Before antiseptic surgery began, opening the abdominal cavity was almost always fatal, and some obstetricians tried to get the child out of the uterus in cases where cesarean delivery is indicated by going in above the pelvis without opening the peritoneum. The uterus was incised near its cervical end. This method, called extraperitoneal cesarean delivery, has been restored for use in cases where there is some infection of the uterus and the operator wishes to save the child without removing the womb. The technic is more difficult than in the classic cesarean, and the operation was not kindly received, but of late some men are having so much success with it that it is reviving, and rightly so. Baisch[107] says that the first eleven women he delivered by extraperitoneal cesarean section recovered more readily than they would from an ordinary laparotomy. In nineteen cases of transperitoneal but cervical section he had no trouble, and six of these were infected cases. The technic of this low incision protects the peritoneal cavity better than the classic incision, apparently. Two of the nineteen women were in slight fever and the uterine fluids were fetid. Two primiparae forty years of age had been in labor seventy hours. Eight of the women were able to leave the clinic on the tenth day. Only one child was lost, and that was a delayed case. Hofmeier[108] compiled 194 cases of transperitoneal cervical cesarean section with three deaths. Küstner did 110 extraperitoneal cesarean sections with no mortality. This makes 304 cases of cesarean cervical section, not the classic operation, with only three deaths, less than 1 per cent. mortality; and fully 50 per cent. of these cases were not surgically clean. From these statistics it is evident that the cervical operation in the hands of competent surgeons should be the operation of choice.
The ordinary practitioner, however, is utterly unfitted to do a cesarean section of any kind. In large cities it is easy to find a trained surgeon to do the operation, but in small towns and in country places there is seldom any one available. The physician who chooses to practise medicine in an isolated place knows that he will almost certainly be called upon to do a cesarean section some day, and he should not take up the responsibility of the general practitioner in such a place until he is competent to do that operation when life depends upon him. This is as things should be; but unfortunately a man who is trained well enough to do major surgery will not live in a small town if he can get into a large city. The physician in any case should be able at least to make the diagnosis in time, before labor sets in, and have the woman sent to the nearest city, if possible. Dr. Bull[109] reported that he had traveled seventy-five miles to see a woman who was having severe hemorrhages at term. He found her in a log cabin, with a centrally implanted placenta (i.e., right across the opening of the cervix uteri), and she had had three hemorrhages before his arrival. He narcotized her, took her in a train to a hospital, delivered her by cesarean section, and saved her and the child. If he had delivered her by version in the log cabin, he would almost certainly have lost both the mother and the child.
The question of removing the uterus comes up when the uterus is infected, or as a method of sterilizing the woman to avoid the danger of a subsequent gestation. Whenever a uterus is gravely infected and a cesarean delivery is finally necessary, the infection is commonly due to ignorance or carelessness, and the physician or midwife is guilty. There should be no such business as that of the midwife who actually delivers the patient. The state should provide physicians for the poor. Even the midwife who calls herself "a practical nurse," but who is not a licensed trained nurse, is commonly a public danger, although some so-called practical nurses are better than the ordinary trained nurses.
Suppose, however, that the uterus is infected unavoidably. If this infection has been done by a competent obstetrician working in a hospital with sterile instruments, it may be safe to deliver the woman by an extraperitoneal or cervical trans-peritoneal cesarean section. If the practitioner has tried to deliver the woman at her home with forceps and has failed, especially if repeated attempts have been made by the physician and an assistant or consultant, the uterus should be amputated. It will not do to deliver by a low cesarean and await developments, because if the infection is serious no subsequent removal of the uterus will save the woman's life. The grave mutilation of removing the uterus is, of course, licit, as it is the only means of saving the woman's life. Some moralists hold that a woman from whom the uterus has been removed is impotent, but this question has never been decided authoritatively, as we shall show in the chapter on Vasectomy; and until it has been so decided the woman must be given the benefit of the doubt.
The question of removing the uterus solely to prevent the danger of subsequent deliveries differs from the condition just considered. If the woman has had a cesarean delivery for an absolutely narrow pelvis, her subsequent deliveries must be by the same method. After a cesarean section there is more or less danger of rupture at the scar in other labors. Some think the danger is greater if the placenta becomes implanted on the scar; others think this implantation does not weaken a good scar. If the convalescence after the cesarean section already done has been abnormal, the prognosis for rupture is not good. Where there has been an abnormal convalescence, each new pregnancy must be watched closely, and often an early subsequent cesarean is indicated to prevent rupture. No matter how well the section has been done, latent gonorrhea may prevent perfect healing of the wound. Twins, hydramnios, and overtime gestation are other causes of rupture. The tendency with obstetricians in the future will probably be to do the section toward the cervical end of the uterus; and as the uterus is thinnest there, it might be thought that it will be more likely to break, but Spalding[110] found the contrary true—the rupturing was usually in the thick part of the uterus. Version, high forceps, uterine tampons, hydrostatic bags, and pituitary extract should be avoided where an old cesarean scar exists, but Vogt and Kroback have done version a few times without rupture. Vogt had one patient with a true conjugate of 63⁄4 cm. (28⁄16 inches) to 7 cm. (23⁄4 inches). She was delivered in the first three labors by craniotomy; in the fourth by version; in the fifth and sixth by cesarean section; in the seventh she had twins one of which was born spontaneously; in the eighth by version and perforation of the after-coming head; in the ninth she refused operation and was delivered spontaneously. Skilful operators have the fewest ruptures after cesarean delivery. Olshausen had one in 120 cases, Leopold none in 232 cases, Schauta none in 177 cases, Küstner none in 100 cases. Olshausen, in a series of 29 cases, operated on two patients twice and upon three patients three times. As early as 1875, Nancrede of Philadelphia had operated the sixth time on the same woman. In such cases the uterus is commonly so broadly attached by adhesions to the belly-wall that it is opened without getting into the peritoneal cavity. In 150 cases of repeated section collected by Polak in 1909 the mortality was only 5 per cent.
A woman may not be sterilized by having the uterus removed, by fallectomy, or otherwise, solely to obviate danger or morbidity from subsequent pregnancies and cesarean deliveries. Such a sterilization would be a grave mutilation without a present excusing danger, and it would render the primary end of marriage always impossible. Such sterilization of a woman is in contravention to the decretal of Gregory[111] as given in the chapter on Vasectomy. It is also against the bull Effraenatam of Sixtus V., who extended all penalties prescribed for abortionists to those who give women drugs which cause sterility, and to those who purposely prevent the development of the fetus or in any manner abet the deed; and the penalties are to be applied to the women themselves who willingly use these means. These penalties are enumerated in the chapter on Abortion. The Congregation of the Holy Office, May 22, 1895, answered negatively the following question: "Si sia lecita la practica sia attiva sia passiva di un procedimento il quale si propone intenzionalmente come fine espresso la sterilizatione della donne?"[112]
The reason for these laws is that any act which deprives one of the power to generate, and which prevents conception and makes the semen fail of its end, is against the chief intrinsic end of marriage and any benefit that arises therefrom, which is the good of offspring. The act is also against the intrinsic end of the semen, which is to generate; and since the semen cannot possibly effect its end, the conjugal act degenerates into an equivalent of onanism. This act of sterilization, done not to save the whole body from immediate danger, is intrinsically evil, and therefore unjustifiable.
To say that marriage is also a licit remedy of concupiscence is no excuse. Marriage is such only in a secondary sense, and this secondary end is necessarily subordinate to the primary end, and coexistent with that primary end, which is the generation of children. Even when a surgeon is doing a Porro operation, his main intention may not be to sterilize the woman. He must directly intend to save her life by removing the infected uterus, and reluctantly permit the sterilization as an evil part of the double effect coming from the causal amputation.