The ectopic fetus cannot, of course, be a formal aggressor because it cannot exercise either intelligence or will. It is not a materially unjust aggressor, because the only action it is capable of is to increase in size in obedience to the natural law of growth. It is not trying in any manner to tear the maternal blood-vessels. It has a right to its own life and a right to grow. Its growth may finally bring about a maternal hemorrhage, but just now it is not causing that hemorrhage. An aggressor is such only while there is an actual attack going on here and now, directed against the victim's life. The fetus is necessarily passive always, never aggressive in any sense of the term, until the actual rupture occurs. If it may be deemed materially aggressive when the actual rupture is taking place, the question becomes irrelevant, because at that time the fetus may be removed for other reasons altogether. If an insane man is in a room with a loaded revolver which he may not use against me, but which he probably will, I may not kill him in self-defence until he actually begins the aggression. The opinion expressed here is the contrary of the opinion I expressed, in 1906, in Essays in Pastoral Medicine.
The second condition proposed is that the ectopic gestation exists without symptoms of maternal hemorrhage, but the child is viable. In such a case it is probably better to remove the fetus at once, but only a skilled abdominal surgeon should attempt the operation because it is likely to be difficult from adhesions. A viable ectopic fetus is usually deformed. Winckel found 50 per cent. of them deformed—the head in 75 per cent., the pelvic end in 50 per cent., the arms in 40 per cent. Compression, infraction, hydrocephalus, and meningocele are common. The longer the fetus is left in, the worse for the mother so far as peritoneal adhesions and danger and difficulty in removing the fetus are concerned.
The third case supposed that the fetus is not viable but the symptoms of maternal hemorrhage are slight. The danger to the mother in waiting is greater here than in case one, and the decision must be made in keeping with evidences in the particular case. The surgeon who assumes responsibility is obliged to remain ready for instant operation.
Where there are symptoms of grave hemorrhage in the mother at any stage of ectopic gestation the surgeon must operate at once, and ligate the bleeding vessels to save the woman's life. The ligation will shut off the blood supply to the fetus, and thus indirectly, permissively, the fetus must be unavoidably allowed to die. This is a clear case of double effect immediately issuing from the same cause, and the operation is morally licit. No matter how young the fetus is, the surgeon or an assistant is to baptize it; if it is very young it may be necessary to split the envelopes to get at the fetus.
[CHAPTER VII]
Cesarean Delivery
In the cesarean delivery (partus cesareus, celiohysterotomy) the infant is brought out through an opening made in the abdominal and uterine walls. The chief indications for this operation may be a contracted maternal pelvis, an abnormally large fetal head or body, death of the pregnant mother before delivery, certain forms of rigidity of the cervix uteri, some cases of stenosis of the vagina, relative vaginal narrowness, blocking tumors, or a ventrofixed uterus. Sometimes abruptio placentae, eclampsia, placenta praevia, and other accidents of pregnancy are taken as indications for cesarean delivery.
An abnormal bony pelvic girdle is the most frequent obstruction to delivery of the fetus. The lower part of the pelvis, called the pelvis minor or true pelvis, supports the muscles of the pelvic floor, and gives shape and trend to the parturient canal. The inlet and outlet of the true pelvis are narrower than its middle portion and are called the superior and inferior straits. The inlet is somewhat cordate in outline, and normally from front to back, at its so-called conjugata vera, it averages 11 centimetres (45⁄16 inches) in depth; from side to side it measures 13 centimetres (51⁄8 inches); obliquely from the right posteriorly to the left anteriorly it is 121⁄2 centimetres (nearly 5 inches), and the other oblique conjugate is 12 centimetres (43⁄4 inches) long. The transverse diameter of the outlet, from right to left, is 11 centimetres; the diameter from front to back, because the coccyx can be pushed back in labor, is from 91⁄2 (33⁄4 inches) to 12 cm. Normal fetal head measurements average from side to side at the widest part, 91⁄2 cm. (33⁄4 inches); from the root of the nose to the occiput, 11 cm.; from the chin to the occiput, 13 cm.; from the vertex to the neck behind, 91⁄2 cm. The size of the fetal head is the most important factor in delivery, so far as the child is concerned, because, as a rule, when the head is delivered the compressible trunk follows readily. Normally the child presents in delivery with the vertex of the head first; other presentations are transitional, abnormal or pathologic. In 48,499 cases Karl Braun found vertex presentations in 95.9 per cent., and Schroeder in 250,000 cases found an average of 95 per cent. The child's head is "engaged" when its largest diameter has passed the plane of the inlet.