Essays In Pastoral Medicine.
by Austin oMalley and James J. Walsh.
PREFACE
The term Pastoral Medicine is somewhat difficult to define because it comprises unrelated material ranging from disinfection to foeticide.
It presents that part of medicine which is of import to a pastor in his cure, and those divisions of ethics and moral theology which concern a physician in his practice. It sets forth facts and principles whereby the physician himself or his pastor may direct the operator"s conscience whenever medicine takes on a moral quality, and it also explains to the pastor, who must often minister to a mind diseased, certain medical truths which will soften harsh judgments, and other facts, which may be indifferent morally but which a.s.sist him in the proper conduct of his work, especially as an educator. Pastoral medicine is not to be confused with the code of rules commonly called medical ethics.
The material of pastoral medicine requires constantly renewed discussion, because medicine in general is progressive enough frequently to devise better methods of diagnosis and treatment, and thus the postulates of the moral questions involved are changed. This discussion, however, is not easily made. The facts upon which the ethical part of pastoral medicine rests are furnished by the physician for the consideration and judgment of the moralist--the physician educated after modern methods knows little or nothing of ethics and can not himself make accurate moral decisions. The moralist, on the other hand, is commonly a poor counsellor to the physician, because long training in medicine is needed before the physical data of the moral decisions is comprehended. The physician, therefore, is at a loss to determine what he may or may not do in {vi} cases that involve the greatest moral responsibility, and the priest is a hesitating guide because the moral theologies do not convincingly present the doctrine in these cases.
Now and then such subjects have been proposed for discussion to a group of physicians and moralists, but usually no practical conclusion has been reached because one side did not understand the other. In 1898 there was a series of articles on ectopic gestation in the _American Ecclesiastical Review_, in which moralists like Lehmkuhl, Sabetti, Aertnys, and Holaind, and some of the leading gynaecologists of America considered the questions but arrived at no decision. The physicians did not understand certain questions, other questions were on obsolete medical practice, essential questions were omitted, and from the data the moralists came to opposed conclusions.
We find also in moral theologies deductions drawn from false medical sources. Reasons are given, for example, to justify the use of a large quant.i.ty of alcoholic liquor at a dose in cases of great pain, typhoid fever, snake-poisoning, and other diseases, in the supposition that such doses will benefit or cure the patient, whereas the physician that would follow that treatment would be guilty of malpractice. There was recently in America a discussion on the relation of ooph.o.r.ectomy to the _impedimentum impotentiae_. One side held that a lack of ovaries const.i.tutes impotence; the other side, that it does not. The discussion was useful because it incidentally gathered the full doctrine of the moralists on this subject, but from the medical point of view there is no connection whatever between these conditions.
A small number of books on pastoral medicine have been written by clergymen that were not physicians, and a few German books by physicians that were also moralists. Those by the physicians draw conclusions from antiquated medical practice, or they are mere popular treatises on hygiene; those by the clergymen have some value on the ethical side, but they are incomplete because the authors had not the necessary medical knowledge. The essays offered in this book by no {vii} means cover the entire field of pastoral medicine, but as far as they go we have endeavoured to offer the medical doctrine of the present day on the questions considered, and that as completely as is necessary to draw the moral inferences.
Since, then, so many of the questions of pastoral medicine are not defined, physicians are likely to follow the doctrine of the standard medical books, which without exception advise them to take the life of a dangerous foetus almost as unconcernedly as they might prescribe an active drug, or in any case to put utility before justice. There is, therefore, an urgent necessity that competent men fix that shifting part of ethics and moral theology called pastoral medicine, and these essays are presented as a temporary bridge to serve in crossing a corner of the bog until better engineers lay down a permanent causeway.
Some may think that the authors are inclined toward an exaggerated charity in suggesting the measure of responsibility for many human actions, but the physician that is brought much in contact with those suffering from mental defects of various kinds soon learns how easily complete responsibility becomes marred. Responsibility is dependent entirely upon free will; and while the great principle of free will remains solid in truth, no two men are free in exactly the same manner. Physical conditions have not a little to do with modifications of freedom of the will. To point out this fact to the clergyman and the physician has been our intention, for a proper appreciation of it will widen the bounds of charity and save many that are more sinned against than sinning from the injury of grievous misjudgment. It is better to run the risk of exculpating a few individuals whose responsibility is not entirely clear when the application of the same principles lifts many others above the rash judgment of those that can be of most help to them.
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 r.e.c.t.u.m and above the v.a.g.i.n.a, 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. Pa.s.sing 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.
[Ill.u.s.tration]
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_, r.e.c.t.u.m. _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.
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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, pa.s.ses, 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 pa.s.ses off through the uterus and the v.a.g.i.n.a. 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 p.r.o.nucleus of the spermatozoon fuses with the p.r.o.nucleus 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 s.e.x 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. Kustner 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.
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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 Interst.i.tial, Isthmic, or Ampullar Pregnancy. From these primary types, by rupture, secondary forms sometimes arise,--Tubo-abdominal, Tubo-ovarian, and Broad-ligament Pregnancy.
The interst.i.tial form, that is, where the ovum is arrested in that part of the tube which pa.s.ses through the wall of the uterus itself, is the rarest of the tubal pregnancies. Rosenthal (_Ein Fall intranturaler Schw.a.n.gerschaft. 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 Interst.i.tial or Ovarian pregnancy in his practice. The interst.i.tial 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 interst.i.tial 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 v.a.g.i.n.a 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 acc.u.mulates 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.