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A LARGE measure of the responsibility of the practice of midwifery is involved in the management of abortions.

In order to be successful the practitioner should study well the causes that lead up to the premature expulsion of the fecundated ovum. This may be due to the father, mother, or the fetus.

The most prominent paternal causes are advanced age, lowered vitality, vicious practices, excessive venery, alcoholism, lead poisoning and syphilis.

On the part of the mother the same causes that operate through the father will be more certain and direct, if they exist in her, to which are to be added malarial and typhoid fevers, pneumonia, smallpox, measles, lagrippe and some other general diseases, surgical operations on the reproductive organs or adjacent organs, sudden shock, severe mental strain or distress, falls or blows on the abdomen, etc. But by far the most common causes of abortion result from diseases, or displacements of the womb itself, to which may be added direct criminal procedures; over fifty per cent. are due to these causes.

* Read before Tri-State Med. Assn. (Miss. Ark. & Tenn.) Memphis, Nov. 15, 1900 VOL. XXI-29 393

A womb in a permanent state of retroversion or flexion is, with rare exceptions, quite sure to expel its contents. Being bound down by adhesions from previous pelvic inflammation, or in a state of extreme prolapsus and retroversion, it cannot accommodate itself by normal expansion and ascent to the growth of the fetus beyond a given limit, and of necessity must take on premature contractions, and abortion is the result. Cotton pickers are said to be peculiarly liable to abort on account of carrying a heavy load of cotton in an apron, which by continual pressure on the abdomen, produces expulsive efforts of the womb. The vicious practice of tight lacing, in order to conceal pregnancy, may produce the same result.

Women suffering from extensive lacerations of the cervix or perineum are liable to abort for want of proper support of the uterine contents. Endometritis and fibromyomata produce their share of these troubles.

I have thus briefly referred to the most common causes of an interruption of pregnancy, and we should not forget that a thorough understanding of the etiology is of prime importance, as thereby only may we be able to adopt suitable preventive measures, which object, considering the dangers incident thereto, and the various sequelæ, is greatly to be desired.

The immediate danger in abortion is from hemorrhage or sepsis. The more remote results are observed in the numerous chronic diseases of the uterus, tubes and ovaries that afflict for life so many women, and fill the offices and infirmaries of the gynecologist.

The treatment of abortion is to prevent it if possible, and when this cannot be done, secure an empty and clean womb, and afterward enforce the ordinary rules of the lying-in chamber.

Rest, absolute; opiates in moderation, proper hygienic environments, and the correction of displacements of the womb, constitute, in the main, the preventive treatment. With this, of course, is included proper medical treatment of any general disease which may act as the immediate or predisposing cause. If there has been considerable hemorrhage, the os and cervix soft and dilated, and any part of the ovum protruding into the cervix, then we will not be able usually to prevent abortion, and should allow it to proceed.

As a rule the fetus will pass away with but little trouble; the greatest difficulty, especially in the early months of pregnancy, being in the removal of the placenta. This can often be done with the finger, but if it cannot, after thorough vaginal irrigation, insert a firm tampon well back to the os, and in a few hours, on removing the packing, the placenta will be found expelled. This simple procedure will not always be sufficient; and if not, and the bleeding continues, by aid of a speculum and good light, with a strip of gauze, pack the uterus firmly and tampon the vagina. This will stop the bleeding, bring on contractions, and expel the whole contents.

If the symptoms, either of continued hemorrhage or sepsis, follow abortion, you may reasonably conclude that there are yet remaining portions of placenta or membranes. Sepsis is known to exist if there is a foul discharge, rigors and fever. These conditions (sepsis or continued slow hemorrhage) must be promptly met by curettage, thorough irrigation, and loose packing of the womb, keeping open the os for drainage. Remember that drainage in all septic conditions is absolutely necessary to safety, whether of the uterus or other organs. For intrauterine irrigation bichloride of mercury or carbolic acid should rarely if ever be used; creolin, lysol or permanganate of potash are quite efficient, and being non-toxic are practically without danger. A solution of permanganate of potash, one grain to the ounce, is one of the very best agents, being slightly astringent, antiseptic, non-irritating, and withal a good local application to a congested mucous surface.

The writer is well acquainted with a case that occurred in the practice of a most competent practitioner, in which speedy death resulted from an injection into the womb of a solution of carbolic acid. The patient complained of the taste of the drug almost as soon as the irrigation was begun, and in a short time was dead, with symptoms of carbolic acid poisoning. With the assistance of two other physicians I irrigated a septic womb with a 1 to 5000 bichloride solution; most alarming symptoms followed. The woman did not die at once, but did later on. I am satisfied the irrigation hastened the issue. Absorption is quite active from mucous surfaces of the birth canal. Patients often complain of the taste of medicine almost

at the instant of its application with a cotton swab to the endometrium.

Repeated curettage and irrigation, and the application topically of compound iodin solution or of alcohol, may sometimes be required to overcome sepsis. We should especially remember in septic conditions not to pack the womb firmly, as we would for hemorrhage, but merely carry a strip of gauze back to the fundus and leave it protruding through the os, simply acting in the place of a drainage tube. A glass drainage tube may be used if thought best, but the gauze will usually be quite sufficient.

As the most alarming feature of abortion is hemorrhage, we may be pardoned for some further remarks relative to its management. True it is a trite subject, but quite commonly met with in practice, and if we preserve the lives and general well-being of such patients, we need to master every detail of the situation. The old plan of giving a little ergot and waiting for nature to have her way, will not do in the presence of any very considerable bleeding. Yet we note this practice is still adhered to by some practitioners, and it is about all the ordinary midwife (who ought to be legislated out of existence) knows to do.

A practitioner of long experience, doing a large practice, came into my office one day and stated that he had recently lost a case from hemorrhage during an abortion; that he had given ergot freely, and had sat by her bedside and faithfully "turned out the clots" as they had formed. He pressed me for an opinion of his methods, and if there was anything more that he could have done. I suggested that "turning out the clot" in abortions in the early months of pregnancy was not good practice. He maintained that the books said, turn out the clot. I modestly insisted that this injunction applied only to post-partum hemorrhage, at or near full term, when a clot of blood in the cervix would act merely as a dam to the current, and that as the hemorrhage proceeded the womb would dilate, and might hold enough blood to destroy the patient, and that rational treatment under these conditions would be to turn out the clot, and enforce contraction of the womb. But this condition did not obtain in early abortions,

and a clot was nature's own method to stop the bleeding, and should not be turned out; that other and more secure measures might be instituted.

Another physician of age and experience related a case in which a short time after labor fainting spells came on, nausea and vomiting, and great prostration. He said she was "bilious," and gave her freely both calomel and quinin, and used mustard plasters; yet in spite of all his efforts, the woman, to his amazement, died in a few hours. He asked an opinion as to the cause of death. I answered "post-partum hemorrhage." But he said there was no hemorrhage at all; that the clothes under her were hardly stained, but the abdomen was swollen, and she just died of heart failure. Here was a plain case of a strong woman actually bleeding to death right under the care of a physician who had overlooked the nature of the trouble. This digression is made not to reflect on the reputation of the medical gentleman in charge of the case, but to illustrate the different conditions involved in the treatment of uterine hemorrhage.

Before we proceed to discuss alarming hemorrhage from abortion, let us examine the practitioner's satchel. If properly filled it will contain a clean Kelly pad, a package each of plain and iodoform gauze, one of prepared wool and cotton, a two-ounce bottle of creolin, a vial of permanganate of potash, a speculum, curette, and an instrument for packing the uterus, a fountain syringe, and one of the most essential articles of all, a clean common household syringe, to which is, or may easily be attached, a large hollow needle. This syringe and needle should be kept in every physician's satchel for the sole purpose of injecting normal salt solution. It is to be preferred to a fountain syringe, for with it more force can be used in pumping the solution into the cellular tissue. Of course the doctor has about his person a good working hypodermie syringe, with tablets of morphia, atropia, digitalis, etc., and some aseptic ergotin. Thus armed you are ready to face the emergency to which you may be called. To find a woman whose pinched features, flickering pulse, a death-like hue of the skin, labored breathing, suggest that there is but a step between her and death, and the few brief moments left need

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