Essays In Pastoral Medicine Part 5

Now, first, if an artificial abortion is induced while the foetus is unviable, the foetus is lost and the mother's condition is not materially improved.

Secondly, if curettement (a sc.r.a.ping away with a sharp spoonlike instrument), cauterization, or amputation of the uterine cervix are performed, the mother is helped very little, if at all, and consequent abortion is frequent.

Thirdly, if caesarean section is done at term the child has a good chance (Sanger saved 16 of 18 children thus in one series: over 88 per centum), but this operation nearly always kills the mother when cancer is present, unless the entire uterus can be removed, and often it can not be removed; that {45} is, the case is inoperable and removal is useless owing to extension of the cancer into the surrounding tissues.

Fourthly, if the mother's condition is hopeless, a caesarean section gives the child a chance for life, but the operation will hasten the mother's death in nearly every case.

The first and second cases here are not practical. If the surgeon can remove the uterus at term after a caesarean section, that is the most reasonable operation for the mother and child, and it offers no moral difficulty.

If the mother's condition is so bad that the uterus may not be removed, the chances are that her death will be hastened by caesarean section, but if caesarean section is not done, from 50 to 63 per centum is the ratio against the saving of the child. I do not think a general rule can be given as regards the certainty of hastening the maternal death: the reckoning is to be made to meet the particular condition. It seems, however, probable that in every case of inoperable carcinoma of the uterus complicating pregnancy a caesarean section would hasten the maternal death. She will die anyhow from the cancer, but in certain cases she may live longer if the section is not done.

If, again, a carcinoma of the uterus is inoperable at term, the delivery of the child may be impossible without caesarean section, from uterine inertia, or the opposition of the dense inflamed tissues, or the friability of these tissues. In such a case without the section she would die, and die probably sooner than with it. The operation would possibly slightly prolong her life, by, say, a few hours or days, and it certainly would give the child a very good chance for its life. She may, of course, die upon the operating table, but she would die in childbed without the section.

The case is different from the ordinary caesarean section done because of a narrow pelvic bony girdle. In the latter condition the chances that the mother will live are very high if the surgeon is competent, but in the carcinoma case she will die no matter who the surgeon may be, and very probably, or almost certainly, her death will be hastened by the operation in the majority of cases.

If the condition is such that the woman can not be delivered {46} without the section, I see no difficulty against operation, because the surgeon can not, as far as I know, say positively whether he will hasten the maternal death or not, and in the circ.u.mstances he may take advantage of the doubt.

If the woman with an inoperable carcinoma uteri may be delivered _without_ section, should such a delivery be chosen although it raises the chances of mortality as regards the child from about 12 per centum to at the least 50 per centum? It is a matter of a very probable hastening of the mother's death as weighed against the safety of the child--the child has about one chance in two of life without the section, and, say, seven chances in eight with the section. The operation is far preferable as regards the child alone, but not preferable as regards the mother alone. Is it then allowable?

In the hysterectomy for fibroma already considered, the mother is saved and the child's inevitable death is certainly hastened; in the caesarean section the child is most probably saved, and the mother's inevitable death is most probably hastened; we might say, in some cases, that her death is undoubtedly hastened. If in the carcinoma case here the child had no chance whatever for delivery except by the caesarean section, while the mother's death would be probably or certainly hastened, she might legitimately consent to the operation or she might legitimately refuse the operation.

The child, however, has, as we said, one chance of delivery in two without the section, while the mother's death will very probably be hastened. If the mother's death would certainly be hastened by the section, her death, although it would be a circ.u.mstance and indirect, not an end nor a means, would not have counterbalanced against it necessarily the saving of the child's life, because the child has one chance in two in any event. In such an hypothesis the operation seems to be unjustifiable.

If, however, the hastening of the mother's death is only probable and not certain, may we oppose that probability to the advantage that must accrue to the child through the section? If the doubt that her death will be hastened is soundly probable, the woman may consent to the operation. She risks through charity the hastening of her own death for a great {47} advantage to the child, but she may risk legitimately immediate death in major surgical operations for an advantage less than the saving of life itself. She may have her skull opened for the removal of a depressed bone that is causing paralysis, she may have her knee-joint opened for the wiring of a patella to prevent lameness, but both these operations always immediately endanger life. She may go into a burning house, jump into a river, and so on, to save her child from possible injury.

AUSTIN oMALLEY.

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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 v.a.g.i.n.a and the cervical ca.n.a.l 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,--Stepha.n.u.s ... Archiepiscopus Cameracensis ...

Quae sequuntur humiliter exponit:

t.i.tus medicus, c.u.m ad praegnantem graviter dec.u.mbentem vocabatur, pa.s.sim 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 quamc.u.mque operationem directe occisivam foetus, etiam si hoc necessarium foret ad matrem salvandam: dubiis haeret t.i.tius circa {50} liceitatem operationum chirurgicarum, quibus non raro ipse abortum hucusque procurabat, ut praegnantes graviter aegrotantes salvaret.

Quare ut conscientiae suae consulat supplex t.i.tius pet.i.t: utrum enuntiatas operationes in repet.i.tis dictis circ.u.mstantiis 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 doc.u.ments 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 mec.u.m 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 quamc.u.mque 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. mec.u.m 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 c.u.m 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 pet.i.t resolutionem insequentium dubiorum:

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

II. Et si mulieris arct.i.tudo 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.