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]
* * * * *
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.
* * * * *
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.
* * * * *
Again, it is undoubtedly the case that in all cases of maternal death
during pregnancy, where the fœtus has arrived at the period of viability,
its immediate extraction by the Cæsarean section should be effected.
We have already referred to this subject, and Kergaradec, who has well
written upon it, lays down the maxim that the operation should always be
performed, even in the fifth month of pregnancy.[159] In some cases,
of placenta prævia, for instance, where the chances are always more or
less against the child’s life, success is less probable; but this in no
wise invalidates the necessity of the operation. The writer has himself
performed it in the complication instanced, and in vain; but he would
none the more hesitate, on this account, to repeat it. There can be
no reason against the procedure in any case, and by it the child may
possibly be saved. In the words of an older writer, “Est enim inhumanum,
post obitum matris, fœtui pereunti et suffocari parato manus auxiliares
denegare, et sæpè viventem adhuc cum matre mortuâ eodem tumulo contegere
et obruere. Idcirco jurisconsulti eum _necis_ reum damnant, qui gravidam
sepelierit non prius extracto fœtu.”[160]
A question has been raised concerning the rights of relatives in
preventing the physician from such discharge of his duty. It has
been asserted that “the father has not only the natural right of his
relationship, but legal power; for Dr. Lever recently mentioned that he
had consulted Dr. Alfred Taylor to know whether he would be justified in
performing Cæsarean section after the death of the mother, without the
consent of the father, as it appeared unjustifiable homicide to allow
the infant to die. Dr. Taylor gave his opinion that, in law, the infant
belonged to the father,—the infant with the life thereof,—and that if
Dr. Lever touched it, even to rescue it from death, an action would lie
against him.”[161] I must, however, declare such doctrine to be false
and pernicious. If signs of the child’s life remain, no physician should
hesitate endeavoring to preserve it, unless restrained by actual force. I
reiterate my conviction that such neglect, or seeming neglect, of fœtal
life is an actual wrong, both against the individual and against society.
Similar points in which physicians are directly interested, as tending
by their apparent disregard of fœtal life to render themselves innocent
abettors of criminal abortion, are not uncommon. Such are neglect of
efforts to prevent miscarriage when threatening, or where it has become
an established habit; and of attempts at resuscitating still-born
children where there is the slightest chance of success, and success has
now been rendered much more probable by the methods of Marshall Hall and
Silvester; the performance of operations of any kind upon a pregnant
woman, even tooth-drawing,[162] that might be delayed; the careless or
unnecessary use of ergot; the relying upon a single and unaided opinion,
where not one life only, but two, may be endangered.
Other instances might be adduced; but enough has already been said to
prove that the importance of the subject we are considering, and the
responsibilities resting upon the profession regarding it, demand as I
have elsewhere suggested,[163] that physicians should possess, should
acknowledge, and should govern themselves by, an _Obstetric Code_—the
necessity of which will be made even more manifest, as we proceed in our
investigation of questions pertaining to Obstetric Jurisprudence. We have
referred to some of its leading principles, but have done no more than
faintly foreshadow them.
Distressing in the retrospect, inconvenient frequently in the
present,[164] such a Code would undoubtedly prove; but it is demanded
of the profession by the progress of our science, by humanity, morality
and religion. Were the facts in the case more generally known, and the
existence and sanctity of fœtal life more universally appreciated, it
would be also demanded by public opinion.
We have now seen that “the absurd enactments still remaining on the
statute book, the careless indifference with which society views the
crime, the reluctance with which means are adopted to prevent its
occurrence, its increase, and its frequent induction by obstetricians,
are all evils which loudly and imperatively call for the closest
investigation.”[165]
We proceed to the other relations of criminal abortion, more especially
to those immediately pertaining to the claims and course of justice.