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.
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.
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. Küstner 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.
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.
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 René 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.
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.
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."
Mark the words "right of another," at the end of the quotation. In a case of pregnancy at term in a woman with a contracted pelvis the foetus would be a contributing instrument of death to the mother, supposing there were no artificial means of delivering her, but such a child is not an aggressor even materially unjust. The child itself is normal, it has a natural right to be where it is, it did not put itself where it is; the mother's contracting uterus crushing the child against her narrow pelvic arch is the direct agency that kills the woman, and the child is only an inert instrument used by the contracting uterus. In such a case the mother might be considered an aggressor materially unjust against the life of the child rather than that the child is the aggressor.
Lehmkuhl (Compendium Theologiae Moralis, 1891, p. 238) says: "Medicus graviter peccat … si media abortus procurat: nisi quando ad salvandam matrem ex probabili opinione liceat." On page 188 he says: "Ex consulto abortum inducere, etiam liceri videtur in praesenti vitae [{20}] maternae discrimine, quod per solam foetus immaturi ejectionem avert! possit … Idque videtur applicari posse ad matrem quae tarn arcta est ut tempus praematuri partus exspectare non possit."
By foetus immaturus here he means an unviable foetus, as is evident from the context. If this probabilism of Father Lehmkuhl's stands (but it does not), a decision in most of the cases that occur in ectopic gestation would be easily made, but even he himself would not take responsibility in the matter, and that before the decision of the Holy Office which defined abortion. Since this decision, made July 24, 1895, Lehmkuhl has entirely withdrawn his opinion.
On May 4, 1898, the Holy Office published the following decree, which was approved by the Pope:
BEATISSIME PATER,—Episcopus Sinaloen. ad pedes S. V. provolutus, humiliter petit resolutionem insequentium dubiorum:
I. Eritne licita partus acceleratio quoties ex mulieris arctitudine impossibilis evaderet foetus egressio suo naturali tempore?
II. Et si mulieris arctitudo talis sit, ut neque partus prematurus possibilis censeatur, licebitne abortum provocare aut caesariam suo tempore perficere operationem?
III. Estne licita laparotomia quando agitur de pregnatione extra-uterina, seu de ectopicis conceptibus?
Feria iv, die 4 Mali, 1898.
In Congregatione habita, etc … EE. ac RR. Patres rescribendum censuerunt:
Ad I. Partus accelerationem per se illicitam non esse, duromodo perficiatur justis de causis et eo tempore ac modis, quibus ex ordinariis contingentibus matris et foetus vitae consulatur.
Ad II. Quoad primam partem, negative, juxta decretum, Feria iv., 24 Julii, 1895, de abortus illiceitate.—Ad secundam vero quod spectat: nihil obstare quominus mulier de qua agitur caesareae operationi suo tempore subjiciatur.
Ad III. Necessitate cogente, licitam esse laparotomiam ad extra-hendos e sinu matris ectopicos conceptos, dummodo et foetus et matris vitae, quantum fieri potest, serio et opportune provideatur.
In sequenti Feria vi., die 6 ejusdem mensis et anni … SSmus responsiones EE. ac RR. Patrum approbavit.
The third question proposed by the bishop is:
"Is laparotomy licit when performed for extrauterine pregnancy or ectopic gestation?"
The approved answer of the Holy Office to this question is:
"In a case of necessity, laparotomy for the purpose of removing an ectopic foetus (conceptus) from the abdomen of the mother is licit, provided the lives of both the foetus and the mother, as far as is possible, are carefully and fitly guarded."
The expression, "dummodo et foetus et matris vitae, quantum fieri potest, serio et opportune provideatur," is capable of various translations and interpretations.
The words might have this meaning: "In a case of necessity you may do laparotomy and remove an ectopic gestation, provided you do not kill either the mother or the foetus." If that is the interpretation, the decree means that we may never remove an unviable ectopic foetus when we know that the foetus is alive, because removal will kill it.
The sentence can also be translated in this sense: "In a case of necessity, you may do laparotomy and remove an ectopic foetus from the mother, provided you take full care to save mother and child if that is possible."
If that is the signification, it is evidently very different from the first interpretation. It would mean: do the laparotomy, remove the foetus, and if you possibly can save both mother and foetus do so, but if you can not, take the best means you can to save one or the other.
If the decree refers only to cases in which the foetus is viable, it would appear to be unnecessary—we need no decree of the Holy Office to let us do a laparotomy to remove a viable foetus. If it does not refer to a viable foetus, it refers to an unviable foetus, but to remove an unviable foetus is to either kill it or to hasten its death.
Génicot (Institutiones Theologiae Moralis, Louvain, 1902, vol. i. p. 358) has this interpretation of the decree:
"In conceptione extra-uterina licebit sane recurrere ad laparotomiam similemve operationem, quando aliqua etiam tenuissima spes affulget salvandi infantem, simul ac mater fere certo liberabitur. … Ubi vero nulla spes hujusmodi [{22}] affulget, neque in hoc casu licebit abortum directe inducere, etiamsi foetus certo moriturus sit antequam in lucem edatur, et baptismum recipere nequeat. Etenim S. Inqu., dum provocat ad responsum 19 August, 1888, satis indicat abortus inductionem a se haberi tamquam operationem directe occisivam foetus ideoque semper illicitam."
There is no question of an abortion in a laparotomy for extrauterine gestation; abortion is altogether a different operation in method and nature. Secondly, the other decree of the Holy Office to which he refers speaks of a direct killing of the foetus, but there is no direct killing of the foetus in the operation for ectopic gestation, nor is the indirect hastening of the foetus's death a means to an end. The decree on abortion is so clear it leaves no room for doubt.
Cardinal Monaco, in the Epistola ad Archiepiscopum Camarcensem, August 19, 1889, says the Holy Office decreed that "In scholis catholicis tuto doceri non posse licitam esse operationem chirurgicam quam craniotomiam appellant, sicut declaratum fuit die 28 Maii, 1884, et quamcumque chirurgicam operationem directe occisivam foetus vel matris gestantis."
Note the words "directe occisivam." Craniotomy is a direct killing, and a direct killing used as a means to an end; moreover it is an altogether unnecessary killing. Artificial abortion in the case of an unviable foetus is also a direct killing as a means to save the mother's life, but the removal of an unviable ectopic foetus is neither a direct killing, nor is it a means toward any end.
Since the meaning of the decree concerning laparotomy in extrauterine pregnancy is by no means clear, we may discuss the question until the law has been fully promulgated, ready to conform to the real meaning of the decree whenever it is explained. In that spirit we may now consider the cases that occur in ectopic gestation.
Case I. A surgeon is called in to treat a woman and he finds her in a state of collapse. He makes a diagnosis of tubal pregnancy, which has gone on to rupture with hemorrhage, and the bleeding will evidently be fatal to the mother unless it is checked. Practically the only chance of saving the [{23}] mother's life is coeliotomy and the ligation of her open arteries. Dr. Howard Kelly (Operative Gynaecology, vol. ii. p. 437) says: "When the hemorrhage is sudden and excessive the patient falls in collapse; but, in spite of these alarming symptoms, she may survive a succession of similar attacks and the foetus and sac may continue to develop." This exception complicates the case slightly. If the surgeon were absolutely certain that the only possible chance to save the woman's life is coeliotomy and haemostasis, the case would be somewhat different from one in which there is some chance of escape by spontaneous haemostasis. That chance, however, is so slight, and so far beyond any means we have for forecasting, that it is mere luck, and it is to be neglected. The surgeon may safely consider the patient in the gravest actual danger.
(a) Before he opens the abdomen he can not tell whether the foetus is alive or not; but the stronger probability is that it is not, and the certainty is that it has no chance at all to remain alive more than a few minutes or hours, unless the surgeon is willing to trust to sheer luck in the expectation that he may happen to have one of Dr. Kelly's exceptions before him.
(b) The operation to save the mother is this: as quickly as possible he makes a vertical slit from four to six inches long through the woman's belly-wall. Then commonly the free blood begins to run out, or it may even spurt out some feet into the air. The surgeon can see nothing for the blood and the presence of the entrails. If the blood is not freshly welling up he bails it out with his hands or a ladle; if it is spurting he at once thrusts in his hand, feels for the foetal sac, lifts it up, and puts on clamps near the uterus on one side and near the pelvic brim on the other. This stops the hemorrhage, and he can then work more leisurely, but unfortunately this also stops the flow of blood to the foetus. He can not first examine the foetus and then stop the hemorrhage. He can not back out even if he finds a live foetus without letting the mother die on the table.
(c) If the placenta is already loose from the Fallopian tube the child is dead or it will die in a few seconds or minutes. If it was not loose the lifting out may tear it loose, and this [{24}] tearing loose will hasten the death of the foetus a few minutes (but give a chance for baptising it).
(d) If the lifting out does not tear loose the supposedly fixed placenta, the foetus either will die anyhow if the mother dies, or it will die if the mother lives, because to save her the surgeon must put ligatures just where the flow of blood will be shut off from the foetus. Commonly there is no time to even look for the foetus until after the maternal arteries have been closed.
(e) The same conditions could exist in the rupture of a pregnancy in a rudimentary uterine horn as in a rupture in tubal gestation.
What is the surgeon to do in a case like this? Fathers Holaind (Amer. Eccl. Rev., January, 1894, in a note on p. 39), Lehmkuhl and Sabetti say: do coeliotomy, ligate the mother's arteries, remove and baptise the foetus.
The analysis of the case is this: (i) The action is the stopping of a fatal hemorrhage in a woman, and possibly, though not certainly, an indirect incidental hastening of a foetus's inevitable death.
(2) The object of the action is the haemostasis, which is good, and the possible indirect hastening of the foetus's death, which is evil, but, as we shall see, excusable evil.
(3) The end of the action is to save the mother's life—a good end.
(4) The circumstances are: (a) that possibly, through mere luck, the woman's condition is not necessarily hopeless: a few women have escaped in this seemingly imminent peril—but that chance of escape is not soundly probable; the stronger probability by far is on the side of a fatal issue; therefore the chance for escape may be neglected, and the woman's case may be regarded as hopeless if operation is foregone.
(b) The quickest possible work on the surgeon's part is necessary, and there is no time or chance to examine the foetus's condition before tying the maternal arteries. Before he opens the mother's abdomen he can tell nothing whatever of the foetus's condition, but the probability is all in favour of the fact that the foetus is already dead or moribund.
(c) The means are coeliotomy, and the ligation of the [{25}] uterine and ovarian arteries to stop the mother's bleeding. This ligation, in the contingency that the foetus is still attached to the Fallopian tube, will also shut off the blood from the foetus, yet the uncertain shutting off of the foetal blood-supply is not intended by the surgeon as a means toward his end in any degree direct or indirect, but it is an evil circumstance associated with the action which may hasten the foetal death—even here the hastening is uncertain.
(5) The action has two effects,—one, the saving of the mother, is directly intended and evidently good; the other, the possible indirect hastening of the foetus's death, may or may not be evil. The moral centre of the whole case is this possible hastening of the foetus's death. If that possible hastening is licit the whole action is licit; if it is not permissible it will vitiate the entire action.
Suppose that there is no doubt that the ligation of the maternal arteries in this case really hastens the foetus's death some minutes: it would still be an indirect volition. Father Lehmkuhl also calls it indirect and licit. Father Sabetti denied that it is indirect, but he held that it is licit for another reason. Sabetti said (Aner. Eccl. Rev., August, 1894): "It is evidently false to say that a means which is directly adopted for obtaining an end is only indirectly contained in the intention of the agent who so adopts it." That is true, but the minor proposition in a syllogism drawn from that statement is to be emphatically denied. The cutting off of the foetal blood is a fact associated with the means, not a means direct or indirect toward the end, which is to save the mother—the means to save the mother is the stopping of her bleeding.
This is not hair-splitting in the opprobrious sense of that term. The bases of all sins are absolutely abstract principles, and because abstract principles can not be pinched or weighed, they have often little meaning for the opposition in an argument. There is only the width of a hair between Heaven and Hell at many places along the frontier, and there is only the difference between a direct or an indirect volition separating murder and a good deed. The best ethics frequently consists in delicate hair-splitting; and despite the protests of sentimentalists, one of the most valuable benefits of Moral Science is [{26}] to show us how to handle moral poisons for good purposes, as a physician uses the material poisons, opium and aconite.
If the foetus in this case of rupture in ectopic gestation were a materially unjust aggressor on the mother's life, the indirect hastening of its death would be justifiable according to all moralists, and the direct hastening would be licit according to Cardinal de Lugo, who was, in the opinion of St. Alphonsus, "post D. Thomam inter alios theologos facile princeps" (Th. Mor., lib. 4. n. 552).
Sabetti held that the foetus is a materially unjust aggressor. His reason for this opinion is that the extrauterine foetus is not in a position in which it has a right to be. If it were in the uterus, its natural position, it would have a right to its position. Ectopic gestation is a disease, not a physiological condition.
Father Aertnys (Amer. Eccl, Rev., July, 1893) denies that the foetus is an aggressor materially unjust. He says: "Nequaquam enim mortem intentat matri, sed actione, quam non ipse sed corpus matris producit, conatur ad lucem pervenire, et iste conatus non nisi ex naturali concursu rerum fit matri causa mortis. Infans ergo non est aggressor et multo minus est aggressor injustus. Hinc nego paritatem cum homine mente capto, qui delirans alteri mortem intentat; hic enim agit motus a sua voluntate, licet absque culpa, et ponit actiones in se injustas, utpote ad necandum directe intentas."
In the same periodical (January, 1894) while repeating this statement he says: "Sive in utero existat sive alibi reconditus sit [sc. foetus], nequaquam mortem intentat matri, siquidem non ipse actione propria conatur egredi, sed corpus matris infantem expellit et haec expulsio a matre emanans fit matri causa mortis."
What Father Aertnys says in these two passages is true of an intrauterine foetus, but it is altogether erroneous when applied to an extrauterine foetus, of which alone there is question here. In extrauterine pregnancy the uterus or any other part of the maternal body does not "try to expel" the foetus; the uterus has nothing at all to do with the case—the very name of the condition is extra-uterine pregnancy. If an ectopic gestation [{27}] goes on to term (a very rare happening), there will be false labour and uterine contractions, and these cease after a time without effect one way or the other; but in all cases of rupture and the like the uterus is outside the question and the mother is passive. There is no attempt by the mother in extrauterine pregnancy at expulsion either before rupture or at any other time unless the dead foetus putrefies, and the maternal tissues "try to expel" it as a foreign body by breaking down into an abscess. The foetus simply grows, and its bulk bursts the tube. If it were in the uterus, the uterus would enlarge synchronously with the foetus and there would be no rupture, but the tube will not give beyond a certain point, therefore it bursts.
In normal uterine pregnancy at term the uterus and other maternal muscles are the active factors in expelling the foetus—the foetus is passive. In ectopic gestation the foetus is active, the mother is passive, and there is no attempt at expulsion from either side. In this case the foetus in the tube through the action of its own vital principle draws nourishment from the mother and grows gradually larger till it bursts the tube (it may even move its arms and legs if advanced), and this rupture tears open arteries wherethrough the mother bleeds, commonly to death. This is evidently material aggression.
Father Aertnys says the foetus differs from the murderous lunatic in this, that the madman is moved by his will, although blamelessly, in doing unjust actions directly intended as homicidal. The fact that the lunatic uses his will has no weight whatever in permitting me to defend my life against him, it is an accidental thing outside the question; but Father Aertnys in mentioning the madman's will means solely, if I understand him, that the madman is really an active aggressor. The foetus, however, is also an active aggressor without using its will. I might fall from a height toward a man and certainly endanger his life while I was not using my will at all, not conscious of the man's presence under me, or even while I was using all the power of my will against the result. In any of these cases I should be a materially unjust aggressor; and if in trying to prevent my body from killing him the man killed me, he would be blameless.
Now, in the first place, the tubal foetus is an aggressor; and since, secondly, its position is unnatural, monstrous, a disease, a thing not intended by nature, it has no right to its position, and it is therefore a materially unjust aggressor. Since it is an aggressor on the very life of the mother in a place where it should not be, the surgeon therefore may at the least stop the fatal bleeding it causes. If the foetus dies as an unwished for, though permitted, consequence of this haemostasis, the surgeon may lament this result, but he is blameless.
The foetus was blocked in its unnatural position through a defect in the mother, nevertheless it remains a materially unjust aggressor. If I by an accidental blow had made a man insane, and later this lunatic tried to kill me, I, or my legitimate protector, might lawfully kill the lunatic in defence of my life. This is an exact parallel to the case of the mother and the extrauterine foetus.
The extrauterine foetus is not like a foetus in a craniotomy case. Where there might be question of craniotomy the foetus is not an unjust aggressor even materially, as has been said: first, because it is not an aggressor in any manner, it is altogether passive; secondly, it has a perfectly natural right to be where it is. In ectopic gestation with fatal rupture the foetus is, first, an active aggressor; secondly, it has no right to be where it is. In craniotomy the foetus is killed as a direct means toward the end that its head may be reduced and extracted and the mother saved; in extrauterine gestation with fatal rupture the foetus is incidentally killed as a consequence of the haemostasis, and not as a means in any sense of the term. In craniotomy the child is wantonly killed since there are other means of saving the mother; in extrauterine pregnancy with fatal rupture the hastening of the death of the child is unfortunately associated with the only possible means we have to save the mother.
In Case I., therefore, we have an action that has an object partly good and partly, very probably, not evil; the end intended is good; the circumstances are justifiable or indifferent; consequently in Case I. the surgeon may do coeliotomy, tie the uterine and ovarian arteries, and if the foetus [{29}] happens to be alive he may reluctantly and indirectly permit the hastening of its death after attempting to baptise it.
Case II. The conditions presented in Case I. are the ordinary and most common that the surgeon meets with in treating ectopic gestation, but other conditions may be found.
Suppose the surgeon, before operation, diagnoses a case of ectopic gestation, but that he can not tell whether or not the foetus is alive. The probability leans toward the side that the foetus is alive, because there is no indubitable history, as physicians say, of maternal symptoms that indicate rupture.
Medical authorities tell him to do coeliotomy at once, ligate the uterine and ovarian arteries, and remove the foetus. Would he certainly or probably be justified in following out this medical doctrine?
The mother is in actual, very probable danger of death, but not in actual, certain danger of death. She may possibly escape if operation is deferred; she has a negligible chance of escape if no operation is performed after the death of the foetus; coeliotomy and ligation of the uterine and ovarian arteries give her by far the surest chance of escape, so sure an opportunity for escape when performed early that it can scarcely be called a mere chance.
If operation is deferred the chances for rupture are about 22 per centum, say, one and a half in five chances, and all ruptures are not necessarily fatal. The chances of the mother's death, however, are much higher than that, because death can come in ectopic pregnancy from causes other than rupture. From 63.1 to 68.8 per centum (say, 66.3 per centum) of ectopic gestations treated by the expectant method result in death to the mother—just two-thirds of the women die. A. Martin in a series of 265 cases of ectopic gestation where the expectant treatment was employed found a maternal mortality of 63.1 per centum; Parry in 500 similar cases found a mortality of 67.2 per centum; and Schauta in 241 cases a mortality of 68.8 per centum.
In the 87 years between 1809 and 1896, 77 cases of coeliotomy for the delivery of viable ectopic foetuses were reported [{30}] in all medical literature with a maternal mortality of about 58.3 per centum. Between 1809 and 1888 there were 37 coeliotomies with a maternal mortality of 86.5 per centum. Between 1889 and 1896 there were 40 such operations, with a maternal mortality reduced to 32.5 per centum by modern surgical methods.
The results as regards the children were almost the same in the two 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 ÓMALLEY.
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.
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 circumstance inseparably joined to the act; fourthly, in craniotomy the killing is utterly [{43}] uncalled for, because the caesarean section, or symphyseotomy (a temporary dividing of the pubic joint to get more room) will do instead, in the hysterectomy, because the child is not viable, there is no alternate way out of the difficulty; fifthly, formal judgment has been pronounced by the Holy Office in craniotomy, no formal judgment has been made as regards this hysterectomy.
Suppose A and B are on a boat hoisting a weighty object to a ship; the tackle breaks, the falling weight mortally hurts B, and wedges him fast to the wrecked boat. The boat is about to sink and drown both men, but if A tips off the weight, and with it unavoidably the entangled B, A can float to safety. A will indirectly hasten the inevitable death of B by throwing off the weight which will drag him down. May A do so? Very probably he may.
Two swimmers, A and B, are trying to save C, who dies in the water, and as he dies he grips A and B so tightly they can not shake the corpse off. A is weak, and he will soon sink and drown owing to the weight of the corpse; B also will later go down with A and C. A, however, cuts his clothing loose from the grip of the corpse (or some one in a boat does so who can do no more) and A is saved; but thus immediately B is drowned, owing to the fact that the full weight of the corpse is upon him. Is A, or the man in the boat, justified? Probably they are. A is the mother, B the foetus, C the diseased uterus, the man in the boat is the surgeon. The mother has herself cut away from the uterus and the foetus's death is hastened.
Again, take an example used by Father Ricaby in his Moral Philosophy, p. 205 (London, 1901). He supposes a visitor to a quarry to be standing on a ledge of rock which a quarryman had occasion to blast, and the quarry man saw that "unless that piece of rock where the visitor stood were blown up instantly, a catastrophe would happen elsewhere, which would be the death of many men, and if there were no time to warn the visitor to clear off who could blame him if he applied the explosive? The means of averting the catastrophe would be, not that visitor's death, but the blowing up of the rock. The presence or absence of the visitor, his death [{44}] or escape, is all one to the end intended: it has no bearing thereon at all."
If these examples of indirect killing are allowable, why may not the surgeon in the rare example presented here remove the uterus and indirectly permit the hastening of the foetus's death? That hastening of death is not an end, nor a means toward an end, but a circumstance only reluctantly and indirectly willed. The end is to save the mother's life, and the means is the removal of a septic or impacted uterus.
It may be objected that an artificial abortion wherein the womb is emptied of an unviable foetus to save the mother's life is only an indirect hastening of this foetus's death, but there is a difference: in abortion the removal of the foetus is the means whereby the end is attained, in the hysterectomy the removal of the tumour is the means whereby the end is attained. This argument is advanced only tentatively and with diffidence, that the matter may be discussed and settled by authority.
Sometimes carcinoma (a cancer) complicates pregnancy—once in 2000 cases is above the average. A carcinoma is a malignant tumour, and the malignancy is made much worse by the stimulus of pregnancy with its increased blood supply. The maternal deaths from carcinoma of the uterus during pregnancy is, according to the latest and most favourable statistics, 30 per centum. The mortality of the children is from 50 to 63 per centum.
Now, first, if an artificial abortion is induced while the foetus is unviable, the foetus is lost and the mother's condition is not materially improved.
Secondly, if curettement (a scraping away with a sharp spoonlike instrument), cauterization, or amputation of the uterine cervix are performed, the mother is helped very little, if at all, and consequent abortion is frequent.
Thirdly, if caesarean section is done at term the child has a good chance (Sanger saved 16 of 18 children thus in one series: over 88 per centum), but this operation nearly always kills the mother when cancer is present, unless the entire uterus can be removed, and often it can not be removed; that [{45}] is, the case is inoperable and removal is useless owing to extension of the cancer into the surrounding tissues.
Fourthly, if the mother's condition is hopeless, a caesarean section gives the child a chance for life, but the operation will hasten the mother's death in nearly every case.
The first and second cases here are not practical. If the surgeon can remove the uterus at term after a caesarean section, that is the most reasonable operation for the mother and child, and it offers no moral difficulty.
If the mother's condition is so bad that the uterus may not be removed, the chances are that her death will be hastened by caesarean section, but if caesarean section is not done, from 50 to 63 per centum is the ratio against the saving of the child. I do not think a general rule can be given as regards the certainty of hastening the maternal death: the reckoning is to be made to meet the particular condition. It seems, however, probable that in every case of inoperable carcinoma of the uterus complicating pregnancy a caesarean section would hasten the maternal death. She will die anyhow from the cancer, but in certain cases she may live longer if the section is not done.
If, again, a carcinoma of the uterus is inoperable at term, the delivery of the child may be impossible without caesarean section, from uterine inertia, or the opposition of the dense inflamed tissues, or the friability of these tissues. In such a case without the section she would die, and die probably sooner than with it. The operation would possibly slightly prolong her life, by, say, a few hours or days, and it certainly would give the child a very good chance for its life. She may, of course, die upon the operating table, but she would die in childbed without the section.
The case is different from the ordinary caesarean section done because of a narrow pelvic bony girdle. In the latter condition the chances that the mother will live are very high if the surgeon is competent, but in the carcinoma case she will die no matter who the surgeon may be, and very probably, or almost certainly, her death will be hastened by the operation in the majority of cases.
If the condition is such that the woman can not be delivered [{46}] without the section, I see no difficulty against operation, because the surgeon can not, as far as I know, say positively whether he will hasten the maternal death or not, and in the circumstances he may take advantage of the doubt.
If the woman with an inoperable carcinoma uteri may be delivered without section, should such a delivery be chosen although it raises the chances of mortality as regards the child from about 12 per centum to at the least 50 per centum? It is a matter of a very probable hastening of the mother's death as weighed against the safety of the child—the child has about one chance in two of life without the section, and, say, seven chances in eight with the section. The operation is far preferable as regards the child alone, but not preferable as regards the mother alone. Is it then allowable?
In the hysterectomy for fibroma already considered, the mother is saved and the child's inevitable death is certainly hastened; in the caesarean section the child is most probably saved, and the mother's inevitable death is most probably hastened; we might say, in some cases, that her death is undoubtedly hastened. If in the carcinoma case here the child had no chance whatever for delivery except by the caesarean section, while the mother's death would be probably or certainly hastened, she might legitimately consent to the operation or she might legitimately refuse the operation.
The child, however, has, as we said, one chance of delivery in two without the section, while the mother's death will very probably be hastened. If the mother's death would certainly be hastened by the section, her death, although it would be a circumstance and indirect, not an end nor a means, would not have counterbalanced against it necessarily the saving of the child's life, because the child has one chance in two in any event. In such an hypothesis the operation seems to be unjustifiable.
If, however, the hastening of the mother's death is only probable and not certain, may we oppose that probability to the advantage that must accrue to the child through the section? If the doubt that her death will be hastened is soundly probable, the woman may consent to the operation. She risks through charity the hastening of her own death for a great [{47}] advantage to the child, but she may risk legitimately immediate death in major surgical operations for an advantage less than the saving of life itself. She may have her skull opened for the removal of a depressed bone that is causing paralysis, she may have her knee-joint opened for the wiring of a patella to prevent lameness, but both these operations always immediately endanger life. She may go into a burning house, jump into a river, and so on, to save her child from possible injury.
AUSTIN ÓMALLEY.
III
ABORTION, MISCARRIAGE AND PREMATURE LABOUR
If pregnancy ends in the emptying of the uterus before the sixteenth week of gestation, the condition is called an abortion; if this happens between the sixteenth and the twenty-eighth weeks, it is miscarriage; if the child is born after the twenty-eighth week but before full term, the birth is premature. The term "abortion" in the popular mind carries with it the notion of criminal interference, and the word "miscarriage" is used for both abortion and miscarriage by the laity; physicians, on the other hand, commonly use the term "abortion" for both abortion and miscarriage. These conditions may occur spontaneously or they may be induced artificially.
Spontaneous abortions are very frequent; perhaps one in every five or six pregnancies is the proportion: the writer has known a single physician, not a specialist in obstetrics, to be called to three in one day and that in private practice. From 150 to 200 children in every 1000 that are conceived never get a chance for baptism. In the early months of pregnancy the foetus is usually dead before expulsion takes place. Twisting of the cord, hydramnios, syphilis, an acute infectious disease in the mother, poisonings of the mother by metals and the like substances, maternal cardiac and renal diseases, chronic inflammations and displacements of the womb, and violent emotions are some of the causes of abortion. In certain women a slight exertion, a misstep, a fall, a ride over a rough road, the debitum conjugale, and similar causes bring on abortion; in other women almost no shock is enough to make them miscarry. Inflammations and displacements of [{49}] the womb cause most of the abortions in the first four months, and after that time syphilis and Bright's disease are the chief forces at work.
If a woman in early pregnancy begins to lose blood from the uterus, and has pain in her back and lower abdomen, abortion is threatened; if this hemorrhage is marked, and the cervix is dilated, the abortion will very probably occur; and the escape of the liquor amnii renders the abortion unavoidable. In this latter case the vagina and the cervical canal are packed with sterile gauze to check the hemorrhage, and after twenty-four hours it is removed. Then commonly the entire ovum comes away with the gauze, or what remains of it is taken out with a curette.
Valvular lesions of the heart in pregnancy make a maternal mortality of about 28 per centum, according to Guérard, and when compensation is lost the mortality may run from 48 to even 100 per centum with different physicians and different cases. The prognosis is good as long as compensation is retained, but very bad if this fails. In the latter condition premature labour is indicated, or the early removal of the viable child. Catholic physicians may not induce artificial abortion of an unviable foetus. The decree of the Holy Office concerning this matter is as follows:
Beatissime Pater,—Stephanus … Archiepiscopus Cameracensis … Quae sequuntur humiliter exponit:
Titus medicus, cum ad praegnantem graviter decumbentem vocabatur, passim animadvertebat lethalis morbi causam aliam non subesse praeter ipsam praegnationem, hoc est, foetus in utero praesentia, una igitur, ut matrem a certa atque imminenti morte salvaret, praesto ipsi erat via, procurandi scilicet abortum seu foetus et ejectionem. Viam hanc consueto ipse inibat, adhibitis tamen mediis et operationibus, per se atque immediate non quidem ad id tendentibus, ut in materno sinu foetum occiderent, sed solummodo ut vivus, si fieri posset, ad lucem ederetur, quamvis proxime moriturus, utpote qui immaturus omnino adhuc esset.
Jamvero lectis quae die 19 Augusti, 1888, Sancta Sedes ad Cameracenses Archiepiscopos rescripsit: tuto doceri non posse licitam esse quamcumque operationem directe occisivam foetus, etiam si hoc necessarium foret ad matrem salvandam: dubiis haeret Titius circa [{50}] liceitatem operationum chirurgicarum, quibus non raro ipse abortum hucusque procurabat, ut praegnantes graviter aegrotantes salvaret.
Quare ut conscientiae suae consulat supplex Titius petit: utrum enuntiatas operationes in repetitis dictis circumstantiis instaurare tuto possit.
Feria iv, die 24 Julii, 1895.
In Congregatione generali S. Romanae et Universalis Inquisitionis … Emi ac Rmi Domini Cardinales … respondendum decreverunt: Negative, juxta alias decreta, diei scilicet 28 Maii, 1884, et 19 Augusti, 1888.
… Sanctissimus Dominus noster … approbavit.
Other documents referring to the same matter are the following:
Epistola ad Archiepiscopum Cameracensem. … Anno 1886, Amplitudinis tuae Praedecessor dubia nonnulla hinc supremae Congregationi proposuit circa liceitatem quarumdem operationum chirurgicarum craniotomiae affinium. Quibus sedulo perpensis, Eminentissimi ac Reverendissimi Patres Cardinales una mecum Inquisitores Generales, feria iv, die 14 currentis mensis, respondendum mandaverunt:
In scholis catholicis tuto doceri non posse licitam esse operationem chirurgicam quam craniotomiam appellant, sicut declaratum fuit die 28 Maii, 1884, et quamcumque chirurgicam operationem directe occisivam foetus vel matris gestantis.
Idque notum facio Amplitudini tuae, ut significes professoribus facultatis medicae Universitatis catholicae Insulensis. …
Romae, die 19 Augusti, 1889. …
R. CARD. MONACO.
The date of this response here is 1889, but in the preceding decree it is given as 1888. In the Acta Sanctae Sedis the date is 1889.
Another letter from Cardinal Monaco is this:
Eme et Rme Dne,—Emi PP. mecum Inquisitores generales in Congregatione habita feria iv, die 28 labentis Maii, ad examen revocarunt dubium ab Eminentia tua propositum—An tuto doceri possit in scholis catholicis licitam esse operationem chirurgicam, quam Craniotomiam appellant, quando scilicet, eâ omissâ, mater et infans perituri sint, eâ e contra admissâ, salvanda sit mater, infante pereunte?
—Ac omnibus diu et mature perpensis, habita quoque ratione eorum quae hac in re a peritis catholicis viris conscripta ac ab Eminentia tua hinc Congregationi transmissa sunt, respondendum esse duxerunt: Tuto doceri non posse.
Quam responsionem cum SSmus D. N. in audientia ejusdem feriae ac diei plene confirmaverit, Eminentiae tuae communico. …
R. CARD. MONACO.
Romae, 31 Mail, 1884.
Emo Archiepiscopo Lugdunensi.
Another decree concerning abortion is in part as follows:
Beatissime Pater,—Episcopus Sinaloen. ad pedes S.V. provolutus, humiliter petit resolutionem insequentium dubiorum:
I. Eritne licita partus acceleratio quoties ex mulieris arctitudine impossibilis evaderet foetus egressio suo naturali tempore?
II. Et si mulieris arctitudo talis sit, ut neque partus praematurus possibilis censeatur, licibitne abortum provocare aut caesaream suo tempore perficere operationem? …
Feria iv, die 4 Mail, 1898.
In Congregatione habita, etc. … EE. ac RR. Patres rescribendum censuerunt:
Ad I. Partus accelerationem per se illicitam non esse, dummodo perficiatur justis de causis et eo tempore ac modis, quibus ex ordinariis contingentibus matris et foetus vitae consulatur.
Ad II. Quoad primam partem, negative, juxta decretum Feria iv, 24 Julii, 1895, de abortus illiceitate. Ad secundum vero quod spectat; nihil obstare quominus mulier de qua agitur caesareae operationi suo tempore subjiciatur. …
In sequenti Feria vi, die 6 ejusdem mensis et anni … SSmus responsiones EE. ac RR. Patrum approbavit.
Pyelonephritis (an inflammation of the kidney where pus is present), from the pressure of the pregnant uterus, is a condition which sometimes obliges the physician to bring about premature labour to save the mother. The symptoms usually appear in the latter half of gestation.
Chorea ("St. Vitus' Dance"), when it develops during pregnancy, has a maternal mortality of from 17 to 22 per centum. It may cause death before the child is viable, and to empty [{52}] the uterus will stop the symptoms. Here the decrees of the Holy Office will occasionally prevent the Catholic physician from interfering.
If a grave surgical operation is imperatively indicated during pregnancy, and may not be put off until after delivery, it should be undertaken in many cases, because modern technique commonly does not bring about an abortion; but, in general, no rule can be given—each case must be judged separately.
If a pregnant woman has at the same time considerable albumen in her urine and a low excretion of urea, her condition is very dangerous. To empty her uterus will, in most cases, relieve the renal trouble, but in any case premature labour is not to be induced rashly: many women escape, when by all the rules they should die.
Eclampsia is a very grave complication of pregnancy, and it was formerly supposed to be uraemia. The disease is characterized by convulsions, loss of consciousness, and coma. It occurs, commonly, in the second half of gestation, but it has been observed as early as the third month. About 70 to 80 per centum of the cases are in primiparous women. The convulsions may come on altogether unexpectedly, but commonly the attack begins with symptoms of toxaemia. Eclampsia may occur before, during, or after parturition. When it comes before term it usually ends in spontaneous or artificial abortion, but at times the woman dies undelivered. Now and then she may recover and be delivered at term.
The kidneys are usually affected, even in those cases in which albuminous urine is not found. There is also a hemorrhagic inflammation of the liver; and oedema and congestion of the brain, with or without apoplexy, are other symptoms of the disease. There are other lesions, but the chief are in the kidneys, liver, and brain.
The aetiology of the disease is not yet known, and there are very many theories offered to explain it. The prognosis is always serious, and the condition is one of the most dangerous found in pregnancy. The mortality varies, but it is about from 20 to 25 per centum in the women, and from 33 to 50 per centum in the children. It is impossible to determine [{53}] the prognosis in particular cases, but a large number of quickly recurring convulsive seizures, with a weak, thready pulse, and a high temperature usually indicate a fatal ending. Apoplexy, oedema of the lungs, and paralysis also, as a rule, end in death.
If the uterus is emptied during the convulsions, these cease either immediately or soon after delivery, in from 66 to 93 per centum of the cases, and the maternal mortality then is about 11 per centum. With the expectant treatment, in convulsive cases, about 28 per centum of the women die, although a use of aconite in these cases may better the prognosis.
Pernicious vomiting (hyperemesis gravidarum) is another complication of pregnancy, which sometimes results fatally if the uterus is not emptied. There are cases, especially those with high fever, which end in death despite all treatment. Here, again, the aetiology of the disease is not known. There is commonly an element of hysteria in the condition, and in such a case moral suggestion often has a curative effect Any bodily irritation is to be removed. Eye-strain alone is enough to cause persistent vomiting. It is very difficult to decide when premature labour is absolutely indicated, because some very bad cases recover spontaneously when all hope is lost.
Hydramnios, or an excessive quantity of liquor amnii, may so distend the uterus as to cause grave danger to maternal life, and if the child is viable the uterus should be emptied.
Intrauterine hemorrhage brought on by a premature separation of the placenta is a very dangerous condition: 32 to 50 per centum of the mothers die, and 85 to 94 per centum of the children. In a marked hemorrhage the only way to save the mother is to empty the uterus, so that it may contract and thus close the patulous vessels.
Placenta praevia is a placenta implanted in the neighbourhood of the internal os of the uterine neck. This is a very perilous condition, calling for the induction of premature labour. The medical treatment is artificial abortion as soon as the condition is diagnosed in any stage of gestation; but this is, of course, in conflict with the decrees of the Holy Office. Under expectant treatment about 40 per centum of [{54}] the mothers die, and 66 per centum of the children. Those children that are born alive commonly die within ten days after delivery. The great foetal mortality is due to premature birth and asphyxiation. Skilful obstetricians get much better results, but skilful obstetricians are unfortunately rare.
When the grave complications enumerated above occur in the early months of pregnancy, before the foetus is viable, the Catholic physician, since by the natural law and the decisions of the Holy Office he is forbidden to induce artificial abortion, must withdraw from the case. If there is no other physician to attend to the woman, he must let her die. He can not withdraw without explanation, and in many cases the explanation of the condition will promptly result in the calling in of a physician who has no scruple in inducing this abortion, no matter how reputable he may be. The universal medical doctrine is to induce abortion in cases where abortion will save the mother's life and the foetus is "too young to amount to anything." This is looked upon as legitimate abortion by the very best men that do not recognise the authority of the Holy Office: they deem the position of the Catholic physician in these cases as altogether erroneous, or even criminal.
The position of the Catholic moralists on craniotomy has turned the attention of many non-Catholic physicians to the immorality of the act, which formerly was deemed entirely permissible. Probably the same good result will be effected in the matter of abortion.
AUSTIN ÓMALLEY.