  Frequency—Causes and Prevention—Habitual Miscarriage—Warning We have learned that forty weeks are required for the full development of the human embryo, but this fact carries no assurance that pregnancy will last so long; in reality, it may end abruptly at any time. If growth is interrupted before the twenty-eighth week (the seventh lunar month), the infant will be too immature to live. Even when born alive, it will usually perish within a few hours, or a few days at most. Children born during the seventh month have occasionally survived; but the prevalent belief that they are more likely to do so than if born a month later is erroneous. That superstition originated at a time when great virtue was ascribed to numbers. Since seven was a sacred number, it was considered more auspicious to be born in the seventh month than in the eighth. Universal experience, however, teaches us that the likelihood of rearing a premature child is, by a rapidly increasing proportion, the greater for every week that it remains within the uterus. This is precisely what we should expect, for the period of its existence there measures the perfection of its development; and that, under ordinary conditions, determines how strong and hardy the child will be. Although during the first six months the outlook for the infant will be equally unfavorable at whatever time pregnancy may be interrupted, physicians prefer to distinguish cases which terminate in the earlier part of this period from those which terminate in the latter part. For technical reasons, the sixteenth week represents a natural point of division. A birth which takes place before that time is called an abortion; one which takes place between the sixteenth and the twenty- eighth week is called a miscarriage. The anatomical reasons which justify such a distinction do not concern us here, and the matter deserves mention merely because the same terms are often employed in a very different sense by the laity. As most of us know, the interruption of pregnancy results sometimes from purely natural causes, and sometimes from the employment of artificial means. As a rule, persons who are unacquainted with medical terminology call a birth of the former kind a miscarriage, and reserve the term abortion for an interruption of pregnancy that is deliberately provoked. Physicians, however, make no such distinction. They use these words, as I have said, simply to indicate how far development has progressed before the termination of pregnancy. Since the term abortion is apt to carry with it the implication of a criminal act, confusion will be avoided if we agree for the time to depart from strictly medical usage and designate as miscarriage the spontaneous termination of pregnancy prior to the twenty-eighth week. FREQUENCY.—Early interruption of pregnancy is extremely common. Some sociologists declare that it is becoming more and more frequent, and see in it a grave national danger. French statesmen attribute the alarming decline of the birth-rate in their country, in great part, to a rapid increase in the number of pregnancies which end prematurely. Reliable English and German statistics indicate that of the pregnancies which come under the observation of physicians approximately twenty per cent, end in miscarriage. In our own country, though extensive and complete data are not available, it is likely that the incidence is equally high. The actual frequency of miscarriage is generally underestimated. Patients themselves often do not know what has really happened. When the accident occurs a few days after conception, bleeding may be its only evidence, which will almost certainly be misinterpreted as an irregularity of menstruation; and professional advice will not often be thought necessary. Moreover, in other cases in which the true situation is appreciated the patient does not feel sick enough to seek medical assistance. If it were possible to include in the statistics all these cases as well as those which are concealed because intentionally provoked, the frequency with which pregnancy is interrupted during the early months would be found somewhat greater than is usually supposed. If we omit the miscarriages which occur within the first few weeks of pregnancy, and which consequently often escape detection, the majority of cases fall within the second and third months. After the fourth month has passed, the probability of such an accident, though not excluded, is greatly diminished. Some statistics recently published by Taussig make this clear. In a series of several hundred cases of miscarriage, one hundred and fifty-seven instances occurred in the second month, two hundred and twenty-two in the third month, seventy-three in the fourth month, thirty-seven in the fifth month, and five in the sixth month. This order of frequency might be anticipated from the anatomical conditions which prevail during the early months of pregnancy, since the attachment of the embryo to the mother is at first relatively insecure, but gradually grows firmer, and becomes as secure as it ever will be by about the fifth month. It is noteworthy that miscarriage occurs much less commonly in the first than in subsequent pregnancies. Indeed, a somewhat greater liability to the accident with each succeeding pregnancy goes far toward explaining the greater frequency of miscarriage among women who have passed the thirty-fifth year than among those who are younger. CAUSES AND PREVENTION.—We have seen that the proportion of pregnancies which end in miscarriage is quite formidable. But this should not be true, as the accident is frequently preventable, and many of these accidents could be avoided by the cooperation of patients. As self-denial and personal inconvenience are often essential, it is only fair to explain their value. Furthermore, the, patient who appreciates the reason for certain directions the physician gives becomes responsible to herself, and is much more likely to carry them out than is one who is cautioned without receiving a satisfactory explanation. At best, however, the advice which the physician is able to offer will be imperfect, for it must not be imagined that everything is known concerning the causation and prevention of miscarriage. While our knowledge is so imperfect we must be content to make the most of what we possess. It must be added that no suggestion such as can be given here will enable anyone to dispense with her own medical adviser. On the contrary, if there is reason to fear miscarriage, the prospective mother should be encouraged to seek his counsel as early as possible. Aside from the hygienic measures which she may learn to carry out for herself, various drugs are often of great value in preventing miscarriage. Since these are not applicable to all cases, they should be employed only upon medical advice. Very early miscarriages may be explained by the loose attachment of the ovum during the first six weeks of pregnancy. This tiny, living sphere, it will be recalled, reaches the womb a few days after conception, and adheres to the uterine mucous membrane. At first, however, its roots are short and delicate, and not so capable of anchoring the ovum as they become later. It is only toward the end of the eighteenth week that the union between the womb and its contents becomes firm. From what we have learned in Chapter II regarding the anatomical conditions in the early days of pregnancy it is obvious that we need not be greatly surprised at the frequency of miscarriage. On the other hand, it must not be forgotten that there are many natural safeguards against accident: to mention only one, the uterus is ingeniously swung in the abdominal cavity so as to afford a large measure of protection against mechanical shock. Usually, the provisions nature has made are sufficient to resist forces from without which tend to dislodge the ovum. Now and then it happens that the most irrational acts will not interrupt pregnancy; indeed, they often seem particularly inert when practised intentionally. Fear of loosening the ovum from its uterine attachment prompts experienced women to caution prospective mothers against any kind of sudden or violent effort. Their advice, however, is often needlessly alarming; a great many traditional precautions lack a reasonable basis. Thus, no harm can possibly result from sleeping with the arms above the head; nor from "over-reaching," as when hanging a picture, though a fall under such circumstances might be dangerous. Patients who have been warned by one experience should always be on their guard if they would avoid repeated miscarriages; others need only lead a sensible, hygienic life, a matter we have already discussed in the chapters dealing with the care of the body and the way to live. For the sake of emphasis, I may here repeat that no prospective mother should become fatigued from any cause; sweeping, moving heavy furniture, lifting heavy articles, and running a sewing machine are not to be attempted. But household duties which do not require strong muscular effort are better assumed than not. Amusements which may cause jolting, or expose one to the danger of falling, involve some risk of miscarriage. Short rides in a carriage or an automobile over smooth roads are free from objection. Railway- travel and sea-voyages are not advisable in the early months; after the eighteenth week they may be undertaken with a greater degree of safety, provided comfortable accommodations are assured, and the patient has never had a miscarriage. A few physicians, even at present, attribute the interruption of pregnancy to strong emotions, including intense joy or sorrow, anger, fright, or even jealousy. Without denying altogether the possibility of such an influence, we may be sure that its importance is greatly exaggerated. It is not unusual to see patients who are able to recall a mental shock of some kind shortly before the miscarriage occurred; nevertheless, in such cases diligent search will usually reveal a physical cause for the accident. Another popular fallacy relates to the effect of drugs upon pregnancy. The use of castor oil and other strong purgatives do not interrupt it. Should the administration of any cathartic be followed by miscarriage, some fault inherent preexisted in the pregnancy, and no amount of precaution would have enabled the patient to reach full term successfully. Quinin in tonic doses may be taken with impunity, and even larger quantities are being constantly used for the cure of malaria without doing the pregnancy any harm. Many other drugs are reputed to have great efficacy in causing the expulsion of the product of conception; unfortunately, they are too well known to require enumeration. They are usually unreliable, and are absolutely inefficient in doses small enough not to endanger the mother's life, provided the pregnancy is a healthy one. Instances in which miscarriage is attributed to the use of some drug are quite common, and we cannot dismiss them without a word of explanation. Such cases generally fall into one of two classes. Often a drug is given credit for efficiency where conception has been erroneously suspected. Shortly after the menstrual date passes, some medicine is resorted to, and the subsequent phenomenon, regarded as the interruption of pregnancy, is really no more than normal menstruation. In another group of cases miscarriage does actually occur, although the medicine employed plays only a minor role in its production. In such instances the irritation which the drug occasions is the last link in a chain of events leading up to the miscarriage, but the main factor lies in some fundamental imperfection in the pregnancy. Physicians recognize a variety of these imperfections, and know that they may be located in the womb, in the embryo, or in the tissues which unite the one with the other. As an intimate knowledge of pathology is often necessary to recognize the underlying, and therefore the actual, cause of the miscarriage, it is not at all surprising that patients frequently err in their interpretations of such accidents, and emphasize unimportant matters. It would lead us too far afield to attempt to discuss every cause of miscarriage. Nevertheless, there are some very important ones, not yet mentioned, which should be understood by the laity, as appreciation of their significance may avert trouble. In some instances, on the other hand, the accident is unavoidable; to know this should afford the patient a large measure of comfort. Irregularities in the position of the womb are often responsible for miscarriage. Such a condition may exist in women who have not borne children, but it is far more likely to occur as a result of childbirth. After delivery, the enlarged womb becomes the seat of intricate changes, the purpose of which is the restoration of the organ to the condition which existed before conception. It dwindles in size, and gradually drops to its accustomed location within the pelvic cavity. Six weeks are usually required for these changes. At the time of birth it is impossible to predict whether the womb will finally resume a satisfactory position. Accordingly, an examination two to four weeks later is essential. In four out of five patients the organ will be found in its proper location, but, even though it is not, suitable measures adopted at once will generally serve to replace and hold it in good position. On the other hand, if the malposition is not recognized until months or years later, simple procedures will prove inefficient, and a surgical operation will become necessary. Were there no other reason for a careful examination at the end of the lying-in period, it would be amply justified by the information which it gives relative to the position of the uterus. Although there can be no doubt that the routine correction of uterine displacements shortly after labor would go far toward restricting the occurrence of subsequent miscarriage, it would be incorrect to leave the impression that miscarriage will always occur if the uterus is out of its normal position. Not infrequently the changes wrought by pregnancy will cause the uterus to right itself spontaneously. Another important cause of miscarriage consists in abnormalities in the lining of the uterus. Through inherent defect or acquired disease this tissue may become unsuited for anchoring or nourishing an ovum. In either event, a surgical procedure, known as curettage, affords the most likely means of restoring it to a healthful state. The operation removes the old lining; and a new one quickly develops, which is often more capable of fulfilling the purpose for which it is intended. An appreciable number of miscarriages depend upon conditions over which medical skill has no control. Under such circumstances, though the accident may be regretted, there is no room for remorse or censure. Often the embryo should bear the blame; if its development is imperfect or if it dies, miscarriage usually occurs very promptly. We are familiar also with a few maternal conditions which seriously affect the embryo, often seriously enough to cause its expulsion, alive or dead. In this respect, certain constitutional disorders are preeminent. Bright's disease and diabetes are prejudicial to the development of the embryo; women suffering from either of them must be watched with great care. Occasionally, such pregnancies come to a premature end in spite of every precaution. Various infectious diseases, as typhoid fever and pneumonia, also are fatal to the embryo if the causative bacteria pass into it. Fortunately this rarely happens, since the placenta generally affords an effectual barrier to their entrance into the embryo. Organic diseases of the mother's heart also may bring about miscarriage. A patient thus affected should place herself under the supervision of a physician as soon as conception is suspected. Now and then physicians are completely at a loss to explain cases of miscarriage. Our ignorance is unfortunate, particularly when repeated miscarriages have occurred and their causation cannot be detected. HABITUAL MISCARRIAGE.—Experience teaches that women who have had one miscarriage must be more careful than other prospective mothers if they would escape a repetition of the accident. Persons who know themselves to be subject to miscarriage should regard no precaution as too burdensome. Not only should they avoid motoring, driving, railroad journeys, sea voyages, and every kind of strenuous exertion, they must accept every opportunity to be quiet and rest. Often such hygienic care yields sufficient protection; but occasionally medicine is also necessary. A number of causes are at hand to explain habitual miscarriage, but, in fairness, it must be acknowledged that physicians are not able to interpret all cases. With one class of patients the muscle fibers of the womb are peculiarly irritable, whereas in another its lining proves incapable of firmly anchoring the ovum. Moreover, derangements of organs which do not belong to the reproductive group may be responsible for the habit. It is a curious fact that the accident is most likely to occur when menstruation would be expected were the individual not pregnant. Obviously, extraordinary precaution is advisable at such times, and if the patient would avoid even the slightest risk, she should not leave her bed. The same purpose will not be served by sitting quietly in a chair, nor by reclining on a couch; complete relaxation and composure are secured only when one lies flat on the back, loosely attired in sleeping garments. I have known several persons with a tendency toward miscarriage who overcame it in this way. Recently one of them who had been delivered prematurely on two former occasions, and who was anxious for a successful issue to her third pregnancy, was willing to remain in bed practically the whole period of gestation. She had her reward; a well-developed infant was born at full term, and has continued to thrive. Prolonged rest in bed, some will say, is debilitating. While that may be true to a degree, untoward effects can always be avoided by systematic massage of the extremities. The abdomen should not be subjected to such manipulations, for they will occasionally provoke painful contractions of the uterus and defeat the purpose of staying in bed. Patients who are not disposed to undergo a long period of enforced rest, no matter what profit may be promised, should at least consent to keep in bed during that period of pregnancy at which a previous miscarriage took place. We know that the event is particularly apt to recur at such a time. Specifically, it is important to remain in bed one week before and one week after the date in question. When pregnancies follow one another in rapid succession, the liability to miscarriage is notably increased. A natural interval between births has been provided, an interval which depends upon the mother nursing her child. Ideally, menstruation, and with it the ripening of the ova (egg-cells), does not occur while the breasts are active; but when the infant does not suckle, the ovaries regularly resume their function in a very short time. Since the circumstances attending miscarriage always deprive the mother of the opportunity of nursing, another pregnancy may quickly ensue unless these facts are appreciated. Those who anticipate the possibility of a premature interruption of pregnancy should realize that the marital relation is inadvisable after conception has taken place. For others, who have no reason to expect irregularity in the course of pregnancy, such a precaution is unnecessary. None the less, women who marry late in life or who first conceive toward the time of the menopause will do well to follow the same rule. The risk of accident may be very slight, but conservative persons will not assume it when the likelihood of subsequent conception is doubtful. Not infrequently the fundamental reason for habitual miscarriage lies in some anatomical abnormality which a surgical operation alone can correct. As the necessity for interference can be determined only after a careful examination, recommendations of wide application are not possible. Nothing short of painstaking study of each case will afford a basis for advice and action. SYMPTOMS.—Very definite warning usually precedes a miscarriage, but the threatening symptoms vary greatly in severity and duration. If appropriate measures are taken promptly, these symptoms may disappear with no harmful result Everyone concedes that bleeding and pain are the chief indications of impending miscarriage, although an occasional patient, profiting by former experience, may find other signs prophetic in her own case. Mature women, accustomed to the regular monthly function of their sex, are prone to treat with indifference a slight discharge of blood occurring during pregnancy. Indeed, it is widely believed that menstruation frequently continues after conception. In point of fact, however, it is very unusual in early pregnancy, and becomes entirely impossible after the fourth month. Accordingly, whenever vaginal bleeding is noticed, some other explanation should be sought; and the patient who would adopt the wisest plan should assume that she is threatened with miscarriage. There are other possibilities, but these are for her doctor to consider. It is true that small hemorrhages are not necessarily followed by miscarriage. One may even experience slight loss of blood repeatedly, and yet give birth to a healthy child at the natural end of pregnancy. None the less, bleeding, however moderate, should always excite suspicion, as we know it usually denotes the breaking to some degree of the connection between mother and child. The extent of the separation usually determines the degree of the hemorrhage, which in turn indicates the seriousness of the accident. The fate of the fetus will depend upon the area of placenta, which has been incapacitated. Flooding, however, always imperils the fetus, and generally warrants the inference that so much of the placenta has been separated as to render further development impossible. On the other hand, so long as the hemorrhage does not exceed the customary flow at the monthly periods, the life of the child is rarely endangered; while a chocolate-colored discharge, and even the loss of small clots, may continue indefinitely without doing serious harm. Under such circumstances, however, the patient should communicate with her medical adviser, and should save for his inspection whatever may be expelled. Pain, the other conspicuous symptom of threatened miscarriage, has not a uniform significance. Since it frequently occurs during the course of pregnancy in association with a number of conditions, it is not a reliable sign of danger. Moreover, the susceptibility to pain varies; thus, of two patients in the same stage of threatened miscarriage one may suffer intensely, while the other remains comparatively comfortable. Typically, the onset of miscarriage is attended by discomfort in the small of the back, which may be continuous, but more often is intermittent. If preventive measures are instituted at the outset, there is hope of relieving the discomfort and averting the miscarriage; but if the warning goes unheeded, the pain will gradually shift to the lower part of the abdomen and become more severe. It often happens that the cramp-like abdominal pain of threatened miscarriage is confused with that associated with intestinal indigestion. A simple test will sometimes decide the question. If due to the latter cause, the discomfort will usually yield to a teaspoonful of paregoric, whereas it will be without effect if miscarriage is imminent. Exceptions to this rule are not uncommon, yet a better one cannot be given; as a physician, even after considering the technical evidence, may find it impossible to decide at once whether or not miscarriage is threatened. No confidence can be placed in many so-called signs of miscarriage, though implicitly trusted by the laity. Lassitude, depression of spirits, and general bodily ill-feeling may forecast the interruption of pregnancy; but more frequently they have no such significance. The same estimate holds true of other symptoms, including diarrhea and a persistent inclination to empty the bladder. Nor does fever always lead to the termination of pregnancy. A moderate rise of temperature is without significance; but high fever, persisting for several days, may result in the death of the fetus and subsequent miscarriage. Nevertheless, prolonged febrile affections, such as typhoid fever, frequently leave pregnancy unharmed. So long as the symptoms are confined to slight bleeding and mild attacks of pain, physicians regard miscarriage merely as threatened. If the bleeding increases, the outlook becomes less favorable, and, as I have said, miscarriage is inevitable when it amounts to flooding. Likewise, rupture of the sack containing the fetus, with escape of the amniotic fluid, indicates that the culmination of events will not long be delayed. The most favorable outcome is when the entire contents of the womb are spontaneously expelled, which unfortunately does not always occur. There is, to be sure, rarely any difficulty in the natural birth of the fetus, for its meager development prevents serious complications. The separation and extrusion of the placenta, on the contrary, are apt to be imperfect when pregnancy ends in the early months, and medical attention is necessary to determine whether the uterus has been emptied completely. This is particularly important, because the retention of placental tissue affords opportunity for several unpleasant complications; and neglect in this regard accounts in part for the belief that miscarriage is certain to leave women irreparably broken in health. AFTER-EFFECTS.—No one will deny that invalidism follows the untimely interruption of pregnancy more often than the birth of children at full term. This is not due, as is sometimes said, to the fact that a miscarriage differs from a normal birth in that it is unnatural, for other reasons are apparent. One of them, the retention of placental tissue, has just been mentioned, but serious consequences resulting from it are almost inexcusable, for, although the placenta may separate less readily and be cast off less thoroughly after miscarriage, modern medical skill can successfully cope with such conditions. Another fruitful source of unfortunate after-effects is the imprudence of the patient. Women should remain in bed fully as long after a miscarriage as after the birth of a mature infant; if they would consent to do so, many ill-effects would be averted. But physicians frequently encounter strong opposition to precautionary measures such as this. Many patients argue, illogically, that less precaution is necessary since pregnancy failed to attain its natural conclusion, and infer that the earlier that it ends the more quickly one may leave the bed. In point of fact, even greater precaution is required than if all had gone normally. Still a third cause for ill- health may be found in physical ailments which antedated the miscarriage but were not recognized until after its occurrence. Invalidism which follows pregnancy and which may be fairly regarded as chargeable to it depends, in most instances, upon an infection acquired at the time of delivery. Infection occurs more frequently when pregnancy ends during the early months, because in this category is included the great majority of criminal abortions, which are usually induced without regard for surgical cleanliness. Fatal complications, or serious consequences which narrowly escape a fatal ending, are common among women who attempt to rid themselves of an unwelcome pregnancy. As they are ignorant of aseptic precautions, their manipulations must necessarily contaminate the site of operation; for this reason and others as well women who attempt to perform an abortion upon themselves imperil their lives. The danger is scarcely less when abortion is induced unlawfully by incompetent operators; for lack of skill, the need of secrecy, and the desire of haste all interfere with necessary aseptic technique. Everyone knows that sad accidents befall those who submit to such operations; but it is not generally recognized that these cases are largely responsible for the ill-repute borne by miscarriage in general. On the other hand, properly supervised miscarriages are attended by no greater danger and probably less than delivery at full term. CRIMINAL ABORTION.—The destruction of a pregnancy, except when its continuance threatens the life of the patient, is forbidden by law. The important ethical and religious aspects of the act which the law thus stigmatizes as criminal we may properly neglect. Although various religions present a diversity of teaching relative to its moral nature, all agree in regarding it as sinful. Equally important, however, is the fact that no matter what opinion anyone may hold as to the morality of the act he is bound to obey the law. This is apparently not clearly understood by the laity, for many persons think that a physician may terminate pregnancy whenever he is so inclined. If the liability to criminal prosecution which a physician would assume should he comply with a request for the means of destroying pregnancy were clearly realized, patients would not beseech him to incur the risk of heavy find and long imprisonment merely to gratify their own convenience or to save them from disgrace. The Common Law, an inheritance from England, enriched with authoritative decisions by our own courts, is the groundwork of the law in all the States, and its principles are binding in the absence of express statutes. At Common Law, abortion is punishable as homicide when the woman dies or when the operation results fatally to the infant after it has been born alive. If performed for the purpose of killing the child, the crime is murder; in the absence of such intent, it is manslaughter. The woman who commits an abortion upon herself is likewise guilty of the crime. The great majority of those who desire the interruption of pregnancy feel they have not assumed an illegal position so long as they avoid instrumental procedures. That is not correct, for even at Common Law it is a misdemeanor to bring about the death of an unborn child by the use of drugs or by any other means. At Common Law there was a difference of opinion as to whether all induced abortions were illegal. Many courts formerly held that quickening was a necessary prerequisite; but under the modern statutes, practically without exception, the law disregards the period of pregnancy at which the abortion is provoked. Since the time of conception determines the beginning of embryonic development, to prove that the act was committed before fetal movements were perceived is no longer a valid defense. This has been emphatically stated by Judge Coulter, of Pennsylvania, who said: "It is not the murder of a living child which constitutes the offense, but the destruction of gestation by wicked means and against nature. The moment the womb is instinct with embryonic life and gestation has begun, the crime may be perpetrated." Each commonwealth has enacted its own statutes for the regulation of abortion. In many states, simply to seek the means for destroying pregnancy is a criminal act. Thus, Indiana, perhaps the most progressive of the States in reconstructing its criminal code to accord with modern sociological teaching, has enacted a law which I quote from Burn's Indiana Statutes, Revision of 1908, Vol. I, page 1029. "Every woman who shall solicit of any person any medicine, drug or substance, or thing whatever and shall take the same, or shall submit to any operation or other means whatever with intent thereby to procure a miscarriage, except when done by a physician for the purpose of saving the life of the mother or child, shall, on conviction, be fined not less than ten dollars, and be imprisoned in the county jail not less than thirty days nor more than one year." To include the woman as a party to the crime is a signal mark of progress toward bringing abortion under effective legal control. Heretofore, the perpetrator alone has been responsible, and in most States he remains so, while the woman is regarded as a victim. Clearly, that is unjust, for criminal abortions are rarely, if ever, performed without application by the subject of the operation. According to most of the statutes no distinction is made between the attempt at abortion and its accomplishment. Irrespective of the outcome, those who supply drugs or employ instruments purposing the destruction of pregnancy are guilty of the offense. An extensive analysis of the various State laws is unnecessary; the mention of a few statutes, selected from different sections of the country, will suffice to indicate the character of prevalent legislation. Massachusetts imprisons those found guilty of abortion for a period of three years or less, and permits a fine of one thousand dollars. In Pennsylvania the same prison sentence is imposed, though the fine may not exceed five hundred dollars. Three years is the minimum imprisonment in Virginia, and a maximum of ten years is allowed. Colorado's law duplicates that of Massachusetts. California imposes no fine, and prescribes a sentence of from two to five years in the State prison. All the statutes make the offense much graver when the woman dies as a result of the practice. Under these circumstances, the crime never takes lower rank than manslaughter; and generally it is murder. Evidently we possess sufficiently stringent laws regarding criminal abortion; yet, as everyone knows, they do not prevent perpetration of the crime. On good authority, we are informed that eighty thousand unlawful abortions are performed annually in New York, in spite of a possible penalty of four years in the State prison. This is due in part to difficulty in securing evidence and failure to prosecute when evidence could be gathered, but more particularly to the fact that the general public does not appreciate the gravity of the offense. The same feeling is illustrated in the advertising of abortifacients. Newspapers and magazines unhesitatingly carry, under the guise of remedies to regulate the health of women, notices of drugs and equipment intended to destroy pregnancy. This is expressly forbidden by many statutes. [Footnote: Thus, the Maryland law provides that "any person who shall knowingly advertise, print, publish, distribute or circulate any pamphlet, printed paper, book, newspaper notice, advertisement or reference containing words or language or conveying any notice, hint, or reference to any person or to the name of any person, real or fictitious, from whom, or to any place, house, shop, or office, where any poison, drug, mixture, preparation, medicine, or noxious thing or any instrument or means whatever; or from whom advice, direction, information or knowledge may be obtained for the purpose of causing the miscarriage or abortion of any woman pregnant with child, at any period of pregnancy, shall be punished by imprisonment in the penitentiary for not less than three years, by a fine of not less than five hundred dollars, nor more than one thousand dollars, or by both, in the discretion of the court."] The knowledge that prohibitory laws exist is sufficient to deter reputable physicians from illegal practice; whereas known laxity in the enforcement of the law continually tempts unscrupulous persons to provoke abortion. Among the poorer classes the procedure is undertaken by ignorant women, while persons in more comfortable circumstances avail themselves of the services of medical men who are usually incompetent and value money above professional honor. The net result is an unpardonable death-rate and a large proportion of invalids. Aside from the legal aspect of the act, the element of personal danger would seem a warning to be heeded by women who contemplate becoming a party to this crime. THERAPEUTIC ABORTION.—If a woman is suffering from tuberculosis or some organic affection, pregnancy may add a serious strain upon the already crippled machinery of her body. Occasionally gestation itself may cause changes which threaten life. In either event the duty of the physician is plain. The law is acquainted with such emergencies, and explicitly permits the termination of pregnancy when undertaken to relieve or cure such conditions. When performed to restore health the operation is called therapeutic abortion. The Maryland law, for example, grants the right to induce abortion whenever two or more physicians see the patient and agree that "no other method will secure the safety of the mother." Similar rules are prescribed by the statutes of other States, but none concedes the right of abortion as a means of keeping the woman from suicide. Since therapeutic abortions are legal, they may be done openly; hence the operation is performed in appropriate surroundings and with every refinement of surgical technique. These fortunate conditions materially alter the outlook; serious consequences of the operation itself need not be feared. Competent surgeons, employing modern methods, may perform hundreds of abortions without the loss of a single patient. Moreover, pregnancy may be terminated safely and expeditiously at any time; the lay view which regards abortion as more serious after the second month than before it is a relic of days gone by. |
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