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ether. In each individual case, we must decide, from the condition of the patient, as to the need of either of these remedies and the necessity of their repetition. The local remedies generally advised are various kinds of astringent vaginal injections, bits of ice and snow passed up to the cervix, hot vaginal injections, the tampon, and the tent. Of these, I shall consider the last three as being those on which we should mainly rely. I suggest the use of hot vaginal injections as the first local remedy to be used. Dr. Fordyce Barker claims that they alone are often sufficient to control the hæmorrhage, and I have repeatedly verified his statement. When this measure fails to check the flow, and there has been no evidence of the decomposition of any part of the retained ovum, the cervix being not yet sufficiently dilated to admit of the introduction of the indexfinger, we should advise the use of the tampon. The method of introducing the tampon, advised by Sims, is the safest. It should be removed every six hours, and the introduction of a new one should be preceded by a thorough vaginal douche of hot carbolized water. While the tampon may be used in such cases, , it must be distinctly understood that, in these very cases, I prefer the use of the tent. This is more efficient in controlling hæmorrhage, and it also aids in dilating the cervix.
For the purpose of introducing the tent, the woman should be placed in the semi-prone position (Sims), and drawn to the edge of the bed. The perineum should be retracted by a Sims speculum in the hand of an assistant. With Emmet's double tenaculum, we seize the cervix by passing its closed blades slightly within the cervical canal; and, with its expanding blades, we can steady the cervix and dilate its canal, thus rendering the introduction of the tent less difficult. One or more tents should be used, as each case may require, and they should not be retained longer than six hours. If we have evidence that decomposition has begun in any part of the retained ovum, we should precede the use of the tent by a thorough intra-uterine injection of hot carbolized water. As but little trouble or delay is caused by the use of the douche, it should be employed immediately before the introduction of the tent. No change in the position of the woman is needed. We pass the closed blades of the tenaculum a little deeper into the cervical canal, and, with its expanding blades, we can open, steady and depress the cervix. This facilitates the introduction of the double canula, catheter, or uterine tube, as well as the return flow of the water. When decomposition has taken place in the ovum before dilatation of the cervix, the douche should be given through a double catheter or canula. After the cervix has been dilated, either by the use of tents or by the efforts of nature, we should use the soft-rubber uterine tube which I now present, made for me by Tiemann & Co., Three sizes were originally designed for the treatment of puerperal septicæmia. The smallest is suitable for cases of abortion. It is smooth, soft, and very flexible, ten inches in length, and six sixteenths of an inch in diameter. It has a number of small circular openings near its end, which are so constructed as to permit a backward current.
With the patient in the position before advised, we proceed to use the uterine douche. To accomplish this, we pass into the uterine cavity through the cervix, between the expanded blades of the tenaculum, either the double catheter or uterine tube, which has already been attached to a fountain-syringe filled with hot carbolized water. The bag of the syringe is but slightly elevated above the body of the woman, and the water is allowed to flow freely through the tube during its introduction. By retaining the tenaculum in position, we are able to insure an unobstructed return-flow of the liquid, and the cervical canal is thus dilated and made patulous during the administration of the uterine injection. The escape of the wash is further encouraged by slightly depressing the vaginal portion of the cervix. By this method of using the douche, two sources of danger are almost absolutely prevented; viz., the admission of air into the uterine vessels, and the passage of the fluid into the peritoneal cavity. The fountain-syringe is preferred because it is impossible to employ force in its use. The object of this injection is to prevent the absorption of any putrid substance from within the uterus. That no woman is safe while the least portion of a dead fætus is retained within the uterus, all will con
cede; and this should lead us to empty the womb at the earliest practicable moment. I specially urge this in all cases of criminal abortion. When decomposition has begun in the ovum, we ought to be doubly anxious for its removal; and, even when local inflammations have developed, the plan of treatment should be the same. The expectant treatment is generally tedious, often treacherous, and sometimes fatal. For the removal of the ovum, we have no instrument as safe and useful as the finger. This we should employ as soon as the cervix will admit of its introduction. If the cervix be not sufficiently dilated at the first visit, we should use, for the purpose of dilating it, one or more tents, in the same way as advised for controlling hæmorrhage. Any suggestion touching the use of the finger in either the detachment or removal of fragments of the ovum seems uncalled for; but, even after due perseverance, we may sometimes fail, even when assisted by the relaxing influence of ether. Then it will be necessary to employ the wire-curette or the shield (female blade) of the blunt hook and crotchet; and with these, we can usually detach and remove any retained fragments of the ovum. In using either of these instruments, the woman should be in the same position as advised for her during the use of the uterine douche. With the tenaculum dilating and fixing the cervix as before, we pass the instrument into the cavity of the uterus precisely as we did the uterine tube, and then, by gently sweeping the instrument around, with firm pressure from side to side and from the fundus to the cervix, we easily detach any fragment that might have previously escaped. In the earlier months we should use the curette; but after the third month, we can do better with the shield of the blunt hook and crotchet.
After using either of them, we should use an intra-uterine injection as before suggested. This cleanses the entire cavity and stimulates the walls of the uterus to contraction.
With the ovum removed and the uterus firmly contracted, but little remains for us to do locally. Septicæmia, we trust, has thus far been either checked or prevented, and the hot carbolized vaginal douche is all that is required; but, in restoring one of these pale, exhausted, and almost lifeless women to health,
our resources are often taxed to the utmost. In many instances, it is a long journey, and the way is often obstructed by various complications. Sound principles of hygiene and dietetics, however, are always demanded, with a careful course in therapeutics. Innumerable nervous complications may arise, various sympathetic affections may complicate the case, and pelvic troubles may be developed that would disconcert the most expert gynæcologist.
In conclusion, I wish to draw your attention to the important subject of the prevention of criminal abortion. To succeed in removing this evil, will require the united efforts of the medical profession. Physicians should denounce the abortionist and his patient as guilty of murder. They should warn each applicant of the wickedness of the proposed crime, the great danger to life, and the many distressing ills that may follow.
DR. ELY VAN DE WARKER, of Onondaga County.—The paper of Dr. Robb is exceedingly timely, as it calls attention to a condition which we are constantly called upon to encounter. That criminal abortion exists in the community, all know; and I am inclined to think that, notwithstanding the most persistent efforts of high-minded medical men, it will continue to exist. The paper has called our attention to what might be done to avert the danger which grows out of loss of blood and of blood-poisoning. I desire to say a few words with regard to the action of ergot upon the uterus at or before the third month. I have never seen any good result from the use of ergot in cases of abortion, especially in criminal abortion. Patients bleed just as seriously after ergotism as without the employment of the remedy ; and the reason is, that the uterus is but partially developed before the third month, and has not the machinery of contraction which it possesses later, Hence, before the third month, notwithstanding the free use of ergot, there will not be that firm and solid aterine contraction which averts hæmorrhage. Furthermore,
uterine contraction produced by ergot at this stage of pregnancy, with the intention of expelling the débris and the ovum, is erratic and irregular, and fails to accomplish this purpose. I therefore believe that time is lost in the hope of relieving a case simply by the use of ergot, whether it be employed hypodermically or otherwise. I also wish to call the attention of the Association to the use of the tampon in these cases. Of course, if we be called to a patient at night and have no other means at hand for arresting hæmorrhage, the use of the tampon would be proper ; but to rely upon this means of arresting hæmorrhage in such cases, I think is a mistake. There is but one means of relief in cases of abortion at the third month, and that is to free the uterus of its contents. Practitioners have used sponge-tents for effecting this object ; but, during the past two years, I have ceased their employment, having found that I could dilate the uterus sufficiently by the uterine dilator to admit of the introduction of the finger, and suoh dilatation is certainly sufficient to enable one to remove the uterine contents at that period of pregnancy. The os is thus easily dilated, little force is required, and, if the patient be made to inhale half a drachm of chloroform, benumbing sensibility but not producing unconsciousness, we can proceed with the operation almost immediately. The mass which is causing the hæmorrhage and exposing the woman to septicæmia can then be brought down by means of the blunt curette, and this done, our object is accomplished. The more quickly the object can be accomplished, without waiting for the action of tents and ergot, the sooner will the patient be restored to health. Sometimes, after using the curette, the uterine cavity is swabbed out with the tincture of iodine, and thus danger from septicæmia can be averted. This procedure is far superior to dilatation with tents, which require some hours to expand the os.
DR. MOSES C. WHITE, of New Haven, Conn., said that the action of ergot at the third month was not to expel the contents of the uterus, but to cause the blood-vessels to contract, and thus prevent abortion.
Dr. R. H. Sabin, of Albany County, related the following case in illustration of the dangers of the tampon:
A few years ago, I was called, at about four o'clock in the morning, to see a lady who was found to be bleeding excessively, the