p;-j
 
 ^ABORTION 
 
 A^D ITS TREATMENT, FROM THE STAl^D-POmi 
 OF PRACTICAL EXPERIENCE 
 
 A SPECIAL COURSE OF LECTURES DELIVERED AT 
 
 THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK 
 
 SESSION OF 1889-'90 
 
 BY 
 
 T. GAILLAED THOMAS, M. D. 
 
 EUERITCS PEOFESSOR OF OBSTETRICS AND GYNECOLOGY 
 
 FROM NOTES 
 
 By p. BRYNBERG PORTER, M. D. 
 
 REVISED BY THE AUTHOR 
 
 NEW YORK 
 D. APPLETON AND COMPANY 
 
 1896 
 
 ^ 
 
 f\
 
 Copyright, 1890, 
 
 By d. appleton and company.
 
 ABORTION AND ITS TREATMENT. 
 
 LECTURE I. 
 
 Vagueness and diversity of opinion in reference to the subject 
 The views here expressed based on practical experience 
 The importance of the uterus in the female economy Im- 
 pregnation and conception The development of the em- 
 bryo Formation of the placenta Definition of abortion 
 Distinction between abortion, miscarriage, and premature 
 labor The natural history of abortion Differences in the 
 way abortion may occur and the necessity of treating each 
 ease according to its individual character and circum- 
 stances. 
 
 GrENTLEMEisT : I have selected abortion as the 
 subject for this special course of lectures, and I 
 shall treat it entirely from a practical point of 
 view. I have chosen this topic for the reason 
 that, as I look back over my experience in the 
 medical profession a career of now more than 
 thirty-five years T recall nothing which in 
 times past has caused me more anxiety and
 
 2 ABORTION AND ITS TREATMENT. 
 
 doubt, or in regard to which I have found it 
 more difficult to get any satisfactory rules from 
 books, than the treatment of abortion. When 
 you come to look for absolute rules in the vari- 
 ous authorities on obstetrics, you will find a 
 great deal of uncertainty and diversity of opin- 
 ion. Only recently a discussion took place on 
 this subject in a public society in this country ; 
 and here, again, in reading the reports of it 
 published in the medical journals, one is at 
 once struck with the want of unanimity among 
 the different participants. 
 
 I w^ant you to understand clearly that in 
 these lectures I am not going to give you the 
 opinions of the latest authorities in Vienna, 
 London, or Paris, but that I will impart to you 
 all that a thirty-five years' practice has taught 
 me about abortion. To give the results derived 
 from such a practical experience is, as I con- 
 ceive, and as I have often had occasion to re- 
 mark in my lectures, the most useful kind of 
 teaching, as such instruction will enable the 
 pupil to commence in his practice at the point
 
 ABORTION AND ITS TREATMENT. 3 
 
 where Ms teacher left off. There is a vast dif- 
 ference between learning and being taught a 
 thing. If yoTi have to learn anything from 
 your own experience, it may take you a long 
 time and involve a waste of much honest effort ; 
 but if you are taught it at the beginning by 
 one who has thoroughly studied the subject 
 and had much personal experience in regard 
 to it, you can readily perceive at how great an 
 advantage this places you. 
 
 The uterus is a most extraordinary part of 
 the female economy. It is the organ which 
 divides one sex from the other. This organ has 
 three entirely distinct and different periods of 
 existence. From birth to the age of thirteen, 
 or puberty, it is undeveloped and unimpor- 
 tant. From thirteen to fifty its career is one of 
 intense activity, and it has a marked influence 
 upon the whole being of the woman. From 
 the age of about fifty to the close of life it 
 sinks into insignificance again, and becomes an 
 atrophied and unimportant organ of no use 
 whatever.
 
 4 ABORTION AND ITS TREATMENT. 
 
 Not only has the uterus these different 
 phases, it is subject to various distinct influ- 
 ences, and one of the most important of these is 
 ovulation. Without taking up any of the moot 
 questions in regard to this function, I will merely 
 say that it certainly affects the uterus by caus- 
 ing active congestion and haemorrhage. A still 
 more marked influence, however, is excited by 
 the meeting of the zoosperm and ovule in some 
 part of the uterine tract. This meeting may 
 take place in the peritonseum, the fimbriated 
 extremity of the Fallopian tube failing to grasp 
 the ovum, and thus permitting it to drop into 
 the abdominal cavity. Next, it may occur in 
 the ovary, next in some part of the Fallopian 
 tube, and next in the uterine cavity. Lastly, 
 it is probable that it may take place in the 
 cervical canal. Impregnation and conception, 
 it should be understood, are two entirely dif- 
 ferent things. Ova may become impregnated 
 twelve times a year, and yet conception may 
 not result. Conception is the fixation of the 
 impregnated ovum, and instantaneously on its
 
 ABORTION AND ITS TREATMENT. 5 
 
 occurrence a communication is set up through 
 the nervous system, while the whole economy 
 of the woman begins to change. In the uterus 
 the muscular fibres commence to grow, and the 
 mucous membrane undergoes rapid develop- 
 ment. Formerly many authorities held that the 
 non-pregnant uterus had no mucous membrane ; 
 but the microscopic researches of recent times 
 have demonstrated its existence. 
 
 I do not propose to give you a disquisition 
 on generation and embryology ; but there are 
 a few essential points with which it is quite 
 necessary that you should be familiar if you 
 wish to comprehend the subject of abortion. 
 After conception has taken place the whole of 
 the mucous membrane becomes thickened, form- 
 ing the decidua i^era, while a portion of it 
 grows upward around the ovum. In olden 
 times it was supposed that the latter was a 
 false membrane, but more careful investigations 
 proved that this was not the case, and that it 
 was merely a hyperplasia of the membrane in 
 this part. The ovum having attached itself to
 
 6 ABORTIOX AND ITS TREATMEXT, 
 
 one particular spot, the exuberant mucous mem 
 brane goes on growing about it until it entirely 
 surrounds it, and this enveloping membrane is 
 still known by the old name decidua rejlexa. 
 You have all seen the bark of an oak growing 
 over and covering a nail driven into the tree. 
 Thus it is with the ovum and the uterine 
 mucous membrane. 
 
 In a little while the allantois is developed, 
 and from the foetal body, which has no connec- 
 tion with the decidua vera and decidua reflexa, 
 two distinct membranes are formed the amnion 
 and the chorion. The latter attaches itself to 
 the uterus by little rootlets which extend into 
 the uterine glands, while the amnion is merely 
 a membrane which secretes a clear fluid known 
 as the liquor amnii. The fcetal ball is every- 
 where attached to the uterine walls, and it gets 
 its nourishment from the carpet-like surface of 
 the uterus. By endosmosis the nutrient mate- 
 rials in the blood of the mother are taken into 
 the circulation of the foetus ; and not only does 
 the chorion take nutriment from the mother's
 
 ABORTION AND ITS TREATMENT. 7 
 
 blood, but it will also take poisons or whatever 
 else happens to be circulating in it. Thus, the 
 foetus may be fatally affected by the hypo- 
 dermic injection of morphine or other poisons 
 into the mother's body. 
 
 The foetus is nourished in this way until the 
 end of the second month, when a change takes 
 place. The placenta begins to form ; and this 
 is a vital point in the subject of these lectures. 
 Up to two and a half months there is no pla- 
 centa, so far as abortion is concerned. Between 
 two and a half and three and a half months 
 the chorion loses all its tufts except at one 
 point. Here it becomes excessively vascular 
 and increased in thickness, and this thickened 
 portion, with the thickened decidua, forms the 
 placenta. The rest of the chorion becomes 
 bald, but is still lightly attached to the de- 
 cidua reflexa. From the third month the pla- 
 centa is the all-important element as regards 
 abortion. 
 
 Abortion is to be defined as the premature 
 casting off of the product of conception before
 
 8 ABORTION AND ITS TREATMENT. 
 
 the end of the fourth month. After the end 
 of the fourth month the physiological condi- 
 tions present are materially different. The term 
 premature labor can not be applied to expulsion 
 of the foetus as early as the fifth month. Au- 
 thorities do not agree as to how it is best to 
 designate such cases occurring between the 
 fourth and seventh months. I know of no bet- 
 ter term for them than miscarriage. After the 
 end of the sixth month we style it premature 
 labor, because there is a possibility of the via- 
 bility of the foetus. I would say incidentally 
 that I often induce premature labor, and I re- 
 gard it as a procedure of the greatest possible 
 importance. With the experience which we 
 now have, it can only be regarded as trifling 
 with a woman's life to allow her to go to full 
 term in cases of aggravated albuminuria from 
 puerperal nephritis, and also in many cases of 
 placenta prsevia. 
 
 In abortion we have the expulsion of the 
 product of conception before the end of the 
 fourth month, in miscarriage between the end
 
 \ ABORTION AND ITS TREATMENT. 9 
 
 of the fourth month and the end of the sixth 
 month, and in premature labor between the end 
 of the sixth and the end of the ninth month. 
 A labor is not regarded as strictly premature, 
 however, which occurs within two weeks of the 
 normal termination of gestation. On account 
 of the difference in the physiological conditions 
 at these several periods, as I have said, the 
 rules of treatment are also entirely different. 
 For example, while it is perfectly proper to 
 use the tampon in the earlier months of preg- 
 nancy, such a procedure might be followed by 
 the most serious consequences during the sixth 
 month. 
 
 We come now to consider the pathology and 
 natural history of abortion. When this acci- 
 dent occurs, one of several things may take 
 place. First, there may be a complete empty- 
 ing of the uterine cavity. A woman makes 
 some unusual exertion or becomes suddenly 
 alarmed from some cause or other, and imme- 
 diately there is a violent and instantaneous con- 
 traction of the uterus, which forthwith expels
 
 10 ABORTION AND ITS TREATMENT. 
 
 its entire contents the decidua vera, the de- 
 cidua reliexa, the amnion, the chorion, and the 
 foetus. Should death ensue (which is not at 
 all likely under ordinary circumstances), the 
 internal surface of the uterus would be found 
 on examination to look very much like raw 
 flesh, and no membranes or anything else would 
 be discovered in its cavity. If you will split 
 open such a foetal shell, which is only met 
 with in the very early stages of pregnancy and 
 is often incorrectly called a "mole," you will 
 find that it has very thick walls and that in 
 its central cavity there is a small amount of 
 liquor amnii and a very small foetus. 
 
 In the second place, the foetus may be ex- 
 pelled with the amnion and chorion, while the 
 decidua vera is left in the uterus. Wheth- 
 er the decidua reflexa is expelled with the 
 foetus or not we can not say, though this is 
 probably the case. In any event, however, 
 this is of very little consequence, as the mem- 
 brane is very thin and of no importance. The 
 important point in this class of cases is that
 
 ABORTION AND ITS TREATMENT. H 
 
 the lining membrane of the uterus is not 
 ripped away, as in the preceding. This mem- 
 brane will come away later in the lochial dis- 
 charge. 
 
 Thirdly, the foetus alone may be expelled. 
 The liquor amnii follows the foetus, which (the 
 delicate umbilical cord being severed) makes 
 its way through the amnion and chorion, which 
 remain in situ in the uterus. This is a compli- 
 cated case. Very often the physician is not 
 consulted until three or four days after the 
 expulsion of the foetus, and he is then informed 
 of the event and told that everything is satisfac- 
 tory. He probably finds the patient perfectly 
 comfortable, with a pulse of 80 and a tempera- 
 ture of 98|, and she and her friends are likely 
 to strenuously object to any interference on his 
 part. Under these circumstances what is he to 
 do? It is certainly a very trying position ; but 
 if he does not insist on emptying the uterus of 
 the contents still remaining in it, the chances 
 are that he may again be summoned, to find 
 that the woman has had a violent chill and is
 
 12 ABORTION AND ITS TREATMENT. 
 
 now in a high fever, with all the signs of putrid 
 intoxication or septicaemia. 
 
 Fourthly and lastly, when utero-gestation is 
 a little further advanced, the fcBtus and mem- 
 branes may be expelled and the placenta left be- 
 hind. In such a case the practitioner is apt to 
 console himself with the idea that everything 
 has come away, and that consequently there will 
 be no farther trouble. A retained placenta is 
 sometimes difficult of removal, and you may 
 perhaps give yourself the benefit of the doubt 
 as to whether there is anything more in the 
 uterus, and run the chances of escaping evU, 
 even if the placenta does remain. Unfortunate- 
 ly, in a large proportion of cases the most seri- 
 ous results will follow if the placenta is allowed 
 to remain. A day or two ago I consulted a cer- 
 tain author in regard to the prognosis of abor- 
 tion, and I found that he pictured it in a very 
 rose-colored way, stating that there was but 
 little danger of a fatal issue, and that the mor- 
 tality was very small. The facts of the case I 
 believe to be directly the opposite of this.
 
 ABORTION AND ITS TREATMENT. 13 
 
 There can be no question whatever that a large 
 number of deaths occur which are directly or 
 indirectly due to abortion, but which are set 
 down to other causes. The principal lesson 
 which I would have you learn to-day is, then, 
 that abortion does not always occur in the 
 same way, and that the physician must be fully 
 prepared to treat each case according to its 
 character and the special circumstances attend- 
 ing it.
 
 LECTURE II. 
 
 The causes of abortion Maternal causes Poisons in the blood 
 Nervous disorders Reflex influences Drugs Foetal causes 
 Compression of the umbilical cord Syphilis Rupture of 
 umbilical vein Injury to fcEtus from external causes 
 Uterine causes Retroflexion and other displacements Fi- 
 broids and other neoplasms Laceration of the cervix 
 Habitual abortion The modus operandi of the causes of 
 abortion Physiological abortion and the folly of interfer- 
 ing with it The use of ergot 
 
 In the last lecture, you will remember that 
 I gave you the technical definition of abortion. 
 I now wish to ask, and answer the question of 
 its meaning from a different standpoint viz., 
 from that of its natural history. From this 
 standpoint what is the definition of abortion ? 
 You must understand that an abortion may 
 take place at any time between the moment of 
 fixation of the ovum and the end of the fourth 
 month, and that anything whatever which causes 
 the uterine body to contract and to overcome
 
 ABORTION AND ITS TREATMENT. 15 
 
 the spMncteric action of the cervix uteri, and 
 thus causes the emptying of the contents of 
 the uterine cavity, constitutes this process. 
 
 Let us consider now what the causes of 
 abortion are. And here let me say that I give 
 you these causes not for the examination-room, 
 but for the bedside. I do not propose by any 
 means to enumerate all the causes. To do so 
 would probably take up our entire hour ; and I 
 have always held that the didactic lecture ought 
 never to take the place of the text-book for the 
 student. What you ought to learn from lect- 
 ures like these is the method of studying a sub- 
 ject. All the minute details of that subject 
 you can derive from private reading, for all 
 the minutiae in any department of medical sci- 
 ence are elaborately set forth in the systematic 
 works at your disposal. 
 
 ]N"ow, suppose that a woman applies to you 
 for advice who tells you that she has been mar- 
 ried eight or ten years, and in that time has had 
 a dozen abortions, and that these abortions have 
 always occurred about the end of the third 
 
 2
 
 16 ABORTION AND ITS TREATMENT. 
 
 montli. Or, suppose that you are consulted by a 
 woman who tells you that she has been married 
 twenty years, that nineteen years ago she gave 
 birth, after a perfectly natural labor, to a well- 
 developed and healthy child, and that since 
 then she has never borne a child, but has had a 
 considerable number of abortions always at the 
 third or fourth month. The problem that is 
 presented to you is to find out what has been 
 the cause of the habitual abortions in these 
 cases ; and what I want to do now is to tell you, 
 as far as I am able, how to look for the cause of 
 the trouble in such instances. It must be borne 
 in mind, however, that a considerable number 
 of cases are met with in practice in which, not- 
 withstanding the fact that the cause of the abor- 
 tions can be determined with positiveness, it is 
 utterly beyond the power of the physician to 
 prevent their occurrence ; and, furthermore, that 
 in many instances no assignable cause for the 
 abortions can be discovered. But if the points 
 to which I am about to direct your attention are 
 fully impressed upon your minds, I can assure
 
 ABORTION AND ITS TREATMENT. 17 
 
 yon that, as you gain experience, the number 
 of this latter class of cases which you meet with 
 will grow steadily smaller. 
 
 All the causes of abortion can be divided into 
 three classes : 
 
 I. Systemic, or those due to a general ma- 
 ternal condition. 
 
 II. Foetal. 
 
 III. Uterine. 
 
 These three classes of causes, as a rule, are 
 entirely independent of each other. 
 
 Let us suppose that, in the case of a woman 
 who has had a number of abortions, the foetus 
 and its envelopes have been carefully examined 
 in every instance, and have been found perfectly 
 normal. It is evident that disease of the foetus 
 has had nothing to do with the causation of 
 the accident, and that there must be something 
 wrong about either the uterus or the general 
 system of the mother. As a rule, however, you 
 will not be able to secure definite information 
 in regard to the condition of the foetus in the 
 different abortions without a long and careful
 
 18 ABORTION AND ITS TREATMENT. 
 
 investigation, as it is likely to be the case that 
 the woman has been attended by several differ- 
 ent physicians at these times. Hence it will be 
 best first to make a thorough examination of 
 the general system of the patient, and then, 
 if you find nothing about that to account for 
 the trouble, communicate with any of the phy- 
 sicians who have attended her in her abortions 
 who can be reached, and learn, if possible, 
 whether in any instance a microscopic exami- 
 nation was made of the product of conception, 
 and, if so, whether evidences of syphilis, or 
 other disease likely to bring about foetal death, 
 were found to be present. 
 
 I will now proceed to give you more in 
 detail the causes which come under each of 
 these three heads. Among the systemic causes, 
 a number are connected with the nervous sys- 
 tem and a number with the blood ; and I will 
 speak first of the latter. It is well known that 
 carbonic-oxide gas has a more certain effect in 
 exciting uterine contractions than ergot itself. 
 It is related that some years ago when Mar-
 
 ABORTION AND ITS TREATMENT. 19 
 
 shal Pelissier, at the head, of a French army, 
 was waging a war of conquest in a certain dis- 
 trict of Algiers, he drove an Arab tribe into a 
 large cave, where they had secreted their valu- 
 ables, and kept them imprisoned there for some 
 days. When the people were finally released, 
 it was found that quite a large number of the 
 pregnant women of the party had aborted, this 
 result being unquestionably due to the poison- 
 ing of their blood by the carbonic-oxide gas 
 which had been generated from the crowding 
 together within confined quarters of so many 
 human beings. It is a curious fact, also, that 
 this poison sometimes has the effect of causing 
 the post-mortem delivery of pregnant women, 
 and I myself have had the opportunity of ob- 
 serving two such instances, the mothers in both 
 of them being nearly at full term. In such 
 instances, which never occur until some hours 
 after death, the carbonic- oxide gas which prO' 
 duces the uterine contractions is given off from 
 the decaying tissues. 
 
 Among other poisons in the blood which are
 
 20 ABORTION AND ITS TREATMENT. 
 
 capable of causing abortion are those which cre- 
 ate the exanthematous eruptions of small-pox, 
 scarlatina, measles, etc. ; and you will occasion- 
 ally find that unusually severe malarial poison- 
 ing will give rise to it. A chill is nothing but 
 a slight convulsion, and in very malarious dis- 
 tricts the chill of the adult is often replaced by 
 the convulsion in children, this sometimes being 
 so severe as to destroy life. This malarial poi- 
 soning, I am convinced, is the cause of some 
 of the cases of habitual abortion which are met 
 with. 
 
 Next we will consider some of the nervous 
 causes. Some women of highly nervous organi- 
 zation are liable to have abortion brought on by 
 the most trivial causes. Indeed, a mere odor 
 has been sometimes declared to produce this re- 
 sult. The nerves are more answerable for abor- 
 tions than the blood ; and prominent among the 
 nervous disorders which are apt to give rise to 
 the accident may be mentioned chorea. Yet, 
 notwithstanding this tendency in general, I have 
 at times met with patients in whom the disease
 
 ABORTION AND ITS TREATMENT. 21 
 
 did not cause abortion, but had such a pro- 
 found effect upon the system otherwise that it 
 was found necessary to produce abortion arti- 
 ficially in order to save their lives. Tetanus is 
 even more liable than chorea to cause abortion. 
 Then, again, the reflex influences may cause it ; 
 and one of the most common of these is sudden 
 fright, I once met with the case of a lady in 
 perfect health who, while on her way to this 
 city on a railway train with her husband, fell 
 asleep and was awakened in sudden terror by 
 the entrance of the train into a tunnel. In- 
 stantly she felt a violent uterine pain, and dur- 
 ing the following night she gave birth to a 
 foetus. Under the placenta I found a clot of 
 blood as large as a pigeon' s egg, which was un- 
 questionably the immediate cause of the abor- 
 tion. The sudden fright acted primarily on the 
 nervous centres, and the result was a severe 
 spasm of the uterus which caused placental apo- 
 plexy. In consequence, the clot mentioned was 
 formed, and the irritation of this clot, acting as 
 a foreign body, gave rise to the contractions
 
 22 ABORTION AND ITS TREATMENT. 
 
 which in a few hours resulted in the emptying 
 of the uterus. 
 
 Again, there are, as you know, certain drugs 
 such as ergot, cotton-root, viscum album, and 
 others which I need not enumerate which have 
 a specific action on the uterus and sometimes 
 produce abortion. It is only necessary to state 
 that ergot is the typical agent of this class. 
 
 When in any case of habitual abortion you 
 have ^ excluded those causes originating in the 
 system of the mother, you will have to direct 
 your attention to the foetus. As to the foetal 
 causes of abortion, it may be stated as a gen- 
 eral proposition that anything which will kill 
 the foetus will produce an abortion. There are 
 only two things which can happen to the dead 
 foetus if it is not cast off. One of these is 
 atheromatous or fatty degeneration, resulting in 
 the so-called "mole," or in that very rare and 
 curious calcification known as uterine stone. 
 But in the great majority of cases the decaying 
 foetus, acting on the nerves of the uterus, pro- 
 duces contraction and expulsion.
 
 ABORTION AND ITS TREATMENT. 23 
 
 During the later months of pregnancy the 
 membranes and other appendages of the foetus 
 are constantly liable to get out of order, and, 
 by reason of sudden movements of the foetus, 
 the umbilical cord is especially apt to become 
 twisted or tied in a knot, occlusion of its vessels 
 sometimes resulting in the death of the foetus. 
 I once knew of a woman who in the ninth month 
 of pregnancy felt the child bound in her uterus. 
 She very soon became ill, and suffered greatly 
 until she was delivered at full term. It was 
 then found that there were two children in 
 utero, one of which was in a perfectly healthy 
 condition, though it was still-born, while the 
 body of the other was so swollen and emphy- 
 sematous that it had to be removed piecemeal. 
 This putrefaction had come on during the two 
 weeks that the foetus (which had no doubt been 
 killed by the knotting of the cord resulting from 
 its violent movement) had remained dead in the 
 uterus. The mother unfortunately died of sep- 
 ticaemia after the labor. Of course, the umbili- 
 cal cord is not liable to get into a knot in the
 
 24 ABORTION AND ITS TREATMENT. 
 
 earlier montlis of pregnancy ; but injury to it 
 may occur as early as the fourth month. 
 
 Syphilis is one of the two most frequent 
 causes of habitual abortion. It may be de- 
 rived from the father or mother, or from both 
 parents, and it affects not only the child, but 
 the membranes, causing fatty degeneration of 
 the placenta, and thus interfering with the 
 aeration of the blood supplied to the foetus. 
 
 Finally, I should mention one other cause, 
 and that is injury to the foetus from external 
 influences. As an illustration of this I will 
 refer to the case of a lady who, while walking 
 across her bed-chamber in the dark, ran against 
 the corner of a table, striking her abdomen, 
 though not with any great force. She thought 
 nothing more of this occurrence, but in two 
 weeks after it she had an abortion, and an ex- 
 amination of the foetus, which was not quite 
 four months old, showed that it had been struck 
 upon the spine by the blow referred to. This 
 was unquestionably the cause of its death and 
 the resulting abortion. A case like this shows
 
 ABORTION AND ITS TREATMENT. 25 
 
 with what care in abortion we must go over 
 the possible causes of the accident. 
 
 Now for the uterine causes. The second of 
 the two grand factors in causing abortion of 
 which I spoke (the first being syphilis) is retro- 
 flexion of the uterus. As to the time when 
 abortions usually take place, it is a well-estab- 
 lished fact, about which there can be no possi- 
 ble doubt, that a large proportion of all abor- 
 tions occur about the end of the third month. 
 Hence, if you have a patient who has been 
 subject to abortion, you should by all means 
 keep her strictly quiet at this particular time. 
 Why, you may ask, are abortions so especially 
 liable to come at this time ? There are several 
 reasons for this. In the first place, this is the 
 third menstrual period, when the nutrition of 
 the foetus is changing its character; secondly, 
 the placenta is now rapidly developing ; and, 
 thirdly, the uterus is beginning to rise out 
 of the pelvis. It is the time, moreover, when 
 syphilis, if present, affects the placenta, and 
 when retroflexion is most apt to be attended
 
 26 ABORTION AND ITS TREATMENT. 
 
 by the conditions instrumental in producing 
 abortion. I wish it to be clearly understood 
 that I am speaking now of habitual abor- 
 tion. 
 
 It is impossible for me to enumerate all the 
 causes of abortion. I therefore ask you to 
 think for yourselves, guided by such hints as 
 I am able to give you from my own experience. 
 If you will stop to consider, you will readily 
 see that uterine fibroids, whether submucous or 
 interstitial, and other neoplasms, must necessa- 
 rily be a frequent cause of habitual abortion. 
 
 "H^iere are still other uterine causes which I 
 am unwilling to pass over without mention. 
 The cervix uteri, as you know, is not obliter- 
 ated until a late period in utero-gestation. It 
 offers a suitable place for the foetal mass to 
 rest upon, and also serves to protect the latter 
 from disturbing influences from below. In cer- 
 tain cases, however, owing to a laceration of 
 the external os in a previous labor, the cer- 
 vix is completely obliterated from below, and 
 laceration of it must therefore be borne in
 
 ABORTION AND ITS TREATMENT. 27 
 
 mind as one of tlie causes of repeated abor- 
 tions. But we are liable to make a great many 
 mistakes if we expect that in every case of 
 habitual abortion in which such a laceration 
 exists we can put an end to this trouble by 
 sewing up the everted lips of the torn os. In 
 many instances this operation will undoubtedly 
 put an end to the habit of abortion, but in 
 others you will find, after you have performed 
 it, that the latter has been due to some other 
 cause. Many women will go on bearing chil- 
 dren to full term, notwithstanding the most ex- 
 tensive lacerations of the os ; and others, with 
 such lacerations, will continually have abor- 
 tions. The difference in these two classes of 
 cases lies in the different nervous organizations 
 of the women themselves. 
 
 Now, a word further in regard to uterine dis- 
 placements. In all the various forms of dis- 
 placement, such as prolapse, anteflexion, retro- 
 version, and retroflexion, abortions are liable to 
 be met with, but in all except the last named 
 they are comparatively rare. In retroflexion
 
 28 ABORTION AND ITS TREATMENT. 
 
 they are exceedingly common, and, as I have 
 already pointed out, this condition and syphi- 
 lis constitute the two grand factors in the pro- 
 duction of habitual abortion. The special rea- 
 son why retroflexion so often leads to abortion 
 is the marked vascular engorgement which is 
 incident to this form of displacement. 
 
 As to the method in which the various 
 causes act, in the case of the accumulation of 
 carbonic-oxide gas in the blood the action is 
 directly upon the uterus itself, as shown by 
 the fact that it is capable of causing post-mor- 
 tem delivery ; but, as a rule, the modus ope- 
 randi of these causes is through the nervous 
 system. 
 
 Let us suppose that the command goes forth 
 from the nervous centres that the fundus uteri 
 shall contract. In the normal condition the 
 sphincteric action of the cervix resists the press- 
 ure of the uterine body from above ; but as the 
 latter, under the influence of the nervous sys- 
 tem, goes on contracting, this resistance will 
 gradually be overcome. At first the woman ex-
 
 ABORTION AND ITS TREATMENT. 29 
 
 periences bearing-down pains (as they have been 
 very properly designated) at long intervals, but 
 later they occur at short ones. The os, acted 
 upon by two forces, begins to dilate. The first 
 of these forces consists of the plug-like action 
 of the foetal ball, and the second is the influ- 
 ence of the nervous system. In a little while 
 the OS internum opens, and then the whole 
 canal does so, while the membranes begin 
 gradually to detach themselves. If the pla- 
 centa is formed, that also becomes slightly 
 detached, and the woman begins to bleed 
 often to an alarming and sometimes to a fatal 
 extent. 
 
 The uterus goes on forcing down its con- 
 tents, and at length a plug gets fully into the 
 cervical canal, this plug very rarely comprising 
 the whole foetal shell, or consisting, as is the 
 very general rule, of the membranes enveloping 
 the foetus, without the decidua vera. Here let 
 me say a word in regard to the old adage, "med- 
 dlesome midwifery is bad." There can be no 
 question that this quotation is sometimes used
 
 30 ABORTION AND ITS TREATMENT. 
 
 as a cloak for ignorance ; but at the same time 
 it is true tliat meddlesome midwifery, properly 
 so called, is just as bad now as it was in the 
 days of Hippocrates. The process of expulsion 
 Just described constitutes the natural history of 
 abortion ; therefore interfere with it as little 
 as possible. 
 
 This is a maxim which it is very difficult 
 for the young practitioner to respect ! There is 
 a great temptation to remove the foetus ; but 
 if you do this the chances are that the mem- 
 branes will be left, and if this be the case they 
 are likely to cause you many a sleepless night 
 before all the consequences of your ill-timed 
 interference are over. But you may perhaps 
 say, " Why, the woman is bleeding to a dan- 
 gerous degree." If the haemorrhage is really 
 alarming, it is certainly your duty to control 
 that at all events ; but as to the pain that the 
 woman is suffering, it is better that she should 
 have this pain than that the uterine contrac- 
 tions should be interfered with by the use of 
 opium or other drugs. Opium is often a price-
 
 ABORTION AND ITS TREATMENT. 31 
 
 less boon in parturition, but it must always be 
 used with, the greatest discrimination. 
 
 After the cervix is sufficiently dilated to ad- 
 mit the greatest diameter of the foetal shell, the 
 entire contents of the uterine cavity can readily 
 come away, and there is likely to be no further 
 trouble. Everything has gone well because it 
 has been a physiological process. It is of the 
 greatest importance that the labor-pains should 
 duly perform their function. Anything which 
 breaks the bag of water and lets out the liquor 
 amnii is a misfortune, and- anything which sepa- 
 rates the foetus from the membranes is a still 
 greater misfortune. During an abortion the at- 
 titude of the physician, beyond the control of 
 haemorrhage, should be an expectant one. He 
 should let the process take its natural course 
 and only offer his assistance, as he would apply 
 the forceps in labor at full term, when Nature 
 is unable to complete the delivery. 
 
 Some of you would perhaps like to ask me 
 whether I would not use ergot under these cir- 
 cumstances. Ergot is indeed excellent in its 
 
 3
 
 32 ABORTION AND ITS TREATMENT. 
 
 place, but it often does a great deal of harm. 
 Both in labor and in abortion it should be 
 withheld until there is no decided obstruction 
 to delivery ; but, when this is the case, one full 
 dose may often be given in the later stages 
 with the most satisfactory results. If it is 
 given in abortion, this should be only when 
 the cervix has become sufficiently dilated to 
 admit the maximum part of the foetal shell.
 
 LECTURE III. 
 
 The habit of abortion Exceptions to the ordinary rules gov- 
 erning abortion Criminal abortion Retention of the prod- 
 uct of conception under extraordinary circumstances The 
 absurdity of so-called maternal impressions Great fre- 
 quency of abortion Prognosis in abortion As to life As 
 to health Elements of danger in abortion Hjemorrhage 
 Putrid intoxication Septicjemia and peritonitis Suppura- 
 tive arthritis Cellulitis and abscess Embolism Tetanus 
 Uterine hydatids Melancholia. 
 
 0]S"E word further in regard to syphilis, 
 which, as I said before, constitutes, with the 
 exception of retroflexion of the uterus, the most 
 important factor in the production of habitual 
 abortion. In order to discover its existence you 
 should make a careful examination of the prod- 
 uct of conception after it is cast off, as well as 
 of both parents. In many instances the evi- 
 dences of the disease are sufficiently plain to 
 the naked eye either in the foetus itself or in 
 the secundines. In others it is necessary to
 
 34 ABORTION AND ITS TREATMENT. 
 
 make a microscopical examination to ascertain 
 the existence of the disease. 
 
 Before I leave entirely the subject of causa- 
 tion, I wish to speak for a moment of the Tiabit 
 of abortion. You will understand, I trust, that 
 this unscientific designation is only applied to 
 a certain class of cases for which we have no 
 better term. In every case of abortion there is, 
 of course, a definite cause ; but sometimes this 
 cause is so obscure or so slight as to entirely 
 escape notice. There are many delicate refined 
 women of nervous temperament in whom the 
 mere hearing of something unpleasant or repul- 
 sive will excite nausea and vomiting, because 
 their nervous systems are thoroughly hyperses- 
 thetic, and in this class of cases the slightest 
 cause is often sufficient to induce an abortion. 
 Such women are so constituted as to their nerv- 
 ous systems that it takes very little to make 
 the uterus bear down on its contents and expel 
 them. It is very difficult for a woman of this 
 kind, even under the most favorable circum- 
 stances, to go to full term without encounter-
 
 ABORTION AND ITS TREATMENT. 35 
 
 ing some occurrence that will give rise to a 
 premature expulsion of the product of concep- 
 tion. This, then, is what I refer to as the 
 habit of abortion, and the expression is re- 
 sorted to only after we are driven to the wall, 
 as it were ; every other cause for the accident 
 having been carefully excluded. 
 
 I now ask you to consider some exceptions 
 to the ordinary rules governing abortion. There 
 are some women who are just the opposite of 
 those in whom we find the extreme facility of 
 abortion which has just been referred to ; they 
 are so hardy that it is exceedingly difficult for 
 them to get rid of the contents of the uterus 
 before the normal termination of pregnancy. 
 Incidentally I may here remark that the prac- 
 tice of criminal abortion is common in this 
 country, and women often perform it on them- 
 selves. They often learn how to introduce the 
 sound into the uterus themselves, and, having 
 done so, they move it about from side to side 
 until they excite the organ to contraction ; and 
 when the process of abortion begins they take
 
 36 ABORTION AND ITS TREATMENT. 
 
 drugs, of which they have read in books, to 
 facilitate the expulsion of the troublesome prod- 
 uct of conception. With many women, you 
 must understand, abortion is not regarded as a 
 great crime, and they are, unfortunately, prone 
 to condone it. 
 
 In this connection,* let me give you a re- 
 markable case which occurred in my own expe- 
 rience. On one occasion, a few years ago, I was 
 sitting at breakfast, when the servant announced 
 that there was a gentleman down-stairs asking 
 to see me who seemed to be crazy. I according- 
 ly went down, and found a fine-looking man 
 about thirty-five years of age who was walking 
 the floor and appeared to be in a perfect agony 
 of anxiety and excitement. He told me that he 
 was a physician from a western town, and that 
 he had come on with his wife who had injured 
 herself in an attempt to produce an abortion. 
 He stated that his wife, believing herself to be 
 pregnant, had become so alarmed, from the fact 
 
 * This case, at the time of its occurrence, was published in 
 detail in the American Journal of the Medical Sciences. P. B. P.
 
 ABORTION AND ITS TREATMENT. 37 
 
 that at her last confinement she had suffered 
 severely from puerperal fever, and that she had 
 insisted on getting rid of the product of concep- 
 tion by artificial means herself. Accordingly, 
 wishing to humor her, he had procured and pre- 
 pared for her an iron umbrella-rib, telling her 
 that if she would introduce it into the uterus 
 her purpose would be accomplished. In his 
 absence she had attempted this procedure, and 
 found that the rib, having once been pushed 
 in, kept going on and on, until at last it was 
 suddenly grasped by something and pulled up 
 entirely out of her reach, disappearing within 
 the uterus. In answer to my inquiry how long 
 his wife had been pregnant, he replied "two 
 months." 
 
 Though this story seemed utterly improbable, 
 I at once went to see his wife at her hotel, and 
 found a very handsome woman lying in bed 
 apparently in a perfectly healthy condition. 
 Her pulse and temperature were normal, and 
 she stated that she suffered no pain whatever, 
 and that the only thing of which she complained
 
 3S ABORTION AND ITS TREATMENT. 
 
 was a slight cougli. Under the circumstances 
 I thought it best to make an examination of 
 her chest, and asked her to sit up in bed for 
 this purpose. As soon as she did this she 
 gave a sudden gasp, as though she were in 
 great agony, and she suffered so greatly from 
 difficulty of breathing that it was five minutes 
 before I could go on with the examination. 
 
 I then believed that the history told by her 
 husband was true, and, fearing that the most 
 serious consequences might ensue, I determined 
 to perform laparotomy at once. Every prepara- 
 tion was accordingly made for the operation, 
 but just as the ether cone was about to be ap- 
 plied to her face an uncle of hers, who was 
 present, remarked to me that if I proceeded 
 it must be on my own responsibility, and 
 that if anything untoward happened he would 
 invoke the law to punish me for my temerity. 
 This announcement somewhat startled me, and, 
 as I had undertaken the case merely to help a 
 fellow-practitioner who was in sore distress, I 
 asked the patient if she would take the risk
 
 ABORTION AND ITS TREATMENT. 39 
 
 of the operation, and she said "no." I then 
 asked her if it was really true that she had 
 used the umbrella-rib and it had disappeared, 
 as stated, and she replied that "she didn't 
 know." In such a state of affairs I felt that 
 it would be utterly unjustifiable for me to go 
 on with the laparotomy, and I accordingly or- 
 dered that the instruments which had been 
 made ready should be put up. In a week after 
 this the woman died. 
 
 The husband utterly refused to have an 
 autopsy made ; but, as I was unwilling to give a 
 certificate of death without learning something 
 more about this obscure case, I insisted on 
 placing it in the coroner's hands, and was thus 
 enabled to obtain a post-mortem examination. 
 The result of the examination was as follows : I 
 found a non-pregnant uterus of normal size, and 
 just to the right of the cervix uteri there was 
 a puncture of the vaginal wall, evidently made 
 by the umbrella-rib mentioned. Through this 
 orifice the rib had gone, and as it passed up- 
 ward through the abdominal cavity it had
 
 40 ABORTION AND ITS TREATMENT. 
 
 scraped the surface of the liver. After trans- 
 fixing the diaphragm, it penetrated the right 
 lung to the extent of two or three inches, and 
 in this position it was found at the autopsy. 
 It was no doubt a spasm of the diaphragm, re- 
 sulting from the irritation of the rib piercing 
 it, which had caused the sudden snatching up- 
 ward of the latter, as described by the hus- 
 band in his narrative. 
 
 The rib was thirteen inches in length, with 
 its point somewhat sharpened, and surrounding 
 its upper extremity, in the lung tissue, there 
 was an abscess, which had not as yet discharged, 
 but from which septic inflaences had emanated. 
 I mention this case not only on account of 
 its peculiar interest, but to show you to what 
 lengths women will go under these circum- 
 stances. In this instance it was the dread of 
 another attack of puerperal fever which ren- 
 dered the patient morbidly anxious about the 
 matter. 
 
 But to return to those exceptional cases in 
 which the product of conception is retained un-
 
 ABORTION AND ITS TREATMENT. 41 
 
 der circumstances which, in the vast majority of 
 instances, would at once result in its expulsion. 
 In Paris pregnant young women who have at- 
 tempted suicide by jumping into the Seine, and 
 have been rescued, have been known to go on 
 to full term without the slightest threatening of 
 abortion, notwithstanding the tremendous shock 
 and mental strain incident to such an adventure. 
 There is a case related, by Mauriceau I think, 
 in which a pregnant woman, excited by an 
 alarm of fire, jumped from an upper window, 
 and, breaking through a shed by the force of 
 her descent, struck upon the stone flagging be- 
 low. When she was picked up it was found 
 that several of the bones of her body were 
 broken, but, nevertheless, she passed on to full 
 term as though nothing had happened. 
 
 Some years ago while a lady, whom I knew 
 very well, was walking out one day in the 
 woods with her husband, a huge black-snake 
 sprang out apparently from the bushes and 
 coiled itself several times around her neck, at 
 the same time spattering her with blood. Her
 
 42 ABORTION AND ITS TREATMENT. 
 
 young brother had killed the snake, and, con- 
 cealing himself in the shrubbery, had intended 
 to throw it down in the path before his sister, 
 but missed his aim, with the result stated. The 
 lady, who was at the fourth month of preg- 
 nancy, was so badly frightened that she was 
 thrown into a state of hysterical syncope, from 
 which she did not recover for hours, and for 
 several days suffered from violent hysterical 
 convulsions ; so that she seemed almost at the 
 point of death. Yet, notwithstanding this fear- 
 ful shock to her nervous system, the uterus 
 never showed the slightest tendency to contract, 
 and her child was born at full term. Before its 
 birth I was consulted as to whether I thought 
 the infant would be marked as a result of the 
 impression made upon the mind of the mother 
 by this incident, and I replied that I felt abso- 
 lutely sure that nothing of the kind was to be 
 apprehended. The sequel proved that I w^as 
 correct. 
 
 I have just received a note from one of you 
 asking my view as to maternal impressions
 
 ABORTION AND ITS TREATMENT. 4,3 
 
 upon the fcetus in utero. I believe that it is 
 utterly impossible for a maternal impression 
 to be stamjjed upon the body of the foetus. 
 The latter is to all intents and purposes out- 
 side of the mother's influence, and Yirchow, 
 the great microscopist, has never been able to 
 detect distinct nerve connection between the 
 two. Wherever there has occurred a case which 
 has seemed to confirm the old idea of the child 
 being affected in this way, it has been, I think, 
 simply a coincidence ; and the argument in fa- 
 vor of the agency of maternal impressions in 
 producing such an effect is one of post hoc, 
 not propter hoc. 
 
 What is the frequency of abortion ? This is 
 something which we do not know, and which, 
 from the nature of the circumstances attending 
 abortion, we can never find out with positive- 
 ness. Statistics have fallen into disrepute by 
 being made to apply to things which can not 
 be definitely ascertained. The premature cast- 
 ing off of the product of conception is often 
 kept a secret, even when there is no criminal-
 
 44 ABORTION AND ITS TREATMENT. 
 
 ity connected witli the occurrence. But, tliough 
 I can not give you any figures, I want to im- 
 press upon you the fact that abortion is exceed- 
 ingly common. Nature seems to have ordained, 
 not only among plants and the lower animals, 
 but also in the human race, that the amount of 
 generative material should be enormous, and 
 also that a large proportion of it should be de- 
 stroyed. 
 
 In the gynaecological clinics which I have 
 held for many years in this college it has 
 always been exceptional to find a woman coming 
 before the class who could say that she had had 
 eight or ten children and never had an abor- 
 tion. In the upper walks of life also abortion 
 is extremely common, but less so than in the 
 lower. 
 
 In regard to the prognosis in abortion it is 
 impossible to speak accurately, because reliable 
 statistics are not attainable, and we can not 
 say, therefore, what the percentage of deaths 
 is. I would say, in general, however, that the 
 prognosis is good, except in criminal cases and
 
 ABORTION AND ITS TREATMENT. 45 
 
 in cases where antiseptic methods are neglected 
 in the treatment. I am speaking now, you will 
 understand, of the prognosis as to life. As to 
 the matter of health I can not express the same 
 opinion, for it is an unfortunate fact that vast 
 numbers of women are invalided by abortion. 
 Criminal abortions are usually performed by 
 charlatans, in the roughest and most unscien- 
 tific manner, and it is no wonder that the results 
 are so frequently disastrous. When, however, 
 abortion is artificially produced by the intelli- 
 gent physician, in fulfillment of indications fur- 
 nished by science, the prognosis is not bad. 
 
 If a woman dies during or after an abortion, 
 what is it that kills her? In order to under- 
 stand this we must, first of all, appreciate what 
 is taking place. The foetal shell, consisting of 
 decidua reflexa, chorion, amnion, and placenta 
 (if the latter has been developed), has got to 
 come out. The decidua vera is usually torn 
 away in places. Let us inquire, therefore, what 
 are the elements of danger, or the seqnelse of 
 abortion.
 
 46 ABORTION AND ITS TREATMENT. 
 
 The principal ones may be stated as follows : 
 
 1. Hsemorrhage. 
 
 2. Putrid intoxication. 
 
 3. Septicaemia and peritonitis. 
 
 4. Suppurative arthritis. 
 
 5. Cellulitis and abscess. 
 
 6. Embolism, 
 
 7. Air in the veins. 
 
 8. Tetanus. 
 
 9. Uterine hydatids. 
 
 10. Melancholia. 
 
 The first five of these conditions are common 
 as sequelae of abortion ; the last five are rare 
 pathological curiosities. 
 
 Let us suppose that you check the haemor- 
 rhage. Is the woman perfectly safe ? No. It 
 may be that, even if the physiological process is 
 not interfered with by the administration of 
 opium or other sedatives, the uterus will not be 
 able to expel its contents. In a short time pu- 
 trefaction of the product of conception ensues, 
 absorption from it takes place, and the patient 
 suffers from what is known as putrid intoxica-
 
 ABORTION AND ITS TREATMENT. 47 
 
 tion. The effect is tlie same as that which would 
 be produced on any one by making an opening 
 in the arm and inserting within it, so that it will 
 come in contact with the tissues, a piece of llesh. 
 As the latter undergoes putrefaction the whole 
 system will become more or less infected, as 
 indicated by headache, pains in the back and 
 limbs, quickened pulse, high temperature, and 
 a general feeling of malaise. 
 
 You will notice that I put septicaemia and 
 peritonitis together under one head. I do this 
 because, in my opinion, peritonitis following 
 abortion never occurs as primary peritonitis, un- 
 less it is of traumatic origin that is, unless the 
 peritonaium has in some way been wounded. In 
 other words, the peritonitis which follows abor- 
 tion is, as a rule, septic in character. As to the 
 origin of the septicaemia and peritonitis ; the 
 finger of the physician may convey to the parts 
 the poison giving rise to the trouble without any 
 influence from the secundines themselves. It is 
 now just nine years ago since I had a very pain- 
 ful realization of how very small an amount of 
 4
 
 4:8 ABORTION AND ITS TREATMENT. 
 
 such poison may cause the most serious results. 
 Just after the opening of my private hospital I 
 was one day performing an ojjeration for the 
 removal of a sloughing fibroid, and it was no- 
 ticed by all present that the odor arising from 
 the putrid mass was of the most disagreeable 
 description. While I was washing my instru- 
 ments after the completion of the operation I 
 chanced to prick my little finger with the point 
 of a tenaculum which had been used during the 
 operation. This was before the days of bichlo- 
 ride in surgery ; but I at once sucked the wound 
 thoroughly, and not only washed it with a car- 
 bolic-acid solution, but applied some pure car- 
 bolic acid to it. This was at 3 p. m. At 7 p. m. 
 on the same day I had a slight chill, and by the 
 next morning my finger was enormously swol- 
 len, while there rapidly followed enlargement 
 of the lymphatic glands of the arm, and an 
 abscess formed in the palm of the hand. 
 
 All this followed from the introduction of a 
 minute portion of septic material into a part 
 not very vascular or abundantly supplied with
 
 ABORTION AND ITS TREATMENT. 49 
 
 nerves. Suppose that such an accident should 
 occur in connection with a uterus enormously- 
 vascular and with its innervation exalted to the 
 highest pitch, as is the case during pregnancy, 
 and you can imagine what the result would be. 
 Now as to suppurative arthritis resulting 
 from abortion. Some twenty years ago I had a 
 lesson taught me which I never can forget. My 
 friend Dr. Lewis A. Sayre, who was ill, asked 
 me to see for him a patient who had recently 
 had an abortion, and on visiting her I found the 
 wrist, elbow, and ankle enlarged and painful 
 from what seemed plainly to me to be acute 
 articular rheumatism. About a week later I 
 was asked by Dr. Sayre to see the same patient 
 with him, and you can imagine my surprise 
 and chagrin when I found an accumulation of 
 pus in each of the joints named. Since then I 
 have always been very suspicious of every case 
 that seemed like acute articular rheumatism 
 when the patient has recently had an abortion, 
 and I would earnestly caution you to be on your 
 guard in regard to such cases, for the trouble
 
 50 ABORTION AND ITS TREATxMENT. 
 
 is mucli more likely to be suppurative arthritis 
 than rheumatism. Such arthritis sometimes 
 ends in death, but, fortunately, the patient just 
 mentioned recovered. This case illustrates very 
 w^ell w^hat I said to you in the first lecture of the 
 difference between learning and being taught. 
 Here I had to learn by my own experience what 
 I ought to have been taught by my instructors. 
 
 I will not stop to speak particularly of cellu- 
 litis and abscess, but will pass on to the next 
 element of danger. A certain number of cases 
 of abortion end very curiously. You are sud- 
 denly called to a patient who has had an abor- 
 tion, and find that she has all at once become 
 hemiplegic, and that the cause of the trouble is 
 embolism. In my large experience I have seen 
 but two such cases. 
 
 The entrance of a small amount of air into 
 the veins is not likely to prove very serious, but 
 when air gets into the large sinuses which are 
 found in connection with the pregnant uterus, 
 a fatal result is very apt to occur. I know of 
 a case of criminal abortion, which occurred
 
 ABORTION AND ITS TREATMENT. 51 
 
 some years ago, in a town about thirty miles 
 from New York, in which the patient died in- 
 stantaneously of heart failure from this acci- 
 dent, the air being introduced through a hol- 
 low instrument which was used in bringing on 
 the abortion. 
 
 Of tetanus resulting from retention of mem- 
 branes in the uterus I have met with two instan- 
 ces in my experience. In such cases the trouble 
 commences in the uterus (arising from putrid 
 infection), and thence is transmitted to the nerv- 
 ous centres as an ascending neuritis. 
 
 Sometimes after an abortion a portion of 
 membrane remains in the uterus, and if this 
 consists of tufted chorion its villi are liable to 
 undergo proliferative degeneration, with the re- 
 sult of the formation of what are known as 
 uterine hydatids. With the multiplication of 
 these hydatids the uterus goes on increasing in 
 size until it attains nearly or quite the propor- 
 tions of the organ at full term, and this condi- 
 tion leads to a great many errors in diagnosis. 
 
 There is only one more consequence of abor-
 
 52 ABORTION AND ITS TREATMENT. 
 
 tion of which I will speak viz., chronic melan- 
 cholia and this, like the last five conditions 
 enumerated in my list, is very rare. This kind 
 of melancholia will be found to run a course 
 less severe, according to my experience, than 
 that following labor at full term.
 
 LECTURE lY. 
 
 Symptoms indicative of commencing abortion Haemorrhage 
 Pain Vomiting Methods of preventing an anticipated abor- 
 tion Nervous influences in the home-life of women Syphilis 
 Retroflexion Laceration of the cervix Fibrous polypi 
 Large flbroids Importance of rest in bed at menstrual period 
 when a tendency to abortion is present The habit of abortion 
 The treatment of abortion actually taking place Rule for 
 deciding whether or not to attempt to stop a commencing 
 abortion Methods of prevention Importance of absolute 
 rest and quiet Use of opium, chloral, and bromides The 
 tampon. 
 
 Let us suppose that a patient has reason to 
 fear that abortion is about to take place, and 
 that you are summoned to attend her. What 
 are the symptoms that will warn you that there 
 is danger of the uterus expelling its contents? 
 There are only three which are of real value and 
 which are worthy of your especial consideration. 
 They are the essential symptoms, and you need 
 not pay attention to any others. The first of 
 these is haemorrhage, and not pain. This pre-
 
 54 ABORTION AND ITS TREATxMENT. 
 
 cedes pain, because the first contractions of the 
 uterus are so slight that they do not give rise 
 to any suffering, even although they are suffi- 
 cient to detach some of the delicate connections 
 between the foetal shell and the uterus. 
 
 The second essential symptom is pain. Af- 
 ter the process has gone on for an hour or so the 
 woman begins to feel an occasional bearing-down 
 pain, and these pains increase in frequency and 
 severity as the uterine contractions increase in 
 force. 
 
 The third symptom to which I would call 
 your attention is vomiting. This sign may, of 
 course, be absent ; but it is curious to notice 
 how frequently it is present. 
 
 'Now let us consider the methods of prevent- 
 ing an abortion which is anticipated ; in other 
 words, the manner of dealing with cases of ha- 
 bitual abortion. Perhaps the patient, without 
 existing symptoms of abortion, will send for 
 you and tell you that she is one month preg- 
 nant, and that she regrets this exceedingly, 
 for the reason that she has had seven or eight
 
 ABORTION AND ITS TREATMENT. 55 
 
 mishaps, one after the other, and has never 
 given birth to a living child. Or she may in- 
 form you that she has been married ten years 
 and had a child nine years ago, but since then 
 only a number of successive abortions. These 
 abortions have always occurred between the end 
 of the second and the end of the fourth month, 
 and she will very probably say that she has sent 
 for you because she wants you to prevent a re- 
 currence now. Or, again ; a patient may state 
 that she is not pregnant now, but that she has 
 had a number of abortions, and would like you 
 to find out before she becomes pregnant again 
 what has been the cause of them, in order that 
 she may prevent the next one that threatens. 
 
 In order to suggest to you how you are to 
 deal with such cases as these T venture to reca- 
 pitulate some of the points which have already 
 been gone over in these lectures, begging your 
 indulgence for my acquiescence in the belief of 
 that French author who thinks that the essence 
 of teaching is contained in '-'- repetition sans 
 cesse.^^
 
 56 ABORTION AND ITS TREATMENT. 
 
 You should always begin by examining the 
 woman very carefully as to her general system. 
 
 See if there be anything in her occupation 
 or habits of life likely to induce abortion. In 
 other words, try to find out whether the cause 
 of the habitual abortions is maternal, and cor- 
 rect it if it be in your power to do so. If in 
 any case you are not certain whether something 
 that you may discover regarding the system of 
 the mother is responsible for the trouble, give 
 her the benefit of the doubt, and treat her as 
 if it were. 
 
 While dealing with this part of our subject 
 let me call your attention to the fact that there 
 are many occult nervous influences in the home- 
 life of women which are liable to have more or 
 less effect in causing abortions. I have in my 
 mind at this moment a refined and wealthy 
 woman of this city who is surrounded by every 
 luxury, but who, unfortunately, has a husband 
 who is the slave of alcohol and opium, and, in 
 consequence, her life has become almost unbear- 
 able from his brutality. There are hundreds of
 
 ABORTION AND ITS TREATMENT. 57 
 
 influences of this kind which so disturb the 
 nervous system of the mother that it is very- 
 difficult for her to go to full term. Cases of 
 the kind of which I am now speaking, you will 
 find, are exceedingly common. 
 
 If no maternal causes are to be found, you 
 should next look for foetal causes. If you have 
 not attended the patient in some of her abor- 
 tions, communicate, if possible, with the physi- 
 cians who treated her, and in this way you may 
 discover what the trouble has been. If it is as- 
 certained that in previous abortions the product 
 of conception has shown evidences of syphilis, it 
 will be your duty to treat the parent who is at 
 fault, for this disease ; and, if you can not make 
 out which one of them is or has been syphilitic, 
 to treat them both. After twelve or fifteen 
 months of such antisyphilitic treatment you 
 will find that there is a strong probability that 
 the abortions may be avoided in the future. 
 
 If you discover neither a maternal nor a foetal 
 cause, you must make a careful examination of 
 the condition of the uterus. The uterine causes
 
 58 ABORTION AND ITS TREATMENT. 
 
 of habitual abortion are, in fact, much more 
 important than either the maternal (systemic) 
 or the foetal. From the emphasis with which I 
 have spoken of this condition, you will natu- 
 rally look especially for retroflexion, and it is of 
 importance to bear in mind that retroflexion 
 may in certain cases exist just at the period of 
 utero-gestation, when the abortions commonly 
 occur, and at no other time. I was strongly 
 impressed with this point very early in my 
 obstetrical practice. I was called to attend a 
 patient who had had nine abortions, and when 
 she became pregnant again I found that the 
 uterus was in a state of marked retroflexion at 
 the end of the third month. I replaced the 
 organ and kept it carefully in position, and the 
 result was that she went to full term and was 
 delivered of a living child. Moreover, she after- 
 ward had several other children. 
 
 The mere perfunctory putting in of a pessary 
 will not be sufficient in these cases. You must 
 replace the uterus, and keep it in position, for 
 if you fail in this, the abortion will take place
 
 ABORTION AND ITS TREATMENT. 59 
 
 as before. It is necessary to watch the uterus 
 carefully every day until the critical period is 
 over. 
 
 Among the uterine causes which I have pre- 
 viously mentioned is laceration of the cervix. 
 Such lacerations, as you are perhaps aware, are 
 capable sometimes of causing complete inversion 
 of the non-pregnant uterus, though such an oc- 
 currence is very rare. If, then, this condition 
 can produce such an effect upon the non-preg- 
 nant uterus, you can readily appreciate how 
 great is the danger of its giving rise to abortion. 
 In some cases, even a small fissure of the os may 
 occasion so much reflex irritation that uterine 
 contractions are set up and an abortion results. 
 
 Another uterine cause is fibrous polypi 
 within the cavity. You may perhaps have 
 noticed what a severe spasmodic cough is occa- 
 sioned by the existence of a small polypus in 
 the larynx. Indeed, wherever these growths are 
 situated they are apt to set up a considerable 
 amount of reflex irritation. I once had a pa- 
 tient in my private hospital who suffered from
 
 60 ABORTION AND ITS TREATMENT. 
 
 the most violent spasm of the rectum. Before 
 examining the parts I supposed that the trouble 
 was probably due to a fissure of the anus ; but 
 when I made an examination I found that there 
 was no fissure present, but that just within the 
 anus there was a little fibrous polypus. I re- 
 moved this, and the patient never had another 
 rectal spasm. In the same way a polypus will 
 act upon the pregnant uterus. 
 
 Large fibroid tumors, however, whether sub- 
 mucous or interstitial, are still more likely to 
 cause abortion, because they exert more press- 
 ure and interfere with the innervation of the 
 organ. 
 
 Here let me impress one point especially 
 upon you. If a woman abort at all, in the vast 
 majority of instances the accident will occur co- 
 incidently with the menstrual epoch. If, there- 
 fore, you have a patient under your care who has 
 shown marked tendency to abort, you should 
 always keep her strictly in bed for twelve days 
 out of every month viz., four days before the 
 menstrual period, four days during the period,
 
 ABORTION AND ITS TREATMENT. 61 
 
 and four days after it. The most perfect rest 
 of both mind and body should be secured ; and 
 she should be carefully shielded against all dis- 
 turbing influences. Even when the active cause 
 of previous abortions has been discovered and 
 removed, a certain influence from this may re- 
 main for a considerable length of time. 
 
 I regard confinement to bed as one of the 
 most important remedies at the command of the 
 intelligent physician in these cases. 
 
 When in any given case you have excluded 
 all maternal, foetal, and uterine causes, you will 
 be forced to fall back upon what I have spoken 
 to you of as the habit of abortion to explain the 
 difficulty. This class of cases seems, as far as we 
 are able to judge, to be due to a hypereesthetic 
 condition of the uterine system of nerves ; and 
 that is all that we know about the matter. The 
 diagnosis is, of course, an empirical one, but, 
 under the circumstances, we can do no better. 
 When you meet with a patient of this kind 
 wait till pregnancy has advanced to the end of 
 the sixth week, and then keep her in bed until
 
 62 ABORTION AND ITS TREATMENT. 
 
 the fifth month. In very many cases you will 
 find that this plan will be successful. The 
 uterus is unable to perform its functions, and 
 therefore you must give it rest, just as you 
 would the other organs under similar circum- 
 stances. 
 
 You will be surprised to see what good re- 
 sults will often follow this empirical treatment. 
 
 I come now to the treatment of abortion ac- 
 tually in progress. We will suppose that it is 
 just after the third menstrual period in utero- 
 gestation, and that the process of abortion has 
 commenced. You find the patient in bed, and 
 she probably tells you that after taking a walk 
 or ride (during which she made no unusual ex- 
 ertion) she felt a sensation of moisture, and, on 
 making an examination, found that she was 
 bleeding freely. At the present time she is oc- 
 casionally having a slight pain. 
 
 What is to be done under these circum- 
 stances ? You at once ask yourself the question, 
 " Am I to try to prevent this abortion from tak- 
 ing place, or should I endeavor to facilitate the
 
 ABORTION AND ITS TREATMENT. 63 
 
 process ? " This is the question to be decided, 
 and the decision must be made at once, for the 
 line of treatment adopted in the one case will, of 
 course, be radically different from that appli- 
 cable to the other. 
 
 Let me offer you a rule for the decision of 
 this important point. Do not allow yourself 
 to be persuaded that the amount of blood lost 
 shall be your guide. It may be that you will 
 find the haemorrhage somewhat alarming, and 
 the patient already showing the usual signs de- 
 noting a severe loss of blood. But on this 
 account do not conclude that the completion of 
 the process of abortion is inevitable. 
 
 Here let me digress for a moment to say that 
 it is possible that the patient may be unwilling 
 to submit to a vaginal examination. If this be 
 the case, take the husband quietly aside and 
 tell him that such an examination is absolutely 
 necessary for the successful management of the 
 case, and that if it be refused the responsibil- 
 ity for the result will be shifted from your 
 shoulders to his. I have never known an in-
 
 64 ABORTION AND ITS TREATMENT. 
 
 stance where an examination was not willingly 
 permitted after tlie matter had thus been fully- 
 explained. 
 
 Now for the rule of which I just now spoke. 
 If the OS uteri be dilated to such an extent 
 that you can pass your finger through it and 
 touch the presenting foetal ball, do not fritter 
 away your own and the patient's time by try- 
 ing to stop the process of expulsion. Such an 
 attempt will almost surely be useless. If, how- 
 ever, the OS be not so dilated, it will be your 
 duty to try to stop the abortion. This is a per- 
 fectly valid rule, because the first stage of abor- 
 tion is dilatation of the cervix, and if that is 
 over there is little chance of prevention. 
 
 Next let us consider the methods of preven- 
 tion. Yery often the woman is told to go to 
 bed, a full dose of opium is ordered, and a bag 
 of ice is placed over the fundus uteri, for what 
 reason I do not know. The physician may or 
 may not apply a tampon, as he sees fit, and 
 then he goes home. He leaves no directions 
 that the light shall be excluded from the apart-
 
 ABORTION AND ITS TREATMENT. 65 
 
 ment or that the children, servants, or friends of 
 the patient shall not have free access to her. In 
 three hours, perhaps, he comes back " to ob- 
 serve the progress of the case." 
 
 I do not regard this as an efficient method 
 of preventing a threatened abortion. My mean- 
 ing may be illustrated by an incident which 
 occurred to me a good many years ago. I 
 was house surgeon in one of the institutions 
 on Ward's Island, and on one occasion the vis- 
 iting surgeon, the late Dr. John M. Carnochan, 
 brought with him to the island the celebrated 
 English authority on nervous diseases, Dr. Mar- 
 shall Hall, who was then on a visit to this coun- 
 try. At the time I had under my care a man 
 who was suffering from violent convulsions, and 
 Dr. Hall asked me how I was treating him. 
 When I told him that I was applying sinapisms 
 to the wrists and lower extremities and ice to 
 the head and was purging him with croton-oil 
 (the recognized treatment for convulsions at that 
 day), he said to me, "Young man, let me tell 
 you of an experience of my own. Not long
 
 66 ABORTION AND ITS TREATMENT. 
 
 since in London I procured two puppies of 
 equal size and appearance and poisoned them 
 with large doses of strychnine. One of them I 
 treated by keeping it in the light and making 
 counter-irritation upon the external surface of 
 the body by frictions, etc. This puppy died. 
 The other I put down in a deep cellar which 
 was perfectly dark and absolutely quiet, and left 
 him without any treatment whatever. The re- 
 sult was that this second puppy got well." 
 
 There were thirty or forty students present, 
 and he then gave a most interesting clinical 
 lecture on the case mentioned, in which he 
 dwelt upon the happy effects of complete rest 
 and the adoption of sedative methods in condi- 
 tions of excitation of the nervous system. The 
 lesson which he taught made a most lasting 
 impression upon my mind. 
 
 The proper way to treat a threatened abor- 
 tion is, in my judgment, the following: In the 
 first place, absolute rest, as far as attainable, 
 should be insisted upon as regards the mind 
 and nervous system as well as the body. The
 
 ABOETION AND ITS TREATMENT. 67 
 
 room, which should be one of large size, should 
 be kept darkened and in perfect silence and no 
 one be allowed to enter it except the nurse (who 
 should be secured at the earliest possible mo- 
 ment), and perhaps the husband if his presence 
 tend to allay the anxiety of the patient. The 
 patient should have complete freedom from all 
 outside cares, and her diet should consist of 
 only the simplest food, such as milk or beef- 
 juice, so that her stomach may have almost 
 nothing to do. 
 
 Is there any drug that will be of service 
 under these circumstances ? you ask. Yes ; give 
 her a full dose of opium, either alone or in 
 combination. I am very fond of using a mixt- 
 ure which contains ten grains of bromide of 
 sodium or potassium, six or seven grains of 
 chloral, and one fifth of a grain of morphine to 
 the dose, repeating it according to circum- 
 stances. Each of these agents produces quiet 
 in its own way the chloral inducing sleep, the 
 bromide exerting its peculiar sedative effect 
 upon the nervous system, and the opium hav-
 
 68 ABORTION AND ITS TREATMENT. 
 
 ing that happy influence, which we all know so 
 well, of robbing life of its cares. 
 
 The first thing of all to do, however, if the 
 patient be bleeding freely, is to make use of 
 a carefully applied tampon. When you come 
 back to see her at the end of three hours you 
 will probably find that she is in a sound sleep, 
 and she will very likely sleep on for four or 
 five hours. In twenty-four hours the tampon 
 may be removed, but the patient should be kept 
 perfectly quiet until all danger of a return of 
 the trouble is over.
 
 LECTURE V. 
 
 Treatment when expulsion is inevitable Antisepsis in abortion 
 Danger of infection from faecal matter The water-closet as 
 a source of peril The tampon the remedy in abortion Opium 
 and ergot both contra-indicated How to make and apply a 
 tampon The removal of the tampon Importance of remov- 
 ing whatever remains of the product of conception Method 
 of doing this Treatment of putrid infection Of septicaemia 
 Of pelvic abscess. 
 
 We come now to the treatment of abortion 
 in cases in which you have decided, in accord- 
 ance with the rules laid down in the last lecture, 
 that the process of expulsion must necessarily 
 take place. Finding the abortion inevitable, 
 you have no right to try any longer to stop it. 
 It may in certain cases be delayed for days or 
 weeks, or even months. The placenta, or some 
 other portion of the uterine contents, may be 
 caused to remain, but, by allowing such a thing 
 to occur, you expose your patient to the immi- 
 nent risk of death from putrid absorption.
 
 70 ABORTION AND ITS TREATMENT. 
 
 What you want to do is to get the woman 
 through with the abortion as quickly as possi- 
 ble, and to leave no nidus for bacteria in the 
 uterus afterward. And this brings me to the 
 subject of antisepsis, upon which I wish to say 
 a few words to you. 
 
 About the importance of antisepsis in gen- 
 eral, and the various methods and agents em- 
 ployed for carrying this out in practice, I can 
 not, of course, stop to speak very fully. I take 
 it for granted that every student of this college 
 is already perfectly well informed on these 
 points. I need only say that I am an enthu- 
 siast on this subject, and I trust that every one 
 of you will be so too. 
 
 Even as to antisepsis in abortion, I can not 
 go into details. I only want to fix in your 
 minds the essentials to be remembered. You 
 will find that many a man who conducts every- 
 thing in a truly antiseptic manner when labor 
 occurs at full term, will neglect the same pre- 
 cautions in cases of abortion. Yet it is just as 
 important that he should be antiseptic in the
 
 ABORTION AND ITS TREATMENT. 71 
 
 latter as in the former. At this time, as some 
 German writer has expressed it, the uterus 
 moults its mucous membrane as a bird its 
 feathers ; and what better culture fluid for nox- 
 ious bacteria could you possibly have than this ? 
 
 Let us glance at the general means for pre- 
 venting the entrance and development of bac- 
 teria. In the first place, you must be thorough- 
 ly aseptic yourself. You should not come to a 
 woman having an abortion, directly from a case 
 of puerperal septicaemia, or other infectious 
 trouble, with your person saturated with its 
 poison. Your clothes, hands, instruments, 
 sponges, and tampon (if you use the latter) 
 should all be aseptic. It is essential, also, that 
 the nurse should be thoroughly aseptic as to 
 her clothes, her hair, her hands, and especially 
 her finger-nails. 
 
 IN'ext, the patient should be rendered aseptic 
 as well. Even in women who have never suf- 
 fered a laceration of the perinseum the distance 
 between the vulva and anus is exceedingly short, 
 and in those who have met with this accident
 
 72 ABORTION AND ITS TREATMENT. 
 
 this normal distance is more or less diminished. 
 Now, as fsecal matter which is, as you know, 
 highly septic is repeatedly passing from the 
 anus, you can readily appreciate how constant 
 and how great is the danger of infection arising 
 from this source. The best of the German au- 
 thorities hold that it is through the vulva that 
 puerperal septicaemia is ordinarily contracted. 
 
 It is of the utmost importance, therefore, 
 that the vulva and anus should be thoroughly 
 bathed with some antiseptic fluid. If bichloride 
 solution be used, it should be of the strength of 
 about 1 to 2,000. 
 
 I insist strongly on this point, for the reason 
 that so little attention has been paid to the mat- 
 ter. You will not find it mentioned in any of 
 the older books ; but I feel assured that it will 
 not be omitted in the next work on obstetrics. 
 It is true now, as always, that we are mending 
 the faults of yesterday by the wisdom of to-day. 
 
 Let me mention a case in illustration. Three 
 or four years ago I was summoned to see, in 
 consultation with an excellent and thoroughly
 
 ABORTION AND ITS TREATMENT. 73 
 
 well-informed physician, a graduate of this col- 
 lege, a wealthy lady residing in a flourishing 
 town some ten miles from New York. She had 
 had a perfectly normal labor, but was now suf- 
 fering from a decided attack of puerperal fever. 
 I questioned the physician thoroughly upon 
 every point likely to afford a clew to the origin 
 of the trouble, but for a long time my efforts at 
 finding out the source of difiiculty were entirely 
 unsuccessful. The doctor was constantly at- 
 tending cases of midwifery, but had not had 
 a single one in which there was any signs of 
 septicaemia. In attending this lady he had 
 taken the greatest care in regard to the condi- 
 tion of his clothing, his hands, and his instru- 
 ments. The nurse also was thoroughly aseptic, 
 and every possible precaution that he could 
 think of was taken. Believing, as I do, that 
 puerperal septicaemia is due to a special poison 
 communicated from some septic source, I began 
 to feel very much puzzled. 
 
 I inquired where the water-closet was, and 
 found that it adjoined the lying-in chamber,
 
 74 ABORTION AND ITS TREATMENT. 
 
 and that it was one of the old-fashioned pan 
 closets still, unfortunately, so much in vogue. 
 In speaking of these. Colonel Waring, one of 
 our best authorities in matters of sanitation, 
 says: "Everything looks like a whited sepul- 
 chre above, but below there is a chamber of 
 horrors ! " I lifted the pan, and a horrible 
 odor assailed my nostrils ! On further inquiry, 
 I found that the patient had been in labor for 
 twelve hours, and that during this time she 
 had had three or four passages, each time going 
 into the water-closet for the purpose. Now, 
 at last, light began to break in upon the aeti- 
 ology of the case. Just think of the position 
 of a woman in the act of defecation or urina- 
 tion. With the downward pressure brought to 
 bear, the labia are rolled out and the vaginal 
 walls widely unfolded. Up from below, to come 
 in contact with all this unfolded surface of mu- 
 cous membrane, rise the emanations from the 
 closet loaded with septic germs ! Here was a 
 woman in the pains of labor subjecting herself 
 directly to the poison of the sewer-pipe, for
 
 ABORTION AND ITS TREATMENT. Y5 
 
 probably at least five minutes at a time, several 
 times during the process of labor! 
 
 When I considered these circumstances I no 
 longer felt any doubt as to the causation of the 
 disease. Can you question the correctness of 
 this opinion as to its origin when you reflect 
 that the air and moisture that came in contact 
 with the vulva and vagina were permeated with 
 every factor instrumental in the production of 
 puerperal septicaemia 1 
 
 Strange to say, this danger is not referred 
 to in any book or monograph in any language, 
 so far as I am aware. It is therefore all the 
 more important that you should get here the 
 lesson which this and similar cases teach. That 
 lesson is this : during abortion, or labor at term, 
 never permit a patient to use anything but the 
 ordinary chamber-vessel or commode for alvine 
 evacuations ! 
 
 I regard it as a point of the utmost impor- 
 tance. Up to the present day nearly all the best 
 hotels in the city of New York are still provided 
 with these old-fashioned pan closets, often im-
 
 ^6 ABORTION AND ITS TREATMENT. 
 
 mediately adjoining the sleeping apartments ; 
 and any lady who is taken with an abortion 
 and nses one of them is exposed to the danger 
 of which I speak. In dismissing this subject I 
 may say that the patient whose case I have 
 narrated finally recovered, although for a time 
 she was at death's door, and for months after- 
 ward was ill with the worst sequelae of puerpe- 
 ral septicaemia. 
 
 Suppose that the abortion is going on, and 
 that the woman is losing large quantities of 
 blood. What is to be done ? You feel that 
 you can not spare the time to remain all day 
 to look after the case, and yet it is manifestly 
 risky to leave the patient. Under these circum- 
 stances have we any efficient remedy which can 
 always be depended upon ? When you hear of 
 a large number of remedies for any affection 
 you may rest assured that there is, strictly 
 speaking, no remedy for it. This is the case, 
 for instance, as regards whooping-cough, for 
 which there is no specific. But we have a 
 specific remedy for malarial fever and we have
 
 ABORTION AND ITS TREATMENT. 77 
 
 one for syphilis. So, too, we have a remedy 
 for abortion, and that is the tampon ! This is 
 the one great remedy, and it will serve you 
 well. In the early period of abortion there is 
 but one danger; that is haemorrhage. When 
 you have properly applied an efficient tampon 
 you can leave your patient in perfect security. 
 The tampon controls the bleeding entirely, and 
 allows the process to go on to a successful ter- 
 mination without danger. 
 
 When you return to the house six or eight 
 hours afterward the x>atient will often tell you 
 that she feels perfectly well. From the nurse 
 you learn that there has been no haemorrhage 
 whatever, and when you come to take away 
 the tampon you will perchance find following 
 it the entire fcBtal shell, unbroken if the period 
 is early in utero-gestation, or the foetus with the 
 membranes and placenta if later. You then 
 have the vulva bathed, not using a vaginal in- 
 jection, and apply an antiseptic pad. 
 
 But, you may ask, if the patient suffers 
 much pain before the expulsion of the fa^tus.
 
 78 ABORTION AND ITS TREATMENT. 
 
 should we not relieve it with opium ? Certainly 
 not. These pains are just what are requisite to 
 complete the work of expulsion, and should not 
 be interfered with. You might as well fasten a 
 ball and chain to your leg when you are about 
 to start to run in a race ! Neither, on the other 
 hand, should you use ergot. To do so while 
 the OS is still undilated would be entirely un- 
 philosophical, as I have had occasion to remark 
 previously. What, then, should you do for the 
 patient ? Nothing whatever if the tampon is 
 properly applied! It is highly important that 
 you should remember that the tampon is tTie 
 remedy in abortion, and in the vast majority of 
 instances it will do its work in a perfectly satis- 
 factory manner. With the tampon in position, 
 you may go about your work, feeling perfect- 
 ly at ease. Your main duty consists in not 
 interfering. Nature is perfectly competent to 
 carry on her work to completion without your 
 aid. 
 
 Let me teach you how to make a tampon. 
 Get some good cotton or cotton batting, and
 
 ABORTION AND ITS TREATMENT. 79 
 
 divide it into twenty-five or thirty flat pieces, 
 two and a half or three inches in diameter. 
 Then prepare some carbolic-acid, solution, of the 
 strength of about five per cent the most con- 
 venient way of doing this is by the use of the 
 tablets which you can find in all the shops 
 and, having put a number of your pieces of 
 cotton into it, boil it thoroughly. In carbolic 
 acid and the boiling process you have two of 
 the best antiseptics known to science. Care 
 must be taken, however, not to have the anti- 
 septic solution too strong. 
 
 When you are ready to apply the tampon, 
 have a table brought to the side of the bed, 
 with a pillow and blanket upon it. The patient 
 should lie upon this table in the Sims position, 
 with one arm thrown back so that the left 
 pectoral muscles touch the table. The best 
 material for the packing of the upper part of 
 the vagina is iodoform gauze ; but if this can 
 not be obtained, use some of your antiseptically 
 prepared cotton, after first squeezing it as dry 
 
 as possible by putting it between the folds of 
 6
 
 80 ABORTION AND ITS TREATMENT. 
 
 a towel and forcibly slapping it. If the os be 
 open, stuff some of the dressing into it ; then 
 you should pack the posterior cul-de-sac^ and 
 then the anterior cul-de-sac. This should all 
 be done with iodoform gauze, if you can get it ; 
 and below this you pack in three or four pieces 
 of antiseptic cotton for the purpose of keeping 
 the upper dressing in place and protecting the 
 vagina from septic influences. It is not bac- 
 teria in general which are likely to do harm, 
 but a particular form of microbe, known as the 
 streptococcus., which is believed by most au- 
 thorities to be the causative agent of puerperal 
 septicsemia. I have yet to see from this method 
 of treatment one solitary case of poisoning from 
 carbolic acid, though I woukl particularly im- 
 press upon you the necessity of beating out the 
 cotton wet with the solution as dry as possible. 
 In these cases I usually employ mercuric bi- 
 chloride as an antiseptic, but I prefer to recom- 
 mend carbolic acid for general use in a course 
 of lectures like this. 
 
 When you remove the tampon it is well to
 
 ABORTION AND ITS TREATMENT. 81 
 
 Tise cotton soaked in carbolic solution for cleans- 
 ing the parts rather than sponges ; especially as 
 it is sometimes difficult to get good sponges. 
 Having done this thoroughly, you can put in 
 a new tampon, if this be necessary. The vulva 
 may be washed with bichloride solution, but it 
 should at once be wiped perfectly dry, for the 
 bichloride, if left long in contact with the ex- 
 ternal parts, is very apt to give rise to eczema 
 of the most violent character. If you employ 
 this agent you should then bathe the vulva 
 with a five-per-cent solution of carbolic acid 
 or creoline, and apply an antiseptic pad con- 
 sisting of carbolized cotton. 
 
 This, held in position by a bandage con- 
 nected with one passed around the waist, pre- 
 vents the access of air, or at least renders the 
 air aseptic. 
 
 In the great majority of instances you will 
 thus have brought your case of abortion to a 
 successful conclusion. Let us suppose, how- 
 ever, that you fail in this, the foetal shell or 
 some portion of the membranes or placenta still
 
 82 ABORTION AND ITS TREATMENT. 
 
 remaining in the uteras after the expulsive 
 pains have ceased. You wait three or four 
 days, and still the process of emptying the 
 uterus has not been completed. In the mean 
 while all pain and all haemorrhage have stopped, 
 and the patient feels perfectly well. There is, 
 in my opinion, nothing more censurable in 
 medicine than " making mountains out of mole- 
 hills " ; but in this case, while everything ap- 
 pears to be entirely normal and there is noth- 
 ing in the outward appearance of the patient 
 to excite the slightest suspicion of alarm, the 
 woman is really in imminent danger until the 
 uterus has been thoroughly and completely 
 emptied. There is no question in my mind 
 about the propriety of at once removing 
 whatever remains of the product of concep- 
 tion. By leaving it retained in the uterus 
 you will be exposing the woman to great 
 risk. There could be no better nidus for the 
 development of putrid intoxication or puer- 
 peral septicaemia, and if she recover, it will be 
 in spite of your criminal negligence. It is
 
 ABORTION AND ITS TREATMENT. 83 
 
 simply a death-trap that you leave within the 
 uterus ! 
 
 Under these circumstances do not consult the 
 friends ; do not ask for a medical consultation ! 
 After labor at full term you would not think 
 of allowing a retained placenta to remain ; and 
 there is no reason why you should act differ- 
 ently now. You should tell the patient and 
 her friends that the after-birth has not come 
 away, and that it is necessary to remove it. If 
 their consent is withheld, the responsibility of 
 the case is with them. There will rarely be 
 any difficulty about the matter, however, when 
 you have fully and frankly explained the cir- 
 cumstances. 
 
 Having placed the patient on a table in the 
 Sims position, and an anaesthetic (preferably 
 ether) having been administered by an assistant, 
 the speculum is held by the nurse, or other 
 attendant, and the vagina swabbed out with a 
 l-to-2,000 bichloride solution. Then, with a 
 tenaculum firmly hooked into it, you pull down 
 the posterior lip of the cervix and remove the
 
 84 ABORTION AND ITS TREATMENT. 
 
 retained secundines with an ordinary large cu- 
 rette. In the mean time if pressure be made 
 over the fundus by one of the attendants, you 
 will be amazed to find how quickly the uterine 
 contents will roll out. 
 
 If the OS be not sufiiciently dilated for the 
 purpose, you must stretch it more widely open 
 by means of Goodell's dilator, which acts on 
 the principle of a glove-stretcher. You need 
 not be afraid that this will do harm. You 
 will sometimes need a small pair of forceps to 
 assist in withdrawing the foetal shell when ar- 
 rested by the internal os. After the uterus has 
 been completely emptied you should wash out 
 its cavity with bichloride solution or carbolized 
 water by means of a catheter or, better, by Ly- 
 man's irrigator, attached to the tube of a fount- 
 ain syringe and carried to the fundus. With 
 the Lyman instrument there is no danger what- 
 ever of the fluid being forced into the Fallopian 
 tubes. 
 
 Ordinarily, you will have no further trouble 
 with the case. But let us suppose that putrid
 
 ABORTION AND ITS TREATMENT. 85 
 
 infection slionld ensue ; whicli, you will remem- 
 ber, is quite a different matter from puerperal 
 septicsemia. Having removed all retained se- 
 cundines in the manner already described, you 
 should carry a stream of warm carbolized water 
 (say at a temperature of from 104^ to 106 F.) up 
 into the uterus by means of a fountain syringe. 
 If you have no fountain syringe, use an ordi- 
 nary Davidson syringe, and if you have no 
 Davidson syringe, take some rubber tubing and 
 make a siphon of it, immersing one end in a 
 bucket containing the antiseptic fluid placed at 
 a suitable elevation. 
 
 If the case be one of true septicsemia, put 
 the patient on a table and with the curette go 
 to the fundus and completely clear out the uter- 
 ine cavity of everything in it. If it contains 
 nothing else, it will be sure to have some of the 
 flaking decidua mra upon its walls, for every 
 uterus that has not been scraped has after 
 abortion a certain amount of this material 
 in it. 
 
 Then wash out the cavity as in the other
 
 86 ABORTION AND ITS TREATMENT. 
 
 case, and you will, as a rule, soon see good 
 results. 
 
 If you leave the uterus unemptied you allow 
 a nidus in which the deadly streptococcus may 
 flourish. Your antiseptic washes will do but 
 little good unless you first remove the dead 
 membrane, which prevents them from acting 
 directly on the uterine walls. Any pieces of 
 the foetal shell or of the placenta that remain 
 should also be taken away, and there is noth- 
 ing better for this purpose than the curette. 
 Be sure that you scrape the whole surface of 
 the cavity, and if you can not get well up into 
 the horns with the ordinary large curette, take 
 a smaller instrument for this part. 
 
 What pathological danger now most promi- 
 nently threatens your patient? She may pos- 
 sibly have tetanus, or embolism, or suppurative 
 arthritis ; but these conditions are so rare as 
 to be only the curiosities of abortion, and it is 
 therefore sufficient that you should be aware 
 of the fact that such affections do occasionally 
 result.
 
 ABORTION AND ITS TREATMENT. 87 
 
 Before the patient gets well, however, she 
 may have further trouble still. You may find 
 her perhaps complaining of pelvic pain, with a 
 pulse of 120 and temperature of 103 F., and 
 discover that she has had a violent chill. On 
 making an examination you may find on one 
 side, between the layers of the broad ligament, 
 a mass of considerable size which may or may 
 not yield a sense of fluctuation. This is a 
 "phlegmon," or areolar inflammation. The 
 condition is very common following abortion. 
 Whenever you find a mass the size of a hen's 
 egg which has formed in the pelvis within ten 
 days after abortion, you may feel pretty confi- 
 dent that it contains pus. It is easy to open 
 such an abscess, but you will find great diffi- 
 culty in securing drainage. The trouble is to 
 keep the wound in the vagina open. Let me 
 show you a very simple drainage-tube which 
 I have used for years with very satisfactory 
 results. The vagina should first be washed 
 out with a carbolic solution. Then, an assist- 
 ant making pressure on the tumor from above,
 
 88 ABORTION AND ITS TREATMENT. 
 
 the patient lying upon the back, you should 
 place your finger upon its lowest point in the 
 vagina. Taking care to avoid any arteries 
 (which can readily be felt), you now slip the 
 point of a pair of long, curved scissors along 
 the finger and "gnaw" your way into the 
 mass, without cutting. When absence of re- 
 sistance tells you that you have got to the 
 centre of the mass, pus will flow out. Now 
 for our drainage-tube. Taking an ordinary 
 soft-rubber tube, I cut it down for a short dis- 
 tance on either side, say about one inch, mak- 
 ing two lips of equal size. With a needle a 
 thread is then passed through the center of 
 the tube, through the lips on either side, and 
 through the tube again, a short distance be- 
 low, and then tied in such a manner as to hold 
 the lips at right angles, but with sufficient 
 looseness to allow them to close when resist- 
 ance is encountered in making traction upon 
 the tube. When the drainage-tube thus pre- 
 pared is to be inserted, the two lips, bent 
 downward, are grasped with forceps and the
 
 ABORTION AND ITS TREATMENT. 89 
 
 tube is carried up into position. When the 
 forceps are withdrawn, the tube will be held in 
 place by the gaping lips, which rest lightly on 
 the edges of the wound ; and when you wish 
 to take it out you have simply to make trac- 
 tion upon it, when the resistance encountered 
 from the edges of the wound will cause the 
 lips to close, and the tube will readily slip out.
 
 LECTUKE yi. 
 
 Remote results of abortion Uterine hydatids Suppurative ar- 
 thritis Tetanus Melancholia Septic peritonitis Chances 
 of error in connection with abortion Twin conception 
 Extra-uterine foetation Uterine hydatids " Molar preg- 
 nancy " DifBculty of the diagnosis of pregnancy Artificial 
 production of abortion Deception on the part of patients 
 Necessity for a consultation before inducing abortion Indi- 
 cations for the artificial induction of abortion Methods of 
 producing abortion Improper methods Danger of uterine 
 tents The best method. 
 
 In the last lecture we spent some time in 
 considering the immediate results following 
 abortion. Let us now glance at some of the 
 more remote ones. Among these, as I have 
 told you, uterine hydatids may occasionally be 
 met with. This condition is simply the result 
 of cystic degeneration of portions of retained 
 chorion. The conduct of the case is simple 
 when once the diagnosis has been made ; and, 
 as in the case of tape- worm, the diagnosis can
 
 ABORTION AND ITS TREATMENT. 91 
 
 only be established by ocular demonstration. 
 To determine the presence of tape-worm it is 
 essential that some portion of the parasite 
 should be seen ; and to make out the diag- 
 nosis of hydatids it is necessary that some of 
 the hydatids should be seen. Having once 
 made the diagnosis, you have only to empty 
 the uterus as you would in the case of any 
 other retained matters. 
 
 Next, as to suppurative arthritis. Patholo- 
 gists are still at variance as to the distinction 
 between pysemia and septicaemia. I think that 
 we are safe in saying that septicaemia is a con- 
 dition which, if it continues long enough, may 
 end in pysemia. As a result of the former, sep- 
 tic embolism is apt to occur in the small ves- 
 sels of the liver, lungs, spleen, and synovial 
 cavities, and pysemic abscesses may form in the 
 joints. In such cases we have simply a sep- 
 ticaemia which has terminated in thrombosis and 
 embolism. The best treatment for suppurative 
 arthritis I believe to be the opening of the affected 
 joints, under strict antiseptic precautions.
 
 92 ABORTION AND ITS TREATMENT. 
 
 In regard to tetanus I have nothing to say. 
 It is a very rare result, and when it occurs it 
 should be treated in the same manner as teta- 
 nus due to any other cause. 
 
 We come next to melancholia. It is proba- 
 ble that many will be inclined to dispute this 
 condition as one of the results of abortion ; but 
 I have seen melancholia (sometimes of a very 
 severe grade) following abortion sufficiently 
 often to feel convinced that this is one of the 
 sequelae that should be apprehended. As to 
 the treatment of this condition, I can only refer 
 you to works on mental disease, in which the 
 management of melancholia in general is fully 
 considered. 
 
 Finally, we come to septic peritonitis. In 
 abortion women sometimes die of haemorrhage, 
 and, as a rule, though not invariably, this oc- 
 curs in criminal abortion. Again, the woman 
 may die in consequence of air getting into the 
 veins. The vast majority of deaths, however, 
 occur from puerperal septicaemia. How, then, 
 shall this condition be treated when met with 1
 
 ABORTION AXD ITS TREATMENT. 93 
 
 By two means, and only two. As soon as the 
 diagnosis is made, put your patient in the 
 Sims position, and, having etherized her, with 
 thorough antiseptic precautions clear out the 
 cavity of the uterus with a dull wire curette. 
 In order to do this satisfactorily it will proba- 
 bly be necessary to dilate the os ; but this can 
 be accomplished with perfect safety in a few 
 minutes by means of the divulsor. You should 
 use, first, a large curette, and then a smaller 
 one, so as to get well up into the cornua, and, 
 if possible, even into the entrance of the Fal- 
 lopian tubes. Then, by means of the douche 
 which I showed you at our last meeting, wash 
 out the uterine cavity with creoline, carbolic- 
 acid solution, or a weak bichloride solution. I 
 would not advise you to use the bichloride in 
 the uterine cavity stronger than in the propor- 
 tion of one to three or four thousand. 
 
 If you have curetted thoroughly, you will 
 be surprised to find how quickly the tempera- 
 ture will come down as soon as you commence 
 the douche. Having thus reduced the tern-
 
 94 ABORTION AND ITS TREATMENT. 
 
 perature, you slioiild treat the case according 
 to the conditions present, bearing in mind the 
 general principles which have been previously 
 laid down. 
 
 We pass now to the consideration of certain 
 chances of error which may arise in connection 
 with abortion, and at the outset I will remark 
 that I want you to remember always that even 
 the best of men may sometimes be deceived. 
 
 A woman has an abortion, say, at the end 
 of the third month. The foetus and the pla- 
 centa come away, and the decidua mra is car- 
 ried off in the lochial discharge that follows. 
 The uterus has apparently cleansed itself thor- 
 oughly. When her next period arrives, how- 
 ever, the woman does not menstruate ; and this 
 is the case at the next period, and the next. 
 At the end of six months, she is delivered of 
 a fully - developed living child. Wow if you, 
 as the medical attendant, are not prepared for 
 this contingency, you may be placed in a very 
 false position. I have had such a thing occur 
 no less than three times in my own experience.
 
 ABORTION AXD ITS TREATMENT. 95 
 
 Under these circumstances the friends of the 
 patient will be very likely to inform you, with 
 an air of superiority, that she never had an 
 abortion at all. The explanation of this is, that 
 one of a pair of twins has been cast off and the 
 other has gone to full term. 
 
 I can tell you a worse case than this, how- 
 ever. A woman has an abortion, and the foetus 
 is cast off with all its membranes entire. Un- 
 der the circumstances, you naturally congratu- 
 late your patient on the happy result of her 
 trouble. In a month, however, you are sent 
 for in great haste, and you arrive to find, to 
 your horror, that the woman is in articulo 
 mortis. A few minutes more and she dies in 
 collapse. An examination shows that, in addi- 
 tion to the foetus in utero, there has been an 
 extra-uterine one, and the fatal result was due 
 to rupture of the Fallopian tube. 
 
 There are two other contingencies, also, 
 which may place you in a false position. One 
 is the following : The foetus is cast off, and you 
 
 think that all the membranes have come away 
 
 7
 
 96 ABORTION AND ITS TREATMENT. 
 
 also. The next month, however, the patient does 
 not menstruate, and then you say that there has 
 been a twin conception, and while one of the 
 foetuses has been expelled the other still re- 
 mains in utero^ and will probably go to full 
 term. About the end of the ninth month, sure 
 enough, the uterus does begin to contract ; but, 
 instead of a living child being delivered, a 
 bucketful of hydatids is cast out. These little 
 cysts of the chorion cling to the uterine walls 
 as ivy clings to the oak, and they go on de- 
 veloping and multiplying to such an extent 
 that the cavity becomes more and more en- 
 larged to accommodate them, and not infre- 
 quently the uterus grows to the size of the 
 organ at full term. 
 
 The other contingency is this : The foetus 
 is cast off, and with it comes a considerable 
 quantity of blood. You examine the clots 
 and find portions of the secundines, and you 
 are therefore induced to tell the patient that 
 everything is over. The fact is, however, that 
 the lower portion of the foetal shell has given
 
 ABORTION AND ITS TREATMENT. 97 
 
 way and the foetus has come out, with a small 
 portion of the membranes ; leaving the re- 
 mainder of the shell still in utero. This shell 
 may remain for months or years, constituting 
 what is known as a "molar pregnancy." In one 
 instance I knew it to remain for twenty years, 
 the mass in the mean time having undergone 
 calcareous degeneration. 
 
 You will find in the community in general 
 very positive ideas regarding pregnancy. Peo- 
 ple think that a medical man ought to know at 
 once whether a woman is pregnant or not, 
 under all circumstances. In fact, however, 
 the diagnosis of pregnancy in the early stages 
 is often one of the most difficult that the 
 physician is called upon to make. Still fur- 
 ther, it is by no means always easy to make 
 the diagnosis even at a later period ; and every 
 now and then a pregnant uterus is cut down 
 upon, under the supposition that it is an ovarian 
 tumor often by most excellent and careful phy- 
 sicians. 
 
 We now come to the consideration of the
 
 98 ABORTION AND ITS TREATMENT. 
 
 question of the artificial production of abor- 
 tion. 
 
 In regard to bringing on abortion artifically 
 you will have to be constantly on your guard, 
 or else you will sometimes be imposed upon. 
 All women may be divided into two great 
 classes those who desire to bear children, and 
 those who do not. It is among the latter class 
 that you will have to look out for deception. 
 For instance, individuals of this class have 
 been known to take small and repeated doses 
 of tartar emetic in order to produce such con- 
 stant and violent nausea and vomiting that 
 the physician felt called upon to bring on 
 abortion to save the patient's life, as he sup- 
 posed. 
 
 Here let me give you one rule which I have 
 always followed and which although I have 
 practiced medicine for thirty-five years, and 
 naturally have some confidence in my own 
 judgment I still follow at the present time. 
 This rule is, Never induce an abortion without 
 first having a consultation. You may per-
 
 ABORTION AND ITS TREATMENT. 99 
 
 haps ask me why. Remember, in the first 
 place, that a human life depends upon your 
 decision. It is better, therefore, that the re- 
 sponsibility should be shared. He who can 
 take a human life into his hands without a 
 desire to thus have the responsibility divided 
 is not, in my opinion, a man of proper feeling. 
 
 If the physician whom you consult does not 
 agree with you that abortion should be pro- 
 duced, the pregnancy may be allowed to go 
 on ; but if he does agree with you on this 
 point, your position is naturally very greatly 
 strengthened. Such a course as I have recom- 
 mended is in the interest both of the patient 
 and of the medical attendant. 
 
 Let us next inquire what are the indications 
 for the artificial induction of abortion. In a 
 general way, it may be stated that whenever it 
 is felt that the prolongation of pregnancy is 
 going to destroy the life or intellect, or to per- 
 manently ruin the health of a patient, abor- 
 tion should be brought on. It is a well known 
 fact, for instance, that a large number of pa-
 
 100 ABORTION AND ITS TREATMENT. 
 
 tients die every year from tlie vomiting of 
 pregnancy. It was to this condition that the 
 gifted Charlotte Bronte, who married some- 
 what late in life and who was believed to be 
 suffering from acute gastritis, unfortunately fell 
 a victim. As I have indicated, you will have 
 to be on your guard against deception. Many 
 women will either use drugs to produce vomit- 
 ing, or else they will suffer from nausea only 
 when the physician is in the room. Such 
 women generally influence their husbands at 
 will, and you must get the evidence of a trust- 
 worthy nurse, or of friends who are not under 
 the influence of the patient. Then, again, the 
 general character of the vomiting, and the con- 
 dition of the patient, will assist you in deciding 
 whether her sufferings are real or not. When 
 you find that the obstinate vomiting is a reality, 
 and it seems probable that the woman will die 
 if she is not relieved, it will be nothing less 
 than criminal not to bring on abortion. In 
 such cases it is astonishing to see how quickly 
 the symptoms are relieved and the patient be-
 
 ABORTION AND ITS TREATMENT. IQl 
 
 gins to improve in every way, when the uterus 
 has once been emptied of its contents. 
 
 But there are other conditions besides un- 
 controllable vomiting which call for artificial 
 abortion. There is some peculiar influence over 
 the kidneys exercised by puerperality, the na- 
 ture of which we do not know. It is a fact, 
 however, that a great many women die annu- 
 ally of puerperal nephritis. As a rule, such 
 nephritis does not begin until after the fourth 
 month, but in exceptional cases it occurs even 
 earlier than this ; or, possibly, the patient may 
 have had desquamative nephritis before the com- 
 mencement of pregnancy. I can not but regard 
 it as cruel to allow a patient with marked symp- 
 toms of this affection to go on in utero-gestation, 
 with the imminent risk of dying in labor of 
 puerperal convulsions, or, if she does not die 
 then, of being doomed to chronic Bright' s dis- 
 ease with its attendant suffering and dangers. 
 
 In the next place, if you have a pregnant 
 patient with cardiac disease of such a charac- 
 ter that you think her life is in danger, it is
 
 102 ABORTION AND ITS TREATMENT. 
 
 your duty to induce abortion. If she should 
 have cancer, or be in the third stage of phthisis, 
 you should not do this, because, in the first 
 class of cases, you have two lives to consider, 
 as the woman may have a long life before her, 
 while in the last it is impossible that she should 
 live under any circumstances. 
 
 The fourth condition which I would men- 
 tion is chorea. In one case only in my expe- 
 rience have I had to induce abortion on account 
 of this affection. The trouble was so violent 
 that I feared the patient would die before the 
 end of gestation, and I therefore brought on 
 abortion at the end of the fourth month. 
 
 Fifth, when the pelvic diameters are very 
 much contracted, so as to render delivery at 
 full term absolutely impossible, the uterus 
 should be prematurely emptied. 
 
 While acknowledging the improvements that 
 are constantly being made in the management 
 of the Csesarean section, Porro's operation, and 
 similar procedures, I still do not believe that, 
 when we can avoid it by inducing abortion, we
 
 ABORTION AND ITS TREATMENT, 103 
 
 are justified in subjecting our patient to the 
 great risk attending these operations even under 
 the most favorable conditions. 
 
 Sixth, in case of violent convulsions from any 
 cause whatever, abortion is indicated. It makes 
 no difference whether the convulsions are choreic, 
 ursemic, epileptic, or of any other character ex- 
 cept hysterical. Even if you succeed in control- 
 ling the seizures for the time being, it is entirely 
 improbable that the woman can go on for five 
 months, or more, longer without a return of the 
 trouble, and most likely in a form so aggra- 
 vated that death will inevitably result. 
 
 Seventh, artificial abortion is called for 
 sometimes on account of uncontrollable uterine 
 haemorrhage. Placenta pra3via is a condition 
 which does not occur at the early period of 
 pregnancy which we are now considering, and 
 the haemorrhage to which I refer is occasioned 
 by the separation and sliding away of the de- 
 cidua rejlexa from the decidua vera. After 
 styptics and the tampon have been given a 
 thorough trial, and the trouble still continues.
 
 104 ABORTION AND ITS TREATMENT. 
 
 there is nothing left for us but to bring on 
 abortion ; for, if this is not done, the most seri- 
 ous results will almost certainly ensue. 
 
 In this enumeration I do not pretend to give 
 you all the conditions which may from time to 
 time call for this measure. I only aim to show 
 you some of the principal ones, as they have 
 been met with by me in actual practice, and to 
 point out to you the general principles which 
 should guide you in deciding whether in any 
 case of serious difficulty that presents itself you 
 ought to resort to artificial abortion. 
 
 The next step naturally is to consider the 
 methods by which abortion is brought on ; and 
 the procedures which I mention first I only refer 
 to in order that you may carefully avoid them. 
 The first method is to introduce a metallic sound 
 into the os uteri, and push it forcibly through 
 the fcetal shell. If there be a brutal and stupid 
 method of inducing abortion, it is certainly this. 
 Yet it is done every day, and is the one com- 
 monly practiced in criminal abortions. There is 
 no doubt whatever about its killing the foetus,
 
 ABORTION AND ITS TREATMENT. 105 
 
 but, after the latter has been killed, its dead 
 body is left to rot in its shroud. You must 
 understand that when I call this procedure bru- 
 tal I do not mean that it is brutal to the patient 
 at the time, for she experiences no pain what- 
 ever from the piercing of the foetal shell ; but 
 that it is brutal in its results, since the foetus 
 may remain in the uterus for three months, oi 
 longer, and during all this time its presence 
 there is attended with the most imminent risk 
 of putrefaction and septicaemia. 
 
 The second method is to take a tent of 
 sponge, sea-tangle, or tupelo, and, by introduc- 
 ing it into the os internum, cause dilatation of 
 the cervical canal, and thus excite the uterus 
 to contract and bear down upon its contents. 
 This is perhaps a little less brutal than the 
 other, but only slightly so. It is impossible 
 to prevent the entrance of bacteria in the 
 use of any kind of tent whatever. Not long 
 since my colleague, Dr. Chambers, had some 
 sea-tangle tents prepared with every antiseptic 
 precaution, but, notwithstanding this, they were
 
 106 ABORTION AND ITS TREATMENT. 
 
 afterward found to teem with bacterial life 
 under the microscope. 
 
 Let me here digress a moment to say a word 
 in regard to sponge tents. I never use them 
 now under any circumstances whatever, and 
 regard them only as something connected with 
 ancient history. They have been superseded 
 by other and better devices, just as the stage- 
 coach and whale-oil have been superseded by 
 the railway and by gas and the electric light. 
 The stage-coach and the oil answered well 
 enough as long as we had nothing better ; 
 and just so it has been with the sponge tent. 
 At the present day these tents ought not 
 to be used in puerperal conditions, and in- 
 deed, I think, not even in non-puerperal con- 
 ditions. I have seen several deaths due to 
 this cause. Now, mark you, I myself have 
 employed them up to two or three years 
 ago ; but formerly I also used to travel by 
 the stage - coach and read by the oil - lamp. 
 I no longer use tents of any kind, however, 
 because there are much better and safer means
 
 ABORTION AND ITS TREATMENT. 107 
 
 at hand for accomplishing the same pur- 
 pose. 
 
 The third method is to take some instru- 
 ment like the uterine sound and, slipping it 
 carefully up into the uterus and along its 
 wall, gradually separate the decidua rejiexa 
 from the decidua vera. There is not a great 
 deal of danger connected with this procedure, 
 and it is the only one of these defective meth- 
 ods of inducing abortion that I would advise 
 you to adopt under any circumstances what- 
 ever. It is much less objectionable than the 
 others, because when you have thus separated 
 the two membranes from each other you still 
 have a living foetus left, and at the same 
 time your manoeuvre has excited uterine con- 
 tractions which will ordinarily result in its 
 expulsion. Still, I would not make use of 
 this method myself. 
 
 Next, I may mention, in passing, the use of 
 certain drugs, such as ergot, savin, pennyroyal, 
 viscum album, or mistletoe, and the root of 
 the cotton-plant. These are things which the
 
 108 ABORTION AND ITS TREATMENT. 
 
 charlatan might resort to, and which are com- 
 monly employed by ignorant women ; but no 
 scientific physician would ever think of placing 
 any dependence upon them whatever. The ef- 
 fect of such drugs is to excite the uterus to 
 tetanic spasms while the os is undilated and 
 the whole organ totally unprepared to perform 
 the work which is expected of it. To make use 
 of them is like driving a spirited horse up to a 
 closed gate, and still urging him to go on when 
 there is no way to get through it. 
 
 Now, having spoken in this disparaging way 
 of the various methods commonly in vogue, 
 you will naturally expect me to show you 
 some better way ; and this I will try to do. 
 These are the methods which have come down 
 to us from the past ; the one to which I will 
 next call your attention is of modern origin, 
 and entirely in accord with the best scientific 
 teaching of the day, as regards the all-impor- 
 tant matter of antisepsis. 
 
 Let us suppose that you have a patient at 
 the end of the third month of pregnancy in
 
 ABORTION AND ITS TREATMENT. 109 
 
 whom exist conditions which, in your opinion, 
 call for the immediate induction of abortion, 
 and that the physician whom you have called 
 in consultation agrees with you as to the pro- 
 priety of this procedure. It is important that 
 the abortion should be brought on promptly. 
 How shall you set about it ? In this way. 
 Anaesthetize the patient with ether, not chloro- 
 form, and place her on a table in the Sims 
 position. The vagina, vulva, and anus having 
 been thoroughly cleansed with carbolized water, 
 take a sponge saturated with bichloride solu- 
 tion (1 to 2,000), and with it fill the vagina with 
 the solution. By this means the os will be 
 placed in a lake of the antiseptic fluid. But 
 may not the bichloride poison the patient ? 
 Well, I have never yet met with this accident ; 
 but, even if the mercury should affect her 
 system to some extent, the dose will not be 
 sufficient to kill her, and it is better to run 
 this slight risk rather than expose her to the 
 danger of septic infection. 
 
 Next you catch the cervix with a little te-
 
 110 ABORTION AND ITS TREATMENT. 
 
 naculum and dip it below the surface of the bi- 
 chloride solution. You will thus perceive that 
 this is a subaqueous operation, and on that 
 account it is as free from the risk of being at- 
 tended with untoward results as it is possible 
 to make it. With a divulsor of small size you 
 stretch the cervical canal as far as you can in 
 all directions. About three minutes is taken up 
 with this procedure, and you then introduce a 
 larger divulsor and stretch the canal still further. 
 If it is at the end of the third month, and the 
 divulsion has been successful, you can now carry 
 your finger through the cervix. You next in- 
 troduce a glass plug, of larger or smaller size, 
 according to circumstances, such as I show 
 you here, and which is as large as the index 
 or the little finger, as the case may require. 
 Having gotten this well up into the cervix, yoa 
 pack the vagina with iodoform gauze, and then 
 apply a tampon in the manner already described 
 to you. This is all you have to do ; and, having 
 done it, you can go home and leave the case 
 to nature.
 
 ABORTION AND ITS TREATMENT. m 
 
 Within twelve hours the woman will proba- 
 bly have pain, and this is the first symptom 
 of abortion under these circumstances. Very 
 likely she will then vomit, and this is the sec- 
 ond symptom. Finally, a little blood will 
 probably ooze through the tampon, and this is 
 the third symptom. 
 
 The plug and the tampon may be left in 
 position for from thirty- six to forty-eight hours. 
 When you remove them you can, if necessary, 
 stretch the os again, and put in a larger plug, 
 sustaining it with iodoform gauze, as in the case 
 of the first one. You need not be anxious to 
 hurry the labor-pains. They will come on fast 
 enough, and the plug will probably be at last 
 forced out by the contractions of the uterus. 
 Behind it will come the product of conception, 
 and then the whole thing will be over. This is 
 all that I ever do now in these cases of artificial 
 abortion, and I am satisfied that you will get 
 good results with this method when you come 
 to practice it. I know also that you will 
 avoid the bad results that are so apt to fol- 
 
 8
 
 112 ABORTION AND ITS TREATMENT. 
 
 low the old methods which I have mentioned 
 to yon. 
 
 I did not mention to you that the plug to 
 which I have made allusion is about an inch 
 and a half in length, and provided with a broad 
 shoulder, which prevents its entrance into the 
 uterine cavity, while the tampon keeps it per- 
 fectly in position in the cervical canal. The 
 following figure represents its shape and me- 
 dium size. 
 
 Where the case is quite urgent, I never hesi- 
 tate to use the divulsor, and with forceps or 
 large curette at once to remove the entire fatal 
 shell. I have done this about a dozen times I 
 think, and so far have had no bad result from 
 the practice. 
 
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 to quote the words of the preface which the editor has wiitten for the new edition, 'a 
 desire to placi in the hands of the practitioner, the teacher, and the student a inean 
 of ready reference to the accumulated knowlerlge which we possessed of scientific and 
 practical medicine, rapid as was its progress and difficult of access as were its fc^t- 
 tered reconis.' The scheme of the work was so comprehensive, the selection of writtrs 
 so judicious, that this end was attained more completely than the most sanguine ex- 
 pectations of the able editor and his assistants could have anticipated. ... In pre- 
 paiing a new edition the fact had to be faced that never in the history of medicine li.nd 
 progress been so rapid as in the last twelve years. New facts have been ascertained, 
 and new ways of looking at old facts have come to be rec<ipnized as true. ._ . . The 
 revision which the work has undergone has been of the most thorough and judicious 
 character. . . . The list of new writers numbe-s fifty, and among them are to be found 
 the names of those who are leading authorities upon the subjects which have been com- 
 mitted to their care." 
 
 New York: D. APPLETON & CO., 72 Fifth Avenue.
 
 THE SCIENCE AND 
 ART OF MIDWIFERY. 
 
 By William Thompson Lusk, M. A., M. D., 
 
 "Professor of Obstetrics and TDiseases of Women and Children in the 
 
 'Bellevue Hospital Medical College ; Obstetric Surgeon to the 
 
 Maternity and Emergency Hospitals ; and Gyncecologist 
 
 to the Bellevue Hospital. 
 
 FOURTH EDITION. REVISED AND REWRITTEN. 
 With 246 Illustrations. 
 
 8vo. Cloth, $^.00 ; sheep, ^6.00. 
 
 " It was the pleasure of the undersigned to write a review of this most 
 excellent and masterly work on obstetrics when it appeared in its first edition. 
 The present is the fourth, an edition enlarged and revised. It is a model of 
 recent medical literature in obstetrics, and can not but give great credit to 
 the author and to American medicine. Model it is of clear, forcible, and 
 beautiful English, of good arrangement of subject-matter, and of thorough- 
 ness of modern obstetric exposition. The changes which have taken place 
 in the theory and practice of obstetrics since the issue of the last edition 
 have made it necessary for the author to present to the profession what is 
 essentially a new book. Most cheerfully will we recommend to the students 
 of medicine a study of Lusk. It ranks well with Playfair, and is second to 
 no book in our language." Chauncey D. Palmer, in the Ohio Medical 
 Journal. 
 
 " The book is now beyond criticism, for it has been accepted by the un- 
 erring judgment of the great body of physicians. We congratulate Dr. Lusk 
 upon this reward for the immense labor he has bestowed upon it." New 
 York Medical yournal. 
 
 " It contains one of the best expositions of the obstetric science and prac- 
 tice of the day with which we are acquainted. Throughout the work the 
 author shows an intimate acquaintance with the literature of obstetrics, and 
 gives evidence of large practical experience, great discrimination, and sound 
 judgment. We heartily recommend the book as a full and clear exposition 
 of obstetric science, and safe guide to student and practitioner." London 
 Lancet. 
 
 " It is but a short time since we had occasion to review this work, of 
 which we were enabled to speak in the highest terms of praise. The rapid 
 advance of many departments of obstetrics has meantime called for a few 
 additions. These having been made, it can be confidently said that Lusk's 
 Midwifery holds a high place among American authors, and deserves to be 
 extensively employed for reference, and recommended to students as a re- 
 liable and unusually readable text-book. " Cawa^a Medical and Surgical 
 yournal. 
 
 Kew York: D, APPLETON & CO., Publishers, 72 Fifth Avenue.
 
 MONTHLY NURSING, 
 
 By A. WORCESTER, A. M., M. D., 
 
 Fellow of the Massachusetts Medical Society ; Physician to the 
 Waltham Hospital. 
 
 SECOND EDITION. 
 
 12mo, 250 pages. Cloth, $1.25. 
 
 " This little work, intended as a text-book for nurses, is a mouel 
 of its kind, and it is a pity that its scope is limited, as its name 
 implies, to obstetric nursing. . . . The book is issued in a neat and 
 attractive style, and contains many practical hints which would not 
 come amiss to the physician, which he would not otherwise learn, 
 except through experience." Weekly Medical Review. 
 
 "This is one of the most practical little books we have seen. 
 Not only does it reveal the duties of the nurse, but it contains an 
 amount of useful details that will be invaluable to the young prac- 
 titioner." Practice. 
 
 "... We regard this book as of great importance, and doctors 
 should insist upon their monthly nurses adopting it as a text-book 
 for constant bedside use." Virginia Medical Monthly. 
 
 " This little volume is one of the most complete treatises of the 
 kind we have seen. Mothers and nurses will find it invaluable." 
 New York Medical Times. 
 
 New York : D. APPLETON & CO., 72 Fifth Avenue.
 
 A MANUAL OF INSTRUCTION 
 
 IN THE PRINCIPLES OF 
 
 Prompt Aid to the Injured. 
 
 INCLUDING A CHAPTER ON HYGIENE, AND THE DRILL 
 
 REGULATIONS FOR THE HOSPITAL CORPS, U. S. A. 
 
 DESIGNED FOR MILITARY AND CIVIL USE. 
 
 By AI.YAH H. DOTY, M.D., 
 
 Major and Surgeon, Ninth Regiment, N. G. S. N. Y. ; Attending Surgeon to 
 Bellevue Hospital Dispensary, New York. 
 
 SECOND EDITION, BEVISED AND ENLARGED. 
 
 13mo. 304 pages, with 134 Illustrations. Cloth, S1.50. 
 
 This book is intended to impart the knowledge necessary for the prompt 
 and intelligent care of persons suffering from haemorrhage, fractures, dislo- 
 cations, wounds, contusions, burns, shocks, sprains, poisoning, the efi'ects 
 of heat or cold, apoplexy, epilepsy, those rescued from the water, and other 
 accidents which are liable to occur at any time, the results of which may be 
 materially influenced by the care and attention which the sufferer receives at 
 the outset. 
 
 The book is of a size convenient for the pocket, and embraces a greater 
 range of subjects than is found in any work of the kind heretofore pub- 
 lished ; and its completeness and simplicity commend it to the general public 
 as well as to that portion which forms the militia of the States of the Union, 
 
 "... This is the most satisfactory little monograph on this subject with which 
 we are familiar. It is enriched by numerous illustrations, taken, with due credit, 
 largely from the works of Esmarch, Flint, and others. In addition to the usual 
 matter contained in such little works, a chapter on Hygiene has been introduced, 
 and also one containing the recently adopted drill regulations of the ambulance 
 corps of the United States Army." Co/miAm Medical Journal. 
 
 "... This book should be In every physician's office. This edition will sus- 
 tain the reputation acquired by its predecessor in every respect, and the work is 
 likely to have a wide field of usefulness." Charlotte Medical Journal. 
 
 " . . . It is a manual written in plain, clear style. It would be of value in the 
 hands of the police of large cities. The instructions are good, and particularly 
 those of the chapter on Haemorrhage. The chapter on Hygiene is a desirable addi- 
 tion." Medical Standard. 
 
 " . . . It is the best hook that the layman, hospital assistant, or nurse can get, 
 and it is a most excellent work for the medical man also. To be pointed in our 
 opinion, we say unhesitatingly it is the best book of its kind we have ever seen." 
 Southern Clinic. 
 
 "... To the ambulance corps connected with the different military organiza- 
 tions it will be especially valuable ; and not less so to all those who may at any 
 time be benefited by the knowledge or application of its excellent precepts and 
 practical suggestions." Co/^eg'e and Clinical Record. 
 
 " . . . The author seems to have succeeded remarkably well in the difficult task 
 of giving to nonmedical persons information which will properly instruct them 
 to cope with emergencies without encouraging them to usurp the functions of the 
 physician or anrgeori." Charleston Sunday News. 
 
 New York: D. APPLETON & CO., 73 Fifth Avenue.
 
 A TEXT-BOOK ON 
 THE DISEASES OF WOMEN. 
 
 By ALEXANDER J. C. SKENE, M. D., 
 
 Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. Y., 
 
 formerly Professor of Gynaecology in the New York Post-Gradnate 
 
 Medical School and Hospital, etc. 
 
 With Two Hundred and Fifty-four niuBtrationsi of which One Hundred and 
 Sixty-five are Original and Nine Chromolithographs. 
 
 SECOND EDITION, REVISED AND ENLARGED. 
 
 SOLD BY SUBSCRIPTION ONLY. 
 
 This treatise is the outconiBvand renresents the experience of a long 
 and active professional life, the gveat^ part of which has been spent in 
 the treatment of the diseases of woimn. It is especially adapted to noeet 
 the wants of the general practitioner in recognizing this class of diseases 
 as he meets them in every-day practice and in treating them successfully. 
 
 The arrangement of subjects is such that they are discussed in their 
 natural order, and thus more easily comprehended and remembered by 
 the student. 
 
 Methods of operation have been much simplified by the author in his 
 practice, and it has been his endeavor to so describe the operative pro- 
 cedures adopted by him, even to their minutest details, as to make his 
 treatise a practical guide to the gynjecologist. 
 
 Although all the subjects which arc discussed in the various text- 
 books on gynaecology have been treated by the author, it has been a 
 prominent feature in his plan to consider also those which are but inci- 
 dentally, or not at all, mentioned in the text-books hitherto published, 
 and yet which are constantly presenting themselves to the practitioner 
 for diagnosis and treatment. 
 
 The illustrations are mostly entirely new, and have been speciallv 
 made for this work. The drawings are from nature, or from wax and 
 clay models from nature, and have been reproduced by processes best 
 adapted to represent in the most truthful and permanent forms the exact 
 appearances of the diseased organs, methods of operation, or instruments 
 which they are designed to illustrate. 
 
 Wherever it has been possible to make clearer the author's methods 
 of treatment by histories of cases which have actually occurred in his 
 practice, this has been done. A simple, typical case, such as is ordi- 
 narily met with, is first described, and then difficult and obscure cases, 
 with the various complications which occur. 
 
 New York: D. APPLETON & CO., 72 Fifth Avenue.
 
 Nr'/'j lllllillllilllllllllllllllllllllllllllllllllllilllll 
 
 '^ ^ 3 1205 00425 9030 
 
 r^4
 
 A A 000101380 4 
 
 THE LIBRARY 
 UNIVERSITY OF CALIFORNIA 
 
 Santa Barbara 
 
 THIS BOOK IS DUE ON THE LAST DATE 
 STAMPED BELOW. 
 
 KOTiS MAR0 9199# 
 
 WD WAR 02 1994 1 
 
 12 
 
 series 9482