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{iii}
ESSAYS IN PASTORAL MEDICINE
BY
AUSTIN OMALLEY, M.D., Ph.D., LL.D,
PATHOLOGIST AND OPHTHALMOLOGIST
TO SAINT AGNES'S HOSPITAL
PHILADELPHIA
and
JAMES J. WALSH, M.D., Ph.D., LL.D.
ADJUNCT PROFESSOR OF MEDICINE AT THE NEW YORK POLYCLINIC SCHOOL
FOR GRADUATES IN MEDICINE; PROFESSOR OF NERVOUS
DISEASES AND OF THE HISTORY OF MEDICINE
FORDHAM UNIVERSITY, NEW YORK
LONGMANS, GREEN, AND CO.
91 AND 93 FIFTH AVENUE, NEW YORK
LONDON AND BOMBAY
1906
{iv}
_Copyright, 1906_
By Longmans, Green, and Co.
_All rights reserved._
THE UNIVERSITY PRESS, CAMBRIDGE, U. S. A.
{v}
PREFACE
The term Pastoral Medicine is somewhat difficult to define because it
comprises unrelated material ranging from disinfection to foeticide.
It presents that part of medicine which is of import to a pastor in
his cure, and those divisions of ethics and moral theology which
concern a physician in his practice. It sets forth facts and
principles whereby the physician himself or his pastor may direct the
operator's conscience whenever medicine takes on a moral quality, and
it also explains to the pastor, who must often minister to a mind
diseased, certain medical truths which will soften harsh judgments,
and other facts, which may be indifferent morally but which assist him
in the proper conduct of his work, especially as an educator. Pastoral
medicine is not to be confused with the code of rules commonly called
medical ethics.
The material of pastoral medicine requires constantly renewed
discussion, because medicine in general is progressive enough
frequently to devise better methods of diagnosis and treatment, and
thus the postulates of the moral questions involved are changed. This
discussion, however, is not easily made. The facts upon which the
ethical part of pastoral medicine rests are furnished by the physician
for the consideration and judgment of the moralist--the physician
educated after modern methods knows little or nothing of ethics and
can not himself make accurate moral decisions. The moralist, on the
other hand, is commonly a poor counsellor to the physician, because
long training in medicine is needed before the physical data of the
moral decisions is comprehended. The physician, therefore, is at a
loss to determine what he may or may not do in {vi} cases that involve
the greatest moral responsibility, and the priest is a hesitating
guide because the moral theologies do not convincingly present the
doctrine in these cases.
Now and then such subjects have been proposed for discussion to a
group of physicians and moralists, but usually no practical conclusion
has been reached because one side did not understand the other. In
1898 there was a series of articles on ectopic gestation in the
_American Ecclesiastical Review_, in which moralists like Lehmkuhl,
Sabetti, Aertnys, and Holaind, and some of the leading gynaecologists
of America considered the questions but arrived at no decision. The
physicians did not understand certain questions, other questions were
on obsolete medical practice, essential questions were omitted, and
from the data the moralists came to opposed conclusions.
We find also in moral theologies deductions drawn from false medical
sources. Reasons are given, for example, to justify the use of a large
quantity of alcoholic liquor at a dose in cases of great pain, typhoid
fever, snake-poisoning, and other diseases, in the supposition that
such doses will benefit or cure the patient, whereas the physician
that would follow that treatment would be guilty of malpractice. There
was recently in America a discussion on the relation of oeophorectomy
to the _impedimentum impotentiae_. One side held that a lack of
ovaries constitutes impotence; the other side, that it does not. The
discussion was useful because it incidentally gathered the full
doctrine of the moralists on this subject, but from the medical point
of view there is no connection whatever between these conditions.
A small number of books on pastoral medicine have been written by
clergymen that were not physicians, and a few German books by
physicians that were also moralists. Those by the physicians draw
conclusions from antiquated medical practice, or they are mere popular
treatises on hygiene; those by the clergymen have some value on the
ethical side, but they are incomplete because the authors had not the
necessary medical knowledge. The essays offered in this book by no
{vii} means cover the entire field of pastoral medicine, but as far as
they go we have endeavoured to offer the medical doctrine of the
present day on the questions considered, and that as completely as is
necessary to draw the moral inferences.
Since, then, so many of the questions of pastoral medicine are not
defined, physicians are likely to follow the doctrine of the standard
medical books, which without exception advise them to take the life of
a dangerous foetus almost as unconcernedly as they might prescribe an
active drug, or in any case to put utility before justice. There is,
therefore, an urgent necessity that competent men fix that shifting
part of ethics and moral theology called pastoral medicine, and these
essays are presented as a temporary bridge to serve in crossing a
corner of the bog until better engineers lay down a permanent
causeway.
Some may think that the authors are inclined toward an exaggerated
charity in suggesting the measure of responsibility for many human
actions, but the physician that is brought much in contact with those
suffering from mental defects of various kinds soon learns how easily
complete responsibility becomes marred. Responsibility is dependent
entirely upon free will; and while the great principle of free will
remains solid in truth, no two men are free in exactly the same
manner. Physical conditions have not a little to do with modifications
of freedom of the will. To point out this fact to the clergyman and
the physician has been our intention, for a proper appreciation of it
will widen the bounds of charity and save many that are more sinned
against than sinning from the injury of grievous misjudgment. It is
better to run the risk of exculpating a few individuals whose
responsibility is not entirely clear when the application of the same
principles lifts many others above the rash judgment of those that can
be of most help to them.
{viii}
{ix}
CONTENTS
_The Authorship of the respective Essays is indicated by the signature
at the end of each Essay_.
Chapter Page
I. Ectopic Gestation 1
II. Pelvic Tumours in Pregnancy 40
III. Abortion, Miscarriage, and Premature Labour 48
IV. The Caesarean Section and Craniotomy 55
V. Maternal Impressions 60
VI. Human Terata and the Sacraments 69
VII. Social Medicine 88
VIII. Some Aspects of Intoxication 105
IX. Heredity, Physical Disease, and Moral Weakness 120
X. Hypnotism, Suggestion, and Crime 129
XI. Unexpected Death 135
XII. Unexpected Death in Special Diseases 150
XIII. The Moment of Death 164
XIV. The Priest in Infectious Diseases 168
XV. Infectious Diseases in Schools 187
XVI. School Hygiene 202
XVII. Mental Diseases and Spiritual Direction 211
XVIII. Neurasthenia 230
XIX. Hysteria 235
XX. Menstrual Diseases 240
XXI. Chronic Disease and Responsibility 245
{x}
XXII. Epilepsy and Responsibility 251
XXIII. Psychic Epilepsy and Secondary Personality 259
XXIV. Impulse and Responsibility 266
XXV. Criminology and the Habitual Criminal 271
XXVI. Paranoia, a Study in Cranks 282
XXVII. Suicides 306
XXVIII. Venereal Diseases and Marriage 311
XXIX. Social Diseases 317
XXX. De Impedimento Matrimonii Dirimente Impotentia 326
APPENDIX. Bloody Sweat 347
INDEX 357
{1}
ESSAYS IN PASTORAL MEDICINE
I
ECTOPIC GESTATION
Ectopic gestation is gestation in the uterine adnexa, the peritoneal
cavity, or the horn of an abnormal or rudimentary uterus. It is
opposed to natural uterine gestation, and, since it includes pregnancy
in an abnormal uterus, it is a more comprehensive term than
extrauterine pregnancy.
In this article the morality involved in the surgical treatment of
ectopic gestation is considered; and to have the data requisite for
judgment it is necessary to describe in outline the anatomy of the
uterine adnexa and the growth of the foetus; to explain the varieties,
effects, diagnosis, and treatment of ectopic gestation; to present the
cases of this condition, or rather this disease, as they occur in
medical practice; to set forth some of the moral principles or laws
that govern medical practice, especially where there is question of
life and death; and finally to apply these principles to the cases
offered for investigation.
The uterus is in the pelvic cavity, between the bladder and the rectum
and above the vagina, into which it opens. It is a hollow,
pear-shaped, muscular organ, somewhat flattened, and about three
inches long, two inches broad, and one inch thick. The base or fundus
is upward, and the neck is downward. Passing out horizontally from the
corners or horns of the uterus, which are at its base, are the two
Fallopian Tubes, one on either side. These are about five inches in
length and somewhat convoluted. They are true tubes, opening into the
uterus, and they are about one-sixteenth of an inch in diameter along
the greater part of their extent The ends farthest {2} from the uterus
are fringed and funnel-shaped; and this funnel-end, called the
Infundibulum or the Fimbriated Extremity, opens into the abdominal or
peritoneal cavity. Near the Fimbriated Extremity of each tube is an
Ovary,--an oval body about one and a half inches long by
three-quarters of an inch in width.
[Illustration]
The Uterus and its Adnexa
_F U_, Fundus or Base of the Uterus. _F T, P T_, Fallopian Tubes. On
the left of the reader the Fimbriated Extremity of the tube is
lifted up to show it. _O, O_, Ovaries. _B L, B L_, Broad Ligament.
_R_, Rectum. _B_, Bladder.
For convenience in description, each tube is divided into four parts:
(1) the Uterine Portion, which is that part included in the wall of
the uterus itself; it extends from the outer end of the horn into the
upper angle of the uterine cavity, and its lumen is so small it will
admit only a very fine probe; (2) the Isthmus, or the narrow part of
the tube which lies nearest the uterus; it gradually opens into the
wider part called (3) the Ampulla; (4) the Infundibulum, or the
funnel-shaped end of the Ampulla. This part is fimbriated, as has been
said, and one of the fimbriae--the Fimbria Ovarica--which is longer
than the others, forms a shallow gutter which extends to the ovary.
{3}
The uterus, tubes, and ovaries lie in a septum which reaches across
the pelvis from hip to hip. This septum is called the Broad Ligament.
If a man's soft felt hat, of the kind called a "Fedora" hat, is held
crown downward with one hand at the front and the other at the back of
the rim, it will represent the pelvic cavity, and the fold along the
crown of the hat coming up into this cavity is very like the Broad
Ligament. As the crown is held downward, the uterus would be in the
middle, its fundus upward, and, of course, altogether outside the hat,
but in the crown fold. The tubes and ovaries would also be outside the
hat and in the crown fold, and the fimbriated extremities would open
by holes into the hat's interior.
The ovum breaks through the surface of the ovary, passes, probably on
a capillary layer of fluid, into the fimbriated extremity of the tube,
and then is moved along slowly through the tube into the uterus.
Ovulation and menstruation occur about the same time, but often one
antedates the other a few days. In exceptional cases they may occur
independently.
If the ovum produced is not fecundated, it gradually shrivels up, and
passes off through the uterus and the vagina. Fecundation of the ovum
rarely occurs in the uterus, but ordinarily in the Fallopian tube,
according to the general opinion of physiologists. After fecundation
the ovum is pushed on into the uterus in from five to seven days,
where it fastens to the wall and develops. Hyrtl (_Kollmann's Lehrbuch
der Entwickelungsgeschichte des Menschen_, Jena, 1898) speaks of a
case in which the ovum appeared to reach the uterus in three days. If
the fecundated ovum is blocked or held in the Fallopian tube, the
embryo grows where the ovum stops, and we have a case of Ectopic
Gestation.
The average time of normal human gestation is ten lunar months or
forty weeks. At the moment the pronucleus of the spermatozoon fuses
with the pronucleus of the ovum in the Fallopian tube and makes the
segmentation nucleus, in my opinion, the soul of the child enters, and
personality exists as absolutely as it does in a child after birth. It
is as much a murder, as such, to unjustly destroy this microscopic
fecundated ovum as it is to kill the child after birth. This is the
opinion of every embryologist I have consulted on the {4} subject,
with the exception of one who said he did not know when the soul
enters.
Technically the product of conception is called the Ovum for the first
two weeks of pregnancy; during the third and fourth weeks it is called
the Embryo, and after the fifth week the Foetus. During the fourth
week the embryo begins to draw nourishment from the maternal blood
through its umbilical vessels, but before that time it obtains
nourishment by osmosis.
The foetus at the end of the eighth week is about one inch in length;
at the end of the fourth lunar month it is from four to six inches
long, and its sex may be distinguished. At the end of twenty-four
weeks, if the normal foetus is born it will attempt to breathe and to
move its limbs, but it dies in a short time. At the end of
twenty-eight weeks of gestation if it is born it moves its limbs
freely and cries weakly. It is nearly fifteen inches in length and
weighs about three pounds. Such an infant might be deemed viable, but
its chances for life are extremely precarious, even in most expert
hands and with the help of an incubator. At the end of thirty-two
weeks of gestation a foetus if born may be raised with skilful care,
but the chances are not promising. It is viable. At the end of forty
weeks the child is at term.
In 1876 Parry collected 500 cases of extrauterine pregnancy from
medical literature, but when Tait in 1883 first operated on a case of
ruptured tubal pregnancy attention was called to the subject. It was
better understood as coeliotomies (opening the abdomen) became common,
and in 1892 Schrenck collected 610 cases that had been reported during
the preceding five years. Kuestner alone has operated on 105 cases in
five years.
There has been much discussion among physicians as to the causes that
arrest the fertilized ovum in the tube, but whatever these causes may
be they do not affect the moral questions which come up in this
article. There may be mechanical obstruction from peritoneal
adhesions, or abnormal conditions resulting from inflammatory diseases
of the tubes, ovaries, and the pelvic peritoneum, but no general cause
that will explain all cases can be ascribed.
{5}
Tait denied the possibility of Ovarian Pregnancy, or a pregnancy where
the ovum fastened to the ovary itself and developed there, but five
fully established cases of this kind have been reported. Dr. J.
Whitridge Williams, professor of Obstetrics at the Johns Hopkins
University, in his textbook on Obstetrics (New York, 1903), collects
twenty-five cases of ovarian pregnancy, where five cases are certain
diagnoses, thirteen highly probable, and seven fairly probable. In
these twenty-five cases ten foetuses reached full term, but four of
the five certain cases ruptured at early periods.
It was formerly thought that primary abdominal pregnancy is quite
common; that is, that the ovum is implanted on some organ within the
abdomen itself, apart from the uterine adnexa. This is now looked upon
as very doubtful, and such cases are probably secondary; that is,
secondary to a pre-existing tubal pregnancy which has ruptured without
great maternal hemorrhage and let the foetus grow within the
peritoneal cavity.
The common form of extrauterine pregnancy is the Tubal Pregnancy. The
ovum may be stopped in any one of the three parts of the tube, and we
find Interstitial, Isthmic, or Ampullar Pregnancy. From these primary
types, by rupture, secondary forms sometimes arise,--Tubo-abdominal,
Tubo-ovarian, and Broad-ligament Pregnancy.
The interstitial form, that is, where the ovum is arrested in that
part of the tube which passes through the wall of the uterus itself,
is the rarest of the tubal pregnancies. Rosenthal (_Ein Fall
intranturaler Schwangerschaft. Centralbl. f. Gyn._ 1297-1305) found it
in only three per centum of 1324 cases of tubal pregnancy. Some deem
the Isthmic variety the commonest. Dr. Howard Kelly (_Operative
Gynaecology_) says he never met a case of Interstitial or Ovarian
pregnancy in his practice. The interstitial form is especially liable
to rupture with suddenly fatal hemorrhage.
About one-fourth of the cases of tubal pregnancy end within the first
twelve weeks by rupture of the Fallopian tube. If the embryo is
implanted in the interstitial end of the tube, the rupture (into the
uterus, or into the abdominal cavity, or into the broad ligament)
takes place later,--about the fourth month, or even considerably after
that time. The reason for {6} the delay here is that the uterus grows
with the foetus. If the foetus breaks into the uterus (a very rare
occurrence), it is either expelled through the vagina almost
immediately or it goes on like a normal pregnancy.
Tait was of the opinion that every case of tubal pregnancy results in
a rupture of the tube not later than the twelfth week, but this
opinion is no longer held. Very rarely a tubal pregnancy goes on
without rupture to full term, as in the cases reported by Williams,
Saxtorph, Spiegelberg, Chiari, and a few others.
Three-fourths, about seventy-eight per centum, of the cases of tubal
pregnancy result in what is technically called "tubal abortion"
instead of rupture. In tubal abortion the connection between the
embryo and the tube-wall is broken by effusion of blood. If the
separation is complete the effused blood pushes the embryo out through
the fimbriated end of the tube into the abdominal cavity, and then the
hemorrhage of the mother commonly ceases. Such an extrusion of the
foetus is called a complete tubal abortion. If the connection between
the foetus and the tube-wall is only partly severed, the ovum remains
in the tube, and the maternal hemorrhage goes on. This is called
incomplete tubal abortion.
In incomplete tubal abortion the maternal blood may slowly trickle
from the fimbriated extremity of the tube into the abdominal cavity,
become encapsulated, and thus form an haematocele. If the fimbriated
extremity of the tube is blocked, the blood accumulates in the tube
and makes an haematosalpynx.
In complete tubal abortion the foetus dies; in incomplete tubal
abortion the viability might depend on the injury done the placenta,
but in almost every case of even incomplete tubal abortion the foetus
dies as a result of its separation from the tubal wall, or from
compression after the bleeding.
In cases of rupture of the tube in extrauterine pregnancy, if the
foetus with its attachments is expelled from the tube into the
peritoneal cavity or into the broad ligament, the embryo dies.
If the foetus or embryo itself alone is expelled into the abdominal
cavity and the placenta remains attached to the wall of the tube and
communicates with the foetus by the umbilical cord which runs through
the tear in the tube, the foetus may {7} possibly live, provided the
mother does not die from hemorrhage. If the foetus goes on growing in
this case, we have an abdominal pregnancy. One such case is reported
by Both where a fully developed foetus was found in the abdominal
cavity even lacking all its membranes, which had been left in the
tube, but a foetus will not live apart from its membranes within the
maternal body.
When an embryo or foetus ruptures the tube and goes into the broad
ligament, it may live or die according to the injury done its
attachments to the tubal wall, but it ordinarily dies. Sometimes such
a broad-ligament pregnancy ruptures again into the abdominal cavity.
Because the bleeding is more likely to be confined within the folds of
the broad ligament, the immediate danger of maternal death from
hemorrhage is less in this than in other forms of rupture.
Concerning tubo-abdominal pregnancy the only remark to be made is
that, owing to adhesions, it is often surgically difficult to remove
such a growth.
If the foetus is expelled after rupture into the peritoneal cavity it
dies, and if the hemorrhage does not kill the mother the dead foetus
if small is absorbed; if large it becomes mummified, or it hardens
into a lithopoedion, or it turns into a yellowish greasy mass called
adipocere, or it putrefies. A lithopoedion may be carried for years.
There are more than thirty cases reported which were carried from
twenty to thirty years in the abdomen, and one case where a
lithopoedion was carried for fifty years.
If the foetus putrefies it causes fatal septicaemia in the mother, or
a perforating abscess, unless it is successfully removed.
There are various abnormalities of the uterus, and in these pregnancy
resembles in effect extrauterine pregnancy. An abnormal uterus may be
unicornis, didelphys, pseudodidelphys, bicornis duplex, bicornis
septus, bicornis subseptus, bicornis unicollis, or bicornis unicollis
with a rudimentary horn. The impregnated ovum may fasten in the
rudimentary horn and be blocked there; then the usual result is
rupture within the first four months, with fatal hemorrhage unless the
bleeding is immediately checked by coeliotomy and ligation.
{8}
As to diagnosis in Ectopic Gestation, Williams (_op. cit._), one of
the authorities at present on the subject, says: "A positive diagnosis
is occasionally made before rupture, but in the vast majority of cases
the condition escapes recognition until symptoms of collapse point to
the probability of rupture or abortion. In advanced cases careful
examination will usually disclose the real condition of affairs, and
when full term has been passed the history is so characteristic that
mistakes should hardly occur."
In the _American Ecclesiastical Review_ for January, 1898 (vol. ix.,
n. i), Father Rene I. Holaind, S. J., published the answers of many
physicians to six questions concerning extrauterine pregnancy. Among
these physicians were Thomas Addis Emmet, Barton Cooke Hirst, Howard
A. Kelly, W. T. Lusk, T. Galliard Thomas, Mordecai Price and his
brother Joseph Price, William Goodell, and Lawson Tait,--all eminent
authorities on this subject. The second question submitted was:
"During pregnancy, at what time and by what means can a differential
diagnosis be made between _intra_ and _extra-uterine_ pregnancy, and
between abnormal gestation and pelvic or other tumour?"
In answer to this question Dr. Emmet said: "There can be no absolute
certainty as to the existence of pregnancy in any case until the
pulsation of the foetal heart can be detected. [After the eighteenth
or twentieth week of gestation.] . . . A diagnosis is difficult in all
cases of abnormal pregnancy, but an expert can, within a reasonable
degree of certainty, arrive at a knowledge of the existing conditions
between the second and third month."
Dr. Hirst said: "In almost all cases of advanced gestation the
differential diagnosis can be made. In early cases it is not always
possible unless conditions be favourable."
Dr. Howard A. Kelly said: "The differential diagnosis between intra
and extrauterine pregnancy can usually be made from the sixth week up
to the end of pregnancy. It is more easily made from the tenth to the
twelfth week on." Writing in the _American Text Book of Obstetrics_
(Philadelphia, 1896), he says: "In the atypical cases, on the
contrary, a positive diagnosis is often difficult or even impossible.
. . . {9} The diagnosis of ectopic gestation after the death of the
foetus is largely dependent upon the clinical history; if this be
deficient, the diagnosis is frequently impossible."
Dr. Lusk said: ".... The frequent discovery of the dead ovum in a tube
when there has been no suspicion of pregnancy shows the difficulty of
a diagnosis." In his text-book (_The Science and Art of Midwifery_,
New York, 1890) is this remark: "Sometimes the diagnosis can only be
decided by the introduction of the sound or a finger into the uterus,
the physician assuming the risk of premature labour, should he find
his supposition of extrauterine pregnancy an error." This means that
sometimes the diagnosis is impossible without running the risk of
causing abortion of a normal uterine pregnancy.
Dr. Thomas said, "After the second month the diagnosis is perfectly
possible." This was also the opinion of Dr. Mordecai Price; and Dr.
Joseph Price holds that the diagnosis can be made "after the third
month, by exclusion." Dr. John F. Roderer, quoting Lawson Tait, says
that "the diagnosis between intra and extrauterine pregnancy can not
be made with certainty before rupture, nor can it be determined
exactly whether an enlargement of the tube is either an ectopic
pregnancy or some form of tumour."
Dr. Goodell's opinion was, "A differential diagnosis can rarely be
made positively at any stage of extrauterine pregnancy."
The diagnosis, then, is difficult; and for the ordinary practitioner,
the average physician, who does perhaps ninety-five per centum of the
medical work of the world, the diagnosis is often impossible. There is
no greater expert than Dr. Thomas Addis Emmet, and he says the
diagnosis is difficult. Others hold that the diagnosis can be clearly
made, and they speak truly as regards themselves, but ordinary skill
finds the diagnosis almost impossible in many cases. Mordecai Price
(_The Pennsylvania Medical Journal_, vol. viii. p. 223) in one year
saw four cases which he and other physicians diagnosed as ectopic
pregnancies with rupture of the tube. When the abdomen had been
opened, uterine pregnancy was discovered with a ruptured tube in each
case, and all the women died.
{10}
The first positive diagnosis of unruptured tubal pregnancy was made by
Veit in 1883, and the first one made in America was by Janvrin in
1886, eight years before Father Holaind's article was written. Before
1883, only eleven years in advance of the same article, when Lawson
Tait performed the first coeliotomy for the purpose of checking
hemorrhage from a ruptured tubal gestation, extrauterine pregnancy was
as mysterious as the old "inflammation of the bowels," which turned
out afterward to be appendicitis. Hence common skill in the difficult
diagnosis of ectopic gestation can not be looked for.
The doctrine given in all the leading medical works at present
concerning the treatment of extrauterine pregnancy is this:
1. As soon as an extrauterine pregnancy is discovered remove the
foetus through an opening made in the mother's abdominal wall. Do
not use electricity or the injection of poisons into the foetal sac,
or the incandescent knife. Emmet and a few others approved of the
use of electricity at times, but this is against the teaching of the
great majority of writers at present. The reason for removing the
foetus at once is that it is apt at any moment to cause rupture and
fatal hemorrhage before surgical aid can be effective.
2. In a case of rupture with free hemorrhage and collapse the only
operation advised is an immediate coeliotomy to stop the bleeding by
ligatures. The rupture should not be approached through the vaginal
wall according to the common doctrine, but through the abdominal
wall.
3. If there is a rupture in which the bleeding is confined and there
is no collapse, do not operate at once unless the haematocele
increases steadily or shows signs of suppuration. Sometimes
evacuation of the haematocele through the vaginal wall is possible.
4. In the later months of an extrauterine pregnancy, whether the
case is intraligamentous or abdominal, perform coeliotomy as soon as
the diagnosis has been made, and remove the foetus, because there is
always danger of sudden and fatal hemorrhage before the surgeon can
reach the source of the bleeding. What is to be done in a case where
the surgeon is certain before operating that the foetus is {11}
dead, has interest only for the physician, and it involves no moral
question.
Operating for extrauterine pregnancy maybe a simple coeliotomy, if any
coeliotomy is really simple, but it commonly is the most dangerous
operation for the mother that the gynaecologist is called upon to
perform.
The discussion of the moral questions that arise in cases of ectopic
gestation which began in volume ix. of the _American Ecclesiastical
Review_ was very valuable, but as the moralists had not full data to
work on their decision as a whole is not satisfactory. The original
cases presented are in part obsolete in the medical practice of
to-day, and important physical conditions were not disclosed in some
of the other parts of the cases. Father Holaind tentatively agreed
with Father Lehmkuhl in one decision, Fathers Eschbach and Sabetti
directly attacked Father Lehmkuhl's reasons, and Father Aertnys
indirectly opposed Father Sabetti's chief argument. These men are all
eminent authorities, but as each, except Father Holaind, was
dissatisfied with the arguments advanced by the others, and as their
data were incomplete, we can not rest the case on their decision.
In Father Holaind's fifth question, if I understand it correctly, he
seemed to think it possible to baptize a foetus through the opening in
the mother's abdominal wall while it lies in the abdominal cavity
before surgical removal. He mentions antiseptic precautions in the
baptism, which would have no meaning if the foetus were out of the
abdomen.
Baptism would not be possible in that case: the priest could not get
at the foetus, he ordinarily could not even see it, and certainly no
surgeon would permit the attempt. There would be no time for the
attempt in a rupture case, even if the foetus could be seen; and there
would be no advantage gained by baptizing the foetus in the abdominal
cavity where the conditions gave time to do so. If it is alive it will
live long enough for baptism after removal from the abdomen, provided,
of course, it is baptized immediately in the operating room. That it
does not breathe is no proof of immediate death. It is not unusual for
a full-term child not to breathe for even an hour or longer after
birth.
{12}
If Father Holaind had not in view baptism within the abdominal cavity,
the question has this meaning: What is the most effective method after
the foetus has been removed from the abdomen to open its enveloping
membranes so as to give it a chance for a life lasting long enough to
allow baptism?
The best method is to slit the membranes with a scalpel or scissors as
quickly as possible. The envelopes, cord, and placenta are essential
parts of the foetus itself, and they grow from itself, not from the
mother. They take the place of the lungs and the alimentary tract,
which do not come into action until after normal birth. It would be
worth discussing whether a baptism on the intact foetal envelopes is
valid, were it not that we may not apply probabilism in such a case.
The remaining matter brought out in Father Holaind's questions will be
considered in the course of this article.
Before presenting the cases of ectopic gestation that occur in medical
practice, the fundamental ethical principles that are to be applied in
judging the morality of the surgeon's interference should be given.
The morality of any action is determined, (1) by the object of the
action; (2) by the circumstances that accompany the action; (3) by the
end the agent had in view.
1. The term _object_ has various meanings, but here it means the deed
performed in the action, the thing which the will chooses. That deed
by its very nature may be good, or it may be bad, or it may be
indifferent morally. In themselves to help the afflicted is a good
action, to blaspheme is a bad action, to walk is an indifferent
action. Some bad actions are absolutely bad, they never can become
good or indifferent (blasphemy or adultery, for example); others, as
stealing, are evil because of a lack of right in the agent: these
may become good by acquiring the missing right. Others are evil
because of the danger necessarily connected with their
performance,--the danger of sin connected with them, or the
unnecessary peril to life. An action to have the moral quality must
be voluntary, deliberate; and mere repugnance in doing an act does
not in itself make the act involuntary.
2. Circumstances sometimes, though not always, can add a {13} new
element of good or evil to an action. The circumstances of an action
are the agent, the object, the place in which the action is done,
the means used, the end in view, the method observed in using the
means, the time in which the deed is done. If a judge in his
official position tells a sheriff to hang a criminal, and a private
citizen gives the same command, the actions are very different
morally because of the circumstances of the agent giving the
command. The object--it changes the morality of the deed if a man
steals a cent or a thousand dollars. The place--what might be merely
a filthy action in a house might be a sacrilege in a church. The
means--to support a family by labour or by thievery. The end in
view--to give alms in obedience to divine command or to give them
to buy votes. The method observed in using means--kindly, say, or
cruelly. The time--to do manual labour on Sunday or on Monday. Some
circumstances aggravate the evil in a deed, some extenuate it.
Others may so colour a deed that they specify the deed, make the
action some special virtue or vice. The circumstance that a murderer
is the son of the man he kills specifies the deed as parricide.
The end also determines the morality of an action (see St Thomas,
_Sum. Theol_. I. 2., q. xviii., a. 4 and 7). Since the end is the
first thing in the intention of the agent, he passes from the object
wished for in the end to choosing the means for obtaining it. Without
the end the means can not exist as such. There are occasions when an
end is only a circumstance: for example, if it is a concomitant end.
When an end is a, _finis extrinsecus operantis_, when it is in keeping
with right reason or discordant thereto, it may become a determinant
of morality.
In every voluntary, or human, act there is an interior and an exterior
act of the will, and each of these acts has its own object. The end is
the proper object of the interior act of the will; the exterior object
acted upon is the object of the exterior act of the will; and as this
exterior act specifies the morality, so does the interior
object--which is the end--specify it, and even more importantly than
the exterior object does.
The will uses the body as an instrument on the external {14} object,
and the action of the body is connected with morality only through the
will. We judge the morality of a blow, not by the physical stroke, but
from the intention of the striker. The exterior object of the will is,
in a way, the matter of the morality, and the interior object of the
will, or the end, is the form. Aristotle (_Ethics_, lib. v., cap. 2)
says: "He that steals that he may commit adultery, is, absolutely
speaking, more an adulterer than a thief." The thievery is a means to
the principal end, and it is this principal end that chiefly specifies
or informs the action.
The means used to obtain an end are very important in a consideration
of the morality of an act. There are four classes of means,--the good,
the bad, the indifferent, and the excusable.
Good means may be absolutely good, but commonly they are liable to
become vitiated by circumstances,--almsgiving is an example. Some
means are bad always and inexcusable,--lying, for example. The
excusable means are those which are bad, but justifiable through
circumstances. To save a man's life by cutting off his leg is an
excusable means.
The existence of excusable means whereby some good actions are
effected does not establish the assertion that the end justifies the
means. The end sometimes may incriminate or sanctify indifferent
means, but it does not in itself justify all means. The means, like
other circumstances, are accidents of an action, but they are in an
action just as much as colour is in a man. Colour is not of a man's
essence, but you can not have a man without colour.
The effect of an action, the result or product of an effective cause
or agency, may in itself be an end or an object or a circumstance, and
it has influence in the determination of morality. Sometimes an act
has two effects, one good and the other bad; and that such an action
be lawful it is necessary (1) that the action itself be good or
indifferent; (2) that the good effect be intended and the evil effect
be not intended (chosen) but only reluctantly permitted; (3) that the
evil effect be not a means to secure the good effect; (4) that there
be present a motive sufficiently grave to excuse or counterbalance the
bad effect. {15} St. Thomas (_Sum. Theol_. 2. 2. q. 64, a. 7) Speaking
of killing a man in self-defence, says: "Nihil prohibet unius actus
esse duos effectus, quorum alter solum sit in intentione, alius vero
sit praeter intentionem. Morales autem actus recipiunt speciem
secundum id quod intenditur, non autem ab eo quod est praeter
intentionem, cum sit per accidens."
That an act, therefore, be morally good, or justifiable, (a) the whole
train of the tendency of the will must be good; that is, (1) the
object, (2) the end, (3) and the circumstances must be good; or (b)
the intention should be good, and the remaining elements in the train
of will-tendency are to be indifferent. That an act be morally bad it
is enough that the object, the end, or the circumstances be
inexcusably bad.
There may be honest doubt as to the existence of evil in the
circumstances or the end, and here enters the matter of probability;
but apart from this, some general rules of morality that govern all
cases may be formulated:
1. An intention or end which is gravely evil always makes the entire
action evil and unjustifiable.
2. An intention or end which is slightly evil, if it is the entire
end of an action, makes the whole action evil but not gravely
evil--makes it, say, a venial sin and not a mortal sin.
3. If an intention or end which is venially evil accompanies
secondarily a good intention or end, and is rather a motive than the
real effective agent in attracting the will, this venial evil does
not vitiate the whole goodness or righteousness of the main action.
Compare the remarks made above in discussing an action that has a
double effect, partly good and partly bad.
4. Circumstances that are gravely evil practically vitiate the
entire action, but circumstances which are venially evil do not
always vitiate the entire action.
Much might be said here concerning conscience as a judge of the
morality in an act, but this discussion is not necessary for our
present purpose. Like other men, physicians often confuse conscience
with inclination, or at best with unfounded opinion. When conscience
is to be a rule of action it must {16} have at the least moral
certitude; or, what is different but practically the same thing, the
opinion of conscience must be at the least genuinely probable. The
term "probable" is used here in a technical sense, and it will be so
used throughout the remainder of this article.
The doctrine of Probabilism is connected with the promulgation of law.
A law, according to St. Thomas (_op. cit._ I. 2., q. 90, a. 4) is:
"Ordinatio rationis ad bonum commune ab eo qui curam habet
communitatis promulgata." Sometimes it is not evident whether or not a
law binds in a particular case, and in such a condition, that is, in
which there is question solely of the existence, interpretation, or
application of a law, we may follow a probable opinion which assures
us the act is licit, although the opinion which says the act is
illicit may be just as probable or even more probable. This is the
fundamental proposition of Probabilism, which is the doctrine
especially of St. Alphonsus Liguori, but it was held centuries before
his time. As the church has never condemned this doctrine, but rather
tacitly approved of it, Catholics may safely follow it, and those that
are not Catholics will find it very reasonable.
A law which is doubtful after honest and capable investigation has not
been sufficiently promulgated, and therefore it can not impose a
certain obligation because it lacks an essential element of a law.
When we have used such moral diligence of inquiry as the gravity of a
matter calls for, but still the applicability of the law is doubtful
in the action in view, the law does not bind; and what a law does not
forbid it leaves open.
Probabilism is not permissible when there is question of the worth of
an action as compared with another, or of issues like the physical
consequences of an act. If a physician knows a remedy for a disease
that is certainly efficacious and another that is probably
efficacious, he may not choose the probable cure, at the least in a
grave illness. Probabilism has to do with the existence,
interpretation, or applicability of a law, as I said, not with the
differentiation of actions.
The term probable means provable, not guessed at, or jumped at without
reason. There must be sound reason {17} adduced to constitute
probability. The doubt must be founded on a positive opinion against
the existence, interpretation, or application of the law. It must be
more than mere negative doubt, more than ignorance, more than vague
suspicion, especially must it be more than a sentimental impression.
There is a mental condition, which easily passes over into disease,
wherein a man habitually can not make up his mind. This flabbiness has
nothing to do with Probabilism. The opinion against a law to
constitute Probabilism must be solid. It must rest upon an intrinsic
reason from the nature of the case, or an extrinsic reason from
authority,--always supposing the authority cited is really an
authority. Many men sitting upon the supreme bench in the Court of
Science and called authorities by friends and newspapers, are only
fools in good company.
The probability must also be comparative. What seems to be a very good
reason when standing alone may be very weak when compared with a
reason on the other side. When we have weighed the arguments on both
sides, and we still have good reason left for standing by our opinion,
our opinion is probable. The probability is, moreover, to be
practical. It must have considered all the circumstances of the case.
The principles presented here have been arranged, as we said, with a
view toward application in judging the morality of actions that may
occur in cases of ectopic gestation, and we shall apply the doctrine
of probabilism in the question, does the commandment "Thou shalt not
kill" bind in certain cases of ectopic pregnancy? It is also necessary
to add the principles underlying our duty to preserve human life.
1. It is never lawful directly or indirectly to kill an innocent
man. "Insontem et justum non occides" (Exod. xxiii. 7). An
_innocent_ man is one that has not by any human act done harm to
another man or to society commensurate with the loss of his life.
_Directly_ means to kill either as an end, say, for revenge, or as a
means toward an end.
A man is a person, an intelligent being, therefore free, and
autocentric; he belongs to no one except to God, who made {18} him;
he is by that very fact distinguished from brutes or things which
may belong to another. Now, if you kill a man, you destroy his human
nature by separating his soul and body, you subordinate and
sacrifice him wholly to yourself, make him entirely yours, which is
unjust. Even the state has no right to kill an innocent man. A
foetus in the womb, only a few hours old, is as much a human being
as a man fifty years of age, and this natural law holds for the
foetus as for the man.
2. It is, however, lawful _indirectly_ to kill a man provided this
man is an unjust aggressor. Cardinal de Lugo (_De Just. et Jure_,
10, 149) and others hold you may even _directly_ kill an unjust
aggressor. _Indirectly_ here means incidentally. An effect happens
indirectly when it is neither intended as an end nor a means, but
happens as a circumstance unavoidably attached to the end or means
intended.
We may not, however, kill an innocent man even indirectly, because no
end is proportionate to the sacrifice of an innocent man's life, but
the case of an unjust aggressor differs from that of an innocent man.
By an unjust aggressor is meant some one that outside the due course
of law threatens your life or the equivalent of your life, or the life
of some one you should or may protect. You may stop such an aggressor,
and if you happen to kill him while trying to stop him, there is no
moral wrong involved. This aggressor may be formally or only
materially unjust: he may be a normal man with a formal intention to
kill you or your ward, or a murderous lunatic that tries to kill you
or your ward, but he must be _unjust_ either formally or materially.
It is natural for every being to maintain itself in existence, to
resist destruction. This is a primary law of nature. As Father Holaind
well said (_Amer. Eccl. Rev._, January, 1894): "The ethical foundation
of self-defence is this: Justice requires a sort of moral equation,
and if a right prevails it must be superior to the right which it
holds in abeyance. At the outset both the aggressor and his intended
victim have equal rights to life, but the fact of the former using his
own life for the destruction of a fellow man places him in a condition
of juridic inferiority with regard to the latter. If we may be {19}
allowed so to express it, the moral power of the aggressor is equal to
his inborn right to life, less the unrighteous use which he makes of
it, whilst the moral power of the intended victim remains in its
integrity and has consequently a higher juridic value. When the person
assailed cannot defend himself, his right _can_ and sometimes _must_
be exercised by those who are bound in justice or charity to protect
the innocent. At the dawn of human life the physician or surgeon
stands as the natural protector both of the mother and of the child;
he is beholden to both.
"The right of self-defence is not annulled by the fact that the
aggressor is irresponsible. The absence of knowledge saves him from
moral guilt, but it does not alter the character of the act,
considered objectively and in itself; it is yet an unjust aggression,
and in the conflict, the life assailed has yet a superior juridic
value. The right of killing in self-defence is not based on the ill
will of the aggressor but on the illegitimate character of the
aggression. Now, an aggressor is _at least materially unjust_ whenever
he perpetrates an act destructive of the right of another."