Part 13

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

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

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

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

AUSTIN OMALLEY.

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THE CAESAREAN SECTION AND CRANIOTOMY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

AUSTIN OMALLEY.

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MATERNAL IMPRESSIONS

There is a wide-spread persuasion that a child, while carried in the womb of its mother, may be marked as the result of incidents that produce violent impressions upon her nervous system. This is so old a conviction in the human race and would seem to be substantiated by so much evidence that it is extremely difficult to convince people that there is no scientific basis for it. As a matter of fact, however, there is something mysterious about the way in which certain things that happen to the mother seem to affect the child in utero. As the result of the common belief in the truth of maternal impressions, mothers sometimes are prone to blame themselves for not having been sufficiently circumspect during the time of their pregnancy, and accordingly they may seek advice and consolation in the matter from clergymen. Women sometimes become very much depressed as a consequence of an unfortunate event of this kind, and as the simple truth is the best possible source of consolation, it would seem that a special chapter should be given to the subject in a work of this kind.