The pneumonia, however, may be slight or severe. In the former in stance, if uterine contraction is absent or can be arrested, resolution takes place rapidly. If, on the contrary, the pneumonia is severe, it always causes abortion. But, while in the first case abortion is usually followed by relief, in the second the pulmonary lesions are aggravated, extend Over both lungs, and death ensues in from two to six days.
What is the actual cause of the expulsion and death of the fcetus? Violent straining, due to coughing, shock, the accumulation of carbonic acid in the blood (which, as Brown-Sequard has shown, incites uterine contractions), and heart-failure have been suggested by various authorities. We believe in the influence of all these factors, but there is one which, in our opinion, is more powerful than all the rest; here, as in variola typhoid fever, it is the elevation of the maternal temperature, an eleva tion which, by causing the death of the fcetus, transforms it into a for eign body, of which the uterus seeks to rid itself.
Prognosis.—We must consider this from both the child's and the mother's standpoint.
1st. The Fcetus.—We have seen that pregnancy is often interrupted, and that, in consequence, the life of the child is often compromised. The prognosis, then, is exceedingly grave, perhaps a little less so during the last three months, but always very serious; and in some cases we can witness, as it were, the death-struggle of the fcetus. The active move ments become disturbed, irregular or spasmodic, then they are seen to grow gradually weaker, and finally to disappear entirely. The same phenomena appear iu the cardiac beats; they are first accelerated, then diminish, become feeble, and finally cease.
2d. The Mother. —Without being nearly as grave for the mother as it is for the fcetus, the prognosis in her case is none the less extremely seri ous; it is sufficient to refer to the statistics presented by authorities. Grisolle reports a mortality of 92.8 per cent., Ricau, 35.8. Bourg-eois, 75, Wernich, 21.1, and Chatelain, 39. As regards the effect of the expul sion of the kettle, it does not seem to be favorable to the mother; thus, out of 82 women who miscarried, 58 died, while only 16 deaths occurred among 74 women, who did not abort. Several writers, on the contrary, affirm that abortion is followed by the resolution of the pneumonia, and hence the advice to induce premature labor. Wernich, Hegar, Martin, r; us
serow, and other German authorities, are positively opposed to this meas ure, on the ground that the sudden change of pressure within the thoracic cavity, resulting from the rapid emptying of the uterus, must inevitably produce fatal pulmonary cedema.
We believe that artificial abortion should not be entirely rejected, but that it should be reserved for special cases. In the face of such a grave complication of pregnancy as pneumonia, we think that, when all methods of treatment have failed, and the life of the mother is seriously threatened, we have no right to deny her a possible chance of being saved, as shown by the eases cited by Thirion and Aran. Moreover, all writers agree in affirming that the emptying of the uterus lessens, at least for the time being, the pulmonary congestion and dyspncea, and consequently affords a decided relief to the patient. Although this relief may be only tempo rary, it is, nevertheless, of benefit to the woman, and, as the child is almost inevitably doomed through the presence of the disease alone, our course should be governed entirely by the mother's interests. Unfortunately, a serious and weighty objection has been presented to those who favor an operation; it is, that the induction of abortion and premature labor always requires a length of time, which may vary from twelve to thirty-six hours, and even longer, during which inteml the disease may make rapid strides and destroy the patients. This objection, we think, loses much of its force if we adopt Barnes's method,—dilate the cervix by dilators of gradually in creasing size, and, when the dilatation is complete, terminate the labor as rapidly as possible, without injury to the woman. As for abortion, we believe that it should be produced still more rarely, and then by ruptur ing the membranes. The induction of abortion and premature labor are, in our opinion, most clearly indicated in cases of double pneumonia, and when pneumonia occurs in a woman already affected with cardiac disease, or in a rachitic subject—in short, in a woman whose respiratory conditien was already bad before the occurrence of the pneumonia.