Should the ovum be contained in the cervical canal, the patient should be placed in the left lateral or preferably in the cross-bed position, the vulva should be washed with sterilised liquid soap, and redundant hair removed with scissors or razor, a vaginal douche given of i in 4,00ci perchloride of mercury or of r dr. to the pint creolin, lysol. or other coal-tar derivative, and the ovum removed by the fingers. This can be easily done if the external us is open. If it be closed, and the cervical tissues stretched over the ovum, a slight snick at two or three points on the margin will allow the enucleation to be effected. A douche should then be given and a sterile pad applied.
Incomplete Abortion.—] f the ovum in whole or part is still in the uterus, the procedure to be adopted will largely depend on whether the cervical canal is fully open or partially closed, and also on the answer to the question whether pregnancy has beyond the third month, as after that date the risk of a serious and alarming haemorrhage is much increased.
If the canal is not yet fully dilated, or if it has closed again after the expulsion of a part of the ovum, the practitioner will do no harm by plugging the vagina. The vulva is first washed and sterilised as already described, and a vaginal douche administered. The posterior vaginal wall is then held back by a speculum or by the first two fingers of the left hand. The plugging material may be iodoform gauze, which can be bought in tins ready sterilised, or bismuth gauze, or pledgets of cotton wool rolled up and fastened with a piece of stout thread or string. The gauze or wool should be wrung out of i dr. to the pint solution of lysol or creolin before being introduced into the vagina. Whatever material is used should be introduced in a methodical manner; the posterior fornix should first be filled, then each lateral fornix, and lastly the vagina in front of the cervix. The plug should be left in place for from S to 12 hours, and a small dose of morphia may be administered to quiet the patient during the interval. The results of the plug are often very satis factory. On removing it dilatation of the cervix will be found to have taken place, and in very many cases the ovum will have been expelled, and will be found in the upper end of the vagina, or protruding through the cervix. Should this not have occurred, the treatment of the case will fall under that detailed in the next paragraph.
When tike us is fully dilated, the practitioner should proceed to empty the uterus. The strictest antiseptic precautions should be taken, the vulva washed again and and an antiseptic vaginal douche given. The cross-bed position will be found the most satisfactory, although the operation may be done with the patient lying on her left side. If the pregnancy is an early one, say before the third month, I think the best way to empty the uterus is with the curette. Many distinguished authorities advise the finger, but I have serious doubts if it is possible at this early stage to pee] the ovum completely off the uterine wall with the finger, and although it may be possible to shell the ovum out of the cervical canal when it has left the uterine cavity, it is certainly not possible to hook it out of the uterus and through the cervical canal with only the tip of one or at most two fingers as a tractor. If the finger alone is used,
there is, therefore, considerable risk of leaving part—it may be a small part—of the ovum behind, and as it is undoubtedly more difficult to provide an aseptic finger than a sterilised curette, there is risk of sepsis. I advise the practitioner to boil his speculum, tenaculum, and curette, and to place them in a basin of lysol or creolin solution. Pass the specu lum, seize the cervix with the tenaculum, and pass the curette carefully into the body of the uterus up to the fundus. Remember that only a very light touch is necessary to detach the ovum from the uterine wall, and go carefully and thoroughly over the whole of its interior. When detachment of the placenta has been effected at one point, it is usually rapidly and easily completed, the uterus begins to contract, and the secundines present at the os, where delivery may he facilitated by grasping them with a pair of ovum or tongue forceps and pulling on the mass. If the foetus is still in the uterus, it may be grasped and extracted with forceps; this will be done more easily if the head be perforated with the curette. The operation is completed by an intra-uterine douche given through a Bozemann's catheter. Before douching it is advisable to pass the finger up to the fundus to make sure that no tags of placenta have been left adhering to the uterine wall. There is little risk of perforating the uterus if the operator will remember that perforations are caused by pushing the end of the instrument too far or by scraping too vigorously, and if these points are remembered the risk is, if anything, rather less with a sharp than with a blunt curette. The aborting uterus sometimes dilates suddenly, and the cessation of resistance gives exactly the sensa tion of the instrument having passed through the wall, but it rapidly regains its tone and relieves the operator's mind. If a perforation actually occurs, no harm will he done provided strict antisepsis has been observed and a flushing curette is not being used. After the third month it is more expeditious, and probably safer, to use the fingers. The uterine cavity is now larger; it is therefore more difficult to be sure of dealing with the whole surface with the curette, and at the same time it affords more room for the skilful manipulation of the fingers. As many fingers as possible should be introduced through the os, and should be used to peel off the placenta, while the other hand grasps the- fundus through the abdominal wall and makes pressure on it, so as to bring every part of the wall within reach of the internal hand. Complete removal should be verified by examination, and an intra-uterine douche then given. If desired, the whole operation of clearing out the uterus may be performed at one sitting, even when the cervix is not dilated, by dilating up to 14 Hegar in the case of a pregnancy of three months or less, or by dilatation and incision of the cervix in a pregnancy which has advanced farther.