series, and perhaps a little better in the latter series. In the first
series the 37 children were alive at delivery: the length of time in
which three of these children lived is not given; three more were
alive but they did not breathe; the others lived from a few seconds to
days, weeks, months or years. One was well at six months, another at
one year, another at seven and a half years, another in its fourteenth
year, another in its fifteenth year. In the second series the results
as regards the children were, as has been said, almost the same. The
40 cases that were reported from 1889 to 1896 are the standard for
this phase of ectopic gestation, because they come under the diagnosis
and treatment of the present day. They represent closely all such
cases that occurred in the entire world between 1889 and 1896, because
physicians report these operations to medical societies, and active
physicians are almost without exception members of such
societies--outside the civilised world these operations do not take
place. In the seven years there were annually less than six cases of
coeliotomy for ectopic gestation at term in the world, therefore
operations at term may be neglected in discussing Case II., and the
argument may be confined to the ordinary cases of expectant treatment.
Schrenck in 1892 collected 610 cases of ectopic gestation which had
been reported between 1887 and 1892; during the same time there were
23 cases (less than 4 per centum) of operations for the delivery of
viable foetuses.
If the physician that has made the diagnosis in this Case II. leaves
the patient, she may have a fatal hemorrhage at any moment. Dr. Howard
Kelly reports (_Operative Gynaecology_, vol. ii. p. 438) a fatal
hemorrhage in two days from rupture where the foetus was only as large
as a Lima bean. The hemorrhage may be so suddenly fatal that the woman
drops {31} to the floor unconscious just as if she had been shot. Dr.
Harris (_International Cyclop. of Surgery_, vol. vi. p. 784) tells of
a case where three of the best obstetricians in Philadelphia met in
consultation daily for 16 days expectantly watching development, but
the woman died from hemorrhage in thirty minutes before any of these
physicians could be called to her aid. Death may be brought about by
anaemia after repeated hemorrhages. Some hemorrhages can be mistaken
for colic by the physician, and this error will defer until too late
the treatment for hemorrhage.
If the woman is living in a hospital where there is a resident surgeon
with instruments ready, she has a better chance than if she is in her
own house. Even if she has a surgeon within call the outcome of the
case for her will depend largely on his skill, his presence of mind,
the preparedness of his instruments, the general condition of the
patient, and many other circumstances.
The instruments, ligatures, gauzes, solutions, dressing, etc., for
coeliotomy are multitudinous, and all must be sterile, or the woman
will be killed by septicaemia even if the hemorrhage is stopped. It is
almost impossible to keep a set of instruments and the other things
used in a coeliotomy always sterile and ready for instant use.
The skin surface of the patient's abdomen must be sterilised, or pus
infection will get into the peritoneum through the wound. In all
ordinary coeliotomies this surface is carefully sterilised by a long
process the night before the operation, a protective dressing is put
on, and the sterilisation is repeated the next day just before the
operation. This is so important that its voluntary omission is
malpractice. In the hurried operation for tubal rupture there would be
no time for sterilisation of the abdominal skin surface, and probably
no time to sterilise the instruments and other things used, especially
the surgeon's hands.
The surgeon to do any coeliotomy needs assistant physicians--one to
anaesthetise the patient, and at the least one other to work with him
in the operation. He should have three or four physicians and one or
two nurses. He can not do a coeliotomy alone. Hence the patient in a
ruptured {32} extrauterine pregnancy must have at the very least two
physicians within call.
The woman, then, in Case II. before operation has one chance in three
of life if no operation is done until the child is viable, and if she
remains alive till the child is viable (when she must be operated
upon) her chances for life will be no better, judging from modern
statistics.
At any moment, therefore, she is in actual peril of death by two
chances in three, and probably more if all special circumstances are
considered. The foetus is a materially unjust aggressor in this case
before rupture or other similar mishap, as it was in Case I., but not
to the same extent. In Case II. it is a materially unjust aggressor as
two is to three; in Case I. it is a materially unjust aggressor as
three is to three.
If a lunatic is just about to fire three cartridges at me, I may know
the chances are only two in three, or even only one in three, that he
will hit me fatally, nevertheless I may licitly kill him to stop the
firing and save my life. The mother in Case II. is in exactly similar
danger of life.
The objection that the danger to my life from the action of the
lunatic exists _hic et nunc_ and that the danger to the mother's life
does not threaten _hic et nunc_, is not of any weight. She is in
actual danger _hic et nunc_, even while the surgeon is in the room
examining her. Moreover, the matter of time here is accidental. If you
give a man a poison that may kill him in ten hours, or one that may
kill him in ten days, the action is essentially the same.
I am of the opinion that if this second case were proposed to moral
theologians many of them would decide that the surgeon should explain
the case fully to the patient or her family, and if immediate
operation were insisted upon he should withdraw from the case.
Nevertheless, as far as I can see, he has sound probabilism on the
side that operation is justifiable.
But, it may be objected, in Case I. the surgeon ligated the uterine
and ovarian arteries to stop an actual hemorrhage, and he permitted
the death of the foetus; in Case II. there is no hemorrhage yet, there
may possibly be none at all. I answer {33} that in Case II. if he
operates he ties the two arteries to forestall an imminent hemorrhage
which might begin within the next hour if it were not securely shut
off, and to forestall sepsis by leisurely and proper precautions, and
exactly as in the first case he permits the death of the foetus, he
indirectly kills an unjust aggressor. If the lunatic is aiming at me I
do not have to wait until he begins firing to licitly shoot at him.
The sooner I shoot, _servato moderamine inculpatae tutelae_, the more
prudent my action.
To put it in another form--in Case II. the surgeon is standing before
a dam (the stretched Fallopian tube) that is threatening to break at
any moment and cause death to a woman below it, because there is a
lunatic (the foetus) behind it tearing away the masonry. If the
surgeon shunts off the water just above the dam (the ligation of the
arteries), he will suddenly let the lunatic who is tearing away the
masonry fall down to the rocks at the bottom of the dam and be killed.
May he let the lunatic fall? Certainly he may. But perhaps the lunatic
will not succeed in tearing away the masonry. He is well provided with
tools to do so; the chances are even two in three that he will
succeed. Is he or the woman to be given the benefit of the doubt? The
woman, by all means; she has a doubt worth in juridic value at the
least twice as much as that which the lunatic has.
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 pass 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 passage 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 assertion 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
constitutes 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 class 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.
{40}
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 vagina, 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.