Part 13

We have already stated that the induction of abortion before the seventh month, undertaken for the child’s sake, must be generally useless; and therefore, as attended with some degree of danger to the mother, generally unjustifiable. As the profession are nearly united on this point, its further discussion is here unnecessary.

We have asserted that the cases where prematurely induced labor is required for the child, are comparatively rare. We now add that while in some respects they are more frequent, in others they are less so than is generally supposed. To necessitate it, there must be disease or deformity on the part of the mother, or disease on the part of the fœtus or its appendages.

It is most frequently performed to avoid the alternative of craniotomy, the necessity of which, unless extreme, can manifestly only be known with certainty, before the expiration of pregnancy, from the experience of past labors. But here too much caution cannot be exercised; the rules of the books and of accepted authorities are not to be blindly followed.

Craniotomy at the full time is still too frequently performed:

Where it has been suggested by the character of a previous labor, children are often, or might be, born living;

Where it seems indicated by direct exploration, as ruled even by recent writers, children are sometimes, or might be, born living;

Where it was formerly thought absolutely essential, the progress of obstetric science has now rendered it often unnecessary.

It is proper that we consider these points, for they bear directly on the question at issue concerning criminal abortion.

It is known that the sex of children exercises an appreciable influence upon the result of labors at the full time, as regards the possibility of their passing alive, unaided or at all, through the pelvis, and as regards the length of the labor, which also progressively endangers the life of the mother and their own; the average female fœtus, in cases at all difficult, having the advantage over the male by its inferiority in size, especially important in the cranial diameters. It is unnecessary for us to do more than refer to the facts by which these assumptions are proved. Where, therefore, craniotomy has been found necessary in a former labor, the child then being male, in another labor a female fœtus may often pass uninjured. However this argument may be lessened in value by the impossibility of previously ascertaining the sex, it is strengthened in the doctrine of chances, by the number of the labor and the sex of the former children; and by the fact that first labors are generally most difficult, whatever the sex of the child.

Furthermore, cases will suggest themselves to most practitioners of experience, in which from difference in the character of the labor or without apparent reason, children are born living at the full time, males, of large size, and presenting by the vertex, where craniotomy had previously, perhaps repeatedly, been performed. An instance of this has occurred to the writer, where the patient had been advised to early abortions from alleged physical incapacity of ever bearing living children; he delivered her, without difficulty, of a large-sized and living boy, at the full time.

Again, it may happen that in labor at the full period, craniotomy may seem decidedly indicated and advisable, but for one reason or another may not be performed, and yet the child, unaided, be born living. The writer’s experience furnishes him with two illustrations of this class: one of them occurred in 1851, the patient his own, Drs. S. sen., and C., in consultation; the other was seen at Edinburgh, in 1854, in the practice of his friend, Dr. G. W. In both cases, permission was refused to operative procedures, the patients being Catholic, and the physicians unable conscientiously to pronounce the fœtus already dead, while the possibility of intra-uterine baptism was not recollected; in both instances the children were born living, and without instrumental aid.

In other cases, where from deformity previously diagnosticated, craniotomy is pronounced necessary if the patient should go her full time, she may do so, the labor be unassisted, and the child yet escape with its life. I instance a remarkable case for some time under my own charge at the Boston Lying-in Hospital, delivered by one of my colleagues, Dr. Dupee, and subsequently reported by Dr. Read. The pelvis was here equably contracted, and to a great degree, but from some difference of opinion, partly as regarded the justifiability of premature labor as compared with craniotomy, the patient was allowed to go her full time. Both mother and child did well.

Finally, by turning, the use of the long forceps and of anæsthesia, children are now constantly saved, where formerly craniotomy and their consequent destruction would have been absolutely indicated. These processes, with the introduction of each of which as an alternative a single name is imperishably connected, are now successfully employed by very many of the profession; they have each of them saved to the writer the disagreeable necessity of fœtal destruction. Where, however, one life is thus preserved, there are still multitudes unnecessarily, and, therefore, unjustifiably, sacrificed.

The comparative frequency of craniotomy in the different countries of Europe is in this connection worth noticing.

The operation is performed, in

Germany once in every 1944 labors; Paris ” ” 1628 labors; France, at large ” ” 1200 labors; Vienna ” ” 688 labors; England ” ” 220 labors; Ireland, formerly ” ” 128 labors; ” at present, Dublin Hospital, 1854, ” ” 105.7 labors.

The remarkable difference between the practice on the continent and in England, so suggestive to us in this country, is undoubtedly owing to the fact that in Catholic States greater value is attached to the life of the child than “in Protestant States, as Britain, where the child is always sacrificed to save the mother.” The immense excess of embryotomy cases in Catholic Dublin furnishes no exception to this rule, drawn as they are from hospital practice under Protestant control.

So far proof by deduction. In many cases involving the question of craniotomy, that operation is not required; in some of them, not even the induction of premature labor.

Two classes of cases remain, each affording more direct evidence; those where craniotomy being absolutely indicated if the patient were allowed to go her full time, that operation is, and those where it is not performed.

Craniotomy, being necessarily fatal to the fœtus, is indicated only to save the mother’s life; to be avoided when any other alternative giving the fœtus a chance of life, and not more than equally hazardous to the mother, can be resorted to. Especially is this the case when it is compared with the induction of premature labor, attended as is the latter, despite a certain amount of danger of its own, with great probability of saving the child, and with decidedly lessened risk to the mother; for craniotomy not merely requires the use of murderous instruments, dangerous to all tissues they may approach or be in contact with, but the operation is usually, though often very improperly, delayed till late in labor, and therefore till the mother’s chances of recovery have been proportionally lessened. Premature labor, on the other hand, though of course involving some risk to the child, is not necessarily fatal to it; nor is it usually so, when properly performed. That there is a choice in this respect between the means employed, will hereafter be shown.

Craniotomy, when absolutely indicated at the close of pregnancy, must be for one of two reasons: that the fœtus cannot pass through the pelvis at the full time alive, though it may do so unmutilated, the operation being performed to save the mother the greater risks of protracted labor; or that it cannot pass at the full time unmutilated, even when dead. We defer the consideration of another supposable instance, where the fœtus in the outset of its viability may pass, but not alive, for this pertains to the consideration of the mother’s safety alone, no alternative availing for the child. In the other cases, if the necessity could be learned in season, from the previous history of the patient or by pelvic exploration, labor should most certainly be prematurely induced, as affording some positive chance of life to the child, and as less dangerous to the mother. It were here worse than foolish, if not criminal, blindly to imitate nature, when, her course being obstructed, she would kill the child.

I have alluded for a double reason to cases, fortunately few, where craniotomy, and much more decidedly premature labor being indicated, the practitioner decides from the outset to perform neither, to give his patient or her child no aid. Such conduct is as cruel and wicked as it is unprofessional, and were not instances occasionally reported, its existence could hardly be believed. We acknowledge with Blundell the evils of meddlesome midwifery, but there are extremes to all things; certainly to the powers of nature and the limits of justifiable delay.

I am aware that I have referred to a reported case, which might in this connection be quoted against the opinion now expressed; but even by its exceptions do we prove the rule. Where chances are so greatly against both mother and child as in these cases if left unaided, it would be the office of the physician, were there no better procedure, by craniotomy to save the one; but at the present day it is no less plainly his duty, where possible, to anticipate labor, and thus save both. I have elsewhere discussed this question at some length, and can only repeat, as is indeed allowed by Churchill, that this is no matter on which to select one’s words; the deliberately sacrificing an unborn, but still living child, in cases where statistics go to prove that the adoption of another mode of delivery, nothing counter-indicating, would give that child a good chance of successful birth, is nothing short of wilful murder, no matter by what schools or by what eminent men it may be sanctioned, and it should be branded as such by the profession.

But, undertaken for the child’s sake, not merely should premature labor be resorted to for the purpose of preventing craniotomy, but often in cases of incurable disease, acute and chronic, of the mother, where it is evident that she must inevitably, or even probably, perish before the full period of pregnancy has been attained. Instances of such acute disease will readily suggest themselves. The question here is merely between the operation under consideration, the Cæsarean section, and doing nothing. The last, suppose the fœtus viable and to be still living, would in many instances be decidedly unprofessional and unjustifiable. Cæsarean section after the mother’s death is comparatively unsuccessful; and before it, is so much more severe and in all probability so much more quickly fatal, that the other should be preferred, unless death be already close at hand.

Instances of chronic incurable disease necessitating the induction of premature labor, may not so readily occur to the mind. The shock of an abortion being frequently greater to the maternal system than that of labor at the full time, it is evident that this rule cannot be universally applied. It cannot in every case of thoracic disease, of the heart, for example, unless its own peculiar symptoms become so aggravated from progressing pregnancy as to render probable earlier decease of the mother, the operation then being performed partly on her account; not so much to save her life as to delay a little her death. But there are other and extreme cases, as cancer of the lower segment of the uterus, or indeed of its fundus, which may have been diagnosticated previously to pregnancy by the use of expansible tents, or of my uterine dilator hereafter referred to, where the mother would probably perish in labor at the full period, with most probably the loss of the child also. Here, by premature labor, the child may be saved, and the mother’s life, greater expansion of the uterus and its more probable laceration being prevented, possibly prolonged.

So far complications on the part of the mother necessitating premature labor for the sake of the child. There are others equally imperative, afforded by itself. Excessive size of the fœtus in comparison with a normal pelvis, as evidenced and rendered probable by previous labors, is hardly of less importance in connection with craniotomy, than where the pelvis is distorted or contracted, and the fœtus of natural size; but the operation in question, as compared with premature labor, we have already sufficiently discussed.

Diseases of the placenta, congestive, inflammatory or degenerative, are no less an indication, where known to exist, for an early delivery. Their diagnosis may be difficult, but yet not wholly impossible. The occurrence of the same disease in past labors, and evident intra-uterine disturbance as discovered by auscultation or by unnaturally frequent and strong fœtal movements, are, taken together, frequently sufficient to establish the fact. The impropriety of allowing such cases to proceed unaided, cannot be too strongly insisted upon. By early delivery, if the fœtus have formerly perished after the period of viability, and in addition, by special medication of the parent, if its death had usually occurred before that time, many valuable lives might annually be saved.

Premature labor as resorted to on the mother’s behalf alone, putting aside the cases we have incidentally considered, where the lives of both herself and her offspring are of necessity taken into account, includes also its induction in the earlier months of pregnancy before the fœtus is viable. It may be required by diagnosticated malformation or monstrosity of the fœtus and by malformations on the part of the mother; by extreme pelvic contraction, congenital or from rickets or malacosteon, preventing the natural passage of a fœtus after viability, by tumors incapable of elevation or displacement, by contraction of the vagina, or by other severe obstetric complications, either recent or of long standing. Of this last class of causes, obstinate vomiting, puerperal convulsions, which are by no means confined to the full period of pregnancy, dropsies, irreducible displacements of the uterus, varix of the external labial vessels, sometimes fatal by laceration from tension, are all instances in point. With regard to each, the necessity of the abortion must be determined with the greatest caution, and resort be had to it, the child still living, with reluctance; especially should this be the case if the complication be supposed on the part of the fœtus, so important is it to avoid its sacrifice, if possible, and the semblance of disregarding its own important claims.