Essays In Pastoral Medicine

by Austin O'Malley; James J. Walsh

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.