rubella during the first 8 weeks of pregnancy, 2 patients; severe debilitation from longstanding ulcerative colitis, under treatment with large doses of steroids, 1 patient; severe depression, 1 patient; psychosis or frontal lobe tumor, 1 patient; exposure by multiple x-rays of one fetus in the first 2 weeks of gestation, 1 patient; meningitis thought to be associated with suspected interference of an early pregnancy, one patient. All of these patients were married except the last one.

During this 2 year period, 8 pregnant or recently pregnant patients were admitted to the closed psychiatric ward after having attempted suicide. One of these patients (Case 257022) was previously mentioned in the group of therapeutic abortions. This 32-year-old married white gravida iii, para ii patient was first admitted to the hospital on June 13, 1965, for termination of an 18 week gestation because of severe debilitation from a longstanding ulcerative colitis. She had received large doses of steroids and her attending physician feared irreparable damage to the fetus. An abdominal hysterectomy was performed for termination of the pregnancy and sterilization. Her immediate postoperative recovery was uneventful. However, 2 months later she was admitted to the closed psychiatric ward in a state of severe depression after attempting suicide. She responded to treatment and was soon discharged. She required readmission Nov. 5, 1965, and subsequently had to be transferred to a psychiatric hospital. A psychiatrist's opinion was that this patient received inadequate psychological preparation for the termination of her pregnancy and sterilization. Professional responsibility demands psychological and spiritual preparation of the patient in the attempt to avoid development of late depression and guilt feelings in all cases of therapeutic abortion.

Six other patients were admitted with the diagnosis of "overdose of drugs," but only one patient was ill enough to be described as semicomatose. One patient was admitted after slashing both wrists with a razor blade. Of the 7 patients who were pregnant when admitted to the psychiatric section, 3 were in the third trimester. Two were in the second trimester and in one the dination of gestation was undisclosed. One patient was questionably pregnant. In no instance was the pregnancy terminated.

In this 750 bed hospital of our community where therapeutic abortion is allowed, two consultants must agree upon the necessity of termination of the pregnancy. Such cases are always

reviewed by the Tissue Committee and the Sevtion of Obstetrics and Gynecology, To date there has been no indication of abuse of the procedure of therapeutic abortion.

There appears to be no necessity for liberalization of the therapeutic abortion laws except (1 to protect the life and welfare of the mother including cases of rape or incest and (2) feta! indications for removal of a suspected malformas tion of the fetus such as may be associated with rubella, excessive exposure to inadiation, or administration of a known teratogenic drug.

In Tennessee during the 11 years of 1953 through 1965, 2.995 males committed suicide as compared to 759 females; as in Minnesota, it was interesting to note a 4:1 ratio of male to female suicides.

DR. CHARLES S. STEVENSON, Detroit, Michigan. Dr. Barno's study is a great testament to the hardness, stability, and the nonindigency of the inhabitants of the state of Minnesota.

In Michigan over this same period (1959 through 1965) we had 223 maternal deaths directly due to puerperal infection. Infection was the second most common cause of maternal deat!. in our state, hemorrhage being the first, with 436 deaths.

Of the 223 deaths from infection in this 16 year period. 138 (62 per cent) were due to septic abortion. The deaths due to septic abortien all occurred in the first 20 weeks of pregnancy. Eighty-five of the deaths 33 per cent) were duc to puerperal sepsis occurring in the second hali of the pregnancy and post partum.

These 138 fatal cases of induced and infected abortion occurred primarily in the greater metres politan Detroit area and nearly all of these were in the medically indigent group of women living in the poorest and most rundown areas in our city.

In a recent 2 year period at the Detroit General Hospital, we saw 66? cases of infected „bontion, and septic shock was present in 12 of these patients. Two of the 12 died, giving a mortality rate of one in 331 cases of septic abortion. Eleven. of the twelve women in shock were Negroes and one was a Mexican woman.

During the same 2 year period, there were 26 deaths from septic abortion in Michigan and if each of these represented 331 cases of septre abortion the ratio known to have obtained at the Detroit General Hospital, there were 8.60 women in Michigan having infected abortions in this period, over 1,000 such cases a year,

In Michigan in the 5 year period from 1950. 1964 there was an average of only 4 deaths a year from septic abortion, whereas in the recent 8 year period 1958-1965) there was an average of 13 fatal cases each year. This indicates about a threefold increase in deaths from septic abor

tion.

During this same 8 year period, there were twenty-odd deaths from air embolism which occurred as a result of passing a rubber catheter * into the woman's uterus in an attempt to bring about abortion. This not only gives further evidence of the size and seriousness of our problem, . but also points up the desperate emotional state of these pregnant women.

Practically all of the abortions in the past 8 years, in our experience at the Detroit General Hospital, have been induced, and the instrument most commonly used in this period has been the rubber male catheter, which can be purchased at any drug store. Many women pass the catheter into the cervix themselves, so they have told us, and also a good many others get their neighbors and friends to do it for them.

A large proportion of the women who have their abortions done or do them on themselves do definitely realize the great danger to their lives such a procedure entails; on the other hand, they tell us that they are desperate, that they already have more children than they can take care of, and that this is their only means of escape from their unwanted pregnancy.

---Nemorrhage

Fig. 1. Maternal mortality trend in Michigan.

ABORTION

for maternal mortality parallel those for the rest of the nation but the trend for the rate of maternal mortality associated with abortions is rising (Fig. 1).

The mortality rate for infection in general is going up Table 1). Maternal mortality from abortion is a significant and increasing per cent of deaths occurring in pregnant women. It is not a static nor insignificant factor as Dr. Barno suggests that it is in Minnesota (Table I).

Michigan figures disagree with the statement made in the original paper, that if a woman develops complications following a criminal abortion, the first thing she does is to contact the physician and that then she is usually and immediately hospitalized if necessary. Michigan women die before they contact the doctor in a rising percentage of our cases. In part, this is due to the word of mouth spread of the popularity for the catheter method of criminal abortion (Table III).

Last, Michigan's incomplete figures for the last 5 year study indicate that more married women die from abortion, regardless of the reason behind the abortion, than do unmarried women. We considered 42 married, separated, and common law wives as against 15 for the group including single, divorced, and widowed. This involves almost 22 times more married than unmarried (Table IV).

These statements are not made with the intent to advocate liberalization of the therapeutic abortion but to show that in at least one state making a greater noise in the population explosion, the problem is not as insignificant as originally presented today.

DR. BALNO (Closing). I would like to ask Dr. Charles Stevenson whether he favors the eradication of the problem of septic abortion in Detroit by allowing an abortion to every woman who requests it? This is the only way that I see you can do it. The desperate emotional state of these women should be managed by psychiatrists.

Dr. Lee Stevenson talked about figures from the State Health Department in Michigan. I can say that in Minnesota we found that in 25 per cent of the instances, there was no correlation between the cause of death on the death certificate and what actually happened. We have personally investigated each one of these cases during the past 16 years.

In 1964, Michigan reported 25 criminal abor tion deaths among a population of 7.8 million. Even if we assume that the same conditions prevail over the entire United States with a population of 196 million, as in the state of Michigan, it would mean that there were a total of only 628 criminal abortion deaths in the United States in 1964.

A few comments are in order to re-emphasize what is happening in some areas insofar as psy

chiatric aspects are concerned. Niswander, Klein, and Randall1 from State University of New York at Buffalo, have recently reported for a 22 year period, 299 of 504 therapeutic abortions for psychiatric disease. The precise psychiatric diagnoses were not given. Of these 299, 293 were done on private patients and only 6 among charity patients. It seems amazing to me that this double standard exists in a teaching institution.

Furthermore, 50 per cent of these women were unmarried. Were they dong just because they were unmarried?

Sterilization was done concurrently with the therapeutic abortion for psychiatric reasons in 40 per cent of the married versus only 4 per cent of the unmarried. How can psychiatric disease be so much more severe in the private patient versus her counterpart, the charity patient? How can psychiatric disease be so severe in the married patient as to warrant concurrent sterilization in 40 per cent versus only 4 per cent in the unmarried group? One might ask, is all of this an exercise in iatrogenic manipulation?

Finally, I would like to say, lest there be some confusion that my remaiks might be based on sectarian prejudice, that my religion is Unitarian.

REFERENCE

1. Niswander, K. R.. Klein. M., and Randall, C. L.: Obstet. & Gynec. 28: 124, 1966.