Essays In Pastoral Medicine

by Austin O'Malley; James J. Walsh

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.

If the mother's condition is so bad that the uterus may not be removed, the chances are that her death will be hastened by caesarean section, but if caesarean section is not done, from 50 to 63 per centum is the ratio against the saving of the child. I do not think a general rule can be given as regards the certainty of hastening the maternal death: the reckoning is to be made to meet the particular condition. It seems, however, probable that in every case of inoperable carcinoma of the uterus complicating pregnancy a caesarean section would hasten the maternal death. She will die anyhow from the cancer, but in certain cases she may live longer if the section is not done.

If, again, a carcinoma of the uterus is inoperable at term, the delivery of the child may be impossible without caesarean section, from uterine inertia, or the opposition of the dense inflamed tissues, or the friability of these tissues. In such a case without the section she would die, and die probably sooner than with it. The operation would possibly slightly prolong her life, by, say, a few hours or days, and it certainly would give the child a very good chance for its life. She may, of course, die upon the operating table, but she would die in childbed without the section.

The case is different from the ordinary caesarean section done because of a narrow pelvic bony girdle. In the latter condition the chances that the mother will live are very high if the surgeon is competent, but in the carcinoma case she will die no matter who the surgeon may be, and very probably, or almost certainly, her death will be hastened by the operation in the majority of cases.

If the condition is such that the woman can not be delivered [{46}] without the section, I see no difficulty against operation, because the surgeon can not, as far as I know, say positively whether he will hasten the maternal death or not, and in the circumstances he may take advantage of the doubt.

If the woman with an inoperable carcinoma uteri may be delivered without section, should such a delivery be chosen although it raises the chances of mortality as regards the child from about 12 per centum to at the least 50 per centum? It is a matter of a very probable hastening of the mother's death as weighed against the safety of the child—the child has about one chance in two of life without the section, and, say, seven chances in eight with the section. The operation is far preferable as regards the child alone, but not preferable as regards the mother alone. Is it then allowable?

In the hysterectomy for fibroma already considered, the mother is saved and the child's inevitable death is certainly hastened; in the caesarean section the child is most probably saved, and the mother's inevitable death is most probably hastened; we might say, in some cases, that her death is undoubtedly hastened. If in the carcinoma case here the child had no chance whatever for delivery except by the caesarean section, while the mother's death would be probably or certainly hastened, she might legitimately consent to the operation or she might legitimately refuse the operation.

The child, however, has, as we said, one chance of delivery in two without the section, while the mother's death will very probably be hastened. If the mother's death would certainly be hastened by the section, her death, although it would be a circumstance and indirect, not an end nor a means, would not have counterbalanced against it necessarily the saving of the child's life, because the child has one chance in two in any event. In such an hypothesis the operation seems to be unjustifiable.

If, however, the hastening of the mother's death is only probable and not certain, may we oppose that probability to the advantage that must accrue to the child through the section? If the doubt that her death will be hastened is soundly probable, the woman may consent to the operation. She risks through charity the hastening of her own death for a great [{47}] advantage to the child, but she may risk legitimately immediate death in major surgical operations for an advantage less than the saving of life itself. She may have her skull opened for the removal of a depressed bone that is causing paralysis, she may have her knee-joint opened for the wiring of a patella to prevent lameness, but both these operations always immediately endanger life. She may go into a burning house, jump into a river, and so on, to save her child from possible injury.

AUSTIN ÓMALLEY.