Abortion as an Etiological Factor 
in Gynaecology and its 
Treatment. 
P.Y 
FRANCIS FOERSTER, M.D., 
Instructor, in Gynaecology at the New York Post 
Graduate Medical School and Hospital, 
Gynaecologist to the German Hospital, Con- 
sulting Gynaecologist to the Lutheran Hos- 
pital (Brooklyn), Gynaecologist to the German 
Dispensary. 
REPRINTED FROM 
THE POST-GRADUATE, 
May, 1894. ABORTION AS AN ETIOTOLOGICAL FACTOR IN 
GYNAECOLOGY AND ITS TREATMENT. 
BY 
FRANCIS FOERSTER, M. D., 
Instructor in Gynaecology at the New York Post Graduate Medical School and 
Hospital, Gynaecologist to the German Hospital, Consulting Gynaecologist 
to the Lutheran Hospital (Brooklyn), Gynaecologist to the 
German Dispensary. 
Undoubtedly, most cases of disease of the female genital tract 
can be traced directly to a defective child-birth. A large con- 
tingent follows such cases, in which from one or another cause 
the normal period of gestation is interrupted, in which a prema- 
ture expulsion of the products of conception occurred. It is a 
daily occurrence, that the Gynaecologist, to his question: “Since 
when are you ailing ? ” receives the answer: “ Since the birth of 
my last child,” or, “ that of a prior one,” but often, “ since such 
and such an abortion or miscarriage.” 
It is not my task to ventilate all the causes by which the 
normal labor can act in a deleterious way on the female genital 
tract. Some changes or derangements, which sooner or later may 
give rise to complaints, can occur even with the normal confine- 
ment. I only wish to remind you of the extreme stretching the 
whole tract experiences, the subcutaneous tearing of the muscular 
structure of the outlet of the pelvis, the injuries to the cervix and 
perinaeum. We also have to take into consideration that after 
the uterus is emptied of its contents the tension of the abdominal 
walls ceases and that all the organs of the abdomen sink to an 
abnormal level, exerting thus undue pressure upon underlying 
structures. 
But all these causes we must look upon as something natural 
and the results as unavoidable, yet factors with which we have to 
deal in Gynaecology. A different aspect is offered by cases, in 
which by certain influences the physiological act of child-birth is 
interfered with and is converted into a pathological one—I mean 
those cases which become infected and have, in consequence, to 
pass through all the different stages of sepsis. This latter category 
is certainly yet a most fertile source for future ailment, although 
we have good reason to assume that our progressive times and the 
increasing instinctive sense for asepsis will do a great deal to 
bring improvement in this direction. Such an improvement 
necessarily must be a slow one, for it is not only the physician 
who comes under consideration, but also the midwife, who is still 
doing the greater portion of obstetric work, especially in our larger 
cities. 
We touch hereby a subject which we must confess is sadly 
I neglected in our country, I mean the question of midwives. While 
Europe is enjoying for many years the benefit derived from early 
efforts to regulate the functions of midwives and to take care of 
their proper instruction and licensing, we still find prevailing in 
our midst the sadest carelessness in this respect. The schools for 
Midwifery—if we can call them such—in this country are mostly 
in the hands of practitioners, who have no respected standing in 
the profession, who take up the matter simply as a business 
speculation. Their abodes are in localities not selected with 
respect to the purpose which they are intended for, but simply to 
meet the limited amount of funds which the proprietor is able to 
spend. As competition amongst these institutions is great, the 
fee asked for a short course is small, the afflux of so-called 
students is consequently large, especially as no further knowledge 
of the applicant is required than their ability to read and write. 
Is this not a weak point in our community ? So much more so 
when we see what ambitious efforts are made in general to elevate 
our educational standing. To so-called graduates of these schools 
our poorer and middle classes take refuge, when the hour of trial 
for the young mother arrives, do we need to wonder, that she 
leaves their hands, when alive, mostly as a physical wreck ? Is 
such a state of affairs becoming to our great city or to our still 
greater country ? Is it not high time that some men of integrity 
take this matter in hand and wipe out the stigma which has 
long enough stained our reputation ? More lives of unfortunate 
women would be saved than any threatened infectious disease can 
destroy; hundreds of children would be amongst the living which 
now through ignorance pass as still-borne. Malpractice thrives 
vigorously here, and we can not and should not allow the control 
of this branch of medicine to pass from our hands. Some time 
ago this question was broached by a practitioner, but no material 
results have followed his efforts. 
I am digressing from my subject, but the importance of the 
matter is an ample excuse. 
When, as we have seen, the normal delivery requires skillful 
hands for its proper conduction, how much more necessary is this 
in cases of abortion, an occurrence in itself pathological; and yet 
we often see these very cases in the hands of ignorant midwives, 
resulting in consequences which endanger the life of the woman 
and render her an invalid forever. But even among physicians 
the importance of an abortion is often underrated and the atten- 
tion which it deserves is not always given. The same physician 
who will frown from undertaking any obstetrical manipulation, 
say application of forceps or peeling off of a placenta without 
thorough cleansing or disinfection of instruments and hands, we 
2 may see in a case of abortion display an inexcusable carelessness; 
a superficial washing of the hands, and he is ready to render his 
questionable services. Fortunately, we find this carelessness not 
the rule, but the exception. It may be difficult to find a reason 
for this neglect. The only explanation that I can think of is that 
in our medical schools the subject “Abortion ” does not receive 
the proper attention. Lying as it does between obstetrics and 
gynaecology, it so happens that it experiences from both sides but 
slight consideration. This same reason may hold good as an 
excuse for the fact that there is no distinct and uniform plan of 
treatment of abortion up to date. 
Let us review the different opinions of our own as well as of 
Gynaecologists abroad; we see at once the greatest differences 
therein prevailing. 
The minority of practitioners we find abstaining from examina- 
tion, if they possibly can help it, trusting to a few drugs altogether. 
Only in cases of persisting haemorrhage can they be induced to re- 
sort to mechanical interference. It must impress us as if the last 
twenty-five years of advance in surgery have passed by here with- 
out leaving their progressive imprints. As then, so to-day, the 
subject is a noli me tangere. The sad experiences of meddlers with 
this sensitive organ, the uterus, in prae-antiseptic times, seem still 
to be fresh in their recollection. The majority of practitioners 
have come, with slight variation, to the following mode of treat- 
ment: After the abortion is in progress, symptoms being haem- 
orrhage and uterine pains, the efforts of nature to throw out the 
products are assisted by the introduction into the vagina of a 
packing of cotton tampons; the result usually is a dilatation of 
the cervical canal and the birth of foetus plus secundines. When 
after inspection the latter prove to have come away in toto, the 
case is considered as ended, a few doses of ergot being given to 
ensure uterine contractions. When the secundines do not come 
away, some leave the case to nature, until they become loosened 
and are expelled ; others pack the vagina again, and if not success- 
ful, an attempt is made to remove them with the fingers. If this 
proves ineffectual, the forceps or a dull curette is used to obtain 
the result. It is not necessary to state that all this must be un- 
dertaken with the strictest observance of anti or asepsis. 
The results can be temporarily satisfactory, only—exception- 
ally they are permanently so. 
The reason why I consider the result mainly illusory, is be- 
cause the measures enumerated are inadequate to the condition 
we have before us. 
I believe, whenever an abortion occurs, that we have to deal 
in most cases with a pathological state of the endometrium, that 
3 our endeavor must be to remove this endometrium and the there- 
on implanted secundines in toto, if we wish to give our patient 
the best chance for recovery and avoidance of the recurrence of 
abortion in the nearest future. 
Observers, whom we all esteem highly—Fritsch, Thomas, 
Schroder, Kaltenbach—speak of an endometritis post abortum 
and describe this condition as being caused by the retention of 
portions of the decidua in utero after abortion. These small part- 
icles attain an inflammatory character and result in a degeneration 
of the entire endometrium giving rise to the often met symptom, 
metrorrhagia post abortum. Kiistner has furnished the incontro- 
vertible proof that endometritis is often the outcome of an incom- 
plete abortion, by demonstrating in the midst of an uterine polypus 
the presence of chorionic villi. 
If then the total removal of the decidua is a necessity, can this 
be done by the above means, especially when we think of the close 
implantation of the secundines on the uterine mucosa in the second 
or third month? To do it thoroughly and effectively we have, to 
use an instrument which allows us to reach the deeper structures; 
we need a sharp curette to obtain this result. Judiciously used we 
cannot produce any more injury than by the use of a dull instrument. 
Whatever the genesis of the abortion maybe, constitutional, ac- 
cidental or criminal, we cannot aid our case in any better way than 
by a thorough curettage of the endometrium. In constitutional 
cases the endometrium is not able to functionate properly, is the 
seat of disease and should be substituted under proper medicinal 
treatment by a new one. In accidental cases we mostly have to 
deal with an endometritis, or else the causes, which are often of 
a trivial nature, would not be able to result in an abortion. In 
criminal cases it is our absolute duty to remove the endometrium, 
for we have good reason to assume that the instrument used for 
producing the abortion may not have been aseptic, a thorough 
curettage and the establishment of proper drainage will be the 
only means we have to prevent the spreading of the septic process. 
Bad after effects do not result from an energetic curettage, retard- 
ation of the next menstrual period or amenorrhea for one or two 
months may occur, surely no disadvantage to women, who are 
usually in an impaired state of health from the loss of blood which 
they suffered. If it wants proof that no harm is done to the pa- 
tients, I can enumerate a number of cases where shortly after such 
a curettement pregnancy followed, which went on uninterruptedly 
to full term. Other operators have had similar experiences in this 
respect. Duvelius mentions sixty cases coming under this category. 
I can also point to the fact that after such treatment the slug- 
gish state of the uterus, which is so often found after abortions—I 
4 mean subinvolation—is a thing almost unknown. From a large 
number of cases which have come under my care, I have yet to 
see the first one where I regret having performed a curettement; 
while on the contrary the expectant plan of treatment, induced 
by misleading or false statements of the patient, has often let me 
feel keenly the awkwardness of my position when I obtained poor 
results, simply by allowing my better judgment to be influenced 
by presenting circumstances. 
For a number of years I followed a treatment of abortion, 
which at first glance may be looked upon as too energetic and 
often unnecessary. Admitted that in its full extent the treatment 
may now and then be unnecessary, I can say on the other hand, as 
we have no means to determine whether all the products of concep- 
tion have come away, nay, if not sepsis itself is on the onset that we 
meet by this radical procedure all the indications. The cases of 
premature birth I would divide into those occurring before, and 
those after the fifth month of gestation. The latter category we 
ought to treat in a similar manner as the cases of birth at full 
term. The placenta being formed, the foetus having a consider- 
able size, we usually find no difficulty provided that we have the 
patience to wait for full dilatation of the cervix and that we use 
the necessary cleanliness. The first class of cases is the one 
under consideration. 
Being summoned to a patient complaining of the usual symp- 
toms of threatened abortion: Uterine contraction, pains and 
haemorrhage, our first step must be a careful examination with 
antiseptic precautions. In case we find the os uteri only very 
moderately dilated, our whole'endeavor should be concentrated to 
the one point, to relieve the symptoms, thus enabling the patient 
to continue the menaced gestation. 
It is a general opinion of practitioners that when uterine 
haemorrhage occurs, combined with uterine contractions, we have 
no efficacious means to prevent the abortion. We must con- 
fess this is generally the case, but would urge most earnestly the 
necessity that before we lentf our hand to bring to a finish the 
process of gestation, we should try our utmost to give to the case 
a more favorable termination. It will happen, by carrying out 
this advice, that cases which we never thought of being able to 
return to the normal will respond to the means employed, and will 
thank you eventually for the efforts which you have made. I 
could relate a number of cases from my own practice, when, con- 
trary to my expectation, I was successful in preserving the life of 
the foetus, but will mention only one case, which I delivered lately 
at full term, after we had been annoyed and frightened every 
month by considerable uterine haemorrhage accompanied by dis- 
5 tinct uterine contractions. This patient has had previously two 
abortions at the third month. 
The supreme remedy to prevent a threatened abortion is rest, 
if necessary opiates or bromides; bed rest must be enjoined for 
several days after the cessation of haemorrhage and uterine con- 
tractions. I am in the habit of giving, as a matter of routine, a 
mixture consisting of Extr. Viburn. prunif. fir. and Iod. of Pot., 
3ss- of the first and 3 grs. of the latter every three hours. 
Rectal enemeta to keep the lower segment of the gut free from 
faecal masses, to prevent undue pressure upon the uterus. If 
these measures prove ineffectual, and the uterine contractions 
result in dilatation of the cervical canal, I apply, after disinfecting 
the vagina, to the cervix a packing of sterile gauze, filling the 
whole vagina as a preliminary step to the emptying of the uterus. 
In case I find on first examination the cervical canal dilated 
and free haemorrhage, with the possibility that part or whole of 
the products of gestation have come away, or when they are still in 
utero, I proceed at once to the removal of the contents. 
The situation here is a totally different one from the cases just 
spoken of. While the os uteri is still closed, the haemorrhage and 
pains being not excessive, everything can be gained by waiting; 
there is no hurry for interference, sepsis is next to impossible. 
When the os is patulous, presenting a ready way of access for 
infection from without to the uterine cavity, matters assume a 
different aspect; the sooner we interfere energetically, the less we 
expose our patient to those deleterious influences. I say ener- 
getically, for I do not believe in repeated examinations, coupled 
with fruitless attempts 'to remove* the contents. I believe the 
finger to be an object much less capable of being kept sterile than 
a properly constructed curette, its tactile sense, almost suppressed 
by the narrowness of the canal, is fully compensated by the im- 
pressions which are communicated to us in handling skillfully a 
delicate steel instrument. 
The manner in which I proceed is the following: The patient 
is brought under the influence of an anaesthetic and put on a suit- 
able bed in lithotomy position. 
The genitals are scrubbed with soap and water and washed 
with a sublim. solution 1:1000. The same solutionis used for 
irrigation of the vagina. If lysol is convenient, I prefer this 
disinfectant in a two per cent, solution, first for its soapy and 
cleansing qualities, and then for its being non-poisonous in this 
concentration. By the aid of bullet forceps the cervix is brought 
down, or in case of parametric infiltration simply fixed and, if 
necessary, dilated by a slow acting dilator. When dilatation is 
sufficient, the foetus and secundines are removed and the uterine 
6 cavity is irrigated by a weak sublim. of lysol solution by a 
Bozemau-Fritsch catheter. After this is done, I proceed to scrape 
the interior of the uterus by means of a sharp curette. I repeat 
the operation until I am satisfied that all portions of the endo- 
metrium has been covered, due consideration being given to 
the region of the cornua. Warm water previously boiled is used 
for irrigation. When the irrigating fluid returns but slightly 
bloody, I insert into the uterus, which appears to me non-septic 
sterile gauze until the whole cavity is tightly packed. In case I 
have the least suspicion of sepsis, I omit the packing, so as to 
have perfect drainage. A vaginal sterile tampon and a T bandage 
conclude this little operation. 
The packing of the uterine cavity is done for this reason: as 
we are not certain that every portion of the endometrium is 
removed, consequently not every particle of secundines gotten rid 
of, the mechanical irritation of the gauze, assisted by a few doses 
of ergot, will bring on energetic contractions of the organ, de- 
stroying the vitality of such fragments, which may be still in utero. 
The gauze is removed on the second or third day, and rest in bed 
continued for five to six days. 
The use of the sharp curette cannot be accompanied by any 
risk even in the hands of the less experienced one, provided he 
keeps in mind that he is using a sharp instrument. The danger 
of perforation of the uterus is much less with a sharp curette than 
with a dull one, as it would require considerable more force with 
the latter to obtain the same result; i. e., total removal of endo- 
metrium, and consequently the risk of perforation is increased, 
especially when we have to deal with a soft septic organ. 
I do not claim originality for this procedure, as many gynae- 
cologists are using the same successfully, here as well as abroad. 
When we read in reports from the Continent, that the above 
results are obtained by the use of a dull curette, we must remem- 
ber that the dull curette as known to us—the wire loop—is not 
meant by that expression, but a moderately sharp instrument. 
Septic cases I have been treating by careful curettement and 
intra uterine irrigation of sublim. solution 1:5000; or lysol, 1 to 2 
per cent., repeated every three to four hours. 
Within the last few years I have changed this treatment some- 
what, obtaining favorable results, which hardly could have been 
anticipated, considering the grave nature of some of the cases. 
After gentle curettage by means of the sharp curette, I irrigate 
the uterine cavity with the above solution and insert into it a 
strip of gauze, well saturated with a sterile mixture consisting of 
one part of amm. sulpho-ichthyol, and two parts of glycerine. The 
vagina is then packed loosely with tampons, saturated with the 
7 same mixture. This way of treatment occurred to me two years 
ago, when I saw in consultation a case of puerperal sepsis, in which 
by the usual treatment no result whatsoever was obtained. Having 
read lately a statement concerning the application of ichthyol to 
the endometrium for endometritis of varying causation, I thought 
I would try its efficacy in this septic case. I introduced the gauze, 
saturated with ichthyol glyc., into the uterus, and to my sur- 
prise I found after three or four hours a falling of the temperature 
of four degrees. I repeated the application next day. On the 
third day I omitted its use, and found a rise of temperature, that 
evening, to 106. From that time on tampons were introduced 
daily for ten days, the case terminating in recovery. In a second 
case of puerperal sepsis, I used the same procedure, with the same 
happy result. In three cases of beginning sepsis following abortion 
I have tried the same measure, all cases ending in recovery. 
The question comes up: How can this apparently bland 
application prove so effective ? We know that ichthyol has only 
very limited antiseptic qualities; it cannot be compared to our 
antiseptics in general use. I am therefore inclined to attribute to 
it the smaller share of the work done by the two agents, glycerine 
and ichthyol. I may say that the well known action of ichthyol, 
on the capillaries in constricting them and diminishing their 
calibre may come into play here, and I would like to extend this 
action to a certain degree to the lymphatics, which may be in- 
fluenced simularly as the blood vessels, being less prone conse- 
quently to carry infectious material. The major portion of the 
action shown I would attribute to the hygroscopic action of the 
glycerine. This agent, abstracting liquid from the superficial as 
well as from the deeper structures it comes in contact with, may 
act in a depleting way upon the lymph-channels and establish to 
some extent a return flow from the lymphatics, the secretion being 
facilitated by the previous abrasion of the diseased endometrium. 
We may call all this hypothetical; it may be so, but the fact 
remains that the action of the ichthyol-glycerine in the two 
puerperal cases stated was a remarkable one, while the results of 
the three cases of beginning sepsis after abortion we must 
principally attribute to the curettage, but cannot deny that even 
here the ichthyol glycerine formed a valuable adjuvant. 
I am aware that it is a rather risky thing to propose in a 
society of general practitioners as ours procedures so surgical and 
so far-reaching in their consequences if they are undertaken by 
men not pervaded by the importance of anti and asepsis. 
Cherishing the hope that you all appreciate the value of anti and 
asepsis, I have taken the liberty to present my views on this 
subject to you this evening. 
8