Part 10

But, you say, this is a vicious circle. You justify the permitted death of the foetus in Case I. because it is a materially unjust aggressor, and it is a materially unjust aggressor because it is in an unnatural position where it has no right to be; but in the present case the mother put it in the unnatural position, and it therefore has a right to be where it is. No: the consequence does not follow. The fact that the mother put the foetus in its unnatural position does not give the foetus a right to be in that position, although it constitutes a ground for her punishment by proper authority. You object again, if this woman has a right to permit the death of the foetus to save her own life, how may she be punished for that death? She will not be punished for the actual coeliotomy which indirectly caused the death of the foetus, but she will be punished for the sin of putting that child in a position in which it had to be killed. This seems to be a distinction without a difference. As far as the mother is concerned, transeat ; but it is a real distinction as far as the surgeon is concerned.

If the woman's condition is a result of accidental infection before or after marriage, the case goes into the class of those discussed above, and operation is justifiable.

If her infection comes after her marriage adulterously, her {39} sin is the greater, but the operation is justifiable for the reasons which were given in the case of culpable infection before marriage.

If she had been infected by her husband, the operation is justifiable--the father is accountable for the foetus's death.

Fortunately the entire case is so nearly hypothetical that it is little more than mere words.

AUSTIN OMALLEY.

{40}

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.