endeavors to use the municipal service, however, may assume considerable responsibility for her own decisions before receiving adequate information and guidance. The following is one example of the problem as it occurs in this situation:

Twenty-five year old para 1001, working as an aide in a State hospital, read about the
'long waiting list for abortion at City Hospitals' in the newspapers. The patient also
read that the waiting lists would get longer and the services would be 'swamped' be-
cause of Medicaid cutbacks. Abortion was therefore sought at one of the abortion
hospitals and a charge of $350.00 was quoted. The patient felt that this charge was too
expensive for her means. She learned that a friend had been ‘turned down' at Harlem
Hospital Center but did not know why the friend was refused; e.g., did not know the
duration of her friend's pregnancy (the sole reason for denial of service at Harlem
Hospital has been gestation beyond 20 weeks). She then decided that there was no
alternative but to obtain assistance to insert a catheter into her uterus, and several
days later, when bleeding and fever ensued, presented at the Emergency Room of
another hospital which ‘had no beds' and referral was made to Harlem Hospital Cen-
ter for care. In other words, the patient herself does the 'shopping'; in the private
sector, the doctor takes this responsibility.

e. Economic motivation and incentives The subtle but firm corrective pressures that are brought about when patients pay for services, as compared to the situation that prevails when staff see the provision of services as being 'charity', have not fully pervaded every aspect of the municipal hospital system. Slowly but surely these benefits are beginning to be reflected in elevated patient expectations and, secondarily thereby, in elevated staff performance. The preexisting attitudinal influences affect all staff (professional and allied), and have, in all areas of patient care, acted as some barrier to the delivery of the highest quality of service in general-they have only been illuminated by the spotlight of attention directed to abortion services in particular.

REFERENCES

1. SWARTZ, D. P., BULLARD, JR., T. H. and FELTON, H. T., 'Introduction of Contraception to an Urban Public Hospital', American Journal of Obstetrics and Gynecology, 97:189–196, January 15, 1967.

2. SWARTZ, D. P., CHO, Y. S. and FELTON, H. T., ‘General Observations from Five Years of Use of Anti-Fertility Agents in an Urban Municipal Hospital', International Journal of Fertility, 13:322339, October-December, 1968.

3. SWARTZ, D. P. and PATCHELL, R. D., ‘Abortion-Management at the Harlem Hospital Center, New York City', Current Therapy, 1972. Philadelphia, Pa.: W. B. Saunders Co. (in press).

4. SWARTZ, D. P. and PARANJPE, M. K., ‘Abortion-Medical Aspects in a Municipal Hospital', Bulletin of the New York Academy of Medicine, 47:845-852, August, 1971.

5. SWARTZ, D. P., PARANJPE, M. K. and POSNER, L. B., ‘Voluntary Abortion in a Municipal Hospital', International Surgery (in press).

ABORTION:

MEDICAL ASPECTS IN

A MUNICIPAL HOSPITAL*

D. P. SWARTZ, M. D. and M. K. PARANJPE, M. D.

Department of Obstetrics and Gynecology

Harlem Hospital Center

New York, N. Y.

HE problems of unwanted pregnancy and of woman's efforts to prevent it or to abort extend into antiquity. Ancient writings recommended the use of various concoctions in the vagina to prevent conception: crocodile or elephant dung, honey, and "tips of the shrub accacia" which, when fermented, can result in the formation of lactic acid. The Hippocratic Oath refers to the insertion of a “pessary" to

induce an abortion.

Induced abortion in Harlem Hospital, New York, N.Y., has been a grave gynecological problem through many years. Dr. Henry C. Falk, Jr., studied the patients and their many complications intensively.' In 1937 Falk classified the cases according to severity and prognosis, from the relatively trivial endometritis (Type I) to Types VI and VII involving generalized peritonitis, perforated uterus and, often, other visceral injury. Endotoxinemia and septic shock associated with abortion have been defined more recently.2

Methods used by patients and nonmedical practitioners in the at*Presented at a Symposium on Abortion, New York City-1970 held by the Section on Pediatrics of the New York Academy of Medicine, March 11, 1970.

Reprinted from BULLETIN OF THE NEW YORK ACADEMY OF MEDICINE Second Series, vol. 47, no. 8, pp. 845-852, August 1971

Copyright 1971 by the New York Academy of Medicine

tempt to induce abortion include: intracervical douche-soap, products advertised for "feminine hygiene," etc.; intrauterine foreign bodyrubber, plastic, or metal; cathartics with or without quinine; ergot compounds; and corrosives such as potassium permanganate tablets.

In 1962 this Department of Obstetrics and Gynecology was required to manage 1,581 "incomplete abortions" representing 42.2% of obstetrical deliveries (Table I).

Between 1963 and 1967, although the total number declined, deaths from complications of abortion continued to occur. In the two years 1968 and 1969 there were 517 and 507 admissions respectively for incomplete abortion, or 23.2 and 22.8% of the obstetrical deliveries; there were no deaths from abortion in those years. Although this is difficult to prove conclusively, as family planning services expanded in our hospital and area, the number and severity of abortion cases declined significantly.

Throughout those years the letter and spirit of the abortion law were observed rigidly and there were no more than six to 12 therapeutic abortions per year.

On July 1, 1970, with the implementation of the New York State abortion law, all this became part of a history which most obstetricians and gynecologists would like to forget. But the first few months of the new voluntary abortion program were not without difficulties. There were severe problems, of reorganization, technical training of staff, emotional and attitudinal readjustment, and a peak workload in vacation months. The general organization of our services and the

Bull. N. Y. Acad. Med.

TABLE II. ABORTION AT HARLEM HOSPITAL, JULY 1, 1975, TO
DECEMBER 31, 1970

adoption of the policy that abortion services should be an integral part of the total maternity-care program rather than a separate and distinct service have been described elsewhere.1

Despite the difficulties, a moderately satisfactory job was accomplished citywide. At Harlem Hospital we were able to keep pace fairly well with the local demand for service, so that the majority of patients had the operative procedure completed within two weeks, or a little longer, from initial inquiry.

Table II shows the volume of work performed during June to December 1970. The four principal methods in use are:

1) Curettage or vacuum evacuation.

2) Intra-amniotic instillation of hypertonic (20% solution) sodium chloride.

3) Hysterotomy (usually reserved for cases of more than 12 week's gestational duration, where the patient desired sterilization also). 4) Oxytocin stimulation-alone or after instillation of sodium chloride.

Since I have been asked specifically to comment upon the medical aspects of abortion as we have observed them, I shall describe briefly some of the problems that each of these methods present.

CURETTAGE AND VACUUM EXTRACTION

Evacuation of the early pregnancy can be accomplished quite satisfactorily by dilation and curettage. However, as the uterus enlarges beyond the size of nine-weeks' gestation, curettage becomes time-consuming, the loss of blood increases and may be excessive, and in some

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instances the contents of the uterus may be evacuated incompletely. The vacuum or suction technique is more expeditious, and usually causes smaller losses of blood. The powerful suction necessary to accomplish the procedure satisfactorily does pose a serious hazard to neighboring viscera in the event of uterine or cervical perforation. The risk of uterine perforation is present even for the most experienced operator, but this risk undoubtedly diminishes with experience.

Regardless of the specific technical method employed, there is significantly less emotional impact on both staff and patients when abortion is completed within the first trimester of pregnancy.

Later complications include secondary hemorrhage, pelvic infection, secondary infertility or sterility, and the cervical incompetence syndrome in later pregnancy."

INTRA-AMNIOTIC INSTILLATION OF SODIUM CHLORIDE

This method has had the handicap of the absence of a fully approved commercial solution of 20% sodium chloride. Most operators agree that interruption by this technique prior to 16 weeks of gestational duration has been generally much less satisfactory than for pregnancies of between 16 and 20 weeks' duration.

Obesity may render amniocentesis difficult, and underestimation or overestimation of uterine size have presented difficulties. An ovarian cyst may be mistaken for the uterine corpus.

The aspiration of blood at the time of amniocentesis indicates an increased risk of intravascular saline infusion with the possible development of the hyperosmolar syndrome, which can be a very serious complication. The presence of impaired renal or cardiac function contraindicates the administration of this high load of sodium chloride.

The patient undergoing abortion in the second trimester of pregnancy can of course experience all of the complications of the puerperium, namely hemorrhage, infection, retained placenta, etc.

HYSTEROTOMY

This is a major operative procedure and carries with it all the risks of such surgery: anesthesia, operative, and postoperative. In addition, if the patient does not desire sterilization, the uterus does bear the incisional scar which creates an additional management problem in subsequent pregnancy.

Bull. N. Y. Acad. Med.