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 Guérard, 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, eâ omissâ, mater et infans perituri sint, eâ e contra admissâ, 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 ÓMALLEY.

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