PS**! || a^?la» Wf 11 ;;!.« ^P mm* i. •J '■<''■!''■ v<" -.,v i •:*■? ' .1 , >*:• "';•,■» < > '"': ' ■"*** ii£; ^>;:., < .>"..'.' Avi-vv;-. •■:-■■■•'■■■-^■ H'W^' •:'''-,'V -■■■■ #^&&»-.-..; ■■■'.■•-.. ■l.'V-'ii} . ■'"■/.ji'.h SEP MP;;' 3^ ► •* ' f .' ".r 's* 2&fi. '<&'&& A C.S.HAL8EY* ^iHOMaorAThic ^ V"lHTAC0.1LLS.- 33 <«a A ■ r vr" - IMV .Yr ^. / 1 r^v/= \ el wte:y »Htk\ NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland ddfld ■/ JJKflWf ■*!»;. f xf£j*J v 'lAli !T] y\v fLkkfl Vt *^HHM1 faSaB KviylB WiPB HP'i 4k f*M '8Kb H^V B^fSj^JW ^rf AfnIV ■^ ^B^v ^BI aiiLgfw FVaBJ jfl[fiWHfc»Y /j3B .& a-, •W HI A SYSTEMATIC TREATISE ON Abortion and Sterility. BY EDWIN M. HALE, M.D., Late Professor of Materia Medica and Therapeutics in Hahnemann Medical College ; Author of " The Homoeopathic Materia Medica of the New Remedies;" " A Monograph on (lel- seminum" and ''Retroversion of the 1'terus ;" Member of the American Institute of Homoeopathy ; of the Illinois State Homoeopathic Association: of the Western In- stitute of Homoeopathy; Honorary Corresponding Secretary of the Massachu- setts State Homoeopathic Medical Society; Honnrary Member of the New- York State Homoeopathic Society; of the Michigan Institute of Homoe- opathy ; Associate Editor of the North American Journal of Homoe- opathy ; of the American Homu-opathie Observer, etc., etc. SECOND EDITION-REVISED. C H I C A G O : C. S. ITALSEY. 147 CLARK STREET. Buffalo: C. S. HALSEY, 270 .Main Street. Philadelphia: F. E. B(ERICKE. New York : WILLIAM RADDE. Boston: OTIS CLAPP. Cleveland: BECKWITH & CO. Cincinnati: SMITH & WORTHIXGTON. Detroit: E. A. LODGE. St. Louis : H. C. G. LUYTIES. London. Eng. : H. TURNER & CO. 1S6S. Entered according to Act of Congress in the year 186S, By 0. S. HALSEY, In the Clerk's Office of the District Court for the Northern District of Illinois. Church, Goodman & Donnelley, Printers, 108 and 110 Dearborn St., Chicago. THIS VOLUME IS INSCRIBED TO A. E. SMALL, A.M., M.D., OF CHICAGO: A most excellent Physician, one of the best of Men. And truest of Friends. PREFACE TO THE SECOND EDITION. In preparing the second edition of this work, the author has aimed to bring the treatment up to the requirements of the present day, and to include all the valuable discoveries in Medicine and Surgery. He has, therefore, made numerous additions and revisions, largely increasing the size of the work, notwithstanding the omission of some of the contents of the first edition. The omission of Part V., or Obstetric Abortion, was prompted by conscientious motives. It was written for physicians — for pure-minded and honorable men — but the information therein contained has probably been prostituted to bad purposes by immoral physicians. It must be admitted, however, that correct information relative to the induc- tion of premature labor is often of incalculable value to the physi- cian, as a means of saving life. In this respect the omission made will be a real loss. I prefer, however, that the profession shall repair this loss by consulting the works of such obstetric authors as Simpson, Cazeaux, Gardner, Barnes, allopathic ; or Guernsey, Ludlam, and other obstetric writers of the homoeopathic school. The treatise on Sterility, which has been added to this edition, contains all that is known up to the present time relative to the causes and treatment of that condition. It is, in fact, a work in itself, nearly equaling, in the amount of matter, that portion devoted to the consideration of Miscarriage. The author, in presenting this edition, trusts that it may prove of real practical value to the profession. Chicago, June 1, 1868. PREFACE TO THE FIRST EDITION. In the Eighth Volume of the North American Journal of Homoeop- athy (1860), an article appeared bearing the title, ''Abortion : Its Prevention and Treatment," in which the writer ventured to call the attention of his professional colleagues to medicines not here- tofore used by members of the Homoeopathic school, and which he believed to be of considerable value as remedial agents for the remo- val of certain abnormal conditions of the organs of generation, which are likely to cause an arrest of development, or premature expulsion of the product of conception. The interest that this article aroused in the professional mind was such that the writer felt justified in enlarging and amending the original paper. It was then issued by the present publisher, in a pamphlet of twenty-two pages, entitled " The Homoeopathic Treatment of Abortion" etc. This small brochure was prefixed by a prefatory letter from Dr. R. Ludlam, in which he kindly commended it to the notice of the homoeopathic school. That edition of the monograph having been exhausted, the writer engaged in a more thorough and systematic study of the subject. Five years having elapsed since the appearance of the original paper, he had gained increased practical experience upon the subject. He has, therefore, attempted to embody these results in the treatise herewith presented to the general medical profes- sion, and especially to physicians of the homoeopathic school. He sincerely hopes this volume will form a useful addition to our medical literature. Chicago, April 2, 1866. CONTENTS. PAGE. Introduction......................................... xiii PART I.—STATISTICS OF ABORTION. Of Foreign Countries................................... 19 Of New York City..................................... 20 Of Boston............................................. 22 Of Chicago............................................ 23 As to the period at which Abortion occurs................. 2.5 OP Criminal Abortion................................... 27 PART II.—ETIOLOGY OF ABORTION. Tabular View of the Causes of Abortion............... 33 Sec. I.—Predisposing Causes. Plethora.........:.................................... 35 Ansemia or Chlorosis................................... 35 Scrofula.............................................. 36 Return of Menstrual Crisis.............................. 36 Zymotic Diseases: Syphilis.............................................. 37 Mercurialization....................................... 38 Variola............................................... 38 Asiatic Cholera........................................ 39 Yellow Fever.......................................... 39 Sec II.—Local Causes. Abnormal Condition of the Ovum and its Appendages....... 39 Moles............................................ 40 Hydatids.......................................... 41 Fatty deterioration of the Chorion and Placenta........ 42 Congestion of the Placenta.......................... 43 Inflammation of the " .......................... 43 Placenta Previa.................................... 44 Sec. III.—Centric Causes. Emotional............................................ 45 Physical.............................................. 45 Medicinal............................................. 46 viil. CONTENTS. PAGE. Galvanism.......................................'..... 48 Cereb'ro-Spinal-Meningitis............................... 49 Sec IV.—Concentric Causes. Parotidean............................................ 55 Thyroidean........................................... 56 Mammary............................................. 56 Gastric.........,..................................... 56 Dental............................................... 57 Renal................................................ 57 Vesical............................................... 57 Rectal ............................................... 57 Vaginal.............................................. 58 Ovarian .............................................. 58 Uterine.............................................. . 59 Sec V.—Functional Diseases of the Uterus. Congestion........................................... 61 Leucorrhoea........................................... 62 " Cervical or Mucous........................... 64 " " Sequelne ............................ 65 " Vaginal or Epithelial......................... 67 Gonorrhoea............................................ 69 Sec VI.—Organic Diseases of the Uterus and Cervix. Ulceration of the Cervix................................ 71 Simple Granulating Ulcer............................... 73 Varicose " ............................... 76 Fissured '■ ............................... 77 Follicular " ............................... 79 Phagedenic '• ............................... 80 Corroding " ............................... 80 Cancerous " ............................... 80 Syphilitic "............................... 80 Sec VII. Induration of the Cervix Utekt........................ 82 Displacements of the Uterus......................... 84 Anteversion .................................. 84 Prolapsus..................-................... 84 Retroversion.................................. 84 Death of Embryo.................................. 87 Coitus............................................ 87 Instrumental Irritation............................. 88 Ovarian Irritation.................................. 89 " Congestion................................. 90 " Inflammation............................... 90 CONTENTS. ix. PAGE. Sec VIII. Medicinal Causes..................................... 90 PART III.—GENERATION: Symptoms, Diagnosis, Pathology, Mechanism and Prognosis of Abortion. Sec I.—Generation. To date of Placental Attachments........................ 115 " Viability.................................... 117 " Delivery.................................... 118 Dimensions and Weight of the Foetus at the different periods of Uterine Life.................................... 119 Sec II.—Symptoms of Abortion. Premonitory.......................................... 123 Actual............................................... 124 Chills............................................ 124 Pain............................................. 125 Hemorrhage .................................... 127 Fever............................................ 130 Complications..................................... 131 Discharges ....................................... 131 Subsequent........................................... 131 Sec III.—Diagnosis of Abortion. Metritis............................................... 134 Peritonitis............................................ 135 Dysmenorrhcea......................................... 135 Dysentery............................................ 135 Congestion of Uterus................................... 136 Hydrorrhcea........................................... 137 Haemorrhage.......................................... 138 Retention in Utero of the Ovum and Appendages........... 140 Sec IV.—Pathology and Mechanism of Abortion. Process of Abortion.................................... 142 After Conception...................................... 143 " twenty days to the third month..................... 143 At sixth month........................................ 146 Sec V.—Prognosis of Abortion. When favorable....................................... 148 '' unfavorable..................................... 149 Natural abortions....................................., 150 Immediate consequences................................ 151 Remote '•■ ....,........................... 151 X. CONTENTS. PART IV.—TREATMENT OF ABORTION. Sec I.—Preventive Treatment. PAGE. Of Plethora........................................... l'^5 Anaemia or Chlorosis ................................ 159 Scrofula........................................... 162 Return of Menstrual Crisis........................... 162 Of Zymotic Diseases. Syphilis.............................................. 163 Mercurialization....................................... 164 Variola............................................... ] 64 Scarlatina............................................ 166 Diphtheria ........................................... 168 Cholera.............................................. 170 Sec II.—Of Local or Organic Diseases. Malformation of the Ovum............................... 171 " " Membranes.......................... 171 Placenta Previa....................................... 172 Organic Disease of Placenta............................. 173 Fatty Degeneration................................ ] 73 Hydatid " ................................ 173 Calcareous " ................................ 175 Molar " ................................ 175 Sec III.—Of Reflex Causes. Centric............................................... 17g Emotion. Fright, etc................................ 17Q Blows, Injuries, etc................................. 177 Medicinal......................................... 173 Concentric............................................ 178 Parotidean Irritation............................... 178 Thyroidal......................................... 179 Mammary......................................... 179 Dental........................................... 18o Gastric........................................... 182 Rectal ........................................... 183 Vesical........................................... 186 Vagina}.........................................' 187 Hysterical..................................... I89 Epilepsy.......................................\\ ]89 Falls, Jumping, Blows, etc........................ I89 Sec IV.—Of Functional Diseases of the Uterus. Congestion......................................... 1 nj Inflammation .................................... " jgo Leucorrhoea....................................... " jqq Cervical.....................,......., " ■. QO CONTENTS. XL PAGE. Vaginal.......................................... *^4 1 Q7 Gonorrhoea............................................ y gEC. v.—Of Ulceration of the Os and Cervix Uteri. Simple Granulating Ulcer.............................. 204 Varicose " ............................... 204 Fissured " ............................... 2o5 Follicular " .................»............. 206 Phagedenic " ............................... 206 Syphilitic " ............................... 208 Resume".............................................. 209 Diphtheria ........................................... 209 Ovarian Diseases....................................... 211 Sec VI.—Of Uterine Displacements. Prolapsus ............................................ 213 Anteversion .......................................... 214 Retroversion.......................................... 214 Sec VII.—Remedial Treatment. Medicinal ............................................ 217 Mechanical........................................... 224 Sec VIII. Conduct of the Physician.............................. 234 Sec IX. Examination of the Patient........................... 237 Sec X. Management of Labor................................. 240 Sec XI.—Sequelae of Abortion. Post-partum Treatment................................. 248 Postural.............................................. 248 Dietetic.............................................. 251 Medicinal ............................................ 25- Of Pelvic Cellulitis.................................... 253 Hypertrophy of the Uterus.......................... 253 Fistula........................................... 253 Inflammation of the Uterus.......................... 253 Puerperal Metritis................................. 254 " Peritonitis............................... 254 Phlebitis......................................... 254 Dropsy........................................... 254 Paralysis......................................... 254 Mental Aberrations................................ 254 Chronic Menorrhagia............................... 255 Mechanical Treatment.................................. 256 Of Prolapsus.......................................... 256 Retroversion....................................... 256 Xll. CONTENTS. PART V.—STERILITY. Causes and Treatment. Sec I.—Constitutional. PAGE. Definition of the term Sterility.......................... 2jJ3 Statistics............................................. OCQ auses ............................................... Sec II.—Psychical. 274 Incompatibility........................................ ^_ Frigidity............................................. Ill Erotism.............................................. Zi0 Sec III.—Ovarian. Absence of the Ovaries................................. *' Imperfect Development, Atrophy........................ 276 Inflammation, Tumors, Dropsy........................... 277 Sec IV.—Uterine. Stricture, Obstruction, Inflammation of Fallopian Tubes..... 278 Absence or Defect of Uterus......................*..... 279 Dysmenorrhcea........................................ 28o Displacements of the Uterus............................. 285 Tumors, Polypi........................................ 2;>3 Inflammation, Leucorrhoea............................... ldt> Ulceration........................................... 30° Amenorrhcea.......................................... 302 Sec V.—Vaginal. Atresia. 303 Non-retaining Vagina................................... 305 Imperforate Hymen.................................... 305 Vaginismus........................................... 30b Vaginitis............................................. 308 Sec VI.—Rectal. Prolapsus Ani......................................... 310 Fissure............................................... 310 PART VI.—JURISPRUDENCE OF ABORTION. A Lecture by A. E. Small, M.D.......................... 313 by Charles Woodhouse, M.D.................... 320 Laws of European Countries............................. 321 " Different States................................ 323 APPENDIX. General Therapeutics.................................. 339 Miscellaneous Therapeutic Agents........................ 348 General Index....................................... 353 INTRODUCTION. The term Abortion is derived from the Latin word aborto, which means, literally — to bring forth before the time. This broad defini- tion allows of no restriction aside from the one given in the literal rendering. The premature expulsion of the contents of the gravid uterus at any date prior to the end of the ninth month, or the normal expiration of pregnancy, is an abortion. In this work, the term has therefore been used in its broadest sense ; but, as will be seen, I have divided the period of pregnancy into two natural divisions, based on the condition of the placenta and the foetus. Two kinds of abortion are treated of, namely: Embryonic, when the impregnated ovum is expelled before the placenta has formed its uterine attachment; F(ETAL, when the expulsion occurs after the last date, and before the end of a normal pregnancy. This is not an arbitrary plan, because it is founded on natural changes and certain periods, which are well recognized in physio- logical-science. Such an arrangement greatly facilitates a study of the subject in a methodical manner. Hitherto no complete and systematic treatise on Abortion has appeared in the literature of any school of medicine. The Allopathic branch of the profession, in which we would naturally look for a work on this subject, possesses but one volume, which treats of it in a monographic manner. Dr. Whitehead's work on "Abortion and Sterility," was pub- lished in 1854. While it is a valuable work of reference on certain points, it is lacking in systematic completeness. It contains some suggestive statistics, and an excellent elucidation of many of the causes of abortion, with their Allopathic treatment; but beyond XIV. INTRODUCTION. this, the author does not extend the work. No mention is made of the intermediate and remedial treatment of the accident itself, or of its numerous and important sequelae. The obstetrical works of Churchill, Ramsbotham, Tyler Smith, Simpson, Cazeaux, Hodge, Meigs, Bennet, Bedford, Byford, Gardner and others (Allopathic); King, Scudder, and Beach (Eclectic) ; and Jahr, Leadam, Pulte, Loomis, Small, Marcy, Ludlam, Guernsey, and others (Homoeopathic) ; all contain much in relation to this subject. I have freely drawn from all these authorities, selecting the practical and useful, and rejecting all that was irrelevant. Of all medical writers, Cazeaux seems to me to have treated the subject of abortion in the most systematic manner. The various periodicals of our school have been examined for clinical experience relating to the treatment of this accident. Considerable practical information on this point has been commu- nicated to me by my professional friends. I am especially under many obligations to Dr. R. Ludlam, Professor of Obstetrics and Diseases of Women and Children in Hahnemann Medical College, for his kind assistance while in the preparation of this work, and also for the use of his large obstetrical library, containing many rare and valuable volumes. I am obliged to state, however, that on many points of import- ance relating to the medicinal and mechanical treatment of abortion I have had to rely almost wholly upon my own experience, and to ascertain the most practical and useful facts by careful experiment and investigation. Abortion has grown to be a subject of such importance to the medical man, that its consideration should no longer be confined to the works devoted to obstetrics and diseases of women, wherein it can but be treated of in a manner not sufficiently complete to sat- isfy the student or investigating practitioner. The same inducements which led me to write a work on Abor- tion, have led me to add to the second edition a treatise on Sterility. With the exception of the monographs of Gardner and Sims, no INTRODUCTION. XV. works on Sterility have appeared in the English language. The former author did not give a sufficiently systematic treatise, and as his treatment was Allopathic, and much of the instrumental treat- ment now obsolete or superseded, the book is practically of little value to our school. The latter author treats almost exclusively of the surgical treatment of the conditions causing sterility. It is the aim of this treatise to include not only the Homoeo- pathic medical treatment of all the causes of sterility, but the latest and most successful surgical treatment of all the abnormal condi- tions leading thereto. The importance of a correct knowledge of the causes and treat- ment of sterility is generally admitted. Next to saving life and ameliorating suffering, the duty of the physician or surgeon is to remove the obstacles which tend to prevent the normal increase of the human race. It must strike every observant and thinking physician that the day for large treatises, on such broad subjects as " Practice," " Materia Medica," " Surgery," " Obstetrics and Diseases of Wo- men," has gone by. No medical writer can do justice to the range of subject naturally included in any one of the above titles, if he is confined to one or even two volumes. Nothing short of an ency- clopoedia of one of the above subjects would satisfy the require- ments of the age, and as an encyclopcedia is made up of separate monographs, it will greatly enhance the value of medical literature if a series of exhaustive monographs appear which shall do away with the necessity for such ponderous works. Moreover, the accu- mulation of such valuable material relating to any one subject pertaining to practical medicine has become so extensive, and withal so scattered through the books, journals and other periodi- cals, that it is the duty of the medical writer to collect the material together, and put it in such a form as to be most available to the student or practitioner. To this end the writer of this volume has directed his labors. He does not claim to present much original matter, although his observations and experience have enabled him to increase somewhat xvi. INTRODUCTION. the common stock of information relative to etiology and treatment. He has drawn freely from all the standard medical works of the day, and from all sources which seemed to him reliable. Medical facts are common property, and it is not necessary to give further credit to authors and observers, than is given in the pages wherein mention is made of the sources of information. This work is intended in no respect for public circulation, and the author would be sorry to think it should ever be perused by the prurient and immoral. If I have not given minute indications for the use of each remedy mentioned in the following pages, it is because of the impossibility of so doing in a work of this kind, without swelling it to an inordi- nate size. The symptoms of, and special indications for, the use of each medicine can be found in the several works on Materia Medica belonging to the Homoeopathic school. I believe that no physician in whose hands this work may fall, will consider the volume a superfluous addition to our literature. PART I. STATISTICS OF ABORTION. 9 STATISTICS OF ABORTION. Tt will be appropriate, before we enter upon the consideration of the causes, pathology, treatment, etc., of Abortion, that we shall make ourselves acquainted with the statistics having a direct bearing upon the subject. The first question which presents itself—Is Abortion constantly increasing?—is so important that we shall present the statistics in as complete a manner as is con- sistent with the plan of this work. The following statistics are taken from an elaborate work* by Horatio B. Storer, M. D., of Boston. Wri- ting of the frequency of abortion in our own country, he says: " Statistics in this country are yet so imperfect that we are necessitated to a process of deduction. * * * If we find that in another country living births are steadily lessening in proportion to the population and to its increase—that natural and preventive causes are insufficient to account for this—while the proportion of still births and of known abortions is constantly increasing, and these last bear an evident yet increasing ratio to the still-births; that in this, country the de- crease of living births, and the increase of still-births, are in much greater ratio to the population, and the proportion of premature births is constantly increasing; and that these relations are constantly and yearly more marked, we are justified in supposing that abortions are * Criminal Abortion in America. 20 HALE ON ABORTION. at least as frequent with us, and probably more so. In many countries of Europe it has been ascertained that the ' fecundity' of the population, or the rate of its annual increase is rapidly diminishing. " In Sweden it has lessened by a fifth; in Prussia, by a fourth ; in Denmark and England, by a third,.and in Russia, Spain, Germany and France, by a half, in a single century ! " In four departments of France, among which are two of the most thriving of Normandy, the deaths ac- tually exceed the births! " Again, as might have been expected, we find that the proportion of still-births, in which we must include abortions, as has hitherto been done, however improp- erly, in all extensive statistics, is enormous, and is steadily increasing; and while the proportion of still- births to the whole number is greatly increasing in Paris, as is the number of known abortions. * * At the Morgue, which represents but a very small fraction of the foetal mortality of Paris, and in this matter almost entirely crime, there were deposited during the eighteen years preceding 1855, a total of 1115 foetuses, of which 423 were at the full term, and 692 were less than nine months, and of these last, 519, or five-sixths, were not over six months, a large proportion of them showing decided marks of criminal abortion. " We now turn to our own country, to which the city of New York holds much the same relation that Paris holds to France. " Since 1805, when returns were first made to the Registry of New York, the number, proportionate as well as actual of foetal deaths, has steadily and rapidly increased. With a population, at that time, (1805) of 76,770, the number of still and premature births was 47; in 1849, with a population at 450,000, the number had swelled to 1320." In brief, while the ratio of foetal deaths to the popu- lation was, in 1805, 1 to 1633.40, in 1849 it was 1 to 340.90; and when we consider that a large proportion STATISTICS OF ABORTION. 21 Still-birth. Ratio. 349 1 to 37.6 533 1 to 26.3 1,818 1 to 19.1 3,744 1 to 15.8 21,702 1 to 13.3 1,942 1 to 11.1 of the reported premature births must always be from criminal causes; and that though almost all the still- births at the fall time, even from infanticide, are ne- cessarily registered, but a small proportion of the abortions and miscarriages occurring are ever reported to the proper authorities, it will be apparent that at the present moment the abortion statistics of New York are far above those of 1849. This the following table will show, as well as the fact that the ratio is steadily increasing: Total mortality. 1804 to 1809 - - - 13,128 lsou to 1815 - - - 14,011 1815 to 1825 - - - 34,798 1S25 to 1.S35 - - - 59,347 1835 to 1855 - - - 289,786 1850 - - - 21,658 " The frequency of abortions and premature births reported from the practice of physicians, and thus to a certain extent, but not entirely, likely to be of natural or accidental origin, is as follows: "In41,09(.) cases registered by Collins, Beatty, La Cliapelle, Churchill, and others, there were 530 abor- tions and miscarriages. Here all the abortions were known: their proportion was 1 to 78.5. "In New York, from 1854 to 1857, there were 48,- 32-°) births at the full time reported, and 1,196 prema- ture. Here all the abortions were not known, probably but a very small fraction of them: the proportion was 1 in 40.4. In the seventeen years from 1838 to 1855 there were reported 17,237 still-births at the full time, and 2,710 still prematurely; the last bearing the pro- portion of 1 to 6.3. In the nine years from 183S to 1S47, there were 632 premature still-births, and 6,445 still at the full time : a yearly average of 1 in 10.2. In the eight years from 1S4S to 1S55, there were 2,078 premature still-births, and 10,792 still at the full time: an average of 1 in 5; while in 1856 there were 387 still prematurely and 1,556 at the full time, or 1 in 4.02. 22 HALE ON ABORTION. "From these figures there can be drawn but one conclusion—that criminal abortion prevails to an enor- mous extent in New York, and that it is steadily and rapidly increasing. ' We cannot refer,' was well said by a former Inspector of that city,* ' such a hecatomb of human offspring to natural causes.'" The same statistics also shew that the reported early abortions, of which the greater number of course escape registry, bear the ratio to the living births of 1 in 40, while elsewhere they are only 1 in 78.5 : and finally, that early abortions, bearing the proportion to the still- births at the full time of 1 in 10.2 in 1846, had increased to 1 in 4.2 in 1856. Almost doubling, therefore, as does New York, the worst of those fearful ratios of foetal mortality existing in Europe, it is not strange that our metropolis has been held up, even by a Parisian, to the execration of the world : " On le voit (l'avortement)," says Tardieu, " en Anierique, dans une grande cite comme New York, constituer une industrie veritable et non poursuivie." " In this description of New York," says Dr. Storer, " we have that of the country." " In Boston, which for morals is supposed to compare favorably with any city of its size in the Union, un- ' doubtedly more than a hundred still-births yearly escape being recorded; a large proportion of which, no doubt, results from criminal abortion." In the State of Massachusetts it appears that during the fourteen years and eight months preceding 1855, there were recorded 4570 still-births, and 11,716 pre- mature births and abortions, the ratio being one abor- tion to three still-births; or, in other words, it would appear from the statistics quoted, that the comparative frequency of abortions in Massachusetts is thirteen times * Report of 1849. STATISTICS OF ABORTION. 23 as great as in the worst statistics of the city of New York ! It must not be forgotten that while nearly every still-birth at the full time is necessarily recorded, there must be but very few registrations of the premature births and abortions actually occurring. Few persons could have believed possible the existence of such frightful statistics. They should call the attention of the whole medical and legal world toward some plan to arrest such awful destruction of embryo human life. In the great city of Chicago no registration of the births has ever been made ; nor do the physicians make any returns relating to the still-births, miscarriages, etc. This is much to be regretted on many accounts. It does not do credit to the municipal authorities, to the influential citizens, nor to those physicians of the domi- nant school, who are supposed to have influence with those in power. It is alleged as an apology for this omission of a civil duty, that the State legislators have never passed a law of Registration of Births, etc.; but this is no valid excuse, when it is in the power of the city authorities to pass an ordinance which would an- swer every purpose of such a law. To the above statistics of the frequency and increase of abortions, I will add those of Dr. Whitehead,* who asserts that " the number of pregnancies which each woman experiences, during the existence of her procre- ative aptitude, is about twelve , or one in every twenty months. This includes abortions, false conceptions, premature deliveries, and all having an unsuccessful issue, the average amount of which will be rather more than one and a half for each individual; or it may be * On Abortion and Sterility, page 198. 24 HALE ON ABORTION. stated, as a general rule, that every seventh pregnancy has a premature termination. These conclusions have been drawn from the subjoined facts. . "Two thousand married women in a state of preg- nancy, admitted for treatment at the Manchester Lying- in Hospital, during parts of the years 1845 and 1846, were interrogated in rotation respecting their existing condition and previous history. Their average age at the time of inquiry was a small fraction below thirty years. The sum of their pregnancies already termi- nated was 8681, or 4.38 for each, of which rather less than one in seven had terminated abortively. But as abortion occurs somewhat more frequently during the latter than in the first half of the child-bearing period, the real average will consequently be rather more than one in seven. Of the individuals submitted to inquiry, 1253 had not then suffered abortion. The average age of these was 28.62 years ; the sum of their pregnancies was 3906, or 3.11 for each person. The remaining 747 had already aborted once at least, and some oftener. Their average age was 32.08 years. The sum of their pregnancies was 5775, or 6.37; that of their abortions 1222, or 1.63 for each person. From the preceding statements it appears that more that thirty-seven out of every hundred mothers, experience abortion before they attain the age of thirty years." Dr. Whitehead's observations do not accord with the popular idea, that early, especially first pregnancies, have more frequently a premature termination than those which come after. He is inclined to believe that the. third and fourth, and subsequent pregnancies, and one or two of the last—namely, those which occur near the termination of the fruitful period—are most com- monly unsuccessful. STATISTICS OF ABORTION. 25 At what period, of pregnancy does abortion most fre- quently occur? The following table, copied from Whitehead, throws some light on this question. It will be noted that the abortions here referred to, were those which were sup- posed to. occur from diseased conditions of the mother or ftetus. Hereafter the subject of .criminal abortions will be referred to. Abortion (which term is here used in its most extensive signification) may occur at any period of utero-gestation. It will be seen that it is much more common at some stages of the process than at others, and is attended with different degrees of danger, according to the circumstances under which it occurs, the nature of the exciting cause being the most important. When it takes place before the end of the sixth month, it is invariably fatal to the offspring, either before birth, or in a short time after ; and at any period before the completion of the process, it is more or less injurious to its well-being. Instances are on record, however, of children born during the early part of the seventh month, having lived in the enjoyment of toler- able health and constitutional vigor to a mature age. " Abortion is at all times fraught with danger to the mother, and sometimes attended with fatal consequences. I oive in the following table the respective periods of 0(')2 cases of abortion, which have occurred under my own immediate observation. It may be noticed that each figure in the first column embraces a period of four weeks, extending from a fortnight before to the same length of time after the month indicated; and as abortions happening earlier than the seventh week of uterine life are so frequently and so nearly simulated, both in married and unmarried females, by certain ute- rine discharges, the result of disordered menstruation, 26 HALE ON ABORTION. events said to have taken place at this early period, except those wherein the escape of an ovum was un- doubtedly found, have not been included in the report." TABLE Showing the Period of Pregnancy at which Abortion occurred in 602 cases, the relative number of Still- born and Living Children, and the number living at the end of a month after birth. Period of pregnancy at which abortion occurred. Number of births at each period. Number still born. Number liv-ing at birth Number liv-ing at end of a month 35 275 147 30 32 55 28 24 38 23 8 17 5 -- 3 " ............. -- 4r " ............ -- 5 " .............. -- 6 " .............. 0 7 " ___......... 3 8 " ........... 1 602 85 30 4 "The foetus of six months' growth is generally consid- ered viable. Of the eight indicated in the table, as having been born alive, when born at this period, seven perished within six hours after birth, and one only attained to the age of ten days. Of the seventeen born alive at seven months, the majority lived over several days, and a few to the end of the third and fourth week. Three still survive, the youngest of whom is now aged nineteen months." Whitehead does not mention the possibility or proba- bility of an abortion occurring at the first month, or even at the third week of pregnancy. Yet it must be admitted by those who have investigated the causes of abortion, that it is by no means improbable, and very possible, for the abortions which occur at that early period to outnumber those of any other month. STATISTICS OF ABORTION. 27 If any disease of the uterus or contiguous organs, or amy constitutional irritation sufficient to cause abortion exists, such causes are more likely to induce abortions at the first month than at any other period. Let us .consider the matter logically. Intimately connected with the subject above treated of, is that of criminal abortion, and the period of pregnancy at wnich it generally occurs. From Dr. Storer's work we learn that " It was Orfila's opinion that criminal abortion was most frequent, in the first two months of pregnancy. This would naturally have 1)0(41 supposed to be the case, as then some doubt always might obtain regarding its existence, and the excuse that the measures resorted to were for the pur- pose of preventing ill effects from an abnormal men- strual suppression, would be more available. Devergie, on the other hand, was inclined to put the limits of greater frequency at from three months to four and a half; while Briand and Chandler thought the crime more common in the third month than the fifth, and in the last month much more frequent than even in the first or second. Tardieu also came to a similar conclu- sion. He ascertained that of 34 cases investigated by himself, 25 were in from the third to the sixth month, mostly in the third; 5 in the first two months; 4 in the second and eighth ; or that the cases in the third month, or shortly after, were five times as numerous as at either an earlier or a later period, and nearly three times as numerous as in both combined. Upon exam- ining the register of the Morgue, we find its statistics strikingly corroborative of this deduction. We have already seen that from 1837 to 1854 there had been 28 HALE ON ABORTION. deposited at the Morgue 692 foetuses of less than months. Of these 23 were from the first to the second month; 79 u second " third 108 li third " fourth 158 u fourth " fifth •150 a fifth " sixth 97 a sixth " , seventh 48 Li seventh" eighth 29 a eighth " ninth "It has been stated that 519, or five-sixths of them all, were not over six months; and it now appears that on a scale twenty times larger than that given by Tar- dieu from his own experience, nearly two-thirds of the foetal deaths induced by abortion were in from the third to the sixth month of pregnancy, the three periods included giving a much larger proportion than any others, and the last two of them being nearly identical. The extreme paucity shown by the above table in the first and ninth months, and the decrease in the seventh and eighth from those preceding, are worthy of remark. It is probable that the sudden increase may be attribut- able to mental reaction after the first shock occasioned by the absolute certainty of pregnancy, is past; and the subsequent decrease to the fact that in many at- tempted criminal abortions, during the latter months, children are born alive, the mother's courage then prov- ing insufficient for infanticide, and its greater and more probable punishment." My observation has shown me that criminal abortions are very frequent in the fourth week after conception. Many women, who are habitually regular to a day, are in the habit of using some drug or instrument if the menses delay a few days, and they have reason to sup- pose conception has taken place. They allege that they STATISTICS OF ABORTION. 29 know by certain sensations that conception has occurred, as early as the third or fourth week. This habit is more frequent than has been supposed, as any physician will ascertain who seeks to investigate the matter. In order to make complete the statistics of abortion, we should be able to present tables representing the average mortality of women who suffer that accident, both from criminal and other causes. " The results of abortion from natural causes," says Dr. Storer, "as obstetric disease, separate or in common, of mother, feet us or membranes, or from a morbid habit consequent on its repetition, are much more than those following the average of labors at the full period. If the abortion be from accident, from external violence, mental shock, great constitutional disturbance from disease or poison, "or even necessarily induced by the skillful physician in early pregnancy, the risks are worse. But if, taking into account the patient's constitution, her previous health, and the period of gestation, the abortion had been criminal, then the risks are infinitely increased." In 34 cases of criminal abortion reported by Tardieu, where the history was known, 22 were followed as a consequence by death, and only 12 were not. In 15 cases* necessarily induced by physicians, not one was fatal. These meagre statistics are all I have been able to obtain relative to the consequences of abortion, to the mother. While I admit that the risks of a fatal result from criminal abortion brought about by other than skillful physicians, or even from diseased condition, are great, I cannot believe the result of abortion "necessarily in- duced by skillful physicians,11 is as fatal as Dr. Storer * Annals de Hygiene, 1856, p. 147. 30 HALE ON ABORTION. asserts. My observation and experience in this matter have been quite extensive, and I have been led to the conclusion that, if the operation is skillfully performed, the fatal results need not exceed one in a thousand. I have not been able to find any statistics relative to the proportionate frequency of the various diseased con- ditions which result from abortion ; but the information which I have received from my colleagues, and the various writers on diseases of women, as well as my own observations, lead me to place the consequences of abor- tion and their relative frequency in the following order: 1. Ulceration, erosion and congestion of the os uteri. 2. Premature and profuse menses. 3. Retroflexion and retroversion of the uterus. 4. Prolapsus uteri. 5. Ovarian disease. 6. Pelvic cellulitis. The statistics relating to the causes of abortion, as well as those having reference to the various other matters connected with the subject, will be found under the appropriate chapters. PART II. CAUSES OF ABORTION. CAUSES OF ABORTION. The following Classification of the causes of Abortion is based upon the one used by Prof. Ludlam in his Lecture before the class of Hahnemann Medical Col- lege. The additions made by myself will be denoted by the initial II. I Constitutional or Predisponent. 1. Plethora. 2. Anaemia or Chlorosis. 3. The Scrofulous Diathesis. 4. Return of Menstrual Crisis. " (a) Syphilis. (b) Mercurialization. r Zymotic J (c) Variola. ' Diseases. ] (d) Scarlatina. (e) Diphtheria. ^ (/) Cholera. (H.) II. Local or Organic. 1. Malformation of ovum. 2. " of membrane. (a) Mal-location of (Placenta Previa.) (b) Organic Disease of Placental (c) Detachment of (d) Fatty Degeneration of Abnormalities. (e) Calcareous " of '/) Hydatids. (H.) » Moles. (II.) III. Reflex {Exciting.) (a) Emotional—as Fright, Anger, Grief, etc. i (b) Direct blows upon the brain or spinal cord. ■ 0entnc- * (c) Medicinal. (H.) (d) Cerebro Spinal Meningitis. 34 HALE ON ABORTION. 2. Concentric. (H.) also Renal. (II.) (H.) (a) Parotidean Irritation. (II.) {b) Thyroideal " (H.) (c) Thoracic (II.) (d) Mammary (e) Dental (/) Gastric {g) Rectal (A) Vesical {{) Vaginal (j) Hysterical (k) Epilepsy. (T) Falls, jumping, blows, etc. (m) Functional and Organic Diseases of the Uterus. (H.) (n) Functional and Organic Diseases of the Ovaries. (H.) (o) Displacements of the Ovaries. (p) Death of Embryo. (q) Genital (Coitus.) (r) " (Instrumental.) MEDICINAL. JEmmenagogues or Oxytoxics. The following list of medicinal agents is necessarily imperfect, but I have placed therein the drugs which may, under certain circumstances, cause abortion. The list is not complete, as there are many medicines not named which have been supposed to cause that accident. Apis mellifica. Actsea alba. Aloes. Asarum europeum. " canadense. Asclepias syriaca. " incarnata. Aletris farinosa. B aptisia tinctoria. Borax. Bovista. Cantharis. Caulophyllum. Cimicifuga. Decodon verticillatus. Gossipium herbaceum. Ilex opaca. Mercurius. Podophyllum. Quinise sulphas. Ruta graveolens Sabina. Secale Cornutum. Sanguinaria. Terebinth. Tanacetum vulgaris. Ustilago madis. SECTION I. PRKDISTOSINO CAUSES. Plethora. The first predisposing cause of Abortion mentioned in the foregoing table is Plethora; but it is oftener a cause of sterility, and will be again alluded to under that head. ()besity may cause abortion in several ways. The deposition of fat in the abdomen and pelvis will have the same effect as a tumor in those localities. In some cases of adiposis the action of the heart is mani- festly impeded, and sometimes entirely arrested, by the deposition of fat in and around it. The same result may obtain in regard to the uterus, and prevent its expansion beyond a certain point, at which abortion would inevitabl)' occur. Dr. Gardner also suggests that the deposit may "press down the uterus, pressing it into the pelvic strait, sometimes producing eversion, or so that the os uteri presses upon the sacrum, where by mere friction its surface becomes abraded, and pro- fuse leucorrlnea ensues." Not only this, but prolapsus and retroversion may be thus caused. Anaunia or Chlorosis. Frequent abortions may cau^e ana?mia; and this condition may in turn predispose to repeated abortions, 36 HALE ON ABORTION. the uterus not having sufficient "tone," or vitality, to retain the product of conception. Chlorotic women are as liable to abortion as those who are amemic, and from the same cause, namely—a lack of vitality in the uterus, and a blood so impoverished that it is incapable of nourishing the foetus. Scrofula. The scrofulous diathesis, by its influence upon the vital powers of the system, causing laxity of tissue, defi- cient nervous force, and depriving the blood of its nor- mal constituents, is a powerful predisponent cause of loss of the ovum at any and all periods of gestation. Return of the Menstrual Crisis. This, as a cause of abortion, especially in the first months, has not been sufficiently appreciated. I have stated in the introduction to this work, that I consider it proper to define "Abortion," as the premature death and expulsion of the ovum at any time after conception, or before the end of the ninth month. I have also mentioned, in another place, the frequency of abortions in the first month. The older accouchers paid much attention to the loss of the Ovum shortly after impregnation. Married women who passed over a monthly period by a few days and then menstruated profusely were believed to have lost the ovum. This was called an effluxion, if it occurred before the tenth day, " because," as Smollie observes, "the embryo and secundines are not yet formed, and nothing but the liquid conception, or geni- tura, is dislodged. Tyler Smith thinks such cases are not uncommon, and the ovum is unobserved, not from CAUSES OF ABORTION. 37 its liquid condition, but because it is so little above the size of the unimpregnated ovum, as not to be visible in the discharges. An ovum of fourteen days has been described by Velpeau, and its size did not exceed three- eighths of an inch in diameter. In the expulsion of an ovum of an earlier date than this, the symptoms hardly differ from those of profuse menstruation. In cases of dysmenorrhcea—especially the pseudo-membranous va- riety, and in cases of profuse menstruation (habitual)— this loss of the ovum may frequently occur at a very early period. It has often been a matter of wonder to me that the uterus should so frequently resist the influ- ence of a menstrual nisus, when abnormal in its charac- ter, or that a diseased uterus could so often bear the recurrence of the crisis when normal, without being irritated to such an extent as to throw off the impreg- nated ovum at such periods. (See Ovarian Irritation?) ZYMOTIC DISEASES. Syphilis. Independent of the power which this blood-poison possesses of causing diseases of the uterus—as ulcera- tion, etc., which will be mentioned in another place- syphilis seems to exercise a blighting power over the product of conception, in such a manner that it is liable to die in utero, of the same poison, and be expelled as a foreign body, at any period of pregnancy, or the membranes may become diseased from the pernicious influence of the malady: in both cases the disease may be transmitted by either or both parents: by the mother through the .circulation, and by the father through the spermatozoa. Writing of this disease, as a cause of sterility, Dr. oo HALE ON ABORTION. Gardner says: "In my opinion it is more often a cause of early abortion from an imperfect development of the ovum, than a cause of sterility, as it is difficult to decide whether the woman was ever impregnated or not. The menses are retained a few days over the usual period; there is finally a somewhat profuse discharge, accom- panied by more pain than usual, and the passage of what are considered clots, but in them lies concealed the semi-developed ovum." Mercurialhation. Mercury, in its various forms, may not only be an immediate cause of abortion, as in the cases of large doses of calomel, elsewhere alluded to, but the system may be so saturated with the poison that the blood and tissues are deprived, by its baleful influence, of the normal vitality necessary to carry on the process of gestation. The effects of this drug upon the organism are not unlike those of syphilis. It has long been re- marked that women whose systems have been saturated with mercurial preparations were very liable to abor- tions, and this without any organic disease being dis- covered in the organs of generation. Variola, etc. Abortion may occur from the intense febrile orgasm, or from the congestive complications which take place during these disorders. All the exanthematous fevers predispose the .system to take on such irritative con- ditions as may bring about miscarriage during or after their accession. The foetus in utero has been known to be attacked with the variola, and be expelled either before or after its death. CAUSES OF ABORTION. 39 According to Cazeaux, "confluent small-pox nearly always occasions abortion, and this is almost uniformly followed by the death of the mother." A static Cholera and Yellow Fever are powerful zymotic poisons, and, like other diseases of this character, effect the foetus through the medium of the circulation. Dr. Pulte* states that during the cholera epidemic of 1848 abortions were very frequent, and were apparently caused by the imponderable poison pervading the at- mosphere at that time. The same phenomena has been noticed during the prevalence of yellow fever in the large cities of the South. Dr. Bouchut, in a quite recent work, mentions his observation of fifty-two cases of cholera in pregnant women, twenty-five of whom aborted in consequence of the disease. SECTION II. LOCAL CAUSES. Abnormal conditions of the Ovum and its Appendages. Dr. Whitehead says these are " so constantly associ- ated with disease of the maternal organs as to lead to the suspicion that the mischief, in a great majority if not in alh instances, originates in the latter." In my own practice, such complication has been almost invari- ably found in those cases wherein I have had an oppor- tunity of making the necessary examination. * Homoeopathic Domestic Physician, 477. 40 HALE ON ABORTION. The ftetus is liable to many diseases which may tend to its death, such as inflammation and dropsy of its venous cavities, dropsy of amnion, disease of the liver or kidneys, tubercular diseases, syphilis, and even small pox; diseases of the umbilical cord, knots upon the cord; strangulation, by the twisting of the cord about the neck of the child. I have seen cases in which the cord was twisted three and four times around the neck. Probably the diseased ovum excites the uterus to con- traction before the actual death of the ovum has occurred. In. many cases of criminal abortion the injury done to the child by instruments, etc., is the real cause of the abortion. The membranes may not be ruptured or separated". The impregnated ova may degenerate into moles, hydatids, or " blighted ova?"1 Genuine moles are to be distinguished from certain fibrinous masses which are sometimes expelled from the uterus. These are called spurious moles, and a close examination will show their real character. Those moles which are the result of impregnation are of vari- ous kinds, consisting of different forms of degeneration of the membranes of the ovum. We can readily dis- tinguish the varieties of moles depending on the carne- ous or fleshy, the hydatigenous, and the fatty, and other degenerations of the membranes. None of these cases can occur without conception. Many authors believed that fleshy moles might occur in nuns, and others presumed to be virgins, without the occurrence of intercourse. Percy believed that hydatids were in- dependent animals, and that their production was com- patible with the purest chastity. Dennison thought they sometimes originated in the uterus as independent CAUSES OF ABORTION. 41 formations, and Sir Charles Clarke Avas of opinion that uterine hydatids might exist apart from pregnancy. Madam Boivin and several other writers are in favor of the belief that this form of degenerated ovum may be retained for many months, or even years, after the ordinary date of labor. Tyler Smith is not aware that any case of this kind has been observed. I have known two cases in my own practice where a hydatid mass was not expelled until the twelfth month after the last appearance of the menses. Those who wish to investi- gate the nature of moles and hydatids can consult Tyler Smith* In the carneous moles there is an arrest of the usual symptoms of pregnancy, and the patient remains out of health. The ovum from the time of its death becomes to a great extent a foreign body, and is a source of irritation to the system generally. No increase of size takes place, so that at the fourth or fifth month the uterus may not be larger than it should be in the fifth or sixth week of normal pregnancy. The complexion is muddy and the breath fetid, with loss of appetite and digestion. Hemorrhage frequently occurs, but not very profuse. The hydatid mole causes symptoms more strongly marked. The increase in size is often enormously rapid, so that at the fifth or sixth month the abdomen is as it should be at the end of pregnancy. The shape of the uterus is often quite different from that existing during natural pregnane)'. There is absence of all foetal move- ments and the sounds of the foetal heart. After three or four months' suspension of the catamenia, there oc- curs a copious discharge of water and blood, resembling * Lectures on Obstetrics. 42 HALE ON ABORTION. red currant juice. This occurs irregularly and in vari- able quantities. The watery discharge is accompanied by pain, and appears to be caused by the breaking down of numbers of the larger hydatids. In a suspected case the discharges should be carefully examined, and of course the detection of a single hydatid renders the diagnosis certain. Excessive flooding often occurs, at frequent intervals, accompanied with discharges of masses of hydatids. The general health suffers pro- foundly, resulting in anaemia, dropsy, and. even paral- ysis. Fatty Deterioration of the Chorion and Placenta. We are indebted to Dr. Robert Barnes for our know- ledge of this frequent cause of abortion. This form of degeneration may affect the secundines at any time between the early weeks of pregnancy and the termina- tion of gestation. Fatty degeneration may exist in the placenta as a post mortem change; that is, it may occur in utero after the death of the foetus. It may happen also as the result of the transformation of effused fibrin in inflammatory disease of the placenta, or of a clot of blood in hemorrhagic effusion. Lastly, it may consist of the metamorphosis of portions of the maternal and foetal structures of the placenta during the life of the foetus. The latter pathological phenomenon is that which is of the chiefest importance in relation to abor- tion. In a placenta affected with fatty degeneration, the lobes of the placenta are altered in appearance, some of them being of yellow fatty color, brittle and exsanguine, the rest presenting their ordinary characters. Exam- ined more minutely, the tufts are found to be glistening, hard and tallowy, and not expanding when placed CAUSES OF ABORTION. 43 under water, as is the case with villi of healthy pla- centa'. The microscopical investigations of Dr. Hassall, show that the villi are studded with spherules and drop- lets of fatty matter and oil. The fatty material is found principally in the cells of the villi, and in the coats of its blood vessels, which vessels do not carry red globules when the degeneration exists to any extent. Dr. Barnes considers constitutional syphilis a frequent cause of this disease. Fatty degeneration causes abortion by destroy- ing the vitality of the ovum ; or owing to the friable condition of the placenta, partial separation may occur; or the partially degenerated blood vessels may burst and lead to placental apoplexy. For a full description of this disease of the placenta and chorion, see Tyler Smith's Lectures on Obstetrics, page 185. Congestion of the Placenta Leads to what is termed apoplectic effusion. Blood may be poured out either on the f- c.i :..r. -' the ..-' ' 'ues. !;'' CAUSES OF ABORTION. 75 Other writers vary as much in their description of ulceration of the os and cervix, as Bennet says, " with- out necessity or advantage." Writing of this lesion the same writer says: " An ulceration occupying the cervix uteri may pre- sent the various modifications which suppurating sur- faces offer in any other part of the body, from the minute granulations of a slight abrasion, to the livid vegetations of an unhealthy sore ; but these modifica- tions of the ulceration require, in reality, no division or classification." The student who would acquaint himself with the various local and constitutional symptoms caused by these ulcerations, may refer to such works as West, Meigs, Scanzoni, Simpson, and particularly Bennet. To the Allopathic school, who attack all ulcerations of the cervix uteri with caustics or constitutional reme- dies—tonics and alteratives—the division of ulceration into different forms and species, may be of no practical use or benefit; but to the homoeopathician, these elassi- lications, or minute descriptions, may be of great value in the selection of the specific remedy, especially when our Materia Medica shall be perfected, partieularl)' the pathological symptoms thereof. After consulting all the more recent writers who des- cribe ulceration of the cervix uteri, and from the results of my own limited observation, I know no better man- ner in which to classify these lesions than the one adopted by Whitehead—namely : Superficial erosion, Fissured ulceration^ Varicose ulceration, Follicular ulceration. Bennet inadvertently sanctions this arrangement, for he mentions—" Abrasion, or Excoriation "—" Ulcera- tion, with Fungous Granulations"—and " Varicose con- 76 HALE ON ABORTION. dition" of the parts—" Aphthae, or Ulcerated Mucous Follicles"—and even a condition when "The lips of the os uteri are very much hypertrophied and indur- ated * * separated by a deep fissure, and the ulcer- ated surface, which is situated deeply between them, can only be discovered with the eye, on their being sepa- rated by a bivalve speculum." We will now examine the peculiar characteristics of the different forms of ulceration : the simple erosion, or granulating ulcer, has already been described. ' Varicose Ulcer.—This variety, according to White- head, is liable to cause abortion in the latter two or three months of pregnancy. It prevails in about six or eight cases out of every hundred, and is often diffi- cult of cure before delivery. It is generally met with in women of the bilious temperament and hard fibre, who have been subject to piles and profuse menstrual discharges, and to derangement of the biliary organs. The premonitory condition of the parts consists in a hardened and hypertrophied state of the cervix, which is traversed in various directions by a number of tortu- ous dark colored trunks, about the thickness of a probe, or goose quill, raised upon the surrounding surface. Larger and more prominent points are here and there noticed, indicating the situation of inosculation of one branch with another; and generally, at one of these points, the ulcerative process is set up, which soon ex- tends through the coats of the vessel, and 1 Hemorrhage follows immediately. The ulcer, which is not long after in being developed, presents an uneven livid aspect, with irregular margins, near which a few tortuous ves- sels may be seen ramifying: it now secretes a quantity of pus, and often has small dark clots of blood or fibrin, the size of a pin's head, lying loose upon the surface. CAUSES OF ABORTION. 77 It usually occupies but one labium, the anterior more frequently, but often the whole circumference of the cervix is implicated. Sometimes the inflammation ex- tends to the body of the uterus, as an acute phlebitis, and thus acquires a serious importance. The symptoms indicating the existence of varicose ulceration during pregnancy, are bearing-down pains of an intermittent character, similar to those of the first stage of labor, aching of the loins and along the thighs, irritable blad- der, with inability to retain the urine the usual length of time, disorded digestion, sickness and headache, lan- guor, and a vaginal discharge of a white glairy mucus at first, which becomes brown, then bloody, and finally purulent. Bennet says this form of ulceration is gener- ally attended with fungous granulations, large, livid, and bleeding at the slightest touch. Whitehead says it causes induration of the cervix, and often degenerates into the Fissured Ulcer.—This form of uterine disease, ac- cording to Whitehead, is perhaps equally prevalent with the superficial variety, and is much more difficult of cure, on account of the extent to which the subjacent textures are implicated. It is found to exist in twenty to twenty-four out of every hundred cases of abortion, not resulting from accidental causes. It is always accompanied by a degree of inflammatory induration which extends more or less deeply on each side of the fissure; this is readily detected by the touch, the cir- cumference of the orifice being uneven and lobulated. There may be one or more fissures, the intervening spaces being healthy or inflamed, excoriated, and in a state of erosion, or superficial ulceration. The fissures \ are often deep, and extend to a considerable distance in an upward direction. 78 HALE ON ABORTION. The discharge, which is seldom so abundant as in the form of disease first described, has a decidedly purulent character, being alkalescent, of a yellow or greenish yellow color, sometimes brown or ichorous, and not un- frequently mixed with blood. This variety of ulcera- tion is considered the most intractable—existing for years. Whitehead thinks it one of the most frequent causes of " habitual abortion." Whether this accident occurs habitually at the third, sixth, or any other period, is owing to the extent of the parts affected by the ulceration, and Dr. A. K. Gardner* adopts this view, and mentions many cases in proof. The discharge be- gins to be mixed with blood as soon as the expansion of the uterus extends itself as far as the diseased parts, the slightest irritation being sufficient to induce haem- orrhage. The careful introduction of the speculum, or digital examination, will cause bleeding. Haemorrhage from fissured ulcer often gives rise to the so-called " menstruation during pregnancy," the habitual con- gestion during the usual menstrual period being suffi- cient to cause bleeding from the ulcerated surface. Regarding this phenomena, Dr. Whitehead thus writes: " The evidence now producedf appears sufficient to establish, as a general rule—to which I am not as yet acquainted with an exception—that the blood discharged in cases of alleged menstruation during pregnancy i.s furnished, not by the lining membrane of the uterus, nor by any healthy secreting surfaces—except some- times the inferior part of the inner cervix—but by the lower extremity of the uterus, external to its cavity, or by the contiguous vaginal reflexion being in a state of * suppurative inflammettion. The fact is always demon- strable by the aid of the speculum." * See cases in "Abortion and Sterility," p. 181. t " Gardner on Sterility." CAUSES OF ABORTION. 79 "The symptoms indicating the presence of the disease in question, are—severe aching of the loins and sacrum, tenesmus, irritable bladder, with frequent desire to void urine, violent pain of the lower part of the abdomen, often confined to one side, at a point a little above the groin, corresponding to the situation of the round liga- ment, and following the course of the inguineo cutane- ous and external pudic nerves." Follicular Ulceration.—This form of disease of the cervix is said to be an inflammation and ulceration of the Nabothean follicles. It occasionally accompa- nies other morbid conditions of the cervix, but is most frequently met with in a distinct form. Whitehead doubts whether it is a primary affection. Upon exami- nation, the part appears to be studded with a number of raised circular spots, having the dimensions of small peas, covered with a white crust, the surrounding sur- face being of a reddish hue. This white pellicle is easily removed by means of lint, exposing a surface of the same form and size, slightly elevated, and appear- ing as if composed of extremely minute granules. The parts are not painful to the touch. These spots are sometimes numerous, as many as fifteen or twenty being visible, but often only* one or two are seen. Owing probably to specific causes they sometimes be- come very prominent, and assume a warty appearance. According to Bennet—who will not admit of any classification of inflammatory ulceration—this follicular ulceration is to be considered the same as any other arising from that cause ; but he admits that " sometimes we find, in the vicinity of the os uteri, several small ulcerated patches, isolated one from the other, but near to it. These multiple ulcerations, which are rare, are * See cases in "Abortion and Sterility,'' p. 181. 80 HALE ON ABORTION. evidently formed, in the first instance, by aphthw, or ulcerated mucous follicles." I have under treatment, at the time of this writing, a case of follicular ulceration of the cervix, associated with hypertrophy of the uterus, and consequent retro- version. The patient had an abortion four months since, caused undoubtedly by these conditions. When this variety of ulceration occurs in cachectic habits, or in women advanced in life, these follicles are liable to inflame and suppurate in considerable numbers, leav- ing circular cavities, which give to the parts a worm- eaten appearance : or the suppurative action may ex- tend, until several of the orifices coalesce, forming a deep, irregular shaped excavation, with callous, over- hanging margins, constituting what some writers have described as the " corroding, or phagaedenic ulcer." Induration and oedema of the cervix is a common con- comitant of this aggravated form of follicular ulceration. Phagedenic, Corroding, Cancerous Ulceration.—Under the above names have been described various forms of ulceration of the cervix, of a malignant character, char- acterized by a tendency to sloughing, with extension of ulceration to the body of the uterus, and a discharge, nearly always of a foetid, corrosive, and otherwise un- healthy character. These forms of ulceration generally lead to organic changes, such as hypertrophy, indura- tion, tumors, etc., which will be treated of hereafter. t:! Syphilitic Ulceration.—There can be no doubt that the syphilitic ulcer is a frequent cause of abortion. It was not until recently that its importance as such was suspected. In treating the abandoned classes in great cities, and even those in higher positions, the physician will do well to be on the look-out for this disease when he is searching for the cause of abortion. CAUSES OF ABORTION. 81 The prinietry venereal sore is very rarely seen attack- ing the lower part of the uterus. The virus is not likely to be c-arried up so high, except in occasional cases. It is chiefly secondary syphilis which affects the uterus. It may have its origin in three different ways, according to Whitehead. (1) As an imperfectly cured primary affection, which was originally a genuine chancre in the external geni- tals. (2) As a result of virulent inoculation upon the lower part of the uterus. (3) As a consequence of secondary inoculation. The possibility of transference of venereal taint under this form, is still a matter of dispute. The constitutional symptoms denoting the presence of secondary syphilis are, pallor of the countenance, languor, precarious appetite, loss of rest, hectic fever- ishness, lumbar and hypogastric pains, disordered secre- tions, and the appearance of the disorder in the off- spring. The local symptoms, enumerated in the order of their frequency, are, (1) Endo-cervicitis, or inflammation of the lining membrane of the cervix uteri, with inflam- mation, excoriation, or ulceration of the labia around the uterine orifice. This appearance was noticed in 10 out of 28 cases. iff) A mottled or patchy appearance of the cervix, consisting of a number of dark red spots of irregular shape, surrounded by lighter colored portions: they sometimes appeared highly irritable and excoriated, but not aphthous; the whole cervix was generally en- larged and slightly indurated and in most cases there were evidences of endo-cervicitis. (;>) Aphthce of the cervix, occurring in 8 out of 2S 6 82 HALE ON ABORTION. cases; the patches, which appeared perfectly white, of a circular or oblong shape, situated upon a dark red base, were easily detached by the aid of lint, and left a bright red surface of similar form and dimensions, having, in some- instances, a very minutely granular aspect. These were associated with hypertrophy of the cervix and endo-cervicitis. (4) Warts were witnessed in 3 out of 28 cases, twice on the cervix and once on the walls of the vagina. They were witnessed in many other cases. The syphilitic ulceration of the cervix cannot be diagnosed from that of a non-venereal character, except by an actual knowledge of the presence of the specific poison in the system of the patient. There is nothing in the appearance of the ulcer or erosion which can show itself to be syphilitic. When we see warts, or the mottled appearance mentioned by Whitehead, we may justly have our suspicions. Syphilis may act as a predisposing cause. (See that chapter.) SECTION VII. Induration of the Cervix Uteri.—This may be a pri- mary or idiopathic affection. Whitehead met with severe cases of chronic induration during pregnancy, in only two of which treatment was effectual in averting abortion. All these persons had aborted; three of them, including the two just mentioned, he had at- tended in the preceding instances, in all of which the same form of disease at that time existed, and in the CAUSES OF ABORTION. 83 remaining four, it is probable, had long before existed. The sum of their abortions was 19 ; the average age of the patients 31 years. This form of disease is usually met with as a chronic affection, the result of previous deep-seated inflamma- tion, a species of prolonged metritis. The enlargement and induration may involve the whole neck, or may be confined to the anterior or posterior lip alone. In either case it may depend on inflammatory action, or upon some general cachexia. In the latter case the in- duration may be accompanied with hypertrophy due to fibrinous deposit, or infiltration of serum into the tissue of the cervix. The last named condition is termed cedema of the cervix. On examination^ one or both labia of the cervix will present the appearance of a hard conical substance, sufficiently large, generally, to occupy the whole orifice of an average-sized glass speculum. If the anterior lip alone is affected, the os is situated behind, and high up, and is with difficulty brought into view. "When both labia are diseased they present a neutral appearance, very much resemb- ling the top of the piece representing the bishop, in games of chess." Their opposing surfaces are often inflamed, excoriated or granular, and the fissures at their base ulcerated, and exuding pus. This form of disease usually occasions abortion be- fore the fifth month, although it may occur consider- ably later. The symptoms of induration, hypertrophy, or oedema, are quite characteristic. A painful sense of constriction around the pelvis and hips-is almost constantly present; a dull, tixed, aching pain of one or both ovarian regions, irritability of the bladder and rectum, pain in the re- gion of the sciatic nerves, a highly excited state of the 84 HALE ON ABORTION. whole nervous system, lassitude, indigestion, etc. Ha- bitual alwntion may be the result of this diseased con- dition of the cervix. Displacements of the Uterus. The various malpositions of the womb may act as causes of abortion. Anteversion, although of rare occurrence, may so irritate the bladder as to set up sufficient reflex action to result in expulsion of the ovum. Prolapsus is a more frequent cause of abortion. This displacement generally occurs previous to preg- nancy, as a result of congestion of the uterus, or indu- ration, with hypertrophy of the cervix, and often from mere muscular atony. In either case the uterus will be found, on examination, low down in the vagina, the lips of the cervix resting on the perineal floor, and the body of the fundus within easy reach with the finger. Until the end of the third month this condition is not generally provocative of any tendency to abortion, but about this time the uterus increases in size, and unless it rises above the promontory of the sacrum it becomes impacted in the pelvis. Any impediment to the proper expansion of the uterus will prove an excit- ing cause of abortion. In prolapsus and retroversion this impediment exists, unless the uterus rises out of the pelvic cavity. Retroversion.—This is the most formidable displace- ment to which the gravid uterus is liable, and one which is more likely to cause abortion than any other. Retroversion during pregnancy was first fully described by William Hunter, and Denman. This affection occurs in its most decided form at about the third or CAUSES OF ABORTION. 85 fourth month, when the uterus is entirely within the pelvis, and when it is of such large size that any alter- ation from its natural position occasions great incon- venience to the neighboring organs. Retroversion during pregnancy may be sudden in its occurrence ; or it may have existed from the period of conception. In the former case it may be caused by unusual exertions, as lifting, jumping, reaching; or from such accidents as falling, jolting; or from diseases in which tenesmus occurs, as dysentery, etc.; also from distension of the bladder. In the latter case the retro- version had either existed previous to conception, or occurred during the first weeks of gestation. For a full description of the symptoms and causes of these dis- placements the reader is referred to my Monograph on that subject.* Retroversion occurring during pregnancy is usually described as arising from excessive distension of the bladder, through neglect, reserve, or restraint on the part of the patient. It is believed that the full blad- der, rising in the abdomen, drags the neck of the uterus uj)wards, while the distended organ presses the fundus uteri backward. The displaced uterus, by the pressure it exerts upon the neck of the bladder, in turn increases the distension of this viscus, and the retroverted uterus at length becomes fixed across the pelvis, the fundus lying in the hollow of the sacrum, and the os being tilted against the pubes, so as, in the worst cases, to render the evacuation of the rectum difficult, and that of the bladder impossible. Recent retroversion may undoubt. edly be caused in this manner; but there are doubtless many cases in which retroversion has existed previous to pregnancy, and no inconvenience is felt from it until * " Retroflexion and Retroversion of the Uterus." 86 HALE ON ABORTION. such time as the uterus, from its size, presses upon the bladder and rectum to such a degree that the displace- ment is looked upon as sudden. In both cases abortion may occur from the irritation set up in the surrounding organs, and in the uterus itself, or from the utter impos- sibility of any further enlargement of the uterus. The syuptoms of retroversion, when the uterus is of such dimensions as*to exert mechanical pressure upon the antero-posterior axis of the pelvis, are, in the first instance, partial or complete retention of the urine, pain in the pelvic region, and a sense of pressure on the rectum, giving rise to a constant desire for defe- cation, even when the bowels are empty. Should these symptoms pass unrelieved, the bladder becomes some- times enormously distended, and even ruptured me- chanically, or the coats inflame and ulcerate, allowing the urine to escape into the peritoneal cavity, and the patient sinks or dies of peritonitis. If the uterus cannot be replaced, and the water is occasionally and with difficulty drawn off, the bladder gradually enlarges and elongates, and its mucous membrane becomes dis- eased ; muco-purulent, ammoniacal and bloody urine is passed, and the kidneys may become diseased by the effects of the backward pressure of the urine. The structures between the bladder and the uterus may become inflamed, and the patient be destroyed by irri- tative fever. In some cases all these mischiefs are arrested or modified by spontaneous abortion. In others the displacement continues to the fifth or sixth month, without destroying the patient, and it has been known to go on to the full term without causing a fatal result. These cases are however very rare, and the occurrence of abortion is less to be dreaded, than a continuance of the displacement. a CAUSES OF ABORTION. 87 Death of Embryo, from any cause, will result in an abortion. The presence of a foreign body in the ute- rus will, in the majority of cases, cause the uterus to exert its expulsive action. There are, however, many cases in which the foetus and its envelopes have passed off in a fluid, disorganized state; and cases are on record even where the embryo after its death was undoubt- edly absorbed. In another class of cases, the dead embryo itself, or the placenta, is left to become a mole or hydatid mass. Coitus, when indulged in to excess, or even its mod- erate indulgence in women whose reproductive organs are irritable from disease, may be a cause of abortion. This may occur at any period of pregnancy, but espe- cially at or about the usual menstrual periods. Coition causes abortion by exciting, from the mechanical irrita- tion it induces, the reflex influences which preside over the uterus. If the os or cervix is diseased, the irrita- tion excites the peristaltic action of the uterus; if not, it is probably the diastaltic action which is aroused. Many cases of habitual abortion will be found to be due to this cause alone, and if abstinence from inter- course be strictly enforced, either wholly or at the men- strual periods, the usual abortions Avill be prevented. As a rule, sexual intercourse should not be indulged in at all, or very rarely, during the period of pregnancy. That it is physiologically unnatural every physician will admit. The general aversion to the act manifested by women during that period, as also the fact that the animal creation rarely, if ever, cohabit during gestation, should teach us that it is improper. Whether sexual connection should be prohibited or not, will depend upon the judgment of the physician. 88 HALE ON ABORTION. Instrumental Irritation.—The use of instruments, whether for criminal or surgical purposes, is a very frequent and powerful cause of abortion at any stage of pregnancy. Criminal abortion is rarely brought about by the administration of drugs; it is generally induced by some instrument which has for its object the puncturing or separation of the membranes, the death of the foetus, or the irritation of the os uteri, by which means the uterus is made to expel the product of conception prematurely. The same may be said when abortion or premature labor is induced by the physician, in a legitimate manner—'/. e. to insure the safety of the mother or child, or both. Instruments have sometimes to be used during pregnancy, for pur- poses foreign to the accident above named, such as replacing a retroverted uterus, or in cases of extreme prolapsus, although such instances are rare. But there are cases on record where a retroverted uterus became so impacted that, other means failing, it was considered justifiable and necessary to use the uterine sound. In such cases it would seem that abortion would be the inevitable result; but I believe the operation might be performed in the early months, and the foetus and membranes remain intact. My opinion is based on several instances which have come under my own observation, where a sound was introduced into the uterine cavity, and turned several times round, with no other effect than slight pain and haemorrhage—preg- nancy not being interrupted, but terminating naturally. Pessaries have been introduced for the purpose of supporting a prolapsed uterus during pregnancy. The presence of such a foreign body in the vagina, may, by exciting the reflex action, cause an expulsion of the ovum; yet pessaries have been worn for several CAUSES OF ABORTION. 89 months by pregnant women, without such a result. Asa general rule, the use of all instruments, intro- duced into the uterus or vagina, should be dispensed with, if possible, during utero-gestation, as well as all surgical operations on these organs, or on contiguous organs or tissues. Instances are not wanting, however, where women have borne the most severe operations, even on neighboring organs, without interfering with the normal advance of pregnancy. Dr. Whitehead gives the treatment, by caustics, of several cases of ulceration of the os, during pregnancy, which treatment was successful, not only in curing the diseased condition, but of preventing an habitual abor- tion due to the ulceration. No positive rule can be laid down as regards the use of such remedial measures, as the irritability of the uterus varies greatly in different individuals. Ovarian.—The functional disorders which may prove exciting causes of abortion are simple irritation, from perverted physiological influences: Congestion and Inflammation. During pregnancy, the ovaries should be in a dor- mant condition. Their functional activity is supposed to be suspended, because there is no use for the ovum, even if it were formed and extruded. In some instances the process of ovulation may go on during pregnancy, at the usual menstrual periods. We know the same process does often occur during lactation; but it is believed that in both cases it is an unnatural proceed- ing, and that it arises from some abnormal irritation of the ovaries. A\ nen this process occurs during preg- nancy, the consequent afflux of blood, or nervous force, to the uterus, is often quite sufficient to induce abortion. We believe that this is the chief cause of that form of 90 HALE ON ABORTION. habitual abortion, which occurs within four weeks after conception, tmt about which so little has been written or known. Congestion and inflummation of the ovaries may cause abortion by the severe reflex irritation which the diseased process originates. The organic diseases liable to cause abortion are, ovarian tumors, dropsy and cystic enlargement. SECTION VIII. MEDICINAL CAUSES OF ABORTION. A list of the medicines which have been known to dause abortion at various periods of pregnancy; toge- ther with others which have been supposed to be detri- mental to the life of the foetus, has been given on a previous page of this work. In order that we may arrive at some definite conclu- sion as to the real influence of the drugs named, it will be proper for us to consider them separately. It is .manifestly impossible for us to classify the medi- cinal causes, as we have classified other morbific influ- ences, for in the present stage of our knowledge of the pathological action of medicines, we cannot decide with absolute certainty whether secale or cimicifuga, etc., cause abortion by their action on the spinal cord (cen- tric), or upon the uterus directly (concentric). We cannot decide whether a medicine causes diastaltic or peristaltic action chiefly; nor can we say positively that aloes induces abortion by irritation of the rectum alone, or terebinth by its action upon the urinary organs. CAUSES OF ABORTION. 91 But as all methods of classification must have a beginning, the following classes may be made, and their imperfections rectified at some future day, when greater pathogenetic or pathological progress shall have been made in our school. Medicines which act as predisponent causes. — Belladonna, calcarea carb., carbo veg., china, chamo- milla, chenepodium, ferrurn, hyosciamus, lachesis, lyco- podium, mercury, nux vomica, platinum, podophyllum, Pulsatilla., plumbum, sepia, siliceei, sulphur, zinc, and many others, which have the power of causing a dys- crasia in the system, or a cachectic state of the body. Met. We do not mean by this to imply that the blaek-oJiosh will invariably cause expulsion of the foetus, for, like all other ecbolic remedies, it requires a consti- tution susceptible to its influence, in order to have its 7 / 98 HALE ON ABORTION. action developed. In the old American "Ilerbals" we are told that this root was used by the Indians to facil- itate labor, and also by their women to produce miscar- riage. Prof. Tully, one of the most extensive observers, has known it to produce abortion, and had great confi- dence in its power as a partus-acceleratur. He thinks all the actceee possess the same power. Since the publication of the work on New Remedies, I have received several letters from correspondents, good medical observers, who assert that they know the decoction of the roots, or the active principle (macrotin) will, in doses of four or six grains, cause abortion in some women, at any period of gestation. I have been cognizant of several instances in which women have induced miscarriage with the root, and also where physicians had administered the macrotin with that result. The symptoms accompanying abortion caused by cimicifuga, are generally these : severe headache, as if the top of the head would be pushed off, or the eyes pressed out; stiffness of the whole body, with torpor, heaviness, and stiffness of the extremities, intermitting labor-like pains in the uterus, with pain in back and thighs, coldness and shivering, palpitation of the heart, neuralgic pains in limbs, contractions of the tendons, lowness of spirits. If enormous doses are given, convulsions and serious injury to the system might ensue, as the remedy acts specifically on the spinal cord and brain ; yet I cannot find any record of the drug having proved fatal. The extensive experience which is being gained by our school, in the use of this remedy, proves that it is of great value in the treatment of many of the diseases of women, especially those occurring, during the'partu- CAUSES OF ABORTION. 99 rient state. It relieves the many pains and disagreeable sensations felt during gestation, prevents miscarriage, conducts accidental abortion safely, if inevitable; and it also controls false pains in the latter months, and facilitates labor, if tedious and unnatural. Decod/m verticil!atus. This plant, known to botanists as lythrum verticilla- tum, and by the common people as swamp loosestrife, or swamp-willow-herb, has the reputation of causing abortion in brute animals. ;'If a great amount of testimony," says Tully,* "will decide anything in medicine, decodon is ecbolic for certain brute animals. This effect is said to be most frequently produced upon ewes, next upon cows, and sometimes upon mares. Any amount of testimony to this effect may be obtained from intelligent farmers, and even much from well educated physicians, who are either farmers themselves, or whose practice is in an agricultural region and almost wholly among farmers." Tully thinks if this plant can cause abortion upon brute animals, it may produce the same effect upon women. Yet he is not aware that it has been verified. He instituted some experiments with it on the cat and i\oy the constant contact of wet bed-clothes. Many of the disastrous sequelae of abortion I believe to proceed from the use and abuse of cold water. Hot Water.—There is, however, one method of ap- plying water in cases of uterine haemorrhage, which appears to be practical and scientific. It consists in the application of cloths saturated with water as hot as can be borne without pain, applied to the lower lumbar 22S HALE ON ABORTION. region. This plan was first recommended by an emi- nent English physician,* on the ground that hot appli- cations to the spine cause contractions of the arteries supplied by the nerves of that region of the spinal cord. It also causes contractions of the uterus in the same manner as dry cupping applied to the lumbar region. The hot applications should be changed very often, and the loss of heat prevented by a covering of oiled silk. I have tested this plan in several cases of uterine haemorrhage, even before the placenta was expelled. It seemed to cause contractions of the uterus, which re- sulted in the arrest of the flooding, and in some cases in expulsion of the after-birth. In one case of advanced uterine cancer, where the floodings were frequent and copious, they were always quiekly arrested by the application of napkins wrung out of hot water, and applied to the lumbar region. It must be borne in mind, that all the above medi- cinal and mechanical means have only been resorted to because the os uteri was not dilated or dilatable; for as soon as this condition of the os is present, we are not justified in depending on the above-mentioned means. The rule to be adopted in all cases of abortion, is: as soon as the os is dilatable or dilated, so as to admit the index finger, the blunt hook or intra-uterine placental forceps should be used for the extraction of the placenta, or such other portions of the embryo as maybe in the uterus. In the early part of my practice I adopted this rule, and have always found it the best, and that any devia- tion from it resulted in a protracted and troublesome case, unless nature expelled the offending substances. * Braithwaite, 1863. TREATMENT OF ABORTION. 229 The blunt hook is the most generally useful instru- ment. It should be about 15 or 18 inches in length, with the hook at one extremity. An extempore hook may, in case of emergency, be made with a piece of strong wire. BLUNT nOOK. The following is the best method of using the hook. The woman lying on her back, with the knees drawn up, and thighs placed a proper distance apart (the pa- tient may lie on the side of the bed, diagonally, or at right angles with the length of the bed, as the physi- cian may choose); pass the index finger of the right hand (or left, if most convenient) up to the os uteri; ascertain if the finger can be passed into the uterine cavity; if so, pass the blunt hook along the palmar surface of the finger until it reaches the dilated os. The instrument is then to be carefully introduced into the interior of the uterus, unless the placenta is found protruding from the os, or engaged in the canal of the cervix, when it is easily removed. The hook once in the uterine cavity, we may feel for the placenta just as we would feel for a cork in a bottle, in the dark. Any one experienced in the use of the hook will readily de- tect when it comes in contact with the placenta. When this occurs, slowly and carefully draw it towards the cervix. When it arrives at that point, we should try to bring it in contact with the end of the index finger, which perhaps has not been withdrawn. With the point of the finger pressing against one side of the mass, the hook is readily forced into the other, and the whole extracted easily. Should the placenta prove too fragile, 230 HALE ON ABORTION. it will have to be extracted in pieces. A little patience and tact will enable the physician to get the whole away. It is often difficult, and even quite impossible, to ex- tract the placenta whole, or in fragments, if it is very fragile. The ordinary blunt hook will not hold in the tissue, but upon the slightest traction tears through; aud this will occur again and again, making the removal of the mass a very tedious process. In view of this difficulty, I have for several years used an instrument of my own invention, which has many advantages over the common hook. The bent extremity, instead of consisting of a single wire, is looped, as will be seen in the-accompanying cut. The loop is about three-eighths of an inch across, and this allows the instrument to get a better hold upon the placenta, and traction will not force it through the fra- gile tissue. It is to be introduced and used exactly in the same manner as the blunt hook. LOOPED HOOK. The Forceps.—The infra-uterine placental forceps is a valuable instrument in some cases. Although not as generally manageable and efficient as the blunt or looped hook, there are many cases where it can be used easily. It differs from the ordinary placental forceps in having a longer curve, as will be seen by the accompanying figure. I do not consider the short forceps of any value except in cases where the placenta is protruding from the os, or lies in the vagina, and here the hook will answer every purpose. TREATMENT OF ABORTION. 231 LONG FORCEPS. The method of introducing the long forceps is the same as advised for the blunt hook. The operator should be very careful or he will pinch the mucous membrane of the vagina or vulva, thereby causing the woman much pain. When the blades of the forceps are in the cavity of the uterus, the instrument should be carefully opened and closed, moving it before each closure, to a different portion of the interior. When the placenta has been seized, the fact will be known by the heindles of tlie forceps not coming in contact. When this occurs, carefully withdraw the instrument, follow- ing the axis of the strait, and the whole or a portion of the placenta will be discovered by the finger in the vagina, between the blades of the forceps. If only a portion is extracted, renew the attempts until the whole is brought away. If the os uteri is well dilated, and the placenta is felt engaging in the cervix, or presenting at the os, or even remains in the cavity of the uterus which lies low in the SHORT FORCEPS. 232 HALE ON ABORTION. pelvis, then the short forceps may be used with advan- tage. The directions given for the use of the long, or infra-uterine forceps apply to this instrument. The hook and forceps may be used at any period of pregnancy, and always as soon as the condition of the os will permit their introduction. At almost any pe- riod, their presence in the womb excites it to contractile efforts, so that there is^little or no haemorrhage at the time of their use. Should we fail to seize the placenta in a reasonable time, the tampon should be used, proper remedies administered, and the case left for twenty-four hours. It often happens that while previous to the use of the hook, forceps or tampon, uterine pains were absent, they afterwards appear and become expulsive. If, therefore, after the tampon has been placed in the va- gina, labor-like pains set in, and after increasing for a time in intensity, suddenly cease, we are warranted in believing the placenta has been expelled. We may then remove the tampon, and in the majority of cases, the placenta will be found in the vagina. We may, however, find only a large clot' or the foetus, which in passing out of the uterus has caused the above symptoms, but after the expulsion of a clot or foetus, the pains commence again after a few hours, or less time; whereas after the expulsion of the placenta, pains do not return, unless the patient is beyond the fifth month, when they are really after-pains. It has been mentioned, that in cases of abortion be- fore the sixth month, the danger from haemorrhage is before the expulsion of the placenta and membranes; while after that date dangerous haemorrhage usually occurs after the after-birth has been expelled. If this statement be fixed in the mind, it will be a valuable TREATMENT OF ABORTION. 233 guide to the practitioner in the treatment of that acci- dent. Before the sixth month medicinal remedies cannot permanently check haemorrhage previous to the dis- charge of the placenta. They may, for a time, exer- cise their specific effect over the bleeding vessels, but if the cause of irritation remains, the haemorrhage will soon return. Remedies like secede, or caulopliyllum, will cause the uterus to contract firmly upon the pla- centa, or force it into the canal of the cervix, but if they do not effect its expulsion, the flooding will return. There is no safety for the woman until the whole pro- duct of conception has passed out of the uterus. After the sixth month severe haemorrhage rarely occurs while the placenta remains in the womb, and it is the want of proper contraction in that organ which causes the flooding. In this case, medicines may be used to advantage, in connexion with the application of cold or hot water, as before mentioned, but the tampon should never be used. The remedies most generally useful in post-partum haemorrhage after the sixth month, are, Secale, caulophyllum, macrotin, erigeron, ipecac, etc. There are other measures which may be resorted to in dangerous and severe cases. Dry cupping over the lower lumbar vertebrae, is said to cause firm and persistent uterine contractions. Galvanism, when applied in a proper manner, has been successfully used in cases of alarming haemorrhage. One pole should be applied to the os uteri, or pubes— the other to the sacral or lower lumbar region, and an interrupted current passed through the uterus. Firm contraction is said to immediately ensue. The same means adopted for the arrest of haemor- rhage during the last three months of pregnancy, are 234 " HALE ON ABORTION. the most useful ones to facilitate the expulsion of the contents of the uterus. The same contractions which expel the placenta will prove efficient for the preven- tion of flooding, if they continue for a proper length of time. As regards the management of the after-birth (and by after-birth is here meant all decidual or placental substances left after the expulsion of the embryo or foetus), it will be considered in a separate chapter. SECTION VIII. CONDUCT OF THE PHYSICIAN. The medical man who is called upon to attend a case of Abortion, occupies a peculiar and anomalous position. There are three classes of cases with which he has to deal, and each requires a different method of action on his part. The first, are married women of respect- ability, in whom the abortion has been brought on by accident, or some of the diseases mentioned among the causes enumerated. In these instances there is usually no hesitation on the part of the patient in admitting to the physician the nature of the illness, and she may not have any objection to its publicity among her friends or neighbors. In some cases, however, women of sensi- tive minds are averse to having a knowledge of the character of the sickness made known even to their nearest friends. In these cases, the evident duty of the physician is, if he has timely notice, to use all the means at his disposal to save the life of the child and arrest the progress of abortion, if he can do so with per- TREATMENT OF ABORTION. 235 feet safety to the mother; or, if called too late, he must exercise his highest skill in conducting the abortion to a safe conclusion, and afterwards proceed to effect a cure of the disease (if any existed) which acted as a cause of the accident. The second class comprises married women who en- tertain wrong ideas concerning their duty, and imagine that lack of means, ill-health, or other adverse circum- stances are sufficient reasons why they should not bear children. This, together with a wish to shirk the trials and responsibilities of maternity, as well as a desire to lead easy lives, or lives of fashion and luxury, leads them to take measures to prevent the fruit of con- ception from reaching maturity. To accomplish this, they resort to quacks, charlatans, or unprincipled wo- men, who are accustomed to induce abortion; or use the various nostrums so shamelessly advertised in many periodicals, or the instruments which are in the hands of so very many of the women of this country. If the abortion is produced by any of the above means, they at- tempt to endure the suffering, and risk the danger, rather than call a physician and thereby have their criminal conduct known to the medical attendant, or their own family. Such patients, when they do call a physician, attempt to hide from him the real nature of the malady, and hope that he will treat the case suc- cessfully without a knowledge of the actual nature of the case. They will call it dysmenorrhoea, an injury from a fall, etc., or a simple menorrhagia, and it re- quires considerable tact to ascertain from them the facts. In these cases, the physician should come to no hasty conclusion, married women rarely seek aid for an attack 236 HALE ON ABORTION. of dysmenorrhoea or menorrhagia, and it is a good rule to suspect the occurrence of an abortion when called to attend such alleged cases. If the woman denies that there is any haemorrhage, as they will often do, or de- clares the attack to be colic or dysentery, then the trouble of detecting the real disease is much more diffi- cult. But the facts being ascertained, (see " Examina- tion of the Patient,") the causes of the abortion, as well as the symptoms present should all be taken into ac- count, and the case treated as above advised. The third class are those unfortunate women, married and unmarried, the victims of the seducer, or of their own perverted passions, who have stepped aside from the paths of virtue, and with the frailty which pertains to humanity, transgressed the laws of God and man. In such cases the honorable physician is placed in a very delicate and trying position. The patient has perhaps applied to him to rid her of the consequences of her sinful conduct, but upon his refusal to do a criminal act she has resorted to some of the unlawful means mentioned above, and brought about the im- pending or actual abortion. In such cases, notwith- standing the sympathies of the physician may be strongly excited, his only proper course should be to attempt to avert the abortion by all the means in his possession, and leave the issue in the hands of Divine Providence. In this way, and no other, can he avoid becoming an accomplice in the destruction of a human being. In relation to the conduct of the physician during and after the abortion, I have a few suggestions to make. There is a great lack of the proper honor and delicacy, regarding a mention of such accidents, both with TREATMENT OF ABORTION. 237 physicians and others. It is common for nurses, friends and physicians to say, that " Mrs. A. or B. has ' slipped upf or to allude to the accident in some such vulgar manner. The unwarranted impertinence of neighbors, who insist upon knowing the nature of every woman's illness, is another reprehensible habit. It forces the physician to equivocate or divulge his patient's secret. The rule which should be invariably adopted by every medical man, is this: Whether in or out of his pettienfs room, during her illness or after, no matter what her condition in life, character or standing in society, in short, under any circumstances whatever, lie should avoid all mention of the occurrence of an abortion in his patient. If people are so devoid of good breeding as to ask im- pertinent questions, he is justified in equivocating to the extent of blinding the questioner. SECTION IX. EXAMINATION OF THE PATIENT. To physicians who have had much experience in the treatment of abortion, I need not dilate on the impor- tance of ascertaining as soon as possible that an abor- tion is impending or in progress, nor need I mention the almost insuperable difficulty which exists in some cases, of satisfying ourselves during our first visits, whether the above accident is what we are called to treat. Patients belonging to the first class previously men- tioned, rarely cause us any trouble, but will frankly say to the medical attendant, "Doctor, I am threatened 238 HALE ON ABORTION. with an Abortion and would like to have you arrest it if possible," or " I am having a miscarriage." This class will often intelligently acquaint us with the history of the case, the present and previous symptoms, and submit sensibly to all necessary examinations for the purpose of ascertaining the real condition. As there is always more or less nervous agitation attending such cases, .manifesting itself especially when the physician is present, a few directions may not be amiss to the student or young practitioner. As it is customary for the messenger, if it is some relative, to acquaint the physician with the nature of the illness, it is to be supposed he will learn something of the nature of the case, either with or without direct questioning, in which case he will feel somewhat pre- pared to meet his patient. Upon entering the room, after some brief salutations, he should quietly take a seat by the bedside of the woman, and place his fingers upon her wrist. Meanwhile the state of the pulse and the ap- pearance of the patient may be noted. If the pulse is weak or thready and the face and lips blanched, it is presumed that severe haemorrhage has occurred; if, on the contrary, the pulse is full, hard or normal, and the face red or natural, there is irritative fever, general re- action, or only the premonitions of abortion, or actual abortion in the early months. We must not, however, judge too hastily, as the mental excitement of the patient may cause a suffused face and quick pulse. Generally the first appropriate question to the pa- tient or her nurse, is : " When did this illness begin?" next "What have been the symptoms until now?" There are instances, however, where the evident ex- sanguification should impel us to ask at once, " How long has she been flooding?" In some cases even, it TREATMENT OF ABORTION. 239 will be found absolutely necessary, without asking a single question, to state to the patient or nurse what must be done, call for material for a tampon and use it immediately, and then ply the patient with active stimulants. So soon as the immediate danger is over, or an abor- tion is ascertained to be progressing, the physician should inquire if the foetus and placenta have been ex- pelled. This is a point upon which the closest inves- tigation is necessary. We are often informed, that " every thing has come away," when in fact the patient or her nurse has seen only the foetus and clots of blood, or perhaps nothing but a mass or masses of coagula. Not one patient or nurse in a thousand ever examines sufficiently the expelled substances. The foetus and after birth, at an early stage, may be passed, enveloped in large coagula, and altogether escape superficial scrutiny, or neither may be present, yet are supposed to be from the general appearance of the mass. It often becomes necessary to have the substances extruded, produced, that we may examine carefully their character. Each clot should be broken and its interior examined for embryo or placenta. If we can- not satisfy ourselves on this point, we must rest in un- certainty until an examination can be made. If one fact, however, is borne in mind, it will greatly aid us in forming our opinion, namely, before the sixth month hcemorrhage rarely, if ever, occurs, after the placenta is expelled. The expulsion of the foetus alone, only causes a subsidence of the pains for a time; it does not have any influence over the arrest of haemorrhage. We have supposed cases where the abortion was ad- mitted, or was evident at first. The second and third classes are more difficult to treat, 240 HALE ON ABORTION. because of the obstacles thrown in the way of a proper knowledge of the case. A physician is called to see a woman. He has no intimation of the nature of her illness. She is said to be in " great pain " or " very sick." She says to him, " I want relief from the pain across me," or " I have a colic." She will state it is from a cold, and assert that it was from a suppression, or intimate that she has been regular, and the attack is only dysmenorrhoeal. A woman who has determined to hide her shame will use every subterfuge that cunning and equivocation can devise. She will deny the presence of flooding, even when her exsanguined appearance plainly indicates the fact. The character of the pain will be an indication to the watchful physician. But an ordinary colic is often intermitting, as also are the pains of dysmenor- rhoea or dysentery. The only way we can, in some cases, arrive at a cor- rect diagnosis, is to seem to assent to the assertions of the patient, while we are questioning in relation to symptoms which, while they seem unimportant to her, are valuable indications to us. When we are satisfied than an abortion is in progress or impending, we should not hesitate to acquaint the patient with our convic- tions, in a courteous but decided manner. Instances are not rare, where careless or ignorant physicians have attended cases of abortion during the first half of gesta- tion, under the idea that they were cases of enteralgia, enteritis, dysmenorrhoea, or even dysentery ; the woman succeeding perfectly in hiding the evidences of the mis- carriage. Every physician should be on the alert and not allow himself to be caught in such a mortifying predicament. Finally, in an examination of a patient, it should be remembered, that no matter what her social TREATMENT OF ABORTION. 241 condition, her character, or the character of those around her, the sick-room is no place for unseemly or rude jests. No coarse allusions or indelicate remarks should be indulged in or allowed by the physician. No one having any regard for manly or professional dignity will countenance such conduct. All manual examina- tions should be conducted with delicacy and gentleness, without any unnecessary exposure of the patient. If instruments are used, all unnecessary flourish and exhi- bition should be avoided, for these are the tricks of quacks and ignorant pretenders. SECTION X. MANAGEMENT OF LABOR. " Abortion," says Professor Hodge, " is a true labor. The two characteristic peculiarities are—first, that there is no placenta, but the whole membrana decidua is in close and vascular connection with the internal surface of the uterus."* Dr. Hodge restricts the term abortion to an expulsion of the ovum before the fourth month, after which period the placenta is formed, and the deci- dual membranes are separated from the uterine surfaces. The practitioner, when called to attend an abortion, should go prepared to meet any emergency which may arise. If he neglects this, and the woman dies, or suf- fers from dangerous symptoms which might have been remedied by the proper medicines and instruments, he is culpable in the highest degree for his criminal care- lessness or ignorance. * System of Obstetrics, page 464. 16 242 HALE ON ABORTION. He should take with him, besides his ordinary pocket- case of remedies, some crude ergot freshly prepared, or a reliable vinous tincture; or the first decimal tritura- tion of cauhphyllin; some oil'of erigeron, TV ; a blunt hook, or abortion forceps; and a piece of charpie, or a sponge, to use as a tampon. If the physician has a well-regulated office, all these can be collected in a moment. Their possession may be of invaluable ser- vice to him, and enable him to save the life of his patient, and his own reputation, both of which might be lost while a messenger was riding miles away to procure the articles desired. The treatment of the premonitory symptoms has already been laid down; also the treatment of the symptoms, such as haemorrhage, etc., which may occur during the progress of an abortion. The management proper of the different stages, will now be considered. If, upon examination, the os is found closed, no haemorrhage, and no change taken place in the body of the uterus, except some descent of that organ in the pelvis, and some unusual turgescence and fullness of the pelvic viscera, such as simple organic irritation would cause; the physician can do no more than to prescribe the appropriate remedy for the condition, and give the proper directions relating to diet and posture, and leave the patient for the time. (See Treatment, page 218). If, however, nervous irritation or contraction has ensued, and the neck of the uterus is found developed at the upper part, it will indicate a partial descent of the ovum into the canal of the cervix. If this occurs, the conical form of the lower portion of the uterus will be found considerably altered—it will have become more spherical. Dr. Lee states that, in all such cases, expul- TREATMENT OF ABORTION. 243 sion will surely follow. This termination will be still more probable if, in addition, the os uteri is found par- tially dilated, and especially if a portion of the ovum be found protruding. There are cases, however, espe- cially in multiparous women, where the internal os remains contracted, while the external is soft and some- what patulous. In these instances, if alternate pains be not severe, there is ground for hope that the ovum will be retained. If, with the above condition, there is still no haemor- rhage, the patient may be left as before, under the use of the remedies, etc., appropriate to the symptoms and state. The remedies indicated are—gelseminum, cimici- fuga, caulophyllum, gossipium and secede, from the 3rd dilution upwards. It is in this condition that full doses of opium have been found most useful by the old school, and also even when haemorrhage is present. (See case, page 223). The best position for the patient to assume, is on the back, with the hips elevated, unless in case of retrover- sion, wdien the woman should lie on the face. Again, if it be positively ascertained that the ovum is blighted, that the liquor amnii is evacuated,* that the haemor- rhage is profuse, and regular alternating pains are established, and especially if the measures for preven- tion have been inefficient, the practitioner should favor, not retard, the expulsive process; and, at the same time, render it as easy and as safe as possible. In this place I must advert to my division of utero- gestation into three stages, for the management of this expulsive stage of abortion, must be varied with each stage of pregnancy. * This occurrence is rare at the early months, as, in a great number of cases, the ovum is discharged entire ; and in all instances the quantity of the amniotic fluid is so small that, when discharged, it escapes notice. 244 HALE ON ABORTION. In the first stage, it is rare that we find much dilata- tion of the os uteri, or can find the embryo presenting. Should we detect the embryo engaged in the canal of the cervix, or even in the vagina, it is not best to re- move it, for its presence in either canal may be useful in exciting uterine contractions; while its removal can do no good, but rather retard the progress of labor. Its presence in the cervical canal may also be useful in preventing haemorrhage, acting as a plug. We should not leave the woman in this condition, without placing a tampon in situ, for fear that haemorrhage occurs in our absence. The presence of the tampon will be of service, too, in hastening the termination of the expul- sive process. The delivery of the after-birth, or secundines, which, in this stage of pregnancy, consist only of the decidual membranes, is the most important duty of the physi- cian. It is difficult to accomplish this with the ordinary wire crochet, or blunt hook, owing to the delicacy of the membranes, and their general adherence to the uterine walls. Neither can we rely upon those uterine- motor medicines (caulophyllin, ergot, etc.) for, in this stage, the contractile power of the uterus is small, owing to the undeveloped condition of its muscular tissue. We must either allow them—if not thrown off by the efforts of nature—to decay, and pass away in a fluid state, or extract them by instrumental means other than the hook. The intra-uterine placental forceps, to which I have alluded on another page, may be used; or the " abortion forceps," originally recommended by Levret, or Hodge's forceps, " the blades of which," he says, " are so arranged that they may present the form of a lever, allowing their easy introduction through the cervix into the uterus, exterior to the ovum." (It is TREATMENT OF ABORTION. 245 only in the third month, or after, however, that such an an instrument can be used.) But, probably, the instru- ment best adapted to remove the contents of the uterus, if the os and cervix are dilated so as to admit the finger, is the " abortion vectis," which I have invented. It is, it is true, only a modification of Hodge's " lever and crotchet," but it is specially adapted for the removal of the embryo in this first stage. The lever and crotchet combined, is better adapted for use in the second stage. The abortion vectis can be insinuated into the uterus, betwen the embryo and the uterine parietes, and, with careful oscillating movements, we may separate the ovum from its adhesions, and generally withdraw it entire. So soon as this is accomplished, haemorrhage and pain will cease, and the abortion is at an end. If, however, even a small portion of the membrane is left in the womb, it will, in certain constitutions, act as a local irritant, keeping up pain and haemorrhage, until it has disintegrated and passed off; or, its absorption may cause irritative fever, which must be treated with sulphite of soda, baptisia, arsenicum, or chlorate of potash, internally, together with injections of clilorate or per-manganate of potash, or baptisia, into the interior of the uterus, to wash away the offending substance, and act as a local disinfectant. The instrument best adapted for this purpose is a hard rubber syringe, holding two ounces, and provided with an extra long and slender pipe. 246 HALE ON ABORTION. If the abortion occurs during the second stage of pregnancy, the management of the labor differs some- what from that of the first stage. The delivery of the embryo-foetus should be left to nature, as recommended in the first stage, and for the same reasons, the delivery of the placenta and membranes may have to be as- sisted in a somewhat different manner. After the third month the placenta is perfect, and is attached to the uterus, while at the same time the decidua ceases to be in such contact with the uterine wall as in the previous stage, the circulation between the mother and child being carried on solely through the placenta. In this stage, abortion may occur with complete detachment of the whole placenta at once, in which case the embryonic mass drops into the lower segment of the uterus, and may be expelled entire, as in the first stage. Oftener, however, the membranes are rup- tured, and the foetus escapes while the placenta retains its connections. In other cases Ave may have ab- normal adherence of the placenta, in which instance the contractions of the uterus, though sometimes quite powerful, are insufficient to detach it. Here the "abortion vectis" will form a valuable instrument, if the os is open sufficiently to admit of its introduction. ^> After it has been detached, however, the blunt or looped hook or forceps will form the best instrument for its extraction. If the os is not sufficiently dilated we may use the tampon, and give gelseminum or bellaelonna until dila- tion occurs. We may then have to administer caulo- phyllin, or ergot, the former in doses of two to four grains of the T^th, the latter in the officinal dose given from time immemorial—namely, one drachm to a tea- TREATMENT OF ABORTION. 247 cup of hot water, taken at four draughts fifteen minutes apart. Those who think the 3rd or 30th attenuation will answer as well are allowed their opinion. An adherent placenta, remaining in spite of the efforts of nature or art, is supposed to be the origin of molar or hydatid masses. But it quite often happens that the whole placenta undergoes putrefactive disin- tegration, or the portions left after instrumental inter- ference, decay ; in which case we may have foetid dis- charges and irritative fever, previously alluded to and treatment given. The management of labor after the sixth month (third stage of pregnancy), is essentially the same as recommended for labor at full time (see standard works on Obstetrics). I will only add a few observations to refresh the memory of the practitioner, namely: The expulsion of the ovum may here be aided by the internal use of uterine motor excitants ; by instru- ments; and by remedies Homoeopathic to non-relax- ation of the os and soft parts. The delivery of the placenta may be aided by trac- tion with the eord (which cannot be done in the earlier months), by caulophyllin, ergot, etc.; and by the instru- ments heretofore named. The haemorrhage must be arrested with ergot, cold water, galvanism, dry cupping, erigeron, the tight band- age, etc., as recommended in cases of natural labor. Here the tampon should never be used, nor those remedies recommended for haemorrhage during the first stage. They are not often adapted to the patho- logical state upon which post-partum flooding depends, and will generally prove insufficient. 248 HALE ON .ABORTION. SECTION XI. SEQUELAE OF ABORTION. The post-partum treatment of abortion, although not of the same importance as the remedial, is a subject which should be fully considered. I believe it has not received that attention from physicians which the sub- ject demands. The post-partum treatment may be properly divided into (a) Postural. (b) Dietetic. (c) Medicinal. (e) Mechanical. The postural treatment is altogether too much neg- lected by a great majority of physicians. It is too often the case that a patient who has had an abortion during the first, or even second stage of pregnancy, is allowed by the attendant to rise from her bed the next day, or a few days thereafter, and attend to her household duties or recreations. I have known women engage in severe work or exercise, or attend parties or balls, but a few days after an abortion in the second month. The physician has a responsibility in this matter. It is his duty to state to the patient, her nurse, or certain members of the family, the importance of the recumbent posture for a certain length of time after the delivery\ This period varies somewhat with the period of pregnancy in which the abortion has occurred. TREATMENT OF ABORTION. 249 It depends, too, in a great measure, upon the severity of the symptoms during the progress of the abortion, and upon the constitution and morbid conditions of the patient. Abortion in the first stage of pregnancy is rarely attended with great loss of blood, the pain is not very severe, and consequently, the strength of the woman is not much exhausted. But an engorged condition of the uterus is generally present, and if the woman is too soon and too often on her feet, or sits up too much, the womb is inclined to sink into the pelvis, and a pro- lapsus or retroversion ensues. If the abortion has been short in its duration, and the symptoms few and not severe, confinement to the bed or couch need not continue more than four or five days. If, however, getting up and standing or walking for an hour or two causes any local uneasi- ness in the back*or abdomen, the recumbent posture should be maintained a portion of the time for several days longer. If, on the contrary, the symptoms have been severe; there has been much haemorrhage; a slow expulsion of the embryo, or its retention in utero; or if it is found on examination that the uterus or its cervix is congested, or the os lacerated or abraded, explicit directions should be given not to allow the patient to sit up or stand on her feet more than a minute or two at a time until eight or ten days have expired. The woman who leaves her bed under these circumstances before that time, does so at the imminent hazard of her future health, and perhaps her life. During the second period, the postural treatment of patients who have aborted is of still greater impor- tance. As it approaches the sixth month, confinement ** 250 HALE ON ABORTION. becomes more and more hazardous, and its sequelae more like those of labor at term. Haemorrhage, when it occurs, is more apt to be pro- fuse and exhausting, the labor more tedious and dan- gerous, and the after treatment more important. It is believed by practical and observing physicians that cancer of the uterus, ulceration of the os and cervix, chronic metritis, prolapsus and retroversion, frequently occur from a too early assumption of the erect position after abortion in the middle period of gestation. In nearly every case, should the symptoms appear ever so slight and unimportant, the woman should keep her bed for a week after the labor has been completed. There are certain cases, however, where the placenta is retained; but the patient improves in strength and health notwithstanding. The placenta may not be expelled for weeks after the woman has left her bed, no decay or putrefaction having taken place. In these cases, we cannot, of course, confine the patient to her bed until its expulsion occurs, nor would it be proper to do so. If severe haemorrhage, congestion, or inflammation, or irritative fever has occurred, the patient should on no account get up until the twelfth day, even if she feels perfectly able to do so. In these instances, how- ever, the woman has not the power of rising, even if she desires to, such is the local pain, general weakness, vertigo, etc., which is caused by the effort. If the accident has occurred during the last three months of pregnancy, nearly the same rules, last men- tioned, should govern us in our postural treatment. The same directions should be given as would be proper after delivery at the ninth month, as the patho- *. TRKATMENT OF ABORTION. 251 logical conditions which ensue are nearly the same as at the latter period. Dietetic. — The diet of the patient who has suffered an abortion is not an unimportant item. Its character will depend on the condition of the system. If fever is present, due to any local inflammation, the aliment should be very light, easily assimilable, and bland. Toast water, rice gruel, flour or farina porridge, light toast or crackers, together with cooling beverages, will he best relished by the patient, and most appropriate. If the fever is irritative, from local irritation or the absorption of morbid matters into the circulation, the food allowed should be of a more nutritious character. Milk, rice, toast, animal broths, beef-tea, wine and whey, cocoa, etc., may be allowed. The physician should be careful to form a correct diagnosis in these cases, and not mistake the irritable pulse of this con- dition for the quick, hard pulse of fever from inflamma- tion. If the patient has lost much blood, or been greatly reduced by the length of the illness, or prostrated by the irritative fever which has attended it, the diet will have to be not only exceedingly nutritious, but suffi- ciently stimulating. We shall be under the necessity of ordering milk-punch, egg-nogg, beef-tea, mutton-broth, soups, all such meats as the patient can relish, and allow her to take them in such quantities as her condi- tion requires. It is very necessary in these cases to give the nutriment at short intervals. If food is given every two or three hours, the quantity taken will be less, and the stomach is not so liable to be overloaded. Dr. Inmaii states that he has seen cases where it was necessary to administer to the patient concentrated nutriment every hour, in order to prevent dangerous 252 HALE ON ABORTION. prostration. It is hardly necessary to caution against allowing indigestible articles of diet, among which may be mentioned raw apples or other uncooked fruits, pickles, salt meats or fish, pastry, confectionery, etc. In this category might be placed ice-cream, were it not that this article is often allowable, especially in cases of great prostration or irritative fever, where there is present great thirst, dryness of the mouth, and a desire for cooling drinks. It may be given in small quanti- ties, a spoonful at a time, and allowed to be slowly melted in the mouth. If taken in too large quantities, or too hastily, it may give rise to colic and even spasms. The medicinal treatment of the sequelae of abortion will depend upon the nature of the pathological condi- tion, and the symptoms present. These sequelae have, the most of them, been de- scribed, and their treatment given, in that part of this work devoted to the causes and their treatment. There are other maladies, which are not mentioned; but which properly belong to the consequences of abortion. They are, pelvic cellulitis; hypertrophy of the uterus; fis- tulas, (vesical, uterine, or between the organs alluded to) ; adhesions of the os and vagina, rendering liable subsequent rupture of the womb during labor or from retained menses, or, in the latter case, discharge of the secretion through the Fallopian tubes and consequent peritonitis; and, finally, inflammation of the mammae, puerperal metritis, phlebitis, dropsy, and paralysis of the lower extremities. Others might be named; but it would swell the list to an extent incompatible with the limits of this treatise. The medicinal treatment of these sequelae will be briefly alluded to. TREATMENT OF ABORTION. 253 Pelvic cellulitis will require those remedies which favor resolution or healthy suppuration, namely: Mer- curius, belladonna, hepa/r sulph., and phytolacca. In some cases the abscess will have to be punctured to give vent to the pus, which, if confined, would burrow, and create troublesome complications. Hypertrophy of the Uterus. — I have observed in many cases of abortion before the sixth month, a large increase in the size of the abdomen in the hypogastric region. It was not ascites, for external examination failed to detect the fluctuation found in dropsy, and moreover the urinary secretion was normal in quantity. An examination of the uterus showed it to be much enlarged—often much larger than before the abortion. I believe this to be a serous infiltration into the uterine parieties, superadded to that condition which Professor Simpson has described as " Sub-involution of the Uterus." I have treated such cases successfully with sepia, arsenicum, kali bromatum and kali hydriodicum. Fistulce, adhesions, etc., will require the attention of the skillful surgeon; but they may be prevented by proper attention on the part of the physician, who, if he has the least fear of such consequences, should make occasional examinations, and by placing a dilator in the os, or pledgets of lint in the vagina, prevent such evils. Inflammation of the Mammce, When the abortion has occurred after the third month, it is not unusual for milk to be secreted. When this happens it will be necessary to arrest the secretion as soon as it can be safely done. This end is best attained by prescribing, for internal remedies, kali hydriodatum, phosphorus and magnesia sulphurica; and externally embrocations of aconite-water (3j to Sj), phytolacca, belladonna, or 254 HALE ON ABORTION. iodide of potash, in ointment or solution. If, from neglect, or in spite of these means, inflammation and abscess supervene, adopt the treatment hereinbefore recommended. Puerperal metritis will require veratrum viride, bella- donna, stramonium, cimicifuga, and external applica- tions of aconite. Puerperal peritonitis, the same remedies. (This dis- ease is not of such frequent occurrence as is believed. It is often confounded with myalgia, which requires caulophyllum, nux-vomica, cimicifuga, helonias, china bryoniet, and colocynth, with external applications of a lotion of gelseminum or arnica?). Phlebitis calls for arnica, belladonna, and hamamelis, — the latter externally applied if possible. Dropsy after abortion is removed by apocynum can- nabinum, eupatorium purpureum, apis mel., cantharis, senecio aureus, and arsenicum. Paralysis of the lower extremities will yield to cau- lopliyllwm, hedeoma, nux vomica, ignatia, citrate of iron and strychnia, secale, and cesculus glabra. Mental aberrations are not uncommon after abortions, and may proceed from reflex influences, or from grief or remorse. These will require careful symptomatic treatment. One of the best remedies for the mental depression following abortion is the cimicifuga, wliich has been successfully used by Professor Simpson, and lately by myself. One of the most common of the sequelae of abortion is premature and profuse menses. They sometimes occur every three weeks; sometimes every two weeks. Although sabina, ipecac, sulphur, and platinum are fre- quently indicated and successful, I have been most suc- cessful, in fact in nearly every case, with senecin and TREATMENT OF ABORTION. 255 calearea carb. In these, as in some other instances in our practice, neither seems to be as useful alone, as when used in alternation. I usually prescribe the senecin in the second decimal trituration, a dose every afternoon and evening, and a single dose of calcarea, third trituration, every morn- ing. It is best to give these remedies, beginning just after the last menstrual period, and continuing them until the next regular period, unless the menses are prema- ture, in which case they may be superseded by ipecac or seibina during the flow. It is rare that the second period will be premature after beginning the use of the above remedies. Chronic menorrhagia of a very obstinate character sometimes follows an abortion. It may arise from atony of the uterus, from irritability, or from a condi- tion of the lining membrane, described by some writers as consisting of an enlarged and hypertrophied state of the villous coat, — a kind of fungous growth of its pa- pillae, from which blood oozes upon the least irritation. For atonic conditions, we should use helonias, trillium, secale, aletris, terebinth, sulphuric acid, and sabina, in the lower dilutions. For irritation, sabina, caulophyllum,platina, etc. The last cause of menorrhagia can only be cured by abso- lute rest and a long course of treatment, with carefully selected remedies, among which may be mentioned erigeron, secede, trillium, cole, senecio, china, ferrum, Pulsatilla, etc., unless we resort to local applications to the diseased surface, applied with the intra-uterine syringe. Several cases have occurred in my practice, which persisted for many months, notwithstanding the use 256 HALE ON ABORTION. of all the most approved medicines recommended for menorrhagia, until topical means were resorted to. One case I cured with injections of tinctura ferr. muri- atis, 10 drops to 5j of water, half of which was used once a day. After the third day, the haemorrhage ceased, and did not return. In another case the per- nitrate of iron, was used successfully. The mechanical treatment includes those appliances which will serve to prevent the occurrence of uterine displacements, or the closure of the vagina or os uteri by adhesions. A prolapsus may be prevented or cured by the same means, together with cool injections containing hama- melis, nux vomica, or helonias, the use of cool hip baths, and the hypogastric bandage. For the prevention of adhesions, the vagina and uterus should be examined, in cases where excoriation or laceration is supposed to have occurred, to ascertain if the vaginal and cervical canals are normally open. The finger will do to explore the former, the sound the latter. If a closure is to be found, pledgets of lint, or pieces of linen spread with calendula cereite on both sides, should be introduced and kept in situ till the danger has passed by. For retroversion I do not hesitate to use the closed lever pessary or the ring, as seems best indicated, and have thus prevented in many cases the uterus from assuming a retroverted condition, which it had attained previous to the abortion. In my pamphlet on Retroversion and Retroflexion of the Uterus (page 2), I alluded to the fact that that form of displacement was a frequent cause, accompani- ment, and consequence of abortion. I advert to it TREATMENT OF ABORTION. 257 again because the subject is too important to be lost sight of by the practical physician. As a cause of abortion, it has been fully treated of in the foregoing pages. As an accompaniment, I did not mention it to the extent I intended to do. A flexed or retroverted uterus is one of the chiefest obstacles to the natural expulsion or extraction of the placenta or any of the products of an arrested conception. Coagula of blood even are sometimes retained a long time in the cavity of the uterus from this cause alone. When the foetus dies, or the membrane becomes de- tached from the womb, that organ sinks in the pelvis, and if any tendency to retroversion exists, that accident is pretty sure to occur. In this case the expelling power of the uterus is altogether destroyed, and it strives with unavailing efforts to throw off its contents. A single glance at the anatomical peculiarities of the uterus will shoAv us how futile these efforts must be. A hollow, pear-shaped muscle is flexed at its neck, or almost doubled upon itself. In this condition the severest spasmodic action of its muscular tissue becomes utterly useless. I have known the most intense spasmodic pains to continue day after day, Aveary the patient out, and no good result until the uterus Avas replaced and kept in a normal position until the offending placenta was expelled. A case Avhich occurred in my practice not long since, so aptly illustrates this subject, that I cannot forbear giving it. A delicate, nervous woman, Avho had had several miscarriages, attended with retro- version, for Avhich she had been treated by several physicians of eminence in our school came under my care. On one occasion, she had lain several Aveeks with a retained placenta, from retroversion, suffering in the meantime from metritis, spasmodic pains, etc., until 17 258 HALE ON ABORTION. the uterus was held in its proper position by a ring pessary, when the placenta came away in a horribly putrid state of semi-liquid putrescency. In the instance in which she came under my care, the foetus (of three months) was expelled; the pains ceased for nearly a day, but returned severely after she had imprudently made considerable effort at stool. After the pains had lasted several hours, I was called, and found them very agonizing and spasmodic. On examination, the uterus was found almost completely retroverted. Not having with me a sound, I left some mother tincture of caulophyllum, ten drops to be taken every half hour until I returned. Not getting relief in two hours, she took, on her own responsibility, a teaspoonful of the tincture at a single dose. The pain ceased altogether in fifteen minutes! This action of caulophyllum should not surprise us, for it is secmdarily Homoeopathic to spasm, in which case Ave know it often requires massive doses to prove curative. On getting on her feet again, however, the pain returned with its original intensity. On my arrival, the uterine sound was with much difficulty introduced, and with considerable effort the uterus was lifted into normal position. Knowing that it would become retroverted immediately if the sound were withdrawn, I introduced a curved elastic pessary while the sound was still in the uterus. This can be done by any one familiar with the former instrument. The sound was then with- drawn, and the uterus elevated as much as possible. Ergot was given in the usual manner, and the placenta was expelled in less than two hours. All pain ceased, and the pessary was allowed to remain for eight days, when the patient was discharged. There have been several cases, which I was obliged TREATMENT OF ABORTION. 259 to treat in the same manner, and in view of the uniform success which has attended the method, I do not hesi- tate to advise the insertion of the elastic curved or ring pessary, in every instance of retained placenta from retroversion. It will sometimes happen that this form of displace- ment will not occur until after the abortion has fully terminated with the complete discharge of the foetus, placenta, and membranes. The patient gets up too soon, and the effort of standing, or straining at stool, or lifting, causes the heavy fundus-uteri to fall backward. The attending physician should warn his patient of the nature and probable occurrence of the accident, and the means to avoid it. She should be instructed to Feport if certain symptoms obtain, that immediate measures for relief may be taken. As soon as the dis- placement is known to have occurred, the physician should enjoin the recumbent position, replace the organ by means of the processes hereinbefore described, and place the patient upon the use of iodide of iron, podo- phyllum, nux vomica, helonias, or belladonna, until the danger of a recurrence of the accident is passed. PART V. STEKILITY. HALE ON STERILITY. 263 STERILITY. In the treatment of this subject, I propose to adopt the generally accepted meaning of the term, namely : The want of the aptitude for being impregnated. This definition does not restrict barrenness to those cases where, from some cause, ovulation does not take place ; for that function may be perfectly performed, and yet, from some abnormal condition of the organs of generation, the ovule can not become impreg- nated. Impotence in the male can not be considered as a cause of sterility, and the consideration of this condition does not fall within the pro- vince of this treatise. Sterility may be congenital, or acquired; or it may exist for years, and a spontaneous cure result from the action of unknown causes. History relates many instances illustrating these conditions. Anna of Austria had been married to Louis XIV. for fifteen years, before she had a child. Another Anne of Austria, wife of Louis XIII., was sterile for twenty-two years. Catalina de Medicis, wife of Henry the Second, was unfruitful during the first ten years of her marriao-e, after which time she became so prolific that she had ten successive children. Many similar cases are reported in the various works on Obstetrics. There is still another class of sterile women, who become so after having one or two children, and are afterwards barren, even when no cause is apparent in the condition of the organs of reproduc- tion. For a proper understanding of the subject, and a full apprecia- tion of the various causes of Sterility, the latest views on the Physiology of Generation should be kept in mind. * It is generally believed that conception consists in the contact of the fertilizing semen of the male, with the ovum, some where in the Fallopian tubes, or the cavity of the uterus. * See page 115. 264 HALE ON STERILITY. It is taught by some authors, however, that the ovum may or does become impregnated in the ovary. Thus, in a standard work we find it stated that " During the act of copulation, the male secretes the semen in the testicle, and deposits it in the vagina of the female, whence the fecundating principle arises, and entering certain ducts specially arranged for that purpose, passes up through the walls of the uterus, out through the ovarian ligament, to the ovary. Here it enters, and impregnates an ovule on that side." * This author gives a plate illustrating the course of the passage of the " fecundating principle" to the ovary, as described above. This doctrine is, however, the same as that taught by Sweden- borg, f who, after a consideration of the various theories of his day, says : " To exhibit, therefore, a general idea of the movement or advance of the genital seed, the process, which we are here in brief to expound, appears to be as follows: " The seminal humor, driven forth into its first receptacle in the internal orifice of the uterus, is taken up by it, and at the same time by the tube of the cervix; after being taken up, it is shut in; and then, after some time, is conveyed away, through certain ducts, into the ligaments of the ovary, which the old anatomists called the vasa deferentia; and thence, by an uninterrupted path of little canals, it goes to the corpora lutea, twisted in intestinal convolu- tions ; and from these, with unerring determination, penetrates, not into the ova, but into the one ovum." The ducts described by Swedenborg, and represented in Guernsey's Obstetrics, are said to " pass within the common coat of the uterus, from the tube of the cervix, immediately into the ligaments of the ovaries." The presence of these ducts, however, have not yet been satisfacto- rily demonstrated by microscopic examinations of the uterus. It remains to be seen whether the theory will be borne out by facts obvious to the senses. It is significant that in the elaborate anatomical description of the uterus, given by Guernsey, no mention is made of these ducts. Without accepting, then, this theory of the process of concep- tion, we shall proceed to treat of the Causes of Sterility, viewed * Guernsey's Obstetrics, page 296. t Generative Organs, 181. HALE ON STERILITY. 265 in the light of the present physiological and anatomical knowledge of the generative organs of woman. With a full appreciation of the imperfections which it contains, I submit the following arrangement or classification of the CAUSES OP STERILITY. I. Constitutional or Predisponent. a. Obesity. b. Chlorosis. c. Scrofula. d. Syphilis. e. Mercurialization. /■ Twin-birth. 9- Prostitution. h. Inordinate Sexual Intercourse. i. Change of Climate. 3- Mineral Waters. k. Improper Diet, and Want of Proper Exerc II. Psychical. a. Incompatibility. b. Frigidity. c. Erotism. Ill . Ovarian. a. Atrophy of the Ovaries. b. Absence " c. d. Imperfect Development of the Ovaries. Inflammation — Chronic — of the Ovaries. e. Degeneration /■ Tumors 9- Dropsy h. Dislocation IV Uterine. (1) Fallopian Tubes. a Stricture of b. Obstruction of c. d. Inflammation of i' " fimbriated extremity. e. Displacement ot (2) The Uterus. a. Absence of 266 HALE ON STERILITY. 6. Atreesia ; Constrictions Occlusions of th« Uterus. Of Cavity and Cervix. Acquired — Congenital. Imperfect Development of Uterus. Atrophy. Displacements. Anteflexion. Retroflexion. Lateroflexion. Prolapsus. Elevation. Inversion. Tumors of Inflammations — Chronic. Endo-Metritis. Endo-Cervicitis. Ulceration. Leucorrhoea. Amenorrhcea. Dysmenorrhoea. Menstrual Irregularities. V. Vaginal. a. Atresia. Congenital. Accidental. b. Absence of Vagina. c. Non-retaining Vagina. d. Imperforate hymen. e. Vaginismus /. Leucorrhoea. VI. Rectal. a. Haemorrhoids. b. Prolapsus ani. c. Fissures of the anus. VII. Medicinal.* Agnus castus. Conium. Apis mel. Cantharides. Amrum. Chimaphila. Baryta carbonica. Ferrum. Cimcifuga. Capsicum. Caladiurn seg. Caulophyllum. Cannabis. Iodine. Iodide of Lead. Kali brom. Lachesis. Mercurius. Moschus. Phytolacca. Phosphc/rus. Platinum. Plumbum. Pulsatilla. Ruta graveolens, Sepia. Senecio. Sabina. Secale cormttum. Trillium. Ustilago. * The above enumeration of the medicinal causes is necessarily imperfect, because much the testimony relating to their sterility-causing power is unreliable. Their claims will be sep- arately considered in another place. P HALE ON STERILITY. 267 STATISTICS OF STERILITY. In general, it is stated by Sims and other authorities, that about every eighth marriage is sterile. This is certainly an astoaishing statement. In no other age of tlie world than this, could such a state of things exist. From what we can learn from ancient writers, both sacred and profane, sterility was a very uncommon occurrence among the Egyptians, Jews, Greeks. Romans, and the nations of Europe. If all other evidence was lacking, the fact that sterility was considered a disgrace among the nations enumerated above, would be sufficient to prove its extreme rarity among their women. In Dr. Duncan's work on " Fecundity, Fertility and Sterility," we find that in the cities of Edinburgh and Glasgow, 15 per cent, of all the marriages between fifteen and forty-four years of age, are sterile. Dr. Lever (Org. Dis. of Uterus, p. 5,) says : " It is found that ^th, or 5 per cent., of married women, are wholly unprolific." Duncan does not ascribe much value to this estimate. Dr. Simpson (Obstetric Works, Vol. I., p. 328,) says it has been observed that, in some portions of Sweden, one barren woman is not met with, for ten fertile. Frank asserts that only one marriage in fifty is unproductive ; but he gives no proof of his estimate. Thompson (Todd's Cyclopcedia, Vol. II., p. 478,) estimates from a census of two large cities, Grangemouth and Bathgate, that one in every 10£ married women were sterile. The same author gives the analysis of 503 marriages, in the British Peerage, resulting as follows : Among 495 marriages, 81 were unproductive ; or, 1 in 6-J- were without any family. Dr. West (Diseases of Women, p. 3,) states that he found the general average of sterile marriages among his patients at St. Bar- tholomew's Hospital, to be, 1 sterile marriage in «very 8.5. Dr. Duncan's tables show that about 7 per cent, of all the mar- riages between 15 and 19 years of age, inclusive, are without offspring. Those that are married at ages from 20 to 24, inclusive, are almost all fertile ; and that, after that age. sterility gradually increases, according to the greater age at the time of marriage. We have no means of ascertaining the exact proportion of sterile women among the older nations. Even at this day, statisticians 268 HALE ON STERILITY. have been remiss in collecting, or unable to obtain, any reliable tables. Dr. Nathan Allen * reports to the Social Science Congress, that • he has ascertained that in New England the birth-rate of the strictly American class is steadily diminishing. "From a careful examination of the census and registration reports, as well as of town and city records, the following facts were developed : " The average number of births to each married couple, and the relative number of children to adults, with the present generation of Americans, did not begin to compare with what it was in New England one or two hundred years ago. " A census of Massachusetts, taken in 1765, reports almost one- half of the population as under sixteen years of age ; whereas, from the best estimates that can be made, not more than one-fourth, or perhaps one-fifth, of the present American population, are under that age. * * * An examination of the records also shows that the average number of children to each family, at the date above mentioned, was from eight to ten ; and that from the second, third and fourth generations, the average ranged from seven to eight; but when we come to the fifth and sixth generations, the number of children diminished more rapidly, averaging only four or five to each married couple ; and that of the present generation, the number will not much, if any, exceed three children. Now, if we take into account the known increase in miscarriages from disease, as well as the greater frequency of criminal abortions, we shall find that this decrease in the birth-rate is due largely to the increase in the number of sterile women. It must be borne in mind that many of the causes of miscarriage are also causes of sterility. A diseased condition causing the for- mer in one woman, will, in another, cause the latter. The statis- tics of sterility are, therefore, closely connected with those of abortion. Now, it i? generally believed that miscarriage from causes not designated as criminal, is one hundred times more frequent now than a few centuries ago ; so we may safely assert the same of sterility. If, therefore, the present rate is one in eight, the ancient rate would be nearer one in eighty. * Psychological Journal, Vol. II., p. 214. HALE ON STERILITY. 269 The statistics of sterility, as connected with certain diseased con- ditions, has been only partially arrived at. We can, therefore, only give a few estimates. As regards the statistics of sterility connected with uterine dis- placements, Sims gives the following table, which shows the influence displacements of the uterus exercise on the sterile condition : Of 250 cases of natural sterility, 103 had anteversion, 68 had retroversion. Of 255 cases of acquired sterility, 61 had anteversion, and 111 had retroversion. Or, out of 505 cases of sterility, 343 had uterine displacement, or about two-thirds of the whole. The statistics of sterility connected with fibroid tumors of the uterus, show that of 225 women who had once borne children and then become sterile, 38 had fibroid tumors, of various sizes and variously seated ; or one in 6.7. Of 250 women who had never borne children, the cause of sterility was found to be complicated with the presence of fibroid tumors, in 57 ; being at the rate of about one in 4.3. (In 100 virgins consulting for some uterine disease, 24 had fibroid tumors, or one in 4.6. These latter would probably be sterile.) CAUSES AND TREATMENT. Chlorosis. — In actual chlorotic conditions, conception rarely occurs. If, with the chlorosis, amenorrhcea is present, fecundation is still more difficult. [See pages 35 and 159, for Treatment.] Scrofula. — Scrofulous women are oftener fruitful than otherwise. There are cases, however, where the diathesis is well marked, and the ovaries or uterus become the seat of its local manifestations, with resulting sterility. [See pages 36 and 162, for Treatment.] Si/philis.__This malady is doubtless a frequent cause of sterility. Whitehead* narrates a case of " sterility of fifteen years," caused by secondary syphilis. * Abortion and Sterility, p. 8M. 270 HALE ON STERILITY. [See Description, page 37; Treatment, p. 163. Also refer to Franklin's Surgery, pp. 538-9.] Mercurialization. — There can be no doubt in the minds of physi- cians who have closely studied cases of sterility, that Mercury some- times causes a difficulty of conception. [See Treatment, p. 164.] Obesity. — This condition is considered, both popularly and by the profession, to be alike the cause and consequence of sterility. Some authorities doubt if obesity is opposed to fecundation. Why this condition should interfere with conception, has never been fully explained. The fact, however, remains ; and every physician in laro-e practice has doubtless observed that sterile women are oftener obese than lean. When a woman becomes normally sterile — i.e., after the climacte- ric period — she is quite apt to become adipose. This fact would seem to prove that there is some connection between barrenness and adiposis. I have known many instances where a woman has had one or two children, and then suddenly become increased in size and weight, with resulting barrenness. These same women, a few years after, from some illness or other cause, would become lean, and again bear children. [See page 35. Also, Treatment, page 135.] Twin-birth. — " There is a popular belief, among a certain class, that when a male and female are born at a twin-birth, the female will be henceforward sterile. It is probable that this belief origi- nated with the graziers, for it is stated as a fact that when a heifer and bull twins occur, the heifer will not conceive. Among cattle- growers, this heifer is called a " free-martin ;" and so undoubted is this belief, that this free-martin is either killed as a calf, or, if raised, is regularly broken to the yoke, and worked like an ox. Many men of intelligence have made this statement to me, and it maybe found in agricultural journals." " Among cattle, such may be the fact, although I very much doubt it. But after a careful examination, I am convinced that such is not the fact in respect to the human race ; as I have known * Gardner on Sterility, p. 108. HALE ON STERILITY. 271 of numerous instances to the contrary, and do not now remember ever hearing one statement in corroboration of this opinion." * Professor Simpson, of Edinburgh, who has made considerable research upon this subject, acknowledges " the infecundity of free- martin cows to be a very general fact, but by no means an univer- sal one." He has also collected the facts relative to the married history of 123 females born co-twin with males, 112 of whom had offspring, and 11 none, although married several years. "In other words, the marriages of the females born under the circumstances, were unproductive in the proportion of one to ten." * Prostitution. — Prostitutes are notoriously sterile. Any one who will wade through the horrible and sickening details of the effects of prostitution, as described by Sanger, f will be convinced that fecundation rarely takes place in utterly abandoned women. To the moralist, this seems to be more a special providence than any physi- cal result. If it were not so, it would be terrible to contemplate the vast increase of crime and misery that would result. According to Sanger, prostitutes who reform and marry, even if not affected with syphilis, are often barren, while others become prolific. Inordinate Sexual Intercourse.— It is stated by some authorities that this habit, equally with prostitution, may be a cause of barrenness. It has been successfully recommended in such cases, that, in order to ensure conception, coitus be indulged in only once during the ten days succeeding the menses. In several cases of sterility, I have found this recommendation to be followed by pregnancy. In some cases, coitus should be prohibited for a whole month, to allow the exhausted organs time to regain their tone. Change of Climate. — According to Casanova, " change of climate will produce sterility, as it has been observed in women born in that region of South America which lies between the rivers Amazon and Nepo. When such women leave their native home to reside in some of the limiting States, they will surely (like many plants, when trans- planted from one climate to another,) become, if not absolutely bar- ren, at any rate less prolific than in their own native land." This may be so ; but the fact is equally apparent, that change of * Simpson's Obstetric Memoirs, Vol. I., p. 294. t History of Prostitution. 272 HALE ON STERILITY. climate often cures sterility. I am informed by the physicians of Cleveland, Buffalo, and New York, that women, sterile for years, have conceived while on a visit to the upper Great Lakes, or a few months' residence at Mackinaw. I have known the same result to follow, in cases of ladies from. Chicago, who supposed themselves sterile, until a visit to Mackinaw, or a trip to Lake Superior, resulted in a pregnancy. A visit to Europe, or the West Indies, is often recommended to sterile women, and with good results. Women, sterile in New England, become prolific in the West; and women who have never conceived in any part of the country east of the Rocky Mountains, become pregnant soon after reaching Cal- ifornia. Baudeloque mentions the case of a high personage, who could not have any children by his wife. During an absence of two years from France, his wife- became pregnant, and gave birth to a boy. After this, his wife remained sterile for four years. After another absence from France, she had another child. The change of climate was evidently the cause of some favorable change in the condition of the reproductive organs. This same couple, by making annual visits, became the parents of eleven children, five boys and six girls. Mineral Waters. — " Long residence near chalybeate springs, and the abuse of drinking or bathing in their waters, have been observed; on the continent, to produce sterility in prolific women."— Casanova. This author believes this result to be due to the iron contained in the water, and floating in the air. He accounts for the cure of ster- ility by ferrum, on homoeopathic principles. Sterile women are often sent to mineral springs for the cure of barrenness; and it is asserted that some springs are noted for their good effects on this condition. Improper Diet, and Want of Exercise. — It is well known to all practical men, that the diet has much to do with fecundity in the human subject, also in animals and plants. One of the best writers on this subject — Mr. Doubleday — says : " It is a fact admitted by all gardeners, as well as botanists, that if a tree, plant, or flower, be placed in a mould either naturally or artificially made too rich for it, a plethoric state is produced, and fruitfulness ceases. In trees, the effect of strong manures and over rich soils is, that they run to superfluous wood, blossom irregularly, HALE ON STERILITY. 273 and almost or entirely cease to bear fruit. In flowering shrubs or flowers, the first effect is that the flower becomes double, and loses the power of producing seed ; next, it ceases, almost, even to flower. On the other hand, when a gardener wishes to save seed, he does not give the plant an extra dose of manure, but he subjects it to some hardship, and selects the fruit that is the least fine-looking, knowing that it will be filled with seed; while the finest fruit will be nearly destitute. " In the animal kingdom, fecundity is totally checked by the pleth- oric state, while it is induced and increased by the deplethoric or lean state. Rabbits, swine, sheep, and horses, when overfed, will not reproduce ; put them out of condition, and they instantly resume their fertility. Tame pigeons, sheep, mares, and numberless sorts of other animals, when they are stuffed to satiety, do not want, or do not care to raise, or are incapable of raising, others." Mr. Doubleday's theory is that " the increase of population is connected with the food of the people." In other words — and the truth of the deduction is evident to all observing men — if the diet of women is composed of articles in which fatty constituents, or carboniferous, abound, — such as sugar, sweatmeats, nuts, and all the rich delicacies such as are found on the tables of the rich and luxurious — such women will become plethoric, adipose, and sterile. If, with this rich and unnatural diet, we find a lack of exercise, an absence of out-door life, and a condition of physical indolence, we have the two causes combined, which, as much if not more than all others, conduce to render the female population of our large towns and cities, unproductive and sterile. If we contrast this sterile class with the hard-working, hardy, plainly-fed and plainly-clad portion of the population — the Irish, German and English — we shall see at once the difference which exists between the two classes, in the capacity for bearing children. Hippocrates was well aware of these facts, for he says : " The want of fruitfulness arises from sedentary life, indulgence in riding in carriages, want of exercise, profuseness in living, fatness, and muscular laxness, in the female sex." Aristotle says : " The condition most favorable to procreation, is a habit of body inured to labor." Lord Bacon says : " Repletion is an enemy to generation." Herbert Spencer, one of the profoundest writers and observers of the age, has the same opinions. 274 HALE ON STERILITY. It is to be hoped that the renewed interest of the present genera- tion in athletic out-door exercises, will have a favorable effect on the organization of woman ; and, in time, undo the evil caused by a century of false fashion. For a further consideration of this subject, so important as a cause of sterility, I refer the physician to that excellent paper on " The Law of Human Increase; or, Population based on Physiology and Psychol- ogy ;* by Dr. Nathan Allen, of Lowell, Mass. II. Psychical. That there are causes of sterility which exist solely in the men- tal constitution of woman, no close observer will deny. The annals of medicine and jurisprudence abound in cases of this character. Among the psychical causes of barrenness, may be enumerated Incompatibility. — There have been many instances known, where, in spite of a perfect development of all the organs of generation, together with a normal healthfulness of function, in both husband and wife, conception did not occur. The reason why such marriages were unfruitful, is said to be some antipathy or antagonism in the mental sphere. Gollman f mentions such instances, and calls them relative causes of sterility. He says : " Such causes are, for example, antipathy or antagonism between the married partners ; extreme differences of age, constitution, and temperament, as when a very old man is married to a very young wife, or vice versa, a very old woman to a very young husband; or when a cold and phlegmatic husband has a wife of a very ardent temperament. Such causes are quite frequent, although it is not always easy to find them out. There are instances of sterility of five, ten or twenty years' standing, and when, after this period, con- ception took place in consequence of a change in the outward rela- tion of the married partners." Several cases have come under my own observation, where hus- band and wife have lived together for ten or twenty years, without the occurrence of conception. These parties became divorced, each married again, and had children. The case of Napoleon and Jose- phine is in point. The Emperor had children by his second wife, and Josephine's first marriage was fruitful. * Quarterly Journal of Psychological Medicine, April, 1868. (Vol. II., page 209.) t Diseases of Urinary and Sexual Organs, p. 243. HALE ON STERILITY. 275 " We frequently see trials of divorce," says Casanova, " reported in the newspapers, brought in by husbands against their wives, for adultery, when the latter had been unfruitful during a number of years of matrimonial life, and become pregnant by other men. Infi- delity, in such cases, was generally found to be the result of ill treatment from their cruel husbands ; consequently their wives could not possibly have had the least degree of love and affection, and therefore no power of reproduction during such behavior." This last sentence embodies the doctrine taught by this singular author, in his unique but illogical work,* heretofore referred to. Frigidity. — Coldness, or an absence of sexual desire, was once supposed to be a cause of sterility; but the most eminent physiolo- gists of this century do not teach that such a condition is a cause. Absence of sexual feeling may arise from some malformation of the external genitals, while, at the same time, the ovaries perform their functions properly. The consideration of this delicate question lies in the domain of psychology. Treatment. — When no organic cause is discovered, the reme- dies are: Kali brom., agnus castus, conium, baryta, in the high attenu- ations ; or, phosphorus, helonias,canth., or nux, in the low attenuations. Erotism.—Excess of sexual excitation, or enjoyment, in one or both, especially in hysterical and passionate women, is stated by some authors to be a cause of sterility. This, like the foregoing, is a subject which I do not propose to discuss in this work. I pre- fer to adhere principally to the more practical details of the patho- logical causes of sterility. Treatment.— Erotism, or erotomania, is best removed by cantha- ris, phosphorus, nux vom., platina, cannabis ind., in the higher poten- cies ; or, kali brom.., lupulin, camphor, or gelseminum, in the low poten- cies. III. Ovarian. Absence of the Ovaries. — Congenital absence of the ovaries has been observed, in a few instances. The persons so abnormally con- stituted, possessed some of the characteristics of woman, but were more masculine than feminine in their appearance. » Contributions to Physiology. 276 HALE ON STERILITY. Imperfect Development. — This condition, which consists in a per- sistence of the foetal condition of the ovaries, is not very rare. It may exist on one side only, though it generally affects both. As in the case of absence, a certain conclusion is not easy; and, as in that case, also, we draw a presumptive conclusion, from want of development in the other organs of generation, absence of the usual signs of the menstrual crisis, and lack of general constitutional vigor and development. Prof. Thomas * gives three cases of this condition, which came under his own observation. Their ages were respectively 24, 18, and 30. Each showed a want of development of the uterus, vagina, and external organs of generation. The two first never menstru- ated, the latter very scantily. Treatment.—In imperfect development, the treatment should consist in administering the remedies homoeopathic to the condition, namely : Conium, iodine, chimaphila, helonias, ferrum, phosphorous, calc. phos., baryta carb., senecio, and the hypophosphite of lime. The action of these medicines may be aided by careful and judi- cious irritation of the uterus, by means of tents, introduced at or near the probable menstrual periods. Electricity has been successfully employed in such cases. It acts by arousing the dormant forces in those organs. One pole of a bat- tery should be placed on the spine, and one over the ovaries ; or one pole in contact with the cervix uteri, and one over the ovaries. These means, together with proper bathing, exercise in the open air, a nutritious diet, etc., will be apt to arouse the undeveloped organs. Atrophy. — Aside from the normal atrophy which occurs at the change of life, the ovaries may become atrophied at any age. It may result from acute ovaritis, pelvic cellulitis, and peritonitis. If both ovaries are affected in this manner, sterility will of course be absolute. Treatment.—If the atrophy be not too far advanced, the atrophy may be arrested by the same means recommended for undeveloped ovaries. An excellent paper on this subject will be found in the North * On Diseases of Women. HALE ON STERILITY. 277 American Journal of Homoeopathy, Vol. II., page 192,* in which the treatment is considered quite extensively. Inflammation.—Acute inflammation of the ovaries may cause such an amount of suppuration and disorganization as to destroy forever their functions; or it may end in chronic inflammation, resulting in destruction of the capability of elaborating healthy ovules. If only one ovary be diseased, sterility will not result. [For Treatment, see page 211. Also, Guernsey's Obstetrics, page 224.] Degeneration of the ovaries may result from acute or chronic inflam- mation. When the disease has reached this stage, no treatment is known that will restore their integrity; and if both ovaries are affected, permanent sterility must result. Tumors of the ovary are not uncommon. They may be divided into : (1) Those which are solid. (2) Those which have cavities, more or less large, in their interior ; — dropsical tumors. (3) Can- cerous (scirrous.) [For Treatment, see page 212. Also refer for full description and treatment, to Guernsey's Obstetrics, pp. 226-228. The reme- dies recommended by this author are : Apis, arnica, belladonna, conium, graphites, lachesis, lycopodium, and zincum; and their characteristic symptoms given. Ovarian tumors of large size have decreased notably, and in some instances apparently disappeared, under the use of chlorate of potassa, kali bromatum, and cJiimaphilla.] Dropsy.— Ovarian dropsy is but a form of ovarian tumor ; a local disease, and not dependent on disorder of the kidneys. [For Treatment, see last paragraph (Tumors.) ] IV. Uterine. fallopian tubes. Any abnormal condition of the Fallopian tubes, sufficient to pre- vent the passage of the ovum from the ovary to the cavity of the uterus, is a cause of sterility. It matters not whether impregna- • •• On Atrophic-Ovarlan Amenorrhoea." 2 278 HALE ON STERILITY. tion takes place in the ovary or the uterus—normal conception can not occur unless the ovum attaches itself to internal wall of the uterus. Among the diseases of the Fallopian tubes, causing sterility, may be mentioned (a) Stricture. — It is said by several European writers, that stric- ture of the uterine end of the Fallopian tube may occur as a result of previous inflammation. The occurrence of a fcetus being devel- oped in the tube, seems to prove that such a condition may occur. Such an abnormality, however, can not be demonstrated during life, unless some unusual dilatation or organic change in the os uteri co- exist. " Theoretically," says Dr. Gardner, " there is little doubt of its existence ; but practically, there is immense doubt of the possibility of recognizing it, save, perhaps, in some exceedingly rare instances." Treatment. — The recommendation of some recent English writers, Tyler Smith the originator, of passing a bougie into the os and through the cervix, and thence into the Fallopian tubes, and, by a series of graduated instruments, removing' the stricture, is itself so seemingly impossible, that it is not now seriously recom- mended. It has never been performed, and doubtless never will be. Gardner * gives cuts illustrative of the method of performing this theoretical operation. (b) Obstructions may occur any where in the course of the tubes, but generally at the two extremities. Tyler Smith says : " I have repeatedly observed that in cases where the Nabothean bodies are met with, small cysts are found in the course of the Fallopian tube, or at its fimbriated extremities. Inflammation of the tube may result in exudation into the tube, blocking up the canal, and rendering it impervious. Catarrhal affections of the tubes may cause obstructions, of a more or less persistent character. Polypoid tumors may also fill up the canal of a tube." Treatment necessarily obscure. (c) Inflammation of the Fallopian tubes may be discovered during life, but its diagnosis from ovarian inflammation is extremely diffi- cult. The tube itself may be the seat of inflammation, causing * Sterility, page 15WT, HALE ON STERILITY. 279 stricture or obstruction ; or, the fimbriated extremity may be affected, resulting in adhesions or displacements. uterine causes. (a) Absence or Defect of the Uterus, in respect of development, will cause absolute sterility. " Complete absence of the uterus has been doubted by many, because a more careful study of cases recorded as authentic, rendered the presence of rudiments of a uterus pre- sumable or evident ; and partly because cases of absence of a uterus which are founded simply on examination of living women, do not seem sufficiently conclusive. Notwithstanding this, it has been proved that the uterus may be entirely absent, and in such cases both the oviducts and ovaries, especially the former, may exist either in a rudimentary state, or may be also wanting." * Burggraeve relates cases where, with absence of the uterus, both the ovaries were normally developed, with Graaflian follicles found in them; but the menstrual flow and sickness were absent. Scan- zoni speaks of extravasations of blood, and formation of cysts, which can not be imagined to take place without ovulation. The breasts are frequently well-developed, the pelvis of the normal dimensions, and sexual desire not absent. In this anomaly, as well as the rudimentary uterus, described by Klob, conception can not occur. The absence of the menstrual flow is, in such cases, a val. uable diagnostic symptom. Atresia of the uterus may be congenital or acquired. Of the former, Klob writes : f " By congenital atresia, we understand that arrest of development in which the external orifice, or, at the same time, a portion of the cervical canal, is either imperforate or entirely absent. As the extremest degree of this anomaly, we might consider that rudi- mentary form in which no cavity has been formed. However, the term atresia is only applied to the slighter anomalies just men- tioned." " The cervix of the uterus is, in rare instances, perfectly imper- forate, and forms a slender cylindrical body, consisting of fibrous connective tissue, interspersed with muscular fibres. In such cases, the vaginal portion of the cervix is either entirely absent, or very * Klob: Pathological Anatomy of the Uterus. t Pathological Anatomy of the Uterus, p. 82. 280 HALE ON STERILITY. imperfectly developed, and small; and the vagina is always rudi- mentary. In other cases, the atresia is limited to the external ori- fice ; the occlusion being also effected by muscular and connective tissue. In such, the vaginal .portion is generally small ; but in some instances, it is found normally developed. Finally, we meet with cases in which the vaginal portion and the cervix are perfectly permeable, but the atresia is formed by the mucous membrane of the vagina passing over and occluding the orifice of the vaginal portion." Congenital atresia, in all its forms, is a very rare anomaly. It may exist unperceived, up to the years of puberty, and acquire pathological importance only at the commencement of menstruation. The menstrual fluid accumulates in the uterine cavity, from which it can not escape ; and, consequently, distending the uterus, it causes that condition termed hoematometra, or retention of the menses. All these forms of atresia cause sterility. A uterus affected with atresia, can not be impregnated ; yet, after a successful operation, not only conception, but maturity of the foetus and a normal deliv- ery, have been known to take place. Acquired atresia, occlusions, or contractions of the uterine cavity, take place usually at its orifices; and as regards frequency, those at the internal orifice are more frequently observed than those of the external, whilst throughout the remainder of the uterine cavity, stricture or occlusion is rarely found. Sometimes the entire uterine canal is diminished by concentric hypertrophy or atrophy. Stricture of the uterine cavity may be caused by annular contrac- tions at a certain point; by the external pressure of fibroid and other tumors; by partial or complete flexions of the uterus ; thickening of the mucous membrane from catarrh ; enlargement of the follicles ; or from the growth of granulating tissues, resulting in a constricting cicatrix. The abuse of caustics, such as nitrate of silver and potassa fusa, in the treatment of ulceration and inflammation of the cervix, is doubtless a frequent cause of occlusion. One such case came under my observation, and required an operation for its remo- val. In the treatment of ulceration during pregnancy, proper cau- tion must be used, or the edges of the os may unite. This has been known to occur, when no local treatment was resorted to. Sterility may result from nearly every form of acquired atresia. Treatment. — For complete congenital atresia of the uterine cav- ity or neck, no surgical treatment can be of avail. In those forms HALE ON STERILITY. 281 of partial atresia, puncture or incision through the occluded por- tions, with the usual precautions against reunions, will be attended with success. Acquired occlusions or contractions, if confined to the canal of the cervix, or its inner and outer orifices, may be successfully treated by the same surgical means. If irora. flexions of the uterus, a proper pessary will remove the stricture. (See flexions and versions of the uterus.) Tumors may sometimes be removed by surgical operations, or the persevering use of such remedies as conium, hydrastin, and iodide of arsenic. Simple occlusions from adhesions of the lips of the os, can readily be removed by the uterine sound, or in severer cases, by the bistoury. Lacerations of the os and cervix should be watched for after mis- carriage and delivery. In closing up, they often completely occlude the os, and it is not ascertained until after the menses occur, at the close of lactation. Instances have been reported where occlusion of the cervical canal has resulted from the use of instruments used for the purpose of criminal abortion. These causes should not be for- gotten, and their results guarded against. If such a condition threatens to occur, from any of the above causes, the os and cervi- cal canal should be kept open by means of tents and bougies, until the danger is past. Imperfectly-developed Uterus. — I have known of several cases of sterility, in otherwise healthy women, from this cause. Such women are nearly always inclined to obesity. Dr. Simpson * says he has seen a considerable number of cases of short or imperfectly developed uteri in the living subject. The imperfect development of the organ was ascertained, on examina- tion by the finger, by the small and atrophied cervix uteri, and by actual measurement of the length of the cavity by the uterine sound. Instead of being 2£ inches in length, the cavity, in such cases, was only two inches, or more frequently only 1£ or 1 inch long. The subjects of this imperfect development were often well made and formed in other respects. But the malformation led to various functional defects, especially to amenorrhcea and sterility. The amen- orrhcea was usually persistent, and when a patient applied for med- ical relief, who was already twenty-five or thirty years of age, this malformation would, in a large proportion of cases, be found to be • Obstetric Memoirs, Vol. I., p. 268. 282 HALE ON STERILITY. the organic cause. In some such cases of amenorrhoea, there was great vascularity of the face, and occasionally a most unconquera- ble form of acene. He has seen, in some of these instances, the wearing of an intra-uterine galvanic, or zinc and copper pessary, followed by the best results, and even occasionally by the cure of the amenorrhoea. The uterus developed itself around such a for- eign body, when it filled its cavity, as it did around a fibrous tumor or an ovum. Dr. Storer, in his note to this article, remarks that he has often seen galvanic pessaries, used by Dr. S. in ordinary cases of amen- orrhoea, which had resisted all the usual means of treatment, and with perfect success. Imperfect development will not only cause amenorrhoea, with sterility, but it causes that kind of difficult menstruation in which the flow is very scanty, and sometimes delaying. This condition is nearly always attended with sterility. I do not think the imperfect development is always congenital, but oftener arises from a sudden check to the first menstruation. I have now two such cases under treatment. In both, a severe cold checked the first or second menses, which began profusely enough, but ever since that date they have been scanty and delaying. Each has been married thirty years, and never have been impregnated. Treatment.—No medicinal agent is of any' service, after the condition has existed a few months. If pulsatilla, senecio, or some remedy appropriate to the sudden suppression, were given immedi- ately, the normal development would not have been arrested. Atrophy of the uterus is an affection of mature age, and generally commences simultaneously with puerperal involution, or it must be considered as marastic degeneration of the organ. In chlorotic women, also, a sort of atrophy of the uterus is sometimes met with, generally complicated with displacements, and derangements of men- struation. Besides these causes, atrophy may result from pressure, or be due to mechanical causes. As regards the extent of the affec- tion, we may distinguish between general and partial atrophy. The latter effects either the body, fundus, cervix, or vaginal portion of the uterus. As regards the cavity of the uterus, a distinction has been made between concentric atrophy, with diminution, and eccentric atrophy, with dilatation of the cavity. (Klob.) Concentric atrophy would doubtless be a cause of sterility ; but it HALE ON STERILITY. 283 is doubtful if atrophy with dilatation would be inimical to concep- tion, although it might act as a cause of miscarriage. Concentric atrophy generally occurs as a sequence to the puerpe- ral state, and is probably one of the causes of that form of sterility which occurs after the woman has given birth to two or more child- ren, and is often connected with atrophy of the ovaries. Senile atrophy, occurring, as it does, after the climacteric age, does not belong to the causes of sterility. Scanzoni mentions, as a cause of atrophy, imperfect innervation of the pelvic organs, consequent upon paralytic conditions of the system (paralysis of the lower half of the body, followed by amen- orrhoea,) and of which he observed several cases. Treatment. — If the atrophy is from excess of puerperal involu- tion, or from a psoric miasm : Iodine, if there is general wasting of the body, with great weak- ness of the joints. Baryta carb., if there is an appearance of premature old age, dimi- nution of sexual desire, and the uterus feels hard, and is diminished in size; menses scanty or suspended. Conium, if there has been swelling and soreness of the mammae, followed by wasting, with induration and atrophy of the cervix uteri ; sexual feeling abolished ; menses scanty or wanting. Chimaphilla, if the breasts have become atrophied and flabby, without previous soreness ; the skin is dry and hard ; and the urine deposits a profuse white sediment, like mucus and chalk. Graphites, sepia, and kali bromatum, are indicated, if the menses are very scanty. If it is caused or attended by chlorosis: Iodide of iron, if, with the iodine-symptoms, there is waxen com- plexion, bloated feet, etc. Ferrum, if the chlorosis is due to deficiency in the red corpuscles of the blood. Helonias, if there is chlorosis with dropsy, or diabetes. In atrophy from imperfect innervation, with paralysis of the lower half of the body, the remedies are nux vomica, conium, secale, ustilago, and phosphorus. Obstructive Dysmenorrhoea, from stricture of the os and cervix uteri, is of frequent occurrence, and often overlooked by ordinary practi- tioners. On the other hand, surgeons who are always looking for 284 HALE ON STERILITY. stricture of the cervix, often mistake the effects of the various flexions of the uterus, for the former condition. Dr. Simpson has an excellent paper on the surgical treatment of this abnormality.* He recommends incision, and mentions several cases of sterility from this cause, cured by the operation. Dr. Mackintosh recommends dilatation, by long, straight bougies, of different sizes. Dr. Sims prefers the bilateral incision of the cervix. His method seems to be superior to all others. Dr. T. G. Comstock, of St. Louis, writes : " One case of ster- ility, I treated successfully by dilating the cervical canal by means of the uterine probe, Atlee's dilator sponge-tents, and Simpson's graduated gutta-percha plugs. This operation, made in another case, under treatment for a year past, has entirely failed ; although the stricture has been overcome. For the last six months, I have been experimenting in cases of dysmenorrhoea, from a narrowing of the cervical canal, by relieving the stricture by incision — that is, dividing it, making the bilateral section of the os and cervix uteri, which is the operation proposed and performed successfully by Drs. Sims and Simpson. " This operation I consider preferable to dilatation, and the results of this practice, I propose to make public at some future period. I am acquainted with a physician who claims to have performed this operation nearly fifty times, without any accident or untoward results, and to have cured many cases of sterility by it.- " Whether this operation is warrantable or not, it is certainly worthy of the attention of gynecologists and surgeons of our school." In the discussion of Dr. Duncan's paper on Dysmenorrhcea,f Dr. Ludlam made the following remarks : " While we are upon the subject of dysmenorrhoea, I will, with the permission of the society, present some instruments for the cure of the obstructive or mechanical variety. Of course you are all familiar with the sponge tent. Here is Simpson's bougie. (It much resembles the tip of his intra-uterine pessary, with the addi- tion of a shoulder at the lower extremity.) It is introduced into the cervical canal. One end is made of zinc, the other of copper, which arrangement may cause it to act as a sort of battery, and by * Obstetric Memoirs, Vol. I., p. 264. t Medical Investigator, Vol. V., page 211. HALE ON STERILITY. 285 that means overcome the constriction. It can be introduced on the end of an ordinary uterine sound, there being a hole in the lower end. Here are Simpson's gutta-percha bougies, recently introduced to the notice of the profession. They are to be introduced into the cervix on a director, and left there to come away of themselves, or they may be withdrawn by this string which you see attached to them. These may be introduced in advance of the menses, and allowed to remain until the flow brings them away. The chief diffi- culty experienced with these bougies, and with the uterine sound, is to get them through the internal os. To overcome this difficulty, Dr. Atlee, of Philadelphia, has made an instrument much like the ordinary glove-distender. It is a little larger than a uterine sound, and may be introduced up to the internal os, and then the cervix can be dilated as the finger of a glove is stretched. I have had a modification of this instrument made. It consists of a guide, or rest, attached to one blade, through which a sound may pass. (See plate.) It often happens that you can not get Atlee's dilator through the internal os, but you can always push it close up to this os, and then it is easily dilated. Now, with and through this guide, you can readily pass the sound into the uterus, and thus open the pas- sage ; or you may put on the end of a director, one of Simpson's bougies, and pass it up, and let it remain in the cervix. Dr. Priestly, of Edinburgh, about five months ago, brought to the notice of the profession, an instrument much like an ordinary urethra dilator. There is a screw at the end, turning which, separates the split por- tion. If you can get this instrument through the constricted inter- nal os, all is right ; but, like the sound, it is often impossible to pass it through this constricted canal. I like Dr. Atlee's instrument much the best." Displacements of the Uterus. — Any of the displacements of the uterus may be a cause of sterility. In the various flexions of hat organ, the bent condition of the cervix causes a stricture at the 286 HALE ON STERILITY. point of flexion. This stricture may form an obstruction to the entrance of the spermatozoa. (See Atresia, Occlusion.) In versions of the uterus, the os uteri is often placed in such situ- ations that the seminal fluid can not readily enter into the cervical canal. Anteversion. — According to West,* anteversion or anteflexion of the uterus may be a cause of sterility, but not more so than uterine diseases in general. Of thirty-three patients affected with this displacement, thirty were married, of whom three were sterile. The remaining twenty-seven had given birth to seventy-three child- ren, and had had twenty-one miscarriages; or, whose labors amounted to 2.7, their miscarriages to 4.7, to a marriage ; while one in 8.5 of the total number, proved sterile. " When ante-flexion is so considerable as to nearly obliterate the uterine cavity at the point of flexion, conception is rendered very improbable ; but still it may take place, if no structural occlusion or atresia has recurred at the above-mentioned point, for there may be space enough left to allow passage to the spermatic fluid, and unless the uterus be held by false membranes, the flexion may be lessened in a horizontal position of the pelvis, during coition, by the weight of the fundus, and thus the occlusion of the cavity be diminished, and the impregnating fluid be allowed to pass. Consid- ering, therefore, the frequency of sterility in females affected with anteflexion (Moyer found 60 ante-flexions in 272 sterile females), other circumstances should be taken into consideration, especially derangements of menstruation in the form of dysmenorrhoea or amenorrhoea ; perhaps, also, the altered position of the vaginal por- tion (the os uteri looking backward,) as well as a certain amount of cervical catarrh." (Klob.) Treatment.— The surgical treatment of anteversion is not attended with much success. The use of pessaries generally accomplishes but little in this displacement; but, in exceptional cases, they are of benefit, and should be tried. They act, not by rectifying the displacement, but by simply lifting up the uterus, and diminishing pressure on the bladder. Anteflexion is more apt to cause sterility than version. If we have in view only the cure of the sterility, I know of no better means than Sims' operation, described by Thomas,f * Diseases of Women, p. 168. t Diseases of Women, p. 829. HALE ON STERILITY. 287 which consists in cutting through the posterior wall of the cervix, thus converting a crooked into a straight canal, and affording a pas- sage-way for the seminal fluid. If this is objected to, the use of the intra-uterine pessary of Peaslee, Simpson, or Detschy, may be tried. If these can be tolerated, the canal may be straightened. Retroflexion and version of the uterus, may cause sterility. But this displacement rarely occurs in women who have not borne child- ren, and the sterility may be preceded by fruitfulness. According to Klob, a retroflexed uterus may frequently conceive. Still, Meyer records 36 cases of retroflexion in 272 of sterility. Retroversion and Retroflexion.— " Retroversion," says Dr. Simpson, " is a cause of sterility ; as shown by impregnation taking place after the displacement is rectified." With reference to the influence of retroversion or flexion on fecundity, West says : " Of twenty-three affected with this dis- placement, four gave birth to live children after the womb had been misplaced, one had five children in spite of a retroversion of fifteen years. In one of the above four, pregnancy was preceded by the replacement of the organ ; but in the other two, not only was the womb misplaced at the time of conception, but was ascertained to continue so after delivery. Four, having given birth to living children, miscarried after the development of symptoms of uterine displacement ; and in one of the number, miscarriage had twice occurred ; while fourteen, having previously given birth to one or more living children, had passed more than a year since the com- mencement of the symptoms, without conceiving. In three of this number, however, though still within the child-bearing age, concep- tion had not taken place for two years, in one instance, and for four years in the other two, previous to the commencement of the symptoms of misplacement of the womb." My own observation goes to show that retroversion and flexion is oftener a cause of miscarriage, than sterility. I have several patients in whom the uterus is permanently retroflexed, the struc- tural changes are such that no permanent straightening of that organ can be effected, yet conception occurs readily ; but, in spite of all the precautions used to keep the womb from retroverting, miscarriage usually occurs between the second and third month. Treatment.__The medicinal and surgical treatment of retrover- sion and retroflexion, has already been treated of, on page 214. 288 HALE ON STERILITY. Two years have now elapsed since that was written. During that time, I have had considerable additional experience in the treatment of this form of displacement; and the result is, that the mechan- ical treatment of retroflexion, when we wish to cure sterility from that cause, should consist in a. The straightening of the uterus at its point of curvature, by means of the stem-pessary, allowing it to remain in the canal of the cervix only a few hours a day ; or, b. The use of the elastic, soft-rubber, Meigs' ring-pessary ; Scat- tergood's pessary; or the lever-pessary of Hodge. It will often occur that a sterility will be cured by the pessary alone, if it is worn during coition. I observed this fact many years ago, before Sims' work was published. I have treated several ladies for retroversion, who objected to the use of the pessary, for the rea- son that "if it was worn, pregnancy would result;" and several have preferred to endure the pain and trouble of a retroflexion, than to use a pessary, for this same reason. Sims relates two cases of obstinate retroversion, with sterility, in which no sort of pessary could be worn, except cotton ; without the cotton pessary, the uterus in each was turned back to an angle of more than 100° from a normal line ; but with this pushed snugly up into the cul-de-sac, the organ was comfortably sustained in posi- tion. Each of these patients conceived during the time of using this instrument. They were taught to apply the cotton pessary, (a wad of cotton-wool, of the proper size, tied in the middle with a strong thread, 8 or 10 inches long,) on rising in the morning, and to remove it on going to bed at night.* Lateroflexion and -version of the uterus, may cause sterility, in the same manner as the before-mentioned displacements. Inclination of the uterus to one or the other side, never attains a high degree ; the fundus is inclined either to the right or left, whilst the vaginal portion takes the opposite direction. Lateroversion is often combined with obliquity of the uterus. This displacement may be congenital or acquired. The latter form may be the result of metritis. I have observed that it occurs, sometimes, after labor or a miscarriage, when the woman persisted*in lying all the time on one side. It may be caused by tumors in the body of. the uterus, ovarian tumors, or disease of the round ligaments. Treatment. — The medicines must be selected by the character- * Uterine Surgery, p. 286. HALE ON STERILITY. 289 istic symptoms of the case. Mechanical treatment by pessaries is of doubtful utility. I think I benefitted one case, and partially removed the flexion, by placing between the cervix and the vaginal wall, an air-filled rubber disc-pessary, of about 2 inches diameter. The fundus was first pushed up as far as possible. The patient was directed to lie altogether on the side opposite to that occupied by the fundus uteri. Prolapsus Uteri.— Unless the prolapsus is attended by other mor- bid alterations in the uterine tissues, and is so complete as to con- stitute procidentia, it does not become a cause of sterility. A partial prolapsus may, indeed, favor impregnation, by allowing the sperma- tozoa a more ready entrance. Whenever the cervix uteri passes through the mouth of the vagina, we call it a procidentia, whether it be to a slight or a great extent. A procidentia may be complete or incomplete; complete, when the vagina is inverted and protruded externally; incomplete, when the cervix uteri alone projecting between the labia for an inch or two, and remaining thus stationary for a long time ; usually, it goes from bad to worse, till it eventually passes entirely through the vulva, forming a tumor of great size, which, at its most depend- ing part, presents the os tincse often ulcerated and bleeding. Some- times the whole body of the uterus protrudes from the vagina; at others, the cervix, greatly hypertrophied and elongated, is the pro- truding portion. For description of prolapsus, and the medicinal and mechanical treatment, see pages 84, 213, and 256. In procidentia, it is evident that no medicinal means are of any value, unless the uterus can be replaced by pressure, and kept in position "by simple mechanical appliances. In complete procidentia, surgical treatment should be resorted to. If the cervix is enlarged and elongated, the operation of amputation is quite successful. Dr. A. K. Gardner reports several cases, in one of which the amputated cervix weighed § ix., 3 ij., $ ; " the largest on record as having been removed during life." He says: " The organ drew up far into the vagina, after the portion was removed." * Dr. Sims savs : f "I amputate the cervix only when its lower * " Amputation of the Cervix Uteri." t Uterine Surgery, page 294. 290 HALE ON STERILITY. segment is too large and too long, and projects so far into the vagina as to present a mechanical obstacle to the retention of the uterus in situ when replaced." This operation may cure a sterility, by allowing a fruitful coition, which is next to impossible when the cervix is hypertrophied, elon- gated, and protruding. The so-called prolapsus uteri without sinking of the fundus, to which Virchow has called attention, may act as a cause of sterility. In this variety, there is complete inversion of the vagina,,with the external orifice of the uterus situated at its extreme end. The enormous elongation of the uterus, affects chiefly the cervix; the substance of which becomes dense and vascular. In this condition of hypertrophy and elongation of the cervix, the uterine cavity is sometimes narrowed, or atresia of the internal'orifice may be found. The indications for treatment, aside from the elevation of the uterus by mechanical supports, are to dilate the internal orifice, by bougies or an operation, after which conception will readily occur, if no other obstacle is pVesent. Dr. Sims' operation for the cure of complete procidentia uteri, consists in removing a portion of the anterior wall of the vagina, bringing the edges together, and fastening them by metallic sutures. This simple operation seems to prevent the return of the uterus to its abnormal position. For a complete history of this successful oper- ation, see(Sims' Uterine Surgery. It seems evident that this oper- ation is vastly superior to the perineal operation, as performed by Mr. Baker Brown, Dr. Savage, and others. In cases where this, or any operation, is objected to, we may do something to alleviate the condition of the patient, and perhaps bring the uterus into such a position as to be capable of being impregnated. Dr. Sims says that in such cases no pessary, except Zwang's, is of the slightest value; while the best support is simply a small tampon of cotton, wet with glycerine, which may be intro- duced in the morning, to be worn all day. It must be remembered that impregnation will occur whenever the seminal fluid is brought in contact with the cavity of the uterus, if the connection between that organ and the ovaries is not dis- turbed. If the uterus is so far protruding that the ovule can not pass from the ovary into its cavity, conception can not take place, even if the semen is thrown into its cavity. HALE ON STERILITY. 291 Elevation of the Uterus. — This displacement, together with its attending organic changes, may cause sterility. By elevation of the uterus, is meant a displacement of the entire organ upward. The fundus ascends into the peritoneal cavity, both peritoneal cavities thereby becoming shallow, and the fornix of the vagina being so stretched as to cause it to become cone-shaped. At the same time, the vaginal portion disappears more or less, leaving merely a button-shaped rudiment. (Rokitansky.) The causes of elevation of the uterus lie either within or are external to the organ itself. The causes that originate in the organ itself are : an increase in volume of body and fundus, unless the latter has been previously bound down by adhesions in the pelvic cavity, in consequence of which, ascent of the uterus would be hin- dered ; distension of the uterine cavity by mucus or blood ; forma- tion of fibrous tumors, etc. To the class of external causes, belong tumors of the broad liga- ments or ovaries, adhesions formed during pregnancy or the puerperal state, previous to complete involution; also, vascular tumors of the vagina, tumors of the pelvis, etc. Slight degrees of elevation are found combined with flexions, and always with anteflexions. The effect of elevation of the uterus, especially when produced by other causes than tumors pressing from below, is elongation of the organ, chiefly of the cervix, to sometimes twice or thrice its normal length; this elongation being generally accompanied with diminu- tion of its cavity, and thinning of its walls. The diminution of the uterine cavity by longitudinal traction, is always more considerable near the internal orifice. Even complete occlusion of the canal may take place. In isolated cases, an obliteration of the canal at the above point occurs in consequence of rupture of so-called Nabo- thean glands, from the ruptured walls of which, connective tissue is produced, which ultimately leads to complete atresia of the canal by agglutination. (Klob.) Mere elevation of the uterus will not cause sterility, for the spermatozoa find no obstacle in distance, if the mucous membrane is healthy, and the cervical canal open. But if occlusion or atresia occur with the elevation, sterility surely results. Treatment.__The removal of the causes of the elevation, by medicinal or surgical means, constitute the indications for treatment. If occlusion or atresia is present, the canal should be opened by the 292 HALE ON STERILITY. operation recommended and practiced by Sims. After this is done, conception will occur as readily as if the uterus was low in the pelvis. If large tumors of the pelvis or uterus caused the eleva- tion, their removal by medicinal and surgical treatment should be attempted. If this is impossible, and the tumors are so large as to offer a probable impediment to child-birth, it is proper to advise the avoidance of pregnancy, or the operation referred to, unless a reten- tion of the menses, or a dysmenorrhoea, render it necessary. Inversion of the Uterus. — This dangerous and infrequent form of displacement consists in the turning of the uterus inside out. As the bottom of a bag may be pushed through its mouth, so that the inner surface becomes the outer : so may that of the uterus. Inversion may be partial and complete : — partial, when the body has become depressed, but has not passed through the os ; complete, when the uterus has been completely turned inside out, and the inverted fundus and body hang in the vagina or between the thighs. Inversion of the uterus generally occurs shortly after labor, when the uterine tissues are relaxed. At such a time, undue traction on the cord, to expedite the birth of the placenta, coughing, sneezing, change of posture, straining at stool, etc., may cause the accident. It is possible that inversion may occur at other times ; and there is evidence on record, that a non-pregnant and undilated uterus may become inverted. * As this displacement may become chronic, it should be placed among the causes of sterility; although Gardner does not mention it. Chronic inversion may continue for many years, giving very little annoyance ; or it may render the life of the patient miserable, on account of haemorrhage and other attending symptoms, and nev- ertheless last for years. Diagnosis. — Inversion may be mistaken for a polypus, or a fibroid tumor. For accurate differentization of this displacement, from tumors, reference is made to Sims, Thomas, Guernsey, Lee, and other authorities. Treatment. — There are three plans of treatment: 1. To return the uterus to its place. 2. To leave it displaced, and adopt means preventive of haemor- rhage. 3. To remove it by amputation. * See Thomas' Diseases of Women, p. 839. HALE ON STERILITY. 293 For the cure of sterility depending on this displacement, the first plan is the only one to be adopted. In chronic cases, the second and third plans were considered the only means possible; but it has been demonstrated by Dr. Tyler Smith, of London, and Dr. White, of Buffalo, that even after the continuance of inversion for 10 or 15 years, reduction is possible. Since these successful attempts, the operation has been performed by Sims, Thomas, and many other obstetric surgeons. The diagnosis having been clearly made, and reduction determined upon, the bowels and bladder should be emptied, and the patient put under the influence of an anaesthetic, and laid on her back upon a strong table. The operator should always be attended by three or four reliable counselors, upon whom he may call, not only for advice, but physical aid. Having thoroughly oiled one hand, the nails of which have been pared, he should now slowly dilate the vagina so as to introduce it, and grasp in its palm the entire tumor. The other hand should be laid upon the abdomen, so as to press just over the ring which marks the non-inverted cervix, and oppose the force exerted through the vagina, so as to prevent too great stretching of this canal. In some cases, a conical boxwood plug has been used.* For other methods of reducing obstinate inver- sions, consult the authorities above named. After the reduction is effected, the patient should remain in bed, with the hins elevated, for a week or more, and the remedies indi- cated by the symptoms should be administered. (Consult — Aletris, belladonna, caulophyllin, cimicifugin, conium, fer- rum, helonine, ignatia, mercurius, nux vom., podophyllin, and sepia.) Tumors of the Uterus. — Sterility may be caused by any of the varieties of abnormal growths known as tumors of the uterus. The most common are: the Polypi, and those denominated Fibrous. They prevent conception, either by blocking up the canal of the cervix, the cavity of the uterus, or the orifices of the Fallopian tubes. Polypi.— Dr. Sims f describes the location and character of these polypi, as follows : 1st. Those growing from or about the os tincse. 2nd. Those growing in the canal of the cervix. 3rd. Those grow- ing in the cavity of the uterus. The first may be fibro-cellular or mucous. The second are almost always mucous*. The third are almost always fibrous. Fibrous. — The uterus is particularly prone to the development of fibroid tumors. They frequently prevent conception, even when located in the parenchyma of the womb ; but not necessarily so. Thevare classed, according to the manner of their attachment to the walls of the uterus, as extra-uterine, intra-uterine, and intramural. Extra-uterine fibroids grow from any portion of the external sur- face of the uterus, and may be pedunculated, or they may be ses- sile with a broad immovable attachment to its outer muscular tissue. The intra-uterine project into the cavity of the womb, and, like the first, may be pedunculated or sessile. * See Thomas' Diseases of Women, page 845. t Uterine Surgery, p. 6T. 3 294: HALE ON STERILITY. The intra-mural are so called because they are imbedded in the walls of the uterus, being interlaced and overlapped in all directions by its muscular fibre. By reference to the statistics, it will be seen that fibroid tumors of the uterus were the cause of sterility in 95 out of 505 cases. Treatment.— The surgical treatment of all these tumors, may be summed up as follows : a. Excision, b. Torsion, c. Ligature. d. Ecrasement. e. Pressure by the sponge tent. Small polypi may be excised by the knife or scissors, if the pedi- cle can be reached ; but large growths are apt to bleed profusely, and even dangerously, after the operation. Dr. Sims, however, regards the haemorrhage as easily managed bv the use of the per-chloride or persulphate of iron. " Small, and even large tumors, may be twisted off with the for- ceps, and the danger from bleeding is less than when excision has been resorted to. (In a case occuring in my own practice, a small mucous polypi attached to the canal of the cervix, near the os externum, was removed by one application of the solid nitrate to the pedicle.)* The ligature, once so popular, is now rarely employed. Ecrase- ment constitutes the safest and most expeditious of-all the operations. Dr. Simpson has used the sponge-tent, with singular success, in the treatment of polypi. For minute directions for operating on polypi, refer to " Sims' Uterine Surgery," " Thomas on Diseases of Women," " I. Baker Brown on Surgical Diseases of Women," and " Franklin's Surgery." No homoeopathic physician should neglect to place these valuable surgical works in his library, for cases may arise where his reputa- tion, and that of our school in the locality of his practice, may dependon his successful surgical treatment of cases of uterine tumors. The medicinal treatment of polypi is not mentioned in allopathic works, because no medicines are believed by them to exert any curative action on such tumors. " The cure of polypus by medicinal agency," says Leadam.f !i can not be accomplished by the old school of medicine, * * * but homoeopathy has rendered results which prove the curative power of its remedies." " Staphisagria and calcarea are those which have been recommended, principally, to remove the state or dyscra- sia upon which the formation of polypi depends." The remedies which are pointed out by Jahr.J are too numerous to be quoted. Guernsey § gives the characteristic indications, in his peculiar man- ner, for the following medicines : Aurum, calc. carb., conium, lye, mercurius, mezereum, nitric acid, petroleum, phosphorus, phosphoric acid, platina, pulsatilla, silicea, staphisagra, teucrium, and thuja. These remedies are also recommended for all varieties of tumors ; but as the indications are theoretical, no clinical cases having veri- * See United States Medical and Surgical Journal, Vol. II., p. 235. t Diseases of Women, page 274. J Diseases of Women, page 224. § Obstetrics, page 99. HALE ON STERILITY. 29o fied them, we may consider their value in polypi or fibroid tumors as quite problematical. The surgical treatment of fibroid tumors is thus summed up by Thomas,§ who seems to have consulted almost every surgical work: a. Absorption, b. Excision, c. Ecrasement. d. Ennucleation. e. Sloughing, f. Gastrotomy. Thomas doubts if their absorption can be excited by any medicine. (Allopathic.) Scanzoni says he does not know of a single case where medicines caused a complete cure. Sims believes that pressure by means of sponge-tent or sea- tangle may cause absorption. The treatment of excision or the ecraseur is fully described by the last-named author. Ennucleation has been successfully practiced by Armussat, Atlee, West, Barber, and others. We do not know whether the English homoeopathic surgeons, Pattison and Marsden, have tried ennucleation on fibroid tumors of the uterus. Sloughing, once recommended by J. Baker Brown, has been abandoned. Gastrotomy, or removal of the tumors, and with them the uterus, is a rare and dangerous operation. Ac- cording to Dr. H. R. Storer, who has written of the history of such operations, there have been 24 operations, with 18 deaths. The medicinal treatment of fibroids is not very satisfactory. In allo- pathic practice, Dr. Channing, of Boston, claims to have cured many by internal medication. Dr. Simpson seems to have great faith in tlie long-continued use of bromide of potassium. Dr. Sims says he has never seen the slightest effect produced on such tumors by internal medication. In homoeopathic practice, no clinical expe- rience has yet been published showing the effects of our remedies in this disease. Guernsey recommends the same medicines as for polypi. I have a case of intra-mural fibroid tumor, which appears to have slightly diminished in size under the use of iodide of arsenic, 3rd, continued for two months. I would suggest the protracted use of hydrastis in cases of fibroid. Inflammation of the Uterus. — Acute and chronic inflammation of the uterus usually result in sterility; not only by the changes pro- duced in the density of the tissues affected, but in the changes effected in the secretions from the diseased surfaces. The varieties of inflammation maybe thus enumerated: 1. Endo- metritis (inflammation of the lining membrane of the uterus). 2, Endo-cervitis (inflammation of the lining membrane of the cervix.) Endo-metritis has been described under the names of uterine catarrh, uterine leucorrhoea, and internal metritis. Its location extends from the inner os, to all portions of the uterine cavity, or fundus. (A variety has been described by Dr. Ilouth, as fundal endo-metritis. In this variety, the inflammation is located in the fundus, occupying only a small spot.) _ As I have not mentioned endo-metritis as a cause of miscarriage, and as it is a frequent cause of sterility, it will be well to devote a space to its consideration. Its chief symptoms are : (a) Leucorrhoea. (b) Men- strual disorders, (c) Pain in back, groins, and hypogastrium. (d) Ner- vous disorders, (e) Tympanitis. (/) Symptoms of pregnancy. (g) Sterility, g Diseases of Women, p. 407. 296 HALE ON STERILITY. Treatment. — Xo mention is specially made of endo-metritis by Marcy and Hunt, Leadam, Gollmann, or Minton. Jahr* treats of it in his own peculiar manner, and Guernsey f gives the only exhaustive description we have in any work in our school. Jahr's remedies are: Alumina, calcarea, kreosotum, mercurius, pulsatilla, sepia, etc.; for which he gives the symptomatic indications. Guernsey gives the characteristic, or key symptoms, of seventy- two remedies; among which, arsenicum, bovista, calcarea, conium, graphites, lachesis, kali bi., kali hyd., mercurius, muriatic acid, nitric acid, platina, podophyllum, pulsatilla, sabina, sepia, sulphur, and zinc, are the most useful, and especially adapted to the chronic form of the disease. In addition to the above medicines, I have found cimicifuga, gel- seminum, hamamelis, helonias, hydrastis, myrica, phytolacca, senecio, tril- lium, and xanthoxylum, useful in some cases. Cimicifuga is especially indicated for the nervous symptoms above mentioned, also the pains in back, loins, etc., are present. Gelseminum is superior to all others, in the acute or sub-acute stao-p. Hamamelis, when the discharge is " rusty," or the menses con- tinue nearly through the month ; (also trillium, erigeron, and senecio.) Helonias for chronic albuminous leucorrhoea (uterine), with great debility. Myrica, when the discharges are offensive, bloody, and corrosive. Phytolacca for nearly the same symptoms, especially if there is syphilis present. Hydrastis, if the discharge is ropy, thick, yellow and tenacious, with great debility. There are many points of resemblance between these and the older remedies, which may be studied to advantage. I believe I have cured cases of sterility from endo-metritis, by means of the persevering use of calcarea, conium, mercurius, nitric acid, sabina, and sepia ; also cimicifuga, helonias, phytolacca, and hydrastis. Some of these remedies, I have used topically, by injecting a solution into the cavity of the womb. One case in particular is worthy of mention : A lady who had borne one child, had been sterile seven years. She had the most profuse, thick, tenacious leucorrhoea, I have ever known. The vagina was also affected with chronic inflammation, and the os abraded. The two latter were cured, the former by injections of hydrastis, the latter by a few applications of nitrate of silver. The uterine discharge, however, still continued ; a thick rope of mucus constantly hung from the os. With a small slender-tubed syringe, I injected, once a week, 3 ii. of a solution of muriate of hydrastia\ into the cavity of the uterus. After six injections, she became pregnant, and went her full time. The remarks of Sims on the surgical treatment of this disease, are so important that I quote them : " The first great principle to guide us, is that of insuring a very free exit from the cavity of the uterus, for the secretions therein generated. The second is that of appropriate local applications to this cavity, for the purpose of mod- * Diseases of Women. t Obstetrics, page 128. % R Muriate of Hydrastia, 3 v. Glycerine, \ ss. Water, | ij. HALE ON STERILITY. 297 ifying or healing, as it were, the diseased surfaces. When the canal of the cervix is contracted, I have freely divided it, as in cases of dysmenorrhoea dependent upon mechanical obstruction ; and this with great relief. The uterine secretions must not remain pent up in its cavity. With a patulous cervix, we may use medi- cated injections, etc." Dr. Sims has met with several cases of fundal endo-metritis, and thus gives its diagnosis : " Place the patient in the left lateral semi-prone position ; introduce the lens speculum ; hook a tenacu- lum slightly into the anterior lip of the the os tincae ; draw this gently forwards, pulling the os open, so as to be able to look right into it ; then pass the sound, previously warmed, gently along the cervix, using no force whatever, but almost letting it go by its own gravity, as it were, to the fundus. This is attended by no pain whatever, till the sensitive point be reached, when it produces the most intense agony — a pain that does not cease, sometimes, for hours after the experiment." In this disease, there is little or no discharge, but generally pain in one or the other hip, generally the left, inguinal region, groin, ovary, and even mammary region. Dr. Sims relates one very severe case, which he cured in a few weeks, by dilating the cervix, and simply injecting into the cavity of the uterus a few drops of glycerine, twice or three times a week. In the course of a year, this patient became a mother, and has had three children since." In another similar case, he says: "A single sponge-tent, followed by the injection of half a drachm of the officinal tincture of iodine, produced almost complete relief at once. A repetition of the same, ten or twelve days afterwards, produced a perfect cure." Endo-cervicitis is known to us by the synonyms of cervical catarrh and cervical leucorrhoea. It is a chronic inflammation of the mucous membrane, extending from the os internum, through the os inter- num, and over the vaginal portion of the cervix uteri. [For description and symptoms, see page 64, " Cervical Leucor- rhoea."] Sims gives the following reasons why cervical leucorrhoea is a cause of sterility : " It is almost always of albuminous consistence, and very difficult of removal. Under the microscope, it presents all the characteris- tics of muco-pus. Sometimes it is merely an exaggerated secretion, without any abnormal qualities. It interferes with conception in two ways: mechanically and chemically; — mechanically, by blocking up the canal of the cervix, and preventing the passage of the spermatozoa; chemi- cally, by poisoning or killing_ them. I have frequently seen conception happen while using the nitrate of silver for granular erosion of the os and cervix uteri. Unless there is some special reason for it, I never interdict sexual congress during the treatment of ordinary cases of cervical engorgement. When conception has taken place under these circumstances, I am satisfied that sexual intercourse must have occurred within ten or twelve hours after the use of the rem. 298 HALE ON STERILITY. edv, or at least before its eschar began to separate, which is always attended with a secretion of muco-pus, that would be fatal to the spermatozoa." " If I were asked what, next to mere mechanical obstruction of the cervix uteri, constitutes the greatest obstacle to conception, I have no hesitation in saying that it was an abnormal secretion from the cervix. We often see the cervical mucus in such large quanti- ties that its mere abundance will mechanically prevent the passage of the semen to the cavity of the uterus. Sir Joseph Oliffe has informed me of the case of the wife of a medical man, who had been sterile for many years, and whose cervix uteri had always presented a little mass of ropy mucus hanging from the os, that obstructed mechanically the canal. At last the doctor had the rational surgi- cal idea to exhaust the cervix of its inspissated mucus; and sexual congress with his wife, immediately afterwards, was followed by conception. " I am now satisfied that the cervical secretion is often poisonous to the spermatozoa, even when it would seem to be almost normal in appearance. This must depend upon some other quality than mere alkalinity, for I have often found all the spermatozoa in the cervical mucus dead, while it manifested no unusual degree of alka- linity when tested by litmus paper ; but when placed under the microscope, it showed an uncommon number of epithelial scales. This demonstrated an abnormal action in the glandular apparatus, that gave rise to this secretion, which seemed to kill the spermato- zoa more by its density than by its chemical action ; for I have noticed that they lived longer in that portion of the mucus that had the fewest number of epithelial scales, and, vice versa, died quicker in that portion that had the most — and that, too, when litmus paper showed no difference in the chemical character of the two." Professor Meigs, of Philadelphia, adds his testimony to the effect of cervical leucorrhoea in preventing conception. That author observes * that some cases of sterility are caused by a plug of viscid lymph filling the canal of the cervix, so obstructing the passage as to render it apparently impossible that any spermatozoa could obtain access to the uterine cavity. "Certain it is," he says, " that some sterile women are always effected with this excessive albuminous mucous production. Surprise has often been expressed on observing that married women, after years of sterile cohabitation, have suddenly become fruitful. In these instances, the want of fruitfulness could not depend on failure of the ovulations. May it not be that that the spontaneous cure of a protracted and sub-acute inflammation, of the kind herein treated of, may have restored the health, and so given power to take away the woman's reproach?" Treatment.— (See pages 192-3-4-5.) Guernsey gives the characteristic indications for seventy-two reme- dies — the same as recommended in uterine catarrh. I have found most useful the medicines which were mentioned in endo-metritis. I have also used topical applications of some of the * On Diseases of the Uterus, page 56. HALE ON STERILITY. 299 remedies to the canal of the cervix, or placed them in apposition to the os uteri, and with the effect of hastening the curative process. I adopted this plan several years ago, and I am every year better sat- isfied with the plan. It has been thought, and is still believed, by many of our school, that topical applications to the cervix, by means of injections, could be productive of but little benefit. But no one who has tested them thoroughly, can doubt their efficacy. Remedies thus applied, act by osmosis, and produce not only a local but in some cases a constitutional effect. Dr. W. H. Holcombe, one of the most logical thinkers of our school, believes in this method of applying properly-chosen remedies.* If sabina, conium, hydrastis, senecio. or any other remedy, is indica- ted by the symptoms, the nature of the discharge, and the patho- logical state, give the remedy internally by the mouth, and apply the same to the os uteri, or even the whole length of the cervical canal. 1 have had patients who could distinctly taste hydrastis, iodine, and other medicines, when thus applied to the cervix. Dr. Sims says his patients complain of the taste of tannin, a few minutes after its application to the cervix uteri. I usually adopt three methods of topical application : (a) Injec- tion (vaginal), adding one drachm of the mother tincture, or a few grains of the medicine selected, to a pint or less of warm water — never cold,f and order a portion to be thrown slowly into the vagina, twice or thrice a day. (o) Tampon.— Add to one ounce of Price's glycerine, a few drops of the medicine selected ; with this, saturate a pledget of cotton — not too wet ; place it in contact with the os uteri in the morning, and allow it to remain till night. The patient can be instructed to place it herself, (c) Injection (cervical).— Use a syringe holding not over half an ounce, with a long delicate tube, having orifices at its sides —none on the end ; introduce this into the cervical canal, half an inch, or an inch in some cases, and slowly inject a weak solution of the remedy indicated. The nozzle should be small enough to permit the fluid to regurgitate back into the vagina, so that it will not enter the cavity of the fundus. I have had the best results follow the use of muriate of hydrastia, five grains to four ounces of water, or equal parts of water and glycerine. Not over one drachm should be injected at once, and repeated not oftener than once a day. I have never tried medicated suppositories, after the plan of Simpson and Sims. These are made of cocoa butter, an inch and a quarter long, and small enough to pass along the cervix, and med- icated with various remedies, so as to bring these into permanent contact with the diseased surface. I imagine that suppositories medicated with conium, hydrastis, iodine, platinum, or other remedies, would act very favorably in cervical induration or hypertrophy. * " Nature and Limitations of the Homoeopathic Law." t Sims asserts that great harm is often caused by cold vaginal washes — that they often cause an indurated condition of the uterus — and also much pain, and even spasms. 300 HALE ON STERILITY. Dr. Sims speaks highly of Dr. Byford's plan of modifying the diseased secretins: surface by pressure* " A bougie of slippery-elm, large enough to fill the cervical cavity, introduced as high as the inflammation extends, and allowed to remain for twenty-four or thirty-six hours, not only prepares the way for other applications. but favorably modifies the disease by its pressure upon the capilla- ries." Sims says the stem-pessary has the same effect. He has known many cases of conception follow the use of the intra-uterine stem ; and he thinks its curative action was more in relieving the condition, by pressure, than mechanically dilating the os internum. Ulceration.—Although ulceration of the os and cervix uteri is generally considered one of the causes of sterility, it is not by any means invariably so. Whitehead, Gardner and Sims enumerate ulceration as a cause of sterility, but admit that it is oftener a cause of miscarriage. Nevertheless, women do frequently conceive, and go through the full period of pregnancy, with the os and cervix more or less the seat of one of the varieties of ulceration. It is only when the engorgement, poisonous discharge, and occlusion of the os, which sometimes attends ulceration, prevents the spermatozoa from pass- ing into the uterine cavity, that sterility results from this condition. According to Doune\ the spermatozoa live in pus and blood. Sims says he " has frequently seen conception to happen when the cervix uteri was the seat of profuse suppuration, so that pus, per se, was no hindrance to this." [For description of the varieties of ulceration, see page 71 ; for treatment, see page 198. Since the first edition of this work, I have somewhat modified my treatment of ulceration, and have attained better results than heretofore. I now reject the teachings of some authorities, that it is improper to treat ulceration by local applications during pregnancy. I am satisfied that it is not only justifiable, but absolutely necessary, in order to prevent mis- carriage. I refer the reader to a typical case and its treatment, in a paper communicated by me to the Transactions of the New York State Homoeopathic Medical Society for 1866.] My present treatment of ulceration may be summed up as follows : (a) I rarely use the solution of nitrate of silver, but prefer, in nearly every case, to touch the erasion, abrasion or ulcer with the solid nitrate. The application should consist of light, quick, delicate touches of the blunt rounded stick. Never use the pointed stick, and never allow it to remain in contact with the surface more than a second. Before the nitrate, or any other drug is applied, the surface should be wiped dry of all secretions adherent to it. (b) Instead of lint as a dressing to the ulcerated surface, cotton, saturated with Price's glycerine, medicated with the remedy indi- cated by the condition. To prepare a dressing to apply to the ulcerated surface, which has or has not been touched by the nitrate, * " Diseases and Accidents Incident to Women." HALE ON STERILITY. 301 take some fine cotton, as much as can be easily held in the hollow of the hand, immerse it in tepid water, and squeeze it gently under the water till it becomes perfectly wet; then press all the water out of it, and saturate it with pure glycerine, or a medicated glycerole. To do this, lay the moistened cotton in the palm of the hand, spread it out circularly for an inch and a half in diameter, more or less, as may be needed, scooping it out in the centre ; then drop half a teaspoonful of glycerine on it, thus held, and rub it into the cotton with the point of the finger, then pour a little more glycerine and rub it in, and so on until the cotton becomes satu- rated. When finished, the cotton should feel soft and pulpy, should be about an inch and a half in diameter, and about half an inch thick. This dressing should be applied immediately after the application of the nitrate, and before the speculum is removed. When I use medicated glycerine, it is usually of the proportion of one drachm of the mother tincture to one ounce of glycerine. For dressing after the nitrate, the calendula glycerole is best; hamamelis glycerole when there is a varicose condition of the cervix, with bleeding. Carbolic acid, (20 drops to 1 § ,) when the ulcer is phagedenic, and tlie discharge sanious and foetid. Hydrastis when the ulcer or erosion discharges profusely a thick purulent matter. Muriate of hydrastia, (3 grs. to § ,) is useful in nearly all cases of chronic abrasion or superficial erosion and ulceration. Kali bichromicun, (1 gr. to § ,) in deep-seated ulcerations, with a red margin and fungous appearance. Many others coufd be named, but the physician must select the medicine carefully, as it is indicated by the condition and symptoms. (c) When the solid nitrate is used, it should not be applied oftener than every five days. The medicated dressings should be used once a day. The patient can be instructed to apply them in the morning, and remove them at night on going to bed. When these dressings are used, no injections are needed for cleanliness; for, as remarked by Dr. Sims, the glycerine " seems to set up a capillary drawage by osmosis, producing a copious watery discharge, depleting the tissues with which it lies in contact, and giving them a dry, clean and healthy appearance. When such a dressing is applied to a pyogenic surface on the cervix uteri for a few hours, and then removed, the sore will be as clear of pus as if it were just washed and wiped dry." Dr. Sims gives a cut illustrating an instrument, the " porta-tampon," which he says any woman can use with ease.* Leucorrhoea. — Leucorrhoea in general can not be considered as a cause of sterility. Such a generalization is not in accordance with the spirit and scope of modern science as developed in physiology and pathology. Leucorrhoea may be said to consist of three varieties : . 1. A discharge from the cavity of the fundus uteri. (Utorrhoea, or endo-metritis.) * Uterine Surgery, p. 295. 302 HALE ON STERILITY. 2. A discharge from the canal of the cervix. (Endo-cervicitis.) 3. A discharge from the mucous membrane of the vagina. (Vagi- nitis.) The first variety has been considered in another place ; namely, in the preceding paragraph, relating to endo-metritis. The second variety has been treated of above, under the head of Endo-cervicitis; also, pages 61 and 194. The third variety will be considered under the head of Vaginal Causes of Sterility. See also pages 67 and 194. Dysmenorrhoea. — This condition, as a cause of sterility, will be found treated of under the head of " Stricture, or Occlusion of the Cer- vix" "Uterine Displacements," " Uterine Tumors," and " Inflam- mations of the Uterus." Dysmenorrhoea is divided into six varieties : Of these, two only are constant causes of sterility ; namely, the obstructive, and the mem- braneous. The other four are only exceptionally causes of barren- ness ; namely, the neuralgic, the spasmodic, the congestive, and the inflammatory. Treatment.—Any thing like a thorough consideration of the treatment of the varieties of dysmenorrhoea, would occupy too much space in this volume. A brief enumeration of the most use- ful remedies, will have to suffice : I. For neuralgic dysmenorrhoea, aconite, agaricus, belladonna, cimici- fuga, ferrum, gelseminum, pulsatilla, platinum, senecio, Scutellaria, xanthox- ylin, zinc, etc. II. The congestive requires aloes, aletris, belladonna, cimicifuga, borax, sabina, hamamelis, murex, etc. III. The spasmodic requires caulophyllin, nux vomica, ignatia, secale, cimicifuga, ustilago, etc. IV. The inflammatory—aconite, belladonna, gelseminum, verat., viride, (for acute) ; and a host of remedies, too numerous to mention, (for chronic.) The so-called pseudo-membraneous has been cured with guaiacum, borax, and a few other remedies ; and Guernsey gives the character- istic, or key-symptoms, of ninety medicines, for the cure of all the varieties. Amenorrhoea.— The pathological conditions resulting in amenor- rhoea, may cause sterility ; but not the amenorrhoea itself. " I do not know," says Dr. Sims, " that conception has ever occurred previously to the appearance of the menstrual flow. * * Many women conceive without menstruating, but it is always during menstrual life." There are on record, cases of conception occurring after the change of life has been passed ten or fifteen years. It may may sometimes occur during a temporary amenorrhoea of a few months. If amenorrhoea arises from a failure in the function of ovulation, conception can not occur. [See Atrophy of the Ovaries, and other ovarian disorders.] If it results from phthisis, or serious chronic diseases, sterility is an accompaniment. If from an atonic or torpid condition of the ovaries or uterus, resulting sterility may be cured HALE ON STERILITY. 303 by remedies homoeopathic to the condition ; such as sabina, aletris, phosphorous, helonias, agnus castus, conium, etc. If the retention of the menses result from some mechanical cause, existing in the cervix or vagina, consult the paragraph treating of stricture, occlusion, etc. Menstrual Irregularities. — It sometimes happens that certain irreg- ularities in the quality, quantity, and time of appearance, of the menses, are the only symptoms attending sterility, which we are permitted to know. Cases will now and then occur, when no exam- ination by the touch or speculum will be submitted to, and we are compelled to prescribe for the symptoms as related to us. The chief remedies for menstrual irregularities are: For scanty menses — conium, agnus castus, caladium, aletris, cocculus, secale, sabina, graphites, natrum mur., senecio, and sepia. For profuse menses — sabina, erigeron, ipecac, crocus, platinum, senecio, ruta, secale. (See the indications for the hundred or more remedies, in Guernsey's " Diseases of Women.) Too-frequent and profuse menses are generally controlled by calcarea, senecio, platinum, crocus, sabina, and xanthoxylum. For delaying menses—pulsatilla, senecio, aletris, natrum mur., graphites, helonias, cimicifuga, etc. Nearly all these irregularities depend on some pathological condi- dition of the generative organs. It will be necessary, then, when possible, to ascertain the nature of the causes, and consult the treat- ment of the conditions, in the preceding pages. V. Vaginal. Atresia -vagina;. — " This, of course, forms an obstacle to the reten- tion of the seminal fluid. It may be congenital or accidental — more frequently the latter ; and oftener the result of a tedious labor, fol- lowed by sloughing." (Sims.) The vagina may be imperforate at the vulva, or m the course ot the canal. The closure may be complete or partial ; the former resulting in complete retention of the menses, the latter causing a painful scanty flow, mistaken sometimes for dysmenorrhoea _ The following causes may be enumerated as productive of it: Arrest of development ; Prolonged and difficult labor ; Chemical agents locally applied ; Mechanical injuries; Sloughing from im- paired vitality ; Syphilitic or other extensive ulcerations. _ Congenital atresia, or arrest of development of. the vagina, in the foetus is a rare anomaly. Aristotle, Celsus, Heister and Ammusat, speak of congenital atresia. Sims says he has seen but one case which mi-ht be called congenital. Drs. Helmuth, Beebe, Franklin, and Comstock, inform me they have met with cases I have met with two cases, occurring in infants ; one in a child two years of a duced, or by an attempt to effect the same, it is murder. * Revised Statutes of Wisconsin, 1858, chap. 169, sect. 58. It will be noticed that the second section of the above statute differs from the first in requiring the proof of pregnancy. t Code of Alabama, 1852, sect. 3230, p. 582 X ffvised Statutes of Louisiana, 1856, p; 138. By its wording, this statute might be forced into the next division. JURISPRUDENCE OF ABORTION. 331 "If any person shall, during the parturition of the mother, destroy the vitality or life of a child, which child would otherwise have been born alive, he shall be punished by confinement in the penitentiary for life, or any period not less than five years, at the discretion of the jury.* "Nothing contained in this chapter shall be deemed to apply to the case of an abortion procured, or attempted to be procured, by medical advice for the purpose of saving the life of the mother."f Indiana.—" Every person who shall willfully administer to any pregnant woman, or to any woman whom he supposes to be pregnant, anything whatever, or shall employ any means with intent thereby to procure the miscarriage of such woman, unless the same is neces- sary to preserve her life, shall be punished by imprisonment in the county jail not exceeding twelve months, and be fined not exceeding five hundred dollars."J Kansas.—" Every physician or other person who shall willfully administer to any pregnant woman, any medicine, drug, or substance whatever, or shall use or employ any instrument or means whatso- ever, with intent thereby to procure abortion, or the miscarriage of any such woman, unless the same shall have been necessary to pre- serve the life of such woman, or shall have been advised by a physi- cian to be necessary for that purpose, shall, upon conviction, be adjudged guilty of a misdemeanor, and punished by imprisonment in a county jail not exceeding one year, or by fine not exceeding five hundred dollars, or by both such fine and imprisonment." || After commenting on the imperfections of the laws of the States relating to criminal abortion, Dr. Storer makes the following just remarks : " If our previous assumptions of the actual character of criminal abortion be granted, and we believe that they have been proved to a demonstration, it must follow from the subsequent remarks that the common law, both in theory and in practice, is insufficient to control the crime ; that in many States of this Union the statutory laws do not recognize its true nature ; that they draw unwarrantable dis- tinctions of guilt; that they are not sufficiently comprehensive, directly allowing many criminals to escape, permitting unconsum- mated attempts, and improperly discriminating between the meas- ures employed; that they require proofs often unnecessary or impos- sible to afford; that they neglect to establish a standard of justifi- * I insert this clause not merely for its relation to the points we are now considering, but for its important bearing on the broad question of infanticide during labor; concerning which it stands in bold and direct antagonism to all the rulings of the common law in this country and abroad. In other respects also, though not faultless, the Texas statute is rationally and admir- ably drawn. f Penal Code of Texas, 1857, p. 103. X Revised Statutes of Indiana, 1852, p. 437. || Statutes of Kansas, 1855, chap. 48, p. 243. 332 HALE ON ABORTION. cation, and thereby sanction many clear instances of the crime ; that by a system of punishments wholly incommensurate with those inflicted for all other offences whatsoever, they thus encourage instead of prevent its increase ; and that in many respects they are at variance, not merely with equity and abstract justice, but with the fundamental principles of law itself. " < It is to be hoped,' has forcibly been written, < that the period is not far remote, when laws so cruel in their effects, so inconsistent with the progress of knowledge and civilization, and so revolting to the feelings and claims of humanity, will be swept from our statutes.'* " In a similar trust, it now behooves us to consider whether, and in what manner, the difficulties in the way of generally suppressing the crime of abortion can be overcome. CAN IT BE AT ALL CONTROLLED BV LAW ? " To this important question I do not hesitate to give an unqualified answer in the affirmative. The fact that criminal abortion is not controlled by law anywhere, cannot be entertained as a valid argu- ment to the contrary of this assertion ; for it is equally the fact, 'as we have seen, that laws against abortion do not as yet exist, which are in all respects just, sufficient, and not to be evaded. " It is evident that in aiming to suppress this crime, the law should provide not merely for its punishment, but indirectly as well as directly, and so far as possible, for its prevention. The punishment of a crime cannot be just, if the laws have not endeavored to prevent that crime by the best means which times and circumstances would allow,f and this is to be accomplished by a twofold process — by rendering on the one hand its detection more probable, and on the other its punishment more certain. As indirect though important measures for the former of these ends, we have already mentioned laws for registration,^ and against * Lee, note to Guy's Principles of Forensic Medicine, p. 134. f Beccari, Crimes and Punishments, 104. X "An efficient and practical remedy for the prevention of this crime would be a law requiring the causes of death to be certified by the physician in attendance, or where there has been no physician, by one called in for the purpose. In this way the cause of death, both in infants and mothers, could be traced to attempts to procure abortion. In three cases which occurred in Boston in 1855, the death was reported by friends to be owing to natural causes, and in each it was subsequently ascertained that the patient died in consequence of injuries received in procuring abortion. It is probable that such cases are by no means rare; and if the cause of death were known, an immediate investigation might lead to the detection of the guilty party."— (Boston Med. and Surg. Journal, Dec. 1857, p. 365.) [Note.—There is no law of the State of Illinois against the concealment of births, and, we believe, none against secret burials. In this cit3r (Chicago) there is also no ordinance against the concealment of births ; and although there is an ordinance providing for the registration of deaths, and against secret burials, yet, owing to the culpable neglect of the city authorities, the JURISPRUDENCE OF ABORTION. 333 concealment of births and secret burials. As a single proof of their possible influence in this respect, out of many that might be adduced, we instance the fact that in Paris the number of premature foetuses deposited at the Morgue, during the nine years from 184G to 1854, inclusive, was found to exceed by more than two-thirds that of the full decade just preceding, from 1836 to 1845.* To render this dif- ference more apparent, we have compiled the following table : Age of Foetuses deposited. Ten years: Nine years: 1836 to 1845. 1846 to 1854. From 2 to 3 months.....21 58 " 3 to 4 "......35 73 " 4 to 5 "...... 56 102 " 5 to 6 " ......69 82 Total.........181 315 " Part of this advance, it is true, is attributable to the increase in the population of Paris, and in the prevalence of criminal abortion; but in great measure it is clearly owing to the enforcement of a more rigid law against secret burials. The above remarks are strikingly corroborated by the fact that of trials for the crime—and we must not forget that these bear but a small ratio to the whole . number of cases preliminarily investigated! — there were in France, during the latter of these periods, fully four times the number occurring from 1836 to 1845. " The establishment of foundling hospitals, by the State govern- ments, has been urged as a preventive of the crime, and, on the other hand, fears have been expressed lest the same means should increase it. For ourselves, however, and from some experience in law is almost a dead letter. Not only do the undertakers neglect to report many cases of burial, but they are unwarrantably permitted to report to the health officer on the causes of death! In consequence the reports of that officer are a standing disgrace to any civilized community, on account of the gross ignorance which they expose. Not only this, but they undoubtedly hide a vast amount of crime, behind their unmeaning and unscientific terms. We will take as an example, the yearly record of the city mortality for 1865. The whole number of deaths for that year were 3,6o9. Ot this number the following are set down as the causes of death: Congestion (!!)........................................ 9° Cramps ("") ........................................ °6 What was the matter with these 183 persons, who died of " cramps?" and the 90 who died of " congestion ? " Is it not disgraceful that such returns are permitted in a civilized city ? How many of these deaths were reallv from criminal causes? How many resulted from criminal abortion? This is onlv known to the All-seeing Eye, and the guilty ones. There were also 132 still-born infants buried in 18G5. Did all these die natural deaths? Does any one suppose that this small number includes all the still-born of this great city?—Hale.] * Register of the Morgue. + From 1846 to 1850,188 cases of criminal abortion were discovered in Paris but, for want of proof, only 22 of them were sent to trial. (Comptes Bendus Ann. de la Justice Criminclle.) 334 HALE ON ABORTION. such cases, we believe that these fears are groundless, and that with equal justice might they be entertained of every large charity having for its end the improvement, sanitary or otherwise, of the masses of society. " We have quoted a statute existing in Massachusetts, though practically unenforced, against one great agent in the increase of abortion, an abuse of its license by the public press. Were such laws to become general, and to be faithfully executed, and were it also made penal to sell any drug, popularly known as emmenagogue, except as advised by physicians, just as the sale of direct poisons is, or should be, controlled by law, the present system of openly advertising by abortionists, would undoubtedly be brought to a close. "In no matter is it of more importance than in cases of suspected criminal abortion that coroners should be intelligent and well edu- cated medical men ; and we could wish that this point might have received especial attention from Dr. Semmes, in his late admirable report to the American Medical Association.* In the sudden excite- ment of an inquest, the guilty are more likely than at a later period to be off their guard, and evidence may often be elicited at this time, which, at the subsequent trial, it would be impossible to obtain. There can be no question of the importance of this point; the coro- ner should be skilled in all that pertains to obstetric jurisprudence ; and if similar knowledge were generally possessed by other officers of justice, attorney, juror, and judge, a far greater number of con- victions, under a proper law, would be secured. " As regards the more direct statutes, we have already considered their important points. " ' In order to render laws effectually preventive,' as has wisely been said, 'they should be consistently framed, and based on justice.'f In accordance with this truly axiomatic doctrine, and with various rulings of the courts, already quoted, no proof should be demanded which is not necessitated by the actual character of the crime. We have seen that neither in intent nor in fact is this an attempt against the person or life of the mother. If she die in consequence, the offender is already amenable for it as homicide ; in the absence of any special statute, at common law. The crime both in intent and in fact, is against the life of the child. " The attempt being proved, it is unnecessary that it should have been consummated, not merely the completion of a crime brino-ing its punishment, but also certain overt acts with intent to the per- petration ; nor is it requisite that any injury, specific or general, should have been inflicted upon the person of the mother. '_' The offence being of equal guilt throughout pregnancy, proof of quickening, the incident, not the inception of vitality,—indicating neither the commencement of a new stage of existence, nor an * Report on the Medico-legal Duties of Coroner. 1857. t Radford, British Record of Obstetric Medicine, vol. i. p. 55. JURISPRUDENCE OF ABORTION. 335 advance from one stage to another,*—and, therefore, an element without the slightest intrinsic value, should not be required. " The crime of abortion should be considered to include, as it does, in the absolute fact of moral guilt, all cases of attempted or intention- ally effected, destruction and miscarriage of the product of impreg- nation ; and this, whether it be living or dead, normal or abnormal, which last expression equally comprehends instances of moles, hydatids, extra-uterine conception, acephalous, anencephalous, and other monsters. " Proof should not, as now, be required of intent to destroy the child.f This should be considered shown by the intent to produce miscarriage, in the absence of lawful justification therefor ; the act in all stages of pregnancy being attended with great danger to the child, and, in much more than a moiety of the period, necessarily fatal to it. " The attempt being considered criminal, it follows that proof of pregnancy is not necessary, and that conviction should be had though it were proved that pregnancy did not exist,\ even that the woman on whom the abortion was attempted, however unlikely, was still a virgin.|| " No discrimination should be made as to the means criminally employed, anfl no escape thus afforded to the guilty; as we have seen still obtaining in Great Britain and many of our own States. " The mother, almost always "an accessory before the fact," or the principal, should not, as now, be allowed almost perfect im- punity. There is no valid reason for such exemption ; there is every reason against it. The woman is covered by the laws of most continental nations of Europe—France, Austria, Germany, Bava- ria, and Italy,—and by many of them her punishment, if married, is greatly increased. Similar severity is also exercised in these countries against the father of the foetus, if he, too, is implicated in the crime. " To allow that abortion is extenuated in the unmarried, it has been said, will 'to the moral and political philosopher appear to have exalted the sense of shame into the principle of virtue, and to have mistaken the great end of penal law, which is not vengeance, but the prevention of crime. Law, which is the guardian and bulwark of the public weal, must maintain a steady and even rigid watch over the general tendencies of human actions."S, But, on the other hand, the measure of punishment should be proportionate, as nearly as possible, to the temptation to offend, and to the kind and degree of evil produced by the offence."^ " We have seen'the increase in moral guilt, and of opportunity for commission and for escape, in the case of nurses, midwives, and * Wharton, Criminal Law, 540. f Smith vs. The State, 33 Maine, (3 Red.) 48. X Rex vs. Phillips; Regina vs. Goodall; Regina vs. Heynes, etc. || Taylor, Medical Jurisprudence, p. 386. £ Percival, Medical Ethics, p. 84. •i Ibid, p. 85. 336 HALE ON ABORTION. other classes of persons, who, from their profession, are brought more directly into contact with pregnant women. By the penal code of Napoleon the First, remarkable in so many respects for the wisdom of its provisions, an increase of punishment was enacted for abortion criminally induced or advised by physicians, surgeons, or other officers of health, including midwives, or by druggists ;* their guilt being enhanced by their greater opportunities and knowledge. " Punishments for the crime of abortion should not, as is now generally the case, be so framed as to render the statute, in fact, if not in name, simply nugatory. Were the murder of adults to be made answerable by merely a year or two in prison, far more con- victions than at present would undoubtedly be secured ; but it is certain that the instances of the crime would be fearfully increased. We have reason to believe that it is precisely thus with the case in hand. " A standard of justification for the instances of necessary abor- tion should be fixed by law. If perfection in this respect be impos- sible, let the nearest approach be made to. it that can. Since my remarks upon the relative rights of the mother and foetus, to the chance of life in doubtful cases, were published in a former paper of the present series, I have received from Dr. Rattermann, late of Tubingen, an essay, written by himself, in which tMs question is discussed at length, and the repetition of abortion upon the same individual, in the early months of pregnancy, is defended. I have carefully considered the several arguments advanced by the gentle- man, and am compelled to adhere to the views I have already expressed. "In presenting a report upon the matter, in 1857, by direction of the Suffolk District Medical Society of Massachusetts, the writer offered the draft of a law, prepared after much thought and consul- tation, with legal as well as with medical men, and embodying the suggestions made above. This was intended for the consideration of the Legislature of the State, in the hope that it might be of aid toward a modification of the present defective law. " Having seen no reason to change the opinion then avowed, but on the contrary, receiving constant confirmation of their truth, I now present the essential portions of that draft, acknowledging most willingly that its wording may, perhaps, with safety, be simplified and condensed ; but contending, in all sincerity and earnestness of purpose, that its general tenor is. what justice and humanity alike, and imperatively, demand at the hands of society. ■' ' Whoever, with intent to cause and procure the miscarriage of a woman, shall sell, give, or administer to her, prescribe for her, or advise, or direct, or cause, or procure her to take any medicine, or drug, or substance whatever, or shall use, or employ, or advise any instrument, or other means whatever, with the like intent, unless the same shall have been necessary to preserve the life of such * Loc. cit., article 317. JURISPRUDENCE OF ABORTION. 337 woman, or of her unborn child, and shall have been so pronounced (in consultation) by two competent physicians ; and any person, with the like intent, knowingly aiding and assisting such offender or offenders, shall be deemed guilty of felony,' etc. etc.; ' and if such offence shall have been committed by a physician, or surgeon, or person claiming to be such, or by a midwife, nurse, or druggist, such punishment may be increased at the discretion of the court. " ' Every woman who shall solicit, purchase or obtain of any per- son, or in any other way procure, or receive, any medicine, drug, or substance whatever, and shall take the same, or shall submit to any operation or other means whatever, or shall commit any operation or violence upon herself, with intent thereby to procure a miscarriage, unless the same shall have been by two competent physicians (in consultation) pronounced necessary to preserve her own life, or that of her unborn child, shall be deemed guilty,' etc. etc.; ' and if said offender be a married woman, the punishment may be increased at the discretion of the court.' " It was also advised that the encouragement of criminal abortion, by publication, lecture or otherwise, or by the advertisement, sale, or circulation of such publication, should be made penal, and that the present well-worded statute against the personal advertisements of abortionists, and their nostrums, should be rigorously enforced. " To the words now quoted were added, and they are still applica- ble, the following : " ' AVe have aimed at a statute, which, while it better defined this atrocious crime, and covered the usual grounds of escape from con- viction, established also the proper standard of competence in all medical questions involving issues of life and death. We believe that it would be the means of preventing much of the present awful waste of human life. But enforce such a law, and the profession would never allow its then high place in the community to be un- worthily degraded ; nor, as now, would those be permitted, unchal- lenged, to remain in fellowship, who were generally believed guilty, or suspected even of this crime.'* * Report to Suffolk District Med. Society, May, 1857, p. 12. 9 2 APPENDIX. general therapeutics OF sterility. Under this head I propose to place those hygienic and thera- peutic measures which find no special mention in the preceding pages. In examining a patient about to be treated for the sterile condition, the first object should be to ascertain the phvsiological, psychological, or pathological cause. If such cause be ascertained, the treatment will be found above. But cases will frequently occur in which the cause can not be satisfactorily ascertained. Either it is not appreciable to the senses, aided by the various aids to diagnosis, or it is not physical in its character. In either case, the physician must base his treatment on general principles, such as change of condition as regards climate, diet, exercise, etc. ; or he must follow the directions of Hahnemann, and select the remedy from the similarity of its symptoms with those presented by the patient, taking into special consideration the general sphere of action of the remedy, (its genius,) as well as its characteristic or key symptoms, and also its special or diagnostic symptoms. To further the proper selection of remedies in cases of sterility, the claims of certain medicines should be considered, and their charac- teristic indications pointed out. This can not be done with absolute accuracy in this, any more than in other diseases or morbid states. By referring to the list of medicinal causes of sterility, it will be seen that the same medicines are enumerated that appear below as the curative agents in sterility. That this should be so, is in accord- ance with the law of cure, which asserts that only those medicines which cause diseases are capable of curing similar ones. No medicine, therefore, can cure sterility, without being capable, either directly or indirectly, of causing that condition. This law is not confined to the action of medicinal agents, but extends to all others ; such as climate, certain habits of life, mental 340 APPENDIX. conditions, and the like. That the curative influence of climate, particularlv, is homoeopathic in its action, is admirably demonstrated by Dr. T. K. Chambers.* It is my belief that nearly all the medicines capable of causing sterility do so by their action on the ovaries. Medicinal agents rarely if ever, by their pathological action, cause cervical leu- corrhoea, displacements of the uterus, occlusions of the cervix, vagin- ismus, or the various other uterine and vaginal causes of sterility. The function of ovulation is the central and all-important function of reproduction. If this is interfered with, sterility results. Medi- cines which act on the ovaries interfere with that function, and thus become sterility-causing agents. The ovarian remedies for sterility are more especially: Agnus castus. Iodine, Apis mel., Iodide of lead, Baryta carb., Iodide of potassa, Capsicum, Kali carb., Caladium, Kali brom., Cannabis, Lachesis, Conium, Phytolacca, Cantharis, Phosplwrus, Chimaphila, Platinum, Hamamelis, Ustilago. The uterine remedies comprise a few of the ovarian, and some others, namely: Aletris, Helonias, Cantharis, Cimicifuga, Borax, Eupatorium purp., Phytolacca, Gossypium, Mercurius, Stillingia, Sabina, Caullophyllum, Secale, Sepia, Ustilago, Senecio, Rata grav., Moschus. Characteristic Indications.—It is impossible in a work of this size to give the general and special symptoms as well as the pathologi- cal indications for the use of the above enumerated medicines. Many of them have been mentioned in the preceding pages in con- nection with the diseases causing sterility. I have therefore thought it best to give the " characteristics" of the remedies as a guide to their selection. Agnus castus.—A complete loss of sexual power and desire ; * See Monthly Horn. Review, March, 1868. APPENDIX. 341 albuminous leucorrhoea; ovarian atony, or suspension of the function of ovulation ; amenorrhoea ; melancholy. Aletris.—General debility; paleness ; inability of the uterus to retain the product of conception ; sterility after abortion. Asarum (can. and europ.)—Said to cause sterility. Apis mel.—Chronic or acute ovaritis with stinging pains, followed by ovarian enlargement. She is troubled with urticaria and pruritus pudenda, also dysuria, with stinging pains during urination. Borax.—" A female had been sterile for fourteen years, on account of a chronic acrid leucorrhoea; she received, amon» other remedies, borax, after which she became pregnant, and the leucor- rhooa improved. Easy conception during the use of borax observed in five women."—(Hahnemann's Chronic Diseases, II.) It is indicated when membranous dysmenhorroea causes sterility ; also for abrasion or erosion of the os uteri, and apthous affections of the vagina and cervix. Baryta carb.—Loss of sexual desire and power; very scanty menses ; general appearance of premature old age; catches cold very easily. Cantharis.—Sterility with great sexual excitement, with irrita- tion of the ovaries (primary effect) ; or sterility from the opposite condition, viz., loss of ovarian function (secondary effect.)* For the first named condition give the 30th, for the latter the 1st. It has been used successfully by Allopaths. Capsicum.—For fat women who are generally chilly, have a masculine appearance; atrophy of the ovaries (?) with amaurosis. Calcarea.—Sterility in adipose women, who have profuse and too frequent menses.f Caladium.—Sterility with melancholy, faint feeling in stomach, foetid urine, asthma, loss of sexual desire, coldness and cold sweat of the sexual organs. Cannabis.—" Great excitation of the sexual instinct, accompanied by sterility." Profuse menstruation, with various urinary diffi- culties.^ Chimaphila.—Atrophy of the ovaries (?) and mammae. The urine is full of mucus ; scaly eruptions on the skin. * Gardner on Sterility, p. 159. t Calc. (xOO) given against a copper eruption in the face, effected pregnancy m a woman who had not conceived for nine years past.—(Ruckert's Therapeutics.) t Cannabis (1st) one drop, and afterwards mere. <8rd). Giving both remedies twice to husband and wife effected pregnancy, after a sterility of six years.—(Ruckert's Therapeutics.) 342 APPENDIX. Conium.—One of the chief remedies in sterility. Atrophy of the ovaries and mammae; albuminous or acrid leucorrhoea; loss of sexual power and desire ; amenorrhoea, or very scanty menses; pain and swelling of the breasts* before the menses. " Vertigo while lying down ; the stream of urine intermits."—(Guernsey.) Professor Tully (Allopath) says :* " In several cases, where per- sons had been married eight or ten years without offspring, I have known a thorough use of good extract of conium employed by the party with whom the difficulty was supposed to exist, result in the subsequent birth of one, two, or more children. Again, when, in the course of a few years after marriage, there had been one, two, or more children, and then a suspension of child-bearing for ten or a dozen years ; after a thorough course of good extract of conium, taken by the party in fault, I have known one, two, or more children born. I recollect prescribing extract of conium for a lady, who had ceased for a long time to bear children. At the time of my prescrib- ing for her, she had some chronic difficulty, I forget what it was, though it could not have been of long duration. I made several calls, at comparatively long intervals, and at each was informed that she was better, and apparently continuing to improve. At last, at one of my visits, her conduct was very petulant, to say the least. She told me she had discontinued the medicine, and should take no more of it; but I could not ascertain the reason of her rejection and refusal of it. In the meantime her husband sat by, laughing. At last the lady left the room, apparently quite angry. Her husband then informed me that she had just become gravid, and at a time when she considered that her previous children were too old, and at what she considered too late a period of her life for child-bearingr since she wa3 a little past forty years of age. He said she consid- ered her existing condition as due to my medicine. I answered that I thought she must, at least, divide the blame between him and my medicine." Cimicifuga.—Sterility with hysteria, spinal irritation, want of vitality in the ovaries and uterus. She is subject to melancholy, severe congestive headaches, chorea and acute rheumatism. (I have known many cases of sterility cured by cimicifuga when all other means failed.) Caullophyllum.—Sterility with spasmodic dysmenorrhoea; she is: subject to rheumatism of the fingers and hands. Eupatorium purp.—Sterility in women who suffer from nervous * Materia Medica, page APPENDIX. 343 exhaustion ; have profuse flow of watery urine from the least excite- ment; loss of sexual desire, uterine and ovarian atony; sterility from frequent abortions.* Gossypium.—May prove of value in some cases of sterility. No pathogenetic indications for its use have yet appeared.f Helonias.—Sterility with chlorosis, debility, diabetes, atony of the generative organs. Iodine.—Sterility with emaciation ; weakness, especially in the knees ; atrophy of the ovaries, and mamruad ; goitre. The testimony in favor of iodine in sterility from Allopathic sources is worthy of our attention. Professor Tully says :\ " A free and protracted use of iodine is said to prove aphrodisiac, i. e., to increase venereal appe- tite, and the power of gratifying it. Valetudinarian women, who have been married a number of years without children, not infre- quently become gravid after a thorough course of iodine.^ Iodide of Lead.—Inatrophic-ovarian sterility. (See N. A. Journal of Horn., vol. 2.) Iodide of Potash.—(See Iodine.) Kali carb.—A prominent medical author asserts that the steril- ity of American women is, to a great extent, due to the excessive use of carbonate of soda in bread. See Hahnemann's Chronic Dis. Natrum brom.—The bromide of potassium causes extinction of sexual desire, and a general paralysis of the reproductive organs. It is pri- marily indicated in sterility from deficient ovulation, and sexual inactivity ; and secondarily, in excessive excitation of the sexual organs, erotomania, etc. Lachesis.—Chronic inflammation and other destructive diseases of the ovaries, also many diseases of the uterus, leading to sterility. Mercurius.—It has been observed that women under the action of mercury, easily conceive.§ It has the power of causing sterility, as all authors attest. Sterility from syphilis ; sterility from poi- sonous leucorrh