Part 4

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.

{40}

II

PELVIC TUMOURS IN PREGNANCY

Tumours of the uterus and its adnexa at times, though rarely, complicate pregnancy, and they may involve certain moral questions that have been little discussed. The tumours that cause difficulty are ovarian and uterine.

Cystic ovarian tumours commonly do not prevent impregnation, if there has been an absence of inflammation. When these cysts are small they may not disturb pregnancy or delivery; large cysts can, however, become a source of danger. They may sink into the pelvis and block the channel of delivery needed by the child at term; they may have their pedicles twisted, and thus become gangrenous and septic. Big cysts of the ovary may during the growth of the pregnant uterus press upon the portal vein, or the diaphragm, or they may burst or cause sepsis. Litzman, in 56 cases of ovarian tumours complicating pregnancy, had only 10 normal deliveries; and Remy held that 23 per centum of these cases, when left untouched, result in death to the mothers. Stratz says the mortality is 32 per centum, and it has gone as high as 40 per centum. Some physicians teach that any ovarian cyst found complicating pregnancy should be removed surgically. Other authorities hold that they should all be treated expectantly: if they threaten the life of the mother, they should be tapped by a trocar through the belly-wall or the vagina, and removed only after labour. This second operation is safe, and I think it should prevail.

Such cysts have often been removed during pregnancy. Orgler reported 146 ovariotomies (removal of the ovaries) performed during gestation with only four maternal deaths--2.7 per centum. If the operation had not been performed {41} about 32 per centum of these women would have died. The chance against saving the child in such an operation is the crux. If there is no operation 17 per centum of the cases result in abortion and the loss of the child, as Remy found from a consideration of 321 cases. In Orgler's series of 146 ovariotomies, where he lost only 2.7 per centum of the mothers, and saved about 30 per centum that would have died (97 per centum in all); he lost 32 children through abortion caused by the ovariotomies, or 22.5 per centum; whereas by the expectant method (without tapping) only 17 per centum of the children were lost.

Bovee of Washington, however, reported 38 cases of removal of the ovaries during pregnancy with one maternal death and only four abortions, or 12.6 per centum. That is considerably less than the loss by the expectant method without tapping. As Bovee succeeded, other men now do, but it would be far better to attempt tapping first. The earlier in the pregnancy either tapping or removal is done the better.

Fibroid tumours of the uterus, complicating pregnancy, occur in about 0.6 per centum of pregnancies, and they usually go on without causing trouble; but again these tumours may block the pelvic outlet, they may dangerously press upon abdominal viscera and the diaphragm; some writers hold they may become inflamed and degenerate with sloughing and gangrene, and thus bring about sepsis and death to the mother and child. That they become gangrenous must very rarely happen; the increased blood supply should prevent gangrene, but cause an increase in the size of the fibroma.