The Ethics of Medical Homicide and Mutilation

by Austin O'Malley

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 hat, of the style called "Fedora," is inverted, the fold along the crown coming up into the cavity of the hat is like the broad ligament. As the crown is held downward the uterus would be in the middle, its fundus upward, and outside the hat, representing the pelvic cavity, but in the crown fold. The tubes and ovaries would also be in the crown fold, or broad ligament, and the fimbriated extremities would open into the interior of the pelvic cavity through holes. The ovum breaks through the surface of the ovary into the pelvic cavity, passes, probably on a capillary layer of fluid, into the fimbria ovarica and thence into the infundibulum, whence it moves along slowly into the uterus.

Ovulation and menstruation occur about the same time ordinarily, and if the ovum produced is not fecundated it gradually shrivels and passes off through the uterus and vagina. Fecundation of the ovum rarely occurs in the uterus, but ordinarily in the Fallopian tube. After fecundation the ovum is pushed on through the Fallopian tube into the uterus in from five to seven days, where it fastens to the wall and develops normally. Hyrtl described an ovum which appeared to reach the uterus in three days. If from some abnormal condition of the Fallopian tube the fecundated ovum is blocked and held in the tube, the embryo grows where the ovum stopped, and we have a case of Ectopic Gestation. In normal pregnancy in the uterus, the uterus grows with the embryo, but a tube does not. In the latter condition, when the ovum is big enough it bursts the tube or slips out through the ampulla, causing hemorrhage or other pathological symptoms.

There are certain rare abnormalities of the uterus through imperfect embryological development, and pregnancy in such a uterus may result in symptoms like those of ectopic gestation. Normally the uterus and vagina are formed by the fusion of the two Müllerian ducts. When these ducts do not fuse perfectly, or when one develops partly, the various kinds of abnormal wombs and vaginas are the results. There may be a double uterus with a single or double vagina, a uterus with a complete or partial septum down the middle, a uterus with one horn, a uterus with a developed horn and a rudimentary horn, and the rudimentary horn may be open or shut, and so on. In many of these conditions the ovum becomes blocked and rupture follows as in ectopic gestation.

When the ectopic ovum begins to develop in the Fallopian tube the placental villi erode the tubal wall and the blood-vessels. At length the ovum slips out of the ampulla—the common result—or the tube bursts. The break may be traumatic in origin, from jarring or a like accident, or it may be spontaneous. If the rupture is through the tube there is hemorrhage into the pelvic cavity; if the ovum slips out of the ampulla the tubal abortion causes hemorrhage as in uterine abortion. In either case the blood with peritoneal fibrin forms a hematocele, and this, with the ovum, may be finally absorbed; or the woman may bleed to death unless the hemorrhage is checked surgically; or the child may live for varying periods up to term. The tube rarely ruptures into the fold of the broad ligament.

The fetus usually dies after rupture or tubal abortion, and if it has not advanced beyond the eighth week it is absorbed. Sometimes it lives. When the rupture or abortion does not tear the placental site the fetus may develop in the abdominal cavity. Between 1889 and 1896 Haines[103] found 40 operations for ectopic gestation done after the seventh month of pregnancy with 10 maternal deaths. Of the children, 27 survived the operation from a few moments to fifteen years. Sittner, in 1903, compiled from the medical reports 142 cases of viable ectopic fetuses, and Essen found 25 additional cases. Since Essen's article more have been reported, about 173 to my knowledge, but the number is considerably larger.

Hirst says an experienced obstetrical specialist sees from 12 to 24 cases of ectopic pregnancy annually. Küstner himself operated on 105 cases in five years. About 78 per cent. of all ectopic gestations result in tubal abortion and 22 per cent. in rupture.

Many specialists now are of the opinion that the diagnosis of ectopic gestation ordinarily is not difficult, but most physicians find it very difficult. Before rupture of the tube or a hemorrhage diagnosis is hardly ever made by any one, and no pelvic condition gives rise to more diagnostic errors. When there is rupture or tubal abortion the symptoms may lead the physician to mistake the condition for uterine abortion. In uterine abortion the onset of the symptoms is quiet, with gradually intensifying and regular pains, resembling labor, in the lower abdomen. In ectopic pregnancy the symptoms of a rupture or tubal abortion arise quickly, with irregular and colicky or very violent pains, localized on one side. In uterine abortion the external hemorrhage is more or less profuse, with clots; in ectopic gestation the external hemorrhage is slight or absent; the shock in the latter case is out of proportion to the visible blood loss. Parts of the ovum, or the presence of the whole ovum, as uterine, are found in ordinary abortion, but in the ectopic condition the ovum proper does not appear. An intrauterine angular pregnancy, or pregnancy in a uterine horn, causing the upper corner of the womb to bulge sidewise, may be mistaken for ectopic gestation. Pregnancy in a retroflexed uterus, tumors of the adnexa, the twisted pedicle of an ovarian tumor, a burst pyosalpinx, an appendicitis in pregnancy, or a combined intrauterine and ectopic gestation, also may confuse the diagnosis. When there is a dangerous hemorrhage from rupture or tubal abortion the diagnosis is usually made without difficulty from the collapse and other signs.

The diagnosis as to whether the fetus in the pelvis is dead or alive may be made (1) from the absence or presence of symptoms of tubal rupture during the second and third months, or of mild symptoms indicating only slight bleeding; (2) from the continuation and progress of the evidences of pregnancy, as nausea, mammary changes, fetal movements, or audibility of the fetal heart; (3) from the presence of a loud uterine blood souffle; (4) from the absence of toxemia or suppuration; (5) from a growth of the uterus and a softening of the cervix; (6) from a gradual increase in the size of the suspected ectopic fetal tumor. In making the diagnosis great caution must be observed, as roughness in manipulation may start hemorrhage or rupture a thinned tube.

The diagnosis may be made: (1) that ectopic gestation exists without symptoms of maternal hemorrhage, and the fetus is not viable; (2) that the same maternal condition may be present, but the fetus is viable; (3) that there may be symptoms of slight bleeding, and the fetus is inviable; (4) that there may be symptoms of grave maternal hemorrhage at any stage of the gestation.

The ordinary medical doctrine in the text-books is that as soon as a diagnosis of ectopic gestation is made laparotomy should be done and the sac with the ectopic fetus removed. If the fetus is alive and inviable this procedure will, of course, kill it. Only a few obstetricians of authority advise an expectant treatment. Schauta found 75 recoveries and 166 maternal deaths in 241 cases treated expectantly—a mortality of 69 per cent.