rarely responsible for the loss of the fetus. I think that force, little less than a blow upon the abdomen sufficiently severe to destroy the child, would have no certain effect.

Tho efforts, violent and criminal, such as running, leaping, dancing to exhaustion, which are often made by those who, for reason, do not wish to become mothers, should convince us that the physical causes of abortion, are not very operative. I heard a young married

woman say once that in the third month of a pregnancy she jumped over a table twenty-four times without producing the effect which she desired. She had an heir at full term, six months afterwards.

Nor do certain drugs, called ecbolics, exert any reliable influence in bringing about abortion. And whilst we caution our patients enciente in reference to the use of ergot, savine, quinine, salycilate of soda, etc., I have never seen any untoward results from the use of any of them. And I have seen married women, desiring to rid themselves of the burden of pregnancy, take the most heroic doses of them, especially of ergot, without the slightest effect.

Complete and Incomplete.

An abortion, especially in the earlier months of pregnancy, may be complete, that is, the ovum or fetus, and decidua be expelled together: a fortuitous result. Or the ovum or fetus may be expelled, and the secundines retained; and these, unless removed by the practitioner at an early day, may undergo partial organization; and then we have what is called a mole, or mass; this, in turn, may be retained for an indefinite time, but, as long as it is retained, it will be a menace to the safety of the woman and provocative of hemorrhage, or sepsis.

Symptoms and Diagnosis. The symptoms of abortion vary with the periods of pregnancy. In the earlier In the earlier weeks of pregnancy the symptoms are those of painful menstruation; and many a fetus escapes observation, unless the vaginal discharges are carefully examined on suspicion of pregnancy. Later on, and especially after the formation of the

placenta, the symptoms of abortion are more or less the symptoms of normal labor. The hemorrhage, a constant attendant on abortion, confirms suspicion of pregnancy, as the expulsion of the fetus makes the fact sure. But if for reason, or without reason, there has been no ocular inspection of the products of expulsion, the diagnosis is uncertain.

This question of diagnosis of an abortion would seem a very easy matter, yet there are few practitioners, I suspect, of long experience, who at some time have not found themselves confronted with cases whose true condition it puzzled their skill to decide.

A physician is summoned to a lady, who tells him that she has missed two menstrual periods and that this is about the time for the third; that she has been compelled to remain in bed for several days on account of the profuse flow, and of harassing and intermitting pains in the lower part of her back and stomach. On questioning her (she is a maried woman), she states that she has no reason to think that she has conceived, has occasionally missed for a period or two and then come right without trouble, has never had a miscarriage. On examination, after turning out a great quantity of clots from the vagina, we find the os but little changed from its normal condition at such a time, the womb itself somewhat enlarged and a little tender. Now is this a case of threatened abortion, or has she already lost the fetus, and are the secundines retained? Or is there a fibroid or a

polypus within the womb? And if for any reason the lady has not the right to be" in a delicate condition," by reason of the impossibility of there having been any lawful coition, a medico-legal question complicates the case, and the doctor is apt to feel that his views of the situation are not entirely satisfactory to himself, and that he would prefer to divide his responsibility with a consultant.

Prognosis.

I have referred to the dangers of abortion-immediate dangers. In my opinion the prognosis of abortion is always grave. He is a fortunate physician, who,

after fifty years of experience, has never seen a fatal case of hemorrhage from the premature expulsion of the contents of a gravid womb. A few years ago I was visiting the family of a friend, when the lady of the house, who seemed unusually well and bright, suddenly left the room, pale and agitated, and requested me to follow her. On reaching her chamber she informed me that she was in the fifth month of pregnancy, and was flooding. I put her to bed and hurried to my office, which was near, and returned in a few minutes with a speculum, and pledgets of cotton already prepared, and tamponned her as promptly and perfectly as possible. She had already lost so much blood that her pulse was quickened and feeble, and her lips pallid. I remained with her, and, though she seemed to rally, yet it became apparent that the packing was inefficient, the blood oozing through so freely that the operation had to be repeated. In the meantime opiates, astringents, cold drinks, etc., were administered, but without effect. Summoning another physician, we removed the packing, used ice very freely, within and without, and repacked. This apparrently controlled the flow better than anything which had been done previously, but there was still the ominous clotless leaking. At the end of ten hours the leaking seemed partially improved, not restrained, but the general symptoms were worse; the patient was pulseless and cold, and we removed the packing; and, finding the os open, hastily emp ied the womb of its contents, not losing five minutes with the operation, and with better opportunities for the use of local remedies, and with strychnia and brandy hypodermically, continued our efforts. But all to no effect; in less than twentyfour hours our patient leaked her life away. The trouble in this instance must have been in the crasis of the blood. Not a clot was ever formed-not the smallest from the beginning of the attack to the last minute. This patient was a lady of fine physique, and in good health. I had attended her in four labors at full term, without any complication; and two years before had removed from

beneath the ramus of her inferior maxillary a large fibroid tumor. This operation was of course attended with quite a loss of blood, but I had no difficulty in controlling the hemorrhage, and could never account for the condition of affairs under which, or owing to which, she lost her life.

And I can recall other cases in which life was saved only by the most prompt and active measures; and others in which for lack of prompt and active measures life was lost.

I can not, therefore, regard the prognosis of abortion as otherwise than grave.

There is always danger of sepsis also following abortion, especially if we have to enter the uterus with fingers or with instruments; but this danger may be averted by antiseptic treatment.

Treatment.

Of the treatment of abortion, as far as prevention is concerned, we have already spoken to some extent in reciting the causes. The patient should lead a quiet life, avoid all causes of excitement, of every character, be put to bed once a regularly recurring menstrual periods, month, for a week, at the time for the

until the fetus is viable. She should

avoid all sexual congress. She should be kept on the plainest and most unstimulating diet. She should be placed for be any reason to suspect any specific months upon specific treatment if there the mother be kept upon five-grain doses trouble. Sir. J. Y. Simpson advises that of chlorate of potash, well diluted, three times a day for the whole period of uterogestation, on the theory of increasing the oxygen of the blood and diminishing uterine irritation and engorgement. I have had no experience with this remedy.

For Threatened Abortion.

There is generally some probability of arrest (except in the case of the habitual abortioner) as long as the fetus is alive and there is no hemorrhage. And, as it is impossible in most instances to say whether the fetus is alive or not, it is our duty to give the mother a chance to complete her term. This we can safely promise, provided the hemorrhage is not

too great. The patient should be put to bed in a cool and quiet room, only the nurse and necessary attendants admitted, and kept under the influence of opium, administered preferably by suppository, or enema, one grain every five or six hours, according to the severity of the pain. If the pain be severe when the physician is called, it is well to begin the opiate treatment by a hypodermic of one fourth of a grain of sulphate of morphia. And it will be well enough to impress upon the patient that her pain must be kept in abeyance; that pain in her case is a great evil as indeed pain in all cases is a great evil, and will be as long as the nervous system governs in all of the functions of the human economy. That late eminent practitioner, Dr. Dickenson of South Carolina, used to say that he killed a pain wherever he found it, as he killed a snake wherever he found it, and enquired what sort of a snake it was afterwards.

I am aware that these views of the use of opium will be considered heretical by many whose opinions are of weight, and that medicinally and morally it is considered a menace to the safety of many; but I will throw in the scales by which it is weighed fifty long years of conscientious labor, and the endorsement of all the experience which all those years have given me. The contention involves the old story of use and abuse. And I hold to opium still, as I hold to the lancet still, guarded by the conservative German motto: Accept of nothing because it is new; reject nothing because it is old."

In some cases, one of the elegant elixirs of viburnum, which are put upon the market so numerously, may be tried; but, if the pain be at all severe, opium in some form will have to be exhibited. Cool acidulated drinks may be administered, but the local application of cold is of questionable propriety, as it may bring

on uterine contraction.

Treatment of Inevitable Abortion.

But if, in spite of all precautionary and sedative treatment, the flow increases or persists, and the patient is becoming blanched and nervous, and the pulse is

quickened ten or fifteen beats in the minute, prompt and radical treatment should be at once adopted. Ergot, and the expectant plan, are not now to be relied on, and are dangerous. The woman should be placed upon a table or brought to the edge of a hard bed, the vagina douched with some antiseptic solution, as a two per cent. solution of carbolic acid, or creolin, or, preferably, with a solution of Tyree's Antiseptic Powder; and, using one blade of Sim's speculum, or the speculum of Edobohls, the perineum should be pulled down and the vagina thoroughly packed with sterilized or antiseptic gauze. This will prevent further hemorrhage, if effectively done, and the patient may be safely entrusted to the nurse for some hours. Uterine action will be certainly induced, and, on the removal of the tampon, at the end of twelve or twenty-four hours, the os will be found patulous, and the finger or forceps may be used to detach and romeve the contents of the womb. Occasionally, in the early stage of pregnancy, the fetus will be found extruded in the vagina, and sometimes, and fortunately, the secundines with it. But such fortuitous result is not to be expected. often. often. Generally the latter are retained, to give further trouble as long as retained-a menace to the mother's life, and a source of anxious care to the docHemorrhage or sepsis may confidently be expected, and we should lose no time in awaiting either.

tor.

If

If the condition of the woman should justify immediate interference, then there should be no delay in the operation necessary for their removal. The character of the operation necessary for this would depend upon the age of the fetus. past the third month, and the placenta be formed, this can usually be removed by the placental forceps. If any unusual adhesion, this process will not prove so easy of execution. Any member of this body who has ever encountered a case of this character will bear me out in this statement. The difficulty will probably consist in the retention of the deciduous membranes, or of an uterine mole, partially organized. Nothing is left to be done in such a case but to curette the

womb. This should be done under the use of chloroform, and should be done only under the strictest antiseptic conditions. Not only should the uterus and vagina be douched with some antiseptic solution, such as one of those just enumerated, but the external genitals, and all the parts adjacent, should be scoured and made thoroughly aseptic. And the physician himself should be equally careful of himself and his hands. The woman then being placed in position for lithotomy, the womb is brought down by vulcellæ, and steadied by the nurse and curetted by a moderately sharp curette. I use a curette, the handle of which is hollow and attached by india-rubber tub. ing to the douche bag, which enables me to curette and douche at the same time.

Objection is sometimes raised to the curette, especially the sharp curette; that there is danger of scraping through the wall of the uterus. Such danger, it seems to me, is very remote, and not at all comparable to the danger attendant on leaving the retained secundines in situ in the womb-not only provocative of hemorrhage as long as they remain, but also of sepsis.

If, after removing the tampon, the mouth of the womb is not sufficiently open to admit the finger or the curette, the divulsor should be used, and the operation completed. After the operation, when the womb has been emptied, it should be tamponned, but not the vagina, with sterilized gauze or iodoform gauze, which may be left in place for twentyfour hours. The subsequent treatment must conform to the condition in each individual case. With care and watchfulness on the part of the doctor and quiet and regimen on the part of the, patient, no danger may be apprehended from the operation, if done antiseptically.

And now, if the Fellows of the Society will bear with me in a personal allusion, I will say that the first curettage or scrap-. ing of the womb which I ever saw, or heard of, was done by myself, soon after the termination of the late war between the States. I was called to a lady who had had an abortion some month or more before I saw her, and who had bled dur

ing the whole time since, until she was almost exsanguine, nearer without blood than any living person whom I ever saw. On examination I found the mouth of the womb sufficiently patulous for the introduction of my finger, and, on introducing the finger, it impinged on some body entirely unfamiliar to my touch. I determined then to go into the womb, in the presence of, but without the approval of, two excellent practitioners, who made an unfavorable prognosis and declined to share the responsibility. I then fastened a small spoon to the end of a whalebone stick, such as we often see lying about ladies' chambers, and made my first curettage. I scraped out a great quantity of anomalous matter, but mostly of gelatinous character and filled with cells almost large enough to be taken for hydatids, and swabbed out the womb with a saturated solution of sulphate of iron, the hemostatic which we had used so generally during the war. There was no more hemorrhage; and I suppose I might say, in the language of the present day, my patient made an uneventful recovery. That statement was true as far as the operation was concerned, as perhaps many other statements to that effect are true, as far as the operation is concerned, but it was a long and tedious pull to get her up to health, for which the family physician should receive more credit than the surgeon.

32 Union Street.

Some Special Articles in the February Issue.

A PSYCOPATHIC HOSPITAL BETWEEN THE HOME AND THE ASYLUM, by Ernest Hall, M. D.; A SYSTEMATIC STUDY OF THERAPEUTICS, by Finley Ellingwood, M. D.; TREATMENT OF CONSTIPATION, by W. O. Bunnell, M. D.; SPECIFIC TREATMENT OF SMALL-POX, by T. C. Osborn, M. D.; TREATMENT OF SYPHILIS, by A. H. P. Leuf, M. D.; GYMNASTIC TREATMENT OF CONSTIPATION, by J. C. Elsom, M. D.; FORMALIN IN THE TREATMENT OF NECROSIS AND ABSCESS, by David Gordon, M. D.; DISORDERS OF THE MALE URETHA

AS SEEN BY THE GENERAL PRACTITIONER, by Lester Keller, M. D.; ERGOT IN LABOR AND PREGNANCY; VALUE OF COLD BATH IN TYPHOID FEVER; TREATMENT OF DRUNKARDS; DIET FOR EASEMENT OF LABOR; CHILD-BEARING IN AFRICA. We still have a few copies of the February number on hand to supply if you subscribe without delay.

Superheated Compressed Air in the Therapeutics of Chronic Catarrhal Otitis Media.

By GEORGE W. HOPKINS, M. D., Cleveland, O.

While engaged in conducting extensive experiments to determine the efficacy of superheated dry air in the treatment of obstinate joint affections, some five years ago, it occurred to the writer that this most important agency might be of some value in the treatment of those obstinate cases of chronic catarrhal otitis media which are characterized by ankylosis of the ossicles. With a view to determining the capabilities of the treatment in this direction, several typical cases were selected, the diagnosis in each instance being confirmed by colleagues of reputation as aurists, and suitable heating devices for their treatment constructed. The first case subjected to treatment is of especial interest at this time as it illustrates, in a measure, the possibilities of treatment even with the crude heater, employed at that time, and also because it has had the best test, that of time, the case having been discharged about five years ago.

The patient, John L. aged 53 years; a carpenter, with excellent family and personal history, has never been seriously ill, but has had nasal catarrh for fifteen years and gradually increasing deafness for ten years.

Examination revealed a typical case of hypertrophic rhinitis. The watch tick could be faintly heard with the watch in very close contact with the left ear. The tick could be heard to a distance of three inches from the right ear. The left ear was selected for the test.

Diagnosis-Chronic catarrhal otitis media, with sclerosis and displacement of the tympanum, ankylosis of the ossicles, slight dilation of the Eustachian tube, and some labyrinthine involvement.

The diagnosis was confirmed by two colleagues of reputation as aurists, before treatment was instituted. Regular, systematic treatment, continued for two years before this experiment was made,

Treatment-The ear was thoroughly cleansed with alcohol for several days before treatment was instituted. The patient was then seated in a comfortable chair, the ear examined and found perfectly clean. Narrow strips of dry gauze were packed into the ear and a large pad of dry gauze placed over the ear. The ear was then covered with the canvassleeve hot-air conductor, and a current of air sent into the canal at a temperature which gradually attained 400° F.

The temperature was easily borne, if gradually increased until a high point was reached, the only discomfort attending the treatment arising from a severe headache which followed it, but which was promptly relieved by a dose of codeine.

Following the hot-air treatment, the Eustachian tube was always inflated with a warm stimulating vapor from a Globe nebulizer, vibratory massage with the nebulizer completing the treatment.

The patient was not allowed to leave the office for a half hour after treatment, and the ear was tightly packed with warm cotton before he went out.

The nose and pharynx received appropriate treatment with antiseptic washes, etc.

Treatments were continued on alternate days for three months, at the end of which time he could hear the watch tick distinctly at thirty-four inches, and surprised his friends by invariably replying to their whispered references to him.

The right ear was then similarly treated, and in ten weeks an equally good result was secured.

Examination showed that the ears were normal in appearance. The patient was discharged January 6, 1897, and careful tests made at frequent intervals since have shown no tendency to recur

rence.

As to the philosophy of such a cure by this agency little can be said at this time, but it seems certain that the intense heat stimulates the circulation through the blood-supply on the posterior side of the manubrium, causing absorption of the