On criminal abortion in America

by Horatio Robinson Storer

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]