Essays In Pastoral Medicine Part 4

In any case of ectopic gestation the foetus has a very faint chance indeed of even living long enough for baptism if the expectant treatment is employed. We have seen that between November 1809 and November 1896 there were reported 77 cases of operation for the delivery of viable foetuses. Eleven of these children survived, 67 died within a few months, and many of these died just after delivery.

Still, probably all might have been baptised. Judging, however, from the geographical distribution of the cases (see Kelly's _Operative Gynaecology_, vol. ii. p. 458) and the names of the operators, only about 14 of these children received baptism.

Now, since Schrenck found 610 ectopic gestations reported in five years, this indicates that the average number of cases of ectopic gestation which occur in the civilised world is at the least 122 a year, for many more (twice as many, at the lowest {34} estimate) are not diagnosed or not reported when diagnosed. In the 80 years, then, between 1809 and 1896 there were at the least 9760 cases of ectopic gestation in the civilised world; in the uncivilised countries there were certainly as many more with not a child saved, or even brought out of the pelvic cavity. To be sure, by rejecting perhaps a third of the cases through bad diagnoses and neglect of reports, there were 20,000 cases; and in all these hardly 20 children baptised--one in a thousand.

Modern surgical methods and improved diagnosis will do little to better the condition, from the nature of the disease. Between 1893 and 1896 there were 21 cases of operation for the delivery of viable foetuses reported, and this list is approximately correct, because the surgeons that operate on such material are men that as a rule report their work even when it is to their discredit. In these 21 cases, 6 mothers, 28 per centum died, 72 per centum recovered. Even if modern surgery should save all the mothers who had escaped until the foetus was viable, and should bring all the children to baptism, there would not be more than about 7 such cases in the world annually. Increased skill in diagnosis would raise the number of children brought to baptism, but it would more than proportionately raise the whole number of ectopic gestations discovered. If 10 foetuses were brought from the pelvic cavity alive in the 130 cases of ectopic gestation of the year, the chances for an extrauterine foetus to only reach baptism at a viable age (not to live after baptism) are only 7 in 100 at a most liberal estimate. Statistics are unreliable, of course, but I am giving odds of two to one. The foetus has a much better chance for baptism if the coeliotomy is done as early in the pregnancy as possible, but it has a negligible chance of life in any case. Since the creation of man there have been less than 15 extrauterine children saved, and of these 15 four were less than a year old when reported, and three under five years of age: the oldest was fifteen years of age, and all were weaklings.

The practical rule, then, is that the ectopic foetus will die anyhow, and operation only _indirectly_ (mark the word) accelerates the inevitable death of a materially unjust aggressor, {35} while it gives the mother the best chance for her life, which is in very grave peril.

Case III. The surgeon before operation diagnoses with the help of consultors extrauterine pregnancy, but he or they can not tell whether the foetus is alive or not. What should he do?

In my opinion he may operate with much more solid probability than that which exists in Case II. If the argument is more for the death of the foetus than for its life, this, of course, strengthens the permissibility of the operation.

(1) The danger to the mother is exactly the same,_caeteris paribus_, as in Case II.; (2) the foetus is only probably alive. An actual danger to life is opposed to the probable life of a materially unjust aggressor; therefore the surgeon may probably operate at once.

Probable here is used in the technical sense of the term.

Case IV. The following case is given because a similar one was proposed in the articles in the _American Ecclesiastical Review_, but it is not a practical case.

The surgeon, after consultation, does not know whether the growth in a woman's pelvis is a malignant tumour or a sac containing an extrauterine foetus. If the growth is a malignant tumour, the woman is in actual and certain danger of life, her death is a mere matter of time if a malignant tumour is not removed, and the sooner the tumour is removed the better. If operation is deferred, metastases of the tumour will have occurred, and operation will be too late. The indication when we find a malignant tumour is, if it is not already too late to operate, to take it out at once.

If the surgeon thinks that the growth may possibly be a foetus, and he puts off the operation until a time when certain signs of pregnancy should be present to establish a diagnosis of gestation, or their lack to establish a diagnosis of tumour, it would almost surely be too late to operate in the event the growth turned out to be a malignant tumour.

As has been said, the case is not practical, because malignant tumours of the tube are so very rare that they are not to be looked for,--only one or two have been observed. {36} Malignant tumours about the tube should be diagnosed. Supposing, however, the case to stand, it offers in favour of operation a probabilism stronger than that in any case except Case I., because the mother's danger is graver, and the argument concerning the foetus is the same as that in Case III.

Case V. Suppose a doubtful case like Case III. or Case IV., but after the surgeon has opened the abdomen he finds a foetus evidently alive.

This is an improbable but a possible case. Case V. then becomes like Case II. with the addition of another grave danger to the lives of both the mother and the foetus, which is the coeliotomy already performed. The suggestion that the surgeon can leave the woman, back out of the case, is absurd. If he closes the abdomen, the coeliotomy may cause tubal abortion, the wound might have to be opened again in a few hours or a few days, and the mother would be left in much greater peril than she was in Case II. For the reasons already given, he should go on with the operation.

Case VI. Suppose a case like Case V. in every particular except that when the surgeon finds the foetus he can not tell whether it is alive or not. He should,_ a fortiori_, finish the operation.

Case VII. A case of ectopic gestation is diagnosed, the conditions are explained to the woman, and she refuses to be operated upon. Is she justified? The probability is one to two that she will escape death if she waits, and much less than one to two if she finally refuses operation. The moralists would tell her she may refuse operation.

Case VIII. Let us suppose a case where a Fallopian tube either has its lumen so narrowed by a gonorrhoeal inflammation that although the spermatozoa may pa.s.s through and fecundate the ovum this fecundated ovum can not get out to the uterus; or, secondly, that the gonorrhoeal infection has completely shut the tube, yet migratory fecundation has occurred through the route of the other tube and the pa.s.sage along the fundus of the uterus to the ovary of the infected side. In either case an ectopic gestation begins.

The first case is improbable from a medical point of view, {37} and the second is barely possible. Gonorrhoeal infection of the tubes is common enough, but when it occurs it usually shuts the tube up permanently. In chronic salpingitis at times the ovarian end of the tube is not wholly closed at once, and since the body of the ovary is very rarely affected by gonorrhoea, there is a possibility worth considering of a tubal pregnancy through migration to occur.

In such a condition the woman might have been infected with gonorrhoea, first, before her marriage through fornication or accident; second, after her marriage through adultery or accident; third, after the marriage by her husband.

If she had been infected through fornication or adultery, she is accountable for the foreseen consequences of her sin, and she has put an impediment for which she is responsible before the embryo. Suppose the physician knows these facts. Then the excuse for indirectly hastening the death of the foetus does not, at first sight, seem to exist, because the foetus is apparently not a materially unjust aggressor. It could easily happen that a surgeon's refusal to operate in a case like this would cause the death of the mother and foetus.

Should he let both perish? Is he to let the mother die for the sake of staving off for a half-hour the certain death of a useless embryo the size of a pigeon's egg? It is not a useless embryo the size of a pigeon's egg, but a human being, the most important thing on earth, and a human being shut off from life and baptism as a direct consequence of that woman's brutal sensuality. But the woman may be the mother of other helpless children. What is to be done? Let us recur to the example of the homicidal maniac.

If I accidently by a blow make a man insane and that insane man afterward tries to kill me, I or my protector may permit his death to save my life. If I maliciously make a man insane and he afterward tries to kill me, may I or my protector kill him in my defence? Some may say that I may not because I have lost all juridic superiority over the madman as a consequence of my sin against him. That position, however, does not seem to be correct.

If it is correct, parity makes the a.s.sertion true that the foetus in the case supposed above may not be indirectly {38} killed to save the mother. If it is not true, the foetus may be indirectly destroyed.

Does my sin against the insane man give him a right to kill me? By no means. Nothing but defence of life or its equivalent gives any private individual the right to kill another. The man might kill me before this aggression of mine, in defence of his sanity, but after the fact such a killing would be mere revenge, or an _actus hominis_, not a right.

The woman, we suppose, has maliciously put the foetus in its position of material aggressor, but has the foetus the right to kill her? No; the foetus is an individual not acting in self-defence, it is merely growing. Has the woman or the surgeon, her protector, the right to permit the death of the foetus to defend the woman's life? I think they have, because the foetus here also is, from its unnatural position, a materially unjust aggressor.

But, you say, this is a vicious circle. You justify the permitted death of the foetus in Case I. because it is a materially unjust aggressor, and it is a materially unjust aggressor because it is in an unnatural position where it has no right to be; but in the present case the mother put it in the unnatural position, and it therefore has a right to be where it is. No: the consequence does not follow. The fact that the mother put the foetus in its unnatural position does not give the foetus a _right_ to be in that position, although it const.i.tutes a ground for her punishment by proper authority. You object again, if this woman has a right to permit the death of the foetus to save her own life, how may she be punished for that death?

She will not be punished for the actual coeliotomy which indirectly caused the death of the foetus, but she will be punished for the sin of putting that child in a position in which it had to be killed. This seems to be a distinction without a difference. As far as the mother is concerned, _transeat _; but it is a real distinction as far as the surgeon is concerned.

If the woman's condition is a result of accidental infection before or after marriage, the case goes into the cla.s.s of those discussed above, and operation is justifiable.

If her infection comes after her marriage adulterously, her {39} sin is the greater, but the operation is justifiable for the reasons which were given in the case of culpable infection before marriage.

If she had been infected by her husband, the operation is justifiable--the father is accountable for the foetus's death.

Fortunately the entire case is so nearly hypothetical that it is little more than mere words.

AUSTIN oMALLEY.

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II

PELVIC TUMOURS IN PREGNANCY

Tumours of the uterus and its adnexa at times, though rarely, complicate pregnancy, and they may involve certain moral questions that have been little discussed. The tumours that cause difficulty are ovarian and uterine.

Cystic ovarian tumours commonly do not prevent impregnation, if there has been an absence of inflammation. When these cysts are small they may not disturb pregnancy or delivery; large cysts can, however, become a source of danger. They may sink into the pelvis and block the channel of delivery needed by the child at term; they may have their pedicles twisted, and thus become gangrenous and septic. Big cysts of the ovary may during the growth of the pregnant uterus press upon the portal vein, or the diaphragm, or they may burst or cause sepsis.

Litzman, in 56 cases of ovarian tumours complicating pregnancy, had only 10 normal deliveries; and Remy held that 23 per centum of these cases, when left untouched, result in death to the mothers. Stratz says the mortality is 32 per centum, and it has gone as high as 40 per centum. Some physicians teach that any ovarian cyst found complicating pregnancy should be removed surgically. Other authorities hold that they should all be treated expectantly: if they threaten the life of the mother, they should be tapped by a trocar through the belly-wall or the v.a.g.i.n.a, and removed only after labour. This second operation is safe, and I think it should prevail.

Such cysts have often been removed during pregnancy. Orgler reported 146 ovariotomies (removal of the ovaries) performed during gestation with only four maternal deaths--2.7 per centum. If the operation had not been performed {41} about 32 per centum of these women would have died. The chance against saving the child in such an operation is the crux. If there is no operation 17 per centum of the cases result in abortion and the loss of the child, as Remy found from a consideration of 321 cases. In Orgler's series of 146 ovariotomies, where he lost only 2.7 per centum of the mothers, and saved about 30 per centum that would have died (97 per centum in all); he lost 32 children through abortion caused by the ovariotomies, or 22.5 per centum; whereas by the expectant method (without tapping) only 17 per centum of the children were lost.

Bovee of Washington, however, reported 38 cases of removal of the ovaries during pregnancy with one maternal death and only four abortions, or 12.6 per centum. That is considerably less than the loss by the expectant method without tapping. As Bovee succeeded, other men now do, but it would be far better to attempt tapping first. The earlier in the pregnancy either tapping or removal is done the better.

Fibroid tumours of the uterus, complicating pregnancy, occur in about 0.6 per centum of pregnancies, and they usually go on without causing trouble; but again these tumours may block the pelvic outlet, they may dangerously press upon abdominal viscera and the diaphragm; some writers hold they may become inflamed and degenerate with sloughing and gangrene, and thus bring about sepsis and death to the mother and child. That they become gangrenous must very rarely happen; the increased blood supply should prevent gangrene, but cause an increase in the size of the fibroma.

A group of gynaecologists maintain that when fibromata cause dangerous symptoms in pregnancy the uterus should be taken out in part or wholly if the tumour is so deeply involved in the uterine wall that it can not be separated. This operation, of course, kills the foetus. At times the child is viable, and a precedent caesarean section will save it. Surgeons do not remove fibromata merely as a precaution, as they sometimes do in the case of ovarian cysts. Other surgeons say it is safe to wait. If the channel of delivery is blocked, these men wait till term and then do caesarean {42} section; in other cases the tumour will often be lifted up out of the way during the later stages of gestation or labour.

In those very rare cases where it is necessary to remove the uterus wholly or in part before the child is viable, and thereby also to kill the foetus, the operation at first glance seems in no wise to differ in nature from a craniotomy upon a living child. The condition, however, is commonly worse than one in which a craniotomy is indicated, because in the latter condition we have a viable child, and the caesarean section to solve the difficulty, but in the former we have a child not viable, and therefore the caesarean section would be useless, except for the opportunity it might give for baptism of the child. In such a case must the surgeon let the mother die lest he hasten the death of a non-viable child?

The action reduces to this, that the surgeon by operating would permit a hastening of the inevitable death of the foetus while saving the mother's life, but the child is not an unjust aggressor, not even a materially unjust aggressor. It has a right to be where it is. The only excuse for hastening its death is to save the mother's life,--there is no question of self-defence; but deliberately to hasten the death of a human being a second of time, except it be done by an individual in self-defence against an unjust aggressor, or by the state for legitimate cause, is murder. It seems probable, however, that there is something to be said in favour of the unavoidable hysterectomy (removal of the womb) in a pregnancy complicated with uterine fibromata that undoubtedly endanger life.

Such cases differ from craniotomy, or the direct killing of a foetus (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 circ.u.mstance 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 p.r.o.nounced 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 circ.u.mstance 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.