Ectopic Gestation, called also extrauterine pregnancy, is gestation outside the uterus in the adnexa or the peritoneal cavity. Pregnancy in the horn of an abnormal or rudimentary uterus is classed with ectopic gestation because the effects are similar, although pregnancy at times in a rudimentary uterus goes on to term normally. The uterus is in the pelvic cavity, between the bladder and the rectum, and above the vagina, into which it opens. It is a hollow, pear-shaped, muscular organ, somewhat flattened, and about three inches long, two inches broad, and an inch thick. The fundus or base is upward, and the neck is downward. Passing horizontally out from the corners or horns of the uterus, which are at the fundus, 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 throughout the greater part of their extent. The ends farthest from the uterus are fringed and funnel-shaped; and this funnel end, called the Infundibulum or 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. 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 that 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 widens into the broader part called (3) the Ampulla; (4) the Infundibulum, or the funnel-shaped end of the Ampulla. One of the fimbriae, the Fimbria Ovarica, is longer than the others, and it forms a shallow gutter which extends to the ovary.

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.

If there are no symptoms of maternal hemorrhage but the fetus is evidently dead, the fetus is to be removed. If it is evidently alive, or doubtfully alive, the treatment must be expectant. The woman is to be removed to a hospital and kept under constant watch, day and night, with everything prepared for immediate operation. Any woman while bearing an ectopic fetus is in constant grave danger of death, but the moralists hold that her danger is not so imminent before actual rupture as to justify the death of the fetus by precautionary removal.

In 1886 the Archbishop of Cambrai proposed the following list of questions to the Holy Office for decision:

1. May a pregnant woman in danger of death from eclampsia or hemorrhage be prematurely delivered of a viable child?

2. May a woman in the same condition be delivered in urgency by means which will kill the infant?

3. May a woman in articulo mortis be delivered of a viable child if the delivery will somewhat hasten her death?

4. May the woman in question 1 be delivered of an inviable fetus?

5. May the woman in question 3 be delivered of an inviable fetus?

6. May a woman who is about to become blind, paralytic, or insane from her pregnancy be prematurely delivered of a viable child?

7. May the woman in question 6 be delivered by means which will kill the fetus?

8. May the woman in question 6 be delivered of an inviable child?

9. May the woman in question 6 be delivered of an inviable child, supposing the child to be in articulo mortis?

10. May an ectopic fetus be killed by operation, electricity, or poison, to avert possible danger of death from the mother?

11. May a surgeon who has opened the abdomen for some condition not uterine incidentally remove a viable ectopic fetus?

12. With conditions like those in question 11, except that the fetus is not viable, may the surgeon remove the inviable ectopic fetus?

Three years later, August 19, 1889, the Holy Office answered these questions comprehensively: "In Catholic schools it may not be safely taught that craniotomy is licit, as was decided May 28, 1884, or any other surgical operation which directly kills the fetus or the pregnant mother." Safely taught here is a somewhat technical expression which has been interpreted by the Holy Office in another connection as meaning that the act is illicit morally.

The Holy Office, May 4, 1898, again decreed: "Necessitate cogente, licitam esse laparotomiam ad extrahendos e sinu matris ectopicos conceptus, dummodo et foetus et matris vitae, quantum fieri potest, serio et opportune provideatur."[104] This decision was not clearly understood, and on March 5, 1902, the same congregation reported the following question: "Is it ever licit to remove from the maternal pelvis an ectopic fetus which is still immature; that is, which has not yet completed the sixth month after conception?" The answer was, "No; according to the decree of May 4, 1898, which prescribes that the life of the fetus and the mother must as far as possible be carefully safeguarded. As to the time, according to the same decree, the questioner will remember that no premature delivery is permissible unless it is effected at such a time and by those methods which in ordinary circumstances safeguard the life of the mother and fetus."[105]

If the fetus is removed and so killed to avert a threatened danger to the maternal life, but not an actually operative destruction of her life, this removal or homicide is an evil means used to avert the danger. There is no question of a double effect, that is, of two effects, one good and the other evil, coming with equal directness from the cause, which is the removal or killing of the fetus; but of a good effect, the averting of the danger to the mother, issuing from an evil cause, the removal and death of the fetus. A good effect does not justify the use of evil means; it is not permitted morally directly to kill the fetus, as in this case, to save the mother from a threatened grave danger.

The case is not like that of the woman who has an operable cervical cancer while she is bearing an inviable fetus. If the cancerous uterus is not removed the woman will surely die; if it is removed she has a reasonable chance of cure; but if the inviable ectopic fetus is not removed it is by no means certain that the woman will die. In the cancer the uterus is directly removed, the fetus is indirectly killed; in the ectopic case the fetus is directly killed, and the danger to the woman's life is removed as a direct effect of the killing.

Again, the killing of the inviable ectopic fetus cannot be justified by maintaining that the fetus is an unjust aggressor against the life of the mother. An aggressor against life may be such formally or materially. A formally unjust aggressor consciously and voluntarily attacks the life of the victim unjustly. This perversion, or evil, in the aggressor's consciously actuated will sets his own right to life in juridic inferiority to that of the victim's right to life, and the victim may defend his own life, even unto the indirect death of the aggressor in necessity.

The materially unjust aggressor attacks the victim's life unjustly, but whether the aggressor is sane or insane, the attack is not voluntary. When an insane aggressor appears to use his will, such use lacks all moral quality because of the absence of intellect and reason; he wills improperly, as a brute is said to will. In either case, nevertheless, there is active aggression directed against the victim's life, which also sets the aggressor in juridic inferiority to the victim, and permits the victim to defend his own life to extremes. As great an authority as De Lugo holds that in such defence, whether the aggressor is formally or only materially such, the victim may directly kill, but direct killing is never necessary, as it is all a matter of intention.

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.