Abortion, as the term is used by physicians, in its widest sense is the ejection or extraction of a fetus from the womb at any time before term. The word is popularly contrasted with miscarriage, where the fetus is ejected through disease or accident; abortion in the lay sense supposes artificial, and commonly criminal, extraction of the fetus. Abortion (from aboriri, to perish) etymologically has an association with destruction of life, but the name is given by physicians to a removal of any premature fetus, even if it is viable. Strictly, however, abortion is an interruption of pregnancy before the fetus is viable, and premature labor is such an interruption after the fetus is viable. Throughout this chapter the words are used in this sense.

Abortion as a medical and moral consideration may be considered from several points of view.

First, involuntary pathologic and accidental interruptions of pregnancy are to be averted, if it is possible to do so, to save the life of the child; and when the abortion is inevitable the treatment has moral qualities which involve the physician and the mother.

Secondly, voluntary and therapeutic abortion has peculiar moral and medical qualities arising (a) from the period of gestation or the viability of the child; (b) from the truth or error in the diagnosis as regards the necessity for interference, and the advantage or damage resulting from the interference.

Thirdly, the technical skill or ignorance of the physician, and the methods he employs may in themselves in any case avert or cause the death of the mother or grave injury to her, and in the forced delivery of premature infants may save, kill, or maim the child.

Fourthly, voluntary criminal abortion has a special malice of its own, which makes it somewhat more criminal than the therapeutic removal of an inviable infant.

Fifthly, there are positive canonical and civil penalties against abortion as it affects the inviable infant.

Pathologic abortions, and those arising from accident or carelessness, are extremely common. Hegar estimated that there is one of these abortions to every eight normal parturitions, and specialists in obstetrics find as many as one abortion to four deliveries at term. These abortions are most frequent from the eighth to the twelfth week of gestation, because the ovum is then not firmly attached to the uterus, and it readily succumbs to external influence. Moreover, the woman is not certain she is pregnant and neglects precautions. Many women, again, are under the error that there is no moral evil in getting rid of the ovum before quickening, and they think quickening occurs only when they feel the fetal movements. Others, erroneously again, fancy that abortion in the early months is not dangerous or injurious to themselves.

The causes of pathologic and accidental abortion are very numerous and often interactive. They may arise from the fetus, the mother, the father, or from violence. The death of the fetus, or diseases of the fetus itself or of its appendages, cause abortion. Weakness of the fetus from alcoholism in the parents, anemia, carbon monoxide and lead poisoning, tobacco poisoning in women who are cigar-makers, and similar conditions in one or both parents, will bring on abortion. Monsters rarely go on to term. Acute or chronic affections in the mother, as typhoid, malaria, smallpox, cholera, scarlatina, measles, tuberculosis, and the like, and syphilis in the mother or father, effect abortion. Other abnormal states that bring on abortion are low blood-pressure in maternal anemia, shock, syncope; hemorrhages into the placenta in maternal nephritis; hemorrhages between the placenta and uterus from diseases of the placenta and decidua, or from traumatism, which detach the placenta; sun or heat stroke; sudden high temperature in fever; toxemias, as in some forms of hyperemesis gravidarum, eclampsia, chorea, hepatic autolysis, and impetigo herpetiformis.

Chronic endometritis, or inflammation of the lining membrane of the uterine cavity, is the commonest maternal cause of abortion, especially of habitual abortion. In this condition hemorrhages in the decidua, or uterine fold that holds the fetus, kill the fetus, or force the ovum off the uterine wall, or excite expulsive uterine contractions. Without hemorrhage endometritis prevents a firm fixation of the ovum, or it may bring about a malposition of the placenta, called placenta praevia. Endometritis at the decidua may cause hydrorrhoea gravidarum, and the accumulated serous secretions from this source are likely to start uterine contraction. Chronic metritis, or inflammation of the deeper tissues of the uterus, is commonly found with endometritis, and it prevents the expansion of the uterine muscle. This condition is more likely to cause abortion than endometritis alone.

Acute gonorrhea, inflammations of the Fallopian tubes, and appendicitis sometimes interrupt pregnancy. Other causes are malformations and diseases of the uterus, infantilism, fibroids, polyps, uterine horns, lacerations and amputation of the cervix, and retroversions and retroflexions of the uterus. At times a replacement of the uterus will avert an abortion.

When the mother has an infectious disease like typhoid, smallpox, cholera, or typhus, the infection may reach the fetus and kill it, or may cause an endometritis with a hemorrhagic tendency. Maternal sepsis may kill the fetus directly or secondarily, and this is true also of maternal syphilis. A sudden rise in temperature may excite expulsive uterine contraction. In pneumonia the excess of carbon dioxide in the blood may bring on abortion. Like pneumonia, anesthesia may kill the fetus if kept up for a long time, or if marked by cyanosis. Prolonged nitrous-oxide anesthesia is especially dangerous to a fetus, but a brief nitrous-oxide anesthesia for the extraction of a tooth may not bring on abortion. The worst tooth stump can be extracted painlessly after local injection of novocain, with no danger to the fetus. The gums remain somewhat sore for a day or two after novocain infiltration, but this inconvenience is a much less evil than total anesthesia, even when there is no pregnancy. It is probable that total anesthesia is morally unjustifiable for the extraction of a single tooth if the tooth is not wedged in.

Violence, accidental or intentional, is a frequent primary or secondary cause of abortion. Sometimes a slight jar, a misstep on a stairway, a nervous shock, a jump from a carriage-step, lifting weights, running sewing-machines, sea-bathing, a rough automobile ride, will bring on an abortion where there is a predisposition. Often in healthy women, on the other hand, extreme violence does not interrupt pregnancy. Surgical operations are classed here with violence. In a neurotic woman a slight operation on an organ not directly connected with the uterus will start expulsive contractions. Again, 66 per cent. of operations on ovarian tumors during pregnancy have left the uterus undisturbed. De Lee says he has removed fibroids from the pregnant uterus, once even exposing the chorion, and has amputated the cervix of a gravid uterus, without interrupting pregnancy. Several cases have occurred where both ovaries have been removed during pregnancy without abortion. The breast has been amputated and a kidney removed from a pregnant woman[79] without disturbing the pregnancy. Wiener[80] did eleven operations for ovarian tumors during pregnancy with only two abortions. Von Holst[81] removed a myoma weighing two and a half pounds from the uterus at the seventh month of gestation without abortion. Davis of Birmingham, Alabama, reported[82] that a woman three and a half months pregnant was shot in the abdomen. The rifle bullet made twenty-five perforations in her intestines. She was taken eighty-five miles, and then Davis cut out five feet of the intestine. She recovered and gave birth to a living child at term.

Double ovariotomy brings on abortion in the early months of pregnancy oftener than in the later, probably from the loss of the corpus luteum, which, it appears, is necessary for the growth of the uterus. Appendicitis and appendectomy are especially likely to interrupt gestation, apparently as a result of infection and because pregnant women are prone to defer operation. The traumatism of criminal abortion, punctures and lacerations from bougies and curettes, and the exhibition of drugs like ergot and cantharides, are sources and results of abortion. Drugs will not empty the uterus unless they are given in poisonous doses which endanger the woman's life.

In the father, syphilis, tuberculosis, general paresis, general debility from alcoholism, unchastity, and senility, and septic conditions of the generative tract, may cause abortion. Many men who work with lead, phosphorus, mercury, or X-rays are sterile, and before they become totally sterile their condition appears to cause debility in the fetus which leads to abortion. In paternal lead poisoning there is a reduction of about 20 per cent. in the weight of the infants at birth, and a general weakness and retardation of the child. The children of lead-poisoned fathers are frequently permanently under weight.

Coition during gestation is a cause of abortion, and the fault here, as a rule, lies with the husband. St. Thomas[83] said: "St. Jerome protests against the sexual approach of the husband to his gravid wife, not that in this condition such an act is always a mortal sin, unless there is probable danger of abortion." St. Alphonsus[84] says if there is danger of abortion the use of the debitum is a grave sin. In n. 924 he again teaches that while it is true that if by the use of the debitum the life or formation of the fetus is endangered or checked the right to the use of the debitum is, in such circumstances, lost, yet he thinks that in pregnancy there is little danger of abortion from this cause, especially near term.

Sabetti-Barrett[85] says the wife is excused from the debitum conjugale if the husband is drunk, or if there is a rational dread of grave injury, or grave danger to health. Genicot[86] thinks that in pregnancy it "can scarcely be shown that there is a notable danger of abortion." Lehmkuhl[87] holds that a married person is not obliged to grant the debitum if there is great danger of abortion; but, he adds, "Even then, if there is a grave danger of incontinence I do not think it certain that there is an absolute obligation to abstain."

Unlike Lehmkuhl, moralists agree that if there is real danger of abortion from marital congress, such an act is illicit, but they are inclined to think that there is little or no danger of abortion, especially at the end of gestation. Authorities on obstetrics, on the contrary, say that one of the causes of abortion in the early months of pregnancy is marital congress; and one of the sources of sepsis in women, which may result in the death of both mother and child, is certainly congress at the end of gestation. This causation of abortion is found especially in neurotic irritable women, in such as have diseases of the generative tract, or a tendency to habitual abortion. Whenever a woman shows any tendency to bleeding during gestation the use of the debitum is undoubtedly contraindicated, because of the proximate danger of both abortion and septic infection. Toward the end of pregnancy the danger from sexual commerce is the risk of infecting the woman's vagina with bacteria which may bring on sepsis through the abrasions incident to parturition. The staphylococcus pyogenes albus, a dangerous septic microÖrganism, exists as a saprophyte in 50 per cent. of male urethras, and the bacillus coli communis is another source of infection from the father during pregnancy. De Lee saw two cases of sepsis that killed both mother and child from such an infection shortly before term. If a physician now examines a woman before delivery without using all the precautions known to prevent sepsis, such as wearing a sterile rubber glove, he is guilty of malpractice; yet certain moralists are inclined to let a husband do what he likes. Moralists talk about the fetus as protected in the membranes. That is nonsense, because it has no relevancy to the question. It can have the slight relevancy of untruth when the woman is rendered septic, because then the membranes are no protection at all.

The mortality statistics of the United States Census Bureau show that a little more than 42 per cent. of the infants who died in the registration area in 1911 did not last throughout the first month of extrauterine life, and of these babies almost seven-tenths died of prenatal and delivery abnormalities. In 1912, in the registration area, which then took in 63.2 per cent. of our population, the total death-rate of infants under a year old was 9035, and of these 3905 died of puerperal infection. In the entire country a very conservative estimate of the annual number of deaths of infants from puerperal sepsis is 5000; and about 15,000 women die here yearly from this etiology alone. Of course most of these deaths are caused by unclean midwives and quacks, but a large number of them are brought about by incontinent husbands. Invalidism from puerperal sepsis happens many times 15,000. Moreover, one-third of all the blindness in the world is caused by septic infection of the eyes at birth and virtually all this septic infection of the eyes is carried in by diseased husbands, although not necessarily by coitus during gestation.

Coition during pregnancy is unnatural because it necessarily fails of the end of coition, which is procreation. Curiously, too, all the lower animals instinctively appear to avoid this act during pregnancy. Men should be told that marriage has restraints as well as celibacy. Women are reminded of the law of the debitum, but not of the occasions when they are even obliged to deny it. If a man cannot keep continent in the presence of his pregnant wife, let him live in another part of the house. Regard for the woman is lacking in many ways. Young girls often marry without having the faintest notion of sexual life, and they are panic-stricken when assaulted. I have known two who were frightened into insanity. Priests should tell young married men that they are human beings, not animals; that they should act like rational beings when they are first married; and that after the wife has become pregnant the husband should not be the cause of abortion in the first three months, nor of puerperal sepsis in the last three months. Priestley,[88] in 2325 pregnancies, found one abortion in every four pregnancies; Guillemot and Devilliers in France, Hirst in Philadelphia, and others report the same proportion. These are natural, not criminal, abortions. If, then, in normal pregnancies about one child in five is lost before birth, husbands should be taught a continence which would to some degree avert this calamity. Superfetation has occurred by coition during pregnancy, and this results commonly in abortion and the death of both fetuses.

Premature labor in cases where the child is viable is produced by the same agencies that interrupt gestation in the early months. Obstetricians think that syphilis is the commonest cause of premature labor, and they estimate that from 50 to 80 per cent. of these premature births are due to syphilis. In a series of 705 fetal deaths in Johns Hopkins Hospital, 26.4 per cent. were due to syphilis. After syphilis the cause of premature labor next in frequency is nephritis with placental hemorrhages and infarcts. Twins are not seldom delivered prematurely because of lack of room in the uterus. For the same reason any tumor of the uterus or abdomen may cause an abortion.

When successive pregnancies are interrupted prematurely the abortion is said to be habitual, and again the commonest cause is syphilis. In this disease, as the virulence of the infection decreases, the gestation is prolonged until a child is born infected with congenital syphilis. This child commonly dies, and later a child strong enough to live appears. Correct treatment of the parents will avert this slaughter of the innocents. Sometimes the syphilis is latent so far as clinical symptoms are concerned, but we may find a positive Wassermann reaction. Hubert reported[89] that 8.8 per cent. of 8652 patients in a clinic at Munich where all were subjected to the Wassermann test had latent syphilis, and in 52 per cent. of these cases in men, and 75 per cent. in women, the infection was altogether unknown to the patients.

Chronic endometritis, where there is no syphilis, will permit habitual abortion, and each abortion makes the condition worse. Nephritis, diabetes, and other constitutional diseases cause habitual abortion.

In the first two months of gestation the decidual fold which holds the ovum against the uterine wall is thick, vascular, and friable. The contracting uterus in abortion expels the decidua with considerable difficulty, but the ovum containing the fetus may slip out easily and be lost. A fetus two months old is about three-fourths of an inch in length. If a physician, nurse, or other person finds the ovum, no matter how small it is, they should open it at once with a scalpel or scissors and baptize the fetus conditionally, even if no sign of life is perceptible. If the fetus is unmistakably dead—a diagnosis not easily made—there is no use in attempting baptism; but always give the fetus the benefit of the doubt. In the first six or eight weeks the whole ovum is usually born developed in decidual tissue; sometimes the ovum will slip out of the decidua and be covered only with shaggy villi, suggestive of a chestnut burr.

During the third and fourth months there may be (1) an abortion of the whole ovum; or (2) the membranes may rupture, the fetus be expelled, and the secundines remain in the uterus, and these may have to be removed by instrument or finger; or (3) the decidua reflexa and the chorion may split and let out the fetus into the amniotic sac: here again the remaining secundines, if they do not come away spontaneously, must be removed. Abortion after the fifth month is like a regular labor at term, but not so energetic.

An abortion may be threatened, inevitable, or incomplete. In each of these conditions there is uterine pain and hemorrhage. In inevitable and incomplete abortions we find softening and dilatation of the cervix, and a presentation or expulsion of part or all of the ovum.

In pregnancy uterine hemorrhage and uterine pain are symptoms of a threatened abortion, but not certain symptoms. Fromme found that 17.9 per cent. of 157 women who had these signs in the early months went on to term. If the fact of pregnancy is not known it is not always easy to differentiate a threatened abortion from other uterine conditions, like chronic metritis, ectopic gestation, a fibroid or other tumor, hemorrhage from cervical erosions or varices, or malposition of the uterus. If the abortion is inevitable the diagnosis is made more readily. The cervix is then more or less dilated and the ovum is palpable. There is rather profuse hemorrhage, flooding, and painful uterine contractions are evident. The rupture of the bag of waters may be simulated by the escape of secretions in hydrorrhoea gravidarum, or the escape of waters may be a primary symptom of graviditas exochorialis. Hydrorrhoea gravidarum is an intermittent discharge of clear or bloody fluid from a catarrhal endometritis under the decidua. It occurs in anemic, weak women, especially multiparae. In graviditas exochorialis the fetus is left within the womb but outside the ruptured chorion, and it may remain there for some time.

When an abortion is incomplete it is absolutely necessary to learn whether the entire ovum and decidual tissue have been expelled or not. When a part or all of the dead ovum is retained the consequences are so grave that they may result in the death of the woman or cause chronic invalidism. Sepsis may result, a placental polyp may form, and even syncytioma malignum may start—this fatal tumor, however, is not so common after incomplete abortion as after hydatid mole formation.

The prognosis as regards health is worse after abortion than after normal pregnancy. The involution of the uterus is slower than in full-term cases, and if infection has occurred there is great likelihood of a chronic endometritis and metritis. The woman may be rendered sterile, or she may become a chronic invalid to be cured only by capital operations.

In threatened abortion examination is to be avoided unless it is absolutely necessary for diagnosis, and then great gentleness is required so as not to excite uterine contractions. The woman is to rest in bed, not so much as raising her head to take a drink of water (which is given to her through a tube), and she is morally obliged to submit to this inconvenience. If she refuses she is accountable for the death of the fetus. If there is bleeding the foot of the bed should be elevated as in hemorrhage in typhoid fever. The routine practice is to quiet the woman and the uterine irritability with morphine and other opium derivatives. Children are readily overwhelmed by opium because their circulation is not sufficient to neutralize the deoxidizing effects of the drug up to safety. While the embryo is connected with the maternal circulation through the placenta the mother's circulation often safeguards the fetus from the effects of the opium. The danger to the child in such cases begins from the opium remaining in its circulation after the child has been separated from the mother. Often, however, fetuses in cases where scopolamine and morphine have been used on the mother during labor are born badly, and even fatally narcotized, despite the connection with the maternal circulation. Nevertheless, even if there is some real danger to the fetus from the use of morphine in a threatened abortion, the cautious use of this drug would be morally justifiable. Should the threatened abortion go on to actual abortion, the fetus will certainly be killed, but the use of morphine on the woman is the best and virtually the only means we have to avert a threatened abortion and so save the fetal life. The immediate double effect from the morally indifferent act of giving a dose of morphine is, on the good side, the saving of the fetal life, and on the other, the evil side, the danger of fetal narcosis, which is not at all certain to follow. Evidently, the good intended effect far overbalances the evil and somewhat hypothetical effect.

After about five days, if the bleeding ceases, the woman may be permitted to go back to her ordinary routine of life, but with extreme caution, and she must return to bed at the slightest show of blood. Morphine is used at the beginning to quiet the patient and the irritable uterus. If the cervix is eroded, applications of a 10 per cent. nitrate of silver solution are made. The bowels are kept locked for three days and a softening enema of olive-oil is used before emptying the bowel.

If the bleeding starts again every time the woman goes about her duties, the abortion may be inevitable. When the cervix is shortened and dilated so that the ovum is palpable and pieces of the decidua or ovum are expelled, the hemorrhage is more or less profuse, and especially if the bag of waters has ruptured and uterine contractions show, the abortion is deemed inevitable. In such a case the fetus may be alive, or it may be dead; and, again, conditions which show all the classic symptoms of inevitable abortion sometimes, though rarely, do not go on to abortion. It is extremely difficult, and often impossible, to tell whether an early fetus is dead or alive. A high, lasting fever sometimes kills the child; so do low blood-pressure, profuse hemorrhages, deoxidation of the blood in pneumonia, separation of the placenta, fatty degeneration of the placenta, and the severe infections—in such cases there is always strong probability that the child is dead when the abortion shows its symptoms. If the fetal tissues that appear indicate maceration, or if the discharge is fetid or purulent, the fetus is dead. Should the fetus be alive, tamponing the vagina to check the hemorrhage often separates the fetus from the uterus by the dissecting force of the blood dammed back, or in any case tamponing is almost certain to excite uterine contractions; thus there is an indirect killing of the fetus.

The treatment of inevitable abortion after the fifth month differs very much from the methods used in the early months. The prime principle is, never interfere until forced to do so. When the hemorrhage is dangerously profuse, so that the woman's life is endangered (an exceptional condition), the uterine cervix and the vagina must be tamponed with sterile gauze and cotton to check the bleeding, but this is a last resort. If the fetus is alive, or probably alive, nothing short of a necessity to save the woman's life by this means justifies the use of the tampon. De Lee advises the routine use of the tampon in threatened abortion, but this doctrine is erroneous medically and altogether false morally. If the physician knows the fetus is dead, he should, of course, tampon at once to get rid of the fetus. The tampon excites uterine contractions and causes destruction of a living fetus by dissecting it loose from the uterine wall through the dammed blood. Elevation of the foot of the bed and the use of morphine will, as a rule, check the bleeding.

When the woman is bleeding to the risk of her life, the tampon is put in to check the bleeding and so save her life. The double effect immediately following this indifferent act is on one side good, the saving of her life; on the other side evil, the killing of the fetus. The good effect is intended, the evil effect is reluctantly permitted. Such a procedure is morally licit.

Where a tampon must be put in, it is left in from sixteen to twenty-four hours, even if the temperature goes up. During this time there are painful contractions of the uterus, as a rule, and these are expulsive. No drug is to be given to allay these pains if the intention is to have a dead or viable fetus expelled. If the pains cease suddenly, this is usually a sign that the fetus has been expelled above the tampon. When the tampon is removed and the entire ovum is found, it is best for the ordinary physician not to meddle with the uterus in any manner. Some advise that the physician should go over the uterine lining with a half-sharp curette to make certain that nothing has been left behind, but this is dangerous advice to any one who is not an expert obstetrician. Should the temperature remain above 100 degrees, the uterus must be cleaned out, and flushing with uterine catheters is not enough: if the gloved finger cannot remove the secundines, the curette is needed.

If, when the tampon has been removed, no ovum is found and the cervix is still closed, another tampon is to be put in for another twenty-four hours, supposing the removal of the ovum is licit. Forcible dilatation of the cervix is always a dangerous operation, and should never be employed when avoidable. Steel dilators have ruptured the uterus and killed the patients again and again even when used by experts. Laminaria tents are not to be recommended; the tamponade is enough.

When the retained ovum cannot be removed by the finger or squeezed out, the free portion of the ovum is to be grasped by an ovum forceps and gently drawn out. The operator should be sure he has a part of the ovum in the forceps and not a part of the uterine wall. If he bites into the uterine wall (a common catastrophe), he may pull a hole in that wall, and then the woman will probably die unless the rent can be closed immediately after opening the belly. When the abdominal cavity has been opened in such an event, the uterus is also to be opened, cleansed, and sutured. This method is safer than curetting where there is a rent. If one is certain the gut has not been injured—and it is extremely difficult to be certain—vaginal anterior hysterotomy may be substituted. Sometimes perforations, when the uterus is not septic and the instruments are clean, are not dangerous. Rest in bed, ice-bags, ergot, and opium cure without operation.

Physicians who are called into an abortion case should always be certain that no one has attempted to pass sounds, curettes, or similar instruments, because a perforation may have been made by the meddler which will be charged to the second man himself.

If a uterus is flexed it is easy to poke a curette or like instrument through it at the bend, especially if the uterus is thin or friable from sepsis. Again, the placental site is raised, it feels rough, and the furrows in it lead one to think part of the placenta is still adherent, whereas all has been removed. Repeated scraping, due to this error, may dig a hole through the uterine wall. Perforation in a septic case is practically always fatal to the woman. The use of the curette supposes a special technic, and no physician should presume to try its use unless he has been carefully and practically instructed.

In inevitable abortion after the third month it may be very difficult to get the embryo out. The cervix, in primiparae especially, may be long, thick, and hard. If the fetus is dead, it may then be removed by morcellement—i. e., by cutting and breaking it into pieces, and then taking out these pieces with an ovum or stone forceps. Sometimes, though rarely, the operator may find it impossible to get the entire fetus away. Then the uterus is packed with weak iodine gauze, and after twenty-four hours the fetal remains are expelled.

In every abortion the presence or absence of extrauterine pregnancy is to be made out. If there is an extrauterine pregnancy, curettage will cause rupture of the sac.

When the interior of the aborting uterus has become septic the old treatment was to empty the uterus at once, but now the treatment is expectant, because the traumatism of the curetting makes the sepsis worse. The commonest and worst infections are of the streptococcus putridus, a pus staphylococcus, and the bacterium coli communis. Curettage lets these microÖrganisms enter the circulation. The cause of this condition is often unskilful attempts at artificial abortion. When the womb contains decomposing material bleeding usually obliges tamponing, and thus often the uterine contents come away in twenty-four hours with the gauze. If there is no hemorrhage there should be no tamponing: it is then better to get dilatation by packing and drain the uterus with gauze. The curette should not be used at all.

Where there is habitual abortion the cause must be found. During gestation syphilis and displacements of the uterus, as causes, may be treated. Endometritis can be cured only when the uterus is empty. Rest in bed at the time when these abortions usually occur, and at the time when menstruation customarily appears, is required. Treatment of the husband is often necessary, as he is virtually always the source of luetic infection.

Attention or inattention to the mother's own hygiene during pregnancy has great effect on the fetus, and care of hygiene may avert abortion. The woman's dress should be simple and warm enough to prevent congestion from changes in temperature. Congestions are likely to affect the kidneys, and care of the renal function is always one of the most important facts connected with pregnancy. No circular constrictions of the trunk by lacing or stiff corsets should be attempted. The corset forces the uterus and child downward into the pelvis and against the lower abdominal wall, causing congestion of the pelvic veins and strain on the abdominal muscles. Tight corsets, preventing the expansion of the uterus and the growth of the fetus, may cause mutilations like club-foot and wry-neck, or even kill the child. The woman who would "preserve her figure" by corsets, to the mutilation, weakening, or killing of her unborn infant, and this is an every-day evil, is either a criminal fool or an unmitigated scoundrel. Tight lacing to conceal pregnancy is a method of murder. High-heeled shoes are somewhat injurious because of the constrained position into which they throw the woman. X-ray photographing of pregnant women is very likely to cause abortion.

The woman's diet should be simple. She must abstain from all alcoholic liquors even if she has been accustomed to their use at meals. She should not overeat on the supposition that she has to feed two persons. Some popular books advise a special diet to reduce the bone-salts and thus get a smaller baby and one more easily delivered. Such advice is criminal. The constipation of pregnancy is not to be treated by strong cathartics like Epsom salt. The kidneys are to be watched; therefore the urine should be examined every three weeks up to the seventh month, then oftener. If there is any suspicion of toxemia or nephritis, the urine should be examined daily. Obstetricians who have any regard for their own conscience and reputation will have nothing to do with a woman who refuses to take this precaution.

Physical exercise should be gentle—say, walking, up to two miles in the daytime. The vast majority of women are too lazy to take physical exercise as a hygienic duty at any time, and during pregnancy their aversion to all effort to overcome indolence is so great they make even themselves believe they cannot. Just as most professional men think they think, most women think they work. There are thousands of women who have servants, yet make not only their families and friends but themselves believe they are worked to death, and their work is the spreading of four or five beds, and the ordering of groceries over the telephone. When these women are pregnant they quit even the bed-making.

Cold and hot baths, Turkish and Russian baths, hot sitz-baths and ocean bathing are not permissible during gestation. Tepid baths and spongings are to be substituted. Near term the bath-tub is not safe because of danger of uterine infection from unclean water. Then shower-baths are better, but these are dangerous if the woman must step over an enameled bath-tub side to take them, because she may slip and fall. Vaginal douches are not to be used in pregnancy except in certain diseased conditions, under the direction of a competent physician.

Therapeutic abortion and therapeutic induction of premature labor are employed in five chief groups of conditions: (1) contracted pelvis; (2) diseases caused by pregnancy; (3) diseases coincident with pregnancy; (4) habitual death of the child after viability but before term; (5) prolonged pregnancy. There is no such act as therapeutic abortion of an inviable child; all abortions of inviable children, when direct, are criminal, and nothing criminal is therapeutic. The consideration of narrow pelvis, and the diseases caused by pregnancy and coincident therewith, will be treated in detail.

When the child dies after viability but before term the cause is most commonly syphilis. In such cases a Wassermann reaction should be made from both parents; and even if it is negative, and no other definite cause for the fetal death can be found, syphilitic treatment should be tried on the father and mother. Bright's disease, even when scarcely diagnosable, anemia, diabetes, adiposity, and hypothyroidism are other lethal causes of habitually still-born infants. Not seldom the cause is in the husband. If he is an alcoholic (and two or three drinks of whiskey a day make any man an alcoholic), if he is especially susceptible to the toxin of tobacco (and tobacco alone may render some men not only sterile but impotent), if he is a worker in poisonous metals, an X-ray operator, a user of narcotics, exhausted with overwork and worry, affected with weakening systemic disease, his germ-cells are unfit for their function. Such men are not technically sterile, but they are practically sterile.

Some women carry the child beyond term, with the effect that the baby is overgrown for normal delivery. The head is harder and more angular than it should be, the long bones stiffer and less pliable, the muscles tenser. All these changes make the delivery so difficult that the overgrown child may be fatally injured at birth. Physicians must be cautious in believing histories of enormous children at previous births at which they were not present. Mothers and nurses are likely to exaggerate the size of infants.

In cases where the children die at a particular time before term, premature labor should be induced to save the child, and when the child has been carried over term it may be necessary to induce labor. In the first condition labor is not to be induced a week earlier than is necessary. We talk so much of a seven months' child as viable that we forget that any child born before the thirtieth week of gestation has very small chance for survival. From 30 to 60 per cent. of all prematurely delivered infants die. The maternal passages do not dilate normally and the child is unformed; its bones fracture readily; it cannot sustain pressures and strains. All induced labors are dangerous to the mother by shock and possible infection, and only very grave necessity justifies any such procedure.

In inducing necessary premature labor the technical method may take on a moral quality. There are over a score of methods, and many of these, although used, are dangerous and should be obsolete. A very common method, begun in 1855, is to insert one or two elastic solid bougies into the uterus between the membranes and the uterine wall. This is a dangerous method and should be obsolete. Other dangerous and obsolete methods are the puncture of the membranes with a trocar high up in the uterus; intrauterine injections of hot or cold water, glycerine, milk, and other liquids; vaginal tamponade alone; irrigation of the vagina with carbon-dioxide water; a stream of hot water directed against the cervix, electricity, X-ray, dilatation of the vagina with a rubber bag, irritation of the nipples, the use of drugs like quinine, cimicifuga, ergot, or cantharides.

If haste is not necessary, packing the cervical canal and the lower uterine segment antiseptically with a strip of gauze three to five yards long and three inches wide and leaving it in for about twenty-four hours is one of the best methods. Where rapid delivery is required, cesarean section must be employed. In cases of somewhat less urgency the membranes are first punctured and balloon dilators are used. In any case puncture of the membranes is the most certain method to start labor, but it has many bad disadvantages. A dry labor in a primipara with an undilated cervix is a grave condition. If the fetal head is not engaged in the pelvis, puncture must not be attempted. When the head is not engaged in the pelvis like a ball-valve, the cord will prolapse, be pinched, and thus the blood supply will be cut off from the child and the loss will kill it. For the same reason, the waters must not be run off too quickly. Many operators insert a bag, dilate, and so start the labor, without puncturing the membranes, where there is no reason for haste.

Therapeutic abortion, as has been said, is never permissible, under any circumstances, if the child is not viable. In certain conditions, say, when a uterine tumor clearly threatens the life of the pregnant woman, or if in extrauterine gestation there is a rupture of the tube, an operation may be permissible, or even obligatory, which has for its direct end the removal of the tumor or the stopping of the hemorrhage. If such a removal or ligation, under these conditions, indirectly causes the abortion of the inviable fetus, or its death from a lack of blood, these indirect effects may be reluctantly permitted. They are cases of an equally immediate double effect, one good and one evil, where all the requirements are fulfilled. A direct abortion of an inviable fetus, however, is never licit even to save the mother's life, and in abortion the killing is direct because it is used as a means to an end. In a ruptured ectopic gestation the primary effect of the physical operation is to ligate the torn arteries to save the woman's life here and now; the secondary effect is the permitted death of the fetus from the shutting off of the blood supply. In the abortion of a premature fetus the primary effect of the operation is to separate the placenta from the uterus, to cut off the child's blood supply, and as a direct consequence of this act, which is essentially evil, the woman's life is saved. The original act in this abortion is evil, and evil may not be done even if good follows. Even in self-defence against an unjust aggressor one may not kill a man to save his own life—he tries to save his own life and reluctantly permits the death of the aggressor. In a killing in self-defence there are two distinct effects; in abortion there is only one effect, and the killing is a means to this one effect. That you may kill an irresponsible insane man who is attacking your life, or the life of one entrusted to your care, is no reason that you may attack a fetus in the womb. There is no parity. The insane man is a materially unjust aggressor; the fetus is not an aggressor at all. The mother placed it where it is; and if any one is an aggressor, she is. In the abortion you directly kill the fetus and indirectly save the woman's life, and this indirection uses the death of the fetus as a means to the end of saving the woman's life. In killing the insane aggressor you directly save the life of yourself or your ward, and reluctantly permit the death of the aggressor. The proofs of the essential immorality of direct homicide have already been established in the general chapter on Homicide.

The assertion that an undeveloped fetus in the womb is not as valuable as the mother of a family is beside the question, and in certain vital distinctions it is untrue. Any human life, as such, whether in a fetus or an adult, is as valuable as another, inasmuch as no one but God has any authority to destroy it, except when it has lost its right to existence through culpable action. Secondly, the quality of motherhood is an accidental addition to a mother's life, not substantial as is the life itself. This quality of motherhood does not create any juridic imbalance of values which justifies the destruction of the rights inherent in the fetus. That the fetus may not be able to enjoy these rights if the mother dies is, again, an irrelevant consideration. There is no question of a comparison of values. A life is a life, whether in mother or fetus, and the destruction of an innocent life by any one except its creator, God, is essentially an evil thing, like blasphemy. An innocent fetus an hour old may not be directly killed to save the lives of all the mothers in the world. Insisting on such comparisons supposes ignorance and sentimental opposition to truth. It is a good deed to save a mother's life; but such saving by killing an innocent human being ceases to be good and becomes indescribably evil, an enormous subversion of the order of the natural law, as it is a usurpation of the dominion over life possessed by God alone. If I owe a man a vast sum of money and the payment of this debt will ruin me and my children, it would be a good thing for me and them to have this creditor put out of the way by death, but that fact is no justification whatever for me to kill the man. The fetus in the womb in a case where there is question of therapeutic abortion is like this creditor: it would be well for the mother to have this fetus out of the way, but that is no justification whatever for her to kill the fetus, or to let it be killed by a physician. The physician who kills such a fetus is exactly like a hired bravo who assassinates a troublesome creditor for a fee, except that the physician does the nasty job for less money.

To hasten even an inevitable death is homicide, and that quality of merely hastening adds nothing for extenuation: every murder is merely a hastening of inevitable death. To give a dying man a fatal dose of morphine "to put him out of misery" is as criminal a murder as to blow out his brains while he is walking the streets in health; to ease pain is not commensurate with the horrible deordination of taking a human life. This subversion of the moral law in the interest of mawkish sentimentality is one of the gravest evils of modern social ignorance. Physicians are constantly mistaking inclination, or the mental vagaries of the nurses who influenced their childhood, for rules of moral conduct. A physician is not a public executioner, nor a judge with the power of life and death: his business is solely to save human life, never to destroy it.

If there were anything in the objection that refusal to do abortion opposes the life of a useless fetus to that of a useful mother of a family, where would such false logic stop? If it held for the taking of life in an unpleasant condition, it would hold a fortiori in every other less unpleasant condition where a life would not be at stake. When a note that you had given falls due and it would bankrupt you to pay it, does this inconvenience let you out of the difficulty in honor, in the moral law, or in the civil law? It certainly does not; but it should if the doctrine of the sentimentalists on abortion were true. An eclamptic woman, or one with hyperemesis gravidarum, conceived the child, got into the difficulty, and she and her physician have no right to tear up the note they have given to the Creator, especially when such tearing implies murder. Suppose, again, a woman has done a deed for which she has in due process of just law been condemned to death; suppose, also, there is only one man available to put her to death, and if this man were killed she could escape. Would her physician be permitted to shoot that executioner to let her out of the difficulty? Certainly not. That, however, is just what the physician does who empties an eclamptic uterus of an unviable fetus. You may not do essential evil that anything under the sun, good, bad, or indifferent, may come of it.

If I may kill a so-called "useless fetus" to save a useful mother, do gross evil to effect great good, why should I stop there? Why, then, may I not rob a church to make my children rich, murder a useless miser to employ his money in founding orphanages, shoot any oppressor of the poor, kick out of doors my senile and bothersome father, reject all my most sacred promises whenever their observance makes me suffer? Where will the sentimental moralist draw the line? That the civil law permits therapeutic abortion is no excuse at all; it is merely a disgrace of the civil law. The American civil law permits many things that are contrary to morality and the law of God: it absolves bankrupts even if they afterward become solvent; it permits the marriage of divorced persons; it levies unjust school taxes; it gives unjust privileges; it squanders the money of the citizens; and so on.

If a woman marries in good faith a man she deemed a gentleman, but who turns out to be a syphilitic sot who disgraces her and makes her life a perpetual misery, immeasurably worse than the condition of any eclamptic woman, no greater blessing could come to her and her children than his death. Would she therefore be justified before any tribunal of God or man in murdering him to get rid of her trouble? No; she must bear with her evil for the sake of social order and of eternal right. So must the eclamptic woman.

If it is murder to kill a child outside the womb, and mere therapeutics to kill it inside the womb, then it is murder to shoot a man on the street, and mere good marksmanship to shoot him to death inside his house, especially if he is an undesirable citizen. All reputable physicians deem a fetus in a normal pregnancy so good that they will not dream of destroying this fetus. They absolutely refuse to effect an abortion to get rid of a fetus which may disgrace an unmarried woman and her family, and they are perfectly right in this refusal. They talk and write with genuine indignation of race suicide. The only reason they have for the refusal to do what they call criminal abortion is that the disgrace or inconvenience of the woman is not commensurate with the destruction of a human life. They observe the natural human instinctive repugnance to murder in this special speech and writing, and then go home and get their obstetrical bags and complacently murder the first baby they find in the womb of a married matron who has a disturbed stomach or kidneys. They show here the fine intellectual acumen and reasoning ability of a chronic lunatic. The first fact in the social order is that justice, law, order, should prevail, no matter what the cost. It might be better that the fetus should die than that the mother should die, though that is not always true. It is not better that an unbaptized fetus should die than that a mother in the state of grace should die. But these are irrelevant considerations. It is never better that the fetus should be killed than that the mother should die. That is a very different matter.

The Mignonette case in 1884, tried in England by Lord Coleridge, is a good example of evaluation of lives as in therapeutic abortion, which came to grief. A ship called the Mignonette foundered 1600 miles from the Cape of Good Hope, and three of its crew, with a boy, were for a long time at sea in an open boat without provisions. When they were almost starved the boy lay on the bottom of the boat, asleep or half conscious from weakness. Two of the men plotted to kill the boy for therapeutic purposes; they needed his flesh to save their own lives. They killed the poor lad just as the therapeutic abortionist kills a fetus. They got his uncooked flesh for four days. Later Lord Coleridge got them and he sentenced both of them to death. Another Lord will get the therapeutic abortionists.

What, then, is the physician to do who meets a case that imperatively calls for therapeutic abortion according to the common medical practice? He can do nothing. The law may seem hard in certain circumstances to those who cannot see beyond the physical; yet that fact does not abrogate the law, which is one of essential morality.

May the physician call in a physician who, he knows, will not scruple to perform the therapeutic abortion on an unviable fetus? If he does, he is as much a murderer as if he did the deed himself. He may not so much as suggest the name of some one who will do the deed. He simply tells the family he can do nothing. If they insist on the abortion he withdraws from the case.

In this connection it is necessary to mention again the question of viability. Langstein reported[90] a study of the growth and nutrition of 250 prematurely born infants, and he found a confirmation of what was already known, that a weight of 1000 grammes (2¹/₅ pounds) and a full body length of 34 centimetres (13³/₅ inches) are the lowest limits for viability under proper circumstances. A fetus 1000 grammes in weight and 34 centimetres in length has completed the sixth solar or calendar month, or the sixth and a half lunar month—it is beginning its seventh month, not ending it, yet it is viable under proper conditions.

The child at term, on a rough average, is from 48 to 52 centimetres (19 to 20¹/₂ inches) in length, and it weighs from about 6³/₅ to 7¹/₂ pounds. It is impossible, however, to obtain the sizes and weights of infants in utero with scientific accuracy, because the date of conception cannot be determined with absolute certainty, and infants in utero vary as they do after birth. A full-term infant sometimes may weigh only 3¹/₂ pounds when the mother is diseased, and at times an eight-months fetus will weigh as much as 8 pounds.

As was said in Chapter III, a fetus of six completed calendar or solar months (not lunar—the duration of gestation is often reckoned in lunar months by obstetricians) is viable provided it is cared for by competent physicians in a hospital. Otherwise it is not viable, except in a strictly technical sense; it will not live more than a few days or weeks.

A full seven-months infant may be reared with proper feeding and skilled care; a six-months infant may be reared (with difficulty) in a hospital with skilled care. If it is certain that the removal of a six-months fetus will here and now save the life of a mother (a very difficult matter to judge by the best diagnosticians), this removal may be done, provided the infant is delivered in circumstances where skilled care, incubator, and proper food are obtainable; otherwise the removal is not justifiable.

The Council of Lerida, in Catalonia, in the year 524, decreed that abortionists of any kind must do penance all their lives, and if they are clerics they are to be suspended perpetually from all ecclesiastical ministration.

The Council of Worms, under Hadrian II., in the year 868,[91] also judged women who procure abortion as certainly guilty of murder.

In the Corpus Juris,[92] among the decretals of Gregory, there is the following law: "If any one, through lust or hatred, does anything to a man or woman, or gives them any drug, so that they cannot either generate or conceive, or bear children, he is to be treated as a murderer."

Sixtus V., in the Constitution Effraenatam, October 29, 1588, mentions a decree of the Sixth Synod of Constantinople, in session in 680 and 681, which subjects those who perform abortion, or kill a fetus, to the punishment inflicted on murderers. Sixtus then decreed that any one who effects the abortion, directly or indirectly, of an immature fetus, whether the fetus is animated, formed, or not, either by blows, poison, drugs, or potions, or tasks of hard labor imposed on pregnant women, or any other method, however subtle or obscure it be, is guilty of murder, and is to be punished accordingly. He recalls all ecclesiastical privileges from clerics who cause abortion, and says that they are to be reckoned as murderers according to the decree of the Council of Trent,[93] and he makes a law that abortionists may never be promoted to orders.

In the fifth paragraph he says: "Moreover, we decree that the same penalties are incurred (1) by those who give potions and poisons to women to induce sterility or prevent conception, or who cause these drugs to be administered, and (2) by the women themselves who freely and consciously take these drinks."

In paragraph seventh he decrees that any one, man or woman, cleric or lay, who procures abortion by counsel, favor, drinks, letters of advice, signs, or in any way whatever, are ipso facto excommunicated, and the excommunication is reserved to the Pope himself.

Gregory XIV., in the constitution Sedes Apostolica, May 31, 1591, gave to priests who have special faculties for the purpose from the bishop, permission to absolve from this excommunication, but only in foro conscientiae. Sixtus V. and Gregory XIV. used the term foetus animatus, in keeping with the old Aristotelian notion of animation.

Pius IX., in the constitution Apostolicae Sedis Moderationi, deleted the epithet animatus, and extended the excommunication to all abortions, no matter at what time of the gestation they occur. He ordered that only the actual physical abortionist is to be excommunicated, not those who counsel the crime. Some moralists hold that those who order abortion are direct abortionists and fall under this excommunication; other moralists oppose this opinion. Pius IX.[94] excommunicates procurators of abortion if actual abortion is effected, and this excommunication is reserved to the bishops, not to the Pope.

In this decree occur the words "Procurantes abortum, effectu secuto," and there has been considerable discussion of the question who are the procurantes, the agents who fall under the excommunication? Again, are craniotomy, cephalotrypsis, decapitation, embryotomy, and exenteration, when performed on the living child, abortions in the sense of the decree, and thus matter of the excommunication?

Those who do abortion are the principal agents who physically, immediately, of themselves, in their own name, or who morally, through others, perform an abortion. The common opinion of moralists is that all those who of themselves or through others bring on an abortion are excommunicated, but that assistants, although guilty of crime, are not excommunicated.

Many eminent moralists are of the opinion that the mother herself who seeks an abortion does not fall under the excommunication because Sixtus V. does not explicitly mention her in this penal law, and a penal law is to be interpreted literally. If a pregnant woman goes to an abortionist and persuades him by speech and pay to do an abortion, she is the direct moral cause of that abortion. If it were not for her, the abortion would not take place. Virtually all abortions done on married women are effected morally by the woman herself. In my opinion, and the new canon law states this explicitly, the woman who procures an abortion on herself or on another woman is excommunicated.

Sabetti-Barrett[95] holds that craniotomy on a living child and the removal of an inviable extrauterine fetus are not abortion in the scope of this excommunication, because as a penal law these operations are not specifically mentioned. All mutilating operations, like craniotomy and the others enumerated above, first kill the fetus, then extract its body from the womb; abortion first extracts the fetus and then lets its die. The result is the same, but the operations differ technically, and a penal law is ad literam. A cleric who procures abortion of an inviable fetus at any time of gestation falls under the excommunication and suspension a sacris perpetually, although he probably is not technically irregular canonically if he procures the abortion before the Aristotelian date of animation. The bull Effraenatam makes the canonical irregularity at the Aristotelian date obsolete practically.

In the church the Holy Office (that is, the Inquisitors-General in matters of faith and morals) is the official authority which interprets, under the approval of the Pope, the morality of acts like abortion and related operations. In 1895 the following difficulty was proposed to the Holy Office for solution:

A physician is treating a woman with a disease which will certainly be fatal to her unless cured medically, and the disease is due to the presence of a fetus in her womb. To save her it is necessary to empty the uterus, but the fetus is not yet viable. The question is, May the physician perform therapeutic abortion in such circumstances?

On July 24, 1895, the Holy Office answered: "The Inquisitors-General in matters of faith and morals, with the vote of their Consultors, decree: Negatively, in accord with the other decrees of May 28, 1884, and August 19, 1888."

In May, 1898, the following questions were proposed to the Holy Office:

I. Is the induction of premature labor licit when a contracted maternal pelvis prevents the birth of a child at term?

II. If the maternal pelvis is so narrow that premature delivery is impossible, is it licit to perform abortion, or to effect cesarean delivery at the proper time?

III. Is laparotomy in extrauterine gestation licit?

May 4, 1898, the Holy Office answered, with the assent of Leo XIII:

I. Premature labor in itself is not illicit, provided it is done for sufficient reason, and at the time and by such methods as will under ordinary circumstances preserve the life of the mother and the fetus.

II. As to the first part, the answer is negative, according to the decree of July 24, 1895, on the unlawfulness of abortion. As to the second part, there is no objection to the cesarean delivery at the proper time.

III. In a case of necessity, a laparotomy to remove an ectopic fetus from the mother is licit, provided the lives of both mother and fetus are, so far as is possible, carefully and opportunely preserved.[96]

March 5, 1902, this question was asked the Holy Office: "Is it ever licit to remove an ectopic fetus from the mother while the fetus is under six months of age from the time of conception?"

The answer was: "Negatively, in accord with the decree of May 4, 1898, by which the lives of the fetus and mother, as far as possible, are carefully and opportunely preserved. As to the time, the questioner is reminded by the same decree that no premature delivery is licit unless effected at the time and by the methods which, under ordinary circumstances, will preserve the lives of mother and fetus."

The English civil law concerning abortion[97] is:

"Whoever shall unlawfully supply or procure any poison or other noxious thing, or any instrument or thing whatsoever, knowing that the same is intended to be unlawfully used or employed with intent to procure the miscarriage of any woman, whether she be or be not with child, shall be guilty of a misdemeanor, and being convicted thereof shall be liable, at the discretion of the court, to be kept in penal servitude for the term of three years, or to be imprisoned for any term not exceeding two years, with or without hard labor."

Alfred Susaine Taylor,[98] commenting on this law, said: "Strictly speaking, there is no such thing as justifiable abortion; the law recognizes no such possibility. A medical man must always remember this when he contemplates emptying a pregnant uterus.

"It is obvious that the only reasons that can be thought of by an honorable man as justifying the induction of labor are (1) to save the life of the mother; (2) to save the life of the child. (Some religions will not contemplate the first reason, but that we are not now concerned with.) It cannot be done for the sake of family honor nor for any similar ethical reason....

"The golden rule is never to empty a uterus without first having a second professional opinion as to its necessity; if this opinion be adverse, do not do it; if it be favorable, it is well to get it in writing, and it is well also to get the written or attested consent of the woman and her husband, and then proceed to do it with all the skill and care possible. The death of the fetus is at any time the most certain means of causing the womb to empty itself, but after the sixth month the operation is performed necessarily with a view to preserving this life, and steps must be taken accordingly." Coke, about 1615, judged that to kill a child in the womb is not murder, but if it is expelled by violence and dies after it leaves the womb, that is murder.

The law in Pennsylvania[99] is: "If any person, with intent to procure the miscarriage of any woman, shall unlawfully administer to her any poison, drug, or substance whatsoever, or shall unlawfully use any instrument, or other means whatsoever, with the like intent, such person shall be guilty of felony, and being thereof convicted, shall be sentenced to pay a fine not exceeding five hundred dollars, and undergo an imprisonment, by separate or solitary confinement at labor, not exceeding three years." It makes no difference in Pennsylvania law whether the child is quickened or not.

The New Jersey, Massachusetts, and Wisconsin laws are like the Pennsylvania law. The law in Iowa[100] is: "If any person, with intent to procure the miscarriage of any pregnant woman, wilfully administer to her any drug or substance whatever, or, with such intent, use any instrument or other means whatever, unless such miscarriage shall be necessary to save her life, he shall be imprisoned in the penitentiary for a term not exceeding five years, and be fined in a sum not exceeding one thousand dollars." To the same effect are the laws in Connecticut, Maine, New York, Ohio, Michigan, Minnesota, Colorado, Texas, and Maryland.

Frank Winthrop Draper, professor of legal medicine in Harvard University,[101] commenting on the Massachusetts law of October, 1903, cap. 212, secs. 15, 16, says: "It is important to recognize the fact that the law does not make any exception or formal recognition in favor of justifiable operations to procure premature labor. The statute is general in its application. It is, of course, obvious that the best sentiment of the medical profession and of obstetric teachers is favorable to interference of pregnancy, (1) whenever there is such anatomical deviation or mechanical obstruction in the mother's pelvis that the birth of a child is impossible; or (2) whenever the mother is suffering from such grave disease that her life is in imminent peril and can be saved only by the arrest of gestation. Under such conditions the physician is not only warranted in inducing premature labor, but is required to do so by a sense of duty to his patient, with a view thereby to save one life at least, and, if possible, the lives of both mother and offspring.

"Nevertheless, as the law now stands, a prudent practitioner will not expose himself to any risk, if a few precautions will save him. In the event of the death of the mother and child in such an emergency, the attending physician might find himself in jeopardy, with the imputation of gross carelessness and criminal neglect hanging over him, an imputation which requires years to remove. So the attending physician should never undertake to do an instrumental operation without these precautions: 1. The consent of the patient, with that of her husband or family. 2. Especially, a consultation with some other physician or physicians in whom there is full confidence. Attention to these simple and sensible safeguards, by making the conduct appear by its candor and openness in the strongest possible contrast with the secret methods of the abortionist, may save great embarrassment."

The ethics of this doctrine is, of course, absurd, as has been shown, and it is cited here only to show how the civil law considers abortion. Wharton and Stille[102] give the same information in a more technical manner. "It is a general rule," they say, "independent of statute, that the act of a physician in aiding a miscarriage is not unlawful, where the miscarriage was the inevitable result of other causes. And the act is justified where the circumstances were such as to induce in the mind of a competent person the belief that a miscarriage was necessary to preserve the life of the mother. And the statutes of many of the States penalize the causing, or attempting to cause, an abortion, unless necessary to preserve the life of the woman, or unless advised by a designated number of physicians to be necessary for such purpose, the absence of both the necessity and the advice being an essential ingredient in the crime. The physician by whom the deed is done, however, cannot act as his own adviser in the matter. And an indictment under the statute must not only allege that the act was not necessary to preserve the woman's life, but must also negative the advice of physicians; and such averments cannot be inserted as an amendment after demurrer.

"The burden of proof rests with the state to show that the means used were not necessary to preserve the life of the woman in question; and the absence of necessity may be determined from circumstantial evidence. But the burden of proof as to the advice of physicians would not fall within the rule controlling the production of proof as to negative matters in general, and would rest with the accused; though it may be proved by a preponderance of the evidence and need not be established beyond a reasonable doubt. But either that the act was necessary to preserve the life of another, or that it was advised by physicians to be necessary for that purpose, is of equally good defence; and the destruction of the child need not have been both necessary and advised by physicians. And statutes of this class apply only in cases in which the death of the mother could reasonably be expected to result from natural cause, unless the child was destroyed, and do not apply to a case in which the mother threatened suicide unless she was relieved from her trouble."