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]