(which were formally forbidden by the Holy Office on May 28, 1884, and
August 19, 1888, and always forbidden by the natural law) in several
factors: first, in craniotomy the child is _directly_ killed, although
it is not an aggressor, in the hysterectomy it is permitted to die, it
is _indirectly_ killed; secondly, in craniotomy there is a viable
child, in the hysterectomy, an unviable child; thirdly, in craniotomy
there is a killing that is a means toward the end of saving the
mother's life, in the hysterectomy there is a permitted hastening of
the foetus's death, and this is only a circumstance inseparably joined
to the act; fourthly, in craniotomy the killing is utterly {43}
uncalled for, because the caesarean section, or symphyseotomy (a
temporary dividing of the pubic joint to get more room) will do
instead, in the hysterectomy, because the child is not viable, there
is no alternate way out of the difficulty; fifthly, formal judgment
has been pronounced by the Holy Office in craniotomy, no formal
judgment has been made as regards this hysterectomy.
Suppose A and B are on a boat hoisting a weighty object to a ship; the
tackle breaks, the falling weight mortally hurts B, and wedges him
fast to the wrecked boat. The boat is about to sink and drown both
men, but if A tips off the weight, and with it unavoidably the
entangled B, A can float to safety. A will indirectly hasten the
inevitable death of B by throwing off the weight which will drag him
down. May A do so? Very probably he may.
Two swimmers, A and B, are trying to save C, who dies in the water,
and as he dies he grips A and B so tightly they can not shake the
corpse off. A is weak, and he will soon sink and drown owing to the
weight of the corpse; B also will later go down with A and C. A,
however, cuts his clothing loose from the grip of the corpse (or some
one in a boat does so who can do no more) and A is saved; but thus
immediately B is drowned, owing to the fact that the full weight of
the corpse is upon him. Is A, or the man in the boat, justified?
Probably they are. A is the mother, B the foetus, C the diseased
uterus, the man in the boat is the surgeon. The mother has herself cut
away from the uterus and the foetus's death is hastened.
Again, take an example used by Father Ricaby in his _Moral
Philosophy_, p. 205 (London, 1901). He supposes a visitor to a quarry
to be standing on a ledge of rock which a quarryman had occasion to
blast, and the quarry man saw that "unless that piece of rock where
the visitor stood were blown up instantly, a catastrophe would happen
elsewhere, which would be the death of many men, and if there were no
time to warn the visitor to clear off who could blame him if he
applied the explosive? The means of averting the catastrophe would be,
not that visitor's death, but the blowing up of the rock. The presence
or absence of the visitor, his death {44} or escape, is all one to the
end intended: it has no bearing thereon at all."
If these examples of indirect killing are allowable, why may not the
surgeon in the rare example presented here remove the uterus and
indirectly permit the hastening of the foetus's death? That hastening
of death is not an end, nor a means toward an end, but a circumstance
only reluctantly and indirectly willed. The end is to save the
mother's life, and the means is the removal of a septic or impacted
uterus.
It may be objected that an artificial abortion wherein the womb is
emptied of an unviable foetus to save the mother's life is only an
indirect hastening of this foetus's death, but there is a difference:
in abortion the removal of the foetus is the means whereby the end is
attained, in the hysterectomy the removal of the _tumour_ is the means
whereby the end is attained. This argument is advanced only
tentatively and with diffidence, that the matter may be discussed and
settled by authority.
Sometimes carcinoma (a cancer) complicates pregnancy--once in 2000
cases is above the average. A carcinoma is a malignant tumour, and the
malignancy is made much worse by the stimulus of pregnancy with its
increased blood supply. The maternal deaths from carcinoma of the
uterus during pregnancy is, according to the latest and most
favourable statistics, 30 per centum. The mortality of the children is
from 50 to 63 per centum.
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 scraping 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 circumstances 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 circumstance 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.
{48}
III
ABORTION, MISCARRIAGE AND PREMATURE LABOUR
If pregnancy ends in the emptying of the uterus before the sixteenth
week of gestation, the condition is called an abortion; if this
happens between the sixteenth and the twenty-eighth weeks, it is
miscarriage; if the child is born after the twenty-eighth week but
before full term, the birth is premature. The term "abortion" in the
popular mind carries with it the notion of criminal interference, and
the word "miscarriage" is used for both abortion and miscarriage by
the laity; physicians, on the other hand, commonly use the term
"abortion" for both abortion and miscarriage. These conditions may
occur spontaneously or they may be induced artificially.
Spontaneous abortions are very frequent; perhaps one in every five or
six pregnancies is the proportion: the writer has known a single
physician, not a specialist in obstetrics, to be called to three in
one day and that in private practice. From 150 to 200 children in
every 1000 that are conceived never get a chance for baptism. In the
early months of pregnancy the foetus is usually dead before expulsion
takes place. Twisting of the cord, hydramnios, syphilis, an acute
infectious disease in the mother, poisonings of the mother by metals
and the like substances, maternal cardiac and renal diseases, chronic
inflammations and displacements of the womb, and violent emotions are
some of the causes of abortion. In certain women a slight exertion, a
misstep, a fall, a ride over a rough road, the _debitum conjugale_,
and similar causes bring on abortion; in other women almost no shock
is enough to make them miscarry. Inflammations and displacements of
{49} the womb cause most of the abortions in the first four months,
and after that time syphilis and Bright's disease are the chief forces
at work.
If a woman in early pregnancy begins to lose blood from the uterus,
and has pain in her back and lower abdomen, abortion is threatened; if
this hemorrhage is marked, and the cervix is dilated, the abortion
will very probably occur; and the escape of the _liquor amnii_ renders
the abortion unavoidable. In this latter case the vagina and the
cervical canal are packed with sterile gauze to check the hemorrhage,
and after twenty-four hours it is removed. Then commonly the entire
ovum comes away with the gauze, or what remains of it is taken out
with a curette.
Valvular lesions of the heart in pregnancy make a maternal mortality
of about 28 per centum, according to Guerard, and when compensation is
lost the mortality may run from 48 to even 100 per centum with
different physicians and different cases. The prognosis is good as
long as compensation is retained, but very bad if this fails. In the
latter condition premature labour is indicated, or the early removal
of the viable child. Catholic physicians may not induce artificial
abortion of an unviable foetus. The decree of the Holy Office
concerning this matter is as follows:
Beatissime Pater,--Stephanus . . . Archiepiscopus Cameracensis . . .
Quae sequuntur humiliter exponit:
Titus medicus, cum ad praegnantem graviter decumbentem vocabatur,
passim animadvertebat lethalis morbi causam aliam non subesse
praeter ipsam praegnationem, hoc est, foetus in utero praesentia,
una igitur, ut matrem a certa atque imminenti morte salvaret,
praesto ipsi erat via, procurandi scilicet abortum seu foetus et
ejectionem. Viam hanc consueto ipse inibat, adhibitis tamen mediis
et operationibus, per se atque immediate non quidem ad id
tendentibus, ut in materno sinu foetum occiderent, sed solummodo ut
vivus, si fieri posset, ad lucem ederetur, quamvis proxime
moriturus, utpote qui immaturus omnino adhuc esset.
Jamvero lectis quae die 19 Augusti, 1888, Sancta Sedes ad
Cameracenses Archiepiscopos rescripsit: _tuto doceri non posse_
licitam esse quamcumque operationem directe occisivam foetus, etiam
si hoc necessarium foret ad matrem salvandam: dubiis haeret Titius
circa {50} liceitatem operationum chirurgicarum, quibus non raro
ipse abortum hucusque procurabat, ut praegnantes graviter
aegrotantes salvaret.
Quare ut conscientiae suae consulat supplex Titius petit: utrum
enuntiatas operationes in repetitis dictis circumstantiis instaurare
tuto possit.
Feria iv, die 24 Julii, 1895.
In Congregatione generali S. Romanae et Universalis Inquisitionis .
. . Emi ac Rmi Domini Cardinales . . . respondendum decreverunt:
_Negative_, juxta alias decreta, diei scilicet 28 Maii, 1884, et 19
Augusti, 1888.
. . . Sanctissimus Dominus noster . . . approbavit.
Other documents referring to the same matter are the following:
Epistola ad Archiepiscopum Cameracensem. . . . Anno 1886,
Amplitudinis tuae Praedecessor dubia nonnulla hinc supremae
Congregationi proposuit circa liceitatem quarumdem operationum
chirurgicarum craniotomiae affinium. Quibus sedulo perpensis,
Eminentissimi ac Reverendissimi Patres Cardinales una mecum
Inquisitores Generales, feria iv, die 14 currentis mensis,
respondendum mandaverunt:
In scholis catholicis tuto doceri non posse licitam esse operationem
chirurgicam quam craniotomiam appellant, sicut declaratum fuit die
28 Maii, 1884, et quamcumque chirurgicam operationem directe
occisivam foetus vel matris gestantis.
Idque notum facio Amplitudini tuae, ut significes professoribus
facultatis medicae Universitatis catholicae Insulensis. . . .
Romae, die 19 Augusti, 1889. . . .
R. CARD. MONACO.
The date of this response here is 1889, but in the preceding decree it
is given as 1888. In the _Acta Sanctae Sedis_ the date is 1889.
Another letter from Cardinal Monaco is this:
Eme et Rme Dne,--Emi PP. mecum Inquisitores generales in
Congregatione habita feria iv, die 28 labentis Maii, ad examen
revocarunt dubium ab Eminentia tua propositum--An tuto doceri possit
in scholis catholicis licitam esse operationem chirurgicam, quam
Craniotomiam appellant, quando scilicet, ea omissa, mater et infans
perituri sint, ea e contra admissa, salvanda sit mater, infante
pereunte?
{51}
--Ac omnibus diu et mature perpensis, habita quoque ratione eorum
quae hac in re a peritis catholicis viris conscripta ac ab Eminentia
tua hinc Congregationi transmissa sunt, respondendum esse duxerunt:
_Tuto doceri non posse_.
Quam responsionem cum SSmus D. N. in audientia ejusdem feriae ac
diei plene confirmaverit, Eminentiae tuae communico. . . .
R. CARD. MONACO.
Romae, 31 Mail, 1884.
Emo Archiepiscopo Lugdunensi.
Another decree concerning abortion is in part as follows:
Beatissime Pater,--Episcopus Sinaloen. ad pedes S.V. provolutus,
humiliter petit resolutionem insequentium dubiorum:
I. Eritne licita partus acceleratio quoties ex mulieris arctitudine
impossibilis evaderet foetus egressio suo naturali tempore?
II. Et si mulieris arctitudo talis sit, ut neque partus praematurus
possibilis censeatur, licibitne abortum provocare aut caesaream suo
tempore perficere operationem? . . .
Feria iv, die 4 Mail, 1898.
In Congregatione habita, etc. . . . EE. ac RR. Patres rescribendum
censuerunt:
Ad I. Partus accelerationem per se illicitam non esse, dummodo
perficiatur justis de causis et eo tempore ac modis, quibus ex
ordinariis contingentibus matris et foetus vitae consulatur.
Ad II. Quoad primam partem, _negative_, juxta decretum Feria iv, 24
Julii, 1895, de abortus illiceitate. Ad secundum vero quod spectat;
nihil obstare quominus mulier de qua agitur caesareae operationi suo
tempore subjiciatur. . . .
In sequenti Feria vi, die 6 ejusdem mensis et anni . . . SSmus
responsiones EE. ac RR. Patrum approbavit.
Pyelonephritis (an inflammation of the kidney where pus is present),
from the pressure of the pregnant uterus, is a condition which
sometimes obliges the physician to bring about premature labour to
save the mother. The symptoms usually appear in the latter half of
gestation.
Chorea ("St. Vitus' Dance"), when it develops during pregnancy, has a
maternal mortality of from 17 to 22 per centum. It may cause death
before the child is viable, and to empty {52} the uterus will stop the
symptoms. Here the decrees of the Holy Office will occasionally
prevent the Catholic physician from interfering.
If a grave surgical operation is imperatively indicated during
pregnancy, and may not be put off until after delivery, it should be
undertaken in many cases, because modern technique commonly does not
bring about an abortion; but, in general, no rule can be given--each
case must be judged separately.
If a pregnant woman has at the same time considerable albumen in her
urine and a low excretion of urea, her condition is very dangerous. To
empty her uterus will, in most cases, relieve the renal trouble, but
in any case premature labour is not to be induced rashly: many women
escape, when by all the rules they should die.
Eclampsia is a very grave complication of pregnancy, and it was
formerly supposed to be uraemia. The disease is characterized by
convulsions, loss of consciousness, and coma. It occurs, commonly, in
the second half of gestation, but it has been observed as early as the
third month. About 70 to 80 per centum of the cases are in primiparous
women. The convulsions may come on altogether unexpectedly, but
commonly the attack begins with symptoms of toxaemia. Eclampsia may
occur before, during, or after parturition. When it comes before term
it usually ends in spontaneous or artificial abortion, but at times
the woman dies undelivered. Now and then she may recover and be
delivered at term.
The kidneys are usually affected, even in those cases in which
albuminous urine is not found. There is also a hemorrhagic
inflammation of the liver; and oedema and congestion of the brain,
with or without apoplexy, are other symptoms of the disease. There are
other lesions, but the chief are in the kidneys, liver, and brain.
The aetiology of the disease is not yet known, and there are very many
theories offered to explain it. The prognosis is always serious, and
the condition is one of the most dangerous found in pregnancy. The
mortality varies, but it is about from 20 to 25 per centum in the
women, and from 33 to 50 per centum in the children. It is impossible
to determine {53} the prognosis in particular cases, but a large
number of quickly recurring convulsive seizures, with a weak, thready
pulse, and a high temperature usually indicate a fatal ending.
Apoplexy, oedema of the lungs, and paralysis also, as a rule, end in
death.
If the uterus is emptied during the convulsions, these cease either
immediately or soon after delivery, in from 66 to 93 per centum of the
cases, and the maternal mortality then is about 11 per centum. With
the expectant treatment, in convulsive cases, about 28 per centum of
the women die, although a use of aconite in these cases may better the
prognosis.
Pernicious vomiting (hyperemesis gravidarum) is another complication
of pregnancy, which sometimes results fatally if the uterus is not
emptied. There are cases, especially those with high fever, which end
in death despite all treatment. Here, again, the aetiology of the
disease is not known. There is commonly an element of hysteria in the
condition, and in such a case moral suggestion often has a curative
effect Any bodily irritation is to be removed. Eye-strain alone is
enough to cause persistent vomiting. It is very difficult to decide
when premature labour is absolutely indicated, because some very bad
cases recover spontaneously when all hope is lost.
Hydramnios, or an excessive quantity of _liquor amnii,_ may so distend
the uterus as to cause grave danger to maternal life, and if the child
is viable the uterus should be emptied.
Intrauterine hemorrhage brought on by a premature separation of the
placenta is a very dangerous condition: 32 to 50 per centum of the
mothers die, and 85 to 94 per centum of the children. In a marked
hemorrhage the only way to save the mother is to empty the uterus, so
that it may contract and thus close the patulous vessels.
Placenta praevia is a placenta implanted in the neighbourhood of the
internal os of the uterine neck. This is a very perilous condition,
calling for the induction of premature labour. The medical treatment
is artificial abortion as soon as the condition is diagnosed in any
stage of gestation; but this is, of course, in conflict with the
decrees of the Holy Office. Under expectant treatment about 40 per
centum of {54} the mothers die, and 66 per centum of the children.
Those children that are born alive commonly die within ten days after
delivery. The great foetal mortality is due to premature birth and
asphyxiation. Skilful obstetricians get much better results, but
skilful obstetricians are unfortunately rare.
When the grave complications enumerated above occur in the early
months of pregnancy, before the foetus is viable, the Catholic
physician, since by the natural law and the decisions of the Holy
Office he is forbidden to induce artificial abortion, must withdraw
from the case. If there is no other physician to attend to the woman,
he must let her die. He can not withdraw without explanation, and in
many cases the explanation of the condition will promptly result in
the calling in of a physician who has no scruple in inducing this
abortion, no matter how reputable he may be. The universal medical
doctrine is to induce abortion in cases where abortion will save the
mother's life and the foetus is "too young to amount to anything."
This is looked upon as legitimate abortion by the very best men that
do not recognise the authority of the Holy Office: they deem the
position of the Catholic physician in these cases as altogether
erroneous, or even criminal.
The position of the Catholic moralists on craniotomy has turned the
attention of many non-Catholic physicians to the immorality of the
act, which formerly was deemed entirely permissible. Probably the same
good result will be effected in the matter of abortion.
AUSTIN OMALLEY.
{55}
THE CAESAREAN SECTION AND CRANIOTOMY