Part 14

The rules for the operation when performed for the mother are the same as when for the child, save that if absolutely required, it may be resorted to at an earlier period. If the child must necessarily be lost, the labor should not be long delayed.

* * * * *

There are several subordinate questions arising in this connection, neither metaphysical nor merely casuistic, but practical, and because bearing on the increase of criminal abortion, directly involving human life to an indefinite extent. One of them we shall now mention.

Let physical incapacity to the birth of a living or viable child through the natural passages be supposed to exist on the part of the mother; that this has been proved by examination, or by the result of a former labor, induced or at the full time. To save the mother’s life, early abortion is once brought on and the child destroyed; the woman and her husband being of course informed of the true state of the case. Is it right or justifiable, again to destroy the fœtus, and as often as sexual lust may repeat impregnation? Or should the patient be left to the risks of a subsequent Cæsarean section, which would at least give the chance of life to her child?

I am aware on which side of this question lies at present the opinion and the practice of the mass of the profession; that Nægele and others have ruled it right always to destroy the fœtus when a refusal to undergo the Cæsarean operation shall have been formally expressed by the mother; and that reports of instances where early abortion has been repeated, even to nine times upon the same patient, are still unblushingly published by men of the standing of Lever and Oldham.

But, on the other hand, in his late admirable justification of craniotomy where absolutely necessitated, Churchill makes use of the following language, which though offered in another connection, is none the less pertinent here: “It is the due appreciation of these relative responsibilities (regarding mother and child) in difficult cases, that distinguishes the wise and experienced accoucheur; he preserves a just counterpoise between them so long as it is possible to fulfil both, and recognizes the proper moment when one ceases. One, I say, not either; for I protest against the notion that we choose which of the two lives we shall save, a notion as false in theory as it is in practice. No man dare make such a choice, for we have neither the necessary knowledge, nor the right, nor the authority, to decide which is the more important life and best worth preserving.”

“My own opinion is that such a course (the repetition of abortion) ought not to be adopted, but that pregnancy should be allowed to proceed, without interruption, to the full period; and when labor declares itself, that the infant should invariably be extracted by the Cæsarean section,” which, when performed in season, is by no means necessarily fatal to the mother, and may preserve life to the child.

The question now so plainly put, is one for the profession soberly to discuss and to answer.

* * * * *

We have already shown that in many cases where instrumental delivery or the induction of premature labor is apparently requisite, the mother, if a Catholic, is sacrificed to the supposed impossibility of administering the right of baptism to the child. We do not, with some, allow that the physician is here justified in deliberately and falsely asserting the child’s death, where such has not taken place, but we have revived the suggestion of a method by which this great and fundamental obstacle may be overcome. We assert that the negligence too often shown by physicians in these cases, the custom of practically leaving the mother and her child to their fate when instrumental delivery shall have been refused upon religious grounds sincerely entertained, is, however wide it may appear from the point, directly incentive to the increase of criminal abortion. Provided the question of necessity is determined, but one course in these cases should be pursued, and that the performance of intra-uterine baptism.

* * * * *

The objections usually made to the induction of premature labor, namely, the uncertainty of all pelvic measurements and of the exact period of gestation, the greater liability to malpresentation, and, from the uninvoluted state of the cervix, to the evils of a lingering labor, lose much of their force when tested by our preceding remarks. If resorted to, the means of its induction are various, and, as regards their justifiability, they present a decided choice. We here omit the consideration of the methods indirect or of doubtful efficacy, as draughts, general or local baths or bleedings, forced exercise, fatigue, and voluntary falls or blows, so frequently resorted to by the uneducated, or used, in addition to other procedures, by the designing to mask the reality; these will be subsequently considered, and we confine ourselves, in comparing the other and more direct methods, only to ascertaining that which is safest and most efficacious, for these points alone can decide their respective justifiability.

The direct and reliable means of inducing abortion, in the physician’s possession, are only instrumental. Draughts of all kinds, whether purgative, emmenagogue, or so-called specific,—aloes, ergot, or savin,—or energetic poisons, expelling the fœtus through a sudden and profound disturbance of the whole maternal system, as arsenic or cantharides, are too unreliable, unscientific, or dangerous either to mother or child. The justifiable methods are confined to those acting directly on the uterus and its contents, by dilating the os or detaching the membranes.

They are, rejecting the local application of belladonna as utterly inert:

1. Local or distant and sympathetic irritation

By the hand; medicinal applications; electricity or galvanism.

2. Puncture of the membranes, and evacuation of their fluid contents.

3. Dilatation of the os, and separation of the membranes from the uterine walls

By sponge tents; the introduction of instruments; or the injection of fluids.

The first of these modes, in all of its applications, is extremely uncertain in effect.

The second, though that usually attempted, is of real avail only toward the close of pregnancy, and is even then decidedly inferior to the last of the methods proposed; at an earlier period it is probably unjustifiable. In thirteen cases reported by Lever and Oldham, where labor was prematurely induced by puncturing the membranes, only four of the children were born living, and in all these the presentation was by the vertex. It has been shown that malpositions are much more frequent in earlier than later pregnancy, and from evident causes, the comparative absence and weakness of the fœtal movements which govern its position in utero, and the want of correspondence in form between itself and the containing organ. Of the nine cases reported where the fœtus was dead, five presented by the vertex, and were therefore probably alive at the commencement of labor, as after death previous to labor, malposition very generally occurs, except there be deficiency of the liquor amnii or the pregnancy have advanced to near its close.

Again, it appears from the same statistics, which as offered for another purpose are the more to be depended upon, that in the successful cases, where the child was born living, the length of time after the operation and before the occurrence of pains, almost doubled that in the unsuccessful cases, where the child was lost; the sum of the hours in the four successful cases exceeding the sum in the nine unsuccessful ones. That is to say, in the one class of cases time was allowed for a certain amount of dilatation of the os and cervix and for some degree of detachment of the membranes, an approach, however slight, to the characters of normal labor; and in the other cases the labor was brought on at once, without either of the above processes having commenced, and when both uterus and its contents were totally unprepared. Had the times, moreover, from the commencement of labor to its close, been given in the two classes of cases, it would probably have been found that the relative proportions were reversed; that the sum of the hours in the unsuccessful cases exceeded that in the successful cases, as would be in strict accordance with the results to the fœtus.

In premature labor, as in that at the full period, the bag of waters is required to be preserved until it has fulfilled its purpose, on the one hand, of a fluid wedge, and on the other, of protection to the child from violence till it has fairly entered the pelvic brim. Puncture is also attended with the danger of directly wounding the uterine tissues.

The last of the methods referred to, dilatation and detachment, combined to a certain extent as they must necessarily be, is in close imitation of the processes observed in natural labor, and is recommended alike by its safety to mother and child, its certainty, and the ease both to physician and patient with which it may be effected.

* * * * *

From the above remarks it is evident that the profession need to exercise great caution lest they directly, though unintentionally, become the abettors of criminal abortion. But this liability is not confined to the instances already mentioned, where abortion has been intentionally induced. Nor is the matter in question one affecting merely the public health and morals, like prostitution or syphilization. It is a liability directly to increase the unjustifiable destruction of human life, and its existence cannot be too strongly impressed upon our minds and guarded against.

So true is this, that two of the French obstetricians, Moreau and Bégin, have not hesitated to express their fears, and not on religious grounds alone; the latter, with Tardieu, giving it as his conviction, that every physician should make a legal declaration of the act to the public prosecutor, immediately on inducing premature labor, even if the period of viability has been reached by the fœtus. The subject has also been discussed by the French Academy of Medicine; and in Great Britain it has been referred to by Radford, in whose opinion an enactment is necessary, “entirely prohibiting obstetric abortion (before the period of viability), as the door for evil purposes is already too open, and would be still more so, if it was legally decided that where performed on supposed obstetric grounds, no inquiry should be made.”

Whenever an abortion is induced by a physician, even if accidentally, it is liable to be thought intentional by the patient and her friends, and consequently by the community, so far as it becomes aware of the fact. Instances of this are within the writer’s knowledge.