Chapter III: Abortion, Miscarriage and Premature Labour

If pregnancy ends in the emptying of the uterus before the sixteenth week of gestation, the condition is called an abortion; if this happens between the sixteenth and the twenty-eighth weeks, it is miscarriage; if the child is born after the twenty-eighth week but before full term, the birth is premature. The term "abortion" in the popular mind carries with it the notion of criminal interference, and the word "miscarriage" is used for both abortion and miscarriage by the laity; physicians, on the other hand, commonly use the term "abortion" for both abortion and miscarriage. These conditions may occur spontaneously or they may be induced artificially.

Spontaneous abortions are very frequent; perhaps one in every five or six pregnancies is the proportion: the writer has known a single physician, not a specialist in obstetrics, to be called to three in one day and that in private practice. From 150 to 200 children in every 1000 that are conceived never get a chance for baptism. In the early months of pregnancy the foetus is usually dead before expulsion takes place. Twisting of the cord, hydramnios, syphilis, an acute infectious disease in the mother, poisonings of the mother by metals and the like substances, maternal cardiac and renal diseases, chronic inflammations and displacements of the womb, and violent emotions are some of the causes of abortion. In certain women a slight exertion, a misstep, a fall, a ride over a rough road, the _debitum conjugale_, and similar causes bring on abortion; in other women almost no shock is enough to make them miscarry. Inflammations and displacements of {49} the womb cause most of the abortions in the first four months, and after that time syphilis and Bright's disease are the chief forces at work.

If a woman in early pregnancy begins to lose blood from the uterus, and has pain in her back and lower abdomen, abortion is threatened; if this hemorrhage is marked, and the cervix is dilated, the abortion will very probably occur; and the escape of the _liquor amnii_ renders the abortion unavoidable. In this latter case the vagina and the cervical canal are packed with sterile gauze to check the hemorrhage, and after twenty-four hours it is removed. Then commonly the entire ovum comes away with the gauze, or what remains of it is taken out with a curette.

Valvular lesions of the heart in pregnancy make a maternal mortality of about 28 per centum, according to Guerard, and when compensation is lost the mortality may run from 48 to even 100 per centum with different physicians and different cases. The prognosis is good as long as compensation is retained, but very bad if this fails. In the latter condition premature labour is indicated, or the early removal of the viable child. Catholic physicians may not induce artificial abortion of an unviable foetus. The decree of the Holy Office concerning this matter is as follows:

Beatissime Pater,--Stephanus . . . Archiepiscopus Cameracensis . . .
Quae sequuntur humiliter exponit:

Titus medicus, cum ad praegnantem graviter decumbentem vocabatur,
passim animadvertebat lethalis morbi causam aliam non subesse
praeter ipsam praegnationem, hoc est, foetus in utero praesentia,
una igitur, ut matrem a certa atque imminenti morte salvaret,
praesto ipsi erat via, procurandi scilicet abortum seu foetus et
ejectionem. Viam hanc consueto ipse inibat, adhibitis tamen mediis
et operationibus, per se atque immediate non quidem ad id
tendentibus, ut in materno sinu foetum occiderent, sed solummodo ut
vivus, si fieri posset, ad lucem ederetur, quamvis proxime
moriturus, utpote qui immaturus omnino adhuc esset.

Jamvero lectis quae die 19 Augusti, 1888, Sancta Sedes ad
Cameracenses Archiepiscopos rescripsit: _tuto doceri non posse_
licitam esse quamcumque operationem directe occisivam foetus, etiam
si hoc necessarium foret ad matrem salvandam: dubiis haeret Titius
circa {50} liceitatem operationum chirurgicarum, quibus non raro
ipse abortum hucusque procurabat, ut praegnantes graviter
aegrotantes salvaret.

Quare ut conscientiae suae consulat supplex Titius petit: utrum
enuntiatas operationes in repetitis dictis circumstantiis instaurare
tuto possit.

Feria iv, die 24 Julii, 1895.

In Congregatione generali S. Romanae et Universalis Inquisitionis .
. . Emi ac Rmi Domini Cardinales . . . respondendum decreverunt:
_Negative_, juxta alias decreta, diei scilicet 28 Maii, 1884, et 19
Augusti, 1888.

. . . Sanctissimus Dominus noster . . . approbavit.

Other documents referring to the same matter are the following:

Epistola ad Archiepiscopum Cameracensem. . . . Anno 1886,
Amplitudinis tuae Praedecessor dubia nonnulla hinc supremae
Congregationi proposuit circa liceitatem quarumdem operationum
chirurgicarum craniotomiae affinium. Quibus sedulo perpensis,
Eminentissimi ac Reverendissimi Patres Cardinales una mecum
Inquisitores Generales, feria iv, die 14 currentis mensis,
respondendum mandaverunt:

In scholis catholicis tuto doceri non posse licitam esse operationem
chirurgicam quam craniotomiam appellant, sicut declaratum fuit die
28 Maii, 1884, et quamcumque chirurgicam operationem directe
occisivam foetus vel matris gestantis.

Idque notum facio Amplitudini tuae, ut significes professoribus
facultatis medicae Universitatis catholicae Insulensis. . . .

Romae, die 19 Augusti, 1889. . . .

R. CARD. MONACO.

The date of this response here is 1889, but in the preceding decree it is given as 1888. In the _Acta Sanctae Sedis_ the date is 1889.

Another letter from Cardinal Monaco is this:

Eme et Rme Dne,--Emi PP. mecum Inquisitores generales in
Congregatione habita feria iv, die 28 labentis Maii, ad examen
revocarunt dubium ab Eminentia tua propositum--An tuto doceri possit
in scholis catholicis licitam esse operationem chirurgicam, quam
Craniotomiam appellant, quando scilicet, ea omissa, mater et infans
perituri sint, ea e contra admissa, salvanda sit mater, infante
pereunte?

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--Ac omnibus diu et mature perpensis, habita quoque ratione eorum
quae hac in re a peritis catholicis viris conscripta ac ab Eminentia
tua hinc Congregationi transmissa sunt, respondendum esse duxerunt:
_Tuto doceri non posse_.

Quam responsionem cum SSmus D. N. in audientia ejusdem feriae ac
diei plene confirmaverit, Eminentiae tuae communico. . . .

R. CARD. MONACO.
Romae, 31 Mail, 1884.

Emo Archiepiscopo Lugdunensi.

Another decree concerning abortion is in part as follows:

Beatissime Pater,--Episcopus Sinaloen. ad pedes S.V. provolutus,
humiliter petit resolutionem insequentium dubiorum:

I. Eritne licita partus acceleratio quoties ex mulieris arctitudine
impossibilis evaderet foetus egressio suo naturali tempore?

II. Et si mulieris arctitudo talis sit, ut neque partus praematurus
possibilis censeatur, licibitne abortum provocare aut caesaream suo
tempore perficere operationem? . . .

Feria iv, die 4 Mail, 1898.

In Congregatione habita, etc. . . . EE. ac RR. Patres rescribendum
censuerunt:

Ad I. Partus accelerationem per se illicitam non esse, dummodo
perficiatur justis de causis et eo tempore ac modis, quibus ex
ordinariis contingentibus matris et foetus vitae consulatur.

Ad II. Quoad primam partem, _negative_, juxta decretum Feria iv, 24
Julii, 1895, de abortus illiceitate. Ad secundum vero quod spectat;
nihil obstare quominus mulier de qua agitur caesareae operationi suo
tempore subjiciatur. . . .

In sequenti Feria vi, die 6 ejusdem mensis et anni . . . SSmus
responsiones EE. ac RR. Patrum approbavit.

Pyelonephritis (an inflammation of the kidney where pus is present), from the pressure of the pregnant uterus, is a condition which sometimes obliges the physician to bring about premature labour to save the mother. The symptoms usually appear in the latter half of gestation.

Chorea ("St. Vitus' Dance"), when it develops during pregnancy, has a maternal mortality of from 17 to 22 per centum. It may cause death before the child is viable, and to empty {52} the uterus will stop the symptoms. Here the decrees of the Holy Office will occasionally prevent the Catholic physician from interfering.

If a grave surgical operation is imperatively indicated during pregnancy, and may not be put off until after delivery, it should be undertaken in many cases, because modern technique commonly does not bring about an abortion; but, in general, no rule can be given--each case must be judged separately.

If a pregnant woman has at the same time considerable albumen in her urine and a low excretion of urea, her condition is very dangerous. To empty her uterus will, in most cases, relieve the renal trouble, but in any case premature labour is not to be induced rashly: many women escape, when by all the rules they should die.

Eclampsia is a very grave complication of pregnancy, and it was formerly supposed to be uraemia. The disease is characterized by convulsions, loss of consciousness, and coma. It occurs, commonly, in the second half of gestation, but it has been observed as early as the third month. About 70 to 80 per centum of the cases are in primiparous women. The convulsions may come on altogether unexpectedly, but commonly the attack begins with symptoms of toxaemia. Eclampsia may occur before, during, or after parturition. When it comes before term it usually ends in spontaneous or artificial abortion, but at times the woman dies undelivered. Now and then she may recover and be delivered at term.

The kidneys are usually affected, even in those cases in which albuminous urine is not found. There is also a hemorrhagic inflammation of the liver; and oedema and congestion of the brain, with or without apoplexy, are other symptoms of the disease. There are other lesions, but the chief are in the kidneys, liver, and brain.

The aetiology of the disease is not yet known, and there are very many theories offered to explain it. The prognosis is always serious, and the condition is one of the most dangerous found in pregnancy. The mortality varies, but it is about from 20 to 25 per centum in the women, and from 33 to 50 per centum in the children. It is impossible to determine {53} the prognosis in particular cases, but a large number of quickly recurring convulsive seizures, with a weak, thready pulse, and a high temperature usually indicate a fatal ending. Apoplexy, oedema of the lungs, and paralysis also, as a rule, end in death.

If the uterus is emptied during the convulsions, these cease either immediately or soon after delivery, in from 66 to 93 per centum of the cases, and the maternal mortality then is about 11 per centum. With the expectant treatment, in convulsive cases, about 28 per centum of the women die, although a use of aconite in these cases may better the prognosis.

Pernicious vomiting (hyperemesis gravidarum) is another complication of pregnancy, which sometimes results fatally if the uterus is not emptied. There are cases, especially those with high fever, which end in death despite all treatment. Here, again, the aetiology of the disease is not known. There is commonly an element of hysteria in the condition, and in such a case moral suggestion often has a curative effect Any bodily irritation is to be removed. Eye-strain alone is enough to cause persistent vomiting. It is very difficult to decide when premature labour is absolutely indicated, because some very bad cases recover spontaneously when all hope is lost.

Hydramnios, or an excessive quantity of _liquor amnii,_ may so distend the uterus as to cause grave danger to maternal life, and if the child is viable the uterus should be emptied.

Intrauterine hemorrhage brought on by a premature separation of the placenta is a very dangerous condition: 32 to 50 per centum of the mothers die, and 85 to 94 per centum of the children. In a marked hemorrhage the only way to save the mother is to empty the uterus, so that it may contract and thus close the patulous vessels.

Placenta praevia is a placenta implanted in the neighbourhood of the internal os of the uterine neck. This is a very perilous condition, calling for the induction of premature labour. The medical treatment is artificial abortion as soon as the condition is diagnosed in any stage of gestation; but this is, of course, in conflict with the decrees of the Holy Office. Under expectant treatment about 40 per centum of {54} the mothers die, and 66 per centum of the children. Those children that are born alive commonly die within ten days after delivery. The great foetal mortality is due to premature birth and asphyxiation. Skilful obstetricians get much better results, but skilful obstetricians are unfortunately rare.

When the grave complications enumerated above occur in the early months of pregnancy, before the foetus is viable, the Catholic physician, since by the natural law and the decisions of the Holy Office he is forbidden to induce artificial abortion, must withdraw from the case. If there is no other physician to attend to the woman, he must let her die. He can not withdraw without explanation, and in many cases the explanation of the condition will promptly result in the calling in of a physician who has no scruple in inducing this abortion, no matter how reputable he may be. The universal medical doctrine is to induce abortion in cases where abortion will save the mother's life and the foetus is "too young to amount to anything." This is looked upon as legitimate abortion by the very best men that do not recognise the authority of the Holy Office: they deem the position of the Catholic physician in these cases as altogether erroneous, or even criminal.

The position of the Catholic moralists on craniotomy has turned the attention of many non-Catholic physicians to the immorality of the act, which formerly was deemed entirely permissible. Probably the same good result will be effected in the matter of abortion.

AUSTIN OMALLEY.

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THE CAESAREAN SECTION AND CRANIOTOMY

In the caesarean section the infant is delivered through an incision in the abdominal or uterine walls. The operation, according to one opinion, takes its name from Caius Julius Caesar, who, it is said, was brought into the world in this manner, _"a caeso matris utero"_; this, however, is a myth.

Up to 1876 the maternal mortality from the operation was about 52 per centum. Between 1787 and 1876 in the city of Paris there was not one successful caesarean section as far as the mothers were concerned. At present on an average less than 10 per centum of the women are lost, and expert surgeons have better results. Up to about 1902 Zweifel had made 76 such sections with only one death, and Reynolds, 23 with no death. Leopold has performed the operation four times on the same woman, and Ahlfeld and Birnbaum have reported instances where the same woman has had five caesarean sections performed upon her. The operation is, of course, capital, and always most serious, even in city hospitals.

The indication for the operation is chiefly a narrow pelvis, which blocks the delivery of the child. There are no reliable statistics as to the frequency of narrow pelves in the United States; but Dr. Williams, of the Johns Hopkins University Hospital, in a series of 2133 cases found 6.9 per centum in white women and 18.82 in negroes. Normally the average female pelvis, at its narrowest diameter, is 11 centimetres wide. This part is called the conjugata vera, and it is the diameter from the promontory of the sacrum behind to a point on the inner surface of the symphysis pubis in front.

In delivery much depends upon the size of the child, and in each case the obstetrician waits until he sees that delivery {56} is impossible by natural means before he resorts to the caesarean section or other operative interference. Of two women with pelves of the same contraction one may require the section and the other may have a normal labour. A bisischial diameter at the outlet of the parturient canal of 7 centimetres or less is an indication for section; so are certain tumours that block the delivery of the child.

When the conjugata vera is less than 7 centimetres in flat pelves, or 7.5 centimetres in generally contracted pelves, the treatment varies in the customary medical practice according as the child is alive or dead, and it varies as the condition of the mother. The common medical doctrine will first be given here before the moral questions that may be involved are mentioned.

If the deformity is diagnosed during pregnancy, the woman is sent to a hospital, the caesarean section is performed, and thus all the children, and nearly all the mothers, are saved. When the narrowness of the pelvis is discovered only during labour, the treatment varies with the condition. If the woman is not septic, and has not been repeatedly examined by the vagina, and if the surroundings are favourable, caesarean section is done; if she is septic, the indications are for the section, or symphyseotomy or craniotomy. Where the conjugata vera is below 5 centimetres in length, the caesarean section is the only method to get the child out, dead or alive, and after the child has been delivered, the uterus, if septic, is removed. If the conjugata vera is at the least 7 centimetres long, symphyseotomy may be done; if the conjugata vera is above 5 centimetres, the mother septic, and the child dead or dying, craniotomy is indicated. Even if the child is not dying, some obstetricians will do craniotomy.

In cases where the conjugata vera is above 7 centimetres in flat pelves and 7.5 centimetres in generally contracted pelves, the treatment can not be reduced to general rules. Delivery without operation occurs in many of these cases, but commonly the condition is obscure to the physician for some time. We can measure the pelves, but the size of the child's head is not satisfactorily measurable.

If the conjugata vera is from 10 to 9 centimetres, or from {57} 9.5 to 8.5 centimetres, labour without operation is the rule, and the child can usually be delivered by forceps. Should the child die during labour in these cases, it is best delivered by craniotomy, unless the longer diameter of its head has already passed the narrowest part of the pelvis.

When the conjugata vera is from 8.9 to 7.5 centimetres, about 50 per centum of the women will be delivered with forceps, but the other half will not. After about two hours of the second stage of labour delivery by forceps is tried, but prolonged traction is not applied. Occasionally delivery will come when least expected, but often it will not. If the head sticks, caesarean section is done in favourable circumstances, and craniotomy in unfavourable circumstances. If there is ground for supposing that septic infection of the mother has begun, the conditions are explained, and if she wishes to have the caesarean section done the risk is left to her. When the breech or face of the child presents in contracted pelves, the condition is especially unfavourable for the child.

There are very many varieties of deformed pelves, but the same rules apply to them as to those already mentioned, except that the caesarean section is oftener indicated. Difficulty also not seldom occurs in women with normal pelves from an excessive size in the child through prolonged pregnancy, bigness of one or both parents, or the advanced age or multiparity of the mother. The child's head alone may be of excessive size. Some monsters offer difficulty in delivery from size or shape, but, of course, they are human beings, and are to be considered as such in delivery. The technique of the caesarean section has only a medical signification, and it need not be described here.

Symphyseotomy is an operation in which the joint of the pelvis at the symphysis pubis is cut, and the pelvis is allowed to gape so as to let out the child. The operation has fallen into disrepute. The mortality as regards the mother is about the same as in the caesarean section, but the mortality of the children is higher. In symphyseotomy the infantile mortality is about 9 per centum, while in the caesarean section it is practically nothing. If in symphyseotomy an error is made in estimating the size of the pelvis or the child's head--and {58} such an error is often possible--the child will be killed, but in the caesarean section these errors make no difference. After the caesarean section the woman recovers promptly; after the symphyseotomy she recovers very slowly, and she may receive permanent injury.

Craniotomy is an operation wherein the head of the child is reduced in size to render delivery possible. The skull is perforated and the brain is broken up and removed or crushed out. Embryotomy is a similar operation wherein the viscera of the child are removed through an incision made in its thorax or belly (evisceration), or the head of the child is cut off (decapitation). There are numerous instruments and methods for performing craniotomy and embryotomy, but they all open the skull or belly, remove the brain or viscera, and then extract the child's body.

If the infant is hydrocephalic and is alive, the advocates of the operation warn us to be careful after opening the head to push the perforator into the base of the skull and stir it around well, so as to be sure the child will not be born alive. Pernice has recently reported a case of hydrocephalus which was delivered by craniotomy, but the operator did not work his perforator efficiently, and the child recovered, and grew up an idiot. A similar case occurred in Baltimore.

The indications for craniotomy among those that advocate its occasional use (and they are many) is in those cases in which the woman is so infected that caesarean section is dangerous, or where a child is hydrocephalic, or where an after-coming head is jammed (in this case even a caesarean section will not effect delivery), or in the case of a narrow pelvis and a moribund child, or finally in the practice of a country physician, who can not in an emergency get an assistant to do a caesarean section. One man can do craniotomy, but it requires three to perform the caesarean section. If the woman's narrow pelvis has a conjugata vera of five or more centimetres, craniotomy, if properly done, is not dangerous to the mother. With a conjugata vera less than 5 centimetres it is more fatal than the caesarean section. If the women are septic, the mortality in {59} craniotomy is from 10 to 15 per centum; in caesarean section about 25 per centum.

As to the morality of craniotomy on the living or moribund child, it is not permissible under any possible circumstances: a consideration of the ethical principles set forth in the article on Ectopic Gestation will make this assertion clear.

The Congregation of the Holy Office on August 19, 1888, decreed that "In scholis catholicis tuto doceri non posse licitam esse operationem chirurgicam quam Craniotomiam appellunt." They gave a similar decision May 28, 1884, and they repeated the prohibition, with the papal approbation, on July 24, 1895. The text of these decrees may be found in the article on abortion, miscarriage, and premature labour.

The Porro operation consists essentially in a removal of the uterus after caesarean section to prevent further conceptions. As a means to prevent conception it is altogether unjustifiable, because repeated caesarean sections in the same woman, if the surgeon is at all competent, are practically no more dangerous than normal labour.

AUSTIN OMALLEY.

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