ABORTION
Abortion, as the term is used by physicians, in its widest sense
is the ejection or extraction of a fetus from the womb at any time
before term. The word is popularly contrasted with miscarriage, where
the fetus is ejected through disease or accident; abortion in the
lay sense supposes artificial, and commonly criminal, extraction of
the fetus. Abortion (from _aboriri_, to perish) etymologically has
an association with destruction of life, but the name is given by
physicians to a removal of any premature fetus, even if it is viable.
Strictly, however, abortion is an interruption of pregnancy before
the fetus is viable, and premature labor is such an interruption
after the fetus is viable. Throughout this chapter the words are used
in this sense.
Abortion as a medical and moral consideration may be considered from
several points of view.
First, involuntary pathologic and accidental interruptions of
pregnancy are to be averted, if it is possible to do so, to save the
life of the child; and when the abortion is inevitable the treatment
has moral qualities which involve the physician and the mother.
Secondly, voluntary and therapeutic abortion has peculiar moral
and medical qualities arising (_a_) from the period of gestation
or the viability of the child; (_b_) from the truth or error in
the diagnosis as regards the necessity for interference, and the
advantage or damage resulting from the interference.
Thirdly, the technical skill or ignorance of the physician, and the
methods he employs may in themselves in any case avert or cause
the death of the mother or grave injury to her, and in the forced
delivery of premature infants may save, kill, or maim the child.
Fourthly, voluntary criminal abortion has a special malice of its
own, which makes it somewhat more criminal than the therapeutic
removal of an inviable infant.
Fifthly, there are positive canonical and civil penalties against
abortion as it affects the inviable infant.
Pathologic abortions, and those arising from accident or
carelessness, are extremely common. Hegar estimated that there is
one of these abortions to every eight normal parturitions, and
specialists in obstetrics find as many as one abortion to four
deliveries at term. These abortions are most frequent from the eighth
to the twelfth week of gestation, because the ovum is then not
firmly attached to the uterus, and it readily succumbs to external
influence. Moreover, the woman is not certain she is pregnant and
neglects precautions. Many women, again, are under the error that
there is no moral evil in getting rid of the ovum before quickening,
and they think quickening occurs only when they feel the fetal
movements. Others, erroneously again, fancy that abortion in the
early months is not dangerous or injurious to themselves.
The causes of pathologic and accidental abortion are very numerous
and often interactive. They may arise from the fetus, the mother, the
father, or from violence. The death of the fetus, or diseases of the
fetus itself or of its appendages, cause abortion. Weakness of the
fetus from alcoholism in the parents, anemia, carbon monoxide and
lead poisoning, tobacco poisoning in women who are cigar-makers, and
similar conditions in one or both parents, will bring on abortion.
Monsters rarely go on to term. Acute or chronic affections in the
mother, as typhoid, malaria, smallpox, cholera, scarlatina, measles,
tuberculosis, and the like, and syphilis in the mother or father,
effect abortion. Other abnormal states that bring on abortion are low
blood-pressure in maternal anemia, shock, syncope; hemorrhages into
the placenta in maternal nephritis; hemorrhages between the placenta
and uterus from diseases of the placenta and decidua, or from
traumatism, which detach the placenta; sun or heat stroke; sudden
high temperature in fever; toxemias, as in some forms of hyperemesis
gravidarum, eclampsia, chorea, hepatic autolysis, and impetigo
herpetiformis.
Chronic endometritis, or inflammation of the lining membrane of
the uterine cavity, is the commonest maternal cause of abortion,
especially of habitual abortion. In this condition hemorrhages in
the decidua, or uterine fold that holds the fetus, kill the fetus,
or force the ovum off the uterine wall, or excite expulsive uterine
contractions. Without hemorrhage endometritis prevents a firm
fixation of the ovum, or it may bring about a malposition of the
placenta, called placenta praevia. Endometritis at the decidua may
cause hydrorrhoea gravidarum, and the accumulated serous secretions
from this source are likely to start uterine contraction. Chronic
metritis, or inflammation of the deeper tissues of the uterus, is
commonly found with endometritis, and it prevents the expansion of
the uterine muscle. This condition is more likely to cause abortion
than endometritis alone.
Acute gonorrhea, inflammations of the Fallopian tubes, and
appendicitis sometimes interrupt pregnancy. Other causes are
malformations and diseases of the uterus, infantilism, fibroids,
polyps, uterine horns, lacerations and amputation of the cervix, and
retroversions and retroflexions of the uterus. At times a replacement
of the uterus will avert an abortion.
When the mother has an infectious disease like typhoid, smallpox,
cholera, or typhus, the infection may reach the fetus and kill it,
or may cause an endometritis with a hemorrhagic tendency. Maternal
sepsis may kill the fetus directly or secondarily, and this is
true also of maternal syphilis. A sudden rise in temperature may
excite expulsive uterine contraction. In pneumonia the excess of
carbon dioxide in the blood may bring on abortion. Like pneumonia,
anesthesia may kill the fetus if kept up for a long time, or if
marked by cyanosis. Prolonged nitrous-oxide anesthesia is especially
dangerous to a fetus, but a brief nitrous-oxide anesthesia for the
extraction of a tooth may not bring on abortion. The worst tooth
stump can be extracted painlessly after local injection of novocain,
with no danger to the fetus. The gums remain somewhat sore for a day
or two after novocain infiltration, but this inconvenience is a much
less evil than total anesthesia, even when there is no pregnancy. It
is probable that total anesthesia is morally unjustifiable for the
extraction of a single tooth if the tooth is not wedged in.
Violence, accidental or intentional, is a frequent primary or
secondary cause of abortion. Sometimes a slight jar, a misstep on
a stairway, a nervous shock, a jump from a carriage-step, lifting
weights, running sewing-machines, sea-bathing, a rough automobile
ride, will bring on an abortion where there is a predisposition.
Often in healthy women, on the other hand, extreme violence does
not interrupt pregnancy. Surgical operations are classed here with
violence. In a neurotic woman a slight operation on an organ not
directly connected with the uterus will start expulsive contractions.
Again, 66 per cent. of operations on ovarian tumors during pregnancy
have left the uterus undisturbed. De Lee says he has removed fibroids
from the pregnant uterus, once even exposing the chorion, and has
amputated the cervix of a gravid uterus, without interrupting
pregnancy. Several cases have occurred where both ovaries have
been removed during pregnancy without abortion. The breast has
been amputated and a kidney removed from a pregnant woman[79]
without disturbing the pregnancy. Wiener[80] did eleven operations
for ovarian tumors during pregnancy with only two abortions. Von
Holst[81] removed a myoma weighing two and a half pounds from the
uterus at the seventh month of gestation without abortion. Davis
of Birmingham, Alabama, reported[82] that a woman three and a half
months pregnant was shot in the abdomen. The rifle bullet made
twenty-five perforations in her intestines. She was taken eighty-five
miles, and then Davis cut out five feet of the intestine. She
recovered and gave birth to a living child at term.
[79] Cronk, _Oklahoma State Med. Assoc. Jour._, July, 1816.
[80] _Amer. Jour. Obstet._, August, 1915.
[81] _Upsala Läkareforenings Förhandlingar_, xxi, 8.
[82] _Journal Amer. Med. Assoc._, October 28, 1916.
Double ovariotomy brings on abortion in the early months of
pregnancy oftener than in the later, probably from the loss of the
corpus luteum, which, it appears, is necessary for the growth of
the uterus. Appendicitis and appendectomy are especially likely
to interrupt gestation, apparently as a result of infection and
because pregnant women are prone to defer operation. The traumatism
of criminal abortion, punctures and lacerations from bougies and
curettes, and the exhibition of drugs like ergot and cantharides,
are sources and results of abortion. Drugs will not empty the uterus
unless they are given in poisonous doses which endanger the woman's
life.
In the father, syphilis, tuberculosis, general paresis, general
debility from alcoholism, unchastity, and senility, and septic
conditions of the generative tract, may cause abortion. Many men
who work with lead, phosphorus, mercury, or X-rays are sterile, and
before they become totally sterile their condition appears to cause
debility in the fetus which leads to abortion. In paternal lead
poisoning there is a reduction of about 20 per cent. in the weight
of the infants at birth, and a general weakness and retardation of
the child. The children of lead-poisoned fathers are frequently
permanently under weight.
Coition during gestation is a cause of abortion, and the fault here,
as a rule, lies with the husband. St. Thomas[83] said: "St. Jerome
protests against the sexual approach of the husband to his gravid
wife, not that in this condition such an act is always a mortal sin,
unless there is probable danger of abortion." St. Alphonsus[84]
says if there is danger of abortion the use of the debitum is a
grave sin. In n. 924 he again teaches that while it is true that
if by the use of the debitum the life or formation of the fetus is
endangered or checked the right to the use of the debitum is, in such
circumstances, lost, yet he thinks that in pregnancy there is little
danger of abortion from this cause, especially near term.
[83] _In. 4, dist. 81._
[84] _Theologia Moralis_, n. 943.
Sabetti-Barrett[85] says the wife is excused from the debitum
conjugale if the husband is drunk, or if there is a rational dread of
grave injury, or grave danger to health. Genicot[86] thinks that in
pregnancy it "can scarcely be shown that there is a notable danger of
abortion." Lehmkuhl[87] holds that a married person is not obliged to
grant the debitum if there is great danger of abortion; but, he adds,
"Even then, if there is a grave danger of incontinence I do not think
it certain that there is an absolute obligation to abstain."
[85] _Theologia Moralis_, n. 936.
[86] _Theologiae Moralis Institutiones_, vol. ii, n. 544.
[87] _Compendium Theologiae Moralis_, n. 1114.
Unlike Lehmkuhl, moralists agree that if there is real danger of
abortion from marital congress, such an act is illicit, but they are
inclined to think that there is little or no danger of abortion,
especially at the end of gestation. Authorities on obstetrics, on
the contrary, say that one of the causes of abortion in the early
months of pregnancy is marital congress; and one of the sources
of sepsis in women, which may result in the death of both mother
and child, is certainly congress at the end of gestation. This
causation of abortion is found especially in neurotic irritable
women, in such as have diseases of the generative tract, or a
tendency to habitual abortion. Whenever a woman shows any tendency
to bleeding during gestation the use of the debitum is undoubtedly
contraindicated, because of the proximate danger of both abortion
and septic infection. Toward the end of pregnancy the danger from
sexual commerce is the risk of infecting the woman's vagina with
bacteria which may bring on sepsis through the abrasions incident
to parturition. The staphylococcus pyogenes albus, a dangerous
septic microörganism, exists as a saprophyte in 50 per cent. of
male urethras, and the bacillus coli communis is another source of
infection from the father during pregnancy. De Lee saw two cases
of sepsis that killed both mother and child from such an infection
shortly before term. If a physician now examines a woman before
delivery without using all the precautions known to prevent sepsis,
such as wearing a sterile rubber glove, he is guilty of malpractice;
yet certain moralists are inclined to let a husband do what he likes.
Moralists talk about the fetus as protected in the membranes. That is
nonsense, because it has no relevancy to the question. It can have
the slight relevancy of untruth when the woman is rendered septic,
because then the membranes are no protection at all.
The mortality statistics of the United States Census Bureau show
that a little more than 42 per cent. of the infants who died in the
registration area in 1911 did not last throughout the first month of
extrauterine life, and of these babies almost seven-tenths died of
prenatal and delivery abnormalities. In 1912, in the registration
area, which then took in 63.2 per cent. of our population, the
total death-rate of infants under a year old was 9035, and of these
3905 died of puerperal infection. In the entire country a very
conservative estimate of the annual number of deaths of infants from
puerperal sepsis is 5000; and about 15,000 women die here yearly
from this etiology alone. Of course most of these deaths are caused
by unclean midwives and quacks, but a large number of them are
brought about by incontinent husbands. Invalidism from puerperal
sepsis happens many times 15,000. Moreover, one-third of all the
blindness in the world is caused by septic infection of the eyes at
birth and virtually all this septic infection of the eyes is carried
in by diseased husbands, although not necessarily by coitus during
gestation.
Coition during pregnancy is unnatural because it necessarily fails
of the end of coition, which is procreation. Curiously, too, all
the lower animals instinctively appear to avoid this act during
pregnancy. Men should be told that marriage has restraints as well
as celibacy. Women are reminded of the law of the debitum, but not
of the occasions when they are even obliged to deny it. If a man
cannot keep continent in the presence of his pregnant wife, let him
live in another part of the house. Regard for the woman is lacking
in many ways. Young girls often marry without having the faintest
notion of sexual life, and they are panic-stricken when assaulted.
I have known two who were frightened into insanity. Priests should
tell young married men that they are human beings, not animals; that
they should act like rational beings when they are first married; and
that after the wife has become pregnant the husband should not be the
cause of abortion in the first three months, nor of puerperal sepsis
in the last three months. Priestley,[88] in 2325 pregnancies, found
one abortion in every four pregnancies; Guillemot and Devilliers in
France, Hirst in Philadelphia, and others report the same proportion.
These are natural, not criminal, abortions. If, then, in normal
pregnancies about one child in five is lost before birth, husbands
should be taught a continence which would to some degree avert this
calamity. Superfetation has occurred by coition during pregnancy, and
this results commonly in abortion and the death of both fetuses.
[88] _Pathology of Intrauterine Death._ London, 1887.
Premature labor in cases where the child is viable is produced by
the same agencies that interrupt gestation in the early months.
Obstetricians think that syphilis is the commonest cause of premature
labor, and they estimate that from 50 to 80 per cent. of these
premature births are due to syphilis. In a series of 705 fetal deaths
in Johns Hopkins Hospital, 26.4 per cent. were due to syphilis. After
syphilis the cause of premature labor next in frequency is nephritis
with placental hemorrhages and infarcts. Twins are not seldom
delivered prematurely because of lack of room in the uterus. For the
same reason any tumor of the uterus or abdomen may cause an abortion.
When successive pregnancies are interrupted prematurely the abortion
is said to be habitual, and again the commonest cause is syphilis.
In this disease, as the virulence of the infection decreases, the
gestation is prolonged until a child is born infected with congenital
syphilis. This child commonly dies, and later a child strong enough
to live appears. Correct treatment of the parents will avert this
slaughter of the innocents. Sometimes the syphilis is latent so
far as clinical symptoms are concerned, but we may find a positive
Wassermann reaction. Hubert reported[89] that 8.8 per cent. of 8652
patients in a clinic at Munich where all were subjected to the
Wassermann test had latent syphilis, and in 52 per cent. of these
cases in men, and 75 per cent. in women, the infection was altogether
unknown to the patients.
[89] _Münchener medizinische Wochenschrift_, lxii, 39.
Chronic endometritis, where there is no syphilis, will permit
habitual abortion, and each abortion makes the condition worse.
Nephritis, diabetes, and other constitutional diseases cause habitual
abortion.
In the first two months of gestation the decidual fold which
holds the ovum against the uterine wall is thick, vascular, and
friable. The contracting uterus in abortion expels the decidua with
considerable difficulty, but the ovum containing the fetus may slip
out easily and be lost. A fetus two months old is about three-fourths
of an inch in length. If a physician, nurse, or other person finds
the ovum, no matter how small it is, they should open it at once with
a scalpel or scissors and baptize the fetus conditionally, even if
no sign of life is perceptible. If the fetus is unmistakably dead--a
diagnosis not easily made--there is no use in attempting baptism;
but always give the fetus the benefit of the doubt. In the first six
or eight weeks the whole ovum is usually born developed in decidual
tissue; sometimes the ovum will slip out of the decidua and be
covered only with shaggy villi, suggestive of a chestnut burr.
During the third and fourth months there may be (1) an abortion
of the whole ovum; or (2) the membranes may rupture, the fetus be
expelled, and the secundines remain in the uterus, and these may have
to be removed by instrument or finger; or (3) the decidua reflexa
and the chorion may split and let out the fetus into the amniotic
sac: here again the remaining secundines, if they do not come away
spontaneously, must be removed. Abortion after the fifth month is
like a regular labor at term, but not so energetic.
An abortion may be threatened, inevitable, or incomplete. In each of
these conditions there is uterine pain and hemorrhage. In inevitable
and incomplete abortions we find softening and dilatation of the
cervix, and a presentation or expulsion of part or all of the ovum.
In pregnancy uterine hemorrhage and uterine pain are symptoms of a
threatened abortion, but not certain symptoms. Fromme found that
17.9 per cent. of 157 women who had these signs in the early months
went on to term. If the fact of pregnancy is not known it is not
always easy to differentiate a threatened abortion from other
uterine conditions, like chronic metritis, ectopic gestation, a
fibroid or other tumor, hemorrhage from cervical erosions or varices,
or malposition of the uterus. If the abortion is inevitable the
diagnosis is made more readily. The cervix is then more or less
dilated and the ovum is palpable. There is rather profuse hemorrhage,
flooding, and painful uterine contractions are evident. The rupture
of the bag of waters may be simulated by the escape of secretions
in hydrorrhoea gravidarum, or the escape of waters may be a primary
symptom of graviditas exochorialis. Hydrorrhoea gravidarum is an
intermittent discharge of clear or bloody fluid from a catarrhal
endometritis under the decidua. It occurs in anemic, weak women,
especially multiparae. In graviditas exochorialis the fetus is left
within the womb but outside the ruptured chorion, and it may remain
there for some time.
When an abortion is incomplete it is absolutely necessary to learn
whether the entire ovum and decidual tissue have been expelled or
not. When a part or all of the dead ovum is retained the consequences
are so grave that they may result in the death of the woman or cause
chronic invalidism. Sepsis may result, a placental polyp may form,
and even syncytioma malignum may start--this fatal tumor, however,
is not so common after incomplete abortion as after hydatid mole
formation.
The prognosis as regards health is worse after abortion than after
normal pregnancy. The involution of the uterus is slower than in
full-term cases, and if infection has occurred there is great
likelihood of a chronic endometritis and metritis. The woman may be
rendered sterile, or she may become a chronic invalid to be cured
only by capital operations.
In threatened abortion examination is to be avoided unless it is
absolutely necessary for diagnosis, and then great gentleness is
required so as not to excite uterine contractions. The woman is to
rest in bed, not so much as raising her head to take a drink of water
(which is given to her through a tube), and she is morally obliged
to submit to this inconvenience. If she refuses she is accountable
for the death of the fetus. If there is bleeding the foot of the
bed should be elevated as in hemorrhage in typhoid fever. The
routine practice is to quiet the woman and the uterine irritability
with morphine and other opium derivatives. Children are readily
overwhelmed by opium because their circulation is not sufficient to
neutralize the deoxidizing effects of the drug up to safety. While
the embryo is connected with the maternal circulation through the
placenta the mother's circulation often safeguards the fetus from the
effects of the opium. The danger to the child in such cases begins
from the opium remaining in its circulation after the child has been
separated from the mother. Often, however, fetuses in cases where
scopolamine and morphine have been used on the mother during labor
are born badly, and even fatally narcotized, despite the connection
with the maternal circulation. Nevertheless, even if there is some
real danger to the fetus from the use of morphine in a threatened
abortion, the cautious use of this drug would be morally justifiable.
Should the threatened abortion go on to actual abortion, the fetus
will certainly be killed, but the use of morphine on the woman is
the best and virtually the only means we have to avert a threatened
abortion and so save the fetal life. The immediate double effect from
the morally indifferent act of giving a dose of morphine is, on the
good side, the saving of the fetal life, and on the other, the evil
side, the danger of fetal narcosis, which is not at all certain to
follow. Evidently, the good intended effect far overbalances the evil
and somewhat hypothetical effect.
After about five days, if the bleeding ceases, the woman may be
permitted to go back to her ordinary routine of life, but with
extreme caution, and she must return to bed at the slightest show of
blood. Morphine is used at the beginning to quiet the patient and the
irritable uterus. If the cervix is eroded, applications of a 10 per
cent. nitrate of silver solution are made. The bowels are kept locked
for three days and a softening enema of olive-oil is used before
emptying the bowel.
If the bleeding starts again every time the woman goes about her
duties, the abortion may be inevitable. When the cervix is shortened
and dilated so that the ovum is palpable and pieces of the decidua
or ovum are expelled, the hemorrhage is more or less profuse, and
especially if the bag of waters has ruptured and uterine contractions
show, the abortion is deemed inevitable. In such a case the fetus
may be alive, or it may be dead; and, again, conditions which
show all the classic symptoms of inevitable abortion sometimes,
though rarely, do not go on to abortion. It is extremely difficult,
and often impossible, to tell whether an early fetus is dead or
alive. A high, lasting fever sometimes kills the child; so do low
blood-pressure, profuse hemorrhages, deoxidation of the blood in
pneumonia, separation of the placenta, fatty degeneration of the
placenta, and the severe infections--in such cases there is always
strong probability that the child is dead when the abortion shows
its symptoms. If the fetal tissues that appear indicate maceration,
or if the discharge is fetid or purulent, the fetus is dead. Should
the fetus be alive, tamponing the vagina to check the hemorrhage
often separates the fetus from the uterus by the dissecting force of
the blood dammed back, or in any case tamponing is almost certain to
excite uterine contractions; thus there is an indirect killing of the
fetus.
The treatment of inevitable abortion after the fifth month differs
very much from the methods used in the early months. The prime
principle is, never interfere until forced to do so. When the
hemorrhage is dangerously profuse, so that the woman's life is
endangered (an exceptional condition), the uterine cervix and the
vagina must be tamponed with sterile gauze and cotton to check the
bleeding, but this is a last resort. If the fetus is alive, or
probably alive, nothing short of a necessity to save the woman's life
by this means justifies the use of the tampon. De Lee advises the
routine use of the tampon in threatened abortion, but this doctrine
is erroneous medically and altogether false morally. If the physician
knows the fetus is dead, he should, of course, tampon at once to get
rid of the fetus. The tampon excites uterine contractions and causes
destruction of a living fetus by dissecting it loose from the uterine
wall through the dammed blood. Elevation of the foot of the bed and
the use of morphine will, as a rule, check the bleeding.
When the woman is bleeding _to the risk of her life_, the tampon is
put in to check the bleeding and so save her life. The double effect
immediately following this indifferent act is on one side good,
the saving of her life; on the other side evil, the killing of the
fetus. The good effect is intended, the evil effect is reluctantly
permitted. Such a procedure is morally licit.
Where a tampon must be put in, it is left in from sixteen to
twenty-four hours, even if the temperature goes up. During this
time there are painful contractions of the uterus, as a rule, and
these are expulsive. No drug is to be given to allay these pains if
the intention is to have a dead or viable fetus expelled. If the
pains cease suddenly, this is usually a sign that the fetus has been
expelled above the tampon. When the tampon is removed and the entire
ovum is found, it is best for the ordinary physician not to meddle
with the uterus in any manner. Some advise that the physician should
go over the uterine lining with a half-sharp curette to make certain
that nothing has been left behind, but this is dangerous advice to
any one who is not an expert obstetrician. Should the temperature
remain above 100 degrees, the uterus must be cleaned out, and
flushing with uterine catheters is not enough: if the gloved finger
cannot remove the secundines, the curette is needed.
If, when the tampon has been removed, no ovum is found and the
cervix is still closed, another tampon is to be put in for another
twenty-four hours, supposing the removal of the ovum is licit.
Forcible dilatation of the cervix is always a dangerous operation,
and should never be employed when avoidable. Steel dilators have
ruptured the uterus and killed the patients again and again even
when used by experts. Laminaria tents are not to be recommended; the
tamponade is enough.
When the retained ovum cannot be removed by the finger or squeezed
out, the free portion of the ovum is to be grasped by an ovum forceps
and gently drawn out. The operator should be sure he has a part of
the ovum in the forceps and not a part of the uterine wall. If he
bites into the uterine wall (a common catastrophe), he may pull a
hole in that wall, and then the woman will probably die unless the
rent can be closed immediately after opening the belly. When the
abdominal cavity has been opened in such an event, the uterus is
also to be opened, cleansed, and sutured. This method is safer than
curetting where there is a rent. If one is certain the gut has not
been injured--and it is extremely difficult to be certain--vaginal
anterior hysterotomy may be substituted. Sometimes perforations,
when the uterus is not septic and the instruments are clean, are
not dangerous. Rest in bed, ice-bags, ergot, and opium cure without
operation.
Physicians who are called into an abortion case should always be
certain that no one has attempted to pass sounds, curettes, or
similar instruments, because a perforation may have been made by the
meddler which will be charged to the second man himself.
If a uterus is flexed it is easy to poke a curette or like instrument
through it at the bend, especially if the uterus is thin or friable
from sepsis. Again, the placental site is raised, it feels rough, and
the furrows in it lead one to think part of the placenta is still
adherent, whereas all has been removed. Repeated scraping, due to
this error, may dig a hole through the uterine wall. Perforation
in a septic case is practically always fatal to the woman. The use
of the curette supposes a special technic, and no physician should
presume to try its use unless he has been carefully and practically
instructed.
In inevitable abortion after the third month it may be very difficult
to get the embryo out. The cervix, in primiparae especially, may be
long, thick, and hard. If the fetus is dead, it may then be removed
by _morcellement_--_i. e._, by cutting and breaking it into pieces,
and then taking out these pieces with an ovum or stone forceps.
Sometimes, though rarely, the operator may find it impossible to get
the entire fetus away. Then the uterus is packed with weak iodine
gauze, and after twenty-four hours the fetal remains are expelled.
In every abortion the presence or absence of extrauterine pregnancy
is to be made out. If there is an extrauterine pregnancy, curettage
will cause rupture of the sac.
When the interior of the aborting uterus has become septic the old
treatment was to empty the uterus at once, but now the treatment is
expectant, because the traumatism of the curetting makes the sepsis
worse. The commonest and worst infections are of the streptococcus
putridus, a pus staphylococcus, and the bacterium coli communis.
Curettage lets these microörganisms enter the circulation. The
cause of this condition is often unskilful attempts at artificial
abortion. When the womb contains decomposing material bleeding
usually obliges tamponing, and thus often the uterine contents come
away in twenty-four hours with the gauze. If there is no hemorrhage
there should be no tamponing: it is then better to get dilatation by
packing and drain the uterus with gauze. The curette should not be
used at all.
Where there is habitual abortion the cause must be found. During
gestation syphilis and displacements of the uterus, as causes,
may be treated. Endometritis can be cured only when the uterus is
empty. Rest in bed at the time when these abortions usually occur,
and at the time when menstruation customarily appears, is required.
Treatment of the husband is often necessary, as he is virtually
always the source of luetic infection.
Attention or inattention to the mother's own hygiene during
pregnancy has great effect on the fetus, and care of hygiene may
avert abortion. The woman's dress should be simple and warm enough
to prevent congestion from changes in temperature. Congestions are
likely to affect the kidneys, and care of the renal function is
always one of the most important facts connected with pregnancy. No
circular constrictions of the trunk by lacing or stiff corsets should
be attempted. The corset forces the uterus and child downward into
the pelvis and against the lower abdominal wall, causing congestion
of the pelvic veins and strain on the abdominal muscles. Tight
corsets, preventing the expansion of the uterus and the growth of
the fetus, may cause mutilations like club-foot and wry-neck, or
even kill the child. The woman who would "preserve her figure" by
corsets, to the mutilation, weakening, or killing of her unborn
infant, and this is an every-day evil, is either a criminal fool or
an unmitigated scoundrel. Tight lacing to conceal pregnancy is a
method of murder. High-heeled shoes are somewhat injurious because
of the constrained position into which they throw the woman. X-ray
photographing of pregnant women is very likely to cause abortion.
The woman's diet should be simple. She must abstain from all
alcoholic liquors even if she has been accustomed to their use at
meals. She should not overeat on the supposition that she has to
feed two persons. Some popular books advise a special diet to reduce
the bone-salts and thus get a smaller baby and one more easily
delivered. Such advice is criminal. The constipation of pregnancy is
not to be treated by strong cathartics like Epsom salt. The kidneys
are to be watched; therefore the urine should be examined every
three weeks up to the seventh month, then oftener. If there is any
suspicion of toxemia or nephritis, the urine should be examined
daily. Obstetricians who have any regard for their own conscience and
reputation will have nothing to do with a woman who refuses to take
this precaution.
Physical exercise should be gentle--say, walking, up to two miles in
the daytime. The vast majority of women are too lazy to take physical
exercise as a hygienic duty at any time, and during pregnancy their
aversion to all effort to overcome indolence is so great they make
even themselves believe they cannot. Just as most professional men
think they think, most women think they work. There are thousands of
women who have servants, yet make not only their families and friends
but themselves believe they are worked to death, and their work is
the spreading of four or five beds, and the ordering of groceries
over the telephone. When these women are pregnant they quit even the
bed-making.
Cold and hot baths, Turkish and Russian baths, hot sitz-baths and
ocean bathing are not permissible during gestation. Tepid baths and
spongings are to be substituted. Near term the bath-tub is not safe
because of danger of uterine infection from unclean water. Then
shower-baths are better, but these are dangerous if the woman must
step over an enameled bath-tub side to take them, because she may
slip and fall. Vaginal douches are not to be used in pregnancy except
in certain diseased conditions, under the direction of a competent
physician.
Therapeutic abortion and therapeutic induction of premature labor are
employed in five chief groups of conditions: (1) contracted pelvis;
(2) diseases caused by pregnancy; (3) diseases coincident with
pregnancy; (4) habitual death of the child after viability but before
term; (5) prolonged pregnancy. There is no such act as therapeutic
abortion of an inviable child; all abortions of inviable children,
when direct, are criminal, and nothing criminal is therapeutic. The
consideration of narrow pelvis, and the diseases caused by pregnancy
and coincident therewith, will be treated in detail.
When the child dies after viability but before term the cause is
most commonly syphilis. In such cases a Wassermann reaction should
be made from both parents; and even if it is negative, and no other
definite cause for the fetal death can be found, syphilitic treatment
should be tried on the father and mother. Bright's disease, even when
scarcely diagnosable, anemia, diabetes, adiposity, and hypothyroidism
are other lethal causes of habitually still-born infants. Not seldom
the cause is in the husband. If he is an alcoholic (and two or
three drinks of whiskey a day make any man an alcoholic), if he is
especially susceptible to the toxin of tobacco (and tobacco alone may
render some men not only sterile but impotent), if he is a worker in
poisonous metals, an X-ray operator, a user of narcotics, exhausted
with overwork and worry, affected with weakening systemic disease,
his germ-cells are unfit for their function. Such men are not
technically sterile, but they are practically sterile.
Some women carry the child beyond term, with the effect that the baby
is overgrown for normal delivery. The head is harder and more angular
than it should be, the long bones stiffer and less pliable, the
muscles tenser. All these changes make the delivery so difficult that
the overgrown child may be fatally injured at birth. Physicians must
be cautious in believing histories of enormous children at previous
births at which they were not present. Mothers and nurses are likely
to exaggerate the size of infants.
In cases where the children die at a particular time before term,
premature labor should be induced to save the child, and when the
child has been carried over term it may be necessary to induce labor.
In the first condition labor is not to be induced a week earlier than
is necessary. We talk so much of a seven months' child as viable
that we forget that any child born before the thirtieth week of
gestation has very small chance for survival. From 30 to 60 per cent.
of all prematurely delivered infants die. The maternal passages do
not dilate normally and the child is unformed; its bones fracture
readily; it cannot sustain pressures and strains. All induced labors
are dangerous to the mother by shock and possible infection, and only
very grave necessity justifies any such procedure.
In inducing necessary premature labor the technical method may take
on a moral quality. There are over a score of methods, and many of
these, although used, are dangerous and should be obsolete. A very
common method, begun in 1855, is to insert one or two elastic solid
bougies into the uterus between the membranes and the uterine wall.
This is a dangerous method and should be obsolete. Other dangerous
and obsolete methods are the puncture of the membranes with a trocar
high up in the uterus; intrauterine injections of hot or cold
water, glycerine, milk, and other liquids; vaginal tamponade alone;
irrigation of the vagina with carbon-dioxide water; a stream of hot
water directed against the cervix, electricity, X-ray, dilatation of
the vagina with a rubber bag, irritation of the nipples, the use of
drugs like quinine, cimicifuga, ergot, or cantharides.
If haste is not necessary, packing the cervical canal and the lower
uterine segment antiseptically with a strip of gauze three to
five yards long and three inches wide and leaving it in for about
twenty-four hours is one of the best methods. Where rapid delivery
is required, cesarean section must be employed. In cases of somewhat
less urgency the membranes are first punctured and balloon dilators
are used. In any case puncture of the membranes is the most certain
method to start labor, but it has many bad disadvantages. A dry
labor in a primipara with an undilated cervix is a grave condition.
If the fetal head is not engaged in the pelvis, puncture must not
be attempted. When the head is not engaged in the pelvis like a
ball-valve, the cord will prolapse, be pinched, and thus the blood
supply will be cut off from the child and the loss will kill it.
For the same reason, the waters must not be run off too quickly.
Many operators insert a bag, dilate, and so start the labor, without
puncturing the membranes, where there is no reason for haste.
Therapeutic abortion, as has been said, is never permissible, under
any circumstances, if the child is not viable. In certain conditions,
say, when a uterine tumor clearly threatens the life of the pregnant
woman, or if in extrauterine gestation there is a rupture of the
tube, an operation may be permissible, or even obligatory, which has
for its direct end the removal of the tumor or the stopping of the
hemorrhage. If such a removal or ligation, under these conditions,
indirectly causes the abortion of the inviable fetus, or its death
from a lack of blood, these indirect effects may be reluctantly
permitted. They are cases of an equally immediate double effect,
one good and one evil, where all the requirements are fulfilled.
A _direct_ abortion of an inviable fetus, however, is never licit
even to save the mother's life, and in abortion the killing is
_direct_ because it is used as a means to an end. In a ruptured
ectopic gestation the primary effect of the physical operation is
to ligate the torn arteries to save the woman's life here and now;
the secondary effect is the permitted death of the fetus from the
shutting off of the blood supply. In the abortion of a premature
fetus the primary effect of the operation is to separate the placenta
from the uterus, to cut off the child's blood supply, and as a direct
consequence of this act, which is essentially evil, the woman's life
is saved. The original act in this abortion is evil, and evil may not
be done even if good follows. Even in self-defence against an unjust
aggressor one may not kill a man to save his own life--he tries to
save his own life and reluctantly permits the death of the aggressor.
In a killing in self-defence there are two distinct effects; in
abortion there is only one effect, and the killing is a means to this
one effect. That you may kill an irresponsible insane man who is
attacking your life, or the life of one entrusted to your care, is no
reason that you may attack a fetus in the womb. There is no parity.
The insane man is a materially unjust aggressor; the fetus is not an
aggressor at all. The mother placed it where it is; and if any one is
an aggressor, she is. In the abortion you directly kill the fetus and
indirectly save the woman's life, and this indirection uses the death
of the fetus as a means to the end of saving the woman's life. In
killing the insane aggressor you directly save the life of yourself
or your ward, and reluctantly permit the death of the aggressor. The
proofs of the essential immorality of direct homicide have already
been established in the general chapter on Homicide.
The assertion that an undeveloped fetus in the womb is not as
valuable as the mother of a family is beside the question, and in
certain vital distinctions it is untrue. Any human life, as such,
whether in a fetus or an adult, is as valuable as another, inasmuch
as no one but God has any authority to destroy it, except when it has
lost its right to existence through culpable action. Secondly, the
quality of motherhood is an accidental addition to a mother's life,
not substantial as is the life itself. This quality of motherhood
does not create any juridic imbalance of values which justifies the
destruction of the rights inherent in the fetus. That the fetus may
not be able to enjoy these rights if the mother dies is, again,
an irrelevant consideration. There is no question of a comparison
of values. A life is a life, whether in mother or fetus, and the
destruction of an innocent life by any one except its creator, God,
is essentially an evil thing, like blasphemy. An innocent fetus
an hour old may not be directly killed to save the lives of all
the mothers in the world. Insisting on such comparisons supposes
ignorance and sentimental opposition to truth. It is a good deed
to save a mother's life; but such saving by killing an innocent
human being ceases to be good and becomes indescribably evil, an
enormous subversion of the order of the natural law, as it is a
usurpation of the dominion over life possessed by God alone. If I
owe a man a vast sum of money and the payment of this debt will ruin
me and my children, it would be a good thing for me and them to
have this creditor put out of the way by death, but that fact is no
justification whatever for me to kill the man. The fetus in the womb
in a case where there is question of therapeutic abortion is like
this creditor: it would be well for the mother to have this fetus out
of the way, but that is no justification whatever for her to kill
the fetus, or to let it be killed by a physician. The physician who
kills such a fetus is exactly like a hired bravo who assassinates a
troublesome creditor for a fee, except that the physician does the
nasty job for less money.
To hasten even an inevitable death is homicide, and that quality
of merely hastening adds nothing for extenuation: every murder is
merely a hastening of inevitable death. To give a dying man a fatal
dose of morphine "to put him out of misery" is as criminal a murder
as to blow out his brains while he is walking the streets in health;
to ease pain is not commensurate with the horrible deordination of
taking a human life. This subversion of the moral law in the interest
of mawkish sentimentality is one of the gravest evils of modern
social ignorance. Physicians are constantly mistaking inclination, or
the mental vagaries of the nurses who influenced their childhood, for
rules of moral conduct. A physician is not a public executioner, nor
a judge with the power of life and death: his business is solely to
save human life, never to destroy it.
If there were anything in the objection that refusal to do abortion
opposes the life of a useless fetus to that of a useful mother of a
family, where would such false logic stop? If it held for the taking
of life in an unpleasant condition, it would hold _a fortiori_ in
every other less unpleasant condition where a life would not be at
stake. When a note that you had given falls due and it would bankrupt
you to pay it, does this inconvenience let you out of the difficulty
in honor, in the moral law, or in the civil law? It certainly does
not; but it should if the doctrine of the sentimentalists on
abortion were true. An eclamptic woman, or one with hyperemesis
gravidarum, conceived the child, got into the difficulty, and she and
her physician have no right to tear up the note they have given to
the Creator, especially when such tearing implies murder. Suppose,
again, a woman has done a deed for which she has in due process
of just law been condemned to death; suppose, also, there is only
one man available to put her to death, and if this man were killed
she could escape. Would her physician be permitted to shoot that
executioner to let her out of the difficulty? Certainly not. That,
however, is just what the physician does who empties an eclamptic
uterus of an unviable fetus. You may not do essential evil that
anything under the sun, good, bad, or indifferent, may come of it.
If I may kill a so-called "useless fetus" to save a useful mother, do
gross evil to effect great good, why should I stop there? Why, then,
may I not rob a church to make my children rich, murder a useless
miser to employ his money in founding orphanages, shoot any oppressor
of the poor, kick out of doors my senile and bothersome father,
reject all my most sacred promises whenever their observance makes
me suffer? Where will the sentimental moralist draw the line? That
the civil law permits therapeutic abortion is no excuse at all; it is
merely a disgrace of the civil law. The American civil law permits
many things that are contrary to morality and the law of God: it
absolves bankrupts even if they afterward become solvent; it permits
the marriage of divorced persons; it levies unjust school taxes; it
gives unjust privileges; it squanders the money of the citizens; and
so on.
If a woman marries in good faith a man she deemed a gentleman, but
who turns out to be a syphilitic sot who disgraces her and makes her
life a perpetual misery, immeasurably worse than the condition of
any eclamptic woman, no greater blessing could come to her and her
children than his death. Would she therefore be justified before any
tribunal of God or man in murdering him to get rid of her trouble?
No; she must bear with her evil for the sake of social order and of
eternal right. So must the eclamptic woman.
If it is murder to kill a child outside the womb, and mere
therapeutics to kill it inside the womb, then it is murder to shoot a
man on the street, and mere good marksmanship to shoot him to death
inside his house, especially if he is an undesirable citizen. All
reputable physicians deem a fetus in a _normal_ pregnancy so good
that they will not dream of destroying this fetus. They absolutely
refuse to effect an abortion to get rid of a fetus which may disgrace
an unmarried woman and her family, and they are perfectly right in
this refusal. They talk and write with genuine indignation of race
suicide. The only reason they have for the refusal to do what they
call criminal abortion is that the disgrace or inconvenience of the
woman is not commensurate with the destruction of a human life.
They observe the natural human instinctive repugnance to murder in
this special speech and writing, and then go home and get their
obstetrical bags and complacently murder the first baby they find
in the womb of a _married_ matron who has a disturbed stomach or
kidneys. They show here the fine intellectual acumen and reasoning
ability of a chronic lunatic. The first fact in the social order is
that justice, law, order, should prevail, no matter what the cost.
It might be better that the fetus should _die_ than that the mother
should die, though that is not always true. It is not better that an
unbaptized fetus should die than that a mother in the state of grace
should die. But these are irrelevant considerations. It is never
better that the fetus should be _killed_ than that the mother should
die. That is a very different matter.
The _Mignonette_ case in 1884, tried in England by Lord Coleridge,
is a good example of evaluation of lives as in therapeutic abortion,
which came to grief. A ship called the _Mignonette_ foundered 1600
miles from the Cape of Good Hope, and three of its crew, with a boy,
were for a long time at sea in an open boat without provisions. When
they were almost starved the boy lay on the bottom of the boat,
asleep or half conscious from weakness. Two of the men plotted to
kill the boy for therapeutic purposes; they needed his flesh to save
their own lives. They killed the poor lad just as the therapeutic
abortionist kills a fetus. They got his uncooked flesh for four days.
Later Lord Coleridge got them and he sentenced both of them to death.
Another Lord will get the therapeutic abortionists.
What, then, is the physician to do who meets a case that imperatively
calls for therapeutic abortion according to the common medical
practice? He can do nothing. The law may seem hard in certain
circumstances to those who cannot see beyond the physical; yet that
fact does not abrogate the law, which is one of essential morality.
May the physician call in a physician who, he knows, will not scruple
to perform the therapeutic abortion on an unviable fetus? If he does,
he is as much a murderer as if he did the deed himself. He may not so
much as suggest the name of some one who will do the deed. He simply
tells the family he can do nothing. If they insist on the abortion he
withdraws from the case.
In this connection it is necessary to mention again the question of
viability. Langstein reported[90] a study of the growth and nutrition
of 250 prematurely born infants, and he found a confirmation of what
was already known, that a weight of 1000 grammes (2-1/5 pounds) and
a full body length of 34 centimetres (13-3/5 inches) are the lowest
limits for viability under proper circumstances. A fetus 1000 grammes
in weight and 34 centimetres in length has completed the sixth
solar or calendar month, or the sixth and a half lunar month--it is
beginning its seventh month, not ending it, yet it is viable under
proper conditions.
[90] _Berliner klinische Wochenschrift_, June 14, 1915.
The child at term, on a rough average, is from 48 to 52 centimetres
(19 to 20-1/2 inches) in length, and it weighs from about 6-3/5 to
7-1/2 pounds. It is impossible, however, to obtain the sizes and
weights of infants _in utero_ with scientific accuracy, because the
date of conception cannot be determined with absolute certainty, and
infants _in utero_ vary as they do after birth. A full-term infant
sometimes may weigh only 3-1/2 pounds when the mother is diseased,
and at times an eight-months fetus will weigh as much as 8 pounds.
As was said in Chapter III, a fetus of six completed calendar or
solar months (not lunar--the duration of gestation is often reckoned
in lunar months by obstetricians) is viable provided it is cared for
by competent physicians in a hospital. Otherwise it is not viable,
except in a strictly technical sense; it will not live more than a
few days or weeks.
A full seven-months infant may be reared with proper feeding and
skilled care; a six-months infant may be reared (with difficulty) in
a hospital with skilled care. If it is certain that the removal of a
six-months fetus will here and now save the life of a mother (a very
difficult matter to judge by the best diagnosticians), this removal
may be done, provided the infant is delivered in circumstances where
skilled care, incubator, and proper food are obtainable; otherwise
the removal is not justifiable.
The Council of Lerida, in Catalonia, in the year 524, decreed that
abortionists of any kind must do penance all their lives, and if
they are clerics they are to be suspended perpetually from all
ecclesiastical ministration.
The Council of Worms, under Hadrian II., in the year 868,[91] also
judged women who procure abortion as certainly guilty of murder.
[91] Cap. 35.
In the _Corpus Juris_,[92] among the decretals of Gregory, there is
the following law: "If any one, through lust or hatred, does anything
to a man or woman, or gives them any drug, so that they cannot either
generate or conceive, or bear children, he is to be treated as a
murderer."
[92] Lib. v, tit. xii, c. 5.
Sixtus V., in the Constitution _Effraenatam_, October 29, 1588,
mentions a decree of the Sixth Synod of Constantinople, in session
in 680 and 681, which subjects those who perform abortion, or kill a
fetus, to the punishment inflicted on murderers. Sixtus then decreed
that any one who effects the abortion, directly or indirectly, of an
immature fetus, whether the fetus is animated, formed, or not, either
by blows, poison, drugs, or potions, or tasks of hard labor imposed
on pregnant women, or any other method, however subtle or obscure
it be, is guilty of murder, and is to be punished accordingly.
He recalls all ecclesiastical privileges from clerics who cause
abortion, and says that they are to be reckoned as murderers
according to the decree of the Council of Trent,[93] and he makes a
law that abortionists may never be promoted to orders.
[93] Session xiv, _De Reformatione_, cap. 7.
In the fifth paragraph he says: "Moreover, we decree that the same
penalties are incurred (1) by those who give potions and poisons to
women to induce sterility or prevent conception, or who cause these
drugs to be administered, and (2) by the women themselves who freely
and consciously take these drinks."
In paragraph seventh he decrees that any one, man or woman,
cleric or lay, who procures abortion by counsel, favor, drinks,
letters of advice, signs, or in any way whatever, are _ipso facto_
excommunicated, and the excommunication is reserved to the Pope
himself.
Gregory XIV., in the constitution _Sedes Apostolica_, May 31, 1591,
gave to priests who have special faculties for the purpose from the
bishop, permission to absolve from this excommunication, but only _in
foro conscientiae_. Sixtus V. and Gregory XIV. used the term _foetus
animatus_, in keeping with the old Aristotelian notion of animation.
Pius IX., in the constitution _Apostolicae Sedis Moderationi_,
deleted the epithet _animatus_, and extended the excommunication
to all abortions, no matter at what time of the gestation they
occur. He ordered that only the actual physical abortionist is to
be excommunicated, not those who counsel the crime. Some moralists
hold that those who order abortion are direct abortionists and fall
under this excommunication; other moralists oppose this opinion. Pius
IX.[94] excommunicates procurators of abortion if actual abortion is
effected, and this excommunication is reserved to the bishops, not to
the Pope.
[94] Sect, iii, cap. ii.
In this decree occur the words "_Procurantes abortum, effectu_
_secuto_," and there has been considerable discussion of the
question who are the _procurantes_, the agents who fall under the
excommunication? Again, are craniotomy, cephalotrypsis, decapitation,
embryotomy, and exenteration, when performed on the living child,
abortions in the sense of the decree, and thus matter of the
excommunication?
Those who do abortion are the principal agents who _physically_,
immediately, of themselves, in their own name, or who _morally_,
through others, perform an abortion. The common opinion of moralists
is that all those who of themselves or through others bring on an
abortion are excommunicated, but that assistants, although guilty of
crime, are not excommunicated.
Many eminent moralists are of the opinion that the mother herself who
seeks an abortion does not fall under the excommunication because
Sixtus V. does not explicitly mention her in this penal law, and a
penal law is to be interpreted literally. If a pregnant woman goes to
an abortionist and persuades him by speech and pay to do an abortion,
she is the direct moral cause of that abortion. If it were not for
her, the abortion would not take place. Virtually all abortions done
on married women are effected morally by the woman herself. In my
opinion, and the new canon law states this explicitly, the woman who
procures an abortion on herself or on another woman is excommunicated.
Sabetti-Barrett[95] holds that craniotomy on a living child and
the removal of an inviable extrauterine fetus are not abortion in
the scope of this excommunication, because as a penal law these
operations are not specifically mentioned. All mutilating operations,
like craniotomy and the others enumerated above, first kill the
fetus, then extract its body from the womb; abortion first extracts
the fetus and then lets its die. The result is the same, but the
operations differ technically, and a penal law is _ad literam_. A
cleric who procures abortion of an inviable fetus at any time of
gestation falls under the excommunication and suspension _a sacris_
perpetually, although he probably is not technically irregular
canonically if he procures the abortion before the Aristotelian date
of animation. The bull _Effraenatam_ makes the canonical irregularity
at the Aristotelian date obsolete practically.
[95] _Compendium Theologiae Moralis_, 1915, n. 1009.
In the church the Holy Office (that is, the Inquisitors-General
in matters of faith and morals) is the official authority which
interprets, under the approval of the Pope, the morality of acts like
abortion and related operations. In 1895 the following difficulty was
proposed to the Holy Office for solution:
A physician is treating a woman with a disease which will certainly
be fatal to her unless cured medically, and the disease is due to the
presence of a fetus in her womb. To save her it is necessary to empty
the uterus, but the fetus is not yet viable. The question is, May the
physician perform therapeutic abortion in such circumstances?
On July 24, 1895, the Holy Office answered: "The Inquisitors-General
in matters of faith and morals, with the vote of their Consultors,
decree: _Negatively_, in accord with the other decrees of May 28,
1884, and August 19, 1888."
In May, 1898, the following questions were proposed to the Holy
Office:
I. Is the induction of premature labor licit when a contracted
maternal pelvis prevents the birth of a child at term?
II. If the maternal pelvis is so narrow that premature delivery is
impossible, is it licit to perform abortion, or to effect _cesarean_
delivery at the proper time?
III. Is laparotomy in extrauterine gestation licit?
May 4, 1898, the Holy Office answered, with the assent of Leo XIII:
I. Premature labor in itself is not illicit, provided it is done for
sufficient reason, and at the time and by such methods as will under
ordinary circumstances preserve the life of the mother and the fetus.
II. As to the first part, the answer is negative, according to the
decree of July 24, 1895, on the unlawfulness of abortion. As to the
second part, there is no objection to the cesarean delivery at the
proper time.
III. In a case of necessity, a laparotomy to remove an ectopic fetus
from the mother is licit, provided the lives of both mother and fetus
are, so far as is possible, carefully and opportunely preserved.[96]
[96] "Dummodo et foetus et matris vitae serio et opportune
provideatur."
March 5, 1902, this question was asked the Holy Office: "Is it ever
licit to remove an ectopic fetus from the mother while the fetus is
under six months of age from the time of conception?"
The answer was: "_Negatively_, in accord with the decree of May 4,
1898, by which the lives of the fetus and mother, as far as possible,
are carefully and opportunely preserved. As to the time, the
questioner is reminded by the same decree that no premature delivery
is licit unless effected at the time and by the methods which, under
ordinary circumstances, will preserve the lives of mother and fetus."
The English civil law concerning abortion[97] is:
"Whoever shall unlawfully supply or procure any poison or other
noxious thing, or any instrument or thing whatsoever, knowing that
the same is intended to be unlawfully used or employed with intent to
procure the miscarriage of any woman, whether she be or be not with
child, shall be guilty of a misdemeanor, and being convicted thereof
shall be liable, at the discretion of the court, to be kept in penal
servitude for the term of three years, or to be imprisoned for any
term not exceeding two years, with or without hard labor."
[97] Statutes 24 and 25, Victoria, cap. 100, sec. 59.
Alfred Susaine Taylor,[98] commenting on this law, said: "Strictly
speaking, there is no such thing as justifiable abortion; the law
recognizes no such possibility. A medical man must always remember
this when he contemplates emptying a pregnant uterus.
[98] _Principles and Practice of Medical Jurisprudence._ London,
1905.
"It is obvious that the only reasons that can be thought of by an
honorable man as justifying the induction of labor are (1) to save
the life of the mother; (2) to save the life of the child. (Some
religions will not contemplate the first reason, but that we are not
now concerned with.) It cannot be done for the sake of family honor
nor for any similar ethical reason....
"The golden rule is never to empty a uterus without first having a
second professional opinion as to its necessity; if this opinion be
adverse, do not do it; if it be favorable, it is well to get it in
writing, and it is well also to get the written or attested consent
of the woman and her husband, and then proceed to do it with all the
skill and care possible. The death of the fetus is at any time the
most certain means of causing the womb to empty itself, but after
the sixth month the operation is performed necessarily with a view
to preserving this life, and steps must be taken accordingly." Coke,
about 1615, judged that to kill a child in the womb is not murder,
but if it is expelled by violence and dies after it leaves the womb,
that is murder.
The law in Pennsylvania[99] is: "If any person, with intent to
procure the miscarriage of any woman, shall unlawfully administer to
her any poison, drug, or substance whatsoever, or shall unlawfully
use any instrument, or other means whatsoever, with the like intent,
such person shall be guilty of felony, and being thereof convicted,
shall be sentenced to pay a fine not exceeding five hundred dollars,
and undergo an imprisonment, by separate or solitary confinement
at labor, not exceeding three years." It makes no difference in
Pennsylvania law whether the child is quickened or not.
[99] _Laws of Pennsylvania_, Act of March 31, 1860, sec. 88. p.
404.
The New Jersey, Massachusetts, and Wisconsin laws are like the
Pennsylvania law. The law in Iowa[100] is: "If any person, with
intent to procure the miscarriage of any pregnant woman, wilfully
administer to her any drug or substance whatever, or, with such
intent, use any instrument or other means whatever, unless such
miscarriage shall be necessary to save her life, he shall be
imprisoned in the penitentiary for a term not exceeding five years,
and be fined in a sum not exceeding one thousand dollars." To the
same effect are the laws in Connecticut, Maine, New York, Ohio,
Michigan, Minnesota, Colorado, Texas, and Maryland.
[100] _Laws of 1897_, Iowa Code, 4759.
Frank Winthrop Draper, professor of legal medicine in Harvard
University,[101] commenting on the Massachusetts law of October,
1903, cap. 212, secs. 15, 16, says: "It is important to recognize the
fact that the law does not make any exception or formal recognition
in favor of justifiable operations to procure premature labor. The
statute is general in its application. It is, of course, obvious
that the best sentiment of the medical profession and of obstetric
teachers is favorable to interference of pregnancy, (1) whenever
there is such anatomical deviation or mechanical obstruction in the
mother's pelvis that the birth of a child is impossible; or (2)
whenever the mother is suffering from such grave disease that her
life is in imminent peril and can be saved only by the arrest of
gestation. Under such conditions the physician is not only warranted
in inducing premature labor, but is required to do so by a sense of
duty to his patient, with a view thereby to save one life at least,
and, if possible, the lives of both mother and offspring.
[101] _Legal Medicine_, 1905.
"Nevertheless, as the law now stands, a prudent practitioner will not
expose himself to any risk, if a few precautions will save him. In
the event of the death of the mother and child in such an emergency,
the attending physician might find himself in jeopardy, with the
imputation of gross carelessness and criminal neglect hanging over
him, an imputation which requires years to remove. So the attending
physician should never undertake to do an instrumental operation
without these precautions: 1. The consent of the patient, with that
of her husband or family. 2. Especially, a consultation with some
other physician or physicians in whom there is full confidence.
Attention to these simple and sensible safeguards, by making the
conduct appear by its candor and openness in the strongest possible
contrast with the secret methods of the abortionist, may save great
embarrassment."
The ethics of this doctrine is, of course, absurd, as has been
shown, and it is cited here only to show how the civil law considers
abortion. Wharton and Stille[102] give the same information in a
more technical manner. "It is a general rule," they say, "independent
of statute, that the act of a physician in aiding a miscarriage is
not unlawful, where the miscarriage was the inevitable result of
other causes. And the act is justified where the circumstances were
such as to induce in the mind of a competent person the belief that a
miscarriage was necessary to preserve the life of the mother. And the
statutes of many of the States penalize the causing, or attempting
to cause, an abortion, unless necessary to preserve the life of the
woman, or unless advised by a designated number of physicians to be
necessary for such purpose, the absence of both the necessity and
the advice being an essential ingredient in the crime. The physician
by whom the deed is done, however, cannot act as his own adviser in
the matter. And an indictment under the statute must not only allege
that the act was not necessary to preserve the woman's life, but must
also negative the advice of physicians; and such averments cannot be
inserted as an amendment after demurrer.
[102] _Medical Jurisprudence_, vol. iii, sec. 526.
"The burden of proof rests with the state to show that the means used
were not necessary to preserve the life of the woman in question;
and the absence of necessity may be determined from circumstantial
evidence. But the burden of proof as to the advice of physicians
would not fall within the rule controlling the production of proof
as to negative matters in general, and would rest with the accused;
though it may be proved by a preponderance of the evidence and need
not be established beyond a reasonable doubt. But either that the
act was necessary to preserve the life of another, or that it was
advised by physicians to be necessary for that purpose, is of equally
good defence; and the destruction of the child need not have been
both necessary and advised by physicians. And statutes of this class
apply only in cases in which the death of the mother could reasonably
be expected to result from natural cause, unless the child was
destroyed, and do not apply to a case in which the mother threatened
suicide unless she was relieved from her trouble."