MISCARRIAGE
Frequency--Causes and Prevention--Habitual Miscarriage--Warning
Symptoms--After-effects--Criminal Abortion--Therapeutic Abortion--
Premature Delivery.
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.
PREMATURE DELIVERY.--In the introduction to this chapter we noted
that the infant becomes viable after the twenty-eighth week, which
marks in a practical sense, the transition of the fetus from an
immature to a premature stage of development. In point of frequency,
premature delivery ranks far below either abortion or miscarriage.
Unlawful interference with pregnancy generally proceeds from a desire
to avoid offspring, and lacks incentive after the infant becomes
capable of living independently. Criminal operations, therefore, are
not a conspicuous cause of premature delivery. Occasionally
physicians resort to artificial means to end gestation during the
later months in order that organic complications may be relieved; but
most premature births occur spontaneously. Sometimes they are due to
ill-health, while in other instances no evidence of disease is found
in either mother or child. Careful study of the individual patient,
however, is generally helpful toward the prevention of repeated
premature delivery.
The course of premature labor closely resembles delivery at full
term. But it is shorter because the infant is small; and the
subsequent loss of blood is not so great. The recovery of the mother
is never retarded by the fact of earlier delivery, though the
conditions which caused it may prevent rapid convalescence.
The outlook for the infant depends upon a great many factors. Most
important among them is the perfection of its development, which may
be estimated most satisfactorily from its weight and length.
Occasionally children have been reared when they weighed as little as
three pounds, but hope that they will survive should not be
entertained unless they weigh four pounds or more. This is attained
about eight weeks before maturity, and corresponds to a length of
forty centimeters (16 inches), measured from the crown of the head to
the heel. Premature children perish, most frequently, either from
incomplete development of their heat-regulating apparatus, which
predisposes them to pneumonia, or from imperfections in the digestive
functions, which increase the liability to malnutrition. To overcome
the first danger, incubators have been devised and have become
familiar to everyone through public exhibitions. A basket or box
supplied with hot-water bottles answers the same purpose, and has the
advantage of better ventilation. The second danger can be overcome
only by proper feeding. Breast-milk provides the most reliable
nourishment for premature infants. If the mother cannot supply it, a
wet-nurse should be procured, and, if the infant has not the strength
to suckle, the milk should be drawn from the breast and fed with a
medicine-dropper or a spoon.
In addition to providing proper food and maintaining an even body-
temperature, care must also be taken to protect these infants from
various harmful influences such as too much handling, strong light,
and loud noises. Although every precaution be observed, frequently
all counts for nothing; but if the child does thrive, there is no
reason for worry about its ultimate development. When a premature
infant lives, the same chances for adult health await it as it would
have had if born in its due time.