Essays In Pastoral Medicine

by Austin O'Malley; James J. Walsh

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.