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.