Part 3

XXIII. Psychic Epilepsy and Secondary Personality 259

XXIV. Impulse and Responsibility 266

XXV. Criminology and the Habitual Criminal 271

XXVI. Paranoia, a Study in Cranks 282

XXVII. Suicides 306

XXVIII. Venereal Diseases and Marriage 311

XXIX. Social Diseases 317

XXX. De Impedimento Matrimonii Dirimente Impotentia 326

APPENDIX. Bloody Sweat 347

INDEX 357

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ESSAYS IN PASTORAL MEDICINE

ECTOPIC GESTATION

Ectopic gestation is gestation in the uterine adnexa, the peritoneal cavity, or the horn of an abnormal or rudimentary uterus. It is opposed to natural uterine gestation, and, since it includes pregnancy in an abnormal uterus, it is a more comprehensive term than extrauterine pregnancy.

In this article the morality involved in the surgical treatment of ectopic gestation is considered; and to have the data requisite for judgment it is necessary to describe in outline the anatomy of the uterine adnexa and the growth of the foetus; to explain the varieties, effects, diagnosis, and treatment of ectopic gestation; to present the cases of this condition, or rather this disease, as they occur in medical practice; to set forth some of the moral principles or laws that govern medical practice, especially where there is question of life and death; and finally to apply these principles to the cases offered for investigation.

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 one inch thick. The base or fundus is upward, and the neck is downward. Passing out horizontally from the corners or horns of the uterus, which are at its base, 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 along the greater part of their extent The ends farthest {2} from the uterus are fringed and funnel-shaped; and this funnel-end, called the Infundibulum or the 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.

F U, Fundus or Base of the Uterus. F T, P T, Fallopian Tubes. On the left of the reader the Fimbriated Extremity of the tube is lifted up to show it. O, O, Ovaries. B L, B L, Broad Ligament. R, Rectum. B, Bladder.

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 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 opens into the wider part called (3) the Ampulla; (4) the Infundibulum, or the funnel-shaped end of the Ampulla. This part is fimbriated, as has been said, and one of the fimbriae--the Fimbria Ovarica--which is longer than the others, forms a shallow gutter which extends to the ovary.

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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 felt hat, of the kind called a "Fedora" hat, is held crown downward with one hand at the front and the other at the back of the rim, it will represent the pelvic cavity, and the fold along the crown of the hat coming up into this cavity is very like the Broad Ligament. As the crown is held downward, the uterus would be in the middle, its fundus upward, and, of course, altogether outside the hat, but in the crown fold. The tubes and ovaries would also be outside the hat and in the crown fold, and the fimbriated extremities would open by holes into the hat's interior.

The ovum breaks through the surface of the ovary, passes, probably on a capillary layer of fluid, into the fimbriated extremity of the tube, and then is moved along slowly through the tube into the uterus. Ovulation and menstruation occur about the same time, but often one antedates the other a few days. In exceptional cases they may occur independently.

If the ovum produced is not fecundated, it gradually shrivels up, and passes off through the uterus and the vagina. Fecundation of the ovum rarely occurs in the uterus, but ordinarily in the Fallopian tube, according to the general opinion of physiologists. After fecundation the ovum is pushed on into the uterus in from five to seven days, where it fastens to the wall and develops. Hyrtl (Kollmann's Lehrbuch der Entwickelungsgeschichte des Menschen, Jena, 1898) speaks of a case in which the ovum appeared to reach the uterus in three days. If the fecundated ovum is blocked or held in the Fallopian tube, the embryo grows where the ovum stops, and we have a case of Ectopic Gestation.

The average time of normal human gestation is ten lunar months or forty weeks. At the moment the pronucleus of the spermatozoon fuses with the pronucleus of the ovum in the Fallopian tube and makes the segmentation nucleus, in my opinion, the soul of the child enters, and personality exists as absolutely as it does in a child after birth. It is as much a murder, as such, to unjustly destroy this microscopic fecundated ovum as it is to kill the child after birth. This is the opinion of every embryologist I have consulted on the {4} subject, with the exception of one who said he did not know when the soul enters.

Technically the product of conception is called the Ovum for the first two weeks of pregnancy; during the third and fourth weeks it is called the Embryo, and after the fifth week the Foetus. During the fourth week the embryo begins to draw nourishment from the maternal blood through its umbilical vessels, but before that time it obtains nourishment by osmosis.

The foetus at the end of the eighth week is about one inch in length; at the end of the fourth lunar month it is from four to six inches long, and its sex may be distinguished. At the end of twenty-four weeks, if the normal foetus is born it will attempt to breathe and to move its limbs, but it dies in a short time. At the end of twenty-eight weeks of gestation if it is born it moves its limbs freely and cries weakly. It is nearly fifteen inches in length and weighs about three pounds. Such an infant might be deemed viable, but its chances for life are extremely precarious, even in most expert hands and with the help of an incubator. At the end of thirty-two weeks of gestation a foetus if born may be raised with skilful care, but the chances are not promising. It is viable. At the end of forty weeks the child is at term.

In 1876 Parry collected 500 cases of extrauterine pregnancy from medical literature, but when Tait in 1883 first operated on a case of ruptured tubal pregnancy attention was called to the subject. It was better understood as coeliotomies (opening the abdomen) became common, and in 1892 Schrenck collected 610 cases that had been reported during the preceding five years. Kuestner alone has operated on 105 cases in five years.

There has been much discussion among physicians as to the causes that arrest the fertilized ovum in the tube, but whatever these causes may be they do not affect the moral questions which come up in this article. There may be mechanical obstruction from peritoneal adhesions, or abnormal conditions resulting from inflammatory diseases of the tubes, ovaries, and the pelvic peritoneum, but no general cause that will explain all cases can be ascribed.

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