Reprinted from Codex Medicus Philadelphia, 
October, 1894. 
REMARKS ON THE TREATMENT OF 
INEVITABLE ABORTION. 
Surgeon-in-Chief of the Kensington Hospital for Women, Philadelphia. 
By Charles P. Noble, M. D., 
IN this paper we shall confine our remarks to a brief discussion of abortion 
and the treatment of inevitable abortion. From the practical standpoint 
cases are best divided into four classes, i. Abortion from natural 
causes. 2. Criminal abortion. 3. Abortion before the end of the third 
month. 4. Abortion during and after the fourth month. 
The dangers attending spontaneous abortion are far less than those of 
criminal abortion. That this is a fact is borne out by universal experience, and 
the reasons therefor are quite apparent. When abortion occurs without 
criminal interference it is because of detachment of the ovum from the womb. 
This may occur suddenly from a fall or a blow, or gradually, as the result of 
morbid changes in the decidua or endometrium, leading to atrophy. In 
either case, the escape of the ovum is facilitated. Moreover, the sac of the 
ovum is not ruptured, and finally, and most inportant of all, no foreign body 
carrying the septic germs has been introduced into the cavity of the womb. 
That is to say, in non-criminal abortion the process begins with a non-infected 
uterine cavity. The only exception to this rule is when abortion is due to 
acute endometritis, frequently of gonorrhoeal origin. Therefore, in a broad 
way it can be stated that in spontaneous abortion the process is likely to be 
completed without sepsis ; and the ovum is likely to be expelled entire. 
In criminal abortion almost always some foreign body is introduced into 
the cavity of the womb. This may cause serious traumatism of the organ, may 
rupture the ovum and may introduce septic germs into the uterine cavity. As 
a matter of fact, all these consequences frequently ensue. Criminal abortion is 
performed almost always by the pregnant woman herself, by a mid-wife, or by 
an ignorant doctor-conditions which favor ill results, owing to the lack of 
technical knowledge. Criminal abortion is almost invariably done when 
the pregnancy is normal and the attachment of the ovum firm. Hence, as a 
rule, the conditions for the expulsion of the ovum are unfavorable, the ovum 
is ruptured and it is firmly attached. 
Abortion occuring before the end of the third month is less dangerous 
than subsequent to that period. Prior to the end of the third month the 
ovum is usually thrown off entire except in criminal cases. This result is 
facilitated by the smaller size of the ovum and by the relatively slight attach- 
ment of the chorion, as compared with that of the placenta in later months. Likewise, the vascular connections of the ovum with the womb are less 
developed, so that the likelihood of free hemorrhage is not so great. More- 
over, the presence of the entire ovum tends to lessen hemorrhage by playing 
the role of the tampon. 
These general considerations have a direct bearing upon the proper treat- 
ment of inevitable abortion. 
The chief dangers to be feared from abortion are sepsis and hemorrhage, 
and the problem in treatment is to prevent the one and avoid the other. In 
case one or both are present, when the case comes under observation, the 
problem is varied. 
The first aim of the practitioner should be to prevent infection. To do 
this, it is essential that his hands and instruments be disinfected, and that 
the same should be done with the patient's vagina and external genitals, 
before any examination or other interference is attempted. This practice is 
the basis of all successful treatment, and its neglect the cause of most of the 
deaths from abortion. 
Both sepsis and hemorrhage are favored by delay in the completion of 
abortion, by lengthening the time in which hemorrhage can occur and the 
time for the multiplication of such germs as may be present in the genital 
tract. Hence, it may be accepted as an axiom, that in inevitable abortion 
the process should be terminated promptly. 
EXPECTANT versus OPERATIVE TREATMENT. 
Experience has shown that in a large percentage of cases the ovum will 
be thrown off entire by the natural effort, and with good results to the 
woman. This fact is the basis of the expectant treatment. Experience has 
demonstrated that this occurs most often in abortion prior to the end of the 
third month. On the other hand, under expectant treatment, in a large 
percentage of cases alarming hemorrhages and septic infection take place, 
with serious and even fatal results. Such ill results are most common in 
criminal abortion, in cases where the ovum is ruptured, and in cases devel- 
oped beyond the third month. These facts are the basis of the operative 
treatment of abortion. 
The remarks which follow are based on my own experience, which is 
now no longer small. 
Expectant treatment should be employed prior to the fourth month, if 
the ovum is entire, hemorrhage trifling and sepsis absent. Treatment may be 
restricted to confining the patient to bed and using vaginal disinfecting 
douches. 
Broadly speaking, all other cases should be treated by emptying the 
uterus promptly. This line of action is urgently required when infection 
has occurred, when hemorrhage is free and when the pregnancy is advanced 
beyond the third month. 
The tampon I have rarely used. It is an unsafe method of treatment. 
When properly applied it guards against hemorrhage, but favors infection. 
Personally, I would never use the tampon longer than twenty-four hours. It 
finds its best use when the patient is somewhat remote from the doctor, and iii cases of such alarming hemorrhage that the emptying of the uterus is con- 
tra-indicated. The most important principles concerning the tampon are: 
i. Use it seldom. 2. Disinfect the vagina, the tampon and the physician's 
hands and instruments. 3. Introduce it by the Sim's method, and pack the 
vagina firmly. 4. The tampon material (cotton or gauze) should be squeezed 
out of sublimate solution, 1-4000. 
Ergot is a remedy which, I believe, does more harm than good. If the 
cervix be widely dilated it will usually do no harm, though even under these 
conditions, at times, it will cause contraction of the internal os and imprison 
the ovum. This result is the rule rather than the exception, when it is 
administered with an undilated cervix. The best rule for the use of ergot in 
abortion is not to give it until the process has been completed. 
To empty the uterus artificially, the patient should be anaesthetized, full 
disinfection practiced, the patient placed in the lithotomy position, two fingers 
or the half hand introduced into the vagina and one or two fingers introduced 
into the uterus. The womb should be forced down by manipulation with the 
physician's other hand-pressing on the patient's hypogastrium. In this 
way the uterus can be emptied in at least ninety per cent, of such cases. In 
a few cases it will be necessary to dilate the cervix with steel dilators. The 
ovum is easily peeled off the womb by using the intra-uterine finger and the 
hand grasping the uterus from without, conjointly. 
When infection has not taken place it is sufficent to remove all portions 
of the ovum, and then to wash out the endometrium with sublimate solution. 
It is prudent, in such cases, to introduce a suppository of idoform contain- 
ing twenty-five grains and to pack the uterus with iodoform gauze. This 
should be removed the following day, when, if the temperature is normal, the 
subsequent treatment may consist of daily vaginal douches of sublimate 
solution. ,, 
It is the fashion at this time to use the curette very freely. My own 
experience in the treatment of abortion antedates the present line of practice, 
and I am able to say from my experience, that the curette is unnecessary 
unless the endometrium has been infected. It is admitted, of course, that in 
skillful hands the decidua can be scraped off with a minimum risk, and in 
such hands the practice is unobjectionable, but for the physician of average 
experience, I am satisfied that it is best to use the fingers alone, in the non- 
septic cases. 
If however, infection has taken place, it is unquestionably better to 
thoroughly remove not only the foetal parts of the ovum, but the maternal 
decidua as well. In the course of nature this is thrown off as detritus, and 
its removal with the curette is simply hastening the result obtained by 
nature's process. A further gain is made by removing a large number of the 
contained germs, and at the same time the culture medium in which they are 
developing. The employment of a very large cutting curette is advisable, as 
this will quickly remove the decidua and be less apt to perforate the uterus, 
than a narrow curette. 
The danger of puncturing the uterus is by no means imaginary. It has been done many times by skillful men, and therefore the risk of this accident 
in the hands of the inexperienced is very considerable. 
The curette should be employed for the removal of the decidua, only 
after first removing all portions ofthe ovum. As showing the necessity for this 
advice, I will refer to the experience of a well-known gynecologist, whose 
skill is universally recognized, who, as he supposed, thoroughly curetted the 
uterus for abortion, and informed the family that everything was removed. 
On the following day, upon visiting the patient, he was shown an entire ovum 
which had escaped from the womb after his departure. This experience 
illustrates the fact that it is impossible to tell with the curette whether or not 
the womb is empty. This can only be done with the finger, and the sooner 
this fact is learned by the practitioner, the fewer will be his disappointments 
and surprises in the treatment of abortion. 
To return to the treatment of cases in which infection has occurred, we 
will say in conclusion, that it is most important in these cases to thoroughly 
douche out the uterus, and to introduce iodoform (in suppository) and iodo- 
form gauze after the completion of the curetting. 
The foregoing line of practice, which has been briefly and somewhat 
dogmatically described, is in my judgment the best for inevitable abortion, 
and were it faithfully followed by the profession in general, I am satisfied 
that death from abortion would very rarely occur, and that the number of 
cases in which it would prove necessary to remove the uterine appendages, 
for incurable inflammatory conditions, would be very materially diminished. 
The practice which is now only too prevalent, of failing to make use of rigid 
antiseptic measures, permitting the process of abortion to drag on for days, and 
at times even weeks, is responsible for most of the deaths which now occur 
from abortion, and also for one-third of the operations which are now per- 
formed for the removal of the uterine appendages for inflammatory conditions. 
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