accomplish the work. Among the many devices to which women--and, I am sorry to say, those in the most fortunate circumstances, in the best walks of life--resort to attain this end is one which certainly shows knowledge and shrewd calculation, but most villainous intent, which is not unfrequently practised, and against which it is well for the physician to be on his guard. It is that of forcing the attendant to uterine examination and treatment upon the plea of disease, well knowing that the germ must thus be destroyed. The woman calls upon a physician--in preference upon some specialist not attending in her family--upon the plea of uterine suffering, well knowing, either from personal experience or the gossip so common among ladies, some of the more common symptoms of this disease--backache, pains in the side, nervousness, weakness, menstrual suffering. She relates her case; upon questioning states that the period is just passed; and, though the examination may reveal nothing, though no application may be made, she well knows the uterine sound will be used. That is what she desires. If an application of iodine or nitrate of silver follows, all the better. Though for reasons far more important the physician should listen to the history of a patient with distrust, and rely must thoroughly upon his own examination, this course is especially indicated in gynecological cases without distinct sign of disease; and these very cases again point to the importance of a careful bimanual examination, and a resort to all other methods before the sound is used; and that in case of an enlargement of the uterus, discoloration of the cervix and vagina, we should under no circumstances introduce an instrument into the cavity unless it is established with absolute certainty that the congestion and increased size are due to pathological and not physiological causes.
Social Causes.--I wish to call attention more particularly to some of the abuses of modern life which not unfrequently interfere with gestation. These exist among all classes of society, high and low: among the poor they are unfortunately forced; among the wealthy they are the result of devotion to fashion and society. As we have seen that in the Old World abortion is common in the rural districts, it is an evidence of hard labor, especially in the field, at the wash-tub, and labor by which the abdomen is compressed, the abdominal muscles freely exercised. It is not only physical labor, but exposure to cold and wet, cold feet, which are to blame; in those more fortunately situated tight lacing, dancing, and consequent colds have a like injurious influence.
I would again allude to the newly-married, who are so subject to the lighter forms of traumatism, the always greater frequency of coition, the congestion and mechanical insult, the bridal trip being especially injurious. During this period of hyperæsthesia it is too great a strain upon the body as well as upon the nervous system: the young husband, unacquainted with woman's strength and needs, is always liable to judge her powers by his own. Railroad travel, the fatigues of sight-seeing, pleasures, theatre, and the dance, are all borne by the patient bride, anxious to please the groom: upon returning home the cares of the new house, excessive social duties, all combine to undermine the strength of a delicate woman in her first gestation. Enfeebled, often depressed by reason of gestation or nervous changes, excessive pleasures are forced upon her by reason of her condition--i.e. bride--and abortion follows; and, we {488} may say, follows in consequence of traumatism. In other walks of life we find other conditions, still with the same unfortunate developments--excessive labor and pleasure during this period, when rest and care are so necessary. It is in young married women partly the pleasures of society, partly the unaccustomed duties imposed, which lead to injury. Ignorant of their condition, ignorant of the care necessary, even when aware of injury unwilling to acknowledge it, desiring to bear up, to show no weakness, they lay the foundation of much future suffering. The cause of so much uterine and pelvic disease in the unmarried, in the society girl, exists to the same extent in the newly-married, only that the injuries caused are far greater in the first period of married life, as the strain both of body and mind is increased in this most susceptible condition.
Local Causes.--Though the local causes on the part of the mother which lead to abortion, diseases of the uterus, especially of its mucous membrane, are equally frequent and equally amenable to treatment, they are of less practical interest to the general practitioner. Diseases of the uterus itself are not so important etiologically as those of its lining membrane: uterine tumors, unless of enormous size, usually admit of the completion of gestation; flexions and versions rarely interfere with the development of the ovum; a prolapsed uterus may bear the foetus to term unless the adhesions are unyielding and impregnation is impossible, because the uterus as it develops with the growth of the ovum rises beyond the confines of the pelvic cavity, and the displacement is thus remedied. Anteflexions and anteversions are always rectified; retroversions in rare cases only lead to abortion; adherent retroflexions are most to be dreaded; when the uterine body, bound down to the pelvic floor, expands within the cavity to such a size as to make escape through the brim impossible, abortion must necessarily follow. Deep lacerations of the cervix make conception improbable and interfere with gestation; cervical catarrh in no way affects its progress. Those morbid conditions of the uterine tissues which are unaccompanied by disease of its mucous membrane rarely lead to abortion.
Uterine contractions due to reflex nervous excitability are perhaps the most common of all these causes, yet here the uterus primarily is not at fault. A state of intense excitability is very often due to general causes, to intense febrile action, to congestion or anæmia; high or low temperature, whether due to external or internal causes, and irritation of the surrounding parts,--all of which conditions tend to increased contractility. Such diseases of the uterus as cause induration of the walls may lead to abortion, like the incarceration of the organ in the pelvic cavity, by reason of prevented distension.
Uterine Mucosa, Decidua.--Of far greater consequence than the conditions existing in the muscular tissue of the uterine wall upon the vitality and development of the ovum are those of the uterine mucosa in its state of physiological hypertrophy as the decidua of pregnancy. This soft, succulent tissue, rich in lymphatics and blood-vessels, is the nidus in which the ovum rests, its immediate protecting shelter, and the source from which nutrition is derived; hence morbid changes of this structure react promptly and forcibly upon the ovum--most so in the earliest stages, when it is altogether dependent upon this structure; less so as gestation progresses. As the ovum grows it becomes more resistant, its {489} tissues more dense, and the source of nourishment is gradually changed to the large uterine sinuses at the placental site. Moreover, the decidua after the third and fourth month, when it has served its term, performed its function, gradually diminishes in thickness, until toward term retrograde metamorphosis is initiated preparatory to the expulsion of this structure, at that time merely forming a line of demarcation in the lax meshwork in its lower layer between the healthy tissue which remains and those structures which are passed off in labor. An inactivity of the mucous membrane, an imperfect development of the deciduous structure due to disease of the mucosa, is a frequent source of abortion. In chronic disease of the uterus or its lining membrane this rapid and healthy development of the decidua after conception is prevented, the delicate membranes of the ovum do not absorb the necessary nutrition, the development of the embryo is checked, morbid conditions of the ovum follow, and abortion results, especially at that time of active development, the period of placental formation. The decidua vera is the least important part of this structure, serving nutritive purposes only in the very first weeks at the site of placental formation, and sheltering the delicate ovum in the nest formed by its soft tissue: it is the decidua serotina, and especially that membrane which holds the ovum in place, the decidua reflexa, which claims attention. But morbid conditions of the vera, the greater part of the mucous membrane, are naturally accompanied by imperfect development of serotina and reflexa, and hence the imperfect imbedding and nutrition of the ovum.
Hypertrophy or excessive morbid development of the decidua may accompany acute infectious diseases, as we find similar conditions in other organs of the body, especially in the larger viscera. These changes, morbid in their character, interfere with development as do the atrophic forms. These hypertrophies may, however, exist independent in their nature, due to local disease of the uterus and its parts, as in chronic endometritis, where in place of the succulent deciduous structure we find an induration and a proliferation of the active tissue usually throughout the entire membrane, rarely localized, of a polypoid form: the chronic catarrhal affections are accompanied by an increase of secretion, morbid in character, which is liable to interfere with the development of the germ. Moreover, hemorrhage more readily occurs under these pathological conditions, usually secondary in character, brought about by minor insults, trivial causes, which would not affect healthy tissues. These hemorrhages, all-important in the early stages, affect development less and less as gestation advances, the importance of the decidua lessening and its functions being superseded. Where a slight extravasation of blood within the deciduous structure may lead to separation and expulsion of the ovum in the first and second months, larger hemorrhages are often without consequence when occurring within the same tissues in the fifth or sixth.
2. The Ovum.--Pathological changes of the ovum itself, of the embryo, of the surrounding membranes are less frequent as primary causes of abortion, and they are of less importance to the practitioner as being in no way amenable to treatment. When they do occur they usually lead to expulsion in the earlier months.
Those conditions liable to lead to abortion are especially diseases of the {490} chorion, placenta, and umbilical cord, rarely of the amnion, the embryo itself, or the amniotic fluid.
Chorion and Placenta.--The chorion being the nutritive organ, supplying the means of communication between mother and child in the earlier stages by the villi over its entire surface, later by the placenta, must necessarily determine the progress or cessation of foetal development by the conditions existing within its own tissues. One of the most striking and notable changes to which it is subject is the hydatiform degeneration of the villi, leading to a formation of the grape mole or hydatiform mole. This is a cystic degeneration of the terminal sprouts, an hypertrophy of the germinal tissue, the young connective-tissue cells, which usually begins at a very early stage: the vascular development is interfered with, the nutritive material is directed to the morbid activity of the chorion, which in its exuberant growth, usually inaugurated in the first weeks, destroys that of the other structures; the delicate tissues of the embryo are soon absorbed, and even the amniotic sac may disappear, the within-lying cavity, which always remains in every malformation as an unmistakable trace of the ovum--a characteristic which serves at once to mark the product of conception. A mole of this kind usually attains the size of an apple, but may grow to that of a child's head, and the period to which it is carried is much longer than that of the mola carnosa--usually five to seven months, sometimes eight or ten. The appearance is that of a conglomeration of cysts, usually the size of a currant or gooseberry, though they are often from that of a pinhead upward, connected everywhere by thin connective-tissue strands; they consist of a delicate transparent membrane enclosing a pale, colorless fluid: in the earlier stages the amnion with its cavity remains, but with the development of the growth that is destroyed, and the appearance of the hydatiform mole as a product of conception even becomes unrecognizable when no longer surrounded by the decidua; as in cases of excessive development, the morbidly-enlarged villi may even break through the decidua vera in their growth, and we find a dense mass consisting of a conglomerate of small cysts united by connective-tissue shreds enclosed in the cavity of the uterus.
Hemorrhage.--In the third or fourth month, at the time of most active development of the villi at the placental site, primary hemorrhage may occur, due to the active vascular development, and thus lead to abortion, but this is rare; frequent as hemorrhage is, it is almost invariably to be traced to some cause.
The Placenta.--In later stages, when the greater part of the chorion appears as a more firm, non-vascular membrane, that part which in connection with the decidua serotina is developed to the placental formation is the most vulnerable point, as it is the connecting link between the foetus and the maternal tissues, and the one source of nutrition. Hemorrhage in this structure, whether in its maternal or foetal portion, if excessive, must lead to a cessation of development, to abortion. Slight hemorrhages, such as must have proved fatal in the earlier stages, no longer interfere with the growth of the ovum, but are absorbed or remain as small hemorrhagic spots, the tufts or cotyledons in which they have occurred appearing as a hard whitish mass of connective tissue. If the hemorrhage is more profuse or widespread, it may lead to abortion directly or to inanition--to death of the foetus, and secondarily to {491} abortion. Inflammation may occur throughout the entire placental site or localized, as in all other points in the connective tissue of the structure, accompanied by vascular development in the first place, followed by induration and shrinkage; frequently remaining as small irregular or conical indurations between the villi or cotyledons, leading to abortion, either by the tendency to hemorrhage thereby excited or the death of the foetus if sufficient of the tissue is destroyed to cause inanition.
Fatty degeneration occasionally results in consequence of insufficient nutrition due to hemorrhage, or after death of the foetus preparatory to premature expulsion--a morbid approximation to the condition upon its maternal surface and in the decidua serotina at term.
Syphilis.--The changes in the chorion and placental tissue accompanying syphilitic disease are rarely the direct cause of abortion or premature expulsion of the ovum; as a rule, they are mere local manifestations of the morbid condition existing in all the foetal structures, and frequently in those of the mother. In the early months, during the period of the chorion frondosum, abortion results from insufficiency of the nutriment absorbed by the indurated villi of the chorion, lacking in vascularity and in succulent embryonic tissue; the structures are more dense, the villi hypertrophied, in the more aggravated cases the vessels entirely obliterated, whilst after the formation of the placenta in later months the existence of syphilis is made evident by appearances similar to those which accompany other chronic inflammatory conditions. The appearance presented by a syphilitic placenta is usually that of cellular hypertrophy, the centre in a state of whitish induration or fatty degeneration according to the stage of the disease. But it is hardly possible to diagnose syphilis with certainty from the appearance of the placenta alone, nor is the placenta usually affected to such an extent as to appear as the prime cause of foetal death. The placenta is usually large as compared to the size of the child, in appearance similar to other inflammatory conditions presented by the placenta, the growth of the foetus being interfered with, whilst that of the placental structure continues until the retrograde metamorphosis is sufficient to result in expulsion. The placenta in a syphilitic foetus is larger than ordinary, 1 to 4, whilst usually 1 to 6. Gummata are rare, so also tumors of the placenta. A myxoma developing from the embryonic tissue is occasionally found. If the foetal portion of the placenta alone is affected, or in the earlier stages the chorion and the decidua healthy, we may with safety infer syphilis on the part of the father alone previous to impregnation.
The Amnion.--The amnion, which serves merely as a container for the preserving fluid, is wanting in vascularity, and consequently but little subject to morbid changes. The only pathological condition which we find in this structure is an inflammatory development, the formation of amniotic bands stretching across this delicate sheath or from some portion of it to the foetus, crippling or cutting its membranes in such a way as to interfere with gestation. Nor does an abundance or want of amniotic fluid affect the development of the embryo or ovum during the earlier stages. It is no more a cause of abortion than the slight changes occasionally found in the amnion itself.
The Umbilical Cord.--The navel-string, however--the sheath stretching from amnion to foetus, enclosing the umbilical vessels--is subject to quite {492} a number of changes, frequently the cause of abortion, occasionally mere results of other complications. Excessive or insufficient length of the cord, which may seriously complicate labor at term, in no way affects the development of the ovum; in the third or fourth month the length of the cord is naturally much greater than that of the embryo, and the resulting coils and knots seem in no way to endanger its existence. Knotting of the navel-string may lead to death of the foetus, but only in the last months, rarely at earlier periods. Stenosis of one or the other of the vessels sometimes occurs, leading to the death of the embryo and consequent abortion: a condition which I have found remarkably frequent is that of torsion of a very long and thin cord in the third and fourth months; but this torsion of the cord seems so frequent in abortion that it must appear as a consequence, movement of the dead foetus apparently leading to a twisting during inactivity of the tissue. A very striking condition of the cord has frequently attracted my attention--lack of embryonic tissue, the gelatin of Wharton, with excessive torsion; the cord flat, thin, in parts thread-like, and usually very much twisted; the embryo retarded in development as compared to the size of the ovum, no other cause being at the same time discernible, neither disease of the uterus nor affection of the system. The torsion is secondary, often wanting, the cord being very thin and thread-like in places, consisting of the amniotic sheath and the vessels, obliterated entirely or in part. Torsion I believe to be secondary, as I have noticed these excessively twisted cords otherwise healthy in cases of abortion; but this peculiar state, which I cannot term otherwise than atrophy of the cord, appears as a frequent primary cause of abortion in the second to the fourth month; torsion and knots may occur at later periods. Ruge of Berlin,[4] who has investigated this subject, thinks that stenosis of the cord in the vicinity of the umbilical insertion is rarely the primary cause of abortion, though often a secondary, resulting from motion and traction on the inactive, dead vessels; whilst Leopold seems to look upon it as the primary cause.
[Footnote 4: Zeitschrift für Gynäcol. u. Geburtsh., vol. i. 1, p. 57.]
I have endeavored to call attention to the various conditions which may lead to abortion, but it is almost impossible to place an estimate upon their relative importance. Whilst uterine contractions, hemorrhage, and abortion may result in one case from a slight nervous excitement, a trifling annoyance, the most violent nervous irritation will in no way affect another; whilst a fall, a jump from a buggy, may lead to a mishap in one patient, the crushing of the abdomen beneath its wheels will not affect another; a trifling fever may appear as the cause in one, and again the most severe pneumonia or typhoid condition will not impair development in another; the child may be carried to term by a mother in the last stages of consumption, whilst a very trifling affection may lead to abortion at other times. So it is with remedies taken internally, though as a rule they have but little effect: a violent aperient may cause abortion, and again, as in one instance which I recall, a woman in the fourth month of pregnancy died rapidly of dysentery resulting from the taking of cathartic pills to produce abortion, and the post-mortem revealed a perfectly healthy ovum in a healthy uterus, whilst the dysentery consequent upon the remedy killed the mother. The careful introduction of a sound into the gravid uterus has led to a separation of the ovum, to hemorrhage, {493} and to abortion, whilst a knitting-needle has been passed into the uterine cavity and through the womb, causing the death of the criminal mother, without in any way disturbing the ovum. The uterus has been regularly treated for supposed disease for three and five months by internal applications, and gestation has progressed. So it is with all these cases: at one time, especially with pre-existing disposition, a slight interference may result in the cessation of development, and at another the most violent insults in no way disturb gestation.
B. Causes of Criminal Abortion.--The causes proper of criminal abortion are immorality among all classes, high and low--among the wealthy fashion, the pleasures of society, and the desire to limit the number of children--a common cause, strange to say, mostly among those very people who can actually afford the expense. The cause direct, the means by which the crime is accomplished, should be known to the practitioner in order that he may detect the deception which is so frequently practised upon him--that he may prevent it if possible, and at least not, by reason of ignorance, be made particeps criminis.
The means resorted to are either external or internal, traumatic and instrumental, or by medication.
Traumatic.--When produced by the patient herself it is either by violent exercise, running up and down stairs, walking and dancing, occasionally by pressure upon the abdomen or by the use of the knitting-needle, catheter, or similar instrument. The more expert or daring only attempt to enter the uterine cavity, as the organ itself may be pierced; if the catheter is successfully introduced, the attachment of the ovum is severed, and with the knitting-needle the sac is punctured.
These attempts are usually made in the second or third month at the second or third missed period. There is, however, a class of experts among the most elegant who have attained such remarkable dexterity as invariably to introduce the instrument successfully into the uterine cavity; and these are in the habit of regularly practising this dangerous experiment when the first days of the expected period have passed without the coming of the flow.
The abortionist either injects fluid into the uterus or introduces a probe or catheter into the cavity. Customs vary in different countries; so Van de Warker states that in France puncture of the membranes is fashionable, whilst here a syringe or sound is used.
Among the most common--and perhaps most harmless--means is the hot foot- and hip-bath, the "sitz-bath," often with the addition of mustard: this, as well as the steaming of the parts by sitting over a chamber filled with hot chamomile tea, is the first step taken by the nervous wife when the menstrual flow has failed to appear sharp on time and she still lives in hopes that it is but a cold which has interfered with the regularity of its return. Even physicians, respectable men in good practice, who may not venture upon bolder measures and wish to keep their conscience clear, are known to advocate this course, though they well know what such a cold means.
Medication is perhaps more commonly attempted, but less successfully, notwithstanding the injuries caused to the system. To follow Van de Warker's thorough study, the remedies used are mainly of two classes--those which act directly, the emmenagogues, oxytoxics, and reflex {494} abortifacients. Notwithstanding the firm popular belief in their efficiency, they are less harmful to the ovum than to the system of the mother, and, as Van Warker says, there is more science and skill used than is generally supposed in the various pills and teas, which are less simple, but no less common, than the foot-baths and the gin-bottle. Ergot is almost sure to be called upon to perform its office. Its action is very uncertain, but if persistently used is readily recognized by its effect upon the vascular and nervous system--uterine or ovarian pains and depressed action of the heart where in spontaneous abortion an acceleration is to be expected; the temperature is lowered, and the sphygmograph shows a remarkably flattened apex with an almost senile pulse. Cotton-root is also commonly used, especially in the South, and is marked by its narcotic action.
Among those termed reflex abortifacients, acting more indirectly by their effect upon surrounding organs, we may notice cathartics, principal among them aloes, which, notwithstanding its purgative action, does not appear to deplete the circulation, but, on the contrary, results in pelvic congestion; but even its excessive use need not in any way affect gestation. I have seen a patient dying amid the resulting dysenteric symptoms, frequent, scanty, and bloody evacuations, accompanied by excessive tenesmus, inflammatory conditions, and abdominal pain, though the uterus did not react and the ovum remained intact. The odor of the drug is imparted, it is said, so intensely to the evacuations that it is unmistakably noticed.
Juniper and black hellebore, the latter especially endangering the life of the patient, are both toxic in their effects. The painful fluid evacuations, accompanied by bearing down, tenderness of the abdomen, pain and sickness at the stomach, dry throat, would characterize the former; the odor the latter, as well as the flushed appearance of the face, with heaviness and pain in the head and frequent micturition. But one of the first and most common remedies to which the desperate woman resorts when she finds a day of the menstrual period passing by without the appearance of the flow is tansy, which seems to act by reason of the uterine congestion which it causes. Though undoubtedly effective at times, it will, like all other drugs thus used, more often cause injury, and even the death of the mother, without disturbing gestation. "Disturbance of the nervous system, profuse salivation, immobility and dilatation of the pupils, and severe strangury," are noted as the symptoms of such poisoning. Hardly less popular is the still more dangerous cantharides.
The female pills and various mixtures more or less openly sold by druggists are, according to the researches of Van de Warker, composed of one or more of the above-mentioned ingredients, and the immense quantities disposed of show how truly abortion is called the crime of the period. Knowledge of the remedies used for these purposes will aid the physician in arriving at a correct diagnosis and enable him to save the child and guard his patient.
PATHOLOGY AND MORBID ANATOMY.--I have endeavored to describe with some accuracy the appearance of the healthy ovum, the sac, and surrounding structures during the various periods of early pregnancy, as it is the comparison with these which will enable the practitioner to distinguish between spontaneous and criminal abortion, enable him to determine the duration of pregnancy, guide him as to the cause, and thus serve to {495} facilitate treatment and perhaps to prevent recurrence. Knowing what has been expelled, whether it is ovum and decidua entire or only in part, the line of action is evident. In all abortions due to an immediate and active exciting cause, whether criminal or resulting from shock or accidental trauma, the ovum is healthy, normal in all its parts, size and development of the embryo corresponding to the period of pregnancy at which the accident occurred; whilst in spontaneous abortions due to accidental causes more or less marked changes exist: the development of the embryo especially is retarded; its life has been destroyed, and growth has ceased, whilst the morbid development of the membranes continues, so that the mass expelled presents more or less of a mole formation--comparatively solid, with thick walls formed by the foetal membranes infiltrated with blood, the cavity often compressed by the surrounding extravasation, the embryo comparatively small or disintegrated in whole or in part.
The ovum is usually separated in its upper portion by hemorrhage, which comes from that point at which the vessels are most fully developed, the future placental site, though still agglutinated. With the inauguration of uterine contractions separation takes place at its lower pole by dilatation of the os, and retraction of the uterine walls from the ovum proper surrounded by the reflexa; as the abortion progresses, the muscular fibres of the fundus force it down into the dilating cervix through the still partially adherent decidua, and the intact ovum is expelled, the inverted decidua following it as the membranes do the placenta in labor at term. Yet these conditions vary greatly with the existing morbid changes.
In traumatic or criminal abortion the perfectly-formed ovum, the delicate cystic body surrounded by its shaggy chorion, is first expelled, to be followed by the decidua, usually--when in a healthy state--first by its anterior and then by its posterior half; whilst if the abortion has been inaugurated by some slowly-acting cause the decidua is hardened, infiltrated with compressed and clotted blood, the small ovum forming merely a part of the solid mass; and thus a firm oval body, coated with blood upon its rough, irregular exterior, appears.
Up to the third month the ovum is, as a rule, expelled as a whole, often even in the fourth. Later, unless decided pathological changes have taken place, the membranes are mostly ruptured and the embryo separately expelled, as in labor at term. In later months this is always the case, and the progress of abortion is greatly impaired by the adherent tissues: the mass of the ovum, which serves so much to excite uterine contractions and promote expulsion, is destroyed by the collapse of the amniotic sac, and separation and expulsion of the membranes are hindered by reason of the smaller amount of resistance offered. Hemorrhage is most likely to occur in the villi of the chorion, between its tissues and the surrounding decidua; if occurring in the latter structure, it appears thick, hard, infiltrated with blood, and no longer presents that soft, succulent appearance, but is firm and brittle.
The ovum as expelled presents three typical forms: First, as above stated, in accidentally-occurring traumatic or criminal abortion we find a healthy ovum with its shaggy chorion, and the inverted decidua attached or soon following, usually in two sections; most common, however, and almost without exception in spontaneous non-criminal abortion, is the {496} mole formation, rarely the hydatiform mole, which has been described, and results only from the peculiar pathological condition of the chorion. The common form is the flesh mole, the mola carnosa, characteristic in appearance, resembling a polypoid growth, a reddish oval or rather pyriform mass with shreds of tissue (the decidua) adherent to its larger upper extremity, darker clots at the elongated lower pole. Upon section the walls show a brittle reddish structure, that of compressed and inspissated coagula, and in the centre a cavity containing fluid and detritus, if not the embryo, lined with a delicate membrane, amnion or amnion and chorion: the shape of the cavity is rather irregular by reason of the bulging protuberances formed by the contraction of the inspissated mass of blood extravasated between or within the tissues. These moles have very much the appearance of uterine polypi, and are often considered as such by physicians who pride themselves greatly upon curing their patients of tumors and the accompanying hemorrhage by a few doses of ergot. Though the macroscopic resemblance is such as to be quite deceptive, the mole upon section will always reveal a cavity, even if very small, containing fluid; and this cavity reveals the above-described characteristic slight bulging protuberances lined with a delicate membrane; whilst the microscopic examination shows the firm walls to consist of nothing but blood-corpuscles: the outer covering, often thoroughly infiltrated with blood, consists of the decidua serotina and reflexa, with more or less of the infiltrated shreds of the vera usually pendent from its upper extremity; when floated in water and cleansed, the outer or uterine surface of these shreds is ragged, rough, often appearing somewhat like the villi of the chorion, hence looked upon as placenta; this peculiar appearance is caused by the torn tissue in the line of demarcation in the lower or central meshy layer of the decidua vera, where it is separated from the lowest layer which remains adherent to the uterine wall. The inner surface toward the ovum will show a slightly wavy, cribriform appearance, the openings of the ducts appearing as fine depressions in the surface. (It must be remembered that this smooth inner surface is in the expelled specimen generally the outer one, as the decidua follows the ovum mostly as the membranes do the placenta at term--inverted.) If the disturbance causing the abortion has been of rapid progress, the cavity is large, the embryo approximating in development the period of expulsion; whilst if the changes have taken place slowly, the walls are thick, the cavity small, and the embryo may appear merely as a small mass pendent from the navel-string, or may have entirely disappeared, and can be traced only by the fine detritus in the amniotic fluid, the cord itself perhaps only in part remaining, and even this may have disappeared. The cavity will always be found toward the pendent pole of the decidua reflexa, as the extravasation takes place mainly in the serotina, giving it the appearance of a thick mass of clotted, compressed blood, and forcing the cavity toward the opposite extremity. These moles are usually more elongated and pyriform, one or two inches in diameter at their upper or larger extremity, three or four inches in length, with a greatly elongated and narrowed lower end, which has been so formed by being first wedged into the slowly-distending cervix.
Such is the appearance in those cases of slow progress in which death of the embryo has probably occurred at an early stage and hemorrhage {497} has been the exciting factor, whether due to disease of the mother or other causes that may have destroyed the vitality of the germ. When resulting from disease of the mucous membrane, especially endometritis or catarrhal affections, it is a more oval tough mass, the main part of which is formed by the thickened and indurated vera; and if this be opened the ovum, in a very early stage of development, will be found within.
The uterus itself presents very much the appearance of the organ after labor; the external os, however, closes more rapidly, less rarely showing the funnel-shaped appearance of the puerperium; the cervix, though somewhat enlarged, is normal in appearance; the cavity is lined by the lower layer of the decidua, soft shreds covered with coagula; but it is lacking in the placental site and the putrid thrombi visible in labor at term.
Involution is slow if we take into consideration the slight distension of the uterus as compared to the process after delivery at term. The organ is in a state of healthy development, not prepared for the following retrograde metamorphosis, unless the expulsion of the ovum has been due to local disease, when some retrograde changes may have been inaugurated; if it results from constitutional causes, the existing depression naturally interferes with restitution. If shreds of tissue, parts of ovum, or decidua remain, absorption or expulsion is retarded. As a morbid or atonic condition so often exists, at least in abortion consequent upon natural causes, subinvolution or inflammatory conditions of the organ itself or the surrounding tissues are hence a frequent sequence.
SYMPTOMATOLOGY.--It will be remembered that abortion is more likely to occur among multigravidæ on account of the greater frequency of disease, especially pelvic affections; that it is most likely to accompany the periodic congestion which recurs at the time of expected menstruation; that it is more frequent in early married life, on account of the greater liability to traumatic injury and the existing nervous disturbance, and toward the menopause in that state of nervous and physical disturbance and lessening uterine activity. The third or fourth month of gestation is the dangerous period, as it is one of change of nutrition for the ovum, of the highest development of the decidua, and intense activity and congestion of the chorion, the rapidly-sprouting vessels finding but little resistance in the embryonic structures of the villi which surround them. Chronic disease of the mother is more likely to interfere with gestation at a later period; and, when knowingly undertaken with criminal intent, the time of choice is either the first month, when the first indications of pregnancy become evident and the menstrual period does not appear at the usual time, or more commonly at the time for reappearance of the third menstrual flow, when the fact of conception has been established to a certainty, and the conscious mother, firm in the belief of the nonviability of the embryo before the fourth month, thinks it harmless to rid herself of the ovum, which she considers a mere growth without life or soul, while she would shrink from destroying what, at a later period, she calls a living being.
SYMPTOMS AND COURSE OF ABORTION.--General Remarks: Preliminary Symptoms.--1. Course of early abortion, first two months.
2. Abortion at the time most common, the third or fourth month: a, spontaneous; b, criminal and traumatic.
{498} 3. Later abortion--in the fifth and sixth months--and hydatiform mole.
The expulsion of the ovum during all periods of pregnancy is characterized by two inevitable symptoms--hemorrhage and pain. It is the time of appearance as well as the relative intensity of these symptoms by which the period of gestation at which the expulsion takes place is at once indicated. In early abortion the hemorrhage is excessive and precedes the pain, the pain being comparatively slight; in labor at term pain is the prominent symptom and precedes the comparatively slight hemorrhage, which does not appear until the pain has almost ceased, and labor is completed after the expulsion of the placenta. Expulsion of the ovum in intervening periods is marked by an approximation of symptoms, though the existing conditions which characterize individual cases greatly modify this typical course.
I have, for the sake of conveniently grouping the symptoms, accepted three periods which serve well to characterize the course which abortion is wont to take in the progressive months of pregnancy. Hemorrhage and pain are the never-failing symptoms--hemorrhage due to the separation of the membranes; pain in the earlier months is due to the dilatation of the rigid, unprepared cervix, which greatly preponderates over the pain which accompanies the expulsion of the comparatively small mass through the once-dilated passage. In the later months, the cervix being gradually prepared, the pain is almost altogether due to the increased effort which is necessary to expel the large mass of the ovum.
1. Early Abortion.--In the first and second months the ovum is small, the vascular development trifling; the decidua preponderates, being greatest in mass and in extent of its vessels; hence this is the most important part. The hemorrhage is considerable, due to the separation of the vascular and hypertrophied mucous membrane, the decidua. The ovum is very small and expelled with comparatively slight pain, the symptoms often resembling those of membranous dysmenorrhoea; no great dilatation of the os is even necessary.
2. In the third and fourth month, the period at which abortion both spontaneous and criminal is most common, the placental formation is inaugurated by the growth of the vascular tufts of the chorion; and it is now that the ovum in toto--or we may perhaps say the membranes, as they are by far the greater part of the ovum--assumes the most important rôle. The abortion is still inaugurated by hemorrhage due to the separation of the vessels, but the pain is greater, as the cervix must dilate more to admit the passage of this larger mass, and an expulsive effort as well is necessary to force the mass out. The greatest amount of pain is caused by the dilatation of the rigid, unyielding cervix, which fortunately remains in this undilatable state until after the period of viability of the foetus, and serves to a great extent as a check upon its more frequent expulsion.
3. Late Abortions.--Now the ovum and foetus are of pre-eminent importance; though the parts are still unprepared, hemorrhage continues to be the preliminary symptom, yet pain follows rapidly upon the inaugural flow, because the ovum is now so large that it cannot descend without dilatation: it must have advanced before abortion can progress to any extent, and the expulsive pains assume greater prominence on account of {499} the increased size of the ovum; the symptoms of labor at term are approximated, and, as the placental formation is developed in the sixth month, pains may at times precede, certainly rapidly follow upon, the preliminary hemorrhage. It is now the placenta which plays the most important part, as in labor at term it is the foetus which is all-determining, upon which all the efforts of expulsion are centred; the membranes, amnion and chorion, are secondary, and the decidua, which was so important a feature in the first months, has by this time entirely disappeared as a factor in the act. The remaining shreds are partially adherent to the ovum, and in part passed slowly off with the lochial flow. Thus we see how the symptoms, at extreme periods so varying, approximate and interlace, and the various organs gradually yield in importance to newly-developing structures.
In the first period, then, the decidua is all-important, whilst the small and yielding ovum causes but little disturbance, not to mention the embryo. In the second period the membranes of the ovum are more important, and together form what is most erroneously termed the placenta in abortion. Then, as the placenta develops, this with the membranes predominates; finally, in labor at term the decidua, first all-important, has vanished as a factor of consequence, and the embryo, in the first stage a minimum, assumes such dimensions as to concentrate upon itself every effort of the obstetrician.
Pain, especially in the earlier months, is liable to be more excessive in primigravidæ, as the external os is closed, the cervix rigid, the time necessary for the expulsion of the ovum greater. In multigravidæ, with ordinarily more yielding and relaxed cervical tissues, the effort of the uterine muscle is concentrated upon the expulsion of the ovum from the cavity proper; and when it once passes the internal os a path is opened, and little or no force but that of gravity is often necessary to complete expulsion, whilst the cervical canal and external os offer formidable opposition in primigravidæ to the forcing out of the ovum, even though it has passed the os internum. A wide range of varying conditions naturally exists, due to the very different states of the cervical tissues: they may be relaxed in primigravidæ or firm and unyielding in multigravidæ, though the opposite is true in typical cases.
PRELIMINARY SYMPTOMS.--The symptoms which accompany death of the embryo and precede the expulsion of the ovum develop with the growth of the latter and its encroachment upon the cervix; although they vary as strikingly as do the symptoms of pregnancy, yet we may say that the larger the ovum, the greater the foetal and placental circulation, the more marked must be the effect of their cessation; the larger the uterus and ovum, the more distinct this feeling of fulness, of pelvic dragging, which accompanies the descent of the gravid organ previous to expulsion of the ovum. The larger the ovum, the more distinct the pains which accompany beginning separation, the more the encroachment upon the cervix, the greater the dilatation which gives rise to the earlier symptoms. These symptoms, however, vary so greatly, and are so often altogether wanting, that they are hardly to be considered, especially during the period in which abortions are by far the most common, in the third and fourth month; and as, in all but traumatic and criminal abortions, the disappearance of such symptoms of pregnancy as have existed {500} is indicative of coming abortion, the death of embryo and ovum often precedes expulsion for a considerable period of time, and the symptoms of pregnancy consequently cease. Symptoms of pelvic congestion, bearing-down pains, pressure upon rectum and bladder, are among those frequently preceding abortion. At times we see a rigor, feverishness, rapid pulse, nervous disturbances, lack of appetite, anæmia, fulness of the head, also palpitation, cold extremities, heavy, uneasy feeling at the pubes and coccyx, lumbar pains, and vesical tenesmus--symptoms which are all unusual, with the exception of the latter. The descent of the enlarged and congested uterus in the pelvis, which always precedes the expulsion of any body from its cavity, frequently causes dragging pains in the pelvis, a fulness, heaviness with pressure upon the bladder and rectum, and an uneasiness at the pubes and coccyx or lumbar and vesical tenesmus. Later, the death of the ovum and foetus will cause more striking symptoms; the cessation of pregnancy will be more marked in mammary changes, but reliable symptoms are rare at all times, and usually wanting in the earlier months.
SYMPTOMS OF ABORTION.--Early abortion is frequently ignored, the symptoms greatly resembling those of profuse and painful menstruation. The course of abortion is inaugurated by hemorrhage, occasionally ceasing: sometimes there is very little pain: again it is quite severe; but the period of expulsion is well characterized; when completed the pain ceases, and with it the hemorrhage. Often the ovum is passed without the knowledge of the mother, even when accompanied by pain, as it is at this time more like that of a dysmenorrhoea.
Abortion in the Third and Fourth Month.--Spontaneous, Non-criminal Abortion.--At this period the ovum usually passes en masse; occasionally, and more often as the fifth month is approached, the membranes are ruptured in the course of its expulsion.
Normal Course.--We have already delineated the normal course of abortion at this period. The death of the embryo has usually preceded, often for weeks, and is characterized by the feeling of pelvic congestion, gastric and vesical irritation, weariness, weakness, and increase of uterine and vaginal secretion; the membranes have developed more or less; expulsion is inaugurated by hemorrhage. If the cause be more violent, the flow of blood is free. Usually there is but a slight oozing, which ceases at times, but gradually increases; the suffering which accompanies uterine contraction is present. Separation of the decidua and dilatation of the cervix are indicated by pain, which is intensified in case of uterine disease, so often present as the cause of abortion: the ovum is expelled as a pyriform mass, its apex imbedded in clotted blood, the inverted decidua adherent to its larger upper pole. If hemorrhage has taken place in the decidua, or the abortion be due to disease of this membrane, it is the most prominent feature and envelops the expelled ovum like a rigid mantle. In traumatic abortion it usually follows; ordinarily the membrane in part or in shreds is expelled with or very soon after the ovum.
Traumatic and Criminal Abortion.--Traumatic, especially criminal, instrumental, abortion varies in its symptoms, so well characterized by Van de Warker, from the spontaneous occurrence. The latter is inaugurated by hemorrhage; constitutional symptoms are wanting, and if they {501} occur usually follow upon injudicious interference. In the former constitutional disturbances are present from the first; so also pains with inflammatory symptoms, mostly in the hypogastric region, abdominal tenderness: the pains of dilatation may even precede hemorrhage, whilst in spontaneous abortion they follow, often after days. The pulse is accelerated from 100 to 120 as a result of the primary insult; tenderness of the sensitive and congested uterus and cervix is rarely wanting; it is, in fact, characterized by Van de Warker as the one almost invariable symptom; vaginal hyperæsthesia, heat, and tenderness of the os are natural results. We have no history of previous accidental or spontaneous abortion: preliminary symptoms are wanting; the occurrence, on the contrary, is inaugurated by violence and shock; constitutional disturbance and hemorrhage follow. The consequences also are liable to be more severe, in accordance with the insults offered.
Recurring Abortion.--Morbid conditions, which interfere with the development of the ovum and lead to abortion, tend greatly to produce similar results if conception again takes place; hence we not infrequently find the repeated occurrence of abortion in a patient once afflicted; and this was formerly looked upon as a habit and known as habitual abortion--a term which must yield to the more correct repeated or recurring abortion, as no such habit exists: it is the continuance of the same cause which brings about a recurrence of the accident in repeated pregnancies. The cause being the same, the results are similar: the abortion will recur at about the same period if conception again take place; if due to a disease of the uterine mucosa, an early interruption is to be expected. The death of the foetus is usually the indirect cause of the abortion, and always precedes it: in these cases, in most instances, it is due to syphilis; at times to other cachectic conditions of the mother or an affection of the uterus or its mucosa. The development of the ovum continues for some time until abortion takes place, and this occurs, if due to changes in the mucosa or decidua, in the first months; if the result of anæmia or cachectic conditions of the mother, of syphilis, in the sixth or seventh month, or toward term. The death of the embryo is followed by retrograde metamorphosis, thrombosis of placental or uterine vessels, and expulsion from one to three weeks later.[5]
[Footnote 5: Geonbert, Thèse de Paris. 1878.]
Plethora as well as anæmia may cause this occurrence; thus Campbell relates a case of seventeen successive abortions occurring in an extremely plethoric person, who was finally enabled to bear a child to term by repeated venesections made monthly; and others record cases of a similar nature: lack of nutrition, anæmic conditions, brought about a remarkable increase in the number of abortions during the siege of Paris and in the succeeding year of want. Chronic endometritis with cystic formations has been repeatedly recognized as leading to recurring abortion; so also laceration of the cervix in case conception does take place. The continuation of the same cause should lead to its recognition, as in most cases it is amenable to treatment; syphilis, inflammation of the endometrium, and laceration of the cervix, among the most frequent causes of such repetition, are the very diseases most thoroughly under our control, so that in the present advanced stage of our knowledge we should no longer hear of such a condition as recurring abortion. Ruge of Berlin {502} considers syphilis as the cause of death of the foetus in 83 per cent. of such cases.
VARIATIONS.--A cessation of the symptoms not infrequently occurs: either with or without treatment the oozing may stop; even if hemorrhage and pains have existed all symptoms may cease. Large clots of blood have been expelled, the patient rests quietly in her bed, and gradually becomes easier; contractions and hemorrhage cease altogether, and she recovers, regains her vigor, and begins to move about. At the time of the following menstrual period the same cycle is repeated, and not until then is the ovum expelled. If the membranes are delicate, these may be ruptured by uterine contraction or by artificial or mechanical interference, and with the collapse of the ovum or the expulsion of its greater mass irritation is lessened and the symptoms subside. Exercise or the congestion and irritation consequent upon the return of the menstrual period will again arouse uterine activity, and the remnants are then expelled, a month or two after the inaugural hemorrhage.
These are conditions which are very frequent when the expulsion is left to nature or the aid of the midwife is sought, but they are with equal frequency produced by unskilful interference. The efforts of the physician are not unfrequently directed to a lessening of the hemorrhage, regardless of the existing conditions: applications are made to the abdomen and ergot is given, both methods of treatment which tend to stimulate uterine contraction; the more powerful circular fibres predominate and contract, the os is closed, the symptoms cease, and the conditions above mentioned are produced. Abortion is prevented for the time being, and sooner or later the patient is astonished by a return, which is, however, accompanied by less hemorrhage and more active labor-pains with a more rapid expulsion. If styptic injections are made into the uterine cavity or pieces of the ovum removed with the uterine dressing-forceps, a similar effect is produced, though the result is a more unfavorable one, as parts of the ovum are removed, and the collapsed membranes and shreds which remain are liable to prolong and aggravate the case, as they do not irritate the uterus and stimulate it to healthy action like the intact ovum.
The interval between the period of expulsion and the inaugural hemorrhage is often one of complete rest and health, more usually one of occasional oozing and malaise. As a consequence, we must have putrefaction and sepsis or the development of placental polypi and hemorrhage. Air is often admitted, either during the efforts at removal or later; if the cervix is not fully contracted, the secretions are more copious and liable to putrefy with the retained shreds. The symptoms are, however, unlike those of septic infection after labor at term, on account of the comparatively intact surface, the absence of the large uterine sinuses: they are insidious, not intense and acute--lack of appetite, weakness, slight increase of pulse and temperature--so that assistance may not be sought until increased suffering, putrid discharge, and high fever necessitate interference. This putrefaction is more liable to take place when the greater mass of the ovum has been expelled and parts alone remain, but will also occur when the entire mass is retained. Even without active interference the symptoms may subside as the disintegrating masses pass away as a putrid discharge, intercurrent hemorrhages at times carrying away larger shreds.
{503} The so-called placental polypi result from the retention of parts of the ovum, especially of the placental portion, chorion, or decidua serotina, which, enveloped in fibrinous coagula, are entered by the proliferating vessels of the surrounding tissue. Such growths, sometimes of the size of a hazelnut or walnut, even to that of a small egg, may be unnoticed for months, but sooner or later give rise to oozing and hemorrhage, and in more fortunate cases are finally expelled. The expulsion of these retained membranes is inaugurated by hemorrhage, which may be preceded by more or less oozing: it is rapid in its course, accompanied by that pain which characterizes the last stage of abortion, and terminates with the appearance of the corpus delicti. It is merely the final scene of the abortion, which was but partially completed weeks or months ago, and the task is greatly simplified. Dilatation of the cervix and separation of the tissues were accomplished in the first stages, and during the interval of rest nature has been quietly making the necessary preparations to facilitate and complete the task undertaken, precisely as during the last months of gestation. Consequently, this expulsion is rapidly accomplished: pain and hemorrhage, even if severe for a time, are not of long duration. I have such a mass--which upon section reveals distinctly the villi of the chorion--which was cast off with all the symptoms of abortion four months after the occurrence of the inaugural hemorrhage and partial expulsion. More frequently I have been called to remove these masses, which have given rise to constant oozing and actual hemorrhages, two and three months after the occurrence of abortion, the adhesion to the uterine wall being so firm that the sharp scoop was called for, and sometimes I have been obliged to remove them piecemeal like a small uterine fibroid.
Late Abortion.--All abortions in the fifth and sixth month approximate in their symptoms those of labor at term; the membranes are ruptured, the ovum is never expelled in toto; the foetus may either precede the placenta or be expelled with it. It is at this period also that the hydatiform mole usually passes away, though it may be retained for a much longer period of time, even beyond the duration of normal pregnancy, the symptoms resembling those of abortion in the third or fourth month. After complete expulsion of the ovum and membranes more active hemorrhage and pain cease, the uterus contracts, but a slight oozing follows, and this becomes more pale and gradually merges into a serous flow.
DURATION.--The course of abortion varies greatly in its duration, and is usually prolonged, death of the ovum frequently occurring weeks before active symptoms are inaugurated, and even these may be slow in developing: a slight and often interrupted oozing may precede a more profuse flow and the dilatation of the cervix, or, as we have seen, the symptoms may cease for weeks and months even after they have been fully inaugurated; again, the ovum may be expelled in part and the remnants be retained for months--four months being the extent of time in which I have seen such retention terminate in expulsion without interference. By the formation of placental polypi the period may be protracted indefinitely.
The question how long abortion may be delayed, for what length of time the membranes may be retained, is far more important than is {504} generally supposed, both from a social and medico-legal standpoint, and is by no means thoroughly understood. I have recently seen a mole formation, the infiltrated foetal membranes, and part of the decidua which had been retained nearly four years--three years and nine months.[6] For four consecutive years the foolish woman, who had brought about abortion and expulsion of the embryo, suffered from occasional menorrhagia, and nausea and vomiting like that which had existed in the first months of pregnancy, until the annoyance became unbearable and medical advice was sought. An examination revealed an enlarged anteflexed uterus, from which a peculiar compressed and elongated mole was removed, after which the symptoms ceased. The case is moreover peculiar, as several of the symptoms were those of pregnancy, which do not generally continue after death of the embryo.
[Footnote 6: Ovum retained nearly four years, E. C. Gehrung, Weekly Medical Review, St. Louis, April 25, 1885.]
For a term of three years a twin embryo has been retained, causing violent epileptiform attacks, always most severe during the menstrual period, which first appeared four weeks after the last labor and continued, to the great detriment of the patient, until the macerated embryo was removed, when recovery took place. This was most probably a twin intramural pregnancy, the twin developing in the tubo-uterine cavity being retained after the expulsion of the one properly located, and then gradually forced into the more commodious uterine cavity.[7] These cases indicate the extent of this still unsettled question.
[Footnote 7: C. K. Patterson, Weekly Medical Review, June 13, 1885.]
TERMINATION.--Dangers of Abortion.--Though fatal results are rare and, when occurring, due to sepsis rather than to hemorrhage, much of female suffering is traceable to this accident, the pathological interruption of pregnancy. Uterine and pelvic disease, especially subinvolution and consequent displacement, diseases of the endometrium and cervical tissue, result from abortion; sterility as well--all diseases which leave their traces indelibly marked upon the system of woman. They are not the direct or necessary consequences of abortion, but rather the results of the underrating of this most decidedly pathological occurrence--an underrating which is unfortunately prevalent among the profession and universal among the laity.
The direct consequences of hemorrhage are rarely severe: if harm ensues from loss of blood, it is not from profuse hemorrhage, but from long-continued oozing, generally that which accompanies the oozing following incarceration in the efforts at delivery, by which the system is depleted, and so weakened that years of care may be necessary for perfect restitution: evil results are much more liable to follow upon ill-timed or injudicious interference, the removal of part of the ovum or the checking of hemorrhage, the closing of the os by cold applications or ergot; equally serious consequences arise from sepsis if putrefaction of the parts retained takes place. The indirect results are even more common, and I cannot too often repeat that these, as well as the before-mentioned direct results, are due to a misapprehension of the existing condition--to an underrating of the importance of abortion. It is looked upon by women as no more than a profuse menstruation; some follow their daily vocations, bearing the suffering, or they may remain in bed during {505} the most profuse flow and the greatest agony, but with the expulsion of the ovum or after a day's rest they resume their daily toils and pleasures. Frequently the midwife or nurse is called, and thus after-treatment neglected; and even the physician too often discharges his patient after a few days' confinement.
The worst consequences follow upon comparatively rapid and easy abortions, which are treated lightly, even by the practitioner; and should he by chance take the proper view of the case, the patient herself is unwilling to observe the necessary care. If she is prudent, she awaits the cessation of the discharge; daily work is then resumed by some, the usual round of pleasures by others. Gradually annoying symptoms appear, local or general; health fails; backaches, dragging-down pains, appear after so long a period that so slight a matter as the abortion, which has occurred months before, is never thought of as the cause of the suffering, and subinvolution is thus the most common result. As in all but traumatic and criminal abortions pathological conditions precede, especially of the pelvic viscera, it is often a diseased organ in which the abortion takes place, and restitution will only be accomplished by time and care, rest and proper treatment.
Subinvolution, chronic uterine lesion, and sterility are a common result of the first abortion in young married women, and in most instances it is the neglect of after-treatment to which these results must be ascribed; it is the underrating of abortion by the laity, and even by the profession; and as natural, healthy labor with too rapid getting up is liable to result in evil consequences slowly developing, so it is true to a far greater extent of simple abortion. The usual termination is in subinvolution, chronic cervicitis, and endometritis.
It is the duty of the physician to impress upon his patient the fact that equal if not greater care is necessary in the management of the pathological condition, of the early termination of pregnancy, than of normal labor at term, and that abortion is to be compared to a severe labor rather than to a simple menstruation. Were the physician summoned at once, much evil would be prevented. But if called at all, it is only when hemorrhage and pain become alarming; yet I am sorry to say that I have seen those who have suffered most, ruined in health and sterile, women in the best walks of life, who have closely followed the advice of able physicians, who skilfully managed the existing trouble, but undervalued the consequences--not giving the necessary time for involution, comparatively slow at this period when the system is so unprepared for a process to which its course is slowly shaped as term approaches.
DIAGNOSIS.--It is of importance to know, when called to a patient, first whether abortion is threatening or actually inaugurated--that is, whether the patient is pregnant, and whether the existing symptoms are those of abortion or of dysmenorrhoea; secondly, whether the abortion can be prevented, and if not, what treatment is to be pursued; and thirdly, whether the abortion is completed?
1. Does pregnancy exist and is abortion inaugurated? or are the symptoms those of dysmenorrhoea, metritis, or uterine tumor? The existence of pregnancy is a condition often difficult to discover, especially in unmarried women intent upon deceit, or in cases where the patient is herself in ignorance and no cessation of the menstrual flow has {506} occurred. The symptoms of pregnancy must be carefully inquired into, as well as the condition of the patient, local and general, during the previous months and previous pregnancy. Dysmenorrhoea, menorrhagia, and membranaceous dysmenorrhoea may simulate abortion; but the pain in dysmenorrhoea is relieved by the discharge, whilst this is not the case in the pain of abortion: on the contrary, as the flow increases, with the dilatation of the cervix and the separation of the ovum, the pain increases; shreds of membrane accompany the discharge of dysmenorrhoea, whilst in the case of abortion the membranes follow the ovum when pain and discharge have almost ceased. In dysmenorrhoea the pain is ovarian, more violent, and aggravated with the cessation of the discharge, whilst in abortion it is uterine, more particularly referable to the cervix in the period of dilatation and to the fundus in that of expulsion, and lessens or ceases with the cessation of the discharge. The hemorrhage due to fibroids and polypi may greatly resemble that of abortion, especially if mole formations occur, but the pregnant and aborting uterus is greater in size than the congested menstrual organ. In the abortion of a comparatively healthy ovum the uterus approximates in size the period of gestation; the ovum as it descends during the pain becomes more broad, round, and tense, whilst in the case of a growth or clot the part which is forced down during a pain is more pointed at its presenting extremity than in the interval. In most cases of abortion, however, the uterus is rather smaller than it should be at the period of pregnancy at which the interruption occurs, and as the membranes are infiltrated with blood a mole formation is approximated; the ovum is more pyriform, pointed in shape; the apex imbedded in clots of blood, so that it resembles in feel, as it descends during the pain, a clot or polypus. The pregnant uterus, however, is more soft and elastic than the diseased organ.
2. Can abortion be prevented? The presence of an ovum being determined, our attention must next be directed to the possibility of its preservation. The distension of the os, especially the amount of hemorrhage, must guide the practitioner in seeking an answer to this important inquiry, upon which treatment must depend. The amount of hemorrhage is indicative of the separation of the ovum, but a slight flow continued for days is by no means as dangerous to gestation as a profuse instantaneous discharge. The os may be dilated, but if the hemorrhage is slight and the ovum out of reach, the progress of abortion may yet be prevented even after pains have been inaugurated, the first pains being those of dilatation. The appearance of rhythmical pains, indicative of expulsive contractions, leaves little hopes for the practitioner to check the course inaugurated. Even if the ovum can be felt, abortion may still be prevented, but if it protrude through the gaping os, little is to be expected, though even under these circumstances prevention is still said to be possible if the hemorrhage has not been severe. But if the liquor amnii has passed, there is no possibility of saving the ovum at any time, though it is claimed that even this can be done if pain or hemorrhage alone exists and the latter be not too severe. Even if the separation has not progressed so far that abortion is inevitable, the question must arise whether it be judicious to attempt prevention or whether abortion should be furthered. This depends upon the condition of the embryo, whether it is destroyed or not; if no previous abortions have occurred, and no {507} known cause, especially predisposing or local, exist, if the size of the uterus corresponds to the period of pregnancy, and there are no symptoms of mechanical interference or trauma, an effort should be made to preserve the ovum; but if there be cause sufficient to account for its death, if the uterus be more hard and round, wanting in the elastic oval of normal gestation, if it be smaller than usual at the period of gestation at which the interruption has occurred, death of the embryo and ovum may be supposed, and, notwithstanding the possibility of prevention, abortion should be hastened and completed, the ovum and membranes expelled.
3. Is abortion completed? Difficult as it often is to answer the question whether the ovum has been expelled, it is almost impossible to say whether the abortion has been fully completed, whether the last remnants of tissue have been evacuated. If the physician has been present or the clots have been saved from the time of the inaugural hemorrhage, it may be easy to determine the condition of affairs; but, unfortunately, these are usually thrown away, and the attendant comes at a late period, at one of suffering and exhaustion, when masses of blood, quantities of clots, with whatever of the ovum they may contain, have been removed. If present, he should crumble each clot and float the coagula in water. Fibrin and blood will soon wash away, and the shreds of tissue become separated and remain floating in the fluid.
An examination of all pieces that have passed will readily reveal the existing stage; but ordinarily the physician has no such clue. The hemorrhage has ceased, the uterus is firmly contracted, the os is closed, and the diagnosis is exceedingly difficult, but it must be determined. If left to nature, time will disclose the true condition of affairs: if the ovum has been expelled, the uterus will rapidly diminish in size, the appearance of the discharge will change--it will become more thin and pale; but if the uterus remains firmly contracted, and does not diminish in size, it is probable that the membranes are retained, and the renewal of exertion, of work, or of a succeeding menstrual period--if not the first, the second--will bring about a recurrence of the hemorrhage and the completion of abortion. If the uterus remains large, hard, globular, it is probable that the ovum, or at least the greater part of the membranes, remains in the cavity.
Unless the hemorrhage has ceased and the os be closed for some time previous to the coming of the physician, he will find the uterus low in the pelvis, the os still yielding, except when ergot has been given or ice applied, and by the introduction of the finger into the uterus the condition of the cavity will be determined: this will in all cases be readily accomplished by pressing with one hand firmly upon the fundus and examining with one or two fingers of the other; if not easily done in this way, the entire hand should be introduced into the vagina; the uterine cavity may then be thoroughly swept with the examining finger; but, though this will reveal an enclosed ovum, the membranes can by no means be detected with ease, and will often escape observation; hence the dull curette is in place: it will sever such tissues as may still be adherent. All excellent instrument, especially if the os be small, is the Récamier curette, or the modification which I have devised for the purpose. Should any doubt exist, dilatation should be at once resorted to for {508} curative as well as diagnostic purposes; a rapid dilatation is in place--not instrumental, but by the tupelo or sea-tangle: this affords positive knowledge of the state of the case, and the cavity can then be thoroughly cleansed. Even the sponge tent is harmless if the abortion is completed, as the cervix is still dilatable and yielding, easily expanded. At all events, the diagnosis is unquestioned and the treatment clear. This is by far better than the expectant plan, which is most commonly followed for fear of interference, allowing the patient to continue perhaps for a month or more in ignorance of her condition--allowing her to resume her labors, exposed to sepsis, hemorrhage, and, in the most favorable case, expulsion of the ovum at any time.
If the os is dilated, the finger should be introduced--if necessary the hand--into the vagina, which can easily be done if the fundus be approximated by the other hand; better still, to use the curette, and I would advise the large blade of my instrument; the small one can at all times be passed into the cavity of the uterus during or immediately after abortion, and usually the larger one also. This examination, if with the scoop, consequent upon dilatation, should be followed by an antiseptic injection, but I would unquestionably advocate a correct diagnosis, whatever means may be necessary to obtain it, as appearances are so deceptive. We need but recall those by no means rare cases which to all appearances are those of completed abortion, yet the patient does not perfectly regain health and strength, and if an examination is made the os is found patulous and membranes or parts of the ovum are retained. If examination and dilatation be neglected, a coming menstrual period will discharge the disintegrating mass, or local and constitutional disturbances, even septicæmia, may be looked for.
PROGNOSIS.--As to prognosis, it is the mother whom we must consider, the dangers present and future, the attachment and dimensions of the ovum, and the possibility of continued gestation. The prognosis of traumatic or criminal abortion is worse than that of the spontaneous form, the result of natural causes, because it is inaugurated by shock, by injury, and inflammatory conditions which are aggravated by the congestion and contraction accompanying the expulsion, for which the tissues are entirely unprepared; whilst in natural, spontaneous abortion, usually the result of some morbid condition, some disease of the system, a cachexia, uterine disturbance, or death of the embryo and ovum has preceded, and a retrograde metamorphosis to a certain extent has been inaugurated; some preparation at least has been made for the coming expulsion; hence the separation is more natural, less violent, less liable to be followed by evil results.
The prognosis is invariably favorable if proper medical aid is summoned in the early stages, but actually it varies greatly, as does the course of abortion--whether completed in a reasonable time or of longer duration, more favorable in the former, less propitious in the latter; if hemorrhage has been profuse or comparatively slight, but of long duration, anæmia is liable to result: if expulsion is long protracted, the dangers of subinvolution, metritis, and perimetritis are great: if the expulsive pains cease before the complete expulsion of ovum or membranes, retention, putrefaction, and sepsis may be inaugurated, and subinvolution, endocervicitis, and endometritis will follow.
{509} The embryo is scarce to be considered: it may be saved if the hemorrhage has not been too severe and accompanied by pain, if the ovum does not protrude into the cervix. The inflammation which usually accompanies traumatic or criminal abortion greatly aggravates the prognosis, but, however good it may be in individual cases, the result will depend greatly upon the after-treatment, upon the time allowed for proper involution, and upon the assistance given it. Though the prognosis at the time of abortion may be a most favorable one for the mother, the result is seriously affected by the care taken during the period of involution, the after-treatment, which is by far more important than generally supposed.
TREATMENT.--The successful treatment of abortion requires knowledge, judgment, and resolution on the part of the practitioner, and in importance it is equivalent at least to the management of labor at term. Two lives may even be at stake, though the opportunity of saving the embryo is, as a rule, afforded only during the period of prophylactic and preventive treatment, as vitality is ordinarily destroyed in the embryo when abortion, as the result of natural causes, is once inaugurated: the life of the mother is not in question, as it is in labor at term, but her health is even more endangered. Attention is now forcibly called to the subject by earnest discussions between the adherents of the expectant and those of the progressive method of treatment, but mainly to the treatment of actual abortion; prevention and after-treatment have been neglected. Important as is the method of treatment employed in case of retention of membranes or ovum, the necessity for such interference, especially the frequency of abortion, would be greatly diminished if the family physician were thoroughly imbued with the importance of the subject and could impress the same upon his patients. If the dangers arising from such premature interruption of gestation were appreciated by the laity and medical attention summoned in the early stages, the management of abortion would become more simple and more successful, and the cases of retention which cause such suffering and injury to women would be far less frequent.
Before entering upon the treatment proper it may be well to review briefly the necessary adjuncts, as proper preparation will aid materially the course to be adopted.
Preparations Necessary with Regard to the Patient.--Many of the preparations necessary in the lying-in chamber are desirable in cases of abortion as well. Attention should be paid to the bowels, as a costive condition will interfere to some extent with the manipulations as well as a rapid and favorable course of expulsion and involution; at best, it is liable to make the patient uncomfortable. The bladder should be evacuated, especially before active measures are resorted to, and the patient should be so clad in night-gown and sacque, with long hose and drawers, that she may be moved and manipulated without exposure.
The bed should be prepared with rubber cloth and quilts, and sufficient quilts, cloths, and towels should be on hand; a bed-pan is desirable, and also a fountain or bulb syringe; the bed should be so placed that the physician may be at the right hand of the patient, and convenient to the light when she is placed in Sims's position of the dorsal decubitus for operative interference.
{510} Antisepsis.--Cleanliness and antisepsis should be observed in the management of abortion as strictly as in that of labor or in surgical operations, as sepsis, either in the form of acute infection or an insidious undermining of the constitution, is among the more frequent of the dangerous consequences which follow in the wake of abortion. Circumstances permitting, it is desirable that carbolated vaseline or vaseline with iodoform, carbolated or some similarly prepared soap, be on hand, and also permanganate of potassium, carbolic or boracic acid, and iodoform. I am in the habit of prescribing carbolic acid for the convenience of use: carbolic acid 2 ounces, alcohol 1 ounce, with 7 of glycerin, which is as concentrated as may be well used (1 to 5, or 20 per cent.), and a proportion readily diluted to 2½ or 5 per cent.
Before and after examinations the hand should be washed in carbolated water or some such disinfectant--permanganate of potassium, corrosive sublimate, or boracic acid--as it appears desirable to use. If carbolic acid is used, the parts should be cleansed with a 2 or 3 per cent. solution. After interference or repeated examinations the vaginal douche should be used, certainly after completion before leaving the patient. If instrumental interference be necessary, and the ovum or membranes forcibly removed, the cavity of the uterus should be washed with hot water, from 115° to 125° F., containing 5 per cent. of carbolic acid, the hot water serving styptic purposes. This may suffice, but it is frequently desirable to mop the cavity with the above-named solution or even the pure liquid after more active interference, especially if some disintegration has taken place and is indicated by odor.
After the use of tampons the vagina should be washed with a 2 or 3 per cent. solution, or 1:2000, of corrosive sublimate; and it is even well that the cotton, before being introduced, should be anointed with either carbolized vaseline or carbolized oil (carbolic acid 2 drachms, olive oil 3 ounces). Iodoform serves an excellent purpose for disinfection of tampons, especially such as are packed into or against the cervix, and as an application to the cavity after the removal of the putrid contents following the hot douche. Borated cotton, or even ordinary cotton or prepared tow, should be on hand to use during the after-treatment in place of cloths for the purpose of receiving the discharge: it is warm, soft, forms a good filter, and can be thrown away or burnt when soiled, whilst the cloths ordinarily used, and often very offensive, are kept for the wash.
Medication.--The most important of all the remedies is opium; in preventive treatment it may be called a specific. It is far preferable to the hypodermic injection of morphine, serving to relax and quiet the uterine muscle and to lessen hemorrhage; for the latter purpose it is often combined with acetate of lead--from ¼ to 1 grain of opium mixed with ½ to 1 grain of acetate of lead, to be given at a dose and repeated when necessary. Ipecacuanha combined with opium acts well in relaxing the tension.
Viburnum prunifolium has long been used as a uterine sedative in these cases in those States where the plant is endogenous, and its use has been widely disseminated since it has found so able an advocate in Jenks. The preparations are not all equally effective, but in the early stages the fluid extract given in teaspoonful doses, according to the amount of hemorrhage and pain either hourly or every two or three hours, has a most {511} decided effect in allaying threatened abortion, in checking hemorrhage, and in quieting pains. It seems to be a uterine sedative. Several ounces may be taken, and successful cases are reported where the pending expulsion was averted and gestation continued to a successful termination after four ounces had been used. Digitalis combined with acetate of lead also deserves recommendation as an effective remedy in the early stages. Quinine may be given to stimulate the system and further uterine contraction, and is invaluable in an asthenic condition or if disintegrating shreds be present.
Nervines, valerian, asafoetida, valerianate of ammonia, bromide of potassium, are of great service throughout the entire course of abortion, as the patient is usually in a nervous almost febrile state. Alone they may serve to allay the irritating symptoms in the early stages, and answer well in preventing the disagreeable effects of opium. Asafoetida may be given by injection or in pills, from ½ to 2 grains at a dose.
Clysmata tend to irritate, and should not be used as long as we may hope to prevent threatened abortion. Such remedies as are indicated in the treatment of this condition, especially opium and nervines, must nevertheless at times be given by injection, as the stomach may refuse to receive and retain them in the irritated condition which accompanies this state. The clysms should always be warmed, of body temperature: two tablespoonfuls of milk of asafoetida or gum arabic form an excellent vehicle, though water or milk thickened with flour or starch, which is always on hand, will do quite well.
Should it be necessary to move the bowels, castor oil is one of the best remedies, whilst cathartics, especially aloes and similar drugs, must be avoided as long as there is hope of preserving the ovum: they certainly further expulsion. Ergot should not be used until after the uterine cavity is emptied, and is decidedly contraindicated whilst the ovum or any of its parts remain adherent in utero. The dangers arising from the use of ergot in the early stages, whilst the ovum is still intact, are rupture of the membranes and forcible contraction, which always prolongs expulsion of the ovum or its membranes; the circular fibres, which predominate, are stimulated most forcibly to action, more particularly so under the conditions which usually exist in abortion: the muscle of the uterine body is hindered in its contraction by the adhesions of ovum and decidua, especially if these membranes are infiltrated; and, moreover, in cases of abortion the tissues of the womb itself are often more or less diseased; the lower portion of the uterus and cervix alone is free to act, the circular fibres of the internal os contract most readily under the influence of ergot, whilst the activity of the fundus is interfered with; thus closing of the outlet and incarceration of the membranes are liable to result. This popular and dangerous drug must not be given until the tissues are expelled, or, if desirable by reason of excessive hemorrhage, its use may be resorted to under one condition: if the membranes are detached, not only free in the uterine cavity, but entering that of the cervix; they may be found massed together firmly, by compression of the uterine walls, into a conical or pyriform mass; and when this has to a great extent passed the internal os ergot may be given. This drug, so dangerous in obstetric practice, is still used with altogether too much freedom in this country, and it would be far better to do without it than to {512} continue the prevalent abuse. I have insisted that this drug must not be given in labors or abortion until the contents of the uterine cavity have been removed. Although but one of our prominent obstetricians approved of the position I took in 1883, and I was then freely attacked, I now urge the point more earnestly, and the doctrine is more commonly accepted: in Germany such men as Martin, Spiegelberg, and others have succeeded in doing away with this dangerous remedy altogether in the institutions under their care, restricting its use to the non-gravid uterus.
As a styptic, hot water, carbolized, serves the best purpose: in the early stages as vaginal douche, in the later as an intra-uterine injection at 120°, it is an invaluable remedy, preferable to other styptics, as it cleanses and removes the coagula. When the cavity has been emptied, especially after the forcible removal of the membranes, it is well to apply carbolic acid to the surface; and it is better for this purpose than tincture of iodine or perchloride of iron, either of which is only to be used in case that hemorrhage does not yield to the before-mentioned remedies.
Anæsthetics.--Though bromide of potash, morphine, or opium may suffice for the relief of the pain in ordinary cases, the use of an anæsthetic is not only desirable, but necessary, if more active measures are resorted to. For purposes of rapid dilatation and the removal of an adherent ovum or membranes anæsthesia is almost indispensable; without this the suffering of the already nervous, debilitated patient is excessive; the uterine and abdominal muscles are tense, and operations thus greatly impeded. An anæsthetic should be given in a rapid dilatation on account of the pain, as well as the greater facility of operating; and it is most necessary in an attempt at expression, as, if made without an anæsthetic, the abdominal muscles are so tense that the uterus cannot be well manipulated from without. I myself prefer chloroform.
Instruments.--A speculum, a dull curette, a sharp scoop, a vulsellum forceps, and uterine dressing-forceps are essentially necessary. Any speculum may be used. The best is Sims's if the semi-prone position be used, or Simon's in the dorsal decubitus. The Schroeder's or my forceps is necessary to steady and bring down the uterus for the introduction of tent or finger and the use of the scoop or the application of styptics. This is in the main the American bullet-forceps, an instrument far superior to the sharp vulsellum which is so popular. The curette I would most recommend is my own modification of Récamier's instrument of pliable metal, one blade resembling that of Récamier's, but curved somewhat more like the uterine sound--sharp upon one side, dull upon the other--to be used for the purpose of severing the ovum or membranes in the line of their adhesion: this is so narrow that it can be introduced into the os even after contraction if this be not almost tetanic, as after the giving of ergot. The other blade is larger, broad and flat, more spoon-like, to be used in case of moderate dilatation of the os, both, however, being for the purpose of severing the adhesions and leaving the ovum intact. The broad blade serves as a lever to remove the ovum or membranes when detached. But if the membranes be ruptured, it is of service in separating these from the uterine wall, leaving them as complete as possible, which will always facilitate removal or expulsion. The irritation caused by the severing of the adhesions with this instrument frequently suffices to inaugurate uterine contraction; and ovum or {513} membranes, being once liberated, are then compressed by the uterine muscle into one mass, thus affording a resistance which the uterus is enabled to grasp and expel. This method I believe to be far more rational than the removal of the membranes with the sharp instrument: it furthers the process of nature more strictly, separating rather than cutting away the tissues, as does the latter. The sharp scoop is an instrument which is only to be used for firm adhesions in secondary cases, where the progress of abortion has temporarily ceased and the membranes have become more firmly attached, especially where disintegration of such adherent parts has taken place to some extent; it is necessary and cannot be dispensed with where remnants have been retained for months and have become firmly attached, simulating polypoid growths. I object to the use of the sharp scoop in recent cases, because it is preferable to follow the line of demarcation indicated by nature, and separate the membranes or the ovum, if still entire, in this strait; whilst the sharp scoop removes them piecemeal, cutting deep into the mucosa at one place, and possibly leaving pieces of embryonic tissue in another.
Dressing-Forceps.--These are serviceable for the introduction and removal of tampons, the cleansing of the uterine cavity, and the removal of a detached ovum when in the cervical canal or almost extruded; but the very common habit of seizing the ovum with this instrument as soon as the apex appears is a most pernicious one: the membranes are ruptured, the continuity destroyed, the mass collapses, and the resistance offered to the contracting muscle as well as the dilating wedge is thus destroyed, and the course of abortion greatly prolonged. No narrow grasping instruments should ever be used to make forcible traction upon the ovum; the tissues, if healthy, are very often delicate, and if degenerated into mole formations, infiltrated with blood, brittle, breaking beneath the instrument, which is always withdrawn grasping simply what is seized between its blades. I know of none of the many ovum-forceps which I can recommend.
Position of the Patient.--For purposes of instrumental interference the patient may be placed on side or back, in the left-lateral, semi-prone position if Sims's speculum be used; I prefer the dorsal decubitus, using Simon's speculum. The bivalve specula might be used if short, like the operating speculum of Albert Smith, but they are not to be recommended, on account of their small diameter and their usually too great length, by which they push the uterus away. The organ should be approximated as nearly as possible to the vulva and finger by the instrument, and this is best done either by a short, broad Sims's or Simon's speculum. Simon's speculum in the dorsal decubitus has among its other advantages that of greater convenience for the purpose of injections. The patient is transversely brought on the bed, with the hips upon the edge, elevated by a folded blanket or hard cushion; the legs are flexed, the feet placed upon two chairs; an oil cloth directly under the parts is folded into a slop-jar standing underneath, so as to receive all refuse matter, which enables the physician to use the douche freely. Bozeman's catheter, with double current for intra-uterine injection, is a very convenient and valuable instrument, though not an absolutely necessary addition to the armamentarium.
The use of gynecological instruments is even more important in {514} abortion than in labor at term: it is by far more convenient to introduce the tent or dilator, and even to use the scoop through the speculum, than blindly with the aid of the finger, guided only by the hand on the fundus. Knife and scissors, needle and thread, may be of use in difficult cases, or in case of a firmly-contracted os with putrefaction of the membranes, for rapid dilatation. German authorities advocate incision with a knife in preference to rapid dilatation where it must be done quickly for purposes of immediate evacuation; should this be resorted to, it is very necessary that after abortion is completed the parts should be again carefully united by close sutures--a method which is only to be recommended to the expert in extreme cases. The Récamier or my own curette can be used effectively without dilatation in ordinary cases, even if the os is somewhat contracted; there is so much relaxation that these instruments can be readily introduced, the os being dilated during the act; and if the sharp instrument be used the particles cut are carried out by the spoon, the douche taking away the remnants. With my own instrument I am in the habit of separating the adhesions and removing the mass more, as with a lever, especially if the ovum be intact. The large blade of the spoon is used to press the ovum down into the hollow of the sacrum, very much as the placenta at term is removed.
PROPHYLAXIS.--In primigravidæ the physician should urge careful attention to all conditions that may further a healthy state. As indicated by the physiology of early pregnancy, this lies mainly in a proper preparation for the changes wrought by the physiological activity of the sexual organs; free scope must be given for their development, and this guarded against all injuries, nervous and traumatic: the congested developing parts and the sensitive, tensely-strung nervous system must be protected against insult; a healthy condition of the system must be established, and possibly existing predisposing causes counteracted.
Young married women, above all, are liable to injury from coition, from over-exertion in this period, from amusement or labor, as well as from the demands of fashion. It is the mother, and more often the family physician, who must see that a free and healthy development is permitted: let it be remembered that the close-fitting corset, the heavy dresses suspended from the hips, exertion whether for pleasure or work, frequent intercourse, as well as mental condition, all affect the fate of the ovum. The menstrual congestion, recurring with greater or less periodicity at the usual time of the flow, is a period of especial danger at which still greater care is necessary. As a rule, we can only say that a strict attention to dietetic laws, which should be observed in every gestation, is of the greatest prophylactic importance. In the case of multigravidæ, especially such as have previously aborted, the same rules must be observed, and, in addition, especial attention must be paid to the removal of such causes as may have resulted in previous abortions. The proper prevention, however, lies in treatment of these conditions before the occurrence of conception: as we have seen, these may be either plethora, anæmia, most usually syphilis or uterine disease, and a lacerated cervix, endometritis, pelvic cellulitis, or retroflexion. The treatment of such morbid conditions should be inaugurated as soon after recovery from an abortion as possible, and continued, in case of constitutional disturbance, after conception has again occurred. Though the avoidance of excessive exercise and perfect quiet {515} are desirable, especially during the menstrual congestion and at that period of gestation when abortion has previously occurred, it is ridiculous to confine the patient to bed at this time, without further treatment, with a view of preventing the recurrence of abortion by rest alone. This is a common practice, and can result in good only in isolated cases; it usually annoys and weakens the patient; and it is high time that this antiquated doctrine should be exploded, and that the attending physician take sufficient interest in his patient to urge examination and local treatment by the specialist if he himself cannot detect and relieve the trouble which has caused, and will continue to cause, such serious disturbance. It is a paramount duty of the physician to inquire into the cause of the previous abortion and to prevent recurrence by its removal: if he himself should have attended her, he should examine the ovum most carefully, and later the patient as regards her constitution and the condition of the uterus and pelvic viscera. If the abortion be due to syphilis of mother or father, this must be treated, an existing disease relieved, a retroflexion of the uterus replaced, a lacerated cervix repaired, or the disease of the endometrium overcome; but the confining to bed of the patient during the period of danger, or even during the many months of pregnancy, will aid but little: this is advisable only when the symptoms of threatening abortion again appear. Moderate exercise is conducive to health, and hence to the development of the ovum, and only in rare cases can abortion be prevented by rest alone: confinement to bed may be resorted to as our only means if we are in a state of ignorance, where the original cause has not been detected or treatment is at the time impossible; and this is partially true in pregnancy of a uterus with a lacerated cervix which has not been repaired. An inflamed or irritated cervix is open to treatment, and even a lacerated cervix can be improved during the existence of gestation.
Preventive Treatment.--If symptoms of threatening abortion, or such as resemble them--oozing, hemorrhage, uterine pain--appear in the pregnant woman, however questionable the diagnosis, the treatment must invariably be directed toward the prevention of threatened abortion. If the symptoms are indistinct, the oozing may be merely that of a congested or eroded cervix during the menstrual period or the existing pains--a reflex symptom due to other causes--and should be treated; but then in addition the necessary means must be at once adopted to prevent threatened abortion; and if we are ignorant of the condition of the ovum, whether healthy with a living embryo or pathologically changed, treatment must be directed toward its preservation until absolute knowledge to the contrary is obtained; and this is, above all, necessary in the earlier months, when it is almost impossible to determine as to its condition. Every effort must be made to preserve the ovum as if healthy; and if it be so, success is by far more likely to crown the efforts of the physician, whilst he will strive in vain if it be a healthy effort of the uterus to rid itself of a dead embryo and the diseased membrane surrounding it. Perfect quiet, mental and physical, rest of body and mind, is necessary; the patient is put to bed and kept quiet, excitement and irritation prevented; no coffee, tea, or stimulants should be given, but acids, cool drinks, sour lemonade, aromatic sulphuric acid, opium alone or in combination with other remedies according to the conditions, are in place. If hemorrhage is profuse, we should further vascular {516} contraction sufficiently to check the flow with chinine, ipecacuanha, or, best, viburnum prunifolium, the fluid extract in teaspoon doses, if very profuse every hour, otherwise every two or three hours; digitalis may be added in case of nervous excitement, which is often intense; so also bromide of potassium, valerian, or asafoetida. Ergot and cold applications to the abdomen must be avoided; the latter are frequently resorted to, as they tend to allay hemorrhage, but at the same time they stimulate uterine contractions too freely. No unnecessary examination must be made, and the patient must be kept in perfect repose until the symptoms have completely disappeared.
TREATMENT OF ABORTION WHICH IS FULLY INAUGURATED AND PROGRESSING.--If all means to overcome the existing conditions and check threatening abortion have failed, if the pains continue, the os dilates, or hemorrhage becomes profuse, the treatment is radically changed. Before this period it was directed to the preservation of the ovum, whilst the object is now to complete delivery. The practitioner must now endeavor to check hemorrhage, allay suffering, and above all empty the uterus at the earliest possible time, and to this latter end all his efforts should be directed. By accomplishing this all other symptoms will be most satisfactorily and perfectly relieved; and though time and patience are remedies which cannot be dispensed with even in this stage, more active interference and local measures are now indicated, which, it will be remembered, were to be avoided if prevention seemed still possible.
The progress of dilatation and separation is often slow, and during this stage one precaution must be observed: whatever measures be adopted, the membranes must be preserved intact. We must avoid all interference with the foetal sac; after this is ruptured the hemorrhage is liable to become more profuse, as an additional source of bleeding is added by the collapse of the ovum, which causes a diminution of the intra-uterine pressure. The succulent and vascular tissues are no longer compressed between the resistant mass of the ovum and the uterine walls, and ooze freely into the cavity; moreover, the resistance and irritation previously existing, whilst the ovum was unbroken, is removed, and uterine contractions, the expulsive efforts, are diminished or cease entirely.
The prominent indication for interference is given by hemorrhage, and such means must be adopted to check this as will at the same time promote the expulsion of the ovum.
Pain.--Opium must now be most sparingly used. Complete relief of pain is not desirable in this stage; uterine contractions, the dilatation of the cervix, should be furthered; nervous irritation and excessive suffering may be relieved by nervines--valerianate of ammonia, bromide of potash, perhaps a hypodermic injection of morphine; regular pains indicative of uterine contraction must not be interfered with under any circumstances.
Hemorrhage.--The treatment previously inaugurated--rest, quiet, cold iced drinks--may be continued, but in addition more active measures must be employed: our main resort in this stage is in local measures, mainly in the tampon. Ergot must not be given, as it may lead to rupture of the membranes or incarceration of the ovum, or both.
The tampon is all-important in the management of this stage of {517} abortion, as opium is in the first and the curette in that of retention; according to the method of its use it will serve a variety of purposes, and by skilful manipulation the object desired can be attained with a fair degree of certainty. The cervical tampon is preferable if the os is contracted and the cervix not dilating; pledgets of cotton have been used to plug the cervical canal, but the tent is far preferable; tupelo or slippery elm should be used. In cases where rapid dilatation as well as relief of hemorrhage is desired the sponge tent may be resorted to, but is, as a rule, to be avoided on account of the dangers of infection and the liability of adhesion of particles of soft tissues with which it comes in contact within the cavity. The tupelo is preferable to sea-tangle, as it may be had in more serviceable size and shape; the slippery elm is most excellent, is everywhere within reach, especially of the country practitioner, and has no superior: when cut in proper size, the edges slightly smoothed, and placed for a moment in warm water, it is soon covered with mucoid exudation, which makes its introduction extremely easy, and its presence within the uterine cavity decidedly less harmful than any other substance: it will readily find its way between the membranes, and a number of tents can be placed side by side, so that the disadvantages of inferior distension are equalized.
The tent is best introduced through the speculum, the cervix being fixed by a tenaculum, Engelmann or Schroeder forceps, and a tampon of salicylated or carbolized cotton placed in the vagina for the purpose of retention as well as disinfection. Care must always be taken that the tent be of sufficient length and passed well into the uterine cavity, to within a half inch of the fundus, as it will then serve not only to compress the bleeding vessels and dilate the cervical canal, but to separate the ovum and stimulate uterine contraction. When the tent or cervical tampon is used the vaginal tampon is unnecessary; each has its proper office to perform.
The Vaginal Tampon.--The vaginal tampon is preferable where the os is patulous and the cervix dilating; if small, packed merely in the cul-de-sac and directly about the cervix, it irritates but little; tents should be thus used if it be desirable to check hemorrhage and the possibility of prevention still exists. If larger and the vagina is more thoroughly packed, it is a violent excitor of uterine contractions, and is used in part for this purpose. The rubber bag or colpeurynter, even when filled with hot or cold water, is of little service in checking hemorrhage, though it serves to stimulate uterine contractions; hence it is of no value in those cases where the vaginal tampon is usually called for. The best method of checking hemorrhage and furthering separation and expulsion of the ovum, when intact, is the thorough packing of the cul-de-sac and larger part of the vagina with balls of cotton; wads of the size of a walnut should be made, and strong thread or string should be tied to each to facilitate removal: clots should be removed and the vagina cleansed with an antiseptic injection of 2 or 3 per cent. of carbolized water preparatory to their introduction. If convenient, salicylated or carbolated cotton should be used; the ordinary cotton wadding or cotton wool may be taken, but then it is desirable to soak at least the first which are introduced in carbolized water, 5 per cent., or carbolized oil, 10 per cent.
Tampons are best placed with the aid of Sims's or Simon's speculum, {518} though the bivalve may also be used. If no instrument is at hand, the vagina may be distended by the fingers, which are so introduced that they separate the parts thoroughly and press down the perineum; the prepared tampons are now seized with the dressing-forceps and securely packed in the cul-de-sac and against the cervix, so that it is firmly surrounded by a compact plug; then the entire vaginal canal is similarly packed to the vulva. Hemorrhage is perfectly checked if the tampon be properly applied; if not, it ceases for a time until the cotton or other material used has been saturated, and then continues as before. If the desired object be attained, the pains will become more severe and rapid and the tampon will be expelled: upon examination the ovum will be found in the vagina or at least within the cervix, and is easily removed. It is stated that the tampon should not be left in place over twenty-four hours: this is certainly the limit, as, saturated with blood and secretions, it is liable to putrefy and thus lead to more unpleasant results. Twelve hours is, as a rule, ample time. If the vagina has been properly packed, hemorrhage is stopped and uterine contractions aroused which should be sufficient to cause dilatation and separation of the ovum. If the desired result be not accomplished at this time, it is best to remove the tampon, and, according to circumstances, introduce another or resort to other measures. After removal of tampons the vagina should always be cleansed by a disinfectant injection. If the os be found closed and uterine contractions have ceased--which is very rarely the case when the vagina has been properly packed--no further measures should be resorted to, as the continuance of gestation may be hoped for.
In case of very profuse hemorrhage the tent or vaginal tampon is necessary, but the hot antiseptic douche is but little inferior as a hæmostatic and excitor of uterine contractions. If carbolic acid is used, 2 or 3 per cent. may be added of corrosive sublimate, 1:2000, and the temperature of the water should be at least from 115° to 125° F.--if gauged by the hand, so hot that the fingers can hardly be kept in the water, at least not without moving them about. The external parts, especially the perineum, must be coated with lard, as they are particularly sensitive and liable to be scorched (vaseline washes off too easily). Emetics or purgatives, though still occasionally recommended, must not be given with a view of promoting separation or expulsion of the ovum.
Removal of the Ovum.--The tampon has been expelled by uterine contractions, and the ovum, as before stated, will probably be found within the vagina or separated and easy of removal. Should the tampon, however, have been previously removed by reason of insufficient action, the hot antiseptic douche may be tried and the vagina again packed.
Constitutional symptoms, excessive suffering, nervousness, debility, rise of pulse or temperature, necessitate immediate removal of the ovum. Under ordinary circumstances this is allowable only if the os be patulous, the cervical canal sufficiently dilated, and the ovum detached; and if the above preliminary steps have been taken, this will usually be the case in an abortion during the first three months. If the cervix permits of the introduction of the finger, a satisfactory examination may then be made if the patient be placed in the proper position, with the hips elevated, the limbs flexed, and the uterus {519} approximated to the examining finger by pressure upon the fundus with the other hand. If this be not possible by reason of thick abdominal walls, the fixation of the cervix with Engelmann or Schroeder forceps is called for. Expression is then preferable to extraction. The dressing-forceps, and even the ovum-forceps, are of but little service for this purpose unless the os be dilated and the ovum completely detached, as they are liable to rupture the sac, and thus increase the difficulty of extraction. The broad, blunt blade of my curette, Récamier's instrument, or Munde's, should be passed into the uterine cavity and swept around the entire circumference of the ovum: the uterine sound properly bent may be used for the same purpose, and if liberated it may be removed by using my instrument as a lever, placing it beneath the ovum in case of retroflexion of the uterus, and anteriorly in anteflexion, and pressing it down toward the pelvic outlet. Expression by hand is still recommended, and is very efficient in relaxed or thin abdominal walls, where both hands may be readily used for manipulation. The fingers are pressed against the uterine fundus--anteriorly in case of anterior displacement, posteriorly if the uterus is retroflexed or retroverted--whilst firm counter-pressure is made by the other hand upon the abdominal walls; the ovum being thus, as it were, squeezed out.
In later months greater dilatation is necessary, the importance of preserving the ovum intact is augmented, and the greatest care must be taken that efforts at expression are not made whilst the ovum is still adherent. I have found great difficulty in detaching the membranes, even when the canal is permeable, with the finger, as has been recommended; and it is for this purpose especially that I have found the large blade of my instrument so valuable. It is readily introduced, pliable, so that it may be bent and properly adapted, and the point of attachment being found it can be passed about the entire ovum in the same plane, loosening without rupturing; and the irritation caused by this manoeuvre is often sufficient to stimulate contractions, so that expulsion will follow. In fact, I consider this of less importance than separation, retention being mostly due to adhesions, especially at the point of placental formation. Once separated, it is a foreign body and an irritant, which is readily expelled. Nature thus teaches us the course which we must follow, to complete separation and dilatation before attempting removal.
TREATMENT IN CASES OF RETENTION OF OVUM OR MEMBRANES.--These are by far the more trying conditions, and, unfortunately, the ones to which the physician is most frequently called. Aid is not summoned at an earlier stage on account of that dangerous underrating of abortion or for fear of unnecessary expense, and the position of the practitioner is made a trying one, as he is ignorant of the state of the case. Clots of blood have passed, but as to the precise conditions he is left in doubt; whether the membranes have ruptured, whether the ovum is expelled in whole or in part, he is not told. He may find the os closed; the size of the uterus reveals but little, as in many cases, at least those of spontaneous abortion, development is retarded; it is smaller than would be supposed at that period of gestation. It is only in case the uterus corresponds at least approximately in size to the time, or if the os be sufficiently dilated, that he can at once decide positively as to the presence of ovum or membranes.
A closed internal os may usually be looked upon as evidence that the {520} retained masses, whether ovum or membranes, are adherent, though in case of sepsis more or less dilatation exists; yet in the latter case the indications afforded by those symptoms are of little importance, as the constitutional symptoms, with the character and odor of the discharge, clearly indicate the existing conditions, and consequently show the course to be pursued. No question exists as to the necessity of immediate delivery in these cases, but as to the manner of treatment in retention of ovum or membranes not disintegrating there is a wide difference of opinion: able men are still inclined to urge a reliance upon nature, yet it is a dangerous course for the practitioner to pursue: successful as it may prove in many cases, it is certainly fatal in some, and but too often followed by the insidious consequences so frequent in its tracks.
Labor at term may be left far more readily to the powers of nature than abortion: the former is a physiological process, the latter pathological. The expulsion of the ovum at term has been preceded by preparatory changes in maternal and foetal parts; the separation of the membranes is facilitated by the fatty degeneration of decidua serotina and vera; the hypertrophied uterine muscle is strained to its utmost, its fibres increased and strengthened for the ordeal, but in the early months no such conditions exist. Though expulsion has been anticipated and the preceding hemorrhage frequently serves to separate the structures, and development ceases with the death of the embryo, a retrograde metamorphosis is inaugurated only in certain cases, and then incomplete, and the frequency of intermittent abortion which we find in cases left to nature is evidence of incompetency to fulfil the task attempted: hemorrhage, more or less protracted, and contraction of the uterus cease; the ovum has been partially separated; its growth is checked, and then a retrograde metamorphosis is inaugurated in the tissues which have been in so active a state of development; this continues until a recurring menstrual period or excessive exercise brings about a renewal of the expulsive effort; and if sepsis has not taken place we usually find that the ovum is expelled with rapidity. When the attempt was first made, it proved ineffectual and the effort ceased; the tissues were impaired in their nutrition, underwent a fatty degeneration tending toward disintegration, and the second attempt of nature, with the parts properly prepared, terminates rapidly and effectually. Though the tendency of the profession at large seems toward a more expectant plan, guided by able authorities--such as Parvin, who urges attention to the old-time remedies, rest, time, and laudanum; and Leishman, who advocates this treatment when hemorrhage has stopped and the os is closed, perhaps aiding nature by the use of ergot--I would advise more active interference. It is indeed true that the ovum or some of its parts may remain in utero for months and then be expelled by a healthy effort of nature, without injury to the patient; but this is not the rule. I have seen such cases, but mostly the health of the patient is affected; even if more active symptoms, such as hemorrhage and sepsis, do not appear, subinvolution certainly follows. In cases less severe the patient is nervous, restless, suffers from insomnia, uterine colic, and occasional oozing; perhaps there is an offensive discharge,--all symptoms which are not sufficient to cause great anxiety, but we may with certainty expect them to result in serious inflammations of the uterus and surrounding tissues--metritis, thrombosis, cellulitis, {521} endometritis, peritonitis; hence why should we wait? Why allow these dangerous membranes to remain, as claimed by some, "as long as no injurious effects appear"? Why wait for these more threatening symptoms when evil results are almost certain to follow upon the retention of such masses, even though hemorrhage and sepsis be at the time wanting? I have removed thoroughly healthy, semi-organized remnants as late as the fifth month after partial expulsion of the ovum; the patients were suffering no very serious inconvenience at the time, nor did any grave consequences directly follow; yet it would have been far better for them had decided steps been taken at the time of the inaugural flow; they were forced to seek advice in some instances by reason of uterine pains and oozing, in others by profuse and sudden hemorrhage; and, though decided injuries were not at the time evident, subinvolution and uterine displacement were certainly threatened.
Various periods are mentioned as preferable for interference. Some say that there is no need for alarm if the placenta remains in utero for twenty-four or forty-eight hours, provided the patient be under observation; but the os is liable to contract, always within a week, sometimes within forty-eight hours, after preliminary hemorrhage, and it certainly is unreasonable to allow complete contraction of the os and thorough cessation of the efforts of nature to take place, with the probability of evil results before us. If the physician is called at a time when the course of abortion seems retrogressive, the os closing, and he is uncertain as to the complete emptying of the uterine cavity, he should satisfy himself of the existing condition; and there is no reason whatever to the contrary in the present era of antiseptic gynecology. He should explore the uterine cavity, determine the state of affairs, and act accordingly. The proper course is clearly indicated: retained tissues should be removed, though it is difficult to formulate precisely the conditions by which action should be guided.
The circumstances permitting of interference and removal are a patulous os, an open cervical canal, and detachment of ovum or membranes: these existing, removal is easily accomplished, and should be undertaken even though no threatening symptoms be present. The indications which at all times determine and obligate immediate removal are--a putrid discharge, hemorrhage and constitutional symptoms, debility, fever or sepsis; then immediate removal is necessary at all hazards.
Though it does not appear advisable to remove the ovum, as urged by Fehling, at once, if the tampon fails after ten or twelve hours' trial, the physician must not wait until threatening local or constitutional symptoms appear, as various evils develop insidiously long before removal is so loudly called for. There are no conditions which could, by any possibility, contraindicate immediate interference if the indications above mentioned exist--not even inflammations, pelvic cellulitis, or fixation of the uterus, as is claimed by some. The limits of active interference being given by the above indications, the practitioner must determine by the greatly-varying symptoms of the individual case, as he does upon the proper time of applying the forceps in labor at term. If parts of the ovum remain in utero, they should be removed as irritating and dangerous; and a patulous os must necessarily lead the practitioner to infer the presence of such a mass; yet this is not a constant symptom: if the os is closed and {522} the presence of membranes presumptive, he should dilate and satisfy himself as to the true state of affairs, dilatation with antiseptic precautions being entirely harmless. If remnants are found, the first step to their removal has already been accomplished in the diagnostic dilatation. This is best attained with the patient in complete narcosis and in proper position. The dorsal decubitus and Simon's speculum are preferable to the left-lateral semi-prone position, as we are better able to manipulate the uterus both externally and internally, especially to control the fundus. If the os be not too firmly contracted, the finger may be introduced when anæsthesia is established, and sufficient dilatation thus accomplished, or the scoop may be at once used without further preparation. If time is no object, the uterus is best dilated with a tupelo or carbolized sponge tent; where immediate action is indicated, the finger or steel dilator is best. Molesworth's instrument, even if ready for immediate action, is liable to dilate within the cervical and uterine cavity, remaining contracted at the point of greatest importance, the internal os. Incision with the knife, the splitting open of the cervix, is now recommended by German authors.
The tampon can be of service only where a larger mass is retained, not if the membranes alone remain. The use of the tent for the purpose of dilating is of advantage if introduced well into the uterine cavity, stimulating the muscle, so that expulsion frequently follows dilatation; but even then the curette should be used--the dull instrument--for a careful examination of the cavity. I have already stated the conditions indicating a resort to the sharp scoop, the Simon's or Sims's, or the dull curette, such as Munde's or my own. The wire loop of Thomas is too weak, and serves more for the removal of already loose masses than for the separation of the tissues, which I consider by far the most important. Where possible, it is always preferable to use the dull instrument for purposes of separation; and there is no better than Récamier's old instrument, or, in case of a large cavity, the broad blade of my own; both may be used without dilatation if the contraction of the os is not excessive. If firmer masses are found, as is frequently the case when the placental remnants have been retained for several months, Simon's sharp scoop is indicated, and the smaller size can be used without previous dilatation; the speculum is not necessary, but desirable, but for the effective handling of the instrument it is best that the patient be placed in the lithotomy position, upon the edge of the bed, the hips elevated, with a rubber cloth underneath. It is all-important that the movement of the scoop should be thoroughly controlled by the unengaged hand grasping the uterine fundus: this will serve to fix the organ well and prevent its escaping the instrument. Where the fundus is out of reach, as in retro-displacement, the Schroeder forceps, which is always of great service in bringing the uterus within reach, must be used. In case Récamier's or my own instrument is used, it is curved to adapt itself to the cavity, and, with one edge pressing firmly against the uterine wall toward the point of attachment of the membrane, it is carried around the entire space, so as to separate such adhesions as may exist, and the released membranes are then forced or pressed out with the instrument. In case the sharp spoon is used, it must be handled with great care, pressing firmly against, but not too deeply into, the uterine wall, and carried in {523} regular parallel strokes from the fundus toward the internal os. After such manipulation the cavity should be well washed out with hot water containing from 2 to 5 per cent. of carbolic acid, bichloride of mercury, borax, or permanganate of potash, either with the ordinary syringe or Bozeman's catheter; after this the entire inner surface of the uterus is touched with carbolic acid, a little cotton wrapped upon the end of an applicator and saturated with the solution answering the purpose very well.
Hot water and carbolic acid usually suffice to thoroughly contract the organ; should this not be the case, should a flabby, atonic condition exist, it is well to place a tampon of iron cotton in the cavity. The applicator is loosely wrapped with cotton of sufficient thickness to fill the cavity; this is steeped in Monsel's solution or the perchloride of iron, the superabundant fluid expressed, and then introduced. Contraction is sure to follow, and the tampon is left in place for three or four days, when it will either be expelled by the action of the uterus or it will be found, coated with healthy pus, barely held in the grasp of the muscle, and can be removed by the slightest traction: no effort should be made, as it will remain firmly fixed until a healthy granulating surface is established. It may be kept in place by a tampon of cotton carbolated, or, better still, prepared with iodoform, which is always a desirable application after interference. Ergot should then invariably be given, either by hypodermic injection or per os--if the stomach is in good condition, a teaspoonful of the fluid extract every three hours during the first day.
Putrid discharge and septic symptoms unquestionably indicate immediate interference; the method, however, remains the same. In case of beginning putrid discharge without constitutional symptoms, the dull curette is greatly to be preferred to separate the sloughing tissue from the healthy uterine structure without injuring the latter; whilst if the uterine structure itself is affected, it is necessary to resort to the sharp spoon to thoroughly remove all that is diseased.
Constitutional treatment must, of course, follow the local measures above advocated. The danger of the sharp instrument, under these circumstances, is in the possibility of lacerating healthy tissues and opening new ways for infection. It can only be used if all diseased tissue is thoroughly removed and the operation followed by cauterization with pure carbolic acid and intra-uterine injection, that all remaining particles, however small, may be washed away.
An active general treatment must accompany these local measures, but upon this I will not dwell, as it is the same which must be followed in all cases of septic poisoning. Quinine is the main stay, and in addition to the remedies in general use ergot is here indicated to further contraction and expulsion of offensive particles and close the capillary and lymphatic canals to the possibility of infection.
AFTER-TREATMENT.--It cannot be too often repeated that the danger resulting from abortion is not the immediate or primary one, but the secondary, even in case of profuse hemorrhage; it is that of anæmia, of general debility, a slow getting up. After abortion we have conditions analogous to those of the puerperium, the dangers of infection, of septicæmia, the greater liability of the system to surrounding influences, {524} epidemic, infectious, malarial; but even greater than after labor at term is that of incomplete involution with its chain of insidious consequences. In the main, the danger of abortion lies in the lightness of the affection and the indifference to after-treatment. Involution is more questionable than after labor at term, and yet time and opportunity are rarely given nature to accomplish this process of restitution. If the abortion is passed easily, the patient rarely keeps her bed, pays little or no attention to the occurrence, certainly none to her getting up, and subinvolution, by far the most frequent sequence to abortion, follows. Abortion is altogether the most prolific cause of uterine disease, in consequence of the indifference with which it is treated, not only by the patient, but by her physician. With the expulsion of the ovum and the cessation of hemorrhage the case is considered finished; even if a physician is called, proper time is not given for restitution of the parts. Although by far less is to be accomplished by the retrograde metamorphosis than after labor at full term, the parts being not so fully developed, they are not so thoroughly prepared for this restitution: retrograde metamorphosis has not been initiated with the inauguration of the abortion, as it has with the inauguration of labor at term. In the latter fatty degeneration is in progress; the tissues are prepared for the restorative process which is to follow: not so in case of abortion; hence nature must be assisted, must be allowed to perform those functions which are necessary to a healthy restoration of the sexual organs.
In the great mass of cases it is not strictly medical attention which is necessary, medical treatment, but mere ordinary care, precaution, and cleanliness on the part of the patient herself, so as to assist the efforts of nature: a week's rest in bed with healthy nutritious diet should be accorded every woman who has aborted, and this must be followed by at least one more week of quiet and confinement to the room, and not until a month after the accident has occurred should the patient resume her ordinary vocations.
I will not enter into the details of the after-treatment, as it is identical with that after labor at term. No decided treatment is called for unless demanded by symptoms peculiar to individual cases, yet ergot, quinine, and tonics are in place, and the same antiseptic precautions must be observed which are so highly appreciated in the lying-in room.
The patient must be kept in a recumbent position, the room quiet, and visitors excluded; a bed-pan must be used; the food must be easily digestible and nutritious; prepared tow or salicylated or borated cotton should be used in preference to the old-fashioned cloth to receive the discharge, and this must be changed with sufficient frequency: the parts must be washed with a lukewarm antiseptic wash, and vaginal injections of the same given as cleanliness demands, at least once a day; these should be hot (110°-120°) to further contraction. Corrosive sublimate 1:2000, carbolic acid 2:100, or boracic acid or borate of soda, serves a good purpose; intra-uterine injections are called for only in case of putrid or offensive discharge.
After the third or fourth day it is well to add an astringent, such as alum or tannin, to the hot vaginal douche, a teaspoonful to the quart, beginning with less, as some are very sensitive to these remedies, and increasing the strength if desirable.
{525} Iron and chinine are serviceable in aiding the system to regain its tone and in guarding against zymotic and malarial influences, to which it is more subject in this weakened condition. Ergot is here in its proper place: a three-grain pill of the aqueous extract should be given, at least during the first week, three times a day; I prefer this to the fluid extract in common use, which is nauseating to many. This drug, so much abused during progressing abortion and in labor before the contents of the uterus are expelled, answers an excellent purpose at this stage, and, together with the hot, astringent douche, may be relied upon to prevent subinvolution.
I can but repeat that the after-treatment should be that of the lying-in room after labor at term, modified according to circumstances, but never to be neglected, not even after the most simple cases. We must remember that it is indifference under these circumstances, under-estimation of the accident, which leads to years of suffering, by which subinvolution so insidiously destroys a vigorous constitution.
Rest, peace of mind, and quiet of body should, together with antiseptic precautions and tonic treatment, follow every abortion, intensified according to the severity of the accident. The two most important, and at the same time most neglected, features in the after-treatment of abortion, both of which are called for in even the most ordinary cases, are rest and cleanliness--rest, quiet of body and mind, to afford the proper conditions for the efforts of nature toward restitution and involution; cleanliness, antisepsis, to prevent external interference with this process and to guard the lacerated cavity of the womb, which offers so ready a receptacle for septic elements, against the dangers which threaten from without and so frequently bring about the rapidly-fatal termination of an apparently simple abortion.
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{527}
DISEASES OF THE MUSCULAR SYSTEM.
MYALGIA.
PROGRESSIVE MUSCULAR ATROPHY.
PSEUDO-HYPERTROPHIC PARALYSIS.
{528}
{529}
MYALGIA.
BY JAMES C. WILSON, M.D.
DEFINITION.--An affection of the voluntary muscles, of which the chief, and often the only, symptom is pain on movement.
SYNONYMS.--Myalgia as a general term has few synonyms. It is sometimes called myodynia. This affection has no essential relation to rheumatism or the rheumatic diathesis; therefore the common use of the term muscular rheumatism as a synonym for myalgia is an error. This error has occasioned much confusion of thought and mistaken medication, and tends to maintain the obscurity which overhangs the subject of the so-called and often miscalled rheumatic affections in general. That true rheumatic processes may extend from serous or fibrous structures to contiguous muscular masses has, in the absence of demonstration, been assumed by many writers of authority, but that acute or subacute rheumatism, with its recognized characters, ever manifests itself primarily or exclusively as an inflammation of muscle-substance is an assumption wholly without clinical or pathological support.
The term myo-rheumatism is as inapplicable as muscular rheumatism, and lacks the sanction of usage. Myositis is a term used to describe (1) an acute inflammation of muscle, often traumatic, and commonly attended by suppuration, and (2) a chronic indurating inflammatory process, not infrequently due to syphilis. Neither of these conditions resembles the affection under consideration in its clinical aspects, nor is allied to it pathologically.
As manifested in particular muscles or groups of muscles myalgia has been described under the terms cephalodynia, torticollis (myalgia cervicalis), pleurodynia (m. pectoralis seu intercostalis), lumbago (m. lumbalis), dorsodynia, omodynia, scapulodynia (m. dorsalis), etc.
This affection must, in the present state of our knowledge, be classified with the diseases of nutrition in the more narrow sense. It is not a diathetic disease.
HISTORICAL CONSIDERATIONS.--To Inman[1] of Liverpool is due the credit of having first pointed out the frequency of this malady and the ease with which it may be mistaken for other and much more serious diseases--an error in diagnosis which has been followed by serious results, especially in the case of nervous and self-centred females and other hypochondriacal persons. It cannot, however, be denied that this author, carried away by his enthusiasm, exaggerated the importance of this local {530} affection at the expense of undervaluing the frequency and significance of other painful disorders which have their origin in the nervous system. To Inman we also owe the term myalgia, which has the positive merit of embodying the idea of pain as the chief symptom of the disorder and the muscles as its seat, and the not inferior negative merit of implying no erroneous theory as to its nature and cause.
[Footnote 1: Thomas Inman, M.D., Certain Painful Muscular Affections, 1856; Spinal Irritation Explained, 1858; _On Myalgia, its Nature, Causes, and Treatment_, 1860.]
This affection is described in few even among the recent textbooks; in others it receives merely incidental mention; in the majority of them it is passed over in silence. Yet it is obvious that the descriptions of muscular rheumatism, which are rarely omitted, are based upon and refer to cases of various kinds which for the most part are not rheumatic at all, and very frequently are examples of true myalgia.
ETIOLOGY.--(A) Predisposing Influences.--Myalgia is "essentially pain produced in a muscle which is obliged to work when its structure is imperfectly nourished or impaired by disease." Hence all influences which unfavorably affect the nutrition of the muscles, all diseases which directly affect the integrity of their structure, predispose them to this affection. The defect in nutrition may be only relative to the amount of work the muscle is called upon to do, or there may be absolute malnutrition, implicating the whole body. The muscle may be impaired by a local disease which affects it alone, or it may share in morbid processes which also involve other and distant structures.
Sedentary occupations, leading as they do to poor nutrition of the muscular system from want of proper use and exercise; malnutrition from a diet deficient in amount or defective in kind, or in childhood from too rapid growth; the chronic wasting diseases; the state of convalescence from acute maladies; and, finally, degenerative diseases of the muscles themselves,--all favor the development of myalgia. Among the acute diseases which by their derangement of nutritive processes especially render those who have suffered from them liable to this painful affection of the muscles during convalescence, is acute articular rheumatism or rheumatic fever. It is this fact, taken together with the use of a misnomer, that has given rise to the view that the muscles share with the serous and fibrous structures in the lesions of that disease, and that myalgia is rheumatism of the muscles.
There is, however, over and above these defects in nutrition, an especial predisposition or idiosyncrasy, the nature of which is unknown, which renders certain individuals far more liable to suffer myalgic pain than others. This predisposition is encountered in those who have an inherited or acquired gouty habit and in those who are free from gout with perhaps equal frequency. It is not associated with a special liability to true rheumatism.
(B) Exciting Causes.--Myalgia is a local affection, and depends for its causation upon a derangement of the balance between the nutrition of the affected muscles and the work they have been called upon to do. Hence the most common exciting cause is (a) overwork pure and simple, especially overwork which brings into excessive and prolonged exercise unaccustomed muscles. Next in frequency is (b) exposure to cold, and especially to damp cold, when overheated or overfatigued. Finally (c), inevitable and incessant contractions, such as are physiological and are performed without consciousness or sensation in a healthy state of the {531} muscles, will, in muscles that are defectively nourished or have undergone fatty, granular, or fibroid degeneration, cause more or less distinct myalgia.
As examples of myalgia due to the first of this group of causes (a) I may cite the pain in the adductors of the thighs after a hard ride when out of practice; the epigastric pain in children suffering from measles or other acute affection attended with persistent cough; and the pain of spasm, in particular that which follows tonic spasm, such as occurs from reflex causes in the calves of the legs at night and in bathers. Many of the pains of childhood, which are classed in common parlance together under the name of growing pains, are myalgic in their nature.
Examples of the second form (b) may be instanced in the pains of wry neck or lumbago, such as often occur in those who, being very tired, but otherwise healthy, fall asleep in a draught of air, or in those who, coming home at evening in cold weather, find a leaking pipe in the cellar, and stooping over to stop it, or in some other emergency of every-day life, bring into excessive use unaccustomed muscles in an atmosphere that is at once cold and damp.
Examples of the third group (c) are common enough in the flying or fixed muscular pains and soreness that occur in wasting chronic diseases and in the convalescence from acute maladies when prolonged muscular effort is too early undertaken. Certain forms of præcordial pain that occur in degenerative lesions of the muscular substance of the heart are without doubt myalgic in character, and will, when the clinical data of such conditions come to be more fully understood, be recognized as having more or less diagnostic value.
SYMPTOMATOLOGY.--The chief symptom, the one symptom that is common to all the cases, is pain. It is sometimes, especially in acute cases, constant; more frequently it is very slight or wholly absent when the patient is at rest, with the affected muscles in full extension, but it is invariably present or aggravated when the muscles are called into action. It is experienced throughout the muscular mass, but is most intense at or near the point of tendinous insertion. Its character is usually stabbing or stitch-like, but prolonged; sometimes it is acutely dragging or tearing; in others it is like the soreness felt on moving a contused or inflamed part. It is frequently in acute cases, almost always in chronic cases, accompanied by a sensation of stiffness in the affected muscles. The pain is essentially the same in all cases, variations in its character and severity being determined by the opportunities afforded the muscle for physiological rest. It is in accordance with this statement that the most obstinate, and the most severe form of myalgia is that which occurs in the intercostal muscles and their fibrous aponeuroses--pleurodynia. Here the affected muscles are constantly concerned in the movements of respiration, and have no time for physiological rest except in the intervals of those movements. Scarcely less stubborn and severe are the myalgias of the great muscular masses, of which the principal function is to maintain by their nicely-balanced and ever-varying contractions the erect position of the head and trunk. Less painful and of shorter duration are the myalgias of the limbs--less painful because prolonged intervals of absolute rest may be voluntarily secured; of shorter duration, because it is by rest that the balance of the nutrition is most speedily restored.
{532} There is usually some degree of tenderness over the whole extent of the myalgic area, becoming more marked in the regions of tendinous insertion, to which it is, however, in many cases restricted. It is elicited upon moderately firm pressure, and is not associated with cutaneous hyperæsthesia.
Spasm is absent in the acute cases, except when the muscles are brought into use. Its occurrence has much to do with the intensity of the suffering then caused: in chronic cases a condition of tonic spasm or spastic rigidity, with more or less persistent painfulness, comes on, and finally in very chronic cases such tissue-changes take place as result in great impairment or absolute loss of contractile power, with or without atrophy.
Objective signs are absent, except that it is evident that the patient assumes by preference an attitude of repose, and that he keeps the involved structures as much at rest as possible. Pyrexia does not occur; the appetite and digestion are not impaired; acid sweats are not present; the urine shows no constant or characteristic alteration; there is no tendency to endo- or pericardial inflammation. If constitutional disturbance be present, it is trifling and due to prolonged local suffering and want of sleep. In by far the greater number of instances the patient remains in his usual health except the local malady.
Myalgia may affect the voluntary, and perhaps also the involuntary, muscles of any part of the body. Those most frequently involved are those subjected to continuous and excessive work, and at the same time liable to exposure to cold and damp. Single muscles or groups may be affected. The most common and important varieties are--
(1) Cephalodynia, manifested as a superficial headache, increased by movement of the scalp and attended by tenderness on pressure.
(2) Torticollis; wry neck, stiff neck--a very common form, involving the muscles of the neck, especially the sterno-cleido-mastoid. The affection is usually limited to one side, toward which the occiput is more or less firmly rotated and flexed. Great pain is experienced in attempting to turn the head in the opposite direction. The position is extremely constrained and awkward; the head cannot be moved in any direction without moving the whole body, and every effort at motion is accompanied by pain which calls forth involuntary grimaces.
(3) Omodynia, Scapulodynia, Dorsodynia--forms in which the muscles of the shoulders and upper part of the back are affected. They are very common, especially among laboring men.
(4) Pleurodynia, Myalgia of the Chest-walls.--The intercostals, pectorals, and serratus magnus may be involved. The pain is frequently referred to the region of the interdigitations of the serratus magnus with the external oblique. It is very often seated in the infra-axillary region, and is much more common on the left side. It is usually very severe, and is increased by all movements that bring the affected muscles into play. The focus of pain is sometimes a very limited spot, which is exquisitely tender upon pressure. Sometimes the pain alters its position from time to time. It is increased by deep inspiratory efforts and such acts as sneezing and coughing. Extreme flexion of the trunk from side to side also aggravates the pain. Pleurodynia sometimes comes on in consequence of severe and protracted cough, as in patients suffering with phthisis. It is then apt to affect both sides.
{533} This form of myalgia simulates pleurisy, from which it is to be distinguished only by careful physical examination.
(5) Myalgia of the abdominal walls usually affects the recti muscles, and often assumes the guise of an acute, agonizing pain in the epigastric or pubic regions--occasionally so severe as to be mistaken for peritonitis. It is sometimes due to cough, especially in measles, but is more commonly met with in overworked and underfed tailors and cobblers as a result of the excessive action of the recti muscles in maintaining the bent posture assumed by such craftsmen at their toil.
(6) Lumbago, myalgia lumbalis.--The great muscular mass occupying the lumbar region is peculiarly prone to attacks of myalgia. Lumbago is very common in the middle and later periods of life. The attack is usually sudden and severe. Both sides are, as a rule, affected, but not to the same extent. There is constant pain across the loins, dull and aching, rarely absent altogether, always sharply aggravated by such movements as bring the affected muscles into play, and then becoming stabbing in character and almost unbearable in intensity. The spine is held stiffly, and the body is often bent slightly forward. Efforts to stand erect, to rise from the sitting posture, or to recover from the stooping position, such as is assumed in lacing one's shoes and the like, greatly aggravate the pain. In the more severe cases the patient cannot stir in his bed. There is usually tenderness upon pressure, and palpation often discovers a distinct sense of abnormal tension and resistance in the muscles.
(7) The aching, dragging pain in the back of the neck common in poorly-nourished, nervous women and in other cases of neurasthenia, the so-called pain of nervous exhaustion, is myalgia. It is felt chiefly during fatigue, is present in the erect posture, and is almost always relieved when the patient lies down. It is referred sometimes to the base of the skull, sometimes to the whole of the back of the neck, but more commonly to the spinal region just above the level of the upper borders of the scapula, and constitutes a harassing symptom of the cases in which it occurs. In this connection it must be pointed out that many of the pains of that obscure condition to which the term spinal irritation has been vaguely applied are myalgic.
Myalgia manifests itself furthermore in the limbs, in the diaphragm, and occasionally in the muscles of the eyeballs.
The COURSE of the attack is in the simpler forms acute and transient; it frequently, however, becomes chronic, and not uncommonly presents the characters of the chronic form from the beginning. Again, it sometimes attacks in succession several muscles or groups of muscles, and in by far the greater number of individuals it shows a tendency to recur from time to time.
DURATION.--The duration of acute attacks is usually brief, lasting from a few hours to several days; that of the chronic form is indefinite, tending to last years, sometimes, under unfavorable circumstances, a lifetime, with varying periods of exacerbation and remission, which are, after the disease is fully established, much influenced by the phases of the weather.
The TERMINATION of acute myalgia is commonly in full recovery, but the tendency to subsequent attacks is to be borne in mind, and guarded {534} against by the exercise of wholesome precautions in the matter of hygiene. Neglected cases of chronic myalgia not rarely terminate in permanent alterations of the muscular structure, with loss of contractile power and rigidity, with or without atrophy.
COMPLICATIONS.--In the acute forms there are no complications, properly so called. In the more severe cases of the chronic form there is danger of nutritive changes in the tissues entering into the formation of joints, and loss of function from want of use.
SEQUELS.--There are no sequels other than those just pointed out.
PATHOLOGY AND MORBID ANATOMY.--As indicated by the various names by which myalgia has been known, the principal theories advanced to account for the morbid manifestations are three in number: (1) that the malady is a rheumatism of the muscles; (2) a form of neuralgia; (3) an inflammation.
(1) Muscular Rheumatism.--That this affection should be popularly associated with rheumatism is not surprising when the character of the pain is regarded, its aggravation on movement, and the temporary or permanent crippling which it occasions; especially when we call to mind the exceedingly vague and indefinite ideas which prevail in regard to rheumatism. But that it should be looked upon, far and wide, among physicians as a form of rheumatism, and described as such in the systematic works--that it should be regarded as due to the same causes as rheumatism and treated from that point of view--is certainly as remarkable as it is misleading.
Let us look at the facts. Nothing is easier: the two affections are under our daily observation side by side; in this climate and among working people few maladies are more common.
On the one hand we behold a constitutional disease with widespread manifestations--a special joint inflammation, which tends neither to the deposit of urate of soda nor to suppuration; a peculiar acid secretion from the skin; highly acid urine; a notable tendency to inflammatory heart complications; marked pyrexia. We observe also a marked disposition to recurrence and to the hereditary transmission of the diathesis.
The phenomena of rheumatism may be ill defined; that is to say, the attack may be subacute, but the features are the same; or they may linger and assume the chronic form, in which fever is replaced by a peculiar alteration in the fluids of the body, showing itself in a dull anæmic complexion and a greasy skin; but in all cases the seat of the disease-signs is in the joints; it is articular.
On the other hand, myalgia is not a general malady nor the expression of one. It is scarcely a disease at all. It is purely local. A muscle or a group of muscles, overworked, cry out, and this cry is interpreted by the sensation of pain. It is to be borne in mind that the overwork may be absolute, or merely relative to the healthfulness of the muscle at the time. In either case there is a derangement between the balance of work and nutrition in the muscle. The secretions are not altered; there is no sweating; the urine presents no abnormal conditions. Endo- and pericarditis never occur as complications; fever is absent.
The attack is often light, and quickly passes away. If it become chronic, further nutritive changes take place. The muscle becomes rigid, and often atrophies. According to Froriep and Virchow, as {535} quoted by Jaccoud[2] and Niemeyer,[3] the fasciculi are beset here and there with thickened connective tissue. Vogel observed in several chronic cases the neurilemma of the nerves supplying the part to be thickened, hardened, and adherent.
[Footnote 2: Traité de Pathologie interne, Paris, 1871.]
[Footnote 3: Lehrbuch der Speciellen Pathologie und Therapie, Berlin, 1871.]
In all cases the affection limits itself to the muscles. The joints remain free. When they undergo changes it is after a long time and as a result of want of use or of reflex disturbances of nutrition through the nervous system. Nothing is known of hereditary predisposition to myalgia. In the manifest tendency to recur in the same individual it and rheumatism are alike. In all essential points their clinical resemblance is of the most superficial kind. It is clear, then, that the processes which give rise to the phenomena of rheumatism do not directly affect the muscular system.
The credit of having first formulated this opinion, previously only vaguely recognized, is due to Roche and Cruveilhier,[4] but Valleix, Garrod, Flint, and other writers, who describe myalgia under the head of muscular rheumatism, coincide in this view. Even the statement that the two diseases are constantly associated is not borne out by the results of extended clinical inquiries. My own observation has not confirmed it. Of 7 cases[5] taken at random to illustrate a point of treatment, 1 had followed an attack of rheumatic fever; 1 occurred in an individual who had many years before suffered from rheumatism; and 5 gave no history whatever of that disease: 1 followed tonsillitis. DaCosta[6] details 2 cases of myalgia--1 in the loins (lumbago), associated with bronchitis or following it, the other occurring during an attack of rheumatic fever and having its seat in the muscles of the neck. In the latter case the constitutional disease yielded to treatment which had no effect upon the local malady. Even were the association much more frequent than it is found to be, the fact would by no means establish a common causation, seeing that myalgia follows other diseases which impair the nutrition of the body. It is worthy of note that the groups of muscles most frequently involved in cases which happen during or after acute diseases are those which must work perforce--those which maintain the equilibrium of the body or carry on respiration, etc. Hence we see wry neck, lumbago, pleurodynia associated with other diseases; affections of the muscles of the extremities after overwork pure and simple.
[Footnote 4: Dict. de Méd. et de Chir. prat., article "Arthrite."]
[Footnote 5: Philada. Med. Times, Nov. 7, 1874.]
[Footnote 6: Penna. Hospital Reports, vol. i.]
(2) Neuralgia.--Many observers have regarded myalgia as a neuralgia, having its seat in the muscles. Valleix[7] wrote as follows: "Muscular rheumatism and neuralgia have, in the correspondence of their symptoms, their course, their exacerbations, in the absence of appreciable anatomical lesions, the greatest resemblance to each other. These affections often pass the one into the other.... The pain, which is the capital symptom of neuralgia, expresses itself, according to our observation, in three ways: If it remain concentrated in the nerves, characteristic isolated painful points are found; here is neuralgia properly so called. If the pain is diffused among the muscles, muscular action is principally painful; we have muscular rheumatism. Finally, if it be spread out upon the skin, an excessive sensibility of the cutaneous surface results, and there exists {536} a dermalgia. These three forms of an affection which is the same may all be present at the same time, or two and two--neuralgia and dermalgia, neuralgia and rheumatism, rheumatism and dermalgia." No wonder he found nothing more difficult than to trace with exactitude the picture of this malady.
[Footnote 7: Loc. cit.]
Flint[8] also regards myalgia as closely allied to neuralgia, and states that, "being one of the neuroses, it has no anatomical characters." It is not difficult to trace the results of this teaching in the widespread confusion prevalent in regard to some very common painful affections, as, for example, that painful form of stitch known as pleurodynia, and the still more distressing gastrodynia. Even those observers who refuse to class these affections as rheumatic are too often at a loss as to whether they are neuralgic or purely muscular. Anstie[9] has concisely contrasted the most important characters of neuralgia and myalgia in a way that strongly urges the clinical differences between them, as follows:
NEURALGIA. | MYALGIA. Follows the distribution of a | Attacks a limited patch or patches recognizable nerve or nerves. | that can be identified with the | tendon or aponeurosis of a muscle, | which, on inquiry, will be found to | have been hardly worked. | Goes along with an inherited or | As often as not occurs in persons acquired nervous temperament, | with no special tendency. which is obvious. | | Is much less aggravated, | Is inevitably and very severely usually, by movement than | aggravated by every movement of the myalgia is. | part. | Is at first accompanied by no | Distinguished from the first by local tenderness. | localized tenderness on pressure | as well as on movement. | Points douloureux, when | Tender points correspond to established at a later stage, | tendinous origins and insertions of correspond to the emergence of | muscles. nerves. | | Pain not materially relieved by | Pain usually completely, and always any change of posture. | considerably, relieved by full | extension of the painful muscle or | muscles.
[Footnote 8: Practice of Medicine.]
[Footnote 9: Neuralgia and Diseases that Resemble it.]
(3) Inflammation.--That the muscular affection under consideration should have been referred to morbid processes of an inflammatory kind is very natural. The use of the term myositis embodies this view, which is held, among others, by Garrod. This author defines muscular rheumatism as "an affection of the voluntary muscles of an inflammatory nature (?), but unaccompanied with swelling, heat, redness, or febrile disturbance." He assigns the combined influence of cold and damp as a cause, especially when associated with over-use of the muscles.
Though some of the gross characters of inflammation are wanting, and the course of acute cases of myalgia is toward a speedy resolution, there are several features of the affection which strongly suggest its inflammatory origin. At all events, the view that the essential pathological conditions consist in a hyperæmia with slight serous exudation, or a partial paralysis of vaso-motor nerves with escape of serum into the intimate tissues of the muscles, has, from a clinical standpoint, much to support it. In the absence of knowledge derived from the actual investigation of the morbid tissue-changes in all the stages of the affection some {537} value is to be accorded to the following facts as confirmatory of this opinion:
It is a local affection; the onset is usually sudden; there is often, from the beginning, a slight but obvious fulness of the muscle; tenderness is present as well as pain; in chronic cases inflammatory increase of connective tissue occurs, with changes in the nerve-sheaths and fatty degeneration of muscle-substance. Moreover, the permanent contraction (contracture) which sometimes finally sets in is the same as that which follows true inflammation of muscles after injuries (traumatic myositis[10]).
[Footnote 10: Erb, Ziemssen's Cyclopædia, vol. ix.]
It is uncertain whether the nerves supplying the muscles are thrown into morbid action by changes in the muscular fibres and in their sarcolemma, or by simultaneous changes in their own neurilemma. However it arise, irritation of sensory nerve-twigs is present, giving rise to pain, along with irritation of motor filaments, which occasions spasm.
It is probable that the ultimate cause of the irritation within the muscular mass, whatever it is, is common to all cases, and that when myalgia occurs in a healthy man after extraordinary muscular effort or exposure to cold damp when fatigued, or in a delicate child who has played too long, or in a poorly-fed weaver working long hours over his loom, or in the consumptive whose cough gives him no rest, or in connection with any chronic disease or acute disease, whether tonsillitis or bronchitis or fever or rheumatism, it is the same thing--the expression of muscles or groups of muscles overworked. It is not a disease; it is not a symptom of disease. It is an accident of many diseases--of any disease that lowers nutrition. And it is not less an accident of health when such muscular effort is demanded as is beyond the capacity of health.
The essential pathology of myalgia is obscure. It is not an inflammation, as that term is generally understood, but there is ground for the opinion that the lesions are of the nature of a subinflammatory process within the muscle. The not uncommon instances in which an injury or contusion--in short, traumatism--has been followed shortly after the recovery by severe myalgia are of further value as illustrating this theory.
The obstacles in the way of precise histological investigation in cases of acute myalgia are so great that it seems probable that further knowledge is to be reached for the most part by way of clinical work.
DIAGNOSIS.--The fundamental question for consideration in this place is whether we are dealing in any given case with local manifestations of a constitutional disease or with purely local phenomena. That the latter is the correct view seems to the writer to admit of no further discussion in this article. This position being assumed, and due regard having already been paid to the differential diagnosis between myalgia and rheumatism, neuralgia and inflammatory myositis, it seems useless to enter upon the consideration of the diagnosis between this and other painful affections to which it bears but slight and superficial resemblances. Spinal irritation, hypochondriasis, locomotor ataxia, alcoholism, syphilis, gout, and lithiasis are on the one hand attended by pains which are clearly not myalgic in character, and on the other hand peculiarly predispose those subject to them to this affection of poorly-nourished and easily-overworked muscles. Each of these diseases, however, presents a complexus of {538} symptoms in which that which is essential and characteristic is readily to be distinguished from that which--as myalgia--is accidental.
A few words concerning the diagnosis of some of the varieties may not be amiss.
In pleurodynia the ordinary physical signs of pleural, pulmonary, and cardiac disease are absent, the painful points characteristic of intercostal neuralgia are not found, and there is little or no constitutional disturbance.
The diagnosis of myalgia lumbalis is, as a rule, unattended by difficulty. The muscular pain in the loins is characteristic. It is greatly increased by efforts to rise or to turn in bed, and is associated with diffused slight tenderness upon pressure, but never with the acute localized soreness of neuralgia or abscess. The practitioner must, however, guard against the danger of mistaking the back pains of more serious affections for lumbago by the careful examination, in all cases, of the back and abdomen, and by the investigation of the condition of the urine. The possibility that pain in this region may be caused by spinal meningitis, lumbar abscess from spinal caries, sciatica, inflammatory affections of the hip-joint, renal calculus, perinephritis, abdominal aneurism, diseases of the pelvic viscera, and the onset of certain of the acute infectious diseases must not be overlooked.
PROGNOSIS.--Under satisfactory conditions as regards hygiene and treatment the prognosis is always favorable. It becomes in chronic cases unfavorable as regards complete recovery when by reason of poverty, unhealthy occupations, unwholesome surroundings, or established wasting diseases the nutrition of the muscles and their physiological rest are permanently interfered with, and the balance between their power and work permanently deranged.
TREATMENT.--The indications are threefold: (a) relief of pain; (b) physiological rest for the affected muscles; (c) restoration of the balance between the nutrition of the muscle and the work it has to do.
(a) Relief of pain is often secured by rest in a posture that permits the complete relaxation of the muscles involved. In acute cases due to overwork pure and simple, and where complete rest is attainable, little other treatment is required. In the course of a few hours or days the function of the muscles is fully restored and their contractions are performed without pain. Where, however, complete muscular relaxation is impracticable or fails to afford relief, anodynes are necessary. Morphine hypodermically is very useful, but this altogether independently of any local action. Continuous dry or moist heat by means of flannels, flaxseed poultices, spongio-piline, etc. may be applied. Various anodyne lotions are useful. Liniments containing aconite, belladonna, chloroform, or chloral also afford relief. The compound belladonna liniment of the British Pharmacopoeia is especially to be recommended. So also are plasters of belladonna, conium, and mustard. Galvanism occasionally gives prompt relief. The same statement may be made of the use of static electricity. The pain sometimes disappears under gentle and long-continued massage.
(b) Rest is usually enforced by the intensity of the pain attending movement. In severe cases the bed is a necessity. In affections of the respiratory muscles, as pleurodynia, firm support of the side, by means of {539} overlapping strips of plaster drawn from the spine downward and forward in the direction of the ribs to the median line in front, is sometimes necessary and always comfortable.
(c) The balance of nutrition is restored by rest. Local means to further this end are such as relieve pain--heat, anodyne and stimulating frictions, massage, and galvanism. The parts must be protected from sudden changes in temperature by extra thicknesses of flannel or sheets of wool or cotton batting--if necessary covered with a piece of oiled silk or fine gum-cloth. In old cases prolonged massage with passive movements, shampooing, and the slowly interrupted galvanic current, alternating with rapid faradic currents, are followed by good results.
As a constitutional measure a Dover's powder at night, followed by mild purgation in the morning, is often indicated. Purgation is especially called for in plethoric or gouty persons, in whom also Turkish or vapor baths are of great service, while poorly-nourished, anæmic subjects demand quinine, iron, lime, and cod-liver oil. If the attack linger, full doses of ammonium chloride, and in old cases potassium iodide in moderate doses well diluted and long continued, are advocated; and in stubborn cases Anstie recommends deep acupuncture of the muscle near its tendinous attachment. In cases marked by a tendency to spastic rigidity the repeated hypodermic injection of atropine may often be relied upon as the speediest means of cure.
Where the general nutrition is poor the local trouble is apt to be obstinate, and often yields only to measures that restore the general health.
{540}
PROGRESSIVE MUSCULAR ATROPHY.[1]
BY JAMES TYSON, A.M., M.D.
[Footnote 1: From the view taken by the author as to the nature of the disease under consideration, it is evident that its proper position would be under affections of the nervous system. But as this view has not been established to the satisfaction of all who have studied the disease, it seems appropriate to place it in the intermediate position selected for it by the Editor, between muscular and nervous diseases.]
SYNONYMS.--Chronic anterior poliomyelitis; Spinal form of progressive muscular atrophy; Adult form of progressive muscular atrophy; Wasting palsy (Roberts); Cruveilhier's atrophy; Amyotrophia spinalis progressiva (Erb).
DEFINITION.--Progressive muscular atrophy is a gradually progressive wasting of a group or groups of voluntary muscles, independent of primary functional inactivity and of local lesion to nerve or muscle.
HISTORY.--We are indebted to William Roberts[2] for the best historical account of this disease up to the date of publication of his monograph. Van Swieten seems to have described the first case, in 1754, but without comment. Cooke in his work On Palsy,[3] published 1822, relates a case which had been under the care of Cline--that of an officer, first attacked in 1795. Caleb H. Parry[4] reported another case in 1825, and Sir Charles Bell[5] three cases in 1830. Abercrombie described a marked case in 1828,[6] Dorwall[7] three striking cases in 1831, and Herbert Mayo[8] two evident cases in 1836. In 1849, Duchenne presented to the Institute of France his memoir on Atrophie musculaire avec Transformation graisseuse. In the next year Aran published his essay entitled Recherches sur une Maladie non encore décide du Système musculaire (Atrophie musculaire progressive),[9] in which he claimed priority in description. He reported in all eleven cases, and regarded it as a primary muscular affection. Aran's researches were very important, and have caused his name to be intimately associated with the disease along with that of Duchenne.
[Footnote 2: An Essay on Wasting Palsy, London, 1858.]
[Footnote 3: London, 1822, p 31.]
[Footnote 4: Collected Works, London, 1825, p. 523.]
[Footnote 5: The Nervous System of the Human Body, London, 1830.]
[Footnote 6: On the Brain and Spinal Cord, 1828, p. 419.]
[Footnote 7: London Medical Gazette, vol. vii., 1830-31, p. 201.]
[Footnote 8: Outlines of Human Pathology, London, 1836.]
[Footnote 9: Archives générales de Méd., t. xxiv., Sept. and Oct., 1850.]
Cruveilhier's studies were commenced as early as 1832, but his results were not published until March, 1853,[10] when he read his memoir before the Academy of Medicine of Paris. He seems to have made the first autopsy, and was much surprised at the absence of any apparent lesion of the {541} spinal cord. So enthusiastic and so exhaustive was his study of the disease that his name, too, has become almost inseparably associated with it, and the term Cruveilhier's atrophy is one of those by which it is known. He concluded from his earlier autopsies that the lesions were solely in the muscular system, which is progressively destroyed, while the brain and spinal cord may remain perfectly normal. In a later case (his third), terminating January, 1853, he found atrophy of the anterior roots of the spinal nerves, and then concluded that the disease resided "not in the muscles themselves, but in the anterior roots of the spinal nerves." But after the termination of his fourth case, in which an autopsy was also secured, he placed the primary lesion in the gray matter of the cord, whence he considered the anterior roots take their origin.
[Footnote 10: Ibid., May, 1853, p. 561.]
Thouvenet,[11] an interne of Cruveilhier's, published in 1851 a thesis based on some cases collected in the Charité, and was the first to claim that the disease resides primarily in the peripheral nerves, and that it must be classed among rheumatic affections.
[Footnote 11: Gaz. des Hôp., Nos. 143 and 145, 1851.]
In December, 1851, E. Meryon[12] read a paper before the Medico-Chirurgical Society of London entitled "Granular and Fatty Degeneration of the Voluntary Muscles." His observations appear to have been made quite independently of any preceding researches. He argues that the primary morbid change is a default of nutrition in the muscular fibres.
[Footnote 12: Med.-Chir. Trans., vol. xxxv. p. 73.]
Subsequently, cases were published in 1853 by Bouvier, Landry, Burg, and Niepce in France; in 1854 by Chambers in England, Guérin and Robin in France, Cohn, Virchow, and Betz in Germany, and by Schneevogt in Holland; in 1855 laborious essays were published by Oppenheimer, Wachsmuth, and Eisenmann, and cases by Hasse, Valentiner, Virchow, Meyer, and Diemer in Germany, and Gros in France. Duchenne's work on Local Application of Electricity, also published in 1855, contains much information on the subject.
Since 1855 the reports of cases and papers on the subject have been so numerous as to make it unprofitable to enumerate them. Among the most notable are those of Eisenmann, published in Canstatt's Jahresbericht for 1856; Roberts's classic work on Wasting Palsy, in 1858; the papers of Lockhart Clarke in 1866 and 1867,[13] and of Swarzenski in 1867;[14] Kussmaul's clinical lecture[15] and Friedreich's treatise[16] in 1873; and Eulenburg's article on "Progressive Muscular Atrophy" in Ziemssen's Cyclopædia of Practical Medicine, published in German in 1875 and in English in 1877. An important case, in consequence of the careful post-mortem study of the nervous tissues, is one recently reported by Wood and Dercam.[17]
[Footnote 13: Med.-Chir. Transactions, xlix., 1866, p. 171, and l., 1867, p. 489.]
[Footnote 14: Die Progressive Muskelatrophie, Berlin.]
[Footnote 15: "Ueber die fortschreidende Bulbärparalyse und ihr Verhältniss zur progressiven Muskelatrophie." Sammlung klinische Vorträge, liv.]
[Footnote 16: Ueber progressive Muskelatrophie, über wahre und falsche Muskelhypertrophie, Berlin, 1873.]
[Footnote 17: Therapeutic Gazette, March 16, 1885.]
ETIOLOGY.--The cause of this affection in a large number of cases is quite unknown. That hereditation plays an important part seems well determined by numerous observations, among which may be mentioned those of Roberts, Friedreich, Hemptenmacher, Trousseau, Meryon, {542} Eulenburg, Sr. and Jr., Naunyn,[18] Hammond, and Osler.[19] In the Farr family, reported by Osler, 13 individuals in two generations have been affected, 6 females and 7 males--a larger proportion of the former than is common in this disease. Of these 9 had died at date of publication of paper. With the exception of two, all occurred or proved fatal after the age of forty. Of the 10 instances in the second generation, 5 are the offspring of males and 5 the offspring of females. The disease has not yet appeared in the third generation, which promises between forty and fifty individuals, several of whom are over thirty years of age.
[Footnote 18: Berliner med. Wochenschrift, Nos. 42 and 43, 1873.]
[Footnote 19: Archives of Medicine, vol. iv., No. 3, Dec., 1880.]
The over-use of the muscles involved seems to be a well-determined cause in certain cases of true muscular atrophy. The following interesting illustrations are given by Eulenburg:[20] Betz observed atrophy of the side three times in the cases of smiths and saddlers, who had to do heavy work with the right hand; Gull, in a tailor after excessive exertion; Hammond reports a case apparently due to excessive use of one thumb and finger in playing faro; Friedreich, one of a dragoon who may have exhausted his left hand in holding the bridle while riding; another in a morocco-leather worker, who used to press hard with his left hand; and a musician who played several hours a day on the bass viol. Schneevogt names two cases of primary atrophy of the shoulder-muscles, especially of the deltoid of the right side--one of a sailor who had to pump for days together on a leaking ship, and the other of the left side in a woman who always carried her child on the left arm while suckling it. Continued threshing and the handling of a musket have both been followed by it in the muscles called into play by these exercises. Roberts was able to trace the effects of over-muscular exertion in producing the disease in 35 out of 69 cases. As a determining cause, at least, therefore, we must admit the over-use of muscles.
[Footnote 20: Op. cit.]
There is reason to believe, too, that this form of atrophy is one of the consequences of senility--that the tendency to connective-tissue overgrowth which characterizes old age operates to produce, in a way to be presently explained, an atrophy of groups of muscles. In a woman aged seventy, now under my care, the fingers of both hands are clawed--became so inappreciably almost, and the condition is still increasing.
In addition to the above-named causes, long-continued exposure to cold, and especially to the action of very cold water, has been named. Traumatic influences, such as injuries to nerve and muscle, have been called upon to account for localized and progressive atrophy, but these are excluded by our definition from the category of true progressive muscular atrophy.
Cases have also occurred in the course of convalescence. Typhoid fever, rheumatism, measles, scarlet fever, cold during salivation, vaccination, childbed, excessive venery, syphilis,--have all been held responsible for a certain number of cases.
AGE AND SEX.--In examining the literature of acute muscular atrophy it is found that cases are reported at all ages. Thus, Wachsmuth, quoted by Eulenburg, found among 49 cases 13 under the age of fifteen, 8 from fifteen to twenty, 22 from twenty to fifty, and only 6 over fifty years. On the other hand, Roberts--who, following Aran, divides the disease into the general form and partial form--says the latter very rarely falls on {543} individuals under adult age or over fifty, while the average age of the instances of the partial form studied by him was thirty-two years and four months. In 10 instances of the general form the patients were under twelve, and 2 more are reported as children; 1 was said to be sixty-nine and another fifty-four, the average being twenty-eight years and three months. Of Eulenburg's own cases, 7 acquired the disease before the age of ten, 6 before the twentieth year, 2 before the thirtieth, 8 before the fortieth, 5 before the fiftieth, and none later. The latter observer also finds that whenever the disease is hereditary it occurs earlier, usually before the close of the twentieth year. This was certainly not the case in the Farr family, reported by Osler.
I am inclined to believe, especially in the light of Charcot's[21] and of Erb's[22] recent studies, that the true spinal form of progressive muscular atrophy is a disease of adult life, and that the majority of cases reported as occurring in early life are instances either of what Erb calls the juvenile form of progressive muscular atrophy or of pseudo-hypertrophic paralysis.
[Footnote 21: "Revision nosographique des Atrophies musculaires progressive," Le Progrès méd., No. 10, 1885, i. 314-335.]
[Footnote 22: "Ueber die Juvenile Form der Progressive Muskelatrophie und ihre Beziehungen zur sogenannten Pseudohypertrophie," Deutsches Archiv für klin. Med., xxxiv. 1884, S. 467.]
As to sex, males predominate. Thus, according to Friedreich's statistics, out of 176 cases but 33 were females, or about 19 per cent. Of Roberts's collection of 99, 84 were males and 15 females. Of 28 cases noted by Eulenburg, 17 were in men and 11 women. This is doubtless owing to the fact that men are subjected to the causes of the disease more than women. For Roberts early noted that women who engage in needlework, washing, and household service are apparently not less liable than men similarly employed, and he found that of those whose labor did not press excessively on any particular sets of muscles females formed even a majority of cases.
Some singular freaks of selection have presented themselves in the matter of sex, particularly in the cases which have been ascribed to hereditation. Thus it will sometimes attack only the male members of a family. A remarkable instance of this was observed by Meryon, in which four sons were attacked and six daughters remained unaffected; and, again, two boys were attacked and two sisters escaped. This may occur also independent of hereditation. Occasionally the reverse takes place, the sisters only being attacked, while the brothers escape.
PATHOLOGICAL ANATOMY AND HISTOLOGY.--Two principal seats of change have been found to exist in connection with progressive muscular atrophy. The first and easiest recognized is, of course, the alteration in muscles; the second, that in the nervous system.
The muscular change is simple, and affords a typical instance of what is known as numerical atrophy. The muscular fasciculi one after another undergo fatty metamorphosis, succeeded by absorption of the resulting fat and substitution of connective tissue. The rate of atrophy varies, but sooner or later the muscle is more or less substituted by fibrous bands and cords, over which may be traced reddish lines which represent muscular tissue in a normal state.
The rationale of these changes has not been always the same. The {544} older observers regarded them as the result of a primary fatty metamorphosis of muscular fasciculi, followed by absorption of the resulting fat. Later it was asserted that the atrophy is secondary to a myositis or inflammation of muscle, beginning as a hyperplasia of the interstitial connective tissue in its finest ramifications between the single primitive fibrils. Along with this are seen the results of irritation in the primitive bundles themselves, shown by swelling and multiplication of the muscular corpuscles, proliferation of their nuclei, and sometimes cloudy swelling. Even hypertrophied muscular fasciculi and dichotomous and trichotomous subdivision have been noted by Friedreich.
It sometimes happens that the hyperplastic process in the intermuscular connective tissue is succeeded by a fatty infiltration of the cells of the connective tissue, and there results a lipomatosis which is invariably outside of the muscular fasciculi and between them. This gives rise to an appearance of hypertrophy which is only apparent, for the muscular fasciculi are themselves wasted, and proportionally paralytic. This is seen to occur particularly in the muscles of the calves of the legs, in which is produced an appearance identical with that in the disease known as pseudo-hypertrophic muscular paralysis, with which, indeed, the condition under consideration is considered by some identical. But although we must admit in certain cases a complication of a certain degree of lipomatosis with progressive muscular atrophy, the two diseases are essentially different; and it is quite likely that in some instances pseudo-hypertrophic muscular paralysis has been mistaken for progressive muscular atrophy.
The changes in the nervous system are not nearly so simple. They have been noted in the peripheral nerves, both in their trunks and in their intermuscular branches; in the anterior roots of the spinal nerves; and in different parts of the spinal cord, including the central gray matter, the antero-lateral and posterior columns; also in the sympathetic system. These nerve-changes are not simultaneous, nor have they been discovered in every case. It is a noteworthy fact, however, that as methods of examination have improved and the manipulative skill of observers has increased the number of negative cases has diminished.
First, as to alterations in peripheral nerves in their ultimate distribution: The character of these is of a kind usually described as irritative; that is, there is a hyperplastic process in the connective-tissue sheaths (neurilemmæ) and their internal prolongations, consisting in nuclear proliferation and thickening of the tubular membrane or sheath of Schwann. Varicose distortion of the medullary sheaths and their subsequent disappearance, together with destruction of the axis-cylinders, also occurs.
The changes in the peripheral nerve-trunks, as studied in the median, ulnar, radial, and musculo-spinal, are essentially the same, resulting in thinning of the diameters of the nerves. These changes, however, are by no means constant.
The anterior roots of the spinal nerves exhibit alterations in a large number of instances. Cruveilhier called attention to them in the celebrated case of the rope-dancer Lecomte. At the autopsy, the brain, the cord, and posterior roots were found normal, but the anterior roots, from the point of exit to where they unite with the posterior, were greatly atrophied. In another case the anterior roots were to the posterior in thickness, in the cervical region, in the ratio of 1:10, while the normal ratio is 1:3; {545} in the dorsal region as 1:5, while the normal is as 1:1½ or 2. The posterior roots, brain, and cord were again unchanged. Up to 1876, Eulenburg had collected 26 cases in which this alteration existed, and 19 in which it was absent. In the case of Wood and Dercum, referred to, this atrophy of the anterior nerve-roots existed, making 27 positive cases and 19 negative.
We come, finally, to the spinal cord as the seat of changes, and we are met by Eulenburg's statistics, according to which, up to the date of his article, there were 34 cases of positive disease and 15 negative. To the former we have again to add the case of Wood and Dercum, making 35 against 15. These alterations are by no means constant as to seat and character. Thus, Valentiner, who seems to have been the first after Cruveilhier, in 1853, to record any, found in 1855, in the centre of the cord, in the neighborhood of the three lowest cervical and upper dorsal nerves, that the elements in the region of transition from gray to white substance were obliterated, and the softened place contained numerous compound granule-cells. Schneevogt also found a softening of the cord from the fifth cervical to the second dorsal nerve, Frommann described a red softening from the medulla oblongata downward, involving chiefly the anterior and lateral columns, and especially the commissures and the innermost parts of the anterior columns lying next the commissure.
Luys found the gray matter in the neighborhood of the cervical enlargement full of hyperæmic vessels, which were surrounded with granular masses (compound granule-cells?). The same granular masses, together with numerous corpora amylacea, were scattered throughout the gray substance. The ganglion-cells of the anterior cornua had almost disappeared in the part affected, and appeared to be replaced by the granular masses. Here and there a few ganglion-cells could be recognized in a state of retrograde metamorphosis, pigmented and bereft of their polar prolongations. In this case the degeneration affected principally the left anterior cornu, and it was the left side of the body which was affected by the atrophy. The anterior roots of the spinal nerves on the left side were also atrophied. Lockhart Clarke found essentially the same changes in no less than six cases, and Duménil, Schueppel, Hayem, Charcot (six or seven autopsies), Joffroy, and lately Wood and Dercum,[23] have added others. The last two observers found changes in the lower portion of the cervical enlargement of the cord, and state in the report of their case that "in the anterior cornua of the gray matter there is a marked diminution in the number of nerve-cells. Of the three groups of these cells, the anterior has almost entirely disappeared, the lateral group is represented by but a few individual cells, while the internal group seems to have undergone a less marked change. All of these cells, with the exception of a few in the internal group, appear shrunken, and are evidently much diminished in size. They have lost in great part their polygonal shape, many of them being fusiform, and present but few processes. Only in the internal group are these cells in any way approaching the normal type, and these are few and seen in only a few of the sections. They present the characteristic size and numerous processes of the typical motor-cell, while they disclose a well-defined nucleus and nucleolus. In the atrophied cells the nuclei can only be distinguished with difficulty.
{546} "The neuroglia of the anterior cornua is increased in amount; the vessels appear shrunken, with thickened walls and large perivascular lymph-spaces.
"In the lumbar cord the cells in the anterior cornua appear normal: in this respect the lumbar cord is in marked contrast with the cervical."
[Footnote 23: Loc. cit.]
Another class of cases recorded by Gull,[24] Schueppel and Grimm, Hallopeau and Westphal, consist in dilatation of the central spinal canal with more or less complete destruction of the gray substance, and in Grimm's case hyperplasia of the connective tissue in the white substance along with increase of the axis-cylinders. The nerve-roots were in a state of fatty degeneration, especially the finer fibres of the anterior roots.
[Footnote 24: Guy's Hospital Reports, 1862.]
Still another set of observations discovers a degenerative atrophy of the white columns only of the cord, sometimes the antero-lateral columns and sometimes the posterior. Virchow, Friedreich, and Swarzenski each found typical gray degeneration of the posterior columns, in one instance recognizable by the naked eye. Atrophy of the antero-lateral columns was noted by Frommann and Baudrimont; atrophy of the antero-lateral columns, conjoined with inflammatory changes in the gray substance and atrophy of ganglion-cells, by Duménil; changes in the antero-lateral gray substance and posterior columns by Clarke. Changes have even been found in the posterior cornua and posterior nerve-roots in a few cases, although not confined to them.
Finally, the lesions of this singular disease have been sought also in the sympathetic, and not without some success. Eulenburg's analysis discovered 5 positive observations and 14 negative ones. To the positive must be added the case of Wood and Dercum, who reported a marked increase in the amount of connective tissue and a granular state of the ganglion-cells without diminution in number. Among the changes in the sympathetic were thinning of its trunk and of the two upper ganglia observed by Swarzenski, and advanced fibrous fatty change of the cervical and thoracic portion, with abundant hyperplasia of connective tissue, disappearance of nerve-fibres and regressive metamorphosis of ganglion-cells by Duménil.
PATHOGENY.--We come now to consider the relation of these changes to the muscular atrophy which constitutes the conspicuous symptom of the disease. There are three possible views of the pathology of this affection. According to one, it is a muscular or myopathic disease in the strict sense of the term. Such muscular disease may be primarily inflammatory, a myositis--as Friedreich sought to prove in his great work--followed by fatty metamorphosis of the sarcous substance and subsequent absorption of the fat; or it may be a simple fatty metamorphosis. According to a second view, it is primarily an affection of peripheral nerves or of the anterior roots of the spinal nerves, with secondary muscular atrophy. According to a third, it is a disease of the spinal cord, and more particularly of the anterior cornua of the gray matter--a poliomyelitis anterior.
A careful study of the morbid conditions as described in the various cases reported leads me to adopt the last view. In the first place, the number of instances of positive disease of the spinal cord exceed those of any other seats of alteration, and although the changes do not always involve the anterior cornua, yet it will be noted, from an examination {547} of the foregoing paragraphs, that a decided majority involve either the anterior cornua alone or these in connection with the antero-lateral columns, the number of cases of disease of the antero-lateral columns alone or of the posterior columns and posterior nerve-roots being very limited. Again, the number of instances in which lesions of the anterior cornua are found increases as our means of accurate investigation improve.
If we add to these considerations the fact that the symptoms are best explained by such a view, little more seems required to establish it. Recalling the well-known observation of Waller, confirmed by Bernard and others, that after section of the anterior root of a spinal nerve the distal end wastes, while the central end remains intact, because it is still connected with its own trophic centre, we have in this the explanation why atrophy of the anterior roots is also so common a symptom in progressive muscular atrophy. The fibres of the anterior roots arise from the cells of the anterior cornua, and disease of the latter must unfavorably influence the nutrition of the former; hence their atrophy. This atrophy of motor nerve-filaments is continued into the mixed nerves distributed to muscles, but is less easily demonstrable by reason of the gradually diminishing size of the nerve-trunks and by the fact that they are united in the mixed nerve with the sensory fibres from the posterior roots, which do not suffer atrophy. In consequence of the degeneration of these nerves follows degeneration of the muscles to which they are distributed, so that the alterations in the latter are altogether secondary.
From this point of view the disease in question is to be regarded as a chronic form of poliomyelitis anterior, while the essential infantile paralysis of Rilliet and Barthez would correspond to the acute form of the disease.
The association of changes in the anterior roots with others in the spinal cord may be explained either on the ground of extension by continuity to adjacent parts, or on that of coincidence. In illustration of the latter I may refer to a case recently reported from Mendel's clinic[25] in Berlin, in which the symptoms of progressive muscular atrophy were associated with those of tabes dorsalis or progressive locomotor ataxia. Here it is not unlikely that the coincidence is merely accidental; and this was Mendel's opinion in this case. In other instances the involvement of other portions of the spinal cord may be a result of an extension of the disease from its true seat, while many cases described as progressive muscular atrophy are not such at all, but are in part the result of other affections of the spinal cord. It is evident, also, that this order may be reversed, as in a case reported by Eulenburg[26] to the Berlin Medical Society.
[Footnote 25: Philada. Medical News, Sept. 12, 1885, p. 188.]
[Footnote 26: Berliner klin. Wochenschr., No. 15, April 13, 1885.]
SYMPTOMS.--The first distinctive symptom of the disease under consideration is the muscular atrophy or wasting. However general it may subsequently become, it is at first localized. The upper extremity is by far the most frequently involved--7 out of 9 times in Aran's cases. Sandahl out of 62 cases found the right upper extremity attacked 37 times, the left in 14 instances, and both in 11. In Friedreich's statistics it occurred first in the upper 111 times out of 146, while the lower was invaded 27 times, {548} and the lumbar muscles 8. Most frequently it begins in some muscle or group of muscles in the right hand, either the interossei or those of the ball of the thumb. Of the interossei, the external interosseus is usually the first affected. Thence it extends to the other interossei, and soon very striking depressions make their appearance between the metacarpal bones, and the extensor tendons on the dorsum, and the flexors in the palm become as distinct as if dissected out. Succeeding this follows contraction of the flexor tendons until the picture seen in Fig. 32 is produced, in which 1 exhibits the anterior surface of the hand, and 2 the posterior.
Opinion is not unanimous as to whether the atrophy when beginning in the hand involves first the thenar muscles or the interossei. Roberts, Wachsmuth, and Friedreich say that it begins, as a rule, in the thumb; Eulenburg, that it invariably begins in the interossei. From the interossei it may creep up the forearm, and thence to the arm, or it may skip the forearm and pass into the arm, although the triceps extensor muscle is usually spared. It may come to a standstill in either of those places, but may involve the muscle of the shoulder, especially the deltoid. When the latter and the arm are involved, a picture like that of Fig. 33 is produced.
Beginning most frequently in the right, both upper extremities become sooner or later involved.
In other instances in which the upper extremities are previously involved the atrophy begins in the shoulder, in the deltoid--here again the right first. Succeeding the deltoid, the scapular and trapezius muscles may be involved in any order, while a grotesqueness of effect is often produced by reason of certain adjacent muscles retaining their natural size or even being hypertrophied. This is particularly the case with the anterior part of the trapezius, which is almost never involved. With the shoulders first affected, the arm and forearm may retain their usefulness and strength; but the power of lifting the arm from the side, and especially of raising it above the head, is lost. And if the patient wishes to lay hold of anything, he must swing his arm forward with a jerk until it is brought in reach of his fingers, and then it must often be caught up by the pathologically hooked terminations of these.
The muscles of the trunk do, however, become at times involved--the pectorales, the latissimi, serrati, and intercostales, and even the {549} diaphragm and abdominal and lumbar muscles. Life is seriously jeopardized when the intercostals and diaphragm are affected, in consequence of interference with respiration. If the intercostals cease to contract, the upper part of the thorax ceases to move, and if the diaphragm is involved, the epigastric and hypogastric regions are drawn in during inspiration, and talking and singing are interfered with. Even a mild bronchitis is apt to be fatal in consequence of the difficulty in expelling the secretions.
The muscular atrophy thus produced is generally accompanied by a corresponding wasting and retraction of the skin, so that this continues applied to the muscles in the usual manner. In some instances, however, this is not the case, and in these a baggy condition of the skin is added, which gives its subject an appearance which has more than once rendered him valuable to the showman as the elastic-skin man, etc. It sometimes happens, on the other hand, that the atrophy is obscured by an accumulation between the muscle and skin of adipose tissue, and an appearance of hypertrophy rather than atrophy may be produced in consequence, analogous to the same state of affairs in pseudo-hypertrophic paralysis, the relations of which disease to progressive muscular atrophy will be considered under the head of Diagnosis.
At almost any stage the disease may come to a standstill, and may continue thus for many years. The time required to attain its various degrees also varies greatly, but the spread is usually slow, requiring, as a rule, years for its completion. A general involvement of the voluntary muscles of the entire body is exceedingly rare.
As stated, the disease may begin in the lower extremity, but much more rarely. It is very seldom that the same order of invasion pursued in the upper extremity is followed in the lower--that is, beginning with the interossei. It may begin in the thigh and involve it alone, or extend to both {550} thighs, or both legs as well. Under these circumstances weakness of the legs is a striking symptom, the patient being unable to stand, often falling down or requiring a cane or crutches to assist him. In illustration of this mode of invasion may be related one of Roberts's cases, that of an adult woman thirty-eight years old, a domestic servant, in whom at thirty-six was perceived a weakness in the right thigh. She first noticed that it grew tired sooner than the left. This gradually increased, until she was compelled to sit much of the day, then to use a stick, and finally crutches. This was accompanied by a gradual wasting of the thigh-muscles. Even in this case the loss of power was greater than would have been expected from the degree of atrophy, the loss of bulk incident to which Roberts believed to have been in part replaced by fat. In other instances, however, the extremest degree of atrophy has been noted where the disease has commenced in the lower extremities.
The deformity produced by the wasting muscle is sometimes further increased--more frequently in the earlier stages--by a painful swelling of the joints, first mentioned by Remak, called by him neuro-paralytic inflammation, and referred to the sympathetic. This may affect the small (phalangeal) as well as the larger joints (shoulder and elbow).
Cases apparently beginning in the face are reported, when the distorted expression resulting is very characteristic.
Aran first, and Roberts afterward, divided cases of the disease into two groups, the partial and general. In the former are included those involving the extremities only; in the latter become involved, sooner or later, the muscles of the trunk, neck, face, mouth, pharynx (muscles of deglutition), thorax (muscles of respiration), and even of the abdomen. Even the tongue is reported as undergoing atrophy.
General wasting palsy, as was early observed by Roberts, is unquestionably a rare disease, and in no case have all the muscles of the body been found implicated in one individual, and a few seem altogether exempted. Such are the muscles of mastication and of the eyeball, including the levator palpebræ.
A second muscular symptom, more or less distinctive, is fibrillar contraction. This consists in a wave-like contraction running along small bundles of muscular fasciculi. The contractions occur spontaneously or are excited by any slight stimulus, as a breath of air or a dash of water, or by tapping the patient, or passing a galvanic current through the parts, and at any stage of the disease, except that they do not occur in muscles wholly destroyed. Sometimes they can be felt by the patient. At other times he is wholly ignorant of them. They are not invariably present, and often they have been observed in muscles atrophied from other causes. They possess, however, a certain amount of diagnostic value, especially when spontaneous.
More rare, and less destructive, are cramps, twitches, and clonic contractions of groups of affected muscles. These, when present, are sometimes exceedingly painful.
Coincident with the wasting of muscles is their loss of function. The power of abducting and adducting the fingers gradually disappears, so also that of flexion and extension, and everywhere the loss of function goes pari passu with the atrophy. As Roberts graphically puts it, "The tailor discovers that he cannot hold his needle; the shoemaker wonders {551} he cannot thrust his awl; the mason finds his hammer, formerly a plaything in his hand, now too heavy for his utmost strength; the gentleman feels an awkwardness in handling his pen, in pulling out his pocket handkerchief, or in putting on his hat. One man discovered his ailment in thrusting on a horse's collar; another, a sportsman, in bringing the fowling-piece to his shoulder."
Along with the atrophy of muscle and loss of power comes a gradually diminishing response to electrical stimulus. Direct muscular faradization fails first to excite contraction, and sometimes fails completely even before voluntary mobility is lost. Indirect muscular faradization continues longer to excite contraction, but it also finally fails. Response to the constant current continues still longer, but it also finally fails to elicit contractions, stronger and stronger currents being required, until finally all fail. The galvanic excitability of nerve-trunks is maintained for quite a long time, but finally also disappears. Some irregularities present themselves in this respect.
A singular electrical reaction, first described by Remak, and said by him to be of frequent occurrence in muscular atrophy, was named by him deplegic contraction. He describes it as follows: When the cathode or negative pole is put below the fifth cervical vertebra, contractions can be produced in the atrophied muscles of the arm when the anode or positive pole is placed in an irritable zone, which extends from the first to the fifth cervical vertebra, or, still better, in the carotid fossa or the triangle between the lower jaw and the external ear. The contractions always take place on the side opposite to that at which the anode is placed, while when the electrodes are placed on the median line they occur on both sides, although when the current is very weak they are limited to the muscles most seriously involved. Meyer, Drissen, and Erb confirmed Remak's statement, while Fieber, Benedikt, and Eulenburg failed to do so. Remak interprets these contractions as reflected from the superior cervical ganglion of the sympathetic. He bases this view upon the fact that the patient perceived a sensation behind the ball of the eye when the current was closed. Eulenburg, on the other hand, regards them as genuine reflex contractions, independent of the sympathetic, and caused either by excessive irritability of the central reflex apparatus or by an abnormal excitability of the muscles themselves.
Sensibility is, in many cases, unchanged, the tactile sense being as delicate as ever, and pain, except accompanying the cramps above described, is absent. At times, however, the atrophy is preceded by paroxysms, which may or may not accompany the clonic contractions referred to. It is sometimes in the course of nerve-trunks, but as often diffuse, as though the muscles themselves were its seat. At other times it is variously described as a soreness, an aching, or a rheumatic pain. Accompanying advanced degrees of the atrophy, however, there is very rarely--in 3 out of 105 cases, according to Roberts--a slight diminution of sensibility, especially in the ends of the fingers, while the faradic sensibility may be similarly diminished.
Modified sensations, as those of cold, numbness, and formication, may be experienced, and reflex excitability may be increased, while the knee-jerk is said to be absent. Unusual sensitiveness to cold is sometimes noted, and a loss of muscular power under its influence, which is again restored by artificial warmth.
{552} Among more inconstant symptoms, denominated vaso-motor, are, in the early stages, fever and slight elevation in local temperature from 2° to 3° C. Fever is less frequently observed toward the termination of the disease, and at this stage a fall of local temperature, as much as 4° C., has been noted. In the same category of vaso-motor symptoms are classed the skin contractions already referred to, hyperidrosis or excessive sweating, and certain very rare oculo-pupillary symptoms, consisting mainly of contraction of the pupil and slow reaction, but including also, in a case reported by Voisin, flattening of the cornea on both sides and defective sight.
COMPLICATIONS.--Progressive muscular atrophy is not infrequently associated with amyotrophic antero-lateral sclerosis and with labio-glossal or progressive bulbar paralysis. Both affections may result as an extension of the disease from the anterior cornua of gray matter, the former into the antero-lateral columns, the latter into the medulla oblongata, or the affection may be primary in either of these two situations, and extend thence into the anterior cornua of gray matter.
When there is also lateral sclerosis, there is rigidity of the lower limbs in addition to the atrophy of the upper--at first temporary, but afterward permanent. This may extend to the upper also, and the arms become fixed in semipronation and semiflexion.
When there is bulbar paralysis there is difficulty in moving the tongue, in speaking, and in swallowing. The mouth remains open, the lower lip drops, the patient cannot whistle or kiss or blow out a candle; he speaks through his nose. On the other hand, the upper part of the face is natural, the orbicularis palpebrarum muscle and occipito-frontalis acting well. As a consequence, the carrying of the food back into the oesophagus is rendered difficult or impossible; swallowing is imperfectly successful; the food sometimes enters the larynx, and the patient dies of suffocation. The saliva dribbles from the mouth. Later, respiration is embarrassed, and performed principally by the diaphragm; there is difficulty in raising mucus, and if bronchitis supervenes the patient dies of suffocation, because he cannot raise the phlegm. Such was the death of Prosper Lecompte, the historic patient of Cruveilhier.
DIAGNOSIS.--As our knowledge of progressive muscular atrophy increases we realize more and more that there have heretofore been included under this name many cases which must now be relegated to other categories. If we confine the disease, as I think we must, to those cases in which there are degenerative changes in the anterior cornua of the gray matter of the cord, we must endeavor to associate with these lesions a set of symptoms which are sufficiently constant, and exclude all other similar combinations. Such a set of symptoms includes the following: insidious and progressive atrophy of groups of muscles, beginning usually in the hand or shoulder, from which, however, it may extend to others in a diffuse and rarer form of the disease. The atrophy is accompanied by a corresponding loss of power in the affected muscles and partial or complete reaction of degeneration in the same, and by fibrillar twitchings. Along with this, sensibility, the special senses, the reflexes, as a rule, and sphincters always remain normal.
This complex of symptoms is to be distinguished from the so-called {553} juvenile progressive muscular atrophy of Erb, and from pseudo-hypertrophic muscular paralysis. In the first there is also slow, symmetrical, but intermittent and often stationary, wasting and weakness of certain groups of muscles, preferably those encircling the shoulder and upper arm, the pelvis and upper thigh and back--"an atrophy," says Erb, "which is very frequently combined with true or false muscular hypertrophy, with a peculiar toughness of the atrophying muscles, but without fibrillar contraction or any trace of the reaction of degeneration or other lesion in the body, be it of the nervous system, organs of sense, vegetative organs, or external integuments."[27] The average age in the juvenile form is much less, Erb's cases ranging from seven to forty-six, or an average of twenty-six and a half, while in the spinal form, or true progressive muscular atrophy, although the age is reduced by reason of the admixture of other cases than those of true progressive muscular atrophy, the average age is much greater. Of Roberts's cases, all of which seem true cases, the youngest was twenty, while the age of the remaining four was thirty-nine, forty-seven, sixty-seven, and thirty-eight.
[Footnote 27: "Juvenile Form der Progressive Muskelatrophie," Deutsches Archiv für klinische Medizin, Bd. xxxiv., 1884, S. 471.]
There are certain symptoms in common in progressive muscular atrophy, as heretofore described, and pseudo-hypertrophic paralysis; and I have already said that Friedreich and others are disposed to consider them one and the same disease; but such is not the case. First of all, while there is wasting of muscle, although obscured in the lower extremities by the fatty infiltration, and while there is loss of power, there are in pseudo-hypertrophic paralysis absolutely no alterations in the spinal cord. Pseudo-hypertrophic paralysis always begins in the lower extremities, while progressive muscular atrophy begins for the most part in the upper. Pseudo-hypertrophic paralysis is a disease of childhood, and strikingly hereditary; and while progressive muscular atrophy in its broadest application is also a disease of childhood and hereditary, it is much less so than pseudo-hypertrophic paralysis; and if, with Erb, we separate the juvenile form from muscular atrophy, progressive muscular atrophy is not a disease of childhood, while heredity is almost entirely removed from it.[28]
[Footnote 28: It cannot but help the reader to get a correct notion of this interesting but still somewhat imperfectly understood disease to be familiar with Erb's formulated conclusions (loc. cit., p. 510):
"There is a peculiar form of progressive muscular atrophy which is characterized by a definite location, definite course, definite behavior of affected muscles, and definite alteration in them, but without alterations in the spinal cord--the condition named by me the juvenile form. It begins in youth or childhood.
"This form agrees in its symptomatology--especially in its localization in the upper half of the body, partly also in the lower--entirely with the so-called pseudo-hypertrophy of muscles, only that in the former a decided lipomatosis leading to an increase in volume is wanting; on the other hand, true muscular hypertrophy is not infrequent in both forms of the disease.
"If this juvenile form occurs in the earliest childhood, it may in all its details be identical with pseudo-hypertrophy, except that the lipomatosis is wanting.
"The anatomico-histological alterations of the muscles are exactly the same in the juvenile form as in pseudo-hypertrophy.
"The juvenile form not infrequently occurs in entire groups in one family, producing the so-called hereditary--better named family-muscular--atrophy.
"If this juvenile-hereditary form occurs after puberty, it affects most frequently, although not exclusively, the upper half of the body. If it sets in, on the other hand, in {554} earliest childhood, it affects preferably the lower extremities and the pelvis. Transitional forms, however, occur also in family groups.
"In the latter form, that occurring in earliest life, we have that which Leyden has proposed to designate as hereditary muscular atrophy.
"Thus, hereditary muscular atrophy is in all essential points identical with pseudo-hypertrophy, and is distinguished from it only in the slighter degree of lipomatosis of the muscles.
"All of these forms have probably nothing to do with spinal progressive muscular atrophy; they differ from it in localization and course, anatomical changes and clinical phenomena in the muscles, and alterations in the spinal cord."]
Still another myopathic condition, which in the light of modern knowledge has to be separated from progressive muscular atrophy, is Duchenne's hereditary infantile atrophy. This is characterized by onset at an early age and by its beginning in the facial muscles. Its clinical features are thus described by Charcot[29] and his pupils Marie and Guénon.[30] Although it mostly begins in infancy, it may not come on until adolescence, or even until middle or advanced age; it is often hereditary; the face-muscles are first involved, particularly the orbicularis oris, and there is a peculiar expression of the countenance; whistling is impossible, and the articulation of labials difficult; the eyes cannot be completely closed or the eyebrows raised. Subsequently other muscles become involved, particularly those of the shoulder girdle, except the deltoid, the muscles of the arm, the long supinators of the forearm, and in the lower extremities the muscles of the buttocks, thighs, and of the anterior external aspect of the leg. The muscles of the hands and fingers are spared. Fibrillar tremors are not present, and there is no reaction of degeneration. The distribution of the atrophy is almost identical with that of Erb's form, except that it begins in the face. It is likewise an hereditary or family disease.
[Footnote 29: Le Progrès médical, No. 10, 1885.]
[Footnote 30: Revue de Médecine, October, 1885.]
PROGNOSIS.--The course of progressive muscular atrophy is never rapid--essentially chronic. Recovery in a well-established case is not to be expected, although it is rare for any one to die of the direct effects of the disease. It is often arrested in its course, and remains at a standstill for years. The wider its distribution and the more numerous the foci of involvement, the more rapid is its course; and when the muscles of deglutition and respiration are involved, and the carrying back of food interfered with, death from asphyxia is liable to be produced by the entrance of food into the larynx or from the accumulation of mucus in what under ordinary circumstances would be a slight catarrh of the respiratory passages.
TREATMENT.--Treatment directed specifically to the cure of the disease is limited. Only where there is reason to believe that syphilis is responsible for it do we find an opportunity to strike at the fons et origo mali by mercurials and iodide of potassium. Yet in Cooke's case, quoted by Roberts,[31] the disease after progressing continuously for five years, during which a variety of modes of treatment was tried, had its further progress stopped by a course of mercury, although no cause of the disease could be assigned.
[Footnote 31: Op. cit., p. 1; also Cooke On Palsy, Lond., 1822, p. 31; also quoted by Graves in his Clinical Lectures, L. lxxxiii.]
In the majority of instances treatment must consist merely in efforts to maintain the general health and strength of the patient and to counteract {555} the obstinate tendency of the spinal disease to produce wasting of the muscles by depressing their nutrition. The former is accomplished by an abundance of nutritious food, fresh air, and out-door life, by gymnastics, chalybeate and other tonics, including arsenic, strychnine, and quinine. The second is attained by electricity, frictions, and massage. Both forms of electricity are useful, the induced current with rapid interruption with a view to counter-irritate and to stimulate the circulation, or by slow interruptions to stimulate individual muscles to contraction, and thus maintain their nutrition. Duchenne recommended the application of currents of moderate intensity, with not too frequent interruptions, and for a few minutes only at a time, so as not to fatigue the fibres undestroyed. He urged particularly the treatment of important muscles like the diaphragm through the phrenic nerves, of the intercostals, and of the deltoids before they were actually invaded by the disease. He relates the case of a man named Bonnard who had lost many of his trunk-muscles, and who was beginning to suffer with dyspnoea, on whom faradization of the phrenic nerves, repeated three or four times a week, was of great service, enabling him to walk considerable distances and to go up stairs without fatigue. Another patient, whose arms were much wasted, was so far restored that at the end of six months he was again able to support his family.
The direct current--galvanism--is useful in advanced stages of the disease, where even the strongest faradic currents fail to produce response. Even where galvanic currents fail to exert contractions the treatment ought to be persevered in for a long time. It may be necessary to use very strong currents at the outset, which may be gradually weakened as contractility returns.
Remak, who especially advocated the use of the continuous current, advised to place the positive pole in front of one mastoid process and the negative pole on the opposite side of the neck near the spinous processes of the vertebræ, not higher than the fifth cervical, by which he produced the contractions already described as diplegic in the fingers and other paralyzed parts.
Galvanization of the sympathetic has been apparently useful in the hands of some--viz. Roberts, Benedikt, M. Meyer, Guthzeit, Erb, Neseman, and others, while the latter reports a case of complete cure by this treatment. Eulenburg tells us, however, that a relapse is said to have occurred in this case; also that neither he nor Rosenthal have had any results from it.
Massage is equally important, and should be used at the same time with electricity, but at a different time of day. Eulenburg refers to a case which was said to have brought the disease to a standstill. There can be no doubt of the value of the measure as an adjuvant to treatment.
In families in which an hereditary tendency exists prophylactic treatment should be used. It should include hygienic measures of the kind already referred to, and the avoidance of undue fatigue and exposure; and in the selection of an occupation these matters should be kept in view.
On the supposition that the disease is a purely local one, gymnastics, involving the exercise of the groups of muscles prone to attack, would {556} be indicated, but assume less importance from our standpoint that it is a spinal disease. At the same time, the patient should have the benefit of any existing uncertainty in the pathogeny of the affection; and as gymnastics are eminently calculated to improve the general health, and thus indirectly to avert the disease, their use is indicated on these grounds.
{557}
PSEUDO-HYPERTROPHIC PARALYSIS.
BY MARY PUTNAM JACOBI, M.D.
SYNONYMS.--Hypertrophic paraplegia of infancy (Duchenne); Myo-sclerosic paralysis (Duchenne); Progressive muscular sclerosis (Jaccoud); Atrophia musculorum lipomatosa (Seidel); Lipomatous myo-atrophy (Gowers); Muscular hypertrophy (Kaulich, Griesinger); Lipomatosis musculorum luxurians progressiva (Heller); Myopachynsis lipomatosa (Uhde); Pseudo-hypertrophic paralysis (Ross); Pseudo-hypertrophy of muscles (Friedreich).
DEFINITION.--Pseudo-hypertrophic paralysis is a rare and predominantly infantile disease, characterized by a considerable increase in the volume of some or all the muscles of the lower extremities, associated with progressive diminution in their functional energy, and accompanied or followed by paresis and atrophy of the muscles of the trunk and upper limbs. Many of the hypertrophied muscles subsequently atrophy; many of the muscles in which atrophy is the most conspicuous lesion pass through a preliminary period of hypertrophy. The proximate cause of these alterations is a profound disturbance in the nutrition of the muscles, attended by great increase of their connective tissue, by wasting of the contractile substance, and by the ultimate replacement of this by fat.
HISTORY.--The honors of the discovery of this remarkable disease may be divided between Duchenne, Meryon, and Griesinger. In 1852[1] the English physician published a series of six cases, four belonging to one family, two to another; but these were described by him under the name of progressive muscular atrophy; and it was left to Duchenne, who in 1861[2] published as a new disease the first case observed by himself, to demonstrate the identity of Meryon's cases with his own.[3] In 1868, Duchenne had collected twelve additional cases, and published an extensive monograph on the subject.[4] But in 1865, Griesinger[5] had excised a portion of muscle from a patient suffering with the disease, and made the first histological examination of its structure. On this account several German writers habitually refer to Griesinger as the earliest authority on the subject. Before Meryon, Partridge in 1847,[6] and Sir Charles Bell in 1830,[7] had described cases of pseudo-hypertrophic paralysis, but without recognizing their separate morbid entity. Bell's case is the following: {558} "A boy at eight years of age began to experience difficulty in rising from a chair. The disease gradually progressed, till at eighteen he had to twist and jerk his body about to get upright. The muscles of the lower extremities, hips, and abdomen were debilitated and wasted. The extensor quadriceps femoris on both sides wasted, but the vasti externi had not suffered as much; a firm body, remarkably prominent, just above the knee-joint, marked the position of the vastus externus. No defect of sensibility or affection of the sphincters. The upper part of the body, shoulders, and arms were strong."[8]
[Footnote 1: Lond. Med. Gaz.]
[Footnote 2: De l'Électrisation localisée.]
[Footnote 3: Duchenne at first doubted this identity.]
[Footnote 4: Archives générales, 1868.]
[Footnote 5: Archiv der Heilkunde.]
[Footnote 6: Lond. Med. Gaz., 1847.]
[Footnote 7: Nervous System, 2d ed., 1830, p. 163.]
[Footnote 8: Loc. cit. This case is quoted in an appendix to Gowers's monograph.]
Autopsies.--The first was made by Meryon: the first which included microscopic examination of the spinal cord was by Cohnheim on a patient of Eulenburg's.[9] Since then autopsies have been made in 12 genuine cases, and in 2 others frequently, though erroneously, ranked with them.[10]
[Footnote 9: Vhdlg. der Bul. Med. Ges., 1866, Heft 2, p. 191, quoted by Eulenburg in Ziemssen's Handbuch, Bd. xii. 2.]
[Footnote 10: Cases of Barth and Müller.]
Of cases without autopsies a collection of 80 was made by Friedreich in the monograph on pseudo-hypertrophy which accompanies his longer monograph on progressive muscular atrophy.[11] Mobius has increased this list to 94;[12] Gowers describes 24 cases,[13] and refers in an appendix to 20 more--18 observed by Adams, 2 by Clifford Albutt.[14] Hammond in the sixth edition of his treatise on nervous diseases, quotes 17 American cases, of which 6 were observed by himself.[15] Gowers estimated that in 1879 about 220 cases had been reported, divided up among a much smaller number of families.
[Footnote 11: Ueber Progressiv Muskel Atrophie.]
[Footnote 12: "Ueber Hereditare Nerven Krankheiten," Volkmann's Samml., 171.]
[Footnote 13: Clinical Lecture on Pseudo-hypertrophic Paralysis, Lond., 1879.]
[Footnote 14: Among Mobius's cases is that related by Pick in the Deutsches Archiv f. klin. Med., Bd. vi., and really a case of progressive muscular atrophy in an adult complicated by lipomatosis in the calf-muscles. Of the other cases, 6 are quoted from the Swedish, 6 are hitherto unpublished, and have been collected by the author from several clinics. There remain cases by Davidsohn, Glasgow Med. Journ., 1872 (3 cases); Berger, Schles. Gesellsch., 1875; Uhde, Arch. f. klin. Chirurg., 1873, Bd. xvi.; Huber, Deutsches Arch. für klin. Med., 1874; Brieger, ibid., 1878, Bd. xxii.; Leyden, Klinik der Ruckenmark. Krank., Bd. ii. S. 529; Schlesinger, Wien. Med. Presse, 1873.
Many other cases have been published since, but without contributing any special information on the disease. Of importance, however, are--Cornil, accompanied by autopsy, Bull. Soc. Méd. des Hôp., 1880; Donkin, followed by recovery, Brit. Med. Journ., 1882, i.; Albutt, Med. Times and Gaz., 1882; Goodridge, Brain, 1882; Barthélemy, France méd., 1880; Suckling, Med. Times and Gaz., 1885; Dowse and Crocker, Lancet, 1881.]
[Footnote 15: These are reported by S. G. Webber, Boston Medical and Surg. Journ., Nov. 17, 1870; Wm. Pepper, Philada. Med. Times, 1871; S. Weir Mitchell, Photographic Review, 1871; C. H. Drake, Philada. Med. Times, 1874; C. T. Poore, New York Med. Journal, 1875; Steele and Kingsley of Missouri (4 cases), Philada. Med. Times, Oct., 1875; George S. Gerhardt (2 cases), Alienist and Neurologist, Jan., 1880.
I have had an opportunity of observing 3 cases of the disease--1 at the Mount Sinai Hospital; 2, brothers, in a private family.]
The material at present on hand is therefore sufficient, if not to solve the problems of the disease, at least to make out a tolerably complete clinical history.
SYMPTOMS.--The early appearance of the morbid symptoms is the first striking peculiarity of the disease. Out of 88 cases whose records I have analyzed, 35 must be considered congenital, since some degree of paresis was observed from the time the child first began to walk;[16] and the effort {559} at walking was unusually late, being deferred till two, three, or even four years of age. In 21 other cases the first symptoms of the disease declared themselves between the ages of three and six[17]--at the age of seven 8 other cases began;[18] between nine and ten, 7 cases;[19] between ten and sixteen were 8 cases;[20] finally, in 7 cases, of which 2 are more than doubtful (cases Barth and Müller), the disease seems to have begun in adult life.[21] Thus, 57 cases, or rather more than two-thirds of the whole number, began before the age of six.
[Footnote 16: These cases are the following: Meryon, Lond. Med. Gaz., 1852 (5 cases); Partridge, ibid., 1847; Duchenne, Électris. local., 1861; Kaulich, Prager Vierteljahr., 1862, quoted by Friedreich; Spielmann, Gaz. méd. de Strasbourg, 1862, quoted by Friedreich; Duchenne fils, Archives gén., 1864 ("De la Paralysie atrophique graisseuse"); Griesinger, Archiv der Heilkunde, 1864; Sigmund, Deutsches Archiv für klin. Med., Bd. i. Heft 6; Wernich, ibid., Bd. ii. Heft 2, 1866; Benedikt, Elektrotherapie, Wien, 1868; Balthazar Foster, Lancet, 1869; Barth, Archiv der Heilkunde, xii. 2, 1871; Chrostek, Oesterreich Zeitschrift für prakt. Heilkunde, No. 38, 1871, quoted by Friedreich; Pekelharing, Arch. Virch., 1882, Bd. lxxxix., quoted by Friedreich; Knoll, Wien. Medizin Jahrbuch., 1872; Friedreich, Pseudo-hypertroph. der Musc., 1878, p. 291; Duchenne, Archives gén., 1868 (7 cases); Hammond, Treatise Nerv. Dis.; Gowers, loc. cit. (5 cases); Ross, Treatise Nerv. Dis., 2, 204.]
[Footnote 17: Cases by Eulenburg, Allgemeine Med. Central Zeitung, Berlin, 1863, quoted by Friedreich; Rinecker, Verhand. du Phys. Med. Gesellsch. zu Wurzburg, 1860, quoted by Friedreich; Heller, Deutsches Archiv f. klin. Med., Bd. i. H. 6 (2 cases); Wernich, ibid., Bd. ii., 1866; Lutz, ibid., Bd. iii., 1867; Benedikt, loc. cit. (5th and 6th cases); Russel, Med. Times and Gaz., 1869 (3d case); Duchenne, loc. cit. (2d, 3d, 6th, 12th, 13th cases); Hammond, loc. cit.; Gowers, loc. cit. (6 cases).]
[Footnote 18: Cases by Eulenburg and Cohnheim, Beitr. klin. Woch., 1865; Seidel, Atrophia Musculorum Lipomatosa, 1867; Heller, loc. cit. (2d case); Wagner, Berl. klin. Woch., 1866 (8 cases); Benedikt, loc. cit. (1st case); Duchenne, loc. cit. (9th case); Gowers, loc. cit. (7th case).]
[Footnote 19: Seidel, loc. cit. (1st case); Coste and Gioja, Schmidt's Jahrb., Bd. xxiv. S. 176; Spielmann, _Gaz. méd. de Strasbourg_, 1862; Boquette, Inaug. Dissert., Berlin, 1868; Russel, loc. cit. (2d case); Rakowac, Wien. Mediz. Wochen., 1872; Brieger, Deutsches Archiv f. klin. Med., Bd. xxii., 1878; Pepper, _Philada. Med. Times_, 1871.]
[Footnote 20: Lutz, loc. cit. (2d case); Ross, loc. cit., p. 190 (observed when adult); Hoffmann, Inaug. Dissert., Berlin, 1867; Russel, loc. cit. (1st case); Gowers, loc. cit. (18th and 20th cases).]
[Footnote 21: Benedikt, loc. cit. (2d and 3d cases); Dyce Brown, Edin. Med. Journ., 1870; Eulenburg, Archiv Virch., Bd. xlix., 1870; Martini, Centralblatt für Med. Wissensch., No. 41, 1871; Barth, Archiv der Heilkunde, xii. 2, 1871; Müller, _Beit. zur path. Ruckenmarkes_, 1871.]
The symptoms are of three kinds: 1st, those dependent on alterations in the function of the affected muscles; 2d, changes in the appearance, consistency, and electrical reaction of these same muscles; 3d, deformities resulting from their structural alteration.
The first muscles invaded are invariably the gastrocnemii,[22] and therefore uncertainty of gait is the first symptom observed. The child is usually backward in learning how to walk, even when two, three, or four years intervene between this acquisition and the first decided appearance of the disease. In the unquestionably congenital disease the act of walking is always imperfectly performed, and the original imperfection gradually deepens into a noticeable uncertainty of gait, and finally into real paresis. It is noticed that the child falls very frequently--at first only when running, afterward even while standing. He then begins to experience difficulty in going up stairs: pulls himself up by the {560} bannisters, and usually drags one leg completely. After a while it becomes quite impossible for him to go up stairs except on his hands and knees.
[Footnote 22: Billroth relates an altogether exceptional case of a limited pseudo-hypertrophy with lipomatous degeneration, localized in the hamstring and adductor muscles of one thigh, in a girl seventeen years old. The only generalized lesion was an immense development of subcutaneous fat (Archiv für klin. Chir., Bd. xiii.).
Dyce Brown (Edin. Med. Journal, 1870) relates a case, also in an adult of twenty-six years, where hypertrophy of the thigh-muscles is said to have preceded by three weeks that of the calves.]
These symptoms all point to failure of power in the gastrocnemii muscles, whose function it is to raise the heel from the ground in running, to steady the heel by their tension during the act of standing, and to raise the foot with considerable force during the act of going up stairs. In descending a staircase or any inclined plane great tension is required of these same muscles, and this act should therefore be even more difficult than that of ascension. But it does not seem to have been as carefully studied.
Attention is not often directed to the infirmity at this early stage, especially if the child be very young, since the apparently excellent development of the legs satisfies the parents that nothing serious can be the matter, and the falling is explained by childish awkwardness. Not infrequently, indeed, this is really due to a rachitis which has preceded the degenerative lesion, and at the early stage of the latter a diagnosis from the less severe disease is always required, and is sometimes difficult to make.
The following test may be applied in doubtful cases: The child (if old enough) is requested while standing to rise on the tips of his toes. This act necessitates a powerful effort on the part of the sural muscles, and of this, even at an early stage of degeneration, they are generally incapable.
Functional weakness may precede for several years all visible alteration of the muscles; the child may not learn to walk at all until two or even three years of age; then walks badly until five or six, when, for the first time, the calves begin to enlarge. More often the paresis precedes the hypertrophy by only a few months or weeks, or the symptoms occur simultaneously. A certain amount of hypertrophy will be overlooked; but when the calves enlarge sufficiently to render the child's stockings too tight, attention is forcibly called to the change. The enlargement is more marked at the upper part of the calf, so that the symmetry of the leg is deranged by it. Often, however, the impression of vigor conveyed by the appearance of the child's legs is with difficulty dispelled by the discovery of their functional weakness.
Eulenburg[23] affirms that the consistency of the muscle is soft and doughy, recalling, when grasped in the hand, a lipomatous tumor. This description, however, does not apply to the early stage of the disease; for then the hypertrophied muscles feel extremely hard to the touch; there is even a stony hardness (Duchenne fils); somewhat later, the hypertrophy continuing, these muscles "seem to make hernial protrusions through the skin" (Duchenne). This appearance is most marked when the subcutaneous fat is atrophied; when, as happens especially in the adult cases,[24] the diseased muscles are covered by a thick layer of subcutaneous fat, their protrusion is concealed. A rapid exchange of the hardness characterizing the first stage of the lesions for a lipomatous softening is of bad omen, as indicating a more rapid and irresistible march in the disease (Mobius).
[Footnote 23: Ziemssen's Handbuch, Bd. xii.]
[Footnote 24: See case by Billroth, quoted p. 853, note.]
At this early stage the electrical reactions of the enlarging muscles are all intact. Disturbances of sensibility, however, are not uncommon. Especially frequent are pains in the back and loins and stabbing pains in the lower limbs. These pains sometimes follow the track of the {561} crural or sciatic nerves; at other times they appear in the joints; sometimes are limited to the affected muscles. The pains are diminished by repose and a recumbent position, but are greatly aggravated by movement. Paræsthesias, or a feeling of cold and formication, are also observed--never anæsthesia. Seidel[25] has found the cutaneous sensibility to be intact, as also the sense of space and pressure. The temperature sensibility has not been tested. The temperature of the affected part is, according to Eulenburg, often lowered several degrees. This statement probably refers to the advanced degree of degeneration. At an earlier stage Ord[26] found the temperature of the calves to be increased.
[Footnote 25: Loc. cit., p. 32.]
[Footnote 26: Med.-Chir. Trans., 1874, 1877.]
Reflex excitability is maintained, not only in this, but in the second stage of the disease, except in the patellar tendon, where it is abolished after the quadriceps extensor has been invaded. This fact may be of importance in diagnosticating paresis depending on incipient pseudo-hypertrophy from that which would be caused by a mild anterior poliomyelitis.
No symptoms of the third kind (deformity) appear in the first period of the disease. The second is ushered in either by the first perceptible degree of hypertrophy in the calves (Duchenne) or by increase of the hypertrophy, which may have already begun during the first period of paresis, and by extension of this to other muscles.
This extension of the lesion is indicated by further derangement in the functions of station and locomotion. To steady himself the child instinctively widens his base of support by placing the feet far apart, and thus straddles while walking in a manner that is highly characteristic. A second peculiarity is an oscillating movement of the trunk from side to side. The trunk is carried over to the side of the foot planted on the ground, the so-called active limb, and while the passive limb is being swung forward. A third peculiarity of attitude, already exhibited in station, but exaggerated by the act of walking, is lordosis. The lumbar portion of the spine, with the abdomen, is carried forward; the shoulders are carried backward, so that a plumb-line dropped from them falls behind the sacrum. Thus, the walk of the patient becomes highly characteristic--the feet planted so far apart; the lumbar portion of the trunk projecting forward; the body oscillating at each step from side to side.
At this stage the act of rising from a sitting or recumbent position becomes more difficult than walking. If near a support, the child always tries to draw himself up by his arms; if a fixed support be lacking, he first gets on his hands and knees, and then, grasping each thigh alternately with one hand, is enabled to get first one foot and then the other on the floor. He then seizes the thighs by successive grasps, each higher than the other, pressing back the flexed hip- and knee-joint as he does so. By this method of apparently climbing up his own thighs the patient is finally enabled to extend his body and arrive at an upright position.
This attitude of the hands, on the knees, and subsequently on the thighs, during the act of rising, is pathognomonic of pseudo-hypertrophy, for it is observed in no other disease.
Corresponding with this increased disturbance in function is the increased visible alteration in the muscles of the lower extremities. The muscles on the anterior part of the legs are not always attacked, but often {562} become hypertrophied and paretic contemporaneously with the gastrocnemii. After these, hypertrophy of the glutæi comes next in frequency. The quadriceps extensor of the thighs may become paretic, and even perfectly paralyzed, without showing any sign of enlargement. In many cases, however, hypertrophy proceeds regularly up the limbs, and invades the thighs simultaneously with the buttocks.[27] The exact proportion of cases is difficult to ascertain, because the history is often imperfect, and at the time of observation the quadriceps extensor is frequently atrophied, even when it has been hypertrophied at an earlier date. The thinness of the thighs is then all the more conspicuous from the hypertrophy of the calves below and of the buttocks above. The sacro-lumbales and quadratus lumborum muscles are also frequently enlarged, next in order to the quadriceps extensor femoris, which, as seen, is rather less often hypertrophied than are the gluteal muscles.
[Footnote 27: Cases in which the calves and thighs are alone described as hypertrophied: those by Kaulich, Griesinger, Sigmund, Wagner, Wernich (2d), Lutz (1st and 2d), Foster, Stoffella, Eulenburg (2d).
Cases of hypertrophy of calves with atrophy of thighs: those by Eulenburg (1st), Lutz (3d), Adams, Barth (2d), Knoll, Friedreich, Gowers (1st, 4th, 5th, 9th, 10th, 11th, 12th, 14th). In Rakowac's case, as also Barth's, the glutæi were also hypertrophied.
Cases of hypertrophy, calves, thighs, glutæi, and sacro-lumbales muscles: Duchenne (1st, 5th, 6th, 7th, 8th, 12th, the last being the miniature Hercules, in which all the muscles were hypertrophied except the pectorals), Heller (2 cases), Benedikt (1st, 2d, 3d, 4th; in the 5th the sacro-lumbales atrophied), Gowers (13th, 20th), Pekelharing.
Cases with hypertrophy of the calves and glutæi, with atrophy of the thighs: Berend, Duchenne fils (hypert. sacro-lumbales), Duchenne (3d, 4th, 10th).
Cases of atrophy of all but calves: Spielmann, Gowers (7th), Hammond (2 cases).
Cases of hypertrophy of calves and deltoids, atrophy of all other muscles: Ross (2 cases).]
The flexor muscles of the leg are much less often affected than these; the adductors and the ileo-psoas rather more frequently. Paresis and moderate hypertrophy of the abdominal muscles, though relatively rare, are observed. Thus, from the foot up to the spinal column the morbid imminence is pronounced on the side of the extensor muscles. The liability to invasion on the part of the flexors is greatest at the foot, where dorsal flexion is early impeded, and diminishes upward toward the abdomen.
Most important for the theory of the disease is the fact that the hypertrophic appearance of the muscles is never accompanied by even a transitory period of increased strength.[28] Some degree of paresis usually precedes the hypertrophy, and becomes intensified when this sets in. The two symptoms, however, are by no means proportioned to one another.
[Footnote 28: In Auerbach's case of true muscular hypertrophy the same paresis was observed.]
There is another anatomical change in the muscles no less characteristic of the disease than is their hypertrophy, which contributes at least as much to the loss of muscular power. This is atrophy of the muscles, which in the lower extremities is almost invariably secondary to a stage of hypertrophy, but which occasionally in the quadriceps extensor constitutes the primary lesion. On the other hand, the calf-muscles, though occasionally retroceding from a state of exaggerated hypertrophy, never atrophy below the normal dimensions.[29]
[Footnote 29: Hammond relates a remarkable case where the muscles of the calves and thighs, having enlarged progressively during about two years, then began to waste, and continued to do so for three years. Then a second stage of hypertrophy set in, and continued at the time of writing (Treatise on Nervous Diseases, 6th ed., p. 508).]
It not unfrequently happens that the atrophic and hypertrophic {563} processes go on simultaneously in the same muscle, and so compensate each other that the muscle varies little or nothing from the normal size. This is especially apt to be the case with the pelvic and lumbo-spinal muscles; and thus functional disturbances will develop for which the mere appearance of the involved muscles seems to furnish no sufficient explanation.
The peculiarities which have been described in station, locomotion, and the act of rising to a vertical position nevertheless all depend on such anatomical lesions of the muscles of the back and lower extremities as render the adequate performance of their functions impossible. Thus, the widening of the base of support by straddling the legs is necessitated by weakness in all the extensor muscles of the limbs--the glutæi, quadriceps, and gastrocnemii--which by their tension should normally provide solid columns for the support of the trunk. The lordosis begins with the first difficulty experienced in steadying the heels, but is increased when the gluteals become incapable of extending the pelvis on the femurs and when the sacro-lumbales are unable to extend the vertebral column on the pelvis. The backward projection of the shoulders, effected by the extensors of the upper portion of the spine, is an instinctive compensation for the lordosis, to prevent the trunk from falling altogether forward in front of the base of support.
The lateral oscillations of the trunk have been variously explained. Duchenne attributed them to weakness of the gluteus medius. This muscle, he asserted, is normally designed to restrain the tendency of the pelvis at each step to incline toward the leg which is off the ground.[30] But, in reality, during the act of walking, the pelvis, and the trunk with it, are inclined toward the leg which is fixed, rotating upon the head of the femur on that side, and being slightly elevated on the opposite side, where the leg is being swung forward. This elevation assists in enabling the swinging leg to clear the ground (Ross, Hueter). The rotation is accomplished by the gluteal abductors on the active or fixed side, the femoral extremity of these muscles being fixed. Weakness of the gluteals must interfere with this rotation, and should therefore diminish lateral oscillation did this depend on the rotary movement.
[Footnote 30: Archives gén., 1868, p. 28.]
In a case examined by Ross, in which the lateral oscillation was much marked, contractions of the gluteus medius were distinctly perceptible to the hand placed just above the great trochanter. In another case, where the gluteals were entirely destroyed, the oscillation, on the contrary, was barely perceptible. Ross himself explains the phenomenon more plausibly as a simple exaggeration of what occurs in normal locomotion. In this the centre of gravity is necessarily shifted at each step from the movable to the fixed leg by the inclination of the trunk and shoulders to the side of the latter. When the legs are placed far apart the body must incline farther in order to bring the weight in the same relative position. Moreover, from the weakness of the anterior tibial muscles the dorsal flexion of the foot, which should take place at the moment the leg is lifted off the ground, is impeded or rendered impossible; and the inclination of the pelvis on one side, which necessitates its increased elevation on the other, thus favors the swinging of the leg by leaving more room between the trunk and the ground (Ross).
The curious manner in which pseudo-hypertrophic patients rise from a {564} sitting or recumbent position has been carefully studied by Gowers, and minutely analyzed by Ross in an adult case. The act to be accomplished demands a series of extensions of the leg and pelvis on the thigh and of the vertebral column on the pelvis. As the extensor muscles are all paretic, this can only be effected by means of the muscles of the upper extremities and of the weight of the body, which the arms compel to serve as a motor force. Thus, from a recumbent position the patient rolls upon his hands and knees: then, grasping the knee, he lifts the leg upright with the foot planted on the ground. The thighs remain strongly flexed, the trunk bent forward over the thighs. The action of grasping the thighs above the knees, which is so characteristic, serves to extend them by a double mechanism. In the first place, the knee-joints are pressed slowly but directly backward. In the second place, by the intermediary of the arms the weight of the body is transferred from the upper end of the femur, above the power of the quadriceps extensor, to the lower end of the lever, near the fulcrum at the knee. Thus a lever of the third order, with the power between the fulcrum and the weight, is partly transformed into a lever of the second order, with the weight between the fulcrum and the power; and thus the enfeebled quadriceps is able to act to more advantage. Moreover, when the body inclines so far forward that the centre of gravity is carried in front of the knees, it then becomes a force applied to the upper end of the femur capable of extending the knees without any action of the quadriceps.
When extension of the knee-joints is nearly complete, extension of the pelvis on the femurs is effected by grasping the thighs alternately higher and higher. By this manoeuvre the femur is pushed back and the trunk is pushed up; and thus is compensated the incapacity of the glutæi to perform their normal action of pulling up the pelvis flexed on the femurs. Enough power remains in these muscles, however, for a long time to complete the extension when, by the pushing movement, this has been nearly effected.
During these actions the patient constantly oscillates the trunk from side to side as he transfers the centre of gravity from one foot to the other. In this, the second stage of the disease, and where the same functional disturbances may arise with very various combinations of hypertrophy and atrophy in the muscles of the lower extremities, a third set of symptoms appears--certain deformities, namely, depending on muscular shrinkage. The earliest, and often the most marked, of these is talipes equinus. The patient becomes unable to plant his heels firmly on the ground, and these are gradually drawn up higher and higher, the patient resting first on the toes, then on the anterior surfaces of the phalanges; ultimately is unable to stand at all, the foot being drawn into a line with the leg, and the astragalus not unfrequently luxated. Some authors explain this deformity by the preponderating action of the gastrocnemius. The paralysis of this muscle, which coincides with its hypertrophy, even when not quite proportioned to it, renders such an explanation highly improbable. The elevation of the heel is due to the gradual shrinkage of the muscular tissue which accompanies the pseudo-hypertrophy; and on this account the talipes is at every stage of its development irreducible.
The other possible deformities in the lower extremities are permanent {565} flexions at the knee- or hip-joints. Both existed in the case recently described by Pekelharing.[31] Before the disease has reached its maximum degree of development in the lower extremities, its progress has usually been marked in another manner--namely, by the invasion of the trunk and arms. In cases 19-22 of Gowers's remarkable series, where four boys out of a family of ten children were affected by the disease, the hypertrophy first involved all the muscles of the lower extremities, and then passed to the trunk and arms.[32]
[Footnote 31: Loc. cit.]
[Footnote 32: Three other boys in this family, and three girls, remained healthy.]
The description of the disease in the upper half of the body may be distinctly separated from that in the lower half, on account of the remarkable differences observed in the mode of the muscular degeneration. In the lower extremities and pelvis primary pseudo-hypertrophy is the rule; atrophy is almost invariably secondary, and below the hips is rarely excessive.[33] In the upper part of the body primary atrophy is the rule for certain muscles, and succeeds rather early to the pseudo-hypertrophy which affects others. Only a few muscles habitually hypertrophy, and remain enlarged until a somewhat advanced period of the disease. The first in this group is the deltoid, which not unfrequently enlarges simultaneously with the gastrocnemii.[34] In one case the triceps humeri, and after that the biceps, are the next most frequently hypertrophied,[35] in some cases even together with atrophy of the deltoids (2d case Seidel). In exceptional cases all the muscles surrounding the shoulder-joint, especially those covering the scapula, are hypertrophied. Thus in the early case of Coste and Gioga[36] the latissimus dorsi and trapezius were hypertrophied, together with the deltoids, and even the muscles of mastication and the tongue. In this case not only the quadratus lumborum, but also the recti abdominis muscles, were hypertrophied. In Chrostek's case the tongue was hypertrophied, although all the shoulder-muscles, and also the sterno-cleido-mastoids, were atrophied.[37] In Duchenne's third case the temporal and masseter muscles were hypertrophied, while no alteration of size in any direction was observed in the arms or shoulders. In Duchenne's twelfth case all the muscles of the body, including the face, were hypertrophied, with the single exception of the pectorals. In Barth's second case, the left sterno-mastoid, the supra and infra spinali, together with the left deltoid, were hypertrophied.
[Footnote 33: The quadricipites femoris, as already noticed, are not unfrequently wasted.]
[Footnote 34: See cases of Kaulich, hypertrophy of calves, thighs, deltoids; Heller, hypertrophy of all muscles of lower limbs, also of abdomen with deltoids; Benedikt (4th and 6th cases); Friedreich (1st case); Adams; Gowers (4th and 11th); Ross (2 cases); Brieger. In a case by Clarke (Med.-Chir. Trans., vol. lvii.) the deltoids were observed to be large seven years after the beginning of the disease. In a case by Duchenne the enlargement of the deltoids, by great exception, preceded that of the gastrocnemii by several months.]
[Footnote 35: Cases of hypertrophy triceps or biceps: Seidel (2d), Rinecker, Griesinger, Wagner (2d, triceps without deltoid), Knoll, Rakowac, Pekelharing, Spielmann (atrophy deltoid).]
[Footnote 36: Schmidt's Jahrb., Bd. xxiv. S. 196. Other cases are given by Wernich (hypertrophy of rhomboids), Barth, Gowers (11th).]
[Footnote 37: Oesterreich Zeitschrift f. prakt. Heilk., 1871.]
In the majority of cases, however, at the time the patient came under observation all the muscles above the quadratus lumborum were atrophied, except the deltoids. In the pectoral, which has never been found hypertrophied, the wasting process always sets in the earliest, and advances to the greatest extent. The pectoral muscle is thus the exact antithesis of the gastrocnemius, while the deltoid more nearly resembles {566} the gastrocnemius than any other muscle of the upper extremity. After the pectoral the latissimus dorsi, then the trapezius scapular muscles (including the serratus magnus), those of the arm and fore arm, the muscles of the neck, are found more or less wasted by the time the disease is fully developed. The wasting is sometimes extreme, as in a case described by Gowers, where the patient maintained a permanently crouching attitude, the spinal column being in extreme cyphosis, all its processes projecting, from the extreme emaciation of the trunk.
In Eulenburg's adult case[38] the atrophy began in the hands, and was regarded by him as a combination of true progressive muscular atrophy in the upper, with lipomatosis musculorum luxurians in the lower extremities.[39]
[Footnote 38: Virch. Arch., Bd. xlix., 1870.]
[Footnote 39: Cases of atrophy (often excepting deltoids): 1st case by Seidel, "simultaneous paresis in upper and lower extremities in four years; atrophy of arms and thighs, with hypertrophy of calves and fore arms; in six years, primary atrophy sterno-cleido-mastoids and pectorals; secondary atrophy of deltoids."
Further: case of Kaulich (atrophy of shoulder-muscles, including deltoid, while triceps and biceps hypertrophied); Duchenne fils; Eulenburg and Cohnheim; Heller (2 cases); Wagner (2d case); Wernich (1st case); Lutz (a girl, case much resembling Eulenburg's adult case); Roquette (atrophy of thighs as well); Hoffmann; Russel; Foster (atrophy of muscles of forearm); Chrostek (notwithstanding hypertrophy of tongue); Friedreich (2 cases); Duchenne (2d); Wagner (2d and 3d); Gowers (9 cases); Ross (2 cases).]
Gowers attaches diagnostic importance to the early signs of atrophy in the latissimus dorsi and great pectoral muscles. The time of their invasion contrasts with that in progressive muscular atrophy, where the process usually begins in the hands and creeps upward to the shoulder-joint.
Neither the atrophic nor the hypertrophic process is necessarily symmetrical on the two sides of the body, but an approximate symmetry is usually observed. The same muscles are usually affected, and in the same way, but not often precisely to the same degree. Fibrillary contractions often occur in the wasting muscles, but not in those which are hypertrophied. The electrical reactions, however, do not differ greatly in the two states. The faradic contractility diminishes in proportion to the diminution in the contractile mass of the muscle, whether this be concealed by the growth of fat and connective tissue or rendered obvious by the general wasting of the whole. But even when contractions can be obtained, these are often abnormally feeble, and by continual diminution in the number of contractile fibres, and increase in the lipomatous masses overlying them, the electrical irritability is ultimately lost. The excitability of the nerves remains intact, and therefore response may be obtained by an indirect excitation after direct excitation of the muscle fails to elicit one.
Eulenburg has occasionally observed one curious phenomenon in the galvanic reaction of nerves. The anode opening contraction grows weaker or even disappears with a progressively stronger current, and then with a still stronger current reappears. This is due to a cross action of the current on the excitability and on the conductibility of the nerve. At a certain moment the increased excitability is compensated by a corresponding increase in the resistance to conduction, and therefore all electrical response ceases. Later, the resistance remaining the same, the excitability is increased and the reaction reappears.
{567} The symptoms of the first order (disturbance of muscular function) and of the third (deformity) are for a long time less conspicuous in the upper than in the lower extremities. When the arms begin to be paretic the patient is crippled in the characteristic manoeuvres by which, during the earlier period of the disease, he palliates the inefficiency of the lower limbs. When he can no longer push up the trunk by means of his arms, he becomes unable to rise from a sitting position at all. Further progress in the atrophy of the erectores spinæ muscles renders even the act of sitting impossible: the patient can only crouch, and ultimately must remain altogether recumbent. The functions of the hands usually remain unimpaired to the last, so that the unfortunate patient is able to amuse himself with knitting and other light work.
Besides the paralytic cyphosis, scoliosis of a high grade is sometimes, though infrequently, developed. It is due to the lateral oscillations with excessive inclination of the upper portion of the trunk.[40]
[Footnote 40: Cases of scoliosis from such cause, where inequality of muscular action cannot be invoked as a cause, help to throw light on the real etiology of the idiopathic deformity so often attributed to irregular muscular action.]
It is rare that any researches have been made on the nutritive functions in pseudo-hypertrophic paralysis. Seidel[41] has analyzed the urine in the two cases (brothers) which form the basis of his memoir. He expected to find a marked diminution in the urea, corresponding to the diminution in the mass and in the functional activity of the muscles. This expectation was based on the assumption, at present considered incorrect, that the elimination of urea is modified by muscular contractions. In the cases examined the actual amount of urea was considerable, rising on several occasions to 40, 43, and 69 grammes in twenty-four hours, and offering, in the first boy, a daily average of 41 grammes. But Scherer estimates that the average elimination of urea in children is, per kilogramme, double that in adults; and on the basis of this calculation the amount of urea eliminated by the patient in question should have been 51 grammes. There was therefore a diminution of about one-fifth.
[Footnote 41: Atrophia Musculorum Lipomatosa, Jena, 1867.]
Seidel has also examined the temperature of the diseased muscles during their contraction either under the influence of the will or of the faradic current. The hypertrophied gastrocnemius muscle showed a rise of 1.5° to 2° less than a healthy gastrocnemius similarly excited. The rise of temperature never occurred during the contraction, but during the ten or fifteen minutes which followed it. The duration of this rise of temperature was always longer than in the control experiment performed on a healthy subject. The observation was the same in hypertrophied and in atrophied muscles, and indicated a notable diminution of heat-production in both.[42]
[Footnote 42: Loc. cit., p. 54.]
The mental functions are not unfrequently impaired. The defective intelligence exhibited by several of his first patients led Duchenne to attribute a cerebral origin to the disease. The internal hydrocephalus discovered at the autopsy of the case so recently published by Pekelharing suggests that this hypothesis may have been too hastily abandoned, and that it may really prove to be correct for certain cases. In many, however, the intelligence is intact or even precocious, and all suspicion of cerebral lesion must be excluded.
{568} COURSE OF THE DISEASE.--As already stated, a period of paresis may precede all signs of hypertrophy for several weeks, months, or even years. From the time that the enlargement of the calves has once begun about a year and a half is required before the maximum of hypertrophy is attained. Then the disease usually remains stationary for two or three years before the third period is ushered in by aggravation of paralysis in the lower and by extension of paralysis, together with hypertrophy or atrophy, to the upper limbs.
When, from complete loss of muscular power, the patient has become permanently condemned to a recumbent position, life may nevertheless be prolonged for ten or twelve years, with integrity of all the vegetative functions. Death finally takes place, in all recorded cases, from some acute pulmonary disease, whose effects are intensified by the atrophy of the external respiratory muscles, which often extends even to the intercostals.
The course of the disease, and consequent prognosis, is much modified in the rare cases in which it attacks girls. Two of Duchenne's thirteen cases were girls: in one the disease was spontaneously arrested, in the other apparently cured. Lutz[43] relates the altogether exceptional history of a family in which five female members were affected--two sisters, also one step-sister, daughter of the mother by an earlier marriage, a sister and niece of the mother, of whom a brother also was diseased. The step-sister and niece both died at six years of age, but the aunt lived to be forty-three (the brother to be forty-two), and one of the girls observed by Lutz, who began to suffer at the age of six, was twenty-eight at the time of observation: paresis had only become marked at seventeen, and locomotion impossible at twenty-two. In the other girl the first symptoms appeared at seventeen, and at twenty-two were still moderate and confined to the lower extremities.
[Footnote 43: Deutsches Archiv f. klin. Med., Bd. iii., 1867.]
In Roquette's female case[44] the disease began at ten; in Hoffman's,[45] at eleven and a half. These cases, with one of Benedikt's, are the only female cases among the 88 I have analyzed.[46] Gowers estimates 30 female cases out of a total of 220, or only 13 per cent. of the whole.
[Footnote 44: Inaug. Dissert., Berlin, 1868, quoted by Friedreich.]
[Footnote 45: Ibid., 1867.]
[Footnote 46: This excludes the adult cases of Eulenburg, where "progressive atrophy of the upper extremities combined with pseudo-hypertrophy of the lower;" the case of Barth, an amyotrophic lateral sclerosis; the case of Müller, a dementia paralytica; and the case of Billroth, where the lesion was localized in the hamstring muscles of one thigh.]
This great preponderance in the male sex is the first of three striking peculiarities which distinguish the clinical history of the disease. The second is its strangely-marked hereditary character. This is not, and indeed hardly could be, shown in a direct line, since the patients are incapable of marriage, or even die before arriving at maturity. But several brothers in a family are usually afflicted. There was, it is true, no trace of heredity in Duchenne's 13 cases, but this author himself recognizes the frequency of hereditary influence in those observed by others. Out of 81 cases analyzed by Friedreich, two or more members of one family were attacked thirty-five times. Thus, the first clinical report, that made by Meryon, described four brothers in one family and two in another. Coste, Griesinger, Wernich, Benedikt, Adams, Russel, Gowers, each relate cases of two members in one family; Heller, Wagner, Billroth, {569} Seidel, have seen three: Moore[47] describes three cases out of a family of seven, consisting of five boys and two girls. Two of the cases I myself have seen were brothers. Gowers[48] relates five cases in the families of two sisters who married two brothers. This same writer refers to three other families in which two brothers were affected; to a fourth family described by Clifford Albutt, where two brothers were paralyzed, the third child dying of Hodgkin's disease; finally, to the family of a clergyman, himself living to the age of seventy-four, having always had large calves, and out of whose eight children two boys and one girl were affected.
[Footnote 47: Lancet, 1880.]
[Footnote 48: Loc. cit., Appendix.]
The families invaded by this singular disease are often remarkably large, and even where several children are affected, many others, even boys, escape. The morbid inheritance is always through the mother, "thus through the ovum--a condition unknown in diseases of the nervous system" (Gowers). This peculiarity belongs to only one other disease, hæmophilia, also almost limited to males. The third fact, which from its all but universality is shown to be of fundamental importance, is that the disease begins during infancy or early childhood. It has been shown that more than two-thirds of all cases began before the age of six. Whether there is ever an intra-uterine origin is still doubtful (Friedreich). This early invasion, often coinciding with the first efforts to walk or to use the muscles which are first attacked, distinctly separates pseudo-hypertrophic paralysis from all diseases which can be traced to definite accidents or to perversion of functions. It implies a profound perversion of nutrition, or rather a misdirection of developmental force.
PATHOLOGICAL ANATOMY.--The anatomical lesions of pseudo-hypertrophic paralysis are to be sought first in the muscles, afterward in the spinal cord, upon which so many peripheric lesions of the nervo-muscular system have recently been shown to depend. The argument from analogy, therefore, has of itself almost sufficed to create a conviction that some disease of the central nervous organs must exist as the real basis of pseudo-muscular hypertrophy.[49] Nevertheless, as will presently be shown, the present evidence in favor of such hypothesis is extremely small.
[Footnote 49: This conviction is fully expressed by Hammond, loc. cit.]
Muscular Lesions.--In the muscles, however, the anatomical changes are profound and varied. They may be divided into three kinds--those affecting the muscular fibre itself; those touching the connective tissue; and, finally, the fat deposited in this.
The lesions of these different elements are variously combined with each other in different muscles, and also at different stages of the disease. Thus, in the muscles of the trunk and upper extremities affected with primary atrophy the increase of fat is always moderate and quite insufficient to compensate the wasting of the contractile mass, while in the gastrocnemii and gluteal muscles the hypertrophied masses are often found to consist entirely of fat, traversed by bands of connective tissue, and indistinguishable from a lipoma.
The muscles have been examined in two ways--in the course of a general post-mortem examination, and also during life by means of excision or extraction by various instruments. Griesinger in 1864[50] excised a piece {570} of the deltoid in a boy of thirteen,[51] and made on it, with Billroth, the first microscopic examination of the diseased muscles. Duchenne, to avoid an operation not devoid of danger for the patient, devised his harpoon, by means of which small fragments of muscles could be torn away. As this instrument is liable to change the relations of the parts separated by tearing, Leech has contrived another, in which the fragment is removed by cutting. By one method or another of harpooning the muscular lesions have been studied during life by Duchenne, Heller, Wernich, Russel, Eulenburg, Martini, Knoll, Rakowac, Friedreich, Ross, Gowers, Auerbach, Hammond, Pepper, in the cases already quoted.
[Footnote 50: Archiv der Heilkunde.]
[Footnote 51: The wound suppurated for a long time.]
Muscular Fibre.--There are contradictory opinions in regard to the first stage of alteration in the muscular fibres. According to most observers, the fibres are seen to directly atrophy; the transverse striæ become dim and gradually disappear, and the primitive bundles shrink in diameter from loss of some of their fibrillæ (Brieger, Hammond, Pepper). Friedreich[52] adds that the complete collapse of the contractile substance in the primitive bundles often leaves empty or shrunken sarcolemma sheaths, which swell the mass of the connective tissue. Friedreich, however, denies that the striation is modified; and its extreme fineness, commented upon by Duchenne, is considered by Ollivier[53] and Ranvier as devoid of pathological significance.
[Footnote 52: Loc. cit., p. 300.]
[Footnote 53: Des Atrophies musculaires, Thèse d'Agrégation.]
The real size of the primitive fibres is best estimated by the method of Cohnheim, who isolated the fibres by boiling the muscular fragment from four to six hours in a mixture containing 100 c.c. of 90 per cent. alcohol and ¾ c.c. of concentrated muriatic acid. Many were found reduced to one-fifteenth or one-sixteenth their normal size.[54] Between atrophied fibres lay a peculiar striped tissue, probably composed of empty sarcolemma sheaths. Side by side with these atrophied fibres were many normal, and others grossly hypertrophied to two or even three times the normal calibre. These were only found in the hyper-voluminous muscles. Some of these exceeded the largest frog-muscle fibres. They lay in bundles of four to six between the small fibres, and seemed to be about equally distributed through the hypertrophied gastrocnemius and atrophied biceps.[55]
[Footnote 54: Berlin. klin. Wochensch., 1865, No. 56.]
[Footnote 55: Hypertrophied fibres have also been seen by Knoll (Medizin Jahrbuch., Wien, 1872), Müller, and Eulenburg.]
Another alteration observed in the muscular fibres was their dichotomous and even trichotomous division. This same lesion has been seen by Friedreich in progressive muscular atrophy.
The presence of hypertrophied fibres in wasting muscles lends a special significance to the cases of true muscular hypertrophy described by Auerbach[56] and Hitzig.[57] Auerbach's observation related to a soldier aged twenty-one, whose upper arm became rather rapidly hypertrophied and paretic. In a fragment excised from the enlarged biceps the fibres were seen to have a diameter of from 96 to 180 µ. (the normal diameter being 33 to 67 µ.). The other arm was not enlarged, and yet examination of fibres obtained by means of a similar excision found them also enlarged. Auerbach suggests that this hypertrophy constituted a preliminary stage {571} in the general process of pseudo-hypertrophic paralysis. In it, as when the excessive volume is known to depend upon the presence of non-contractile tissue, the arm, far from increasing in strength, was paretic.[58]
[Footnote 56: Virch. Arch., Bd. liii., 1871.]
[Footnote 57: Berlin. klin. Wochen., Dec. 2, 1872.]
[Footnote 58: Mobius (loc. cit.) declares that neither of these cases bears any relation to pseudo-hypertrophy.]
Connective Tissue.--Far more conspicuous than the alterations in the contractile fibre of the muscles are those of its connective tissue. The perimysium internum, between the primitive bundles, proliferates abundantly, and the hyperplasia gradually extends correlatively with the wasting of the muscular fibres, until the hypertrophied mass is mainly composed of connective tissue. Broad bands replace the thin lamellæ normally present between the primitive bundles; the parenchyma of the muscle seems stifled in a sclerosis. It is then that it offers the feeling of stony hardness so often noticed in the clinical history.
Charcot, Knoll, Müller, and Barth describe a rich development of nuclei and of spindle-shaped cells in this new connective tissue, this being especially abundant in the neighborhood of the small vessels and in their adventitia. Eulenburg and Leyden, however, affirm that the connective tissue is unusually poor in nuclei, and thence infer that the hyperplasia is compensatory, and not due to inflammation.
In some cases, as in those of Duchenne examined by Ordonez, the sclerosis and atrophy of contractile tissue constitute the entire lesion of the muscle. Only a few fat-cells are interspersed among the bands of connective tissue or penetrate between the primitive bundles. The fatty infiltration tends constantly to increase, apparently by the same process as governs the growth of normal adipose tissue--namely, the deposit of fat in connective-tissue cells; and ultimately not only muscular fibre, but the hyperplastic connective tissue, is concealed in a yellowish glistening mass indistinguishable from a lipoma.[59]
[Footnote 59: See case of Billroth.]
The growth of fat contributes to the apparent hypertrophy of the diseased muscles, but much less so than does the hyperplasia of connective tissue which invariably precedes it. Great rapidity of fatty infiltration marks a more rapid and irresistible progress in the disease, a lower stage of nutritive degradation. Fat-cells are found penetrating between the primitive bundles of fibres in the atrophied as well as in the hypertrophied muscles; but there the fatty substitution is always much less complete.
In contrast with this fatty infiltration true fatty degeneration of the muscular fibre is as rare in pseudo-hypertrophy as in progressive muscular atrophy. This fact is emphasized by Pepper from observation of the harpooned fragment examined by him,[60] also by Cohnheim.[61] In Meryon's first case,[62] however, the post-mortem examination of the muscular fibres found them "totally degenerated, their substance changed into a mass of granules and oil-globules, while the sarcolemma was destroyed." In Brieger's case[63] the fibres were filled with fat-globules.
[Footnote 60: Philada. Med. Times, 1871.]
[Footnote 61: Loc. cit.]
[Footnote 62: Med.-Chir. Trans., vol. xv., 1852.]
[Footnote 63: Deutsches Archiv, Bd. xxii.]
The sclerotic process which precedes the stage of fatty infiltration is far from being completed when this latter begins. Both processes, initiated nearly at the same time, continue together, and at the death of the patient may be found existing in about equal proportion, or the one {572} markedly predominating over the other. In cases of long duration the hypertrophied muscles, as already stated, are found converted into masses of fat, divided by stripes and bands of connective tissue. With death earlier in the disease the enlargement is found to be due to masses of connective tissue englobing muscular fibres and interspersed with fat-cells.
In the wasted whitish-red muscles the proliferation of connective tissue is sometimes more, sometimes less, marked; in the pale-yellowish muscles fat accumulates by interstitial deposit, but does not overlay and conceal the remnant of muscular fibre.
Central Nervous Organs.--While the examinations of the diseased muscles have been frequent, post-mortem examinations are still relatively few, although their records are rapidly increasing. The first was made by Meryon[64] on the first of his series of six cases. Charcot has examined a case for Duchenne; Cohnheim has made a celebrated autopsy for Eulenburg;[65] Gowers and Clarke have together published a fourth.[66] The cases by Müller and Barth are still habitually--though, as we shall see, erroneously--included among the autopsies of pseudo-hypertrophic paralysis. Ross[67] and Leach have, however, a fifth indubitable case with autopsy; and more recently Cornil,[68] Brieger,[69] Bay,[70] Schultze,[71] Pekelharing,[72] and possibly Goetz and Drummond,[73] have all described post-mortem examinations. The data for discussion, therefore, are to be derived from 14 cases. Of these, the spinal cord was found perfectly healthy in 7, those related by Meryon, Cohnheim, Charcot, Cornil, Brieger, Bay, Schultze--all most competent observers. The cases by Barth and Müller require some special consideration, for, although rejected as irrelevant by most authors, Hammond still adduces them in proof of the central origin of pseudo-hypertrophic paralysis.
[Footnote 64: Loc. cit.]
[Footnote 65: Loc. cit.]
[Footnote 66: Med.-Chir. Trans., 1874; also monograph by Gowers.]
[Footnote 67: Loc. cit.]
[Footnote 68: Union méd., 1880.]
[Footnote 69: Deutsches Archiv f. klin. Med., Bd. xxii. H. 2.]
[Footnote 70: Virch. Jahresb., 1877.]
[Footnote 71: Virch. Arch., 1879, Bd. lxxv.]
[Footnote 72: Arch. Virch., Bd. lxxxix., 11, 2, 1882.]
[Footnote 73: Quoted by Pekelharing--the first from the Aerztliches Intelligenz Blattmünchen, 1879; the second from the Lancet, 1881, vol. ii., No. 16.]
Müller's case[74] is that of a woman thirty-four years of age who at the age of four fell out of bed, and from that time began to walk with difficulty, and ultimately acquired a double talipes equinus. The right leg atrophied, the left remained of tolerable thickness. At the age of thirty-four she was admitted to an insane asylum during the incipient stage of dementia paralytica, and death occurred two years later of pneumonia. The autopsy showed--1st. That the calf-muscles on both sides were converted into masses of fat, streaked with whitish-red remnants of muscular tissue. The short muscles of the feet were atrophied; all the other muscles of the body normal. 2d. In the brain the blood-vessels showed a thickening of the adventitia by delicate connective-tissue fibrillæ, between whose meshes nucleated cells were strewed. The ependyma of the ventricles was thickened and granular, and their cavity was filled with serous effusion. 3d. In the cord was found diffused degeneration, especially of the lateral columns, consisting in thickening of the interstitial connective tissue, with proliferation of its cells; atrophy of a part of the primitive nerve-fibres with granular degeneration of the {573} medullary sheath, and occasionally atrophy of the axis cylinder. The adventitia of the blood-vessels was thickened, the perivascular spaces dilated. In the central gray substance the ganglion-cells were everywhere intact, but the intercellular substance was thicker, and seemingly composed of a thick net of stout, finely-granular fibres. Traces of an infantile polio-myelitis were found in the lower part of the lumbar enlargement (atrophy of the anterior cornua, especially the right, together with their ganglion-cells).
[Footnote 74: Beiträge zur pathol. des Ruckenmarkes, 1871.]
The final lesion of importance was the obliteration of the central canal, which was moreover surrounded by a dense ring of connective tissue. In this case the suddenness of the original paresis, the atrophy of the right leg, and the lesions of the lumbar cord found at the autopsy prove that the initial disease was an acute anterior polio-myelitis. Upon this a very localized pseudo-hypertrophy seems to have been grafted during childhood, while in adult life a chronic lepto-meningitis and internal hydrocephalus were certainly the cause of the symptoms, and probably of the lesions in the cord.
That such lesions in the cord may be the consequence of chronic hydrocephalus is well argued by Pekelharing in regard to his own recently published case, which in some respects closely resembles that by Müller. The patient was a boy in whom muscular paresis was congenital, and who from birth had exhibited deficient intelligence with an abnormally large head. At the autopsy, made at fourteen, ventricular effusion was found in the brain, and in the cord irregular dilatation of the central canal and great dilatation of blood-vessels and accumulation of leucocytes in its immediate neighborhood. Some ganglion-cells in the inner and anterior groups of the anterior cornua were shrunken and deprived of their prolongations. The author suggests that in this case the cerebral hydrocephalus was the primary disease; that the central canal in the spinal cord was dilated by extension of the effusion from the brain; that a partial reabsorption of such effusion had caused hyperæmia ex vacuo in the tissue immediately surrounding the canal; and that the emigration of leucocytes and partial alteration of the ganglion-cells both resulted from this hyperæmia.
In Müller's case the central canal and adjacent tissue were also the part of the cord most diseased; but the canal was obliterated by proliferation of the ependyma, not dilated. In Barth's case also[75] the central canal of the cord was found obliterated. The patient was a man of forty-four, who since the age of forty had suffered from stiffness in the left ankle and difficulty of walking. After a year the stiffness extended to the right ankle; in two years the paresis had mounted to the thighs, and was accompanied by severe pains. Paresis and pain then appeared in the upper extremities, which gradually atrophied. After two years the patient was entirely confined to bed, and two years later was unable even to sit up. Later, the muscles of the neck became hypertrophied. No mention is made of perceptible hypertrophy in other muscles, nor of contractions or tremors other than fibrillary. But at the autopsy was discovered a lateral sclerosis extending the entire length of the cord, associated with partial atrophy of the ganglion-cells in the anterior cornua. In both the gray and white substances the blood-vessels were dilated, and, {574} as already stated, the central canal was obliterated. The brain was healthy. The supinators of the upper extremities, the gastrocnemii at the lower, were richly infiltrated with fat streaked with long bands of connective tissue; the remaining muscles were atrophied.
[Footnote 75: Archiv der Heilkunde, xii. 2, 1871.]
The anatomical lesions in this case are identical with those of the special symptom-complex described by Charcot as amyotrophic lateral sclerosis. Certain symptoms of lateral sclerosis are wanting to complete the clinical history, but at least as many are lacking for a typical history of pseudo-hypertrophic paralysis. Only the muscles of the neck hypertrophied: the gastrocnemii and adductors, primarily atrophied, later regained some of their original size. The fatty infiltration of the calf and muscles was unattended by pseudo-enlargement or by retraction: it resembled a fatty substitution due to nerve-paralysis, rather than the hyperplastic process of pseudo-hypertrophy.
Setting aside the three foregoing cases, three remain which, together with an unimpeachable history of pseudo-hypertrophic paralysis, show positive lesions in the spinal cord. The first and the most famous was made upon a patient of Gowers by Lockhart Clarke.[76] Changes were found scattered through the entire length of the cord. "In the upper cervical region were patches of incipient disintegration in the gray network of the lateral portion of the cord, the lateral white columns being healthy. Here and there in the gray substance of the anterior and posterior cornua the intercellular matrix was wasted and disintegrated, especially in the neighborhood of the blood-vessels and at the bottom of the anterior median fissure. Here were accumulated globules of myeline and other débris of nerve-tissue. The blood-vessels were distended, their perivascular spaces enlarged. Patches of disintegration of nerve-fibres of the lateral and posterior columns were seen in the lower cervical and in the dorsal regions. Globules of myeline and masses of fatty matter were at some points accumulated at the entrance of the posterior nerve-roots, and even, to a much less extent, adjacent to the anterior roots. The most extensive lesion existed in the lowest part of the dorsal region. In the lateral gray substance on each side was an area of softening containing an actual cavity just outside each posterior vesicular column. The latter remained undamaged.