Part 7

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;[144] 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,[145] and can only repeat, as is indeed allowed by Churchill,[146] 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.

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.

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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[147] and others[148] 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.[149]

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.”[150]

“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,”[151] 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.

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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,[152] 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.

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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,[153] 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.[154]

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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;[155] 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.”[156]

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.

Accidental abortions, caused by a physician, may be from two causes: error or insufficient care in diagnosis, or the absence of all likelihood of the existence of pregnancy. When cases are reported in apparent innocence of fault, and by eminent practitioners, of the pregnant uterus having been tapped for ovarian dropsy; of craniotomy having been attempted upon an infant’s fundament instead of its skull, and of the same operation in another instance undertaken upon the promontory of the mother’s sacrum, it cannot be alleged, I care not by whom, that this caution is unnecessary or these fears unfounded. The writer will state a few cases that have happened under his own observation. He has twice known abortion to be accidentally occasioned by the use of sponge tents;[157] the patients being near the close of their menstrual lives, and neither themselves nor the physicians in attendance supposing that the contents of the enlarged uterus could be fœtal; in one of these cases the woman had never before been pregnant, and in the other not for many years. He has twice known the introduction of an intra-uterine pessary to be followed by abortion; in neither case was there any probability of the existence of pregnancy, save in the fact that the patients were married. He has known abortion to be produced by the application of lunar caustic to the os, in a case where, from the character of the operator, no suspicion could be entertained of the uterus having been more deeply tampered with.

In cases like these, the practitioner would seem to render himself liable to the charge of malpractice, even though by the improbability of malicious intent he escaped that of criminal abortion. In all instances where there exists the slightest suspicion or possibility even of pregnancy, the only rule for operative interference must be, unless circumstances imperatively prevent, to wait the few months or weeks necessary to establish the diagnosis. Justice to the profession and to the risk of error demand that where such precaution is not had, it should be replaced by a consultation, which would at once dispel any suspicion of carelessness or malpractice, and prevent a criminal charge.

All that we have said regarding surgical obstetrics, applies as forcibly to its medicinal procedures. Though draughts and potions of every kind are, as we have remarked, of doubtful or indirect efficacy for inducing abortion, yet with some of them instances of its occurrence do at times result. In supposed obstructive amenorrhœa, unless of several months standing, and in early pregnancy where established, the physician who does not intend it, must take care lest accidentally or carelessly, by purging, vomiting or over-bleeding, he produce a miscarriage.

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But there is still another point in this connection we must not pass over. We state it in the following inquiries, received from one of the most eminent practitioners of the Eastern States, and put to us in all sincerity.

“Are there not cases where a physician would be justified in suggesting a course such as he would use in amenorrhœa, even where he might _suspect_, but not _know_, the existence of pregnancy? Suppose a mother of several children, which she has had in rapid succession, and the physician feels assured that health, and possibly life, will be endangered if another pregnancy occurs; would he be criminal if he were to use common means for amenorrhœa if the menses have been absent six weeks? Are the cases always so plain that a man can decide, and may he not balance a choice of evils?”

Covering as these questions do, much of the ground already gone over, we may answer them at once, and decidedly in the negative. They apply more especially to the early months of pregnancy, where it is always impossible to know its existence; and were direct or probable emmenagogues, or instrumental interference, to be here allowed, criminal abortion might be always induced before quickening, sanctioned and permitted by the rules of medicine. To justify abortion, life must certainly or very probably be endangered, not possibly merely, which is true in every pregnancy, and might be alleged at every trial for the crime.

Hufeland advised, as a “golden rule,” always to suppose the existence of impregnation in such cases, and to act accordingly; that is, to temporize long enough for the fœtus, if present, to make its sign. “Thereby,” he says, “the physician will avoid much mischief, and preserve his conscience as well as his reputation.”[158]

The ideas on this subject held by my friend, are without doubt widely entertained by the profession. This paper will have served a good purpose and have saved many fœtal lives, if it do no more than carry conviction of the error and its likelihood to indefinitely extend the crime.

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