Germany once in every 1944 labors;
Paris ” ” 1628 labors;
France, at large ” ” 1200 labors;
Vienna ” ” 688 labors;
England ” ” 220 labors;
Ireland, formerly ” ” 128 labors;[141]
” at present, Dublin
Hospital, 1854, ” ” 105.7 labors.[142]
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.”[143] 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;[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.
* * * * *
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.
* * * * *
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.
* * * * *
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: