{"collection":"philosophy-ethics","full_text_available":true,"graph_url":"https://unchartedknowledge.5gfusion.net/v2/api/page/gutenberg_42764/graph","html_url":"https://unchartedknowledge.5gfusion.net/v2/page/gutenberg_42764","id":"gutenberg_42764","license":"Public Domain (US)","rights_basis":"gutenberg_metadata_copyright_false","source":"gutenberg","source_url":"https://www.gutenberg.org/ebooks/42764","summary":null,"tags":["Category: Health & Medicine","Category: Philosophy & Ethics","Category: Religion/Spirituality","Medical ethics"],"text":"Note: Project Gutenberg also has an HTML version of this\n      file which includes the original illustrations.\n      See 42764-h.htm or 42764-h.zip:\n      (https://www.gutenberg.org/cache/epub/42764/pg42764-images.html)\n      or\n      (https://www.gutenberg.org/files/42764/42764-h.zip)\n\n\n      Images of the original pages are available through\n      Internet Archive/Canadian Libraries. See\n      http://archive.org/details/theethicsofmedic00omaluoft\n\n\nTranscriber's note:\n\n      Text enclosed by underscores is in italics (_italics_).\n\n      Small capital text has been replaced with all capitals.\n\n      The text (page 234) contains one chemical formula in\n      which the numbers enclosed in curly braces are subscripted\n      (C{17}H{21}NO{4}).\n\n\n\n\n\nTHE ETHICS OF MEDICAL HOMICIDE AND MUTILATION\n\nby\n\nAUSTIN O'MALLEY, M.D., PH.D., LL.D.\n\n\n\n\n\n\n\n[Illustration: printer logo]\n\nNew York\nThe Devin-Adair Company\n1922\n\n\n\nNihil obstat\nArthur J. Scanlan, S.T.D.\n_Censor Librorum_\n\nImprimatur\n\n[see Transcriber's note below] JOHN CARDINAL FARLEY\nArchbishop of New York\n\nCopyright, 1919, by\nThe Devin-Adair Company\n\nAll Rights Reserved by\nThe Devin-Adair Company\n\nThird Printing\n\nPrinted in U.S.A.\n\n\n\n\nCONTENTS\n\n\n  CHAPTER I\n\n  GENERAL PRINCIPLES CONCERNING SUICIDE AND HOMICIDE\n\n                                                                  PAGE\n\n  There is a Supreme Being who alone is master of life. The\n  Natural Law. The nature and determinants of morality.\n  Probabilism. Permissive suicide. Suicide is illicit.\n  Conscience. Homicide, direct and indirect. Self-defence.\n  Formal and material aggressors. Legalized homicide.\n  Bibliography                                                    1-22\n\n\n  CHAPTER II\n\n  GENERAL PRINCIPLES CONCERNING MUTILATION\n\n  Mutilation. Canonical irregularity. Self-mutilation. The\n  double effect in morality. Direct and indirect mutilation.\n  The State and mutilation. The dominion of the State            23-32\n\n\n  CHAPTER III\n\n  WHEN DOES HUMAN LIFE BEGIN?\n\n  Ancient and modern opinions. The fetus is animated at the\n  moment of conception. The single cell as the primal\n  life-organ. Cell growth and division. Germ cells. The\n  development of the embryo. Fetal viability. Theories\n  of development. The Aristotelian and Thomistic opinions.\n  The formal principle. A soul exists. The primordial\n  cell is a sufficient organ for the soul. Metabolism\n  in the cell. Cell motion. Animal heat and energy.\n  Life in separated tissues. The soul in monsters                33-82\n\n\n  CHAPTER IV\n\n  WHEN DOES HUMAN LIFE END?\n\n  The heart and life. Resuscitation after apparent death. The\n  last sacraments in apparent death. Suspended animation.\n  The living fetus in the womb of a dying or dead\n  mother. Methods of resuscitation. Signs of death               83-91\n\n\n  CHAPTER V\n\n  ABORTION\n\n  Abortion and miscarriage. Causes of abortion, fetal,\n  maternal and paternal. Surgical operations and abortion.\n  The debitum in pregnancy. Premature labor. Threatened,\n  inevitable, and incomplete abortions. Treatment. The\n  use of the tampon. Precautions against abortion. Therapeutic\n  abortion. Methods of inducing abortion. Artificial\n  abortion of an inviable fetus is never licit. Decrees\n  of the church concerning abortion. The civil law\n  on abortion                                                   92-123\n\n\n  CHAPTER VI\n\n  ECTOPIC GESTATION\n\n  Ectopic gestation or extrauterine pregnancy. Anatomy of the\n  uterus and its adnexa. Place of fecundation. The abnormal\n  uterus. Tubal rupture and tubal abortion. Diagnosis.\n  Decrees of the church on ectopic gestation. Removal\n  of an inviable ectopic fetus except in present\n  peril of life is illicit                                     124-132\n\n\n  CHAPTER VII\n\n  CESAREAN DELIVERY\n\n  Indications for cesarean delivery. Abnormal pelves.\n  Symphyseotomy. Varieties of cesarean delivery. Morality.\n  Amputation of the uterus after cesarean delivery.\n  Precautionary sterilization of a cesarean case is illicit    133-142\n\n\n  CHAPTER VIII\n\n  PLACENTA PRAEVIA AND ABRUPTIO PLACENTAE\n\n  Nature and effects of placenta praevia. Treatment. Morality\n  and methods of treatment. Abruptio placentae. Morality\n  of fetal removal                                             143-146\n\n\n  CHAPTER IX\n\n  ABDOMINAL TUMORS IN PREGNANCY\n\n  Tumors blocking parturition. Fibroids or myomata. Ovarian\n  tumors. Cancer. Effects and morality of operation            147-152\n\n\n  CHAPTER X\n\n  APPENDICITIS IN PREGNANCY\n\n  Occurrence. Time of operation. Diagnosis                     153-154\n\n\n  CHAPTER XI\n\n  PUERPERAL INSANITY AND STERILIZATION\n\n  Causes. Varieties. Prognosis. Precautionary sterilization\n  of puerperal psychopaths is illicit                          155-157\n\n\n  CHAPTER XII\n\n  NEPHRITIS IN PREGNANCY\n\n  Frequency. Effects. Abortion as a treatment. Varieties of\n  nephritis. Pyelitis. Catalepsy                               158-161\n\n\n  CHAPTER XIII\n\n  ECLAMPSIA PARTURIENTIUM\n\n  Definition. Symptoms. Prognosis. Causes. Precautions\n  against eclampsia. Forced delivery. The expectant\n  treatment. Relative mortality and morality of the\n  methods. Cesarean delivery as a treatment. The expectant\n  treatment is apparently the best                             162-169\n\n\n  CHAPTER XIV\n\n  HEART DISEASES IN PREGNANCY\n\n  Factors in abnormal gestation. The use of pituitrin. Weak\n  pains and the diseased heart. The diseased heart in\n  actual parturition. Operative risk in cardiopaths. Heart\n  block and mitral regurgitation in labor. Prognosis           170-176\n\n\n  CHAPTER XV\n\n  HYPEREMESIS GRAVIDARUM\n\n  Pernicious vomiting. Occurrence. Symptoms. Stages. Effects.\n  Causes. Therapeutic abortion in pernicious vomiting.\n  Treatment                                                    177-181\n\n\n  CHAPTER XVI\n\n  CHOREA GRAVIDARUM AND HYSTERIA\n\n  Varieties of chorea. Differentiation. Prognosis. Hysteria.\n  Causes. Epidemics of hysteria. Symptoms. Prognosis           182-186\n\n\n  CHAPTER XVII\n\n  ACUTE YELLOW ATROPHY OF THE LIVER IN PREGNANCY\n\n  Icterus gravis. Causes. Symptoms. Prognosis                  187-188\n\n\n  CHAPTER XVIII\n\n  INFECTIOUS DISEASES IN PREGNANCY\n\n  Effects on mother and fetus. Abortions in infectious\n  diseases. Placental permeability. Typhoid. Smallpox.\n  Pneumonia. Influenza. Scarlatina. Measles. Cholera.\n  Tuberculosis. Artificial abortion in tuberculosis            189-200\n\n\n  CHAPTER XIX\n\n  SYPHILIS IN PREGNANCY AND MARRIAGE\n\n  Prognosis. Abortion. Infection of mother and fetus. Colles'\n  Law. Erroneous notions on the curability of syphilis.\n  Once a syphilitic probably always a syphilitic. The\n  professional secret in syphilis. Nature of secrets. The\n  physician may warn an innocent person                        201-211\n\n\n  CHAPTER XX\n\n  GONORRHOEA IN MARRIAGE\n\n  The cause of gonorrhoea. Tests of cure. Effects on a woman.\n  Chronicity. Prevalence. Surgical treatment in women.\n  Morality of the surgical treatment. Conservative surgery.\n  Salpingotomy. Ovariotomy. Evil effects of\n  ovariotomy. Internal secretion of the ovary. Results of\n  various operations. Pregnancy after operation. Morality\n  of infection. General effects of gonorrhoea. Ophthalmia\n  neonatorum and gonorrhoea                                    212-229\n\n\n  CHAPTER XXI\n\n  DIABETES IN PREGNANCY\n\n  Fatality of diabetes in pregnancy. Diagnosis. Sterility\n  of diabetics. Prognosis. Heredity in diabetes. Therapeutic\n  abortion in diabetes                                         230-231\n\n\n  CHAPTER XXII\n\n  CHILDBIRTH IN TWILIGHT SLEEP\n\n  Twilight sleep to avert pain in parturition. Stages of labor.\n  Drugs used. Scopolamine and morphine. Danger in\n  the use of these drugs in labor. Contradictory report\n  of physicians on twilight sleep. Eminent authorities opposed\n  to the methods. Baer's report on the evil effects.\n  The methods are morally illicit and useless                  232-244\n\n\n  CHAPTER XXIII\n\n  VASECTOMY, OR STERILIZATION, BY STATE LAW\n\n  The States that have this law. Reasons for the law. Hereditary\n  transmission of certain diseases. The operation.\n  Its effects. Restoration of the function of the interrupted\n  vas deferens. Vasectomy and impotence. Onanism.\n  Vasectomy effects impotence from the moral\n  point of view. Other conditions in the male that effect\n  moral impotence. Immorality of artificial impregnation.\n  Vasectomy a grave mutilation. Vasectomy as ordinarily\n  practised is illicit. The State and vasectomy.\n  The limitations of the State's dominion. The State surgeon\n  and vasectomy. Bibliography                                  245-268\n\n\n  CHAPTER XXIV\n\n  THE ETHICS OF BIRTH CONTROL                                      269\n\n  Index                                                            281\n\n\n\n\nPREFACE\n\n\nIn this book is discussed the morality involved in the ordinary cases\nof medical homicide and mutilation. Craniotomy has been omitted\nbecause this operation on the living child is never morally licit,\nand when done on the dead fetus it has no moral quality that requires\nexplanation.\n\nThe articles may seem to be intended for Catholic physicians and\nspiritual directors alone, but the desire in writing them was to\nreach all practitioners, to the end that the Natural Law which\nbinds every man may be observed. Morality is not made such in\nits fundamental principles by any religious creed, but by the\nrequirements of Divine Order, which finally prevails no matter what\nthe opposition. Killing and maiming without sufficient extenuation\ndid not become unlawful solely by the establishment of Christianity.\nPractically, however, physicians who have no religion, or a religion\nwhich is so illogical as to pay no attention to dogma, or even to\nrail at it as obtrusive, necessarily gravitates to the emotional in\nmorality, and the principles of this book will not even interest\nthem. Dogmas are abstract propositions, and all human society rests\non abstract propositions. The most vital facts in morality, the basic\ndistinction between crime and all that is virtuous or indifferent\nmorally, is in abstract principle alone, but physicians and pastors\nwho are not trained in philosophy and rational religion cannot\nappreciate an abstract principle--they are influenced only by the\nconcrete.\n\nObstetrical text-books, unfortunately, are written by such emotional\nmen; by men who lack all training in ethics other than that\ninculcated in childhood out of the mental vagaries of the women in\nthe household; and these authors prescribe therapeutic homicide as\nif it were a drug in the American Pharmacop\u0153ia. The reader is told\nthat if the patient is a Catholic he is to respect her religious\n\"prejudices\"; if she is not a Catholic one need not bother about\nmoral scruples when it is necessary to take a life to stop fits.\nSince the civil law does not prosecute a physician for therapeutic\nabortion on an inviable child, most physicians deem such an act\nnot only permissible but scientific, and they hold that if a man's\nconscience will not let him kill a fetus to alleviate maternal\ndistress he is guilty of malpractice.\n\nDecrees of the Catholic Church are cited in these pages, not because\nmorality is an asset of the Catholic Church alone, but because\nit alone pronounces officially on these medical subjects after\ncareful consideration by competent specialists. This Church has\nmade decisions in comparatively few medico-moral cases, and the\nquestions still undecided authoritatively are very numerous. They\nare quite difficult, too, because judgment supposes a knowledge\nof both medicine and ethics, a combination seldom found in one\nperson. As physicians do not know ethics, and moralists do not know\nmedicine, there is often trouble in getting at even a statement of\nthe questions at issue between them. In the preface to _Essays in\nPastoral Medicine_, in 1906, I mentioned a noted case of this kind,\nand in 1911 a similar incident occurred in a discussion of the\nmorality involved in the sterilization of criminals and the defective\nby the state. This dispute was taken up by the leading canonists and\nmoral theologians in the United States, Belgium, Holland, Austria,\nSpain, Italy and France, and for nearly two years these men wrote\narticle after article based upon utterly erroneous physical data.\n\nThe books we have on medico-moral subjects are either obsolete at\npresent, or insufficient; or, more commonly, they are the work of\namateurs in medicine. These last are worthless when they are not\nharmful. If, however, I may judge from the questions sent to me for\nanswer by clergymen and physicians from all parts of the country,\nour theological seminaries and medical schools are in grave need of\ncourses on the morality of medical practice. In this book, to the\npreparation of which I have given years of anxious thought because of\nthe extreme responsibility involved in its decisions, the data for\nthe most important parts of such courses are presented.\n\n  AUSTIN O'MALLEY.\n\n\n\n\nTHE ETHICS OF\n\nMEDICAL HOMICIDE AND MUTILATION\n\n\n\n\nTHE ETHICS OF MEDICAL HOMICIDE AND MUTILATION\n\n\n\n\nCHAPTER I\n\nGENERAL PRINCIPLES CONCERNING SUICIDE AND HOMICIDE\n\n\nA Discussion of euthanasia through the use of narcotics in cases of\nincurable diseases periodically recurs, and the opinions of those in\nfavor of putting the patient out of his misery are expressions of\nmere sentimentality, as in Maeterlinck's essay, _Our Eternity_. They\nthink either that the passing of a law by a legislature removes all\nmoral difficulty, or that morality is a trifle which should never\nstand in the way of expediency. Those who oppose this method of\neuthanasia base their argument, first, on the fact that many patients\nsupposed by even clever diagnosticians to be incurable recover\nhealth; and, secondly, on the fact that the giving power of life and\ndeath to physicians is liable to grave abuse. This side misses the\ncentral truth and argues from accidental and secondary premises.\nWhether it is expedient, humane, or impolitic to kill incurable\npatients are almost irrelevant considerations: the fundamental\nquestion to be answered here is, Is there a Supreme Being who alone\nis master of life, to give it or to take it?\n\nBy its very definition such a Being is necessary (as opposed to\ncontingent), self-existent; its essence always has been and always\nwill be actualized into existence, and that from itself alone; it is\nan individual substance of an intelligent nature, and therefore a\nperson. A contingent being is one that happens to be (_contingere_);\nit is of necessity neither existent nor non-existent; it has no\nlogical aversion to existence, but in itself it has no more than\na possibility of actuality. A necessary Being, on the contrary,\nessentially must be; it cannot not be; it is absolutely and\nessentially its own existence.\n\nThere must be such a Necessary Being. If there were not, all things\nwould be contingent, which is an absurdity. The absurdity arises\nfrom the fact that if all things were contingent nothing would be\nactual, nothing could ever come into existence, because there would\nbe nothing to bring the primitive potentiality of the contingent\nbeings into actual existence. The sufficient reason for the existence\nof contingent beings is either in themselves or in something outside\nthemselves. It cannot be in themselves, because as they do not yet\nexist they are nothing; therefore it is in a Being which is not\ncontingent, but whatever is not contingent is necessary. Therefore\nthe existence of contingent beings absolutely requires the existence\nof a Necessary Being, which always was in existence. The ordinary\nname for this Necessary Being is God. Contingent beings are all\ncreatures, all organic and inorganic beings without exception. There\nis, then, a God, the first cause or creator of all contingent beings,\namong whom is man; and since God created man wholly, this creature is\nwholly subservient to God, under the dominion of God, and his life is\nowned solely by God; God alone is the master of life and death, and\nhe alone can delegate such mastery.\n\nFrom the relation between the Creator and the creatures arises the\nnatural law. Violation of this law is the source of all moral evil\nin the world, and of much of the physical evil. Reason shows us\nthis law, and the method of observing it; and reason and unreason,\nobservance or disregard, of the order fixed by the natural law are\nthe foundation of happiness and unhappiness. Whatever a human being\nis or does, he must seek happiness; that is an essential quality\nof his being. Happiness is the satisfying of our desires; but as\nour desires are limitless, only infinite good can satisfy them. The\nsole sufficient good that sates all human longing is the infinite\nNecessary Being, and to be happy we must be united with that Being.\nObviously the only possible method of possessing this infinite\nGod is through mental union, by undisturbable contemplation of his\ninfinite truth, goodness, being, beauty, and his other attributes. If\nperfect, everlasting happiness is not in that, in what can it be? Is\nit in human fame, honor, riches, science, art, man, woman, or child?\nNone of these can give _lasting_ happiness, and no other happiness is\nreal happiness.\n\nNow, the only means we have to obtain union with infinite good is to\nfollow out the condition inexorably placed by God, which is to act\nin life in keeping with right reason, to obey the law. Man's supreme\nhonor is in freedom from the tyranny of unreason, and in a full\nobedience to external and immovable order, with the belief that his\nchief duty is to apprehend and to conform thereto.\n\nThis is morality. From the beginning men have held that certain\nacts are wrong and to be avoided, and that others are to be done.\nWhat is wrong, moreover, is such of its own nature, not from our\nwill: we deem the fulfillment of duty, obedience to law, the first,\nhighest, and last necessity of life. If we deny this truth we let in\nchaos. What is right or wrong is one or the other on its own merits,\nprescinding from its pleasurableness or pain.\n\nWe must seek good whether we will or not. Good is the sole object\nupon which the will operates, it is the raw material of the will's\nbusiness. The ultimate standard of this good is God himself as its\nexemplary cause, but proximately the standard of moral good is our\nrational nature. Through our reason we judge whether a thing is good\nor bad; that is, whether it perfects or injures us; and as it is good\nor bad for us our will's tendency toward it is good or bad. Many acts\nare indifferent in themselves, but take on a good or bad quality from\nour intention; others are good or bad in themselves apart from our\nvolition: charity is good, lying is bad, whether they are willed by\nus or not.\n\nThe morality of any action is determined (1) by the object of the\naction; (2) by the circumstances that accompany the action; (3) by\nthe end the agent had in view.\n\n1. The term _object_ has various meanings, but here it means the\ndeed performed in the action, the thing which the will chooses. That\ndeed by its very nature may be good, or it may be bad, or it may\nbe indifferent morally. To help the afflicted is in itself a good\naction, to blaspheme is a bad action, to walk is an indifferent\naction. Some bad actions are absolutely bad; they never can become\ngood or indifferent--blasphemy or adultery, for example; others, as\nstealing, are evil because of a lack of right in the agent: these\nmay become indifferent or good by acquiring the missing right.\nOthers are evil because of the danger necessarily connected with\ntheir performance,--the danger of sin connected with them, or the\nunnecessary peril to life. An action, to have a moral quality, must\nbe voluntary, deliberate; and mere repugnance in doing an act does\nnot in itself make the act involuntary.\n\n2. Circumstances sometimes, though not always, may add a new element\nof good or evil to an action. The circumstances of an action are\nthe Agent, the Object, the Place in which the action is done, the\nMeans used, the End in view, the Method observed in using the means,\nand the Time in which the deed is done. If a judge in his official\ncapacity tells a sheriff to hang a criminal, and a private citizen\ngives the same command, the actions are very different morally\nbecause of the circumstance of the agent giving the command. The\nobject--it changes the morality of the deed whether one steals a\ncent or a thousand dollars. The place--what might be an offensive\naction in a residence might be a sacrilege in a church. The means--to\nsupport a family by labor or thievery. The end in view--to give alms\nin obedience to divine command or to give them to buy votes. The\nmethod used in employing the means--kindly, say, or cruelly. The\ntime--to do manual labor on Sunday or on Monday. Some circumstances\naggravate the evil in a deed, others excuse or attenuate it. Others\nmay so color the deed that they specify it, make it some special\nvirtue or vice. The circumstance that a murderer is the son of the\nman he kills specifies the deed as parricide.\n\n3. The end also determines the morality of an action. Since the\nend is the first thing in the intention of the agent, he passes\nfrom the object wished for in the end to choosing the means for\nobtaining it. Without the end the means cannot exist as such. There\nare occasions when an end is only a circumstance: for example, if\nit is a concomitant or extrinsic end. When this extrinsic end is in\nkeeping with right reason or when it is discordant thereto, it may\nbecome a determinant of morality. In every voluntary, or human, act\nthere is an interior and exterior act of the will, and each of these\nacts has its own object. The end is the proper object of the interior\nact of the will; the exterior object acted upon is the object of\nthe exterior act of the will; both specify the morality, but the\ninterior object or end specifies more importantly, as a rule, than\nthe exterior object does. The will uses the body as an instrument on\nthe external object, and the action of the body is connected with\nmorality only through the will. We judge the morality of a blow not\nby the physical stroke, but from the intention of the striker. The\nexterior object of the will is, in a way, the matter of the morality,\nand the interior object of the will, or the end, is the form.\nAristotle said: \"He that steals to be able to commit adultery is more\nof an adulterer than a thief.\"[1] The thievery is a means to the\nprincipal end, and this principal end chiefly specifies or informs\nthe action.\n\n  [1] _Ethics_, v, c. 2.\n\nThe means used to obtain an end are very important in a consideration\nof the morality of an act. There are four classes of means--the\ngood, bad, indifferent, and excusable. Good means may be absolutely\ngood, but commonly they are liable to become vitiated by\ncircumstances,--almsgiving is an example. Some means are bad always\nand inexcusable--lying, for instance. The excusable means are those\nwhich are bad, but justifiable through circumstances. To save a man's\nlife by cutting off his leg is an excusable means. The end sometimes\nmay vitiate or hallow indifferent means, but it does not in itself\njustify all means. Means, like other circumstances, are accidents\nof an action, but they are in the action just as much as color is\nin a man. Color is not of a man's essence, but we cannot have a man\nwithout color.\n\nThe effect of an action, the result or product of an effective cause\nor agency, may in itself be an end or an object or a circumstance,\nand it has influence in the determination of morality. Sometimes\nan act has two immediate effects, one good and the other bad. For\nexample, ligating the blood-vessels going to the uterus to stop a\nhemorrhage and so save a woman's life, a good effect, has also in\nectopic gestation while the fetus is living another immediate effect,\nnamely, to shut off the blood supply from the fetus and so kill it, a\nbad effect. To make such a double-effect action licit there are four\nconditions which are explained in the chapter on Mutilation.\n\nThe doctrine of Probabilism is very important in morality. Any law\nmust be promulgated before it really becomes a law, and promulgation\nin a rational conscience is sufficient. Sometimes there is rational\ndoubt of the existence, the interpretation, or the application of a\nlaw in a given case. Here probability is the only rule we can follow.\nA law which is doubtful after honest and capable investigation has\nnot been sufficiently promulgated, and therefore it cannot impose a\ncertain obligation because it lacks an essential element of a law.\nWhen we have used such moral diligence as the gravity of the matter\ncalls for, but still the applicability of the law is doubtful in\nthe action in view, the law does not bind; and what a law does not\nforbid it leaves open. Probabilism is not permissible where there is\nquestion of the worth of an action as compared with another, or of\nissues like the physical consequences of an act. If a physician knows\na remedy for a disease that is certainly efficacious and another that\nis doubtfully efficacious, he may not choose this probable cure.\nProbabilism has to do only with the existence, interpretation, or\napplicability of a law, not with the differentiation of actions.\nThe term probable means provable, not guessed at, not jumped at\nwithout reason. The doubt must be positive, founded on reason, not\na matter of mere ignorance, suspicion, emotional bias. The opinion\nagainst a law to permit probabilism must be solid. It must rest upon\nan intrinsic reason from the nature of the case, or an extrinsic\nreason from authority, always supposing the authority is really an\nauthority. The probability is to be comparative also. What seems to\nbe a very good reason when standing alone may be weak when compared\nwith reasons on the other side. When we have weighed the arguments\non both sides, and we still have a good reason for holding our\nopinion in a doubtful case, our opinion is probable. The probability\nis, moreover, to be practical. It must have considered all the\ncircumstances of the case.\n\nThere is, then, a Supreme Being whom we _must_ obey, who created\nand owns human life primarily; there is also a moral law. On these\nfacts rests the argument relating to the destruction of human life.\nHow far, then, has a human being dominion over his own life, and,\nsecondly, over the life of any one else?\n\nSt. Thomas,[2] Lessius,[3] and others offer as one argument to prove\nsuicide is not licit, that it is an injury to society or the state\nof which the suicide is part, and to which the use and profit of\nhis service rightly belong. Lessius, while developing this proof,\nacknowledges its weakness.\n\n  [2] _Summa Theologica_, 1, 2, q. 64, a. 5.\n\n  [3] _De Justitia et Jure_, lib. 2, cap. 9.\n\nIf there were only one man in the world, and no society or state,\nsuicide would still be illicit, because its basic deordination lies\ndeeper than society or the state. If suicide were a moral evil solely\nbecause it deprives the state of the suicide's life, then for the\nsame reason no one might become a citizen of another state, emigrate,\nnor might man abandon society and live as a recluse. Moreover, if a\nman were detrimental to the state rather than beneficial, in this\npoint of view that fact alone would justify suicide, and the state\nwould then be justified in permitting or even commanding suicide; and\nwe shall show later that the state has not this power.\n\nIt is true that the injury done the state or society by loss of use\nand profit, by scandal and similar evils, is a solid argument against\nsuicide, as such injury aggravates the deordination of suicide,\nbut in itself the injury done to the state and society is not the\nfundamental reason against suicide.\n\nSt. Thomas[4] argues against suicide because it is contrary to\nthe charity a human being should have for himself. This is true\nordinarily, and suicide takes on part of its guilt just because it\nis an offence against the rational regard a person should have for\nhimself; yet this argument is not basic. We are told that if one sins\nagainst charity in killing his neighbor, _a fortiori_ he sins in\nkilling himself. Yet suppose just what the advocates of euthanasia\nsuggest, viz., that a neighbor is in great agony and incurable: then\nthe act of killing him takes on a quality of charity rather than\nof uncharity. And so for the suicide: if the patient is willing to\nbe killed, there would be no uncharity; if he were unwilling, then\nhomicide in any form would be uncharitable and unjust. The argument\nfrom charity, therefore, is too narrow to fit the whole case; and its\nvery weakness is a source of error for the advocates of euthanasia.\n\n  [4] _Ibid._\n\nStill another argument is often advanced against suicide, viz., that\na man is obliged to love his own life, since it is the foundation, or\nthe necessary condition, to him, of all good and every virtue, and\nthis circumstance makes the destruction of that life unlawful. That\nargument has solid truth, but if it held absolutely it would prevent\nus from desiring death in any case, and no one denies that there are\nconditions in which a desire for death is fully legitimate. No desire\nfor death, however, can give the slightest justification for the\ndestruction of life.\n\nAgain, the argument that suicide is cowardice is not broad enough.\nFortitude is a mean between fear and rashness, and this argument\nmaintains that the suicide sins against fortitude by rashness. If we\nhave good reason it is not rash to expose ourselves to death; the\nsoldier may do so, the person struggling to save a neighbor's life,\nand so on; it may be the highest form of fortitude thus to expose\noneself to death. If the suicide can persuade himself that by his act\nhe is seeking greater good than the life he possesses he would have\nreason for his act, and at least be above cowardice. This argument is\none that can be turned at times so as to cut the fingers of the man\nthat uses it. The fundamental reason that suicide is not lawful is\nthat man cannot be master of his own life, and therefore he may not\ndispose of it as he pleases.\n\nSuicide is the direct killing of oneself on one's own authority.\nA killing is _direct_ when death is intended as an end, or chosen\nas a means to an end. Direct killing is positive by commission, or\nnegative by omission. In such cases the will directly rests in the\ndeath as a voluntary and free act. A killing is _indirect_ when the\nact of which death is the effect by its nature and the intent of the\nagent is directed toward another end, but concomitantly, or as a\nconsequence, results in death. In such case death is an accidental\neffect, and comes indirectly from the activity of the will--it is not\nnecessarily voluntary. If one has a right to do that other deed, or\nif it is his duty to do it, and there is a proportion between it and\nhis life, he may do the deed and permit the consequent death.\n\nA direct homicide may be done on one's own authority, or on that\nof another person. It is done on one's own authority if the agent\nassumes a natural individual dominion over life, and by virtue of\nsuch dominion directly kills himself or another; it is done on the\nauthority of another when a man directly kills himself or another\nby the mandate of a positive divine or human law, and in the name\nand on the authority of a positive divine or human legislator. It is\nevident that God, as Creator, has supreme dominion over human life,\nand therefore by his positive authority he may command a man directly\nto kill himself. God, however, does not by the natural law confer on\nman the right thus to kill. The question here is of the natural duty\nor right which comes from the natural law alone.\n\nDirect suicide on one's own authority may happen in two ways:\npositively, that is, by doing an act which is directly homicidal;\nor negatively, by omitting an act necessary for the preservation of\nlife. That a negative homicide be direct, death must be intended as\nan end or means. If, however, one voluntarily intends an end or a\nmeans, but for the sake of antecedent good or evil omits some act\nnecessary to preserve life, his suicide is indirect, _per accidens_,\nand not always illicit unless there is a precept against just such\nan omission. Man has no dominion over his own life, he has only\nthe use of it; and the natural law obliges us while using a thing\nwhich is under the dominion of another not to omit ordinary means\nfor its preservation. We are not, however, held to extraordinary\nmeans. His own death is criminally imputable to him who negatively\nand indirectly kills himself by omitting the ordinary means for\npreserving his life, because the precept he is under to preserve his\nown life makes his act voluntary. If he omits extraordinary means,\nthe death is not criminally imputable to him because there is no\nprecept obliging such means. Certain circumstances may by accident\noblige one to use extraordinary means to preserve one's own life--a\ndependent family, a public office in perilous times, or the like. The\nproposition, then, is: The natural law does not give a man absolute\ndominion over his own life.\n\nI. The natural law gives no rights except such as are finally founded\nin human nature itself; but human nature cannot give a title to\ndominion over one's own life; therefore the natural law does not give\nman such a right.\n\nEvery natural right is either congenital or acquired. The title to\na congenital right is human nature itself; the title to an acquired\nright is some act consequent to the exercise of human activity. The\nright to such exercise is, in turn, congenital and founded in human\nnature.\n\nIf nature established the title to dominion over one's own life it\nwould thereby establish the power of destroying that life, and thus\nof removing the fundamental title to all rights; but nature exists\nas the foundation for rights, not for the subversion of rights;\ntherefore human nature cannot give a final title to dominion over our\nown life.\n\nAgain, this minor of the first argument is confirmed by the fact that\nif nature even remotely established the power of self-destruction\nthere should be in nature itself some natural tendency to such\ndestruction, but the direct contrary is the fact.\n\nII. The natural law cannot grant a right to man which is not a means\nto the common end of human life; but absolute dominion over one's own\nlife is not such a means, therefore the natural law cannot give one\ndominion over his own life.\n\nThe natural law is only an ordination of man to that common end of\nhuman life and to the means toward that end. As regards the minor of\nthis second argument, an absolute dominion over his own life would\ngive man power to stop all his human activity, yet the common end of\nhuman life is attainable only by man's activity. The stopping, or the\npower of stopping, all activity cannot be a means to that end.\n\nIII. The natural law cannot give man a power which is opposed to the\nessential needs of human nature itself; but that a man should have\nabsolute dominion over his own life is opposed to an essential need\nof human nature itself, therefore the natural law cannot give such a\npower.\n\nDominion over his own life implies the power in man of rebelling\nagainst the subjection which he owes to God; but human nature\nessentially demands that man be in subjection to God, since dominion\nover one's own life and subjection to God are contradictory.\n\nAgain, if man had absolute dominion over his own life he could stand\naloof from all influx of the natural law and avoid every duty arising\nfrom that law. A law, however, cannot give a power which nullifies\nitself.\n\nThe objection that suicide is licit because no injury can be done\na man by an act if the man is willing to submit to the act, is\nirrelevant. The injury in suicide is not to man at all, but to God.\n\nThere is also nothing in the objection that a gratuitous gift may be\nrenounced. Life is not a gratuitous gift; it is an onerous gift with\nobligations inseparably affixed thereto which forbid the destruction\nof the gift.\n\nIV. Destruction is an act proper to a master alone. Man cannot be\nmaster of his own life; he can have dominion of things that are\noutside himself, distinguishable from himself, but not of the very\nexistence of himself, which is not really distinguishable from\nhimself. The definition of dominion supposes relation. The offices\nof master, father, magistrate, are relative conditions which suppose\nsuperiority over _another_ person, not over oneself. Even God is not\na superior over himself, although he has all perfection. For this\nreason a man cannot sell himself; he can sell only his labor.\n\nGod, who should have absolute dominion over all creatures, and who\nhas, wills to confine these creatures to certain lines of action\nin keeping with the creature's nature. This is the law underlying\neven the moral law when it touches humanity; it is the eternal law\ncoeternal with God's decree of creation, but not necessary as God is.\nWhen this law exists in the mind of God it is the eternal law; when\nit exists in the minds of creatures it is the natural law, governing\nthe free acts of intellectual creatures. When the natural law becomes\na motive to the human will, obliging but not forcing it, a law\nthrough knowledge within the consciousness of a man regulating his\nbehavior, it is called the law of conscience.\n\nConscience is an act, a practical judgment on one's own action in\nsome particular case. It testifies, accuses, excuses, restrains,\nurges. It is a rational faculty, not an emotional, sentimental power.\nEmotion blinds its judgments. Yet mere emotion, and that foolish\ndeordination of emotion called sentimentality, are promptings which\nthe ignorant mistake for conscience and obey. Conscience is the\nenlightened eye of the heart, not the vagary of any appetite that\nblunders into action. It must be educated; left to itself, it is\nguilty of all the perversions of the streets.\n\nThe natural law is immutable, not subject to recall by every rascal\nunder the goad of the flesh. In morality what was, is; what was once\nright because reasonable, always will be right and reasonable. Since\nopposition to the natural law as applied to man is repugnant to human\nnature, no power can make opposition to that law licit. For the same\nreason this law is not subject to evolution. Truth in morality is\neternal. What is ugly now was ugly a millennium ago; what was immoral\nyesterday was immoral in the sixth century. If our ancestors thought\npermissible what we know to be illicit, our ancestors were ignorant;\nthe fact has not changed. It was as immoral to steal, lie, or murder\nin the day of Abraham as it is to-day.\n\nThe ultimate tendency of man is toward happiness, and, of course,\nhappiness, or any other perfection, is impossible without existence;\nhence the instinctive recoil from the destruction of our life, which\nis the requisite condition for happiness. Even those that abnormally\ndestroy their own life do so with horror for the destruction\nitself, and act thus unreasonably to escape evil, not to escape\nlife; or they seek what they think will be a better life. We can do\nno other injury to a man so great as the depriving him of his life,\nfor that deprivation destroys every right and possession he has. He\ncan recover from all other evil, or hold his soul above every other\nevil, but death is the absolute conqueror. No matter how debased or\nhow diseased a man's body may be, no one may dissociate that body\nfrom its soul, except in defence of individual or social life under\npeculiarly abnormal conditions; but even such defence is permissible\nonly while the defender respects other human life and the social\nlife, while he is innocent, has done no harm to society commensurate\nwith the loss of his own life.\n\n        \"The weariest and most loathed worldly life\n    That age, ache, penury, and imprisonment\n    Can lay on nature is a paradise\n    To what we fear of death.\"\n\nExistence, no matter how sordid, is immeasurably better than\nnon-existence, for non-existence is nothing; and when we consider\neternal life after separation from the body, even as a probability,\nthat raises existence to infinite possibilities above the void\nof non-existence. A human life, even in an Australian Bushman,\nin a tuberculous pauper, in the vilest criminal, is in itself so\nstupendously noble a thing that the whole universe exists for its\nupholding toward betterment. The raising of human life toward a\nhigher condition has been the sole tendency of all the magnificent\ncharity, sacrifice, patriotism, and heroism the best men and women of\nthe world since time began have striven in. The necessary first cause\nitself is life, and life is by far the most sacred thing possible for\nthe first cause to effect. Eternal life is the greatest reward of the\njust.\n\nIt is not permissible under any possible circumstance _directly_ to\nkill an innocent human being. By killing directly is meant either (1)\nas an end desirable in itself, as when a man is killed for revenge;\nor (2) as a means to an end. By an innocent human being is meant\na person who has not by any voluntary act of his own done harm\ncommensurate with the loss of his own life.\n\nTo kill a human being is to destroy human nature, by separating the\nvital principle from the body; to destroy anything is to subordinate\nand sacrifice that thing absolutely to the purposes of the slayer;\nbut (1) no one has a right so to subordinate another human being,\nbecause man and his life are solely under the dominion of God. If\na man may not kill himself, as we proved above, because he is not\nmaster of his own life, he surely may not kill another to whom he is\nno more closely related as master than he is to himself. (2) No man\nhas a right to subordinate another human being as is done in slaying\nhim, because this other human being is a person, an intelligent\nnature, and consequently free, independent, referring its operations\nsolely to itself as to their centre. This very freedom differentiates\nman from brutes and inanimate things. These are not independent;\nthey are rightly possessed by man; but man may be possessed by no\none except God. Even extrinsic human slavery is abhorrent to us as a\ncorollary of the intrinsic freedom of man, which is absolute. This\nintrinsic freedom is such that we may not under any circumstances\nlawfully resign it to another's possession. This is one of the chief\nmoral objections to oath-bound secret societies which exact blind\nobedience. All morality depends on that freedom, all peace in life,\nall civilization, and society itself.\n\nThe end of our struggles, toil, fortitude, temperance, thrift, is\nfreedom,--freedom to do and to hold, freedom from the thraldom of\nvice and barbarity. The rational endeavor of every civilized nation\nis that it be free; and this means solely that every citizen thereof,\nfrom the highest to the lowest, is made secure in his rights as a\nhuman being. It intends that justice should prevail. Nearly all the\nunhappiness, crime, moral misery, and much of the physical misery in\nthe world are due to a disregard for liberty, for the safeguarding\nof men in their inalienable rights. Give every man his bare rights\nas a man and all troubles of capital and labor, all race problems\nwould cease, the prisons would be empty, war would be unknown. Our\nstruggle toward justice, toward the protection of the rights of man,\ntoward liberty, must go on, or anarchy and social destruction will\nensue. Now, as there is nothing greater and nobler than liberty, the\nfreedom of the sons of God to do what they have a right to do, and as\nevery human being has a right to that liberty, so there is nothing\nbaser than its contrary, the destruction of that liberty; and no\ndestruction is so final as that of killing the man, no usurpation\nso abhorrent to human nature and all liberty. Abhorrence for such\na destruction is the primal instinct of all human beings; even the\nirrational reflexes of our bodies react quickest in protecting us\nfrom that destruction.\n\nJustice and order must prevail; that is a fundamental natural law\nto which all other laws are subordinate. Justice, moreover, is a\nmoral equation, and whenever one right transcends another it must be\nsuperior to the right it holds in abeyance. The right an innocent\nhuman being has to his life, however, is so great that no other human\nright can be superior to it while he remains innocent. Subversion\nof this right by creatures is intrinsically evil, as blasphemy and\nperjury are evil, although not in exactly the same degree.\n\nThere are occasions upon which it is permissible to kill,\n_indirectly_, innocent persons. An effect is brought about indirectly\nwhen it is neither intended as an end for its own sake, nor chosen as\nmeans toward an end, but is attached as a circumstance to the end or\nthe means. Means help to an end, circumstances often do not, although\nthey may affect the morality of an act.\n\nSuppose two swimmers, Peter and Paul, are trying to save Thomas, who\ndies in the water; as he dies Thomas grips Peter and Paul so tightly\nthat they cannot shake the corpse off. Peter is weak, and he will\nsoon sink and drown, owing to his weakness and the weight of the\ncorpse; Paul also will go down later, owing to the weight of Peter\nand Thomas. Peter, however, cuts his own clothing loose from the grip\nof the corpse and is saved; but Paul immediately is drowned, owing\nto the fact that the full weight of the corpse comes upon him. Is\nPeter justified in cutting himself loose? Certainly he is. This is an\nexample of indirect killing, a case of double effect, one good, the\nsaving of Peter's life, the other evil, the loss of Paul's life, both\nproceeding immediately and equally from the causal act, the cutting\nloose of the clothing. The good effect is intended, the bad effect is\nreluctantly permitted.\n\nAgain, let us set the same condition for Peter, Paul, and Thomas; but\nPeter is not able to cut himself loose. John, a fourth person, can\ncut Peter loose and save him, but can do no more; he must let Paul go\ndown with the corpse of Thomas. May John cut Peter loose? Certainly\nhe may, on the principle _quod liceat per se licet per alium_. This\nis another case of double effect, with the extenuating circumstances\nas above.\n\nSuppose, however, Peter represents a living infant in the womb\nof Ann, and that she is in labor; further, this infant cannot be\ndelivered owing to the contraction of Ann's pelvis. May John, a\nphysician, cut away Peter by craniotomy and so save Ann's life?\nCertainly he may _not_. John here _directly_ brains Peter to save\nAnn, although Peter is not an unjust aggressor; he does a murder to\nget a good effect, and the end does not justify the means. There are\ntwo effects, but the good effect follows from the bad one, and not\nimmediately from the causal act.\n\nTake another example: Peter is a swimmer disabled by cramps and about\nto drown; Paul, going to save Peter, is seized by Peter, and both\nare now in danger of drowning; John goes to help Peter and Paul.\nHe cannot get Peter's grip loose by ordinary means, and he sees he\ncan save only one man, either Peter or Paul. May John knock Peter\nsenseless to loosen his grip from Paul, bring in Paul, and thus leave\nPeter to drown? Certainly he may. You have the double effect here\nalso. Moreover, Peter is a materially unjust aggressor; he is like a\nmaniac trying to kill Paul. In the craniotomy case the child is not\na materially or formally unjust aggressor, it is not doing anything\nat all. It is where the mother put it, and it has a full right to its\nposition and its life.\n\nJohn most probably might also knock Paul senseless and save Peter,\nif through affection or similar motive he preferred this course.\nHe would then be justified by the double-effect principle alone,\nalthough Paul is in no sense an aggressor. The intention of the blow\nwould have to be solely to loosen Paul's hold.\n\nIn a just war a commander may shell an enemy's works and indirectly\nthereby kill non-combatants. The gunners that cause the death of the\nnon-combatants do not intend this death; they permit it as the evil\neffect which comes immediately with the good effect (the capture of\nthe works) from the causal act of firing the guns.\n\nIf we keep within the bounds of a just defence we may protect\nourselves against an unjust aggressor to the effusion of his blood,\nor even, if need be, to killing him. An aggressor is any one who\ndoes injury to us contrary to our rights and the ordination of\nright. A formally unjust aggressor is a sane intelligent person who\nintentionally attacks us; a materially unjust aggressor is one who\nis not intelligent, not responsible, as an insane person, a child,\nor a sane person who is injuring us unintentionally. This question\nis important in medicine because the fetus _in utero_ is often\nerroneously called an unjust aggressor.\n\nIt is a primary law of nature that every human being should and will\nstrive to resist injury and destruction. Justice requires a moral\nequation, and if one right prevails over another it must be superior\nto the right it supersedes. At the outset both the aggressor and\nthe intended victim have equal rights to life, but the fact that\nthe aggressor uses his own life for the destruction of a fellow man\nsets the aggressor in a condition of juridic inferiority to the\nvictim. The moral power of the aggressor here is equal to his inborn\nright to life, _less_ the unrighteous use he makes of it; while the\nmoral power of the intended victim remains in its integrity, and has\ntherefore a higher juridic value.\n\nThe right of self-defence is not annulled by the fact that the\naggressor is irresponsible. The absence of knowledge saves him\nfrom moral guilt, but it does not alter the character of the act\nconsidered objectively; it is yet an unjust aggression, and in the\nconflict the life assailed has still a superior juridic value. In\nany case the right of wounding or of killing in self-defence is\nnot based on the ill will of the aggressor, but on the illegitimate\ncharacter of the aggression.\n\nThe condition's of a blameless defence (_moderamen inculpatae\ntutelae_) are: (1) that the aggressor really threatens the defender's\nlife, and there is no means of offsetting that violence except like\nviolence; (2) that no more violence is used than is adequately\nrequired: if the aggression can be stopped by wounding the aggressor\nthe defender is not to kill him; (3) that the violence in the defence\nis used with the intention of defence, not in revenge, hatred, anger,\nor the like motives.\n\nWe may do an act good in itself from which a double effect\nimmediately follows, one good, to which the agent has a right, and\nthe other bad, which the agent is not obliged to omit if permitted\nby him and not intended; but in the case of a necessary defence of\nlife against an unjust aggressor, made even with the death of the\naggressor, the defence is such an act, provided the moderation of a\nblameless defence is observed.\n\nThe evil effect here is not a means to the good effect, nor does it\nmore immediately follow from the act done. The evil effect is an\neffect _per accidens_, and thus not directly voluntary, either in\nitself, because it is not intended, or in its cause. It lacks the\ncondition necessary to make it voluntary in cause as regards the\naccidental effect since the act is not prohibited precisely because\nthis accidental effect follows.\n\nThe act in the case is good in itself; it is an application of\nphysical force in defence of a proper right, and any right supposes\na compulsive power. The two effects of this double-effect act are:\n(_a_) the preservation of the defender's life, and (_b_) the death of\nthe aggressor. The first effect is good because the defender has a\nright to his own life; the other effect is evil, not only physically\nfor the one who dies, but morally inasmuch as the death conflicts\nwith the dominion of God. This death, however, is an accidental\neffect of the act, because in general the defensive act is not\ndirected by its nature to that death but to the preservation of the\ndefender's life; nor does the death follow more immediately than the\npreservation. Thus it is not a means of the defence. Finally, the\ndefensive act is not prohibited precisely lest that death follow: not\nin justice, for there is no justice in any right of the aggressor\nwhich requires from the defender an omission of defence unto the loss\nof life; there is no obligation in charity, since charity does not\noblige us to love another more than ourselves, or to exalt the good\nof another above our own.\n\nIn an aggression which is merely material--say, in an attack by an\ninsane man--the defender has a right to the infliction of such damage\nas is necessary and proportionate to an efficacious defence. The\nright of the aggressor yields to the superior right of the defender,\nnot through the fault of the aggressor but through his misfortune.\nThere is a collision where both rights cannot be exercised at the\nsame time, and there is no reason obliging the defendant to forego\nhis own right.\n\nWe may defend another against an unjust aggressor because we can\nassume that the attacked person communicates to us the use of his\nown coactive right. If the aggressor is our own father, mother, son,\nor daughter, or in general any one to whom charity obliges us more\nthan to the person attacked, we are not permitted to kill our own kin\nbecause charity does not oblige us to prefer the good of an alien\nto the good of one of our blood. Ordinarily we are not obliged in\njustice or charity to defend another at the risk of our own life.\n\nWe may kill an unjust aggressor, _servatis servandis_, in defence\nof good equivalent in value to life: for example, to prevent life\nimprisonment, the loss of reason, a mutilation which would render us\nuseless, the loss of a woman's chastity.\n\nThere are cases of _accidental_ homicide, in medicine and elsewhere,\nwhich have an element of guilt in them. If a death follows\naccidentally upon an act which in itself is licit, and the agent\nuses all proper precautions, he is not morally guilty in case of\nan accidental death following his act. This is true even if the\nagent foresaw a probable death but did not intend it. If, however,\nthe agent's primary act is illicit in itself, and an accidental\ndeath follows from this act, the agent may be guilty of homicide,\nprovided the first act in itself is naturally likely to cause\nhomicide. Should the first act be always dangerous, such that\ndeath commonly follows from it, like rocking a row-boat, aiming a\nsupposedly unloaded gun at a person and pulling the trigger, striking\na pregnant woman, drinking whiskey and then overlying an infant in\nthe bed, throwing building material from a roof to a street, racing\nan automobile through a crowded thoroughfare, sending a crew out in\na rotten ship, and so on, the accidental homicide that follows is\nimputable to the agent no matter how much precaution he may say he\nhas used to avert such a death.\n\nSuppose, secondly, the original act of the agent is illicit but such\nthat accidental death rarely follows from it; then if he takes due\nprecaution he is not ordinarily guilty of homicide. He has, say,\nstolen an automobile, and is going along the street leisurely, when a\ncareless child runs off the sidewalk under the machine and is killed.\n\n1. No person, then, may hasten his own death or permit any one else\nto hasten it.\n\n2. No physician may in any possible condition kill a patient merely\nto effect euthanasia.\n\n3. The state has no more right than the physician to permit the\nkilling of patients to bring about euthanasia.\n\nWere such permission given to physicians it would immediately be\nabused by men with even the best intentions. In all countries and\nin the largest cities the medical profession is swarming with\nquacks. What is done in crass ignorance by licensed physicians and\nspecialists every day in the name of medicine is appalling. Professor\nOrth of the Pathologic Institute in Berlin makes the statement that\nof all the appendices that have been submitted to him for microscopic\nexamination after removal by conservative and supposedly skilled\nphysicians, 17 per cent. showed no disease at all, and should\nnot have been removed. In this country the percentage of normal\nappendices removed because of vague abdominal pains is much larger.\n\nThe _Journal of the American Medical Association_ (June 7, 1913)\ngave a list of post-mortem examinations where the diagnosis made\nby men with a reputation for fair work had been correct in only the\nfollowing ratios:\n\n                                   Diagnosis     Diagnosis\n                                    correct.     incorrect.\n                                    Per cent.     Per cent.\n  Diabetes Mellitus                    95             5\n  Typhoid Fever                        92             8\n  Aortic Regurgitation                 84            16\n  Cancer of Colon                      74            26\n  Lobar Pneumonia                      74            26\n  Chronic Glomerular Nephritis         74            26\n  Cerebral Tumor                       72.8          27.2\n  Tuberculous Meningitis               72            28\n  Gastric Cancer                       72            28\n  Mitral Stenosis                      69            31\n  Brain Hemorrhage                     67            33\n  Septic Meningitis                    64            36\n  Aortic Stenosis                      61            39\n  Phthisis, Active                     59            41\n  Miliary Tuberculosis                 52            48\n  Chronic Interstitial Nephritis       50            50\n  Thoracic Aneurism                    50            50\n  Hepatic Cirrhosis                    39            61\n  Acute Endocarditis                   39            61\n  Peptic Ulcer                         36            64\n  Suppurative Nephritis                35            65\n  Renal Tuberculosis                   33.3          66.7\n  Bronchopneumonia                     33            66\n  Vertebral Tuberculosis               23            77\n  Chronic Myocarditis                  22            78\n  Hepatic Abscess                      20            80\n  Acute Pericarditis                   20            80\n  Acute Nephritis                      16            84\n\nPneumonia is a very common disease, extremely dangerous, and by\nskilful treatment it is very often cured, yet of these 100 cases 66\nwere not diagnosed. I recently saw a severe case of double pneumonia\nwhich a physician was treating as \"indigestion,\" and he was giving\npepsin tablets for the supposed indigestion. There is such a thing\nas extraordinary scientific precision in medical work, but it is\nrare; the ordinary physician treats symptoms without knowing the\ncause of the symptoms; that is, the symptom-treater is a quack,\nand if euthanasia were legalized thousands of such quacks would\nbe permitted to murder with an overdose of morphine any querulous\nold man or woman who might fall into their hands. Osteopaths and\nchiropractors are masseurs, and they know very little of massage, but\nthey are licensed by legislatures to practise medicine, and some of\nthem even try obstetrical malpractice. They, too, would be licensed\nto inflict euthanasia. Pure homeopathy is little more than a name at\npresent; it is faith-healing without prayer. It attenuates its drugs\n100 per cent. for thirty repetitions, to a degree expressible by one\nwith sixty ciphers. Consequently it gives sugar of milk or alcohol\nin minute quantities plus a label, and one cannot make much of an\nimpression on any disease with a label. Such practitioners also would\ncome under the euthanasia act.\n\n\nBIBLIOGRAPHY\n\n     Cardinal John de Lugo. Disputationes Scholasticae et Morales,\n     vol. vi; De Justitia et Jure, disputatio x.\n\n     St. Augustine. I Contra Petilianum, cap. 24; Ad Marcellianum\n     Comitem, cap. 21; De Civitate Dei, cap. 17 to 28.\n\n     Aristotle. III Ethicorum, cap. 7, and lib. v, cap. ii. Plato.\n     Phaedo.\n\n     Cicero. Quaestiones Tusculanae. I, lib. v; De Somno Scipionis.\n\n     Lessius. De Justitia et Jure, lib. ii, c. 9, dub. 6, 7.\n\n     Molina. De Justitia et Jure, vol. i, tr. 2, disp. 119; vol. iv,\n     tr. 3, disp. 1 and 9.\n\n     St. Thomas Aquinas. Summa Theologica, 2, 2, q. 64, a. 5, 7.\n\n     St. Alphonsus Liguori. Theologia Moralis, vol. iv, tr. 4. See\n     this book for opposed opinions and a bibliography.\n\n     Costa-Rossetti. Philosophia Moralis, thesis 120.\n\n     Ferretti. Philosophia Moralis, theses xci, xciv.\n\n     Macksey. De Ethica Naturali, theses xxxiv _et seq._\n\n\n\n\nCHAPTER II\n\nGENERAL PRINCIPLES CONCERNING MUTILATION\n\n\nThe members of the human body may be injured (1) by a blow, which\nwithout bloodshed causes pain or a bruise; (2) by a wound, which\nbreaks the continuity of the tissues; (3) by mutilation, which,\nwithout killing, removes some member requisite for the integrity\nof the body. The term Mutilation as applied to the human body has\nvarious meanings. In the civil law mutilation of a person is called\nMayhem, an old form of the word Maim, and is defined by Blackstone[5]\nas \"such hurt of any part of a man's body as renders him less able in\nfighting to defend himself or annoy his adversary.\" By statute in the\nUnited States and Great Britain the scope of the offence has been so\nextended as to include injuries to a person which merely disfigure or\ndisable. Mutilation in the civil law now implies the taking away of\nsome part of a legal instrument, as a will, contract, or the like, by\nany one who has no right to make this alteration.\n\n  [5] _Commentary_, bk. iv, p. 205.\n\nIn canon law mutilation is like malicious or accidental mayhem in\nthe civil law, and it has also a technical phase in relation to\nirregularity as affecting the reception of ecclesiastical orders.\nThe mutilation requisite to irregularity as affecting the reception\nof Holy Orders may differ from mutilation in its purely moral and\naccidental aspects. Broadly, an irregularity is a canonical and\npermanent impediment to the reception and exercise of ecclesiastical\norders. It does not exist unless it is actually promulgated in some\ncanon, and it is not necessarily grounded on corporal deformity.\nDefects of the body that cause canonical irregularity are such as\nwould render the public ministration of a clergyman either impossible\nor indecent.\n\nMolina, treating of mutilation, says[6] it does not exist unless\nthere is an amputation or shortening (_detruncatio_) of a member.\nWhen a foot or hand is so weakened without amputation that it cannot\nexercise its function the person is said to be maimed or lame, not\nmutilated. He holds that a finger, and _a fortiori_ a phalanx of\na finger, are not properly members. In defining mutilation as a\ncause of canonical irregularity[7] he contends that the weakening\nof a member so that it cannot perform its function is not a true\nmutilation canonically. He does not agree[8] with Cajetan, de Soto,\nand others who hold that an important part of a whole member is\nequivalent to a member so far as technical canonical mutilation is\nconcerned. Molina says that a part of the body as a member to fulfil\nthe requirements of the law on mutilation as a cause of irregularity\nmust have a distinct, complete function of its own, not be a mere\npart conducing to the function. Ballerini[9] agrees with Molina,\nbut he draws attention to a decretal of Innocent I. which makes an\namputation by oneself of even a part of one's own finger a full\ncanonical irregularity, because of the unnatural quality of the act.\n\n  [6] _De Justitia et Jure_, disp. 19, tr. 3.\n\n  [7] _Ibid._, disp. 68, tr. 3.\n\n  [8] _Ibid._, n. 69.\n\n  [9] _Theol. Moral._ vol. vii.\n\nSuarez defines mutilation thus: \"Mutilare significat proprie membrum\naliquod abscindere\"[10]--to mutilate means, strictly speaking, to\ncut off any member. He holds with Cajetan that an important part of\na member is in itself equivalent to a member. A reason he offers\nfor his opinion is that a eunuch is enumerated among those who are\ncanonically mutilated, but the eunuch, he tells us, \"does not lack\nany member which in itself has a function in the body independent of\nall other organs.\" This is not true. The testicles, which the eunuch\nlacks, have two distinct functions, independent of other organs--they\nmake the spermatozoa and an important internal glandular secretion.\nThese facts were not known in Suarez's time (1548-1617). Suarez adds\nthis remark: \"There can be a grave sin in a marring [_diminutio_] of\nany chief member, although there may be no grave mutilation; as,\nfor example, to cut off a part of a finger is undoubtedly a mortal\nsin, yet, in the opinion of all moralists, it is not enough to cause\nirregularity.\"\n\n  [10] _De Censuris_, etc., disp. 44, sec. 2, 2.\n\nSt. Alphonsus Liguori defines mutilation thus: \"Mutilation here\nsignifies that some principal member be separated from the body; that\nis, a part of the body that has in itself a distinct function, as a\nfoot, hand, eye, ear, etc.\"[11] He says[12] canonical irregularity\nas a punishment is not incurred by a person who cuts off another\nman's finger, thumb, lips, nose, auricle, or who knocks out teeth,\nbecause these are supposed by canonists not to be properly members\nof the body, but parts of members. To blind a man in one eye is\nnot enough to cause canonical irregularity; the eye must be taken\nout.[13] All these injuries are of course mutilations in the moral\nsense of the term. To blind a man without removing the eye, to cut\nout his spleen in the treatment of Banti's disease, to remove a\nwoman's ovary or uterus, to cut off part of the point of a finger,\nto crop the top of an auricle, to knock out a tooth, and any other\npermanent marring of the body, even to cause an unsightly scar across\nthe face, are all mutilations in the moral sense of the term. A\nphysician, midwife, nurse, or parent who neglects an infant's eyes,\nand so permits ophthalmia neonatorum to blind the child, is guilty of\ngrave mutilation. In the year 1914, in the Chicago schools, 45,176\nchildren were found suffering from various defects, and 35,425 were\nadvised by the examining physicians to seek treatment; in each of\nthese cases the parents were informed of the nature of the disease\nand the necessity for treatment, but only 40 per cent. of the parents\npaid any attention to the notices. Of 5754 cases of diseased tonsils,\nwhich are likely to affect the heart permanently, only 4 per cent.\nwere treated; of 1254 cases of discharging ears only 10 per cent.\nwere treated, although such a condition may go on to deafness if not\nattended to. These parents were criminally guilty of grave neglect\nin permitting the mutilation of the heart and ears.\n\n  [11] _Theol. Moral._, lib. 7, cap. 5, disp. 4, n. 365.\n\n  [12] _Ibid._, n. 378.\n\n  [13] _Ibid._, n. 382.\n\nAny notable mutilation inflicted upon oneself is akin to the\nmalice of suicide, and when perpetrated on another it is related\nto homicide. The dominion over the members of the body, as over\nthe whole body, belongs to God alone. Man is constituted by his\nparts, members, taken together, and if he were master of his members\nhe would be master of himself. Again, each member of the body is\nnaturally united to that body and ordained for determined organic\nfunctions; so it is wrong to render these members unfit for their\nnatural function or to separate them from the body, unless such\nactions are necessary for the preservation of life itself. Although\nman is not master of himself, he is the administrator of himself;\nand therefore when the amputation of any member is necessary for the\npreservation of the life of the whole body it is licit to subordinate\nthis part to the good of the whole.\n\nA direct mutilation is one intended as an end, or as a means to an\nend; it is a voluntary and free act. An indirect mutilation is one\nin which the mutilation is the natural effect of the act, but the\nintention of the agent is directed toward another end. The mutilation\nfollows indirectly from the activity of the will, but there is a\nsatisfying proportion between the accidental effect (the mutilation)\nand the end intended. In such an act there are two effects which\nfollow the causal act _aeque immediate_, or directly (not indirectly,\nthat is, not all from the other effect, but each immediately from\nthis cause): one effect is good (to save life, avoid unbearable pain,\nor the like), and the other evil (the mutilation), but the good\neffect is the end intended, the evil effect is reluctantly permitted.\nSuch an act is licit provided the usual conditions of the double\neffect are present, that is:\n\n1. The action that is the cause of the good and bad effects must be\nitself good or indifferent morally.\n\n2. The good and the bad effects must each be an immediate result of\nthe causal act; the good effect may be not so subordinated to the\nevil effect as to be obtainable only through the evil effect.\n\n3. The bad effect must not be intended, either immediately or\nremotely; it may at most be tolerated as unavoidable.\n\n4. There must be a sufficiently grave reason for the act.\n\nIndirect mutilation may be licit when the evil to be avoided is\nproportional to the mutilation. Direct mutilation, where there is one\ndirect effect of, say, the surgical operation, namely, to remove the\nsomatic organ, is not licit, except for the good of the whole body;\nand that good to the whole body must be juridically equivalent to\nthe damage done the body by the mutilation. There is to be a direct\neffect in such mutilation, which is the good of the whole body. It is\nnot permitted to kill directly to save the life of another, but it\nis permissible to mutilate directly to save the whole body. Direct\nmutilation, however, is never unavoidable because the agent can\nalways correctly order his intention before the operation.\n\nAll direct mutilation, unless for the good of the whole body, implies\ndeordination: it offends against the supreme dominion of God, who\nreserves to himself, as Creator, ownership of human life and its\norgans. As we may not destroy life, which belongs to God, we may not\namputate a member to suppress any vital function. The exception which\npermits us to mutilate a member or organ is, as has been said, the\nadequate good of the whole body. The reason for this is that man is\nthe administrator of his members, to the good of the whole person.\nEach member is not for itself but for the whole body.\n\nThe good of the body is the sole cause that renders direct mutilation\nlicit. The members of the body by their nature are not immediately\nsubordinate to anything except the conservation of the total\nnatural good, or that of the body. Therefore direct mutilation is\nnot permissible to effect immediately spiritual good, or the good\nof the soul. We may not castrate a man, or do vasectomy on him, to\npreserve his continence, because there is no immediate subordination\nand connection between the members of the body and the salvation\nof the soul. Moreover, as St. Thomas says,[14] \"Spiritual health\ncan always be preserved by means other than amputation of bodily\nmembers,\" that is, through moderating by the will the use of these\nmembers. If a mutilation that immediately conduces to the good of the\nwhole body, happens also to do good to the soul, this second effect\nis then legitimate. (The various mutilations of the body by surgical\noperations will be considered separately hereafter.)\n\n  [14] 2, 2, q. lxv, a. 1, ad 3.\n\nMay the state, then, sterilize criminals, and persons afflicted with\ndangerous hereditary diseases, to prevent the propagation of moral\nand physical defectives? This question is considered specially in\nanother chapter.\n\nThere is an error gradually infecting all nations of late which is\nthat the state, as such, is above morality; that what the civil\nauthority permits or orders is by that fact alone made licit or\nobligatory. Hence the interference with individual liberty, with the\nrights of man, shown by laws for the mutilation of the physically\ndegenerate, laws conferring privileges on one part of the community\nto the detriment of another, meddling in parental rights, and so on.\nPolitical error has come to such a pass that the men on the street\nthink any majority is justified, solely because it is a majority,\nin recalling a judge or a law, in overriding authority for the\nsatisfaction of appetite. The sovereign people tries to be subject\nand sovereign at the same time, and it deems its rulers mere hired\nmen who may be discharged at will like cooks.\n\nA law is a rule and standard of action; a just, permanent, and\nrational ordination for the good of the community, promulgated by one\nwho has charge of that community. Dominion is the power of claiming\na thing as one's own, the right of ownership; and if this possessor\nhas created the object, his dominion may be absolute. A governor,\nlawgiver, judge, has power or jurisdiction for the good of the\ngoverned. The business of government, of the state, is to protect\neach citizen in the pursuit of temporal happiness, to develop his\nnatural faculties, establish and preserve social order, wherein each\ncitizen is secured in his natural and legal rights, and is held up\nto the fulfilment of his own duties so far as they bear on the good\nof the community as such; and also to put within the reach of all\ncitizens, as far as possible, a fair allowance of means to acquire\ntemporal happiness, or external peace and prosperity. This is the\nwhole business of the state. The state is for the people, and it may\nnot transgress an inch beyond its proper limits, which are as hard\nand fast as those that bind the individual citizen. The citizen is\nnot to be treated solely as an industrial or military unit; nor are\nmaterial progress and military power, or even sheer intellectual\ncivilization, to be the sole aim of the state. The state should\ndevelop a man's entire nature, physical, mental, and moral.\n\nWe must obey civil authority, but we are not slaves or chattels of\nthat authority. The state's authority over us is not dominative; it\nis only a power for our good and utility. The civil authority has no\nmore right to invade the rights of its meanest citizen than it has\nto lie or to blaspheme. God gives civil authority to the established\ncommunity, and the community entrusts this to its ruler; authority\nis a divine institution, rulers are directly a human institution and\nonly indirectly divine. When the ruler has once been set up, has had\nauthority entrusted to him, obedience must be given to him while he\nacts in keeping with his contract. Kant and his followers erroneously\nseparate the juridic from the moral order; they deny that beyond the\nstate there are any rights preeminent to the state's rights, yet they\nsay there is an innate liberty which belongs to every human being\nequally and inalienably. The moral order comprehends all factors that\nare necessary to make the free activity of man in every respect well\ndisposed, and among these factors is the juridic order itself. Man is\nnaturally social, and whatever means are necessary to preserve human\nsociety are also naturally befitting man. Such means are to preserve\nfor each man what are his, and to abstain from injuring other men.\nNow, so to act, that is, to abstain from murder, theft, and the like,\nto fulfil contracts, are strictly juridic duties, and at the same\ntime moral duties. Therefore the moral order comprehends the juridic\norder.\n\nThe end of the state, then, is not the public good considered as an\nend in itself. The individual citizen is not his own end in life, and\nso no mere multitude of men ever can become their own end. If the end\nof the state is the public good, then private good is subordinate\nto this, and the public good becomes man's final end, which is\nsubversive of human dignity and is despotism.\n\nA clear definition of the power of the state to interfere with the\nrights to life and limb of the individual citizen is very important,\nbecause, as has been said, of late there is an alarming tendency\non the part of the civil authority to override the rights of\nprivate citizens, even in the most democratic forms of government.\nEncroachment on the liberty of the individual is characteristic of\nunchristian political societies, and all states are now receding from\nChristianity. A striking example of this tyranny is the laws recently\npassed in ten American states for the mutilation of degenerates. This\ndefinition is more readily made by considering concrete examples of\npublic conduct.\n\nSuppose an enemy demands from a city the surrender for execution\nof an innocent man on pain of the burning of the city and the\ndestruction of its inhabitants. May the city cut off that member for\nthe safety of the whole body politic, as a person may cut off his own\nhand to save his life? The state has not dominion over the life of a\ncitizen, nevertheless it may kill a citizen in punishment of crime,\nbecause the punishment is useful to the whole people, is for the\ncommon good, is preservative of the social life. Why, however, should\nthe state be permitted to kill a criminal rather than an innocent\nman, since it has no dominion over the life of either, and we suppose\nthe death of each is necessary for the public good? If you answer by\nsaying a man may cut off a diseased member but not a sound one to\nsave his body, and the state in like manner may cut off a criminal,\nunsound member, but not an innocent one, this answer does not remove\nthe difficulty: we may cut off even a sound member to save the body.\nSuppose, for example, a man caught by the arm and in danger of death\nfrom a flood; he might sever a sound arm to escape death if no other\nmeans presented. In like manner the state might cut off an innocent,\nsound member to save its life from the enemy, as described above.\n\nThis reasoning, however, is open to objection. The state has no\ndominion over the life of its members, and there is a vast difference\nbetween the members of the human body and those of a body politic.\nA member of a human body has no right in itself against the other\nmembers; nor is it capable of natural injury, since it is not\nseparable from the whole suppositum, or person. The suppositum, or\nperson, has a right to the use of the members; it alone is injured\nwhen a member is amputated; and the members are solely for the\nutility of the suppositum. Therefore we may licitly destroy a member\nto save the suppositum for which this member exists.\n\nThe state, however, is not a suppositum in this sense; it may not\nwrest the life of its members to its own utility, because the\ncitizens are not for the state; on the contrary, the state is for\nthem and their utility. That a rational being should be for the\nutility of another person or a society makes him a slave and supposes\ndominion in the user. A slave is differentiated from a subject\nby the fact that the subject is only politically governed--that\nis, governed for his own utility and good; the slave is governed\ndespotically--that is, for the utility and good of his master. The\nstate may not, as a master, use the life of a subject for its own\nutility alone. Although the suppositum does not own its members,\nyet since the members are not separable from the man, are not\nself-centred as are the citizens in a state, the man may use them for\nhis own utility. They are as slaves under a master, not as subjects\nin a body politic; therefore they may be sacrificed for the good of\nthe suppositum.\n\nThis is the argument used by De Lugo; Molina follows the same line of\nthought; but both authorities finally reach the conclusion, in the\ncase of the enemy and the citizen whose life is required, that the\nstate may at least drive this citizen out of the city to save its own\nexistence. Molina also draws attention to the fact that there is a\ngreat difference between a member of a body politic and a member of\nthe human body; this identification, if pushed far enough, becomes\nan analogical quibble.\n\nSome hold that a judge or the civil authority in general may kill\nor maim a criminal by gubernatorial power alone, prescinding from\ndominative power, and this not to the utility of the criminal but for\nthe utility of society. The killing of a criminal, these objectors\nsay, is not for the good of the criminal; it is a deterrent, a\nprotective act, for the good of society. This is not true. The penal\nlaw which the criminal breaks was not made solely for society; it was\nintended also for the utility of the person who becomes a criminal.\nThe law was made and the punishment established that all subjects\nindiscriminately should be helped to live honestly and blamelessly,\nand to this end it was necessary to decree and inflict punishment as\naffecting all offenders. The obligation to receive punishment is in\na manner essential to man. As he naturally requires direction and\ngovernment unto virtue in his political and social life, he has a\nconnatural obligation to endure punishment when he violates the law\nmade for his advantage--one condition cannot exist without the other.\nHence punishment really is to the utility of the criminal.\n\n\n\n\nCHAPTER III\n\nWHEN DOES HUMAN LIFE BEGIN?\n\n\nBy the embryologists from the moment the spermatozo\u00f6n joins the\nnucleus of the ovum until the end of the second week of gestation\nthe product of conception is called the _Ovum_; from the end of the\nsecond week to the end of the fourth week it is the _Embryo_; from\nthe end of the fourth week to birth it is the _Fetus_. At what moment\nduring these three stages does the human soul, the substantial form\nof a man in the full comprehension of the term, enter the product of\nconception? When does the thing become a human being?\n\nThe question is evidently one of the greatest importance. If the\nrational soul does not enter until the ovum has developed into\nan embryo, or only after the embryo has passed on into the fetal\ncondition, the destruction of this ovum, by artificial abortion\nor otherwise, would be a very different act morally from such\ndestruction after the soul had turned the new growth into a living\nman. If the product of conception has first only a vegetative vital\nprinciple, and this is later replaced by a vital principle that is\nmerely sensitive, and this again is finally superseded by a rational\nvital principle, the destruction by abortion or otherwise of the\nvegetative or sensitive life would not be a destruction of a rational\nlife. In this hypothesis the killing of the embryo would be a great\ncrime, because the embryo would be in potency for the reception of\nhuman life, but the act would not be murder.\n\nThe discussion concerning the moment the human soul enters the body\nis older than Christianity, and it was taken up by many of the early\nGreek and Latin Fathers of the Church, and revived again and again\ndown to the present day. Plato thought the soul enters at birth;\nAsclepias, Heraclites, and the Stoics held it is not infused until\nthe time of puberty; Aristotle[15] said the soul is infused in the\nmale fetus about the fortieth day after conception, and into the\nfemale fetus about the eightieth day.\n\n  [15] _IX, De Animalibus_.\n\nTertullian,[16] Apollinaris, and a few others advocated\nTraducianism,[17] or a transmission of the spiritual soul by the\nparents. He said souls are carried over by conception and by the\nparents, so that the soul of the father is the soul of the son, and\nfrom one man comes the whole overflow of souls. St. Augustine used\nthe metaphor, one soul lit from another as flame from flame, without\ndecay in either. Augustine was in doubt as to the origin of the\nsoul, and inclined to traducianism, because it seemed to him better\nto explain the doctrine of the transmission of original sin. \"Tell\nme,\" he wrote to St. Jerome in 415,[18] \"if souls are created singly\nfor each person born to-day, when do infants sin so that they need\nremission in the sacrament of Christ, sin in Adam from whom the flesh\nof sin is propagated?... Since we cannot say that God makes of souls\nsinners, or punishes the innocent, nor may we hold that souls even of\ninfants which without baptism leave the body are saved, I ask you how\nthat opinion can be defended which thinks that all souls are not made\nfrom the single soul of the first man, yet as that soul was one to\none man, these are particular to particular individuals.\"\n\n  [16] _De Anima_, cap. 27.\n\n  [17] From _tradux_, a planted vine-shoot made to take root.\n\n  [18] Migne, vol. xxxiii, col. 720.\n\nAgain, St. Augustine said:[19] \"I do not know how the soul came into\nmy body; he knows who gave it, whether he drew it [_traxerit_] from\nmy father, or created it new as in the first man.\" In the _Book of\nRetractions_,[20] speaking of the articles he had written against the\nAcademicians before he was a bishop, he says: \"As to the origin of\nthe soul, how it is set in the body--whether it is from that one man\nwho first was created ... or, as in his case, is made particularly\nfor each particular individual, I did not then know, and I do not\nknow now.\" St. Gregory the Great also said he could not tell whether\nthe human soul descends from Adam or is given particularly to each\nman.\n\n  [19] _De Anima et ejus Origine_, i, xv.\n\n  [20] I, cap. i, n. 3.\n\nSt. Gregory of Nyssa, however, who died about 385, thirty years\nbefore St. Augustine wrote the letter to St. Jerome, held that the\nsoul is infused into the body at the moment of conception, and he\nargues with absolute precision for his opinion.[21] St. Maximus the\nTheologian, who was martyred in 662, inveighs[22] against the notion\nthat the soul is vegetative at first, then sensitive, and finally\nintellectual, and he thinks the assertion of Aristotle that the fetus\nis not animated before the fortieth day is altogether untrue.\n\n  [21] Migne, _Patrologia Graeca_, vols. xliv and xlvi.\n\n  [22] Migne, _Ibid._, vol. xci, col. 1335.\n\nSt. Anselm, who died in 1109, very dogmatically denied that the fetus\nis animated at conception,[23] and after his time the doctrine of\nAristotle, which is commonly called the Thomistic opinion, became\nalmost general. Vincent of Beauvais, however, a contemporary of St.\nThomas, opposed the Thomistic doctrine. Albertus Magnus[24] had the\nsame opinion as St. Thomas, and probably taught it to St. Thomas. In\nthe middle ages all held that each soul is directly created by God,\nand is infused into the embryo, not at the instant of conception,\nbut when the embryo is sufficiently formed to receive it, which, as\nAristotle said, happens at about the fortieth day in males and the\neightieth day in females. The Thomists maintained the succession of\nthe three souls; many others opposed this particular opinion.\n\n  [23] _De Conceptione Virginis_, cap. xii.\n\n  [24] _Summa, De Homine_, q. xvi, art. 3.\n\nThomas Fienus, a physician and a professor in the University of\nLouvain, in 1620 published a book[25] in which he held that the soul\nis infused about the third day after conception, and his argument\nfor the early advent of the soul is very sound. As a result of\nFienus's revolutionary argument, Florentinus in 1658 brought out a\nbook at Lyons, called _De Hominibus Dubiis Baptizandis_, in which he\nheld that no matter what the age of the aborted fetus, if it could\nbe differentiated from a mole it should be baptized. This book was\nbrought before the Congregation of the Index. The congregation did\nnot condemn the book, but the author was forbidden to teach that his\ndoctrine holds _sub gravi_. The book went through many editions and\nwas approved by the faculties of the principal universities and the\ntheologians of the leading religious orders.\n\n  [25] _De Vi Formatrice Foetus Liber._\n\nZacchias, chief physician to Innocent X., in 1661 published his\n_Questiones Medico-Legales_, and in this he maintained that \"the\nhuman fetus has not at any time any kind of soul other than a\nrational, and this is created by God at the first moment of\nconception, and is then infused.\"[26] By 1745 the opinion of\nZacchias as to the moment life begins was virtually general among\nphysicians, and has since remained the doctrine of physicists. Modern\ndiscoveries by biologists have confirmed the fact that human life\nexists in the impregnated ovum exactly as it does in all stages of\nlife, and no scientist holds any other opinion. There are, however,\na few moralists at the present day who incline to the old Thomistic\ndoctrine or to modifications of it.\n\n  [26] Tom. ii, lib. ix, tr. 1.\n\nSt. Alphonsus Liguori[27] was a follower of the Thomistic opinion.\nHe affirmed: \"They are wrong that say the fetus is animated at the\ninstant of conception, because the fetus certainly is not animated\nbefore it is formed, as is proved from Exod. xxi: 22, where in the\nSeptuagint version we find: 'He that strikes a gravid woman and\ncauses abortion, will give life for life if the child was formed;\nif it was not formed, he will be fined.'\" This argument by St.\nAlphonsus is invalid apart from any facts that may bear upon either\nthe Thomistic or the modern opinion concerning the quickening of\nthe fetus. The text from the Septuagint Exodus is (1) too doubtful\nin itself to be the basis of any argument; but (2) even if it were\nauthentic just as it stands, the conclusion St. Alphonsus draws from\nit is not warranted by the premises. The Septuagint text differs\nfrom the Vulgate and the Hebrew texts. The Vulgate has it thus: \"Si\nrixati fuerint viri et percusserit quis mulierem praegnantem, et\nabortum quidem fercerit, sed ipsa vixerit, subjacebit damno quantum\nmaritus mulieris expetierit et arbitri judicaverint; sin autem mors\nfuerit subsecuta, reddit animam pro anima, oculum pro oculo, dentem\npro dente, manum pro manu, pedem pro pede, adustionem pro adustione,\nvulnus pro vulnere, livorem pro livore.\"[28] This version has nothing\nwhatever to say about the _foetus formatus_ or _non formatus_; it is\nmerely an application of the Semitic Lex Talionis, and the form of\nthe law is clearly corrupt and inaccurate.\n\n  [27] _Theologia Moralis_, lib. iv, tr. 4, n. 594.\n\n  [28] If men quarrel, and one strike a woman with child, and she\n  miscarry indeed, but live herself, he shall be answerable for so\n  much damage as the woman's husband shall require and as arbiters\n  shall award. But if her death ensue thereupon, he shall render\n  life for life, eye for eye, tooth for tooth, hand for hand, foot\n  for foot, burning for burning, wound for wound, stripe for stripe.\n\nThe passage quoted by St. Alphonsus as that of the Septuagint is not\nexact even as the Septuagint has it. The full text is: \"If two men\nfight, and one strike a woman that hath [a child] in the womb, and\nher babe come forth not yet fully formed,[29] in a fine he shall\nbe mulcted; whatsoever the husband layeth upon him he shall give\naccording to decision [_i.e._, of the judges]. But if it [the babe]\nbe fully formed he will give life for life, eye for eye, tooth for\ntooth, hand for hand, foot for foot, burning for burning, wound for\nwound, stripe for stripe.\"\n\n  [29] \u03ba\u03b1\u1f76 \u1f10\u03be\u03ad\u03bb\u03b8\u03b7 \u03c0\u03b1\u03b9\u03b4\u03af\u03bf\u03bd \u03b1\u1f50\u03c4\u1fc6\u03c3 \u03bc\u1f74 \u1f10\u03be\u03b5\u03b9\u03ba\u03bf\u03bd\u03b9\u03c3\u03bc\u03ad\u03bd\u03bf\u03bd--not moulded out\n  into form; \u1f10\u03be\u03b5\u03b9\u03ba\u03bf\u03bd\u03af\u03b6\u03b5\u03b9\u03bd, to mould out into form: \u03b5\u1f30\u03ba\u03c9\u03bd, an icon,\n  image, likeness.\n\nThis is (1) evidently nothing but an application of the Lex Talionis,\nwith no thought whatever of the biological animation, as such, of\nthe fetus. It means that if a fully formed fetus be aborted, either\nno real damage is done, as such a child is viable; or the formed\nchild may be maimed, and then the Lex Talionis is to be applied. If\nthe fetus is not fully formed it is not a fit subject of the Lex\nTalionis since it cannot lose an eye, a tooth, and so on, because it\nlacks these organs and therefore the law of retaliation is not to be\nenforced.\n\n(2) Suppose, however, the writer of the text as the Septuagint has\nit did think with St. Alphonsus that the formed fetus is animated,\nand the unformed is not animated, even then the conclusion drawn\nby St. Alphonsus is not warranted by the text. The laws of Exodus\ndo not teach embryology, physiology, or any other part of physical\nscience; and no authority worth a hearing holds that the Scriptures\nwere intended to be infallible treatises on obstetrics or astronomy.\nLike the other parts of the Bible, the laws of Exodus presuppose the\nunscientific biological, astronomical, and other physical notions of\nthe time in which they were written--the moral truth is the matter\nthe Scripture is dealing with; there no inaccuracy is to be found.\nSt. John (1:13) speaks of those who believe in Christ's name, \"Qui\nnon _ex sanguinibus_, neque ex voluntate carnis, neque ex voluntate\nviri, sed ex Deo nati sunt.\" Here he expresses the contemporary\nnotion, which is also the Thomistic opinion, that men are generated\nfrom the specialized blood of their parents. He was interested\nsolely in conveying the truth that those who received Christ were\nregenerated by him, not through heredity; and he does so, although\nthe biology is inexact. If St. Alphonsus's conclusion is valid as\nfrom the text of Exodus, then men are generated _ex sanguinibus_, and\nso on indefinitely.\n\nThe Massoretic text of this passage seems to be the best preserved:\n\"If men fight, and one hurt a woman who is with child, and her child\ncome forth, yet there is no mischief, he [who struck her] shall be\nmulcted in a fine; whatsoever the husband of the woman layeth upon\nhim he shall pay according to the judges. But if there be mischief,\nthen he shall give life for life, eye for eye, tooth for tooth, hand\nfor hand, foot for foot, burning for burning, wound for wound, stripe\nfor stripe.\" Here the Hebrew text follows the Lex Talionis exactly.\nIf, in a brawl, a man's pregnant wife is struck and abortion results,\nthe offender pays the penalty. If the abortion does not kill or maim\nthe child, the culprit is fined by the Sanhedrim; if the child is\nkilled or maimed, then the penalty is according to the Lex Talionis.\nIn the Hebrew text also there is no mention of a distinction between\na _foetus formatus_ and _non formatus_.\n\nWhether the fetus is animated at conception or some time later,\nthere is no foundation whatever for the notion that the female is\nquickened later than the male. As was said before, Aristotle held\nthat the human male fetus is animated at the fortieth day, the female\nat the ninetieth day, and the old moralists accepted his statement.\nAt the fortieth day, however, no one can differentiate sex unless\nthe microscope is used, and this particular use of the microscope is\naltogether modern--the knowledge requisite for such use was not in\nexistence sixty years ago. At the twentieth day, with the microscope\nand a stained specimen, a biologist can recognize whether the\nprimordial ova are present or absent and thus determine sex. Only at\nthe eighty-fourth day can sex now be differentiated without the aid\nof the microscope, but then the embryo must be dissected: nothing can\nbe told from its external appearance. Sex can first be distinguished\nby the external appearance only at about the one hundred and twelfth\nday, the end of the fourth month of gestation. Therefore when\nAristotle said the male fetus is animated at the fortieth day, and\nthe female at the eightieth or ninetieth day, he was romancing.\n\nThe question, then, narrows to this: Is any human fetus animated\nimmediately at conception, or from forty to eighty days after\nconception? The reason given by the followers of Aristotle for\ndeferring animation is that the vital principle requires organs in\nthe receptive material, but the embryo in the early stages, they say,\nlacks these organs. This notion, however, as to the lack of organs\nis altogether erroneous, and the rational soul enters the embryo\nin the oval stage, immediately after the pronuclei unite: there is\norganization in that stage of human life sufficient to receive the\nsubstantial form or soul. We do not know how long after insemination\nthe pronuclei unite, but the proposition here is that as soon as\nthey unite the human soul enters. Fecundation usually occurs after a\nmenstruation, but not necessarily so; the spermatozo\u00f6n may live in\nthe tube for seventeen days awaiting the ovum.\n\nThe human body is made up of billions of microscopic living cells,\nall of which are derived by fission and differentiation from the\ntwo original single germ-cells, the ovum and the spermatozo\u00f6n.\nSome nerve-cells have long processes running along the white\nfibres through the entire length of the body, but they cannot be\ndifferentiated except by the microscope. In the body are also\nvarious liquids which are not cellular, as water, saliva, tears,\nurine, blood and lymph plasma, and the gastric, intestinal, and\nglandular juices, and these are secreted or excreted by the somatic\ncells. The cells assimilate nutritive material carried to them by\nthe blood, excrete refuse substances, secrete glandular products,\nand are the media for all human operations below certain acts of the\nintellect.\n\nA typical animal cell is commonly spherical in shape, but it\nmay take a great variety of forms through compression. It has a\ncell-body or protoplasm, which is called also cytoplasm, especially\nwhen contrasted with the nuclear karyoplasm, and a nucleus. A few\ncells, like fat-cells and the human ovum, have an external covering\nmembrane, or cell-wall. There is a part called the Centrosome\nobservable in many cells, and this is made up of one or two minute\ndots surrounded by a radiating aster called the Attraction-Sphere.\nThe centrosome is concerned in the process of cell-division and\nin the fertilization of the ovum; it is an important organ in the\nproduction of cell from cell, though its full nature and function\nare not yet known. The Plastid, or Protoplast, is another less\nimportant part found in certain cells; and in this by enlargement\nand differentiation are formed starch, pigment, and in some cases\nchlorophyl. Vacuoles are seen in cells; and there is an opinion that\nthese may be a special kind of plastid: some vacuoles pulsate.\n\nThe Nucleus is the most important part of a cell, the centre of\nits activity. The specific qualities of organism in origin and\ndevelopment are based upon nuclei, so far as the material element\nof the living cells is concerned. Vital stimuli pass through the\nnucleus into the surrounding protoplasm, and these stimuli control\nmetabolism. The nutritive cytoplasm assimilates, but the vital\nprinciple energizes this assimilation through the nucleus, for a\npart of a cell deprived of the nucleus may live for a time, but it\ncannot repair itself. Constructive metabolism ceases when the nucleus\nis lost. A toxic disease like diphtheria kills by disintegrating\ncellular nuclei.\n\nIn the nucleus are several elements, the chief among which is\nChromatin. Chromatin takes various forms, but commonly it is an\nirregular network. From the chromatin are derived the Chromosomes\nin the prophases of indirect cell-division which is the process of\ncell-division in the human body, except in lymph-cells and white\nblood-corpuscles, which split directly, or by Amitosis. Indirect\ncell-division is called Mitosis or Karyokinesis. In the male and\nfemale chromosomes, according to a common opinion of biologists,\nall the elements of parental and phyletic physical heredity are\ntransmitted to the embryo.\n\n[Illustration: Fig. I\n\nA CELL.\n\nThroughout the Cytoplasm is a mesh containing numerous minute\ngranules called Microsomes.]\n\nThe production of cell from cell is accomplished either by direct\nsplitting of the nucleus and cytoplasm into two new cells, or by\nindirect division through a series of stages. In a typical direct,\nor amitotic, division the nucleus is constricted in the middle\nand divides into two daughter-nuclei. These by amoeboid movements\nwithdraw to the poles of the cell; the cell finally divides between\nthem, and thus two cells are formed. These, again, split into four,\nthe four into eight, and so on. An amoeba by direct division can\nseparate into two distinct new animals in ten minutes.\n\nHeredity here is simple. In unicellular organisms, such as Rhizopoda\nand Infusoria, each individual grows to a certain stage, and\nthen divides into two parts, which are exactly alike in size and\nstructure, so that it is not possible to decide whether one is older\nor younger than the other. These organisms reduce the size of their\novergrown bodies by division. Each individual of any such unicellular\nspecies is a part split off serially from an organism which started\ninto life ages ago. Some of them have come down in uninterrupted\nlife from geological epochs that passed away eons before the first\nman was created. Many of these unicellular plants and animals have\nimmeasurably the most ancient form of life on earth. Heredity with\nthem depends upon the fact that each offspring is merely half of its\nparent. In some cases the division has a sexual quality: two cells in\n_Paramecium_, and, like Infusoria fuse and then divide if they come\ninto contact; they can, however, split without this sexual process.\n\nMulticellular plants and animals do not reproduce by simple division,\nand the half of the parental body does not pass over into the\nprogeny. Sexual reproduction is the chief means of multiplication in\nmulticellular organisms, and in no case is it completely wanting; in\nmost it is the only method of reproduction. In multicellular animals\nthe power of reproduction is in the germ-cells, which differ from\nthe somatic cells. Germ-cells do not maintain individual life as\nthe body-cells do, but the germ-cells alone preserve the species.\nFrom two of these germ-cells under certain conditions is developed a\ncomplete bodily organism of the same species as the parents. These\ntwo cells are in a sense the undying cells; the somatic cells die.\n\nMulticellular animals--Man, for example--grow embryologically by\nMitosis or Indirect Division. As in Direct Division, typically,\nthe nucleus in mitosis splits first and the cytoplasm secondly;\nbut before the nucleus divides its content undergoes a series of\nchanges. The chromatin loses its reticular arrangement and gives\nrise to a definite number of separate bodies, usually rod-shaped,\nknown as Chromosomes. In this process the chromatin becomes a\nconvoluted thread, called the Skein or Spireme. The thread thickens\nand opens out somewhat, and finally breaks transversely to form\nthe chromosomes, which may be rods, straight, curved, ovoid, and\nsometimes annular. Commonly the nuclear material fades away and\nleaves the chromosomes in the cell-plasm. (Fig. II, 2 and 3.)\n\n[Illustration: Fig. II\n\nDIAGRAM OF MITOSIS.\n\n1. Cell with resting Nucleus. 2. Prophase: Chromatin in\nthickened convoluted threads, beginning of Spindle. 3. Prophase:\nChromosomes. 4. Prophase: Spindle in long axis of the Nucleus,\nChromosomes dividing. 5. Anaphase: Chromosomes moving toward\nthe Centrosomes. 6. Chromosomes at the poles forming the\nDiaster, beginning splitting of the Cell-body. 7. Telophase,\nDaughter-Nuclei returning to resting state. 8. Daughter-Nuclei\nshowing Monaster below. 9. The two new Cells.]\n\nIt is almost an established fact that each species of animal and\nplant has a fixed and characteristic number of chromosomes, which\nregularly recurs in the division of all its cells. In forms arising\nby sexual production the number is even. The number of chromosomes\nin the human cell is said to be forty-eight. There are, according\nto some observers, forty-seven chromosomes in man and forty-eight in\nwoman. There seem to be twice as many chromosomes in white men as\nin negroes. Wilson gives the number[30] of specific chromosomes for\nseventy-four animals and plants. Germ-cells as differentiated from\nthe somatic cells have in the perfected cell always half the number\nof chromosomes found in a somatic cell.\n\n  [30] _The Cell in Development and Inheritance_, p. 207.\n\nWhile these changes are going on in the chromatin the Amphiaster\nforms. This consists of a fibrous spindle-shaped body, the Spindle,\nat either pole of which is an Aster made up of rays. In the centre of\neach aster is a Centrosome, and this may have a Centrosphere about\nit. As the amphiaster grows the centrosomes are grouped in a plane at\nthe equator of the spindle, forming the Equatorial Plate. (Fig. II,\nNo. 4.) The process so far makes up the Prophases of the Mitosis.\n\nIn the Metaphases of the Karyokinesis begins the actual division of\nthe cell. Each chromosome splits lengthwise into exactly similar\nhalves, and these, in the Anaphases of the mitosis, drift out to the\nopposite poles of the spindle to form the daughter-nuclei of the new\ncells. The daughter-nuclei receive precisely equivalent portions of\nchromatin from the mother-nucleus, and this is an important fact in\nmitosis. As the chromosomes go toward the poles the cell-body begins\nto constrict at the equator.\n\nIn the final phases, the Telophases, the cell divides in a plane\npassing through the equator of the spindle, and each daughter-cell\nreceives half the chromosomes, half the spindle, and one of the\nasters with its centrosome. A daughter-nucleus is reconstructed\nin each cell from the chromosomes. The aster commonly disappears\nand the centrosome persists, usually outside the new nucleus, but\nsometimes within it. Every phase of mitosis is subject to variation\nin different kinds of cells, but the outline of the division given\nhere is the fundamental method.\n\nThe germ-cells differ from the body-cells in general by containing\nhalf the number of chromosomes characteristic of a given animal\nor plant. If the body-cell has, say, twenty-four chromosomes, the\nspermatozo\u00f6n of the animal or plant from which the cells are taken\nwill have twelve chromosomes and the ovum will have twelve. When\nthe nuclei of these two cells unite in fertilization the resulting\nprimordial cell will have the twenty-four chromosomes restored,\nthe specific number for this plant or animal. In o\u00f6genesis and\nspermatogenesis the phases of \"Reduction,\" wherein the ovum and\nspermatozo\u00f6n get rid of half the chromosomes during the stages of\nmaturation of these germ-cells, are somewhat similar for both sexes.\nThe process is very complicated, but it is of importance in the\ntheories of inheritance. All the physical characteristics in a human\nbeing that come to him from his parents and remoter ancestors are\nsupposed, by the biologists, to reach him through the chromosomes in\nthe nuclei of the single parental germ-cells. The maternal physical\nheredity is handed on through the chromosomes in the ovum. The fetus\nin the womb is a parasite, autocentric, feeding at the start from\nthe deutoplasm, or yolk, in the ovum, and later from the supplies\nbrought to it by the maternal blood. The physical material it gets\ndirectly from the mother is very probably all in the chromosomes\nof the fecundated ovum. Some weeks elapse, and the embryo is quite\nadvanced before it begins to draw food from the mother at all. So far\nas the father is concerned, there is no doubt whatever that every\nphysical and pathological characteristic that can be handed down--and\nthere are many such qualities--must come through the chromosomes\nof the paternal spermatozo\u00f6n. Certain physical characteristics\nare passed on for centuries in a family--the Norseman's body in\nnortheastern Ireland, the skin-pigment in the American negro, and so\non indefinitely--and these qualities cannot come down except through\nthe chromosomes. The germ-plasm has come to us from the first man,\nand it will be passed on to the last person of the race--we are all\nliterally uterine brothers.\n\nIn the reduction of the germ-cells, if the primordial cell that\nfinally produces the ovum has, say, four chromosomes, these four\nchromosomes first split longitudinally and reduce into two tetrads,\nor two groups of four chromosomes. Outside the nucleus is a spindle\ntoward which the two tetrads move; they pass out of the nucleus and\nbecome the equatorial plane of the spindle; each tetrad divides into\ndyads (pairs of chromosomes), and one pair of these dyads remains in\nthe ovum, while the other pair leaves the ovum entirely and becomes\nthe nucleus of an abortive cell, called the First Polar Body. Later\na second polar body forms and carries another dyad (two chromosomes)\nout of the ovum, leaving only one dyad, or two chromosomes, in the\ngerm-cells; that is, half the number of chromosomes that were in the\nprimordial cell.\n\nThe reduction-division in spermatozoa is similar, but the end process\nleaves four active spermatozoa, whereas in the ovum the final\nresult is one ovum and three practically inert and cast-off polar\nbodies. The reduction-division in both ovum and spermatozo\u00f6n is in\nreality far more complicated than the broad summary given here. In\nparthenogenetic insects and animals a polar body takes the place of\nthe spermatozo\u00f6n, and fuses with the egg-nucleus to start mitosis.\n\nIn general, the new nuclei in the cells formed by division are not\nmade _de novo_, but arise from the splitting of the nucleus in the\nmother-cell. The new nucleus assimilates material, grows to maturity,\nand divides again into two daughter-nuclei. Whatever be the number\nof chromosomes that enter a new nucleus as it forms, the same number\nissues from it in mitosis. Boveri said,[31] \"We may identify every\nchromatic element arising from a resting nucleus with a definite\nelement that enters into the formation of that nucleus, from which\nthe remarkable conclusion follows that in all cells derived in the\nregular course of division from the fertilized egg, one half of\nthe chromosomes are of strictly paternal origin, the other half of\nmaternal.\" It is not strictly true to say that the germ-nuclei fuse:\nthey send in two sets of chromosomes that lie side by side, as has\nbeen frequently demonstrated since 1892[32] in many of the lower\nforms of life, and this law almost certainly extends also to man.\n\n  [31] _Jenaische Zeitschrift_, 1891, p. 410.\n\n  [32] See Wilson, _op. cit._, p. 299.\n\nThe primordial germ-cells appear in the human fetus about the\ntwentieth day and finally mature at puberty. Then an ovum at\nmenstruation breaks out through the surface of the ovary, and is\ntaken by the fimbriae of the Fallopian tube into the lumen of this\ntube. Fecundation happens near the outer or ovarian end of the\nFallopian tube, and the fecundated ovum finally is passed on to\nfasten on the wall of the uterus. The spermatozo\u00f6n is a ciliated cell\nwith the power of locomotion, through the movement of the tail of the\ncell. It can move 0.05 to 0.06 mm., or its own length, in a second.\nIt thus passes up through the uterus and out through the Fallopian\ntube, against the cilary motion of the tubal cells, until it meets\nthe ovum.\n\nA human ovum is a typical cell, but it has a covering membrane, and\na minute quantity of deutoplasm or yolk, which is not alive, and\nis food for the growing embryo before the embryo begins to draw\nsustenance through the placenta. The eggs of birds have a large\nquantity of food stored in the yolk, since their embryos live in\nthe ovum and draw food therefrom during the entire period which\ncorresponds to the time of gestation in mammals. The \"white\" and the\ncalcareous shell of a hen's egg are adventitious parts, added in the\noviduct after the egg leaves the ovary.\n\nThe spermatozo\u00f6n is a complicated organism. The head is partly\ncovered with a thin protoplasmic cap, and it contains the nucleus\nwith the chromatin. In the neck are two centrosomes. The tail\nis in three parts with an axial filament throughout, which is a\nbundle of extremely minute fibrils. In the middle part the axial\nfilament is surrounded by an inner sheath; outside this sheath\nis a spiral filament lying in a clear substance; and outside the\nspiral filament is a finely granular layer of protoplasm, called the\nMitochondria. This organism is a living animal cell, and it can live\nin an incubator, or in the Fallopian tube for two or three weeks,\naltogether removed from the living male body that produced it. Sir\nJohn Lubbock[33] says he kept a queen ant alive for thirteen years.\nThis ant, which died in 1888, had been fertilized in 1874, and never\nafterward. She laid fertile eggs for thirteen years; that is, the\nspermatozoa in her oviduct retained their vitality for thirteen years.\n\n  [33] _Journal of the Linnean Society_, vol. xx, p. 133.\n\nThe human spermatozo\u00f6n is a living cell: it has (1) the requisite\nstructure; (2) the chemical composition of an organic being;\n(3) a figure in keeping with its species; (4) an origin from a\nliving progenitor; (5) the _explicatio naturae_; (6) the power\nof assimilation; (7) the _duratio viventium_; (8) the power of\nreproduction; (9) motion and locomotion. As soon as the ovum breaks\nthrough the surface of the ovary it has all the qualities of the\nspermatozo\u00f6n except locomotion. These two cells are animal cells,\nnot vegetable; just as single-celled protozoa, like Actinophrys,\nActinosphaerium, Closterium, Stentor, and the Amoebas are animals,\nnot plants. It is not possible in our present knowledge sharply to\ndifferentiate ultimate forms of plants from animals. To say that\nanimals have the qualities of plants plus a sentient vital principle\nis not enough. It is very doubtful that even the so-called sensitive\nplants feel, and it is practically certain that many low forms of\nanimal life do not feel--they have no sentient mechanism. Plants have\nthe qualities enumerated above plus the power of drawing nutriment\ndirectly from inorganic material, while animals can draw nutriment\ndirectly only from organic material; yet some fungi, bacteria\nfor example, will grow and thrive only on organic material, and\nanimals will take up mineral drugs. It is questionable, however,\nthat minerals which thus find a way into animal cells are really\nassimilated. They excite or irritate these cells into intenser\naction, and thus cause growth, rather than affect development by\ndirection. The so-called mineral tonics used in medicine act by\nirritation.\n\nThis irritation or stimulation by drugs can in certain very low forms\nof animal life start mitosis in the unfertilized ovum, and thus build\nup part, at the least, of a specific embryo parthenogenetically:\nhere probably a polar body takes the place of the spermatozo\u00f6n.\nLoeb, by treating the unfertilized egg of Arbacia (a sea-urchin) with\nmagnesium chloride, started mitosis that resulted, it is said, in a\nperfect Pluteus larva.[34]\n\n  [34] _American Journal of Physiology_, 1899, iii, 3.\n\nThe human ovum is about half the size of a period in the type of this\npage, and two hundred and fifty spermatozoa will fit side by side\nalong the horizontal diameter of the lowercase letter _o_ here. The\nnuclei of these cells are extremely minute: they must be stained and\nbe observed with a high-power objective on the microscope before they\nbecome visible. This small nucleus of the spermatozo\u00f6n penetrates\nthe covering membrane of the ovum, enlarges, and becomes the male\npronucleus. The pronucleus unites permanently with the pronucleus of\nthe ovum, and together they form the Cleavage or Segmentation Nucleus\nof the fertilized ovum. This new nucleus gives rise by division to\nthe innumerable myriads of nuclei in the growing body. Hence every\nnucleus of the child apparently contains nuclear material derived\nfrom both parents, as has been said.\n\nThe two perfected germ-cells before fecundation are in a state of\nnuclear rest after the numerous mitotic changes that have taken\nplace in the maturation of these cells. When these nuclei unite in\nthe ovum an intense activity at once is set up. Biologists offer\nvery many theories to explain this awakening force. Herbert Spencer,\nHerting, and others held that protoplasm when perfected tends to\npass into a state of stable equilibrium and consequent lessened\nactivity, but fertilization restores it to a labile state. This and\nsimilar theories are verbose amplifications of the obvious fact that\nthe cells start to divide and the biologists do not know the cause.\nThe soul, of course, cannot have anything to do with the matter,\nbecause you cannot smell a soul. \"Senescence and rejuvenescence\" is\nanother sonorous explanation that does not explain, used by Minot,\nEngelmann, and Hansen. Weismann rejects these theories for his own\n\"Fertilization as a Source of Variation.\" Anyhow, the fertilized cell\nstarts to divide regardless of the biologists. Adult cells may be\nstimulated to divide by chemical irritation, by mechanical pressure\nas in the formation of calluses, traumatism, by any agency that\nbrings about an abnormal condition of the body, but this fact does\nnot explain the normal fission of the fecundated ovum.\n\nIn about fifteen days from the date of fertilization the ovum passes\nthrough the following stages:\n\n1. The ovum, with a full series of mitotic changes of the ordinary\nsomatic type described above, divides, subdivides, and grows within\nthe cell-wall until a rounded mass of cells is formed, which is\ncalled the Morula or Blastula--the original cell-wall, of course,\nstretches to hold these new cells. They are of unequal size, and they\ndivide at unequal rates.\n\n2. An albuminous fluid collects within the morula, and thus the\nVesicle or Blastocyst is formed. The blastocyst is called more\ncommonly the Cleavage Cavity or the Segmentation Cavity. As this\ncavity widens the cells are seen to be arranged in two groups--(_a_)\nan enveloping layer, the epiblast, from the outermost plate of which\ndevelops later the Trophoblast, or the nourishing and protecting\ncovering of the embryo; (_b_) an Inner Cell Mass, made up of granular\ncells, attached to the epiblastic layer at the Embryonic Pole of the\nVesicle. These two stages probably take place in the Fallopian tube,\nand thereafter the embryo is in the cavity of the uterus.\n\n3. In the third stage the Inner Cell-Mass separates into two layers\nderived from the inner cell-plate of the blastula. The mass flattens\nand spreads peripherally, until finally it is divided into two\nlayers. The outer is the Ectoderm and the inner is the Endoderm or\nHypoblast. The three steps just described have not yet been seen in\nthe human species by any one, but they are inferred very confidently\nfrom what is well known of the development in mammals most closely\nresembling man in physical formation.\n\n4. By the conversion of the one-layered blastula into two layers of\ncells, the Gastrula stage of the embryo is attained. The Gastrula\nconsists of two layers of cells surrounding a central cavity, which\nis the Archenteron, or the body-cavity that will hold the intestines.\nDuring the past twelve years many specimens of human gastrulas have\nbeen observed. The earliest form was that seen in 1908 by Teacher\nand Boyce.[35] This embryo was 1.95 mm. in length by 0.95 mm. in\nwidth, about twice the size of a pin-head. It showed on section the\nendoderm, the ectoderm, and the beginning mesoderm, enclosed in a\nspherical mass of trophoblastic cells. The mesoderm is a plate of\ncells lying between the endodermic and ectodermic plates. When the\nmesoderm develops into two plates, a cavity, called the Primitive\nCoelom, appears between the plates. The Coelom becomes the space\nbetween the viscera and the body-walls in later development.\n\n  [35] _Contributions to the Study of the Early Development and\n  Embedding of the Human Embryo._ Glasgow, 1911.\n\nFrom the primary embryonic layers of cells, the ectoderm, the\nendoderm, and mesoderm, all the parts of the body are built up. From\nthe ectoderm are produced the skin, nails, hair, the epithelium of\nthe sebaceous, sweat, and mammary glands, the epithelium of the mouth\nand salivary glands, the teeth-enamel, the epithelium of the nasal\ntract, of the ear, of the front of the eye, and the whole spinal cord\nand the brain, with their outgrowths.\n\nFrom the endoderm come the epithelium of the respiratory tract,\nof most of the digestive tract with the liver and pancreas, the\nepithelium of the thyroid body, the bladder, and other minor parts.\n\nFrom the mesoderm are developed bone, dentine, cartilage, lymph,\nblood, fibrous and alveolar tissues, muscles, all endothelial cells,\nas of joint-cavities, blood-vessels, the pleura and peritoneum, the\nspleen, kidneys and ureters, and the reproductive bodies.\n\nThe epiblast now with its mesoblastic lining begins to form the\nChorion, an embryonic intrauterine appendage; and the endoderm\nencloses the Archenteron or primitive gut. Before the end of the\nsecond week of gestation the heart is indicated as two tubes in the\nmesoderm, and the blood-vessels begin to be produced in the yolk-sac.\nAbout the twelfth day the mouth-pit shows, and the gut-tract is\npartly separated from the yolk-sac. The medullary plate of the\nnervous system is laid down about the fourteenth day, and the nasal\narea is observable. The maternal blood escapes into spaces about\nthe embryo enclosed by masses of embryonic cells, which have not\nseparated from one another, but which are known collectively as\nSyncytium.\n\n5. With the third week the stage of the embryo, technically so\ncalled, begins. During this week the body of the embryo is indicated.\nThere are three layers of cells, already mentioned, the ectoderm,\nmesoderm, and endoderm, and these lie on the floor of the enveloping\nAmnion. The amnion is a loose fluid-filled sac (the caul) enveloping\nthe fetus to protect it from jarring. The fluid in it is the \"waters\"\nthat escape in parturition when the infant breaks through the caul.\nThe archenteron in the third week shows the beginning of a division\ninto two parts: the part that will go to the body proper of the\nembryo, and the part outside the body of the embryo which will form\nthe yolk-sac, or umbilical vesicle, from which the embryo will draw\nsustenance until the placental vessels have been formed. The part of\nthe archenteron that remains within the embryo proper begins in this\nthird week to be moulded into the head-cavity. The forepart of the\narchenteron will later make the alimentary tract from the mouth to\nthe middle of the duodenum, or small intestine beyond the stomach.\nThe other part of the archenteron wall make the Allantois, the hind\ngut and the bladder. The allantois becomes a part of the fetal\numbilical cord after the formation of the placenta.\n\nDuring this third week the dorsal outline of the embryo is concave;\nthe heart has a single cavity, which will begin to divide during\nthe fourth week; the vitelline blood circulation begins, and the\nblood-vessels of the visceral arch are laid down. The digestive\nsystem is advanced to a gut-tract, which is a straight tube connected\nwith the yolk-sac. The liver evagination is present and the oral\npit is a five-sided fossa. The respiratory system is represented by\nthe _anlage_ of the lungs, a longitudinal protrusion of the ventral\nwall of the esophagus. The genito-urinary system begins as the\nWolffian bodies. The mesoderm starts to segment to form the skin,\nand the neural canal (from which develop the spinal cord and brain)\nfor the nervous system forms. The fourth ventricle of the brain is\nindicated, and the vesicles of the fore brain, mid brain, and hind\nbrain are recognizable. The ears, nose, and eyes, muscular system,\nskeleton, and limbs are also beginning to be recognizable. At about\nthe sixteenth or eighteenth day of gestation the various parts of the\nembryo rapidly differentiate.\n\nIn the fourth week all these parts advance. The atrium cavity of\nthe heart begins to divide; the alimentary tract shows the pharynx\nand esophagus, stomach, and gut; the pancreas starts, the liver\ndiverticulum divides, and the bile-ducts appear. The lung _anlage_\nbifurcates and the primitive trachea is seen. The ventral roots\nof the spinal nerves appear, the interior ear is indicated, and\nthe eye is deeper. The buds of the legs and arms appear about the\ntwenty-first day--by the thirty-second day even the fingers are\npresent. The four heart-cavities are formed, the intestinal canal is\nnearly closed, the first indications of the liver and kidneys appear.\nThe child now has reached the fetal stage, and its living body is\nmade up of myriads of cells all derived from the original fertilized\novum. The fetus is then one centimetre, or two-fifths of an inch, in\nlength--about the length of the word \"fetus\" here.\n\nAt the end of the second month the fetus is two and a half\ncentimetres long. The ears appear, and the tail-like process at the\nlower end of the spine disappears. The arms show the three parts,\narm, forearm, and hand; and a little later the thigh, leg, and foot\nare differentiated. The navel begins to close, the liver develops,\nthe abdomen is yet partly open.\n\nAt the end of the third lunar month the fetus is seven to nine\ncentimetres long. The intestinal canal is formed and contains\nbile. The body resembles that of a human being, but the head is\nproportionately very large. Bony tissue begins to appear.\n\n[Illustration: FIG. III.\n\nThe Development of the Fetus.]\n\nAt the end of the fourth lunar month the fetus is ten to seventeen\ncentimetres long. Some muscles are movable. The heart-beat is strong.\nSex is distinguishable externally. The skin is bright red, and so\ntransparent that the blood-vessels are visible through it.\n\nToward the close of the fifth lunar month the head is about the size\nof a hen's egg. The skin is somewhat less transparent. There are\nindications of hair and nails. The eyelids are closed. Parts of the\nbrain and spinal cord are formed. Such a fetus may live for five or\nten minutes if removed from the womb, and it may make attempts at\nrespiration.\n\nAt the end of the sixth lunar month the fetus, if born, may live\nfor several hours under favorable circumstances. Its respiratory,\ndigestive, and related organs are not developed, and no artificial\nfeeding will keep such a child alive. The brain cortex, the organ of\nconsciousness, begins to laminate into three strata of nerve-cells at\nthe beginning of the sixth month.\n\nHere the time of fetal viability outside the womb may be considered.\nLangstein, of the Augusta Victoria Hospital in Berlin, reported[36]\na study of the growth and nutrition of 250 prematurely born infants,\nand he found that a weight of 1000 grammes (2-1/5 pounds) and a full\nbody length of 34 centimetres (13-3/5 inches) are the lowest limits\nfor viability under proper circumstances. A fetus 1000 grammes in\nweight and 34 centimetres in length has completed the sixth solar\nmonth, or the sixth and a half lunar month; that is, it is viable at\nthe _beginning_ of its seventh month, _servatis servandis_.\n\n  [36] _Berliner klinische Wochenschrift_, June 14, 1915.\n\nThe child at term, as a rough average, is from 48 to 52 centimetres\n(19 to 20-1/2 inches) in length, and it weighs from about 6-3/5 to\n7-1/2 pounds. It is impossible, however, to obtain the sizes and\nweights of infants _in utero_ with scientific accuracy, because the\ndate of conception cannot be determined with absolute certainty, and\nindividual fetuses vary as do infants after birth. A full-term infant\nsometimes may weigh only 3-1/2 pounds when the mother is diseased,\nand again an eight-month fetus will weigh as much as 8 pounds. Large\nmuscular and fat women have large babies; women of the well-to-do\nclasses have larger babies than do the poor; women who work during\ngestation bear smaller babies than do those women that rest. Mothers\nwho work in tobacco, lead, or phosphorus have puny babies; white\nchildren are larger at birth than negro children; boys at term are 3\nto 5 ounces heavier than girls.\n\nLangstein says that prematurely born infants weighing from 900\ngrammes (31-1/2 ounces) to 1500 grammes (3-1/2 pounds)--that is,\nall born before the seventh solar month--must be kept in hot-water\nincubators in a room with ordinary ventilation. Babies weighing 2000\ngrammes (4-1/2 pounds) or more get along in an ordinary crib if they\nare kept surrounded with hot-water bags. Such children are to be fed\nwith human milk through a catheter passed into the mouth or they\ndie of inanition. Only a few of them are strong enough to suck from\na bottle, and these give up the effort after a few days and die.\nThey cannot utilize fat, even from milk; and all artificial food is\ndangerous.\n\nMost of the prematurely born become rachitic, and even human milk\nis not preventive of this condition. Rachitis is a constitutional\ndisease, characterized by impaired nutrition of the bones and\nchanges in their shape. In the third or fourth month craniotabes is\nfrequent--that is, an atrophy of the skull bones with the formation\nof small conical pits. These infants show also a morbid tendency\nto convulsions--spasmophilia. Such diseases are caused by a lack\nof mineral salts, which normally are carried to the fetus by the\nplacental blood during the last two months of gestation. Because of\nthis lack premature infants require the administration of lime salts\nin their food; they also need iron because they are anemic.\n\nA fetus, then, of six calendar, or solar, months (not lunar) is\nviable if treated in a hospital by competent physicians. Otherwise\nit is not viable, except in a strictly technical sense; it will not\nlive more than a few days or weeks. Reports of infants younger than\nsix months as having been successfully reared are not credible--it is\neasy to make an error in the reckoning.\n\nA full seven-months infant may be reared with proper feeding and\nskilled care; a six-months infant may be reared (with difficulty) in\na hospital with skilled care. If it is certain that the removal of a\nsix-months fetus will here and now save the life of a mother (a very\ndifficult matter to judge by the best diagnosticians), this removal\nmay be done, provided the infant is delivered in circumstances where\nskilled care, incubator, and proper food are obtainable; otherwise\nthe removal is not justifiable. That the ordinary physician says it\nis necessary to empty the uterus is not a sufficient reason, as he is\nlikely to act from ill-digested information set forth by professorial\npagans, who place no value whatever on human life in an infant.\n\nA most important and essential circumstance in the matter of\ninducing abortion at the end of the sixth month of gestation to\nsave a mother's life is that in practically every case requiring\nsuch interference the diseased condition of the mother has checked\nthe growth of the fetus, and the fetus therefore is really not a\nsix-months child in development. Such an undeveloped fetus is not\nviable. Eclamptic women, and those who have nephritis, are most\nlikely to have undeveloped fetuses. In cases of this kind the seventh\nmonth should be completed before interference.\n\nHow is this human body in all its complexity developed from the\nmicroscopic germ-cells? There has been a vast deal of ink spilled in\nstriving to solve this mystery, but we come out empty by the same\ndoor wherein we went. The early Preformationists guessed that the\novum contains an embryo fully formed in miniature, and development\nis a mere unfolding of what had already existed. The biologists of\nto-day mention the Preformationists with superior scorn, and then\npresent Preformationism under other names. Weismann's theory is the\nmost fashionable at present.\n\nIn a paper read at the Darwinian Memorial Congress in 1909, Weismann\nsaid: \"With others I regard the minimal amount of substance which\nis contained within the nucleus of the germ-cells in the form of\nrods, bands, or granules, as the _germ-substance_, or _germ-plasm_,\nand I call the individual granules[37] _ids_. There is always a\nmultiplicity of such _ids_ present in the nucleus, either occurring\nindividually or united in the forms of rods and bands (chromosomes).\nEach _id_ contains the primary constituents of the _whole_\nindividual, so that several _ids_ are concerned in the development\nof a new individual.\" Actually there are such things as chromosomes,\nand when these are stained and are under the highest power of the\nmicroscope they appear to be granular. These granules Weismann calls\n_ids_. Beyond the fact that there are such granules, all else is\nsheer guessing.\n\n  [37] _Id_ is a word derived from N\u00e4geli's term idioplasm, which\n  means the chromosome granule.\n\nHe says further: \"In every complex structure thousands of primary\nconstituents must go to make up a single _id_; these I call\n_determinants_, and I mean by this name very small individual\nparticles, far beyond the limit of microscopic visibility, vital\nunits, which feed, grow, and multiply by division. These determinants\ncontrol the parts of the developing embryo,--in what manner need not\nhere concern us.\"\n\nThere is some truth here. The _id_ is made up of molecules and atoms,\nions and electrons, and in some manner, of course, these have to do\nwith the development of the embryo; but as to the manner we have not\nthe slightest knowledge, and just this knowledge is what we need\nto make the theory anything more dignified than a child's game at\nguessing. There is a structural differentiation in the unsegmented\novum, with all the embryonal axes foreshadowed in it, but this tells\nus nothing more than that the egg contains the man in germ.\n\nHe goes on: \"The determinants differ among themselves; those of a\nmuscle are differently constituted from those of a nerve-cell or a\nglandular cell, etc., and each determinant is in its turn made up of\nminute vital units, which I call _biophors_, or the bearers of life.\"\n\nThat these so-called determinants differ among themselves may be\ntrue, if they exist at all, which is just the point to be proved.\nGiving Greek names to inventions does not turn invention into fact.\nThese supposed determinants, he says, \"may vary quantitatively if\nthe elements of which they are composed vary; they ... and their\nvariations may give rise to _corresponding_ variations of the organ,\ncell, or cell-group which they determine.\" Professor Dwight said:[38]\n\"This is what is palmed off on us for science!\" Weismann assures us\nwe _must_ admit this farrago of clumsy fiction, otherwise we should\nbe forced \"to assume the help of a principle of design.\"[39] In the\nname of common sense, then, admit a principle of design, and be done\nwith it!\n\n  [38] _Thoughts of a Catholic Anatomist_, p. 48.\n\n  [39] _Contemporary Review_, September, 1893.\n\nDarwin's Gemmule Theory is the same guessing; and Weismann rejects it\nbecause he did not think of it first. As a theory the gemmule plot\nis just as good and just as bad scientifically as Weismann's. The\nchief objection to such imagining is that after its authors have put\nit into print a few times they lose all sense of humor, and mistake\nphantasms for facts.\n\nUp to the present time we have discovered no living organism lower in\ngrade than the cell. If life ever originated from inorganic matter,\nit appeared in an organized cell. The Weismann ids, biophors, and\nthe rest, supposing they existed outside his own imagination, are\nnot more capable of independent life than is a chromatin granule. In\nany event, these biophors could not have originated spontaneously\nin the first living being; and if they could not so have come into\nexistence, life could never have begun. However primitive any\norganism is, it must be able to nourish itself and to develop into\na higher specific form; but such a variety of functions supposes\ndifferentiated structure, composed of unstable chemical substances,\na correlation of parts, a purposeful anticipation of ends. Inorganic\nsubstances, crystals, and the like are characteristically stable,\nnot unstable; and these could not have been brought into the organic\nstate on an earth burnt to a cinder and devoid of chlorophyl, which\nitself presupposes organic cells. Whence came also the absolutely\nessential form of energy, directive of vegetative life? The only\npossible explanation is that life was created, not evolved by a\nstranger miracle from a lump of lava.\n\nWe know the successive steps in the growth of the embryo from the\ntime of fertilization to the end of gestation, but how this vital\nprocess is effected is not so evident. What we are certain of is\nthat there is a vital principle of some kind from the beginning,\nand this is the matter of real importance in the present discussion.\nThe old moralists held that this principle in the human being is\nat first vegetative; after a while that vegetative vital principle\nis expelled by a sensitive principle; and finally this sensitive\nsoul is expelled by the rational vital principle, or human soul.\nSt. Thomas[40] says: \"Some tell us the vital acts that appear in\nthe embyro are not from its soul, but from the soul of the mother,\nor from the primitive force in the semen. Both these statements are\nfalse. Vital operations, as sensation, nutrition, growth, cannot come\nfrom an extrinsic principle; therefore it must be admitted that a\nsoul pre\u00ebxisted in the embryo, nutritive at first, then sensitive,\nand finally intellectual.\" After showing that an intellectual soul\ncannot be evolved from lower forms, he concludes: \"Therefore we say\nthat since the generation of one thing is always the corruption of\nanother, in man as in other animals, when a more perfect form comes\nin this supposes the corruption of any precedent form; so, however,\nthat the sequent form has all perfection that was in the destroyed\nforms, and something in addition: and thus through many generations\nand corruptions the final substantial form is attained in man and\nother animals. This is apparent to the senses in animals generated\nfrom putrefaction. Therefore the intellectual soul is created by God\nat the end of human generation, and this soul is both sensitive and\nnutritive, all precedent forms having been destroyed.\"\n\n  [40] I, q. 118, a. 2, ad 2.\n\nThere is no such thing as the generation of any animal or other\nliving being from putrefaction; but that is irrelevant. St. Thomas's\nargument proves conclusively that _if_ man has first a merely\nvegetative soul, and secondly a merely sensitive soul, which includes\nthe power of the vegetative soul, and thirdly an intellectual soul,\nwhich does the work of all three, that this final intellectual\nsoul is not an evolution of the first two, but a new form that\nreplaces these after they have served their purpose and have been\nannihilated. It does not even attempt to prove that man really has\nfirst a merely vegetative soul, and secondly a sensitive, and lastly\nan intellectual soul; it supposes all this. It starts out with the\nerroneous Aristotelian theory and takes it for granted. The reason\nfor this statement is that the rational substantial form requires\ndisposed matter to work upon, and the Thomists suppose (again\nerroneously) that in the human embryo during the period immediately\nafter conception there is not enough matter to be a receptacle for\nthe rational soul.\n\nThe soul according to the Thomists, who use the Aristotelian\ndefinition, is the first entelechy of a natural organic body that has\nlife in potency.[41] It is the determination that gives the body its\nspecific and substantial being; the primal actuation of a body or\nmatter, since only in matter is there a distinction between potency\nfor substantial being and substantial actuality. An entelechy is a\nrealization, actuality, full perfection; sight, for example, is the\nentelechy of the eye. This body is natural, not merely instrumental;\nit is energized by an immanent principle, not moved by an external\nforce like a tool. The body is also organic; it must have organs,\nfaculties, parts destined to perform definite functions. To say the\nentelechy has life in potency means that since life, or the operation\nof the soul, is an immanent act, there must be a receptacle within\nwhich it can be immanent, and the soul is the primal actualization\nof that organic body, which is in potency to produce those immanent\nactions in which life consists. A body might be in potency while it\nstill has no principle of operation, or, secondly, while it has such\na principle but is not using it. In the second condition the human\nbody is in potency for life at the moment of actualization.\n\n  [41] \u1f21 \u03c8\u03c5\u03c7\u03ae \u1f10\u03c3\u03c4\u03b9\u03bd \u1f10\u03bd\u03c4\u03b5\u03bb\u03ad\u03c7\u03b5\u03b9\u03b1 \u1f21 \u03c0\u03c1\u03ce\u03c4\u03b7 \u03c3\u03ce\u03bc\u03b1\u03c4\u03bf\u03c2 \u03c8\u03c5\u03c3\u03b9\u03ba\u03bf\u1fe6 \u1f40\u03c1\u03b3\u03b1\u03bd\u03b9\u03ba\u03bf\u1fe6\n  \u03b4\u03c5\u03bd\u03ac\u03bc\u03b5\u03b9 \u03b6\u03c9\u1f74\u03bd \u1f14\u03c7\u03bf\u03bd\u03c4\u03bf\u03c3 (_De Anima_, ii, 1).\n\nA form fixes a thing in its pr\u03c7\u03bf\u03bd\u03c4\u03bf\u03c3oper species, and the rational\nsoul is such a form for the human body. This substantial form is the\ncompletion, perfection, in operability and existence, of the matter\nthat receives it. It is the formal cause of man, not the efficient\ncause, although it is the efficient cause of subsequent vital\noperations. An efficient cause makes something numerically different\nfrom itself by its own real and physical action; a formal cause and\na material cause do not make anything different from themselves\nnumerically, but they intrinsically constitute the effect--they are\nintrinsic causes.\n\nThe human soul as the substantial form virtually contains vegetative\nand sensory faculties, and through these lower organic capacities it\ninforms and animates the body. That form, together with the matter,\nthe body, does the vital acts of the composite human nature. The\nrational soul enters the body at the beginning, and first uses its\nvegetative faculty until the fetus is far enough advanced to be a\nsubject for the action of the sensory faculty of the soul. Later,\nsome time after the birth of the child, when the body is sufficiently\nformed, the intellectual faculty comes into use.\n\nThe nature of a vital principle is that in which it normally\nissues. If it issues as a rational substantial form, as in man, it\nwas rational from the beginning. If it was not rational from the\nbeginning, a rational principle replaced a sensory vital principle,\nand that sensory vital principle replaced a vegetative vital\nprinciple. The only reason for these replacements would be that the\nearly human embryo, as has been said, lacks organization sufficient\nto sustain a form higher than a vegetative principle. If this were\nsufficient reason for deferring the advent of the rational soul, then\na baby six months after birth would have no rational soul because\nit certainly lacks the supposedly requisite organs. However, as the\nrational soul is whole in each part of the adult body in the totality\nof its essence and perfection, but not in the totality of its virtue,\nbecause certain organs are lacking in particular parts of the\nbody, it is in the embryo whole in the totality of its essence and\nperfection, but not in its virtue because certain organs are not yet\nformed, and it is thus from the moment of conception.\n\nAs to the soul itself, Kant held that the soul is not a real, but\nonly a logical substance. The Pantheists, Transcendentalists, and\nNeo-Hegelians try to identify the soul with the divine consciousness.\nThe Associationists (Hume, Davis, H\u00f6ffding, Sully) say that the soul\nis a mere group of sensations. The Agnostics and Positivists (Locke,\nHerbert Spencer, James, Comte) write volume after volume on the\nsoul to prove that they know nothing about it. Then the Materialists\nassert that there is no soul of any kind; that we secrete thought\nas a mule secretes sweat. Yet the vital operations of man are\ninexplicable as resultants of the physical and chemical properties\nof matter. There is an intrinsic energy that unifies the actions\nof man, directs processes, controls the tendency of organic matter\nto pass into the fixity of the inorganic, and effects metabolism.\nThis intrinsic energy is the entelechy, substantial form, or what is\npopularly called the soul.\n\nIn any organic body there is a formal principle. We know that there\nare activities that proceed from organic bodies, and a formal\nprinciple of such activity is a substantial entity whence the\norganism derives basically its own kind of action, which determines\nand orders the activity. There are acts of perception in animals\nsuch that an external object becomes so internal to the organism of\nthese animals that it is known by one expressed and immanent image,\nnot only as something objectively existing but as good or hurtful to\nthe perceiving animal. The innate and elicited appetites by which\nthe animal tends toward or away from the object are recognized, as\nare the spontaneous motions which are directed by that knowledge.\nThere must be a principle whence these actions proceed, and this is\neither an accident of matter or something substantial. It is not an\naccident of matter, because action can never arise from an accident;\nit must proceed from a substance. If you say this principle whence\nthese actions arise is not an accident of matter, but matter itself,\nyou would have an extended, composite, inert mass acting; but even if\nsuch thing could act, it could never effect a simple immanent image\nof an object or group of objects external to itself.\n\nNo mere machine can build up itself, can make any remote approach\nto metabolism as an organized body can; and the principle of this\nimmanent action is not matter itself, because it uses, makes,\nsubordinates matter to itself. That principle is positively one, not\none by continuity as matter is. Matter as in a crystal grows by mere\naggregation, an organism grows by assimilation; a crystal loses\nforce in formation and growth, an organism accumulates force.\n\nThe theory that denies the existence of this formal principle does\nnot explain the phenomena of life in organic beings. Uniformity\nof tendency toward an end is not a characteristic of mere matter;\nneither is a harmonious interaction of parts, nor the dependence of\nparts on the unit, nor motion, nor the reproduction of the species.\n\nMoreover, most of the greatest physical scientists strongly maintain\nthat there must be a formal substantial principle in all living\nthings. Among these are Wallace, N\u00e4geli, Askenasy, Preyer, Fechner,\nAgassiz, von Baer, E. de Beaumont, Blanchard, A. Braun, Brongniart,\nBronn, Burmeister, Delff, Milne-Edwardes, Flourens, Goeppert,\nGriesbach, Heer, Koelliker, Mivart, Quatrefages, Quenstedt, Spiers,\nVolger, R. Wagner, Liebig, and Joseph Hyrtl.\n\nThe formal principle which coexists with matter in the organic\nbody is really though not perfectly distinguished from matter. A\nformal principle which is necessary for sensation should be either\nperfectly simple, or at the least so one that its parts together\nmake up one essence: matter, however, cannot have such unity, and\nas a consequence the formal principle must be distinct from matter.\nAnything is like its operation, and the parts of any sensitive\nactivity always result in an activity that is essentially one. If we\ntouch a table, by that single touch we at once know that the object\nis one, wooden, hard, angular, smooth, extended, and so on, and we\nalso know that one subject perceives all these varied qualities.\nOne eye can convey knowledge at once of a thousand objects miles\napart, and these objects can be brought into one perception only by a\nsimple subject. An extended complex subject like matter would get one\nimpression (if it could perceive any impression) on one side, one on\nanother, and so on, but it could not unite these.\n\nThe formal principle which is in organic bodies is a true substantial\nform, actuating the body both as to its nature and substance.\nTogether with the body, this principle makes a being one in itself,\nsuch that the matter and the form separably are incomplete as\nregards operation and being. Now, a form is that principle through\nwhich anything is established in its own species; light, for example,\nis the form of a luminous body, heat of a hot substance. A body,\nhowever, is established in the human species by receiving a rational\nsoul, and this soul, then, is its form. It is also a substantial form\nbecause the soul itself is a substance, not an accident dependent\nupon another subject. Moreover, from its union with the body another\nsubstance--man--arises, and not a thing added to a substance. Man's\nbody is alive, therefore it is a living substance; but life in its\nsecondary actuality is an operation; in its primary actuality it is\nan essence. The body is made a living substance, not from itself, but\nfrom the soul which is added to it. When the soul departs the body is\nno longer alive. Now, a principle which by a communication of itself\ndetermines the body in its essence and differentiates it as a living\nsubstance from everything else, is a substantial form. A substantial\nform, then, or a soul, exists.\n\nThe soul, however, must have disposed matter for most of its\noperations; it cannot exist as a substantial form _bombinans in\nvacuo_; but it does not need a human organism complete in all its\nparts as a necessary condition for its indwelling. There is organized\nmatter enough in the first cell that comes into existence after the\nfusion of the germ-nuclei to hold this rational form, or soul, as\nperfectly as it needs to be held in this first stage of human life.\n\nTo inform the embryo any principle, whether it is the rational soul\nor a force derived from the parental organism, must have organs; and\nif organs are present, then the embryo is fit to receive the human\nsoul, as the only objection to its presence is a supposed lack of\norgans. To use other principles when the human soul itself could be\npresent would be a _multiplicatio entium sine necessitate_, which is\na condition repugnant to the universal method of the Creator.\n\nIt has been said that the vital activity in the fertilized ovum does\nnot proceed from the rational soul because, \"in the first place, it\nresults from the fusion of two vital activities, neither of which is\nrational; secondly, it results in the formation, by fission, and\ndifferentiation, of two distinct and separate living cells, each\ncontaining within itself a principle of vital activity. Now this\nprinciple of vital activity cannot be a rational soul, for each cell\nhas its own principle of activity, and in man there is but one soul.\"\n\nIn the first place, that vital activity does _not_ result from the\nfusion of two vital activities neither of which is rational. It\nresults _after_ the nuclei come together, by particular creation,\nand replaces their activity--the generation of the last vital force\nis the corruption of the first that existed in the separate nuclei,\nnot a derivative of that first force. Again, when the embryo is\nin the two, four, eight cell stage, and so on, there are not two,\nfour, eight vital principles present, but one. Substantial unity is\nessential to life of any kind, no matter how low its grade; and if\neach cell had an independent vital principle, any form of resultant\nlife in the mass would be impossible. An aggregation has no unity of\nsubstance; there would be as many substances or natures as there are\nindividual beings in the aggregate, no matter whether ordered or in a\nmob, consequently no life at all as a life.\n\nThe embryo in the two-cell stage is not made up of two independent\norganisms, any more than the right and left halves of an adult man\nare two independent organisms. The cells in the two-cell stage\nof the embryo are the right and left halves of the body, not two\nindividuals, as has been proved repeatedly by biologists. Roux[42]\npunctured with a hot needle one of the cells in the two-cell stage\nof a frog embryo without killing the embryo, and it grew into a\nhalf-frog larva. Analogous results were obtained by operating in\nthe four-cell stage. Later, Pfl\u00fcger, Schultze, Enders, and Morgan\ncorroborated the work of Roux. Newport[43] discovered this fact sixty\nyears ago.\n\n  [42] Virchow's Archiv (1888), 114.\n\n  [43] _Phil. Trans._, 1854.\n\nIn analyzing the structure and functions of the individual cell we\nregard it as an independent elementary organic unit, but this view is\nsolely a matter of convenience, almost a convention. All the billions\nof cell's in an adult man are inseparable parts of the single living\nperson. No cell exists as an independent organism in multicellular\nanimals, except the germ-cells, and these only after separation from\nthe gland of origin. Indeed, the biological theory of heredity,\nalready mentioned here, wherein the germ-cell is supposed to carry\nforward the entire heredity, is now changing toward the view which\nmakes all the somatic cells influence the germ-cells; that is, the\nbody-mass of cells sends on heredity through the germ-cell as the\ninstrument. Adult organisms do not make cells _de novo_. New cells\nare formed by division from pre\u00ebxisting cells, but some biologists\nthink the body-cells so affect the new germ-cells as to influence\nheredity.\n\nThe cells are organs, nodal points, of a single formative power\nwhich pervades the mass of cells as a whole. The protoplasm of each\ncell is not only in direct apposition with its neighbors, but nearly\nall biologists are now inclining to the opinion, which Heitzmann\nproposed in 1873, that division of cell from cell is incomplete\nin nearly all forms of tissue; and that even where cell-walls are\npresent (an exceptional condition in mammals) they are traversed by\nstrands of protoplasm, by means of which the cells are in organic\ncontinuity. The whole body, he contended, is thus a syncytium (a\nmass of continuous protoplasm stippled with nuclei), with the cells\nas mere nodal points in an almost homogeneous protoplasmic mass.\nThere are cell-bridges between the sieve-tubes of plants. In 1879\nTangl discovered such connection between the endosperm cells of\nplants, and later Gardiner, Kienitz-Gerloff, A. Meyer, and many\nothers demonstrated that in nearly all plant tissues the cell-walls\nare connected by intracellular bridges. Ranvier, Bizzozero, Retzius,\nFleming, Pfitzner, and many other observers have found these\nprotoplasmic bridges in animal epithelium. In the skin of a larval\nsalamander they are quite conspicuous. They are known to occur also\nin smooth muscle-fibre, in cartilage cells, in connective-tissue\ncells, and in some nerve-cells. Harrison found, in 1908, that in\nfrogs the nerve-fibres develop out of these intracellular bridges.\nDendy in 1888, Retzius in 1889, and Palladino in 1890 have shown\nthat the follicle cells of the ovary are connected by protoplasmic\nbridges, not only with one another, but also with the ovum; and\nsimilar connection between somatic cells and germ-cells has been\nfound in a number of plants. Thus even the germ-cell is not\nindependent until it has actually broken away from the gland. A.\nMeyer holds that both the plant and animal individual are continuous\nmasses of protoplasm, in which the cytoplasmic substance forms a\nmorphological unit, no matter what the cell is. That opinion is\nnot finally settled as regards the animal after the fetal stage,\nbut it is much stronger as regards embryos. In the early stages of\nmany arthropods it is certain that the whole embryo is at first\nan unmistakable syncytium. This is almost established also for\nAmphioxus, the Echinoderm Volvox, and other animals. Adam Sedgwick\nholds that it is true for vertebrates up to a late embryonic stage.\nMitosis, then, is a form of growth of a mass, not a generation of new\nindividuals.\n\nWhether chromatin or any other element in the germ-cell be the\nidioplasm in which heredity inheres, differentiation is a progressive\ntransformation, through physical and chemical changes, of the\nsubstance of the ovum, and this transformation occurs in a definite\norder and a definite distribution in the ovum. The changes result in\na cleavage of the egg into cells, the boundaries of which sharply\nmark the areas of differentiation. These cells take on specific\ncharacters. In the four-celled stage of an annelid egg these four\ncells contribute equally to the formation of the alimentary canal\nand the cephalic nervous system, but only one of them, the left-hand\nposterior cell, gives rise to the nervous system of the trunk and to\nthe muscles, connective tissues, and germ-cells. The relation between\nthe four original cells, or blastomeres, and the adult parts arising\nfrom them, is not fixed, because in some eggs these relations may\nbe artificially changed. A portion of the egg which normally would\ndevelop into a fragment of the body will, if split off from the\nothers, give rise to an entire body of a diminished size.\n\nConklin says[44] that in the ascidian Styela \"there are four or\nfive substances in the egg which differ in color, so that their\ndistribution to different regions of the egg and to different\ncleavage cells may be easily followed, and even photographed, while\nin the living condition. The peripheral layer of protoplasm is yellow\nand it gathers at the lower pole of the egg, where the sperm enters,\nforming a yellow cap. This yellow substance then moves, following the\nsperm nucleus, up to the equator of the egg on the posterior side,\nand there forms a yellow crescent extending around the posterior side\nof the egg. On the anterior side of the egg a gray crescent is formed\nin a somewhat similar manner, and at the lower pole between these two\ncrescents is a slate-blue substance, while at the upper pole is an\narea of colorless protoplasm. The yellow crescent goes into cleavage\ncells which become muscle and mesoderm, the gray crescent into cells\nwhich become nervous system and notochord, the slate-blue substance\ninto endoderm cells, and the colorless substance into ectoderm cells.\nThus within a few minutes after the fertilization of the egg, and\nbefore or immediately after the first cleavage, the anterior and\nposterior, dorsal and ventral, right and left poles are clearly\ndistinguishable, and the substances which will give rise to ectoderm,\nendoderm, mesoderm, muscles, notochord, and nervous system are\nplainly visible in their characteristic positions.\" Conklin followed\nthese cells in every division until the embryo was developed, making\na complete genealogy up to the ovum proper.\n\n  [44] _Heredity and Environment_, p. 123, Oxford Press.\n\nDe Vries[45] assumed that the character of each cell is determined\nby \"Pangens\" that migrate from the nucleus into the protoplasm.\nDriesch and Oscar Hertwig held that the peculiar development of a\ngiven blastomere is a result of its relation to the remainder of the\ncell-mass, an outcome of the action upon it by the whole system of\ncells of which it is a part. Hertwig said:[46] \"Each of the first\ntwo blastomeres contains the formative and differentiating forces\nnot simply for the production of a half-body, but for the entire\norganism; the left blastomere develops into the left half of the\nbody only because it is placed in relation to a right blastomere.\"\nWilson[47] and Driesch[48] came to the same conclusion about the\ntime Hertwig wrote. Driesch said:[49] \"The relative position of a\nblastomere in the whole determines in general what develops from it;\nif its position be changed it gives rise to something different; in\nother words, its prospective value is a function of its position.\"\n\n  [45] _Intracellul\u00e4re Pangenesis._ Jena, 1889.\n\n  [46] _Jenaische Zeitschrift_, 1892, 1.\n\n  [47] _Journal of Morphology_, 1893, 1894.\n\n  [48] _Studien_, iv, p. 25.\n\n  [49] _Ibid._, p. 39.\n\nA discussion of this matter will be found in Wilson,[50] but the many\nexperiments made in the study of this subject show conclusively that\nthe cells, singly, grouped, and in mass, are a morphological unit,\nnot an aggregation of distinct individuals. They are not, of course,\nabsolutely homogeneous, because such a body could not have organs.\nThe substantial form, therefore, is not confined to the first cell.\n\n  [50] _The Cell in Development and Inheritance_, pp. 413 _et seq._\n  New York, 1906.\n\nThe cell-mass, then, has a unity sufficient to be the receptacle of\na human vital principle; again, the basic vital operation of the\nhuman body at any age is metabolism, and this is actually carried on\nin the first somatic cell of the embryo as in the cells of the adult\nman. In the development of the human body in the embryonal stage\nthe energy of cell-division is most intense in the early cleavage\nstage, and this diminishes as the limit of growth approaches because\nfurther division is not needed. When that limit is attained a more\nor less definite equilibrium is established. Some of the cells in\nthe fully formed body cease to divide, the nerve-cells, for example;\nothers divide under special conditions, as the blood-cells, the\nconnective-tissue cells, gland-cells, epithelial and muscle cells;\nothers continue to divide throughout life and thus replace worn-out\ncells of the same tissue, as the Malpighian layer of the skin.\nCells grow, divide, function, reproduce themselves, and so on, all\nthrough their vital activity, sustained by the material brought to\nthem by the blood. Weismann[51] and other biologists think that the\nvital processes of the higher animals are accompanied by a renewal\nof the morphological elements in most tissues. The material is\ncarried to the fetus in the womb by various agents, but mostly by the\nmaternal blood after the embryo uses up the yolk; and when the fetal\ncirculation has been established the nutritive material is taken from\nthe maternal blood into the fetal circulation through the placenta,\nand then carried to the cells by the fetal circulation itself. After\nthe child has been born the stomach and intestines take in the food.\nThe stomach does very little with it except in a preparatory manner;\nthe intestines further prepare it, pass it into the body, where it\nis again modified by other organs, and finally it is carried by the\nblood to the cells. The cells really use it; the other organs are\nthe farmers, grocers, railways, and the like; the cells are the\nconsumers. So far as the essential processes are concerned, the\nembryological cells act as do the adult cells.\n\n  [51] _The Duration of Life._\n\nThe first cell has contractility, protoplasmic motion; it can absorb\nperfectly all food-stuffs necessary for it from the deutoplasm of\nthe ovum, and the water that passes in from without to the ovum. In\na few days the embryonic cells have used up the deutoplasm and are\ntaking up food from the maternal blood as perfectly as any adult cell\ndoes, and are exercising their function of building up and sustaining\nwhatever part of the body they are destined for; and this with all\nthe complicated metabolism of the adult cell. Cell metabolism is the\nfundamental, chief, organic act of any human body at any age. That\nthe embryo does this impelled by the _virtus formativa_ transmitted\nfrom the parents is a mere gratuitous assumption to fit the theory\nthat the embryonic cell lacks organic power. The fundamental organ\nthat conserves the body in its very existence under the government\nof the soul is the apparatus which effects metabolism. Incessant\nchemico-vital change is a characteristic of all living substances,\nfrom the single cell up to the adult man; and in all cases this\nactivity has to do with a transformation of the complex molecules\nwhich build up the protoplasm or are associated with its operations.\nThe totality of the chemical changes, or exchanges, in living cells,\nthe transformation of unorganized food materials so that these may be\nassimilated, and the chemical processes in the tissues themselves,\nall are metabolism. Growth and repair (anabolism) occur side by side\nwith the destruction of elementary tissue substance (katabolism),\nand the duration of life rests on these processes; and all are mere\ncell activities. Food-stuffs (water, inorganic salts, proteids,\nalbuminoids, carbohydrates, and fats) undergo more or less combustion\nor oxidation. Oxygen unites with carbon to form carbon dioxide, and\nwith hydrogen to form water; the nitrogen of the highly complex\nproteid substances reappears in combination with carbon, hydrogen,\nand oxygen as urea, uric acid, and other compounds; and other ingesta\nare thus transformed through oxidation. All maintain the temperature\nof the body, replace outworn parts, and accomplish the body's work.\nOxidation occurs to a slight extent in the blood, but the specific\nreactions are intracellular. Even when nothing exists but the cells\nand the blood, as in the beginning embryo, the cells really do the\nwork, and they do the work as they do in the adult.\n\nThe cells also from the very beginning are the organs that make the\nanimal heat necessary for life. Rubner[52] proved that the source of\nat least 90 per cent. of the animal heat in the body is a result of\nthe chemical changes--oxidation--in the food ingested: the other 10\nper cent. is caused by muscular contractions, the flow of blood, the\nfriction of joints, and like motions. This oxidation is more active\nin young animals than in adults, and in each it is, of course, a\ncellular process.\n\n  [52] _Zeitschrift f. Biologie_, 1893, bd. 30, p. 73.\n\nLiving matter contains hydrogen, oxygen, sulphur, chlorine, iodine,\nfluorine, nitrogen, phosphorus, carbon, silicon, potassium,\nsodium, calcium, magnesium, and iron. The removal of one of these\nelements causes the death of the body. They must be arranged in a\ndefinite, prescribed order to constitute cellular protoplasm, and\nany disarrangement of this order causes intoxication, disease,\nor death. Hydrogen is a constant product in the putrefaction of\nanimal matter, of animal food, and is present in the intestinal\ntract. Oxygen is found dissolved in water and loosely combined in\nblood as oxyhemoglobin. All the elements, except fluorine, combine\nwith oxygen, forming oxides, and the process is called oxidation.\nThe production of heat and all vital motion depend on oxidation,\ndecomposition of matter. In the nuclei of cells there is a so-called\n\"oxygen-carrier,\" a nucleo-proteid, which contains iron, and this\nappears to be the chief oxidizing agent in the body. Chlorine, which\nin hydrochloric acid is essential to digestion, is ingested as\nchloride, and leaves the body chiefly through the urine and sweat.\nIodine is a necessary part of the thyroid gland, an indispensable\nvital organ. Fluorine is found in all cells. Nitrogen goes into the\nbody combined in proteids; and phosphorus, combined in the alkalies\nand alkaline earths of the foods. Carbon occurs in all cells and\nleaves them through the lungs as carbon dioxide.\n\nThe amount of energy set in action in the body in the decomposition\nof any food is equal to the energy that had been expended in the\nsynthesis of that food from its organic elements, and the liberated\nenergy set free in the body appears as heat, work, and nervous\nimpulse. In a plant the chlorophyl and the sun's rays combine water\nand the carbon dioxide of the air into sugar and free oxygen. This\nsugar is changed in a plant into starch, cellulose, and fat, and\nalso, when combined with some nitrogen, into proteid. An animal eats\nthis plant, which contains starch, cellulose, fat, and proteid, and\nit either adds these ingredients to its own substance or oxidizes\nthem so as to prevent the destruction of its own substance. These are\nthe ends of all food. Broadly speaking, plants synthesize elements;\nanimals analyze them, reduce them into simpler bodies.\n\nSuch processes, and those of the other elements of the body, which\nhave to do with the changing constituents of the human organism,\nare all cellular processes--metabolism. Hence the chief organic\nact of the body is metabolic; the basic organ of man is the cell.\nArms, legs, heart, brain, stomach, and similar organs are secondary,\nthough some of the latter are essential for certain operations. Now,\none cell is an organ amply sufficient for metabolism, for the chief\norganic act of the body; hence it is a fitting receptacle for a\nsubstantial form, a soul. Therefore there is no reason why the soul\nmay not be present in the one-cell stage of the embryo; and since\nthere is no reason why it should not be present, but many why it\nshould, it is present.\n\nConklin says:[53] \"The fertilized egg of a star-fish, or frog, or\nman is not a different individual from the adult form into which it\ndevelops, rather it is a star-fish, a frog, or a human being in the\none-celled stage. This fertilized egg fuses with no other cells,\nit takes into itself no living substance, but manufactures its own\nprotoplasm from food substances; it receives food and oxygen from\nwithout and it gives out carbonic acid and other waste products;\nit is sensitive to certain alterations in the environment, such\nas thermal, chemical, and electrical changes--it is, in short, a\ndistinct living thing, an individuality. Under proper environmental\nconditions this fertilized egg-cell develops, step by step, without\nthe addition of anything from the outside except food, water, oxygen,\nand such other raw materials as are necessary to the life of any\nadult animal, into the immensely complex body of a star-fish, a frog,\nor a man. At the same time, from the relatively simple reactions\nand activities of the fertilized egg there develop, step by step,\nwithout the addition of anything from without except raw materials\nand environmental stimuli, the multifarious activities, reactions,\ninstincts, habits, and intelligence of the mature animal.\"\n\n  [53] _Heredity and Environment._\n\nAn objection to the opinion that the soul is in the embryo from\nthe beginning is made from a consideration of the facts that there\nappears to be an aptitude for life in certain animal cells and\ntissues after removal from the original host, or after the death\nof the host; and, secondly, that in other separated tissues life\nis undoubtedly made evident under proper conditions. Some parts of\nthe human body can be grafted upon another human body, and human\nsarcomatous cells have been made to grow _in vitro_. Hair often\nlengthens after the death of a person, if no embalming fluid has been\ninjected. Dr. Alexis Carrel[54] substituted a piece of a popliteal\nartery, taken from an amputated human leg and kept in cold storage\nfor twenty-four days, for a part of the aorta of a small bitch,\nand the dog lived for four years afterward and died in parturition.\nMagitot of Paris, in 1911, took a piece of the cornea from an\nextirpated human eye, and with it replaced a part of an opaque cornea\non another man, and this second man could see through the new cornea.\nSurgeons now remove skin, bone, and other tissues from still-born\ninfants and accident cases, preserve these, for weeks if necessary,\nin petrolate and Ringer's solution in cold storage, and then graft\nthem on patients to repair lesions in skin, bone, cartilage, or other\nparts of the body.\n\n  [54] _Journal of the American Medical Association_, vol. lix, n.\n  7, p. 523.\n\nIf these separated tissues are alive, what is the origin and nature\nof the life? Again, if there is a low form of life in these separated\ntissues, remaining after the departure of the human soul, why could\nnot such a low form of life precede in the embryo the advent of the\nhuman soul?\n\nWhat is the nature of the \"life\" in the parasitic sarcomatous tissue\nwhich has been seen to proliferate for a short time _in vitro_? We\ndo not know, nor is it relevant to the question. That there is life\nof any kind in the cold-storage graft of bone and skin is certainly\nnot evident; rather every evidence points to the absence of all life.\nWhen taken out of cold storage, and the ordinary forces which corrupt\na dead body are permitted to work, these grafts corrupt exactly as\nany part of a corpse does. That there is life of any kind in these\ngrafts is a gratuitous assumption. In cold storage they are kept\nready for assimilation into the body as food may be kept. Bone and\nskin grafting is merely a peculiar form of assimilation. Food taken\ninto the body through the stomach and entrails is prepared in the\nbody and assimilated into the substance of the bones or skin or other\ntissues; the graft is ready for assimilation without this preparation\nbecause it is already bone or skin.\n\nThe vital principle in a man, or in anything else, is at the end,\nwhen it normally issues, of the same nature as it was in the\nbeginning. If it is at perfection a substantial primary form, it\nalways was such--a substantial form cannot issue from an accidental\nform. If the substantial form is the form of the cells in the\ncompleted organism, it was such before that organism was perfected,\nunless it replaced a lower substantial form; but there is, we repeat,\nabsolutely no need for such a secondary form at the beginning. If\nthe cells of the embryo (not the infused germ-cells, which are\nnot the embryo) had a _forma corporeitatis_, or _cellularis_, or\nwhatever you wish to call it, the human soul when it did come would\nnot confer primal existence, would not be a _forma substantialis_,\nbut an accidental form. \"In proof of which,\" says St. Thomas,[55]\n\"we must consider that a substantial form differs from an accidental\nform in this, that an accidental form does not give being simply, but\nsuch or such being; as heat does not give being simply, but heated\nbeing. So when an accidental form comes in, a thing is not said to\ncome into existence or to be generated, simply, but to become such or\nsuch an object, or to find itself in such or such a condition. So,\nalso, when an accidental form disappears, a thing is not said to be\ndestroyed simply, but only to a certain degree. A substantial form,\nhowever, gives being simply; and therefore by its advent a thing is\nsaid to be generated simply, and by its recession to be destroyed\nsimply. If, therefore, it happened that any substantial form other\nthan the intellectual soul pre\u00ebxisted in matter, by which the subject\nof that soul would come into actual being, it would follow that\nthe soul would not confer being simply, and therefore would not\nbe a substantial form; also that the coming of the soul would not\nbe a generation simply, but only _secundum quid_--all of which is\nevidently false.\" Again, St. Thomas says:[56] \"Some tell us the vital\nacts that appear in the embryo are not from the soul, but from the\nsoul of the mother, or from the primitive force in the semen. Both\nthese statements are false.\"\n\n  [55] I, q. 76, corp.\n\n  [56] Ia, q. 118, a. 2, ad 2.\n\nAn application of the opinion offered here--that is, that the human\nsoul is infused at the instant of conception--to multiple and\nmonstrous embryos offers no real difficulty. There are two kinds of\nhuman twins--those from two distinct ova and those from one ovum. Two\nova may come from one or different ovaries, or even from one Graafian\nfollicle, be fertilized at the same time and develop synchronously.\nIf the ova are placed at some distance apart in the uterus, two\nplacentas appear; if the ova are near each other the placentas may\nfuse, but their circulations do not. Each child will have its own\nfetal envelope.\n\nIn twins from two distinct ova there is no difficulty in seeing that\nthe souls are placed in these in the same manner as the soul is put\nin the normal single embryo. When the twins come from one ovum the\ncondition is not so simple. The oval nucleus is the essential part\nthat goes from the maternal side, and human ova at times contain\ntwo nuclei, as occasionally hens' eggs do; a double-yoked hen's egg\nhas two nuclei, and two nuclei have been found in a single yolk.\nK\u00f6lliker, St\u00f6ckel, and von Franque have observed double germinal\nvesicles in single human ova. In such a condition two spermatozoa\ncould fecundate the two nuclei and the development go on as in the\ncase of twins from distinct ova.\n\nThere is a theory which holds that homologous twins (uni-oval)\ncan develop from a single germinal vesicle which splits into two\nprimitive streaks and two gastrulas. According to this opinion, if\nthe germinal vesicle divide entirely, two fetuses develop which are\nalways of the same sex, and which resemble each other so closely in\nappearance that it is very difficult to differentiate them. This\ntheory holds also that should the germinal vesicle not split fully,\nthe lack of fission causes the various kinds of double monsters. The\ngerminal vesicle that supposedly splits into two is not fecundated by\ntwo spermatozoa, they say, because where there is only one nucleus in\nthe beginning, the entrance of a second spermatozo\u00f6n commonly kills\nthe ovum. This last assertion has been disproved of late.\n\nSome followers of the splitting theory hold that double monsters\narise from the union of two originally separate primitive traces\n(_Verwachsungstheorie_). Others say that a single primitive trace\nof blastoderm cleaves more or less thoroughly and makes the double\nmonster (_Spaltungstheorie_). The earliest human double monster\n(Ahlfeld's case) was in the fourth week of gestation; therefore\nwhatever is held in these theories as regards human monsters is only\nthrough analogy with lower animals.\n\nGerlach[57] saw bifurcation at the cephalic end of a chicken embryo\nsixteen hours old. In this case the first change was a broadening of\nthe anterior end of the primitive streak; next a forked divergence\nappeared, and by the twenty-sixth hour the bifurcation was half as\nlong as the undivided posterior part. Whether this was a case of two\nnuclei or not is not known.\n\n  [57] _U. d. Entstchungsweise der vordern Verdoppelung. Deutsch.\n  Archiv. f. klin. Med._, 1887.\n\nWhat seems to make for the fission theory is that in non-parasitic\ndouble terata, no matter how unequally nourished or how variable in\nextent, the union between the halves of double monsters is symmetric,\nand the same part of each twin is joined. This fact is used as a\nreason to exclude a fortuitous growing together of dissimilar areas\nof cell-masses, at least in non-parasitic cases. Born,[58] in a study\nof fish ova, found that eggs which produce double monsters begin\nwith a segmentation like that of the simple normal ovum. Composite\nspermatozoa have been observed with two and three heads and one body\nand tail-piece, but the significance of these abnormal cells is not\nknown.\n\n  [58a] _U. d. Furchung des Eies bei Doppelbildungen. Breslauer\n  Aertzliche Zeitschrift_, 1887.\n\nEmbryos of sea-urchins in the two-cell and four-cell stages can be\nseparated by shaking into isolated blastomeres, and the segments will\ngrow into full though dwarfed larvae. The same division with the\ngrowth of dwarfed larvae has been made in Amphioxus, in the teleost\nFundulus, in Triton, in a number of Hydromedusae and several other\nlow forms of life. When the division is not made completely double\nmonsters result.\n\nUp to a certain stage of development the blastomeres of the Medusa\nembryo are totipotent, or capable of developing into any part of\nthe body. The limitation of development in a particular case lies\nin the cytoplasm rather than in the nuclei of the cells. If frogs'\neggs are fastened in abnormal positions, inverted or on the side, a\nrearrangement of the egg material results, wherein the nucleus and\ncytoplasm rise and the deutoplasm sinks. This change of axis shifts\nthe embryo. If an egg is turned upside down in the two-cell stage,\na whole embryo, or half a double embryo, may arise from each of the\ntwo blastomeres, instead of a normal half-embryo. A half-embryo or\na whole dwarf may arise according to the artificial position of the\nblastomere. Each of the two blastomeres contains all the materials\npotentially for the formation of the whole body, and these materials\nbuild up a whole body or a half body according to the grouping they\ntake on. Primarily the egg cytoplasm, in low forms of animal life,\nis totipotent; it has no fixed relation with the parts to which it\ngives rise, and may be artificially modified or differentiated.\nThese effects, from position and traumatic dislocation, suggest\nexplanations for teratic forms in higher animals.\n\nHuman terata are now commonly classified in four groups: (1)\nHemiteratic; (2) Heterotaxic; (3) Hermaphroditic; and (4) Monstrous.\nHemiterata are giants, dwarfs, persons showing anomalies in shape,\ncolor, closure of embryonal clefts, in absence or excess of digits,\nor like defects. The Heterotaxic group are persons whose left or\nright organs are reversed in position. A true Hermaphrodite would\nhave the complete reproductive organs of both sexes, but such an\nindividual has not been observed. There is never any question of\ndouble personality in hermaphrodites.\n\nTerata more properly so called may be single, double, or triple;\nand single monsters may be autositic or independent of another\nfetus, or they may be omphalositic, dependent upon another which is\ncommonly well developed and which supplies blood for both through\nthe umbilical vessels. There are four genera of autositic single\nmonsters, with eight species and thirty-four varieties. Of the\n_monstra per defectum_ the commonest are caused by a failure of\nclosure in the embryonal medullary canal, which leaves part of\nthe brain and spinal cord or their bony covering lacking. Some\nterata, as the Acephalia, have no brain or spinal cord, but they\ndie in the fetal stage. The Anencephalia may have a spinal cord, a\nmedulla oblongata, and parts of the basal ganglia, but the cerebral\nhemispheres are wanting. Such monsters are sometimes born at term\nand live for several days: they cry, suckle, show some reflexes and a\nsense of pain, and move the arms and legs.\n\nI described the various kinds of terata in _Essays in Pastoral\nmedicine_,[58b] and of these the most important in the matter under\ndiscussion here are the double and triple monsters. Many of the\ndouble monsters evidently were two persons. There is only one well\nauthenticated case of a triple human monster, and this happened in\nItaly in 1831. It had a single broad body with three distinct heads\nand two necks, and was killed in delivery. There is no proof as to\nwhether it was one or more persons. The standard of judgment in such\ncases as regards the presence of one or two souls in the monster\nis the evidence of one or more distinct consciousnesses. A monster\ndouble from the navel or breast downward (_terata anadidyma_) is,\nI think, one person. There was an example of a monster in this\ngroup which was divided from the foreheads downward; or better,\nthe distinct twins were united by their foreheads only; but such a\nform is very exceptional. In my article on \"Human Terata and the\nSacraments,\" in _Essays in Pastoral Medicine_, in 1906, I expressed\nthe opinion that a monster which is single to the navel and double\nbelow is composed of two persons, but I now am of the opinion that\nsuch a monster is only one person, because there is apparently only\none consciousness. There are about eight cases of two-headed monsters\nknown which were evidently two persons in each case, and several\nterata kata-anadidyma, divided above and below but joined at the\nsternum, abdomen or sacrum. Several ischiopagic twins, joined at the\npelvis with the heads at the opposite ends of the double body, are\ngrouped with either the katadidyma or kata-anadidyma. It is commonly\nnot difficult to recognize individuality or duality of personality in\nmonsters, but it is not easy to explain the origin of life, to point\nout the moment the _second_ soul enters these fused or undivided\ntwins.\n\n  [58b] Chap. vi, p. 69. New York, 1906.\n\n  We can artificially obtain double embryos of frogs by inverting\n  the blastomeres in the two-cell stage.[58c] We thus get united\n  twins with heads turned in opposite directions, twins united back\n  to back like the Blazek Sisters, twins united by their ventral\n  sides, and double-headed tadpoles, but we have no knowledge of\n  how similar doubling in human monsters takes place; we must guess\n  vaguely from analogy. There was one soul, at least, present from\n  the one-cell stage of the human monster; when the second soul\n  is created and infused we do not know, but the moment of the\n  creation of this second soul has no practical significance in\n  this discussion.\n\n  [58c] See Wilson, _op cit._., p. 421.\n\n  The presence of certain kinds of monsters in the uterus can\n  be diagnosed before labor, but double monsters are mistaken\n  for ordinary twins. A woman who has given birth to a monster\n  is likely to have subsequent monstrous fetuses. Where the\n  intrauterine existence of a single monster is suspected the X-ray\n  will at times clear up the diagnosis. Women gravid with monsters\n  commonly abort early in pregnancy, but even united twins may go\n  on to term. Those monsters that offer an obstacle to delivery\n  by the abnormal bulk of one or the other end are mostly twins\n  joined above or below the navel; those joined at the middle are\n  easier of delivery. Monsters that are joined at the pelves are\n  commonly in a straight line, and may not be difficult to deliver.\n  Most double monsters cannot be delivered alive except by cesarean\n  section, and the fact that the content of the uterus is monstrous\n  is, as a rule, not diagnosed until it is impossible to attempt\n  cesarean section without killing the mother through infection.\n  In such a condition the double monster would, in the ordinary\n  medical practice, be delivered by craniotomy, exenteration,\n  cleidotomy, or the like operation.\n\n  The _Rituale Romanum Pauli V_[59] gives the following directions\n  for the baptizing of human terata:\n\n  \"18. In monstris vero baptizandis, si casus eveniat, magna\n  cautio, adhibenda est, de quo si opus fuerit, ordinarius loci,\n  vel alii periti consulantur, nisi mortis periculum immineat.\n\n  \"19. Monstrum, quod humanam speciem non praeseferat baptizari non\n  debet; de quo si dubium fuerit, baptizatur sub hac conditione;\n  _Si tu es homo ego te baptizo_, etc.\n\n  \"20. Illud vero, de quo dubium est, una ne, aut plures sint\n  personae non baptizetur, donee id discernatur: discerni autem\n  potest si habeat unum vel plura capita, unum vel plura pectora;\n  tune enim totidem erunt corda et animae, hominesque distincti, et\n  eo casu singuli seorsim sunt baptizandi, unicuique dicendo: _Ego\n  te baptizo_, etc. Si vero periculum mortis immineat, tempusque\n  non suppetat, ut singuli separatim baptizentur, poterit minister\n  singulorum capitibus aquam infundens omnes simul baptizari,\n  dicendo: _Ego vos baptizo in nomine Patris, et Filii, et Spiritus\n  Sancti_. Quam tamen formam in iis solum, et in aliis similibus\n  mortis periculis, ad plures simul baptizandos, et ubi tempus non\n  patitur, ut singuli separatim baptizentur, aliis nunquam, licet\n  adhibere.\n\n  \"21. Quando vero non est certum in monstro duas esse personas, ut\n  quia duo capita et duo pectora non habet distincta; tune debet\n  primus unus absolute baptizari, et postea alter sub conditione,\n  hoc modo: _Si non es baptizatus, ego te baptizo in nomine Patris,\n  et Filii, et Spiritus Sancti_.\"\n\n  [59] Tit. ii, cap. 1, nn. 18, 19, 20, 21.\n\nAny kind of monster coming from the human womb, if it is only a\nhead and lacks a body (Acardiacus Acormus), or is a body and lacks\na head and heart (Acardiacus Acephalus), or is a Foetus Anideus,\nwhich is a shapeless mass of flesh covered with skin, should be\nbaptized, provided _it shows signs of life_. Number 19 in the Ritual\nwould be liable to an interpretation which is too narrow if it were\nnot that very monstrous fetuses, which appear to a lay observer to\nbe not human, are as a rule delivered dead. Here it may be worth\nwhile to mention that a hybrid between a human being and a lower\nanimal is impossible. As to number 20, the rule for differentiating\nunity or duality of personality is not the number of heads, but the\nnumber of evident consciousnesses, and this differentiation commonly\ncannot be made at birth. There have been examples of two-headed\nmonsters delivered alive, which were single as to soul because the\nconsciousness evidently was one.\n\n\n\n\nCHAPTER IV\n\nWHEN DOES HUMAN LIFE END?\n\n\nThe moment human life begins in the human fetus is a subject of\ndispute, but the moment human life ends is a mystery--we have no\nmethod of determining exactly just when the soul leaves the body.\nDaily throughout the world the priest reaches a patient who has just\ndied. Conditional absolution, extreme unction, baptism might have\nbeen administered if there were signs of life, but the heart and\nlungs are still, \"the patient is dead,\" and the priest leaves without\ndoing anything. Yet it is always probable that the patient does not\ndie at once even in a case of decapitation.\n\nBichat, at the beginning of the last century, called the brain,\nlungs, and heart \"the tripod of life,\" and from time immemorial we\nhave based our judgment of the presence of somatic death on the lack\nof consciousness, respiration, and circulation in the patient. The\nheart, however, beats after consciousness and respiration cease (and\nsometimes respiration continues after the pulse cannot be felt), and\nthis cardiac activity may go on for more than a half hour after all\nthe normal clinical signs of death have appeared--after respiration\nhas quit, when no heart-sounds can be heard by the stethoscope and\nmuscular relaxation indicates death.\n\nThe stimulus of the heart-beat probably starts at the juncture\nof the superior vena cava with the right auricle of the heart.\nSome biologists think that in this spot life takes its last stand\nbefore the final retreat, but that fact is disputed of late. In\nthe hospital of the Rockefeller Institute for Medical Research in\nNew York, Dr. G. Canby Robinson[60] made records from about eight\npatients before and during the actual stopping of the heart, using\nthe electrocardiograph, which can be employed without disturbing\nthe patient. He thus found--only in one case, however--that the\nheart may beat for a half hour after all vascular and circulatory\nsounds have ceased to be audible. In a letter to me Dr. Robinson\nsaid: \"Undoubtedly the heart continues to show activity sufficient\nto be recorded by the string galvanometer very frequently after\nrespiration has ceased, both in man and the lower animals; but this\ndoes not necessarily mean that it continues to be an efficient pump,\nmaintaining the circulation. Undoubtedly also in other instances the\ncardiac activity ceases before the respiration, but I have never\nobtained electrocardiographic records of such cases.\"\n\n  [60] _A Study with the Electrocardiograph of the Mode of Death of\n  the Human Heart. Journal of Experimental Medicine_, 1912, xvi,\n  291.\n\nCrile's experiments upon dogs show that it is possible to resuscitate\nthese animals after they have been apparently dead for periods of\ntime up to seven and a half minutes. The cessation of the blood\ncirculation causes degenerations in the nerve cells and fibres, and\nthese lesions may last even if the animal has been resuscitated.\nCrile thinks the human respiratory centre may survive anemia from\nthirty to fifty minutes; the vasomotor and cardiac centres, about\ntwenty to thirty minutes; the spinal cord, eight to ten minutes; the\nmotor cortex, eight to ten minutes; the portion of the brain used in\nconscious activity as such, six to seven minutes. The higher neurons\nhave been stimulated into reflex activity twenty-five minutes after\ncomplete clinical cardiac cessation of activity.\n\nIn any attempt to resuscitate a person apparently dead the\nmaintenance of the blood circulation is the chief end. If,\nhowever, the blood is not oxygenated the circulation will not go\non automatically. Artificial respiration is used, and the active\nprinciple of the adrenal gland is injected to stimulate the heart.\nIf the heart has stopped in diastole,--that is, when distended with\nblood,--this distention must be relieved by cardiac massage, commonly\nthrough an opening in the thoracic wall. Intratracheal insufflation\nof oxygen is also to be employed, as a rule.\n\nIn _Essays in Pastoral Medicine_[61] I mentioned several cases of\nresuscitation after what had appeared to be certain death. Two of\nthese had been \"dead\" for forty-five minutes before they were revived\ntemporarily. Wayne Babcock[62] reported a number of new cases of his\nown. One was a resuscitation which lasted for forty-three hours, and\nwhich was begun twenty-five minutes after respiration had ceased.\nThe patient was a very fat negress who had collapsed after the use\nof scopolamine. A man whose arm had been torn off died from shock in\nthe operating-room. After fifteen minutes of artificial respiration\nthe circulation started again, and he was kept alive for six hours\nin this manner, but he died as soon as the artificial respiration\nwas discontinued. An exactly similar case was kept alive for seven\nhours by artificial respiration. One of Babcock's cases was a woman\nof eighty-seven years of age, who apparently died on the table during\nan operation for strangulated hernia. After ten minutes of cardiac\nand respiratory cessation she was revived. She died four days later\nof peritonitis. A man fifty-six years of age undergoing the same\noperation ceased breathing and his heart stopped. He was completely\nrevived and cured.\n\n  [61] New York, 1906, p. 164.\n\n  [62] _Proceedings of the American Therapeutic Society_, 1912.\n\nFather Juan Ferreres[63] holds that aborted and newly born children\nshould be baptized, although they give no sign of life, if they show\nno clear evidence of putrefaction. This opinion is mine also, but the\nword maceration should be substituted as more exact. Eschbach[64]\nsays: \"Infantes recenter natos et in vitae discrimine positos, aut\nfoetus abortivos plane formatos, cum vel levissimus in eis motus\napprehenditur, absolute baptizari oportet: cum autem sine motu et\nsensu iidem videantur neque tamen adhuc corrupti aut putrefacti sint,\nsine mora baptizentur conditionate: _Si vivis, ego te baptizo_, etc.\"\nThese quotations give the common opinion of moralists at present,\nand this opinion is fully safe. Eschbach, however, would have the\nfetus \"plane formatus,\" which is erroneous and an echo of the old\nAristotelian notion. If the fetus is visible at all, open the\nmembranes and baptize it conditionally, even if it is not as big as a\npea.\n\n  [63] _La Muerte Real y Apparente_, 4th ed., p. 21. Madrid, 1911.\n\n  [64] _Quaestiones Physiologicae-Theologicae_, disp. 3, p. 2, c.\n  3, a. 3.\n\nAn infant born apparently dead may be resuscitated after a delay\nvery much longer than would be possible in an older person, provided\nalways the infant has not begun to breathe.\n\nFerreres mistakes cases of catalepsy which have recovered\nconsciousness for cases of apparent somatic death. In these\ncataleptic conditions the blood circulation does not completely\ncease--if it did the nervous centres would be disintegrated. The case\nhe reports on p. 26,[65] of the woman resuscitated by Rigaudeaux in\n1748, was one of catalepsy, if it ever happened. The same is true\nof the case from Gaspar de los Reyes,[66] which probably had some\nfoundation in a condition of catalepsy, but which more probably is a\nsheer invention by Reyes. It looks like an anecdote from a medieval\nFlorentine _novella_.\n\n  [65] P. 30 in the English translation.\n\n  [66] P. 35; p. 39, English translation.\n\nOld writers speak of cessation of the pulse for long periods.\nBallonius[67] mentions a person in whom there was no pulse for\nfourteen days before death; Ramazzini[68] describes a cessation of\nthe pulse for four days before dissolution; Schenck[69] tells of a\ndisappearance of the pulse for three days, with recovery. These all\nwere apparently cataleptic cases, where the circulation was very\nfeeble and the radial pulse was not palpable. Cheyne gives an account\nof a Colonel Townsend who had the power of apparently dying at will.\nHe could so suspend the heart action that no pulse could be felt,\nand after a short while the circulation would become normal again.\nThe longest period in which he remained in this condition was about\nthirty minutes. St. Augustine mentions a priest named Rutilutus who\nhad a power like that of Colonel Townsend, and Caill\u00e9[70] reported a\nsimilar case.\n\n  [67] _Opera Medica Omnia._ Geneva, 1762.\n\n  [68] _Epistolae_, 1692.\n\n  [69] _Observationum Medicarum_, etc. Frankfort, 1600.\n\n  [70] _New Orleans Medical and Surgical Journal_, xvi.\n\nThe fakirs of India carry this power to great lengths. Braid,[71]\non the authority of a Sir Claude Wade, says a fakir was buried\nunconscious at Lahore in 1837, and the grave was guarded day and\nnight by sentinels from an English regiment. Six weeks after the\nburial the man was dug up and he presented all the appearance of\na corpse. The legs and arms were shrunken and stiff, and the head\nreclined on the shoulder, as happens in corpses. There was no\nperceptible circulation anywhere, yet he revived.\n\n  [71] _Treatise on Human Hibernation_, 1850.\n\nHonigberger, a German physician in the service of Runjeet Singh,\ndescribed[72] a fakir of the Punjaub who was put into a sealed vault\nfor forty days, and the seal of Runjeet Singh was on the coffin.\nGrain was sown above the vault and it was well above the ground\nwhen the man was taken out of the vault and resuscitated. Sir Henry\nLawrence testified to the truth of this story. The fakir's chin was\nshaved, Honigberger says, before the burial, and the beard did not\ngrow while he was in the vault.\n\n  [72] _Medical Times and Gazette_, vol. i. London, 1870.\n\nIn keeping with these stories are many curious accounts of recovery\nafter hanging. These are frequent in writings of the sixteenth\nand seventeenth centuries, when hanging was almost an every-day\noccurrence. These narratives are much more authentic than the\nanecdotes told of recovery after premature burial, which are as old\nas literature. Paul Zacchias[73] tells of a young man who died of\nthe plague and was set out with the corpses for burial. He revived\nand was taken back to the pest-house. He \"died\" again and was again\nprepared for the grave, but he came to a second time. The stock story\nin these premature burial cases is that of the woman who is revived\nby a thief who cuts her finger in an effort to steal the rings buried\nwith her.\n\n  [73] _Quaestiones Medico-Legales_, 1701.\n\nThe important fact, however, is that in any case of death the exact\nmoment in which the soul leaves the body is not knowable by any\nmeans we have at present, and where there is question of giving the\nsacraments the person apparently dead should have the benefit of the\ndoubt. He is to receive conditional baptism, absolution, or extreme\nunction (preferably by the short method), in case these sacraments\nare required. For a whole hour after apparent death the probability\nthat the soul has not departed is so strong that, in my opinion, a\npriest who does not give the necessary sacraments is virtually as\nguilty as if he neglected to administer them to a person evidently\nalive. Crile, one of the best medical authorities on this matter of\nsomatic death, holds that the human respiratory system may survive\nanemia for from thirty to fifty minutes. How long after the hour a\npriest may administer the sacraments is not known, but a second hour,\nor even a third, are not unreasonable periods of time during which\nthe sacraments may be administered conditionally. The sacraments\nare for man, and there is no irreverence if they are administered\nconditionally and the priest explains to the bystanders the reason he\nhas for his action.\n\nIf a pregnant woman dies slowly, the fetus in her womb is likely to\ndie owing to lack of oxygen; if she dies suddenly, the child may\nlive for variable periods in various cases. Brotherton reported\na case where a living child was taken from a woman twenty-three\nminutes after the death of the mother. Tarnier, the noted French\nobstetrician, told of a remarkable incident which happened in Paris\nduring the rioting by the Commune after the war of 1870. The rioters\nfired on a maternity hospital, and a pregnant woman sitting on a bed\nin a ward was instantly killed by a bullet through her head. After a\nwhile she was discovered dead, and Tarnier was sent for to save the\nfetus, as its heart-sounds could be heard through the abdominal wall.\nWhen he began the operation the hospital was fired upon again, and\nit was necessary to carry the corpse to the cellar of the building.\nThere Tarnier, an hour and three quarters at least after the death\nof the women, extracted a living child from the corpse. Hirst[74]\ntells of another case which was narrated to him by an American naval\nsurgeon who saw it in the harbor of Rio Janeiro during the revolution\nat the beginning of the present republic of Brazil. A woman near term\nwas killed instantly by a piece of shell. As soon as she fell to the\nground a Brazilian surgeon, who was standing near by, cut open her\nabdomen with a penknife and drew out the child, but it was already\ndead.\n\n  [74] _A Textbook of Obstetrics_, 7th ed., p. 643. Philadelphia,\n  1912.\n\nMack[75] was called to a pregnant woman, and he found she had died\nsuddenly about five minutes before he arrived. He at once opened the\nuterus with a small lancet and extracted a child which was beyond\nthe livid stage and had no heart-sound. He worked on the child for\nforty minutes, using the ordinary methods for reviving asphyxiated\nchildren, but got no sign of life. Then he injected a hypodermic\nsyringeful of a 1:1000 epinephrin solution through the umbilical cord\ninto the abdomen and continued the reviving motions. In ten minutes\nthe child was crying vigorously, and it was a healthy baby afterward.\n\n  [75] _Journal of the American Medical Association_, August 28,\n  1915.\n\nGunn and Martin,[76] in experiments on rabbits poisoned by chloroform\nand apparently dead, found they could resuscitate about 70 per cent.\nof the animals if treatment was begun within ten minutes after the\nheart ceased beating. They started artificial respiration through a\ntube in the trachea, then injected epinephrin into the pericardium,\nand afterward massaged the heart through an opening in the abdomen.\nThe rate of compression of the heart in this massage must be somewhat\nless than half that of the normal beat, and at short intervals the\nmassage is to be stopped to allow the spontaneous beats to develop.\nCompression should be gradual and the relaxation abrupt. The massage\nis applied by one of these four methods, and they are arranged\nhere in the order of their efficiency: (1) by direct compression\nof the heart through an opening in the thorax; (2) by compression\nabove the diaphragm through an opening in the belly-wall; (3) by\nsimple compression of the abdomen; (4) by simple compression of the\nthorax. Epinephrin, or pituitary extract, is used as an adjuvant\nintravenously to increase the cardiac movement after it has been\nstarted. The same methods will probably be effective in man, and have\nbeen used successfully.\n\n  [76] _Journal of Pharmacology and Experimental Therapeutics._\n  Baltimore, July, 1915.\n\n       *       *       *       *       *\n\nWhen a woman is _in articulo mortis_ with a living fetus in her womb,\none should not wait for her death. If one waits, he will nearly\nalways lose the child. The cervix should be dilated forcibly, the\nchild turned and delivered. Even if this forcible delivery should\nhappen to hasten somewhat the mother's death, the action would be\nmorally licit. It would be a double-effect action; the two effects\nwould proceed immediately and equally from the act, which is\nindifferent morally; one effect, the good one, is to save the child\nfor baptism at least, and possibly permanently; the second, evil but\nreluctantly permitted, is the possible hastening of the maternal\ndeath. I should be willing even to slit the cervix, if necessary,\nprovided the diagnosis were certain, with the possibility of tearing\nthe uterus, in a case where the dilatation of the cervix would be too\nslow a method; but this supposition is scarcely practical.\n\nZsako[77] gives a method for determining the interval since death\nby muscular phenomena. Tapping with a percussion hammer on certain\nmuscles of the body excites a reflex contraction up to from an hour\nand a half to two hours after death. The contraction may be elicited\nin the same manner on the living, but it is more evident on a cadaver\nowing to the absence of antagonistic tonus in the muscles. Some\nmuscles may move for four hours after death. Tapping along the radius\nfrom the elbow downward, he says, a point is found where the stroke\ncauses extension of the hand; tapping along the radius above the\nwrist makes the thumb bend; tapping on the spaces between the bones\nof the hand closes up the corresponding fingers; tapping on the back\nof the foot extends the toes, on the leg adducts the foot, on the\ntibia along the middle third extends the leg. When the lower third\nof the thigh is tapped across the muscles move, and if the back is\nstruck between the scapula and the spine the shoulder blades move\ntoward each other. If there is no response the person must be dead\nfrom two to four hours. I have had no experience with this method.\n\n  [77] _M\u00fcnchener medizinische Wochenschrift_, January 18, 1916.\n\nSatre[78] reported that many soldiers brought into the\ndressing-stations apparently dead from shock, head or spinal wounds,\nor gas asphyxiation, were revived after artificial respiration\nhad been applied, sometimes for even six hours before results were\nobtained. Two tests were used to find out whether the patient was\nalive or not. In such cases ten c.c. of a 20 per cent. alkaline\nsolution of fluorescine is injected subcutaneously, and if there is\nany circulation this dye will be carried to the eye and turn the\nconjunctiva green. The second test is to push a fine puncture-needle\ninto the spleen or liver and thus remove a particle of the pulp.\nThis pulp is put on blue litmus-paper and drawn free from blood. If\nthe litmus-paper turns red the man is dead; if it remains blue he\nis alive. The reaction of the living pulp is alkaline, blue; this\nbecomes acid, red, a half-hour after death; an hour after death the\nacid reaction is quite marked.\n\n  [78] _Presse M\u00e9dicale_, Paris, xxiv, 66.\n\n\n\n\nCHAPTER V\n\nABORTION\n\n\nAbortion, as the term is used by physicians, in its widest sense\nis the ejection or extraction of a fetus from the womb at any time\nbefore term. The word is popularly contrasted with miscarriage, where\nthe fetus is ejected through disease or accident; abortion in the\nlay sense supposes artificial, and commonly criminal, extraction of\nthe fetus. Abortion (from _aboriri_, to perish) etymologically has\nan association with destruction of life, but the name is given by\nphysicians to a removal of any premature fetus, even if it is viable.\nStrictly, however, abortion is an interruption of pregnancy before\nthe fetus is viable, and premature labor is such an interruption\nafter the fetus is viable. Throughout this chapter the words are used\nin this sense.\n\nAbortion as a medical and moral consideration may be considered from\nseveral points of view.\n\nFirst, involuntary pathologic and accidental interruptions of\npregnancy are to be averted, if it is possible to do so, to save the\nlife of the child; and when the abortion is inevitable the treatment\nhas moral qualities which involve the physician and the mother.\n\nSecondly, voluntary and therapeutic abortion has peculiar moral\nand medical qualities arising (_a_) from the period of gestation\nor the viability of the child; (_b_) from the truth or error in\nthe diagnosis as regards the necessity for interference, and the\nadvantage or damage resulting from the interference.\n\nThirdly, the technical skill or ignorance of the physician, and the\nmethods he employs may in themselves in any case avert or cause\nthe death of the mother or grave injury to her, and in the forced\ndelivery of premature infants may save, kill, or maim the child.\n\nFourthly, voluntary criminal abortion has a special malice of its\nown, which makes it somewhat more criminal than the therapeutic\nremoval of an inviable infant.\n\nFifthly, there are positive canonical and civil penalties against\nabortion as it affects the inviable infant.\n\nPathologic abortions, and those arising from accident or\ncarelessness, are extremely common. Hegar estimated that there is\none of these abortions to every eight normal parturitions, and\nspecialists in obstetrics find as many as one abortion to four\ndeliveries at term. These abortions are most frequent from the eighth\nto the twelfth week of gestation, because the ovum is then not\nfirmly attached to the uterus, and it readily succumbs to external\ninfluence. Moreover, the woman is not certain she is pregnant and\nneglects precautions. Many women, again, are under the error that\nthere is no moral evil in getting rid of the ovum before quickening,\nand they think quickening occurs only when they feel the fetal\nmovements. Others, erroneously again, fancy that abortion in the\nearly months is not dangerous or injurious to themselves.\n\nThe causes of pathologic and accidental abortion are very numerous\nand often interactive. They may arise from the fetus, the mother, the\nfather, or from violence. The death of the fetus, or diseases of the\nfetus itself or of its appendages, cause abortion. Weakness of the\nfetus from alcoholism in the parents, anemia, carbon monoxide and\nlead poisoning, tobacco poisoning in women who are cigar-makers, and\nsimilar conditions in one or both parents, will bring on abortion.\nMonsters rarely go on to term. Acute or chronic affections in the\nmother, as typhoid, malaria, smallpox, cholera, scarlatina, measles,\ntuberculosis, and the like, and syphilis in the mother or father,\neffect abortion. Other abnormal states that bring on abortion are low\nblood-pressure in maternal anemia, shock, syncope; hemorrhages into\nthe placenta in maternal nephritis; hemorrhages between the placenta\nand uterus from diseases of the placenta and decidua, or from\ntraumatism, which detach the placenta; sun or heat stroke; sudden\nhigh temperature in fever; toxemias, as in some forms of hyperemesis\ngravidarum, eclampsia, chorea, hepatic autolysis, and impetigo\nherpetiformis.\n\nChronic endometritis, or inflammation of the lining membrane of\nthe uterine cavity, is the commonest maternal cause of abortion,\nespecially of habitual abortion. In this condition hemorrhages in\nthe decidua, or uterine fold that holds the fetus, kill the fetus,\nor force the ovum off the uterine wall, or excite expulsive uterine\ncontractions. Without hemorrhage endometritis prevents a firm\nfixation of the ovum, or it may bring about a malposition of the\nplacenta, called placenta praevia. Endometritis at the decidua may\ncause hydrorrhoea gravidarum, and the accumulated serous secretions\nfrom this source are likely to start uterine contraction. Chronic\nmetritis, or inflammation of the deeper tissues of the uterus, is\ncommonly found with endometritis, and it prevents the expansion of\nthe uterine muscle. This condition is more likely to cause abortion\nthan endometritis alone.\n\nAcute gonorrhea, inflammations of the Fallopian tubes, and\nappendicitis sometimes interrupt pregnancy. Other causes are\nmalformations and diseases of the uterus, infantilism, fibroids,\npolyps, uterine horns, lacerations and amputation of the cervix, and\nretroversions and retroflexions of the uterus. At times a replacement\nof the uterus will avert an abortion.\n\nWhen the mother has an infectious disease like typhoid, smallpox,\ncholera, or typhus, the infection may reach the fetus and kill it,\nor may cause an endometritis with a hemorrhagic tendency. Maternal\nsepsis may kill the fetus directly or secondarily, and this is\ntrue also of maternal syphilis. A sudden rise in temperature may\nexcite expulsive uterine contraction. In pneumonia the excess of\ncarbon dioxide in the blood may bring on abortion. Like pneumonia,\nanesthesia may kill the fetus if kept up for a long time, or if\nmarked by cyanosis. Prolonged nitrous-oxide anesthesia is especially\ndangerous to a fetus, but a brief nitrous-oxide anesthesia for the\nextraction of a tooth may not bring on abortion. The worst tooth\nstump can be extracted painlessly after local injection of novocain,\nwith no danger to the fetus. The gums remain somewhat sore for a day\nor two after novocain infiltration, but this inconvenience is a much\nless evil than total anesthesia, even when there is no pregnancy. It\nis probable that total anesthesia is morally unjustifiable for the\nextraction of a single tooth if the tooth is not wedged in.\n\nViolence, accidental or intentional, is a frequent primary or\nsecondary cause of abortion. Sometimes a slight jar, a misstep on\na stairway, a nervous shock, a jump from a carriage-step, lifting\nweights, running sewing-machines, sea-bathing, a rough automobile\nride, will bring on an abortion where there is a predisposition.\nOften in healthy women, on the other hand, extreme violence does\nnot interrupt pregnancy. Surgical operations are classed here with\nviolence. In a neurotic woman a slight operation on an organ not\ndirectly connected with the uterus will start expulsive contractions.\nAgain, 66 per cent. of operations on ovarian tumors during pregnancy\nhave left the uterus undisturbed. De Lee says he has removed fibroids\nfrom the pregnant uterus, once even exposing the chorion, and has\namputated the cervix of a gravid uterus, without interrupting\npregnancy. Several cases have occurred where both ovaries have\nbeen removed during pregnancy without abortion. The breast has\nbeen amputated and a kidney removed from a pregnant woman[79]\nwithout disturbing the pregnancy. Wiener[80] did eleven operations\nfor ovarian tumors during pregnancy with only two abortions. Von\nHolst[81] removed a myoma weighing two and a half pounds from the\nuterus at the seventh month of gestation without abortion. Davis\nof Birmingham, Alabama, reported[82] that a woman three and a half\nmonths pregnant was shot in the abdomen. The rifle bullet made\ntwenty-five perforations in her intestines. She was taken eighty-five\nmiles, and then Davis cut out five feet of the intestine. She\nrecovered and gave birth to a living child at term.\n\n  [79] Cronk, _Oklahoma State Med. Assoc. Jour._, July, 1816.\n\n  [80] _Amer. Jour. Obstet._, August, 1915.\n\n  [81] _Upsala L\u00e4kareforenings F\u00f6rhandlingar_, xxi, 8.\n\n  [82] _Journal Amer. Med. Assoc._, October 28, 1916.\n\nDouble ovariotomy brings on abortion in the early months of\npregnancy oftener than in the later, probably from the loss of the\ncorpus luteum, which, it appears, is necessary for the growth of\nthe uterus. Appendicitis and appendectomy are especially likely\nto interrupt gestation, apparently as a result of infection and\nbecause pregnant women are prone to defer operation. The traumatism\nof criminal abortion, punctures and lacerations from bougies and\ncurettes, and the exhibition of drugs like ergot and cantharides,\nare sources and results of abortion. Drugs will not empty the uterus\nunless they are given in poisonous doses which endanger the woman's\nlife.\n\nIn the father, syphilis, tuberculosis, general paresis, general\ndebility from alcoholism, unchastity, and senility, and septic\nconditions of the generative tract, may cause abortion. Many men\nwho work with lead, phosphorus, mercury, or X-rays are sterile, and\nbefore they become totally sterile their condition appears to cause\ndebility in the fetus which leads to abortion. In paternal lead\npoisoning there is a reduction of about 20 per cent. in the weight\nof the infants at birth, and a general weakness and retardation of\nthe child. The children of lead-poisoned fathers are frequently\npermanently under weight.\n\nCoition during gestation is a cause of abortion, and the fault here,\nas a rule, lies with the husband. St. Thomas[83] said: \"St. Jerome\nprotests against the sexual approach of the husband to his gravid\nwife, not that in this condition such an act is always a mortal sin,\nunless there is probable danger of abortion.\" St. Alphonsus[84]\nsays if there is danger of abortion the use of the debitum is a\ngrave sin. In n. 924 he again teaches that while it is true that\nif by the use of the debitum the life or formation of the fetus is\nendangered or checked the right to the use of the debitum is, in such\ncircumstances, lost, yet he thinks that in pregnancy there is little\ndanger of abortion from this cause, especially near term.\n\n  [83] _In. 4, dist. 81._\n\n  [84] _Theologia Moralis_, n. 943.\n\nSabetti-Barrett[85] says the wife is excused from the debitum\nconjugale if the husband is drunk, or if there is a rational dread of\ngrave injury, or grave danger to health. Genicot[86] thinks that in\npregnancy it \"can scarcely be shown that there is a notable danger of\nabortion.\" Lehmkuhl[87] holds that a married person is not obliged to\ngrant the debitum if there is great danger of abortion; but, he adds,\n\"Even then, if there is a grave danger of incontinence I do not think\nit certain that there is an absolute obligation to abstain.\"\n\n  [85] _Theologia Moralis_, n. 936.\n\n  [86] _Theologiae Moralis Institutiones_, vol. ii, n. 544.\n\n  [87] _Compendium Theologiae Moralis_, n. 1114.\n\nUnlike Lehmkuhl, moralists agree that if there is real danger of\nabortion from marital congress, such an act is illicit, but they are\ninclined to think that there is little or no danger of abortion,\nespecially at the end of gestation. Authorities on obstetrics, on\nthe contrary, say that one of the causes of abortion in the early\nmonths of pregnancy is marital congress; and one of the sources\nof sepsis in women, which may result in the death of both mother\nand child, is certainly congress at the end of gestation. This\ncausation of abortion is found especially in neurotic irritable\nwomen, in such as have diseases of the generative tract, or a\ntendency to habitual abortion. Whenever a woman shows any tendency\nto bleeding during gestation the use of the debitum is undoubtedly\ncontraindicated, because of the proximate danger of both abortion\nand septic infection. Toward the end of pregnancy the danger from\nsexual commerce is the risk of infecting the woman's vagina with\nbacteria which may bring on sepsis through the abrasions incident\nto parturition. The staphylococcus pyogenes albus, a dangerous\nseptic micro\u00f6rganism, exists as a saprophyte in 50 per cent. of\nmale urethras, and the bacillus coli communis is another source of\ninfection from the father during pregnancy. De Lee saw two cases\nof sepsis that killed both mother and child from such an infection\nshortly before term. If a physician now examines a woman before\ndelivery without using all the precautions known to prevent sepsis,\nsuch as wearing a sterile rubber glove, he is guilty of malpractice;\nyet certain moralists are inclined to let a husband do what he likes.\nMoralists talk about the fetus as protected in the membranes. That is\nnonsense, because it has no relevancy to the question. It can have\nthe slight relevancy of untruth when the woman is rendered septic,\nbecause then the membranes are no protection at all.\n\nThe mortality statistics of the United States Census Bureau show\nthat a little more than 42 per cent. of the infants who died in the\nregistration area in 1911 did not last throughout the first month of\nextrauterine life, and of these babies almost seven-tenths died of\nprenatal and delivery abnormalities. In 1912, in the registration\narea, which then took in 63.2 per cent. of our population, the\ntotal death-rate of infants under a year old was 9035, and of these\n3905 died of puerperal infection. In the entire country a very\nconservative estimate of the annual number of deaths of infants from\npuerperal sepsis is 5000; and about 15,000 women die here yearly\nfrom this etiology alone. Of course most of these deaths are caused\nby unclean midwives and quacks, but a large number of them are\nbrought about by incontinent husbands. Invalidism from puerperal\nsepsis happens many times 15,000. Moreover, one-third of all the\nblindness in the world is caused by septic infection of the eyes at\nbirth and virtually all this septic infection of the eyes is carried\nin by diseased husbands, although not necessarily by coitus during\ngestation.\n\nCoition during pregnancy is unnatural because it necessarily fails\nof the end of coition, which is procreation. Curiously, too, all\nthe lower animals instinctively appear to avoid this act during\npregnancy. Men should be told that marriage has restraints as well\nas celibacy. Women are reminded of the law of the debitum, but not\nof the occasions when they are even obliged to deny it. If a man\ncannot keep continent in the presence of his pregnant wife, let him\nlive in another part of the house. Regard for the woman is lacking\nin many ways. Young girls often marry without having the faintest\nnotion of sexual life, and they are panic-stricken when assaulted.\nI have known two who were frightened into insanity. Priests should\ntell young married men that they are human beings, not animals; that\nthey should act like rational beings when they are first married; and\nthat after the wife has become pregnant the husband should not be the\ncause of abortion in the first three months, nor of puerperal sepsis\nin the last three months. Priestley,[88] in 2325 pregnancies, found\none abortion in every four pregnancies; Guillemot and Devilliers in\nFrance, Hirst in Philadelphia, and others report the same proportion.\nThese are natural, not criminal, abortions. If, then, in normal\npregnancies about one child in five is lost before birth, husbands\nshould be taught a continence which would to some degree avert this\ncalamity. Superfetation has occurred by coition during pregnancy, and\nthis results commonly in abortion and the death of both fetuses.\n\n  [88] _Pathology of Intrauterine Death._ London, 1887.\n\nPremature labor in cases where the child is viable is produced by\nthe same agencies that interrupt gestation in the early months.\nObstetricians think that syphilis is the commonest cause of premature\nlabor, and they estimate that from 50 to 80 per cent. of these\npremature births are due to syphilis. In a series of 705 fetal deaths\nin Johns Hopkins Hospital, 26.4 per cent. were due to syphilis. After\nsyphilis the cause of premature labor next in frequency is nephritis\nwith placental hemorrhages and infarcts. Twins are not seldom\ndelivered prematurely because of lack of room in the uterus. For the\nsame reason any tumor of the uterus or abdomen may cause an abortion.\n\nWhen successive pregnancies are interrupted prematurely the abortion\nis said to be habitual, and again the commonest cause is syphilis.\nIn this disease, as the virulence of the infection decreases, the\ngestation is prolonged until a child is born infected with congenital\nsyphilis. This child commonly dies, and later a child strong enough\nto live appears. Correct treatment of the parents will avert this\nslaughter of the innocents. Sometimes the syphilis is latent so\nfar as clinical symptoms are concerned, but we may find a positive\nWassermann reaction. Hubert reported[89] that 8.8 per cent. of 8652\npatients in a clinic at Munich where all were subjected to the\nWassermann test had latent syphilis, and in 52 per cent. of these\ncases in men, and 75 per cent. in women, the infection was altogether\nunknown to the patients.\n\n  [89] _M\u00fcnchener medizinische Wochenschrift_, lxii, 39.\n\nChronic endometritis, where there is no syphilis, will permit\nhabitual abortion, and each abortion makes the condition worse.\nNephritis, diabetes, and other constitutional diseases cause habitual\nabortion.\n\nIn the first two months of gestation the decidual fold which\nholds the ovum against the uterine wall is thick, vascular, and\nfriable. The contracting uterus in abortion expels the decidua with\nconsiderable difficulty, but the ovum containing the fetus may slip\nout easily and be lost. A fetus two months old is about three-fourths\nof an inch in length. If a physician, nurse, or other person finds\nthe ovum, no matter how small it is, they should open it at once with\na scalpel or scissors and baptize the fetus conditionally, even if\nno sign of life is perceptible. If the fetus is unmistakably dead--a\ndiagnosis not easily made--there is no use in attempting baptism;\nbut always give the fetus the benefit of the doubt. In the first six\nor eight weeks the whole ovum is usually born developed in decidual\ntissue; sometimes the ovum will slip out of the decidua and be\ncovered only with shaggy villi, suggestive of a chestnut burr.\n\nDuring the third and fourth months there may be (1) an abortion\nof the whole ovum; or (2) the membranes may rupture, the fetus be\nexpelled, and the secundines remain in the uterus, and these may have\nto be removed by instrument or finger; or (3) the decidua reflexa\nand the chorion may split and let out the fetus into the amniotic\nsac: here again the remaining secundines, if they do not come away\nspontaneously, must be removed. Abortion after the fifth month is\nlike a regular labor at term, but not so energetic.\n\nAn abortion may be threatened, inevitable, or incomplete. In each of\nthese conditions there is uterine pain and hemorrhage. In inevitable\nand incomplete abortions we find softening and dilatation of the\ncervix, and a presentation or expulsion of part or all of the ovum.\n\nIn pregnancy uterine hemorrhage and uterine pain are symptoms of a\nthreatened abortion, but not certain symptoms. Fromme found that\n17.9 per cent. of 157 women who had these signs in the early months\nwent on to term. If the fact of pregnancy is not known it is not\nalways easy to differentiate a threatened abortion from other\nuterine conditions, like chronic metritis, ectopic gestation, a\nfibroid or other tumor, hemorrhage from cervical erosions or varices,\nor malposition of the uterus. If the abortion is inevitable the\ndiagnosis is made more readily. The cervix is then more or less\ndilated and the ovum is palpable. There is rather profuse hemorrhage,\nflooding, and painful uterine contractions are evident. The rupture\nof the bag of waters may be simulated by the escape of secretions\nin hydrorrhoea gravidarum, or the escape of waters may be a primary\nsymptom of graviditas exochorialis. Hydrorrhoea gravidarum is an\nintermittent discharge of clear or bloody fluid from a catarrhal\nendometritis under the decidua. It occurs in anemic, weak women,\nespecially multiparae. In graviditas exochorialis the fetus is left\nwithin the womb but outside the ruptured chorion, and it may remain\nthere for some time.\n\nWhen an abortion is incomplete it is absolutely necessary to learn\nwhether the entire ovum and decidual tissue have been expelled or\nnot. When a part or all of the dead ovum is retained the consequences\nare so grave that they may result in the death of the woman or cause\nchronic invalidism. Sepsis may result, a placental polyp may form,\nand even syncytioma malignum may start--this fatal tumor, however,\nis not so common after incomplete abortion as after hydatid mole\nformation.\n\nThe prognosis as regards health is worse after abortion than after\nnormal pregnancy. The involution of the uterus is slower than in\nfull-term cases, and if infection has occurred there is great\nlikelihood of a chronic endometritis and metritis. The woman may be\nrendered sterile, or she may become a chronic invalid to be cured\nonly by capital operations.\n\nIn threatened abortion examination is to be avoided unless it is\nabsolutely necessary for diagnosis, and then great gentleness is\nrequired so as not to excite uterine contractions. The woman is to\nrest in bed, not so much as raising her head to take a drink of water\n(which is given to her through a tube), and she is morally obliged\nto submit to this inconvenience. If she refuses she is accountable\nfor the death of the fetus. If there is bleeding the foot of the\nbed should be elevated as in hemorrhage in typhoid fever. The\nroutine practice is to quiet the woman and the uterine irritability\nwith morphine and other opium derivatives. Children are readily\noverwhelmed by opium because their circulation is not sufficient to\nneutralize the deoxidizing effects of the drug up to safety. While\nthe embryo is connected with the maternal circulation through the\nplacenta the mother's circulation often safeguards the fetus from the\neffects of the opium. The danger to the child in such cases begins\nfrom the opium remaining in its circulation after the child has been\nseparated from the mother. Often, however, fetuses in cases where\nscopolamine and morphine have been used on the mother during labor\nare born badly, and even fatally narcotized, despite the connection\nwith the maternal circulation. Nevertheless, even if there is some\nreal danger to the fetus from the use of morphine in a threatened\nabortion, the cautious use of this drug would be morally justifiable.\nShould the threatened abortion go on to actual abortion, the fetus\nwill certainly be killed, but the use of morphine on the woman is\nthe best and virtually the only means we have to avert a threatened\nabortion and so save the fetal life. The immediate double effect from\nthe morally indifferent act of giving a dose of morphine is, on the\ngood side, the saving of the fetal life, and on the other, the evil\nside, the danger of fetal narcosis, which is not at all certain to\nfollow. Evidently, the good intended effect far overbalances the evil\nand somewhat hypothetical effect.\n\nAfter about five days, if the bleeding ceases, the woman may be\npermitted to go back to her ordinary routine of life, but with\nextreme caution, and she must return to bed at the slightest show of\nblood. Morphine is used at the beginning to quiet the patient and the\nirritable uterus. If the cervix is eroded, applications of a 10 per\ncent. nitrate of silver solution are made. The bowels are kept locked\nfor three days and a softening enema of olive-oil is used before\nemptying the bowel.\n\nIf the bleeding starts again every time the woman goes about her\nduties, the abortion may be inevitable. When the cervix is shortened\nand dilated so that the ovum is palpable and pieces of the decidua\nor ovum are expelled, the hemorrhage is more or less profuse, and\nespecially if the bag of waters has ruptured and uterine contractions\nshow, the abortion is deemed inevitable. In such a case the fetus\nmay be alive, or it may be dead; and, again, conditions which\nshow all the classic symptoms of inevitable abortion sometimes,\nthough rarely, do not go on to abortion. It is extremely difficult,\nand often impossible, to tell whether an early fetus is dead or\nalive. A high, lasting fever sometimes kills the child; so do low\nblood-pressure, profuse hemorrhages, deoxidation of the blood in\npneumonia, separation of the placenta, fatty degeneration of the\nplacenta, and the severe infections--in such cases there is always\nstrong probability that the child is dead when the abortion shows\nits symptoms. If the fetal tissues that appear indicate maceration,\nor if the discharge is fetid or purulent, the fetus is dead. Should\nthe fetus be alive, tamponing the vagina to check the hemorrhage\noften separates the fetus from the uterus by the dissecting force of\nthe blood dammed back, or in any case tamponing is almost certain to\nexcite uterine contractions; thus there is an indirect killing of the\nfetus.\n\nThe treatment of inevitable abortion after the fifth month differs\nvery much from the methods used in the early months. The prime\nprinciple is, never interfere until forced to do so. When the\nhemorrhage is dangerously profuse, so that the woman's life is\nendangered (an exceptional condition), the uterine cervix and the\nvagina must be tamponed with sterile gauze and cotton to check the\nbleeding, but this is a last resort. If the fetus is alive, or\nprobably alive, nothing short of a necessity to save the woman's life\nby this means justifies the use of the tampon. De Lee advises the\nroutine use of the tampon in threatened abortion, but this doctrine\nis erroneous medically and altogether false morally. If the physician\nknows the fetus is dead, he should, of course, tampon at once to get\nrid of the fetus. The tampon excites uterine contractions and causes\ndestruction of a living fetus by dissecting it loose from the uterine\nwall through the dammed blood. Elevation of the foot of the bed and\nthe use of morphine will, as a rule, check the bleeding.\n\nWhen the woman is bleeding _to the risk of her life_, the tampon is\nput in to check the bleeding and so save her life. The double effect\nimmediately following this indifferent act is on one side good,\nthe saving of her life; on the other side evil, the killing of the\nfetus. The good effect is intended, the evil effect is reluctantly\npermitted. Such a procedure is morally licit.\n\nWhere a tampon must be put in, it is left in from sixteen to\ntwenty-four hours, even if the temperature goes up. During this\ntime there are painful contractions of the uterus, as a rule, and\nthese are expulsive. No drug is to be given to allay these pains if\nthe intention is to have a dead or viable fetus expelled. If the\npains cease suddenly, this is usually a sign that the fetus has been\nexpelled above the tampon. When the tampon is removed and the entire\novum is found, it is best for the ordinary physician not to meddle\nwith the uterus in any manner. Some advise that the physician should\ngo over the uterine lining with a half-sharp curette to make certain\nthat nothing has been left behind, but this is dangerous advice to\nany one who is not an expert obstetrician. Should the temperature\nremain above 100 degrees, the uterus must be cleaned out, and\nflushing with uterine catheters is not enough: if the gloved finger\ncannot remove the secundines, the curette is needed.\n\nIf, when the tampon has been removed, no ovum is found and the\ncervix is still closed, another tampon is to be put in for another\ntwenty-four hours, supposing the removal of the ovum is licit.\nForcible dilatation of the cervix is always a dangerous operation,\nand should never be employed when avoidable. Steel dilators have\nruptured the uterus and killed the patients again and again even\nwhen used by experts. Laminaria tents are not to be recommended; the\ntamponade is enough.\n\nWhen the retained ovum cannot be removed by the finger or squeezed\nout, the free portion of the ovum is to be grasped by an ovum forceps\nand gently drawn out. The operator should be sure he has a part of\nthe ovum in the forceps and not a part of the uterine wall. If he\nbites into the uterine wall (a common catastrophe), he may pull a\nhole in that wall, and then the woman will probably die unless the\nrent can be closed immediately after opening the belly. When the\nabdominal cavity has been opened in such an event, the uterus is\nalso to be opened, cleansed, and sutured. This method is safer than\ncuretting where there is a rent. If one is certain the gut has not\nbeen injured--and it is extremely difficult to be certain--vaginal\nanterior hysterotomy may be substituted. Sometimes perforations,\nwhen the uterus is not septic and the instruments are clean, are\nnot dangerous. Rest in bed, ice-bags, ergot, and opium cure without\noperation.\n\nPhysicians who are called into an abortion case should always be\ncertain that no one has attempted to pass sounds, curettes, or\nsimilar instruments, because a perforation may have been made by the\nmeddler which will be charged to the second man himself.\n\nIf a uterus is flexed it is easy to poke a curette or like instrument\nthrough it at the bend, especially if the uterus is thin or friable\nfrom sepsis. Again, the placental site is raised, it feels rough, and\nthe furrows in it lead one to think part of the placenta is still\nadherent, whereas all has been removed. Repeated scraping, due to\nthis error, may dig a hole through the uterine wall. Perforation\nin a septic case is practically always fatal to the woman. The use\nof the curette supposes a special technic, and no physician should\npresume to try its use unless he has been carefully and practically\ninstructed.\n\nIn inevitable abortion after the third month it may be very difficult\nto get the embryo out. The cervix, in primiparae especially, may be\nlong, thick, and hard. If the fetus is dead, it may then be removed\nby _morcellement_--_i. e._, by cutting and breaking it into pieces,\nand then taking out these pieces with an ovum or stone forceps.\nSometimes, though rarely, the operator may find it impossible to get\nthe entire fetus away. Then the uterus is packed with weak iodine\ngauze, and after twenty-four hours the fetal remains are expelled.\n\nIn every abortion the presence or absence of extrauterine pregnancy\nis to be made out. If there is an extrauterine pregnancy, curettage\nwill cause rupture of the sac.\n\nWhen the interior of the aborting uterus has become septic the old\ntreatment was to empty the uterus at once, but now the treatment is\nexpectant, because the traumatism of the curetting makes the sepsis\nworse. The commonest and worst infections are of the streptococcus\nputridus, a pus staphylococcus, and the bacterium coli communis.\nCurettage lets these micro\u00f6rganisms enter the circulation. The\ncause of this condition is often unskilful attempts at artificial\nabortion. When the womb contains decomposing material bleeding\nusually obliges tamponing, and thus often the uterine contents come\naway in twenty-four hours with the gauze. If there is no hemorrhage\nthere should be no tamponing: it is then better to get dilatation by\npacking and drain the uterus with gauze. The curette should not be\nused at all.\n\nWhere there is habitual abortion the cause must be found. During\ngestation syphilis and displacements of the uterus, as causes,\nmay be treated. Endometritis can be cured only when the uterus is\nempty. Rest in bed at the time when these abortions usually occur,\nand at the time when menstruation customarily appears, is required.\nTreatment of the husband is often necessary, as he is virtually\nalways the source of luetic infection.\n\nAttention or inattention to the mother's own hygiene during\npregnancy has great effect on the fetus, and care of hygiene may\navert abortion. The woman's dress should be simple and warm enough\nto prevent congestion from changes in temperature. Congestions are\nlikely to affect the kidneys, and care of the renal function is\nalways one of the most important facts connected with pregnancy. No\ncircular constrictions of the trunk by lacing or stiff corsets should\nbe attempted. The corset forces the uterus and child downward into\nthe pelvis and against the lower abdominal wall, causing congestion\nof the pelvic veins and strain on the abdominal muscles. Tight\ncorsets, preventing the expansion of the uterus and the growth of\nthe fetus, may cause mutilations like club-foot and wry-neck, or\neven kill the child. The woman who would \"preserve her figure\" by\ncorsets, to the mutilation, weakening, or killing of her unborn\ninfant, and this is an every-day evil, is either a criminal fool or\nan unmitigated scoundrel. Tight lacing to conceal pregnancy is a\nmethod of murder. High-heeled shoes are somewhat injurious because\nof the constrained position into which they throw the woman. X-ray\nphotographing of pregnant women is very likely to cause abortion.\n\nThe woman's diet should be simple. She must abstain from all\nalcoholic liquors even if she has been accustomed to their use at\nmeals. She should not overeat on the supposition that she has to\nfeed two persons. Some popular books advise a special diet to reduce\nthe bone-salts and thus get a smaller baby and one more easily\ndelivered. Such advice is criminal. The constipation of pregnancy is\nnot to be treated by strong cathartics like Epsom salt. The kidneys\nare to be watched; therefore the urine should be examined every\nthree weeks up to the seventh month, then oftener. If there is any\nsuspicion of toxemia or nephritis, the urine should be examined\ndaily. Obstetricians who have any regard for their own conscience and\nreputation will have nothing to do with a woman who refuses to take\nthis precaution.\n\nPhysical exercise should be gentle--say, walking, up to two miles in\nthe daytime. The vast majority of women are too lazy to take physical\nexercise as a hygienic duty at any time, and during pregnancy their\naversion to all effort to overcome indolence is so great they make\neven themselves believe they cannot. Just as most professional men\nthink they think, most women think they work. There are thousands of\nwomen who have servants, yet make not only their families and friends\nbut themselves believe they are worked to death, and their work is\nthe spreading of four or five beds, and the ordering of groceries\nover the telephone. When these women are pregnant they quit even the\nbed-making.\n\nCold and hot baths, Turkish and Russian baths, hot sitz-baths and\nocean bathing are not permissible during gestation. Tepid baths and\nspongings are to be substituted. Near term the bath-tub is not safe\nbecause of danger of uterine infection from unclean water. Then\nshower-baths are better, but these are dangerous if the woman must\nstep over an enameled bath-tub side to take them, because she may\nslip and fall. Vaginal douches are not to be used in pregnancy except\nin certain diseased conditions, under the direction of a competent\nphysician.\n\nTherapeutic abortion and therapeutic induction of premature labor are\nemployed in five chief groups of conditions: (1) contracted pelvis;\n(2) diseases caused by pregnancy; (3) diseases coincident with\npregnancy; (4) habitual death of the child after viability but before\nterm; (5) prolonged pregnancy. There is no such act as therapeutic\nabortion of an inviable child; all abortions of inviable children,\nwhen direct, are criminal, and nothing criminal is therapeutic. The\nconsideration of narrow pelvis, and the diseases caused by pregnancy\nand coincident therewith, will be treated in detail.\n\nWhen the child dies after viability but before term the cause is\nmost commonly syphilis. In such cases a Wassermann reaction should\nbe made from both parents; and even if it is negative, and no other\ndefinite cause for the fetal death can be found, syphilitic treatment\nshould be tried on the father and mother. Bright's disease, even when\nscarcely diagnosable, anemia, diabetes, adiposity, and hypothyroidism\nare other lethal causes of habitually still-born infants. Not seldom\nthe cause is in the husband. If he is an alcoholic (and two or\nthree drinks of whiskey a day make any man an alcoholic), if he is\nespecially susceptible to the toxin of tobacco (and tobacco alone may\nrender some men not only sterile but impotent), if he is a worker in\npoisonous metals, an X-ray operator, a user of narcotics, exhausted\nwith overwork and worry, affected with weakening systemic disease,\nhis germ-cells are unfit for their function. Such men are not\ntechnically sterile, but they are practically sterile.\n\nSome women carry the child beyond term, with the effect that the baby\nis overgrown for normal delivery. The head is harder and more angular\nthan it should be, the long bones stiffer and less pliable, the\nmuscles tenser. All these changes make the delivery so difficult that\nthe overgrown child may be fatally injured at birth. Physicians must\nbe cautious in believing histories of enormous children at previous\nbirths at which they were not present. Mothers and nurses are likely\nto exaggerate the size of infants.\n\nIn cases where the children die at a particular time before term,\npremature labor should be induced to save the child, and when the\nchild has been carried over term it may be necessary to induce labor.\nIn the first condition labor is not to be induced a week earlier than\nis necessary. We talk so much of a seven months' child as viable\nthat we forget that any child born before the thirtieth week of\ngestation has very small chance for survival. From 30 to 60 per cent.\nof all prematurely delivered infants die. The maternal passages do\nnot dilate normally and the child is unformed; its bones fracture\nreadily; it cannot sustain pressures and strains. All induced labors\nare dangerous to the mother by shock and possible infection, and only\nvery grave necessity justifies any such procedure.\n\nIn inducing necessary premature labor the technical method may take\non a moral quality. There are over a score of methods, and many of\nthese, although used, are dangerous and should be obsolete. A very\ncommon method, begun in 1855, is to insert one or two elastic solid\nbougies into the uterus between the membranes and the uterine wall.\nThis is a dangerous method and should be obsolete. Other dangerous\nand obsolete methods are the puncture of the membranes with a trocar\nhigh up in the uterus; intrauterine injections of hot or cold\nwater, glycerine, milk, and other liquids; vaginal tamponade alone;\nirrigation of the vagina with carbon-dioxide water; a stream of hot\nwater directed against the cervix, electricity, X-ray, dilatation of\nthe vagina with a rubber bag, irritation of the nipples, the use of\ndrugs like quinine, cimicifuga, ergot, or cantharides.\n\nIf haste is not necessary, packing the cervical canal and the lower\nuterine segment antiseptically with a strip of gauze three to\nfive yards long and three inches wide and leaving it in for about\ntwenty-four hours is one of the best methods. Where rapid delivery\nis required, cesarean section must be employed. In cases of somewhat\nless urgency the membranes are first punctured and balloon dilators\nare used. In any case puncture of the membranes is the most certain\nmethod to start labor, but it has many bad disadvantages. A dry\nlabor in a primipara with an undilated cervix is a grave condition.\nIf the fetal head is not engaged in the pelvis, puncture must not\nbe attempted. When the head is not engaged in the pelvis like a\nball-valve, the cord will prolapse, be pinched, and thus the blood\nsupply will be cut off from the child and the loss will kill it.\nFor the same reason, the waters must not be run off too quickly.\nMany operators insert a bag, dilate, and so start the labor, without\npuncturing the membranes, where there is no reason for haste.\n\nTherapeutic abortion, as has been said, is never permissible, under\nany circumstances, if the child is not viable. In certain conditions,\nsay, when a uterine tumor clearly threatens the life of the pregnant\nwoman, or if in extrauterine gestation there is a rupture of the\ntube, an operation may be permissible, or even obligatory, which has\nfor its direct end the removal of the tumor or the stopping of the\nhemorrhage. If such a removal or ligation, under these conditions,\nindirectly causes the abortion of the inviable fetus, or its death\nfrom a lack of blood, these indirect effects may be reluctantly\npermitted. They are cases of an equally immediate double effect,\none good and one evil, where all the requirements are fulfilled.\nA _direct_ abortion of an inviable fetus, however, is never licit\neven to save the mother's life, and in abortion the killing is\n_direct_ because it is used as a means to an end. In a ruptured\nectopic gestation the primary effect of the physical operation is\nto ligate the torn arteries to save the woman's life here and now;\nthe secondary effect is the permitted death of the fetus from the\nshutting off of the blood supply. In the abortion of a premature\nfetus the primary effect of the operation is to separate the placenta\nfrom the uterus, to cut off the child's blood supply, and as a direct\nconsequence of this act, which is essentially evil, the woman's life\nis saved. The original act in this abortion is evil, and evil may not\nbe done even if good follows. Even in self-defence against an unjust\naggressor one may not kill a man to save his own life--he tries to\nsave his own life and reluctantly permits the death of the aggressor.\nIn a killing in self-defence there are two distinct effects; in\nabortion there is only one effect, and the killing is a means to this\none effect. That you may kill an irresponsible insane man who is\nattacking your life, or the life of one entrusted to your care, is no\nreason that you may attack a fetus in the womb. There is no parity.\nThe insane man is a materially unjust aggressor; the fetus is not an\naggressor at all. The mother placed it where it is; and if any one is\nan aggressor, she is. In the abortion you directly kill the fetus and\nindirectly save the woman's life, and this indirection uses the death\nof the fetus as a means to the end of saving the woman's life. In\nkilling the insane aggressor you directly save the life of yourself\nor your ward, and reluctantly permit the death of the aggressor. The\nproofs of the essential immorality of direct homicide have already\nbeen established in the general chapter on Homicide.\n\nThe assertion that an undeveloped fetus in the womb is not as\nvaluable as the mother of a family is beside the question, and in\ncertain vital distinctions it is untrue. Any human life, as such,\nwhether in a fetus or an adult, is as valuable as another, inasmuch\nas no one but God has any authority to destroy it, except when it has\nlost its right to existence through culpable action. Secondly, the\nquality of motherhood is an accidental addition to a mother's life,\nnot substantial as is the life itself. This quality of motherhood\ndoes not create any juridic imbalance of values which justifies the\ndestruction of the rights inherent in the fetus. That the fetus may\nnot be able to enjoy these rights if the mother dies is, again,\nan irrelevant consideration. There is no question of a comparison\nof values. A life is a life, whether in mother or fetus, and the\ndestruction of an innocent life by any one except its creator, God,\nis essentially an evil thing, like blasphemy. An innocent fetus\nan hour old may not be directly killed to save the lives of all\nthe mothers in the world. Insisting on such comparisons supposes\nignorance and sentimental opposition to truth. It is a good deed\nto save a mother's life; but such saving by killing an innocent\nhuman being ceases to be good and becomes indescribably evil, an\nenormous subversion of the order of the natural law, as it is a\nusurpation of the dominion over life possessed by God alone. If I\nowe a man a vast sum of money and the payment of this debt will ruin\nme and my children, it would be a good thing for me and them to\nhave this creditor put out of the way by death, but that fact is no\njustification whatever for me to kill the man. The fetus in the womb\nin a case where there is question of therapeutic abortion is like\nthis creditor: it would be well for the mother to have this fetus out\nof the way, but that is no justification whatever for her to kill\nthe fetus, or to let it be killed by a physician. The physician who\nkills such a fetus is exactly like a hired bravo who assassinates a\ntroublesome creditor for a fee, except that the physician does the\nnasty job for less money.\n\nTo hasten even an inevitable death is homicide, and that quality\nof merely hastening adds nothing for extenuation: every murder is\nmerely a hastening of inevitable death. To give a dying man a fatal\ndose of morphine \"to put him out of misery\" is as criminal a murder\nas to blow out his brains while he is walking the streets in health;\nto ease pain is not commensurate with the horrible deordination of\ntaking a human life. This subversion of the moral law in the interest\nof mawkish sentimentality is one of the gravest evils of modern\nsocial ignorance. Physicians are constantly mistaking inclination, or\nthe mental vagaries of the nurses who influenced their childhood, for\nrules of moral conduct. A physician is not a public executioner, nor\na judge with the power of life and death: his business is solely to\nsave human life, never to destroy it.\n\nIf there were anything in the objection that refusal to do abortion\nopposes the life of a useless fetus to that of a useful mother of a\nfamily, where would such false logic stop? If it held for the taking\nof life in an unpleasant condition, it would hold _a fortiori_ in\nevery other less unpleasant condition where a life would not be at\nstake. When a note that you had given falls due and it would bankrupt\nyou to pay it, does this inconvenience let you out of the difficulty\nin honor, in the moral law, or in the civil law? It certainly does\nnot; but it should if the doctrine of the sentimentalists on\nabortion were true. An eclamptic woman, or one with hyperemesis\ngravidarum, conceived the child, got into the difficulty, and she and\nher physician have no right to tear up the note they have given to\nthe Creator, especially when such tearing implies murder. Suppose,\nagain, a woman has done a deed for which she has in due process\nof just law been condemned to death; suppose, also, there is only\none man available to put her to death, and if this man were killed\nshe could escape. Would her physician be permitted to shoot that\nexecutioner to let her out of the difficulty? Certainly not. That,\nhowever, is just what the physician does who empties an eclamptic\nuterus of an unviable fetus. You may not do essential evil that\nanything under the sun, good, bad, or indifferent, may come of it.\n\nIf I may kill a so-called \"useless fetus\" to save a useful mother, do\ngross evil to effect great good, why should I stop there? Why, then,\nmay I not rob a church to make my children rich, murder a useless\nmiser to employ his money in founding orphanages, shoot any oppressor\nof the poor, kick out of doors my senile and bothersome father,\nreject all my most sacred promises whenever their observance makes\nme suffer? Where will the sentimental moralist draw the line? That\nthe civil law permits therapeutic abortion is no excuse at all; it is\nmerely a disgrace of the civil law. The American civil law permits\nmany things that are contrary to morality and the law of God: it\nabsolves bankrupts even if they afterward become solvent; it permits\nthe marriage of divorced persons; it levies unjust school taxes; it\ngives unjust privileges; it squanders the money of the citizens; and\nso on.\n\nIf a woman marries in good faith a man she deemed a gentleman, but\nwho turns out to be a syphilitic sot who disgraces her and makes her\nlife a perpetual misery, immeasurably worse than the condition of\nany eclamptic woman, no greater blessing could come to her and her\nchildren than his death. Would she therefore be justified before any\ntribunal of God or man in murdering him to get rid of her trouble?\nNo; she must bear with her evil for the sake of social order and of\neternal right. So must the eclamptic woman.\n\nIf it is murder to kill a child outside the womb, and mere\ntherapeutics to kill it inside the womb, then it is murder to shoot a\nman on the street, and mere good marksmanship to shoot him to death\ninside his house, especially if he is an undesirable citizen. All\nreputable physicians deem a fetus in a _normal_ pregnancy so good\nthat they will not dream of destroying this fetus. They absolutely\nrefuse to effect an abortion to get rid of a fetus which may disgrace\nan unmarried woman and her family, and they are perfectly right in\nthis refusal. They talk and write with genuine indignation of race\nsuicide. The only reason they have for the refusal to do what they\ncall criminal abortion is that the disgrace or inconvenience of the\nwoman is not commensurate with the destruction of a human life.\nThey observe the natural human instinctive repugnance to murder in\nthis special speech and writing, and then go home and get their\nobstetrical bags and complacently murder the first baby they find\nin the womb of a _married_ matron who has a disturbed stomach or\nkidneys. They show here the fine intellectual acumen and reasoning\nability of a chronic lunatic. The first fact in the social order is\nthat justice, law, order, should prevail, no matter what the cost.\nIt might be better that the fetus should _die_ than that the mother\nshould die, though that is not always true. It is not better that an\nunbaptized fetus should die than that a mother in the state of grace\nshould die. But these are irrelevant considerations. It is never\nbetter that the fetus should be _killed_ than that the mother should\ndie. That is a very different matter.\n\nThe _Mignonette_ case in 1884, tried in England by Lord Coleridge,\nis a good example of evaluation of lives as in therapeutic abortion,\nwhich came to grief. A ship called the _Mignonette_ foundered 1600\nmiles from the Cape of Good Hope, and three of its crew, with a boy,\nwere for a long time at sea in an open boat without provisions. When\nthey were almost starved the boy lay on the bottom of the boat,\nasleep or half conscious from weakness. Two of the men plotted to\nkill the boy for therapeutic purposes; they needed his flesh to save\ntheir own lives. They killed the poor lad just as the therapeutic\nabortionist kills a fetus. They got his uncooked flesh for four days.\nLater Lord Coleridge got them and he sentenced both of them to death.\nAnother Lord will get the therapeutic abortionists.\n\nWhat, then, is the physician to do who meets a case that imperatively\ncalls for therapeutic abortion according to the common medical\npractice? He can do nothing. The law may seem hard in certain\ncircumstances to those who cannot see beyond the physical; yet that\nfact does not abrogate the law, which is one of essential morality.\n\nMay the physician call in a physician who, he knows, will not scruple\nto perform the therapeutic abortion on an unviable fetus? If he does,\nhe is as much a murderer as if he did the deed himself. He may not so\nmuch as suggest the name of some one who will do the deed. He simply\ntells the family he can do nothing. If they insist on the abortion he\nwithdraws from the case.\n\nIn this connection it is necessary to mention again the question of\nviability. Langstein reported[90] a study of the growth and nutrition\nof 250 prematurely born infants, and he found a confirmation of what\nwas already known, that a weight of 1000 grammes (2-1/5 pounds) and\na full body length of 34 centimetres (13-3/5 inches) are the lowest\nlimits for viability under proper circumstances. A fetus 1000 grammes\nin weight and 34 centimetres in length has completed the sixth\nsolar or calendar month, or the sixth and a half lunar month--it is\nbeginning its seventh month, not ending it, yet it is viable under\nproper conditions.\n\n  [90] _Berliner klinische Wochenschrift_, June 14, 1915.\n\nThe child at term, on a rough average, is from 48 to 52 centimetres\n(19 to 20-1/2 inches) in length, and it weighs from about 6-3/5 to\n7-1/2 pounds. It is impossible, however, to obtain the sizes and\nweights of infants _in utero_ with scientific accuracy, because the\ndate of conception cannot be determined with absolute certainty, and\ninfants _in utero_ vary as they do after birth. A full-term infant\nsometimes may weigh only 3-1/2 pounds when the mother is diseased,\nand at times an eight-months fetus will weigh as much as 8 pounds.\n\nAs was said in Chapter III, a fetus of six completed calendar or\nsolar months (not lunar--the duration of gestation is often reckoned\nin lunar months by obstetricians) is viable provided it is cared for\nby competent physicians in a hospital. Otherwise it is not viable,\nexcept in a strictly technical sense; it will not live more than a\nfew days or weeks.\n\nA full seven-months infant may be reared with proper feeding and\nskilled care; a six-months infant may be reared (with difficulty) in\na hospital with skilled care. If it is certain that the removal of a\nsix-months fetus will here and now save the life of a mother (a very\ndifficult matter to judge by the best diagnosticians), this removal\nmay be done, provided the infant is delivered in circumstances where\nskilled care, incubator, and proper food are obtainable; otherwise\nthe removal is not justifiable.\n\nThe Council of Lerida, in Catalonia, in the year 524, decreed that\nabortionists of any kind must do penance all their lives, and if\nthey are clerics they are to be suspended perpetually from all\necclesiastical ministration.\n\nThe Council of Worms, under Hadrian II., in the year 868,[91] also\njudged women who procure abortion as certainly guilty of murder.\n\n  [91] Cap. 35.\n\nIn the _Corpus Juris_,[92] among the decretals of Gregory, there is\nthe following law: \"If any one, through lust or hatred, does anything\nto a man or woman, or gives them any drug, so that they cannot either\ngenerate or conceive, or bear children, he is to be treated as a\nmurderer.\"\n\n  [92] Lib. v, tit. xii, c. 5.\n\nSixtus V., in the Constitution _Effraenatam_, October 29, 1588,\nmentions a decree of the Sixth Synod of Constantinople, in session\nin 680 and 681, which subjects those who perform abortion, or kill a\nfetus, to the punishment inflicted on murderers. Sixtus then decreed\nthat any one who effects the abortion, directly or indirectly, of an\nimmature fetus, whether the fetus is animated, formed, or not, either\nby blows, poison, drugs, or potions, or tasks of hard labor imposed\non pregnant women, or any other method, however subtle or obscure\nit be, is guilty of murder, and is to be punished accordingly.\nHe recalls all ecclesiastical privileges from clerics who cause\nabortion, and says that they are to be reckoned as murderers\naccording to the decree of the Council of Trent,[93] and he makes a\nlaw that abortionists may never be promoted to orders.\n\n  [93] Session xiv, _De Reformatione_, cap. 7.\n\nIn the fifth paragraph he says: \"Moreover, we decree that the same\npenalties are incurred (1) by those who give potions and poisons to\nwomen to induce sterility or prevent conception, or who cause these\ndrugs to be administered, and (2) by the women themselves who freely\nand consciously take these drinks.\"\n\nIn paragraph seventh he decrees that any one, man or woman,\ncleric or lay, who procures abortion by counsel, favor, drinks,\nletters of advice, signs, or in any way whatever, are _ipso facto_\nexcommunicated, and the excommunication is reserved to the Pope\nhimself.\n\nGregory XIV., in the constitution _Sedes Apostolica_, May 31, 1591,\ngave to priests who have special faculties for the purpose from the\nbishop, permission to absolve from this excommunication, but only _in\nforo conscientiae_. Sixtus V. and Gregory XIV. used the term _foetus\nanimatus_, in keeping with the old Aristotelian notion of animation.\n\nPius IX., in the constitution _Apostolicae Sedis Moderationi_,\ndeleted the epithet _animatus_, and extended the excommunication\nto all abortions, no matter at what time of the gestation they\noccur. He ordered that only the actual physical abortionist is to\nbe excommunicated, not those who counsel the crime. Some moralists\nhold that those who order abortion are direct abortionists and fall\nunder this excommunication; other moralists oppose this opinion. Pius\nIX.[94] excommunicates procurators of abortion if actual abortion is\neffected, and this excommunication is reserved to the bishops, not to\nthe Pope.\n\n  [94] Sect, iii, cap. ii.\n\nIn this decree occur the words \"_Procurantes abortum, effectu_\n_secuto_,\" and there has been considerable discussion of the\nquestion who are the _procurantes_, the agents who fall under the\nexcommunication? Again, are craniotomy, cephalotrypsis, decapitation,\nembryotomy, and exenteration, when performed on the living child,\nabortions in the sense of the decree, and thus matter of the\nexcommunication?\n\nThose who do abortion are the principal agents who _physically_,\nimmediately, of themselves, in their own name, or who _morally_,\nthrough others, perform an abortion. The common opinion of moralists\nis that all those who of themselves or through others bring on an\nabortion are excommunicated, but that assistants, although guilty of\ncrime, are not excommunicated.\n\nMany eminent moralists are of the opinion that the mother herself who\nseeks an abortion does not fall under the excommunication because\nSixtus V. does not explicitly mention her in this penal law, and a\npenal law is to be interpreted literally. If a pregnant woman goes to\nan abortionist and persuades him by speech and pay to do an abortion,\nshe is the direct moral cause of that abortion. If it were not for\nher, the abortion would not take place. Virtually all abortions done\non married women are effected morally by the woman herself. In my\nopinion, and the new canon law states this explicitly, the woman who\nprocures an abortion on herself or on another woman is excommunicated.\n\nSabetti-Barrett[95] holds that craniotomy on a living child and\nthe removal of an inviable extrauterine fetus are not abortion in\nthe scope of this excommunication, because as a penal law these\noperations are not specifically mentioned. All mutilating operations,\nlike craniotomy and the others enumerated above, first kill the\nfetus, then extract its body from the womb; abortion first extracts\nthe fetus and then lets its die. The result is the same, but the\noperations differ technically, and a penal law is _ad literam_. A\ncleric who procures abortion of an inviable fetus at any time of\ngestation falls under the excommunication and suspension _a sacris_\nperpetually, although he probably is not technically irregular\ncanonically if he procures the abortion before the Aristotelian date\nof animation. The bull _Effraenatam_ makes the canonical irregularity\nat the Aristotelian date obsolete practically.\n\n  [95] _Compendium Theologiae Moralis_, 1915, n. 1009.\n\nIn the church the Holy Office (that is, the Inquisitors-General\nin matters of faith and morals) is the official authority which\ninterprets, under the approval of the Pope, the morality of acts like\nabortion and related operations. In 1895 the following difficulty was\nproposed to the Holy Office for solution:\n\nA physician is treating a woman with a disease which will certainly\nbe fatal to her unless cured medically, and the disease is due to the\npresence of a fetus in her womb. To save her it is necessary to empty\nthe uterus, but the fetus is not yet viable. The question is, May the\nphysician perform therapeutic abortion in such circumstances?\n\nOn July 24, 1895, the Holy Office answered: \"The Inquisitors-General\nin matters of faith and morals, with the vote of their Consultors,\ndecree: _Negatively_, in accord with the other decrees of May 28,\n1884, and August 19, 1888.\"\n\nIn May, 1898, the following questions were proposed to the Holy\nOffice:\n\nI. Is the induction of premature labor licit when a contracted\nmaternal pelvis prevents the birth of a child at term?\n\nII. If the maternal pelvis is so narrow that premature delivery is\nimpossible, is it licit to perform abortion, or to effect _cesarean_\ndelivery at the proper time?\n\nIII. Is laparotomy in extrauterine gestation licit?\n\nMay 4, 1898, the Holy Office answered, with the assent of Leo XIII:\n\nI. Premature labor in itself is not illicit, provided it is done for\nsufficient reason, and at the time and by such methods as will under\nordinary circumstances preserve the life of the mother and the fetus.\n\nII. As to the first part, the answer is negative, according to the\ndecree of July 24, 1895, on the unlawfulness of abortion. As to the\nsecond part, there is no objection to the cesarean delivery at the\nproper time.\n\nIII. In a case of necessity, a laparotomy to remove an ectopic fetus\nfrom the mother is licit, provided the lives of both mother and fetus\nare, so far as is possible, carefully and opportunely preserved.[96]\n\n  [96] \"Dummodo et foetus et matris vitae serio et opportune\n  provideatur.\"\n\nMarch 5, 1902, this question was asked the Holy Office: \"Is it ever\nlicit to remove an ectopic fetus from the mother while the fetus is\nunder six months of age from the time of conception?\"\n\nThe answer was: \"_Negatively_, in accord with the decree of May 4,\n1898, by which the lives of the fetus and mother, as far as possible,\nare carefully and opportunely preserved. As to the time, the\nquestioner is reminded by the same decree that no premature delivery\nis licit unless effected at the time and by the methods which, under\nordinary circumstances, will preserve the lives of mother and fetus.\"\n\nThe English civil law concerning abortion[97] is:\n\n\"Whoever shall unlawfully supply or procure any poison or other\nnoxious thing, or any instrument or thing whatsoever, knowing that\nthe same is intended to be unlawfully used or employed with intent to\nprocure the miscarriage of any woman, whether she be or be not with\nchild, shall be guilty of a misdemeanor, and being convicted thereof\nshall be liable, at the discretion of the court, to be kept in penal\nservitude for the term of three years, or to be imprisoned for any\nterm not exceeding two years, with or without hard labor.\"\n\n  [97] Statutes 24 and 25, Victoria, cap. 100, sec. 59.\n\nAlfred Susaine Taylor,[98] commenting on this law, said: \"Strictly\nspeaking, there is no such thing as justifiable abortion; the law\nrecognizes no such possibility. A medical man must always remember\nthis when he contemplates emptying a pregnant uterus.\n\n  [98] _Principles and Practice of Medical Jurisprudence._ London,\n  1905.\n\n\"It is obvious that the only reasons that can be thought of by an\nhonorable man as justifying the induction of labor are (1) to save\nthe life of the mother; (2) to save the life of the child. (Some\nreligions will not contemplate the first reason, but that we are not\nnow concerned with.) It cannot be done for the sake of family honor\nnor for any similar ethical reason....\n\n\"The golden rule is never to empty a uterus without first having a\nsecond professional opinion as to its necessity; if this opinion be\nadverse, do not do it; if it be favorable, it is well to get it in\nwriting, and it is well also to get the written or attested consent\nof the woman and her husband, and then proceed to do it with all the\nskill and care possible. The death of the fetus is at any time the\nmost certain means of causing the womb to empty itself, but after\nthe sixth month the operation is performed necessarily with a view\nto preserving this life, and steps must be taken accordingly.\" Coke,\nabout 1615, judged that to kill a child in the womb is not murder,\nbut if it is expelled by violence and dies after it leaves the womb,\nthat is murder.\n\nThe law in Pennsylvania[99] is: \"If any person, with intent to\nprocure the miscarriage of any woman, shall unlawfully administer to\nher any poison, drug, or substance whatsoever, or shall unlawfully\nuse any instrument, or other means whatsoever, with the like intent,\nsuch person shall be guilty of felony, and being thereof convicted,\nshall be sentenced to pay a fine not exceeding five hundred dollars,\nand undergo an imprisonment, by separate or solitary confinement\nat labor, not exceeding three years.\" It makes no difference in\nPennsylvania law whether the child is quickened or not.\n\n  [99] _Laws of Pennsylvania_, Act of March 31, 1860, sec. 88. p.\n  404.\n\nThe New Jersey, Massachusetts, and Wisconsin laws are like the\nPennsylvania law. The law in Iowa[100] is: \"If any person, with\nintent to procure the miscarriage of any pregnant woman, wilfully\nadminister to her any drug or substance whatever, or, with such\nintent, use any instrument or other means whatever, unless such\nmiscarriage shall be necessary to save her life, he shall be\nimprisoned in the penitentiary for a term not exceeding five years,\nand be fined in a sum not exceeding one thousand dollars.\" To the\nsame effect are the laws in Connecticut, Maine, New York, Ohio,\nMichigan, Minnesota, Colorado, Texas, and Maryland.\n\n  [100] _Laws of 1897_, Iowa Code, 4759.\n\nFrank Winthrop Draper, professor of legal medicine in Harvard\nUniversity,[101] commenting on the Massachusetts law of October,\n1903, cap. 212, secs. 15, 16, says: \"It is important to recognize the\nfact that the law does not make any exception or formal recognition\nin favor of justifiable operations to procure premature labor. The\nstatute is general in its application. It is, of course, obvious\nthat the best sentiment of the medical profession and of obstetric\nteachers is favorable to interference of pregnancy, (1) whenever\nthere is such anatomical deviation or mechanical obstruction in the\nmother's pelvis that the birth of a child is impossible; or (2)\nwhenever the mother is suffering from such grave disease that her\nlife is in imminent peril and can be saved only by the arrest of\ngestation. Under such conditions the physician is not only warranted\nin inducing premature labor, but is required to do so by a sense of\nduty to his patient, with a view thereby to save one life at least,\nand, if possible, the lives of both mother and offspring.\n\n  [101] _Legal Medicine_, 1905.\n\n\"Nevertheless, as the law now stands, a prudent practitioner will not\nexpose himself to any risk, if a few precautions will save him. In\nthe event of the death of the mother and child in such an emergency,\nthe attending physician might find himself in jeopardy, with the\nimputation of gross carelessness and criminal neglect hanging over\nhim, an imputation which requires years to remove. So the attending\nphysician should never undertake to do an instrumental operation\nwithout these precautions: 1. The consent of the patient, with that\nof her husband or family. 2. Especially, a consultation with some\nother physician or physicians in whom there is full confidence.\nAttention to these simple and sensible safeguards, by making the\nconduct appear by its candor and openness in the strongest possible\ncontrast with the secret methods of the abortionist, may save great\nembarrassment.\"\n\nThe ethics of this doctrine is, of course, absurd, as has been\nshown, and it is cited here only to show how the civil law considers\nabortion. Wharton and Stille[102] give the same information in a\nmore technical manner. \"It is a general rule,\" they say, \"independent\nof statute, that the act of a physician in aiding a miscarriage is\nnot unlawful, where the miscarriage was the inevitable result of\nother causes. And the act is justified where the circumstances were\nsuch as to induce in the mind of a competent person the belief that a\nmiscarriage was necessary to preserve the life of the mother. And the\nstatutes of many of the States penalize the causing, or attempting\nto cause, an abortion, unless necessary to preserve the life of the\nwoman, or unless advised by a designated number of physicians to be\nnecessary for such purpose, the absence of both the necessity and\nthe advice being an essential ingredient in the crime. The physician\nby whom the deed is done, however, cannot act as his own adviser in\nthe matter. And an indictment under the statute must not only allege\nthat the act was not necessary to preserve the woman's life, but must\nalso negative the advice of physicians; and such averments cannot be\ninserted as an amendment after demurrer.\n\n  [102] _Medical Jurisprudence_, vol. iii, sec. 526.\n\n\"The burden of proof rests with the state to show that the means used\nwere not necessary to preserve the life of the woman in question;\nand the absence of necessity may be determined from circumstantial\nevidence. But the burden of proof as to the advice of physicians\nwould not fall within the rule controlling the production of proof\nas to negative matters in general, and would rest with the accused;\nthough it may be proved by a preponderance of the evidence and need\nnot be established beyond a reasonable doubt. But either that the\nact was necessary to preserve the life of another, or that it was\nadvised by physicians to be necessary for that purpose, is of equally\ngood defence; and the destruction of the child need not have been\nboth necessary and advised by physicians. And statutes of this class\napply only in cases in which the death of the mother could reasonably\nbe expected to result from natural cause, unless the child was\ndestroyed, and do not apply to a case in which the mother threatened\nsuicide unless she was relieved from her trouble.\"\n\n\n\n\nCHAPTER VI\n\nECTOPIC GESTATION\n\n\nEctopic Gestation, called also extrauterine pregnancy, is gestation\noutside the uterus in the adnexa or the peritoneal cavity. Pregnancy\nin the horn of an abnormal or rudimentary uterus is classed with\nectopic gestation because the effects are similar, although pregnancy\nat times in a rudimentary uterus goes on to term normally. The uterus\nis in the pelvic cavity, between the bladder and the rectum, and\nabove the vagina, into which it opens. It is a hollow, pear-shaped,\nmuscular organ, somewhat flattened, and about three inches long, two\ninches broad, and an inch thick. The fundus or base is upward, and\nthe neck is downward. Passing horizontally out from the corners or\nhorns of the uterus, which are at the fundus, are the two Fallopian\ntubes, one on either side. These are about five inches in length\nand somewhat convoluted. They are true tubes, opening into the\nuterus, and they are about one-sixteenth of an inch in diameter\nthroughout the greater part of their extent. The ends farthest from\nthe uterus are fringed and funnel-shaped; and this funnel end,\ncalled the Infundibulum or Fimbriated Extremity, opens into the\nabdominal or peritoneal cavity. Near the Fimbriated Extremity of each\ntube is an Ovary, an oval body about one and a half inches long by\nthree-quarters of an inch in width. For convenience in description,\neach tube is divided into four parts: (1) the Uterine Portion, which\nis that part included in the wall of the uterus itself: it extends\nfrom the outer end of the horn into the upper angle of the uterine\ncavity, and its lumen is so small that it will admit only a very fine\nprobe; (2) the Isthmus, or the narrow part of the tube which lies\nnearest the uterus: it gradually widens into the broader part called\n(3) the Ampulla; (4) the Infundibulum, or the funnel-shaped end of\nthe Ampulla. One of the fimbriae, the Fimbria Ovarica, is longer than\nthe others, and it forms a shallow gutter which extends to the ovary.\n\nThe uterus, tubes, and ovaries lie in a septum which reaches across\nthe pelvis from hip to hip. This septum is called the Broad Ligament.\nIf a man's soft hat, of the style called \"Fedora,\" is inverted, the\nfold along the crown coming up into the cavity of the hat is like the\nbroad ligament. As the crown is held downward the uterus would be in\nthe middle, its fundus upward, and outside the hat, representing the\npelvic cavity, but in the crown fold. The tubes and ovaries would\nalso be in the crown fold, or broad ligament, and the fimbriated\nextremities would open into the interior of the pelvic cavity through\nholes. The ovum breaks through the surface of the ovary into the\npelvic cavity, passes, probably on a capillary layer of fluid, into\nthe fimbria ovarica and thence into the infundibulum, whence it moves\nalong slowly into the uterus.\n\nOvulation and menstruation occur about the same time ordinarily, and\nif the ovum produced is not fecundated it gradually shrivels and\npasses off through the uterus and vagina. Fecundation of the ovum\nrarely occurs in the uterus, but ordinarily in the Fallopian tube.\nAfter fecundation the ovum is pushed on through the Fallopian tube\ninto the uterus in from five to seven days, where it fastens to the\nwall and develops normally. Hyrtl described an ovum which appeared\nto reach the uterus in three days. If from some abnormal condition\nof the Fallopian tube the fecundated ovum is blocked and held in the\ntube, the embryo grows where the ovum stopped, and we have a case\nof Ectopic Gestation. In normal pregnancy in the uterus, the uterus\ngrows with the embryo, but a tube does not. In the latter condition,\nwhen the ovum is big enough it bursts the tube or slips out through\nthe ampulla, causing hemorrhage or other pathological symptoms.\n\nThere are certain rare abnormalities of the uterus through imperfect\nembryological development, and pregnancy in such a uterus may result\nin symptoms like those of ectopic gestation. Normally the uterus and\nvagina are formed by the fusion of the two M\u00fcllerian ducts. When\nthese ducts do not fuse perfectly, or when one develops partly, the\nvarious kinds of abnormal wombs and vaginas are the results. There\nmay be a double uterus with a single or double vagina, a uterus with\na complete or partial septum down the middle, a uterus with one\nhorn, a uterus with a developed horn and a rudimentary horn, and the\nrudimentary horn may be open or shut, and so on. In many of these\nconditions the ovum becomes blocked and rupture follows as in ectopic\ngestation.\n\nWhen the ectopic ovum begins to develop in the Fallopian tube the\nplacental villi erode the tubal wall and the blood-vessels. At length\nthe ovum slips out of the ampulla--the common result--or the tube\nbursts. The break may be traumatic in origin, from jarring or a like\naccident, or it may be spontaneous. If the rupture is through the\ntube there is hemorrhage into the pelvic cavity; if the ovum slips\nout of the ampulla the tubal abortion causes hemorrhage as in uterine\nabortion. In either case the blood with peritoneal fibrin forms a\nhematocele, and this, with the ovum, may be finally absorbed; or the\nwoman may bleed to death unless the hemorrhage is checked surgically;\nor the child may live for varying periods up to term. The tube rarely\nruptures into the fold of the broad ligament.\n\nThe fetus usually dies after rupture or tubal abortion, and if it\nhas not advanced beyond the eighth week it is absorbed. Sometimes\nit lives. When the rupture or abortion does not tear the placental\nsite the fetus may develop in the abdominal cavity. Between 1889\nand 1896 Haines[103] found 40 operations for ectopic gestation done\nafter the seventh month of pregnancy with 10 maternal deaths. Of the\nchildren, 27 survived the operation from a few moments to fifteen\nyears. Sittner, in 1903, compiled from the medical reports 142 cases\nof viable ectopic fetuses, and Essen found 25 additional cases. Since\nEssen's article more have been reported, about 173 to my knowledge,\nbut the number is considerably larger.\n\n  [103] Kelly's _Operative Gynaecology_. New York, 1898.\n\nHirst says an experienced obstetrical specialist sees from 12 to 24\ncases of ectopic pregnancy annually. K\u00fcstner himself operated on 105\ncases in five years. About 78 per cent. of all ectopic gestations\nresult in tubal abortion and 22 per cent. in rupture.\n\nMany specialists now are of the opinion that the diagnosis of ectopic\ngestation ordinarily is not difficult, but most physicians find it\nvery difficult. Before rupture of the tube or a hemorrhage diagnosis\nis hardly ever made by any one, and no pelvic condition gives rise\nto more diagnostic errors. When there is rupture or tubal abortion\nthe symptoms may lead the physician to mistake the condition for\nuterine abortion. In uterine abortion the onset of the symptoms is\nquiet, with gradually intensifying and regular pains, resembling\nlabor, in the lower abdomen. In ectopic pregnancy the symptoms of a\nrupture or tubal abortion arise quickly, with irregular and colicky\nor very violent pains, localized on one side. In uterine abortion the\nexternal hemorrhage is more or less profuse, with clots; in ectopic\ngestation the external hemorrhage is slight or absent; the shock\nin the latter case is out of proportion to the visible blood loss.\nParts of the ovum, or the presence of the whole ovum, as uterine,\nare found in ordinary abortion, but in the ectopic condition the\novum proper does not appear. An intrauterine angular pregnancy, or\npregnancy in a uterine horn, causing the upper corner of the womb to\nbulge sidewise, may be mistaken for ectopic gestation. Pregnancy in a\nretroflexed uterus, tumors of the adnexa, the twisted pedicle of an\novarian tumor, a burst pyosalpinx, an appendicitis in pregnancy, or\na combined intrauterine and ectopic gestation, also may confuse the\ndiagnosis. When there is a dangerous hemorrhage from rupture or tubal\nabortion the diagnosis is usually made without difficulty from the\ncollapse and other signs.\n\nThe diagnosis as to whether the fetus in the pelvis is dead or alive\nmay be made (1) from the absence or presence of symptoms of tubal\nrupture during the second and third months, or of mild symptoms\nindicating only slight bleeding; (2) from the continuation and\nprogress of the evidences of pregnancy, as nausea, mammary changes,\nfetal movements, or audibility of the fetal heart; (3) from the\npresence of a loud uterine blood souffle; (4) from the absence of\ntoxemia or suppuration; (5) from a growth of the uterus and a\nsoftening of the cervix; (6) from a gradual increase in the size of\nthe suspected ectopic fetal tumor. In making the diagnosis great\ncaution must be observed, as roughness in manipulation may start\nhemorrhage or rupture a thinned tube.\n\nThe diagnosis may be made: (1) that ectopic gestation exists without\nsymptoms of maternal hemorrhage, and the fetus is not viable; (2)\nthat the same maternal condition may be present, but the fetus is\nviable; (3) that there may be symptoms of slight bleeding, and the\nfetus is inviable; (4) that there may be symptoms of grave maternal\nhemorrhage at any stage of the gestation.\n\nThe ordinary medical doctrine in the text-books is that as soon as\na diagnosis of ectopic gestation is made laparotomy should be done\nand the sac with the ectopic fetus removed. If the fetus is alive\nand inviable this procedure will, of course, kill it. Only a few\nobstetricians of authority advise an expectant treatment. Schauta\nfound 75 recoveries and 166 maternal deaths in 241 cases treated\nexpectantly--a mortality of 69 per cent.\n\nIf there are no symptoms of maternal hemorrhage but the fetus is\nevidently dead, the fetus is to be removed. If it is evidently alive,\nor doubtfully alive, the treatment must be expectant. The woman is\nto be removed to a hospital and kept under constant watch, day and\nnight, with everything prepared for immediate operation. Any woman\nwhile bearing an ectopic fetus is in constant grave danger of death,\nbut the moralists hold that her danger is not so imminent before\nactual rupture as to justify the death of the fetus by precautionary\nremoval.\n\nIn 1886 the Archbishop of Cambrai proposed the following list of\nquestions to the Holy Office for decision:\n\n1. May a pregnant woman in danger of death from eclampsia or\nhemorrhage be prematurely delivered of a viable child?\n\n2. May a woman in the same condition be delivered in urgency by means\nwhich will kill the infant?\n\n3. May a woman _in articulo mortis_ be delivered of a viable child\nif the delivery will somewhat hasten her death?\n\n4. May the woman in question 1 be delivered of an inviable fetus?\n\n5. May the woman in question 3 be delivered of an inviable fetus?\n\n6. May a woman who is about to become blind, paralytic, or insane\nfrom her pregnancy be prematurely delivered of a viable child?\n\n7. May the woman in question 6 be delivered by means which will kill\nthe fetus?\n\n8. May the woman in question 6 be delivered of an inviable child?\n\n9. May the woman in question 6 be delivered of an inviable child,\nsupposing the child to be _in articulo mortis_?\n\n10. May an ectopic fetus be killed by operation, electricity, or\npoison, to avert possible danger of death from the mother?\n\n11. May a surgeon who has opened the abdomen for some condition not\nuterine incidentally remove a viable ectopic fetus?\n\n12. With conditions like those in question 11, except that the fetus\nis not viable, may the surgeon remove the inviable ectopic fetus?\n\nThree years later, August 19, 1889, the Holy Office answered these\nquestions comprehensively: \"In Catholic schools it may not be safely\ntaught that craniotomy is licit, as was decided May 28, 1884, or\nany other surgical operation which directly kills the fetus or the\npregnant mother.\" _Safely taught_ here is a somewhat technical\nexpression which has been interpreted by the Holy Office in another\nconnection as meaning that the act is illicit morally.\n\nThe Holy Office, May 4, 1898, again decreed: \"Necessitate cogente,\nlicitam esse laparotomiam ad extrahendos e sinu matris ectopicos\nconceptus, dummodo et foetus et matris vitae, quantum fieri potest,\nserio et opportune provideatur.\"[104] This decision was not clearly\nunderstood, and on March 5, 1902, the same congregation reported the\nfollowing question: \"Is it ever licit to remove from the maternal\npelvis an ectopic fetus which is still immature; that is, which has\nnot yet completed the sixth month after conception?\" The answer\nwas, \"No; according to the decree of May 4, 1898, which prescribes\nthat the life of the fetus and the mother must as far as possible\nbe carefully safeguarded. As to the time, according to the same\ndecree, the questioner will remember that no premature delivery is\npermissible unless it is effected at such a time and by those methods\nwhich in ordinary circumstances safeguard the life of the mother and\nfetus.\"[105]\n\n  [104] \"In a case of necessity, it is licit to do a laparotomy\n  for the removal of an ectopic gestation sac from the maternal\n  pelvis, provided the life of both fetus and mother be carefully\n  safeguarded.\"\n\n  [105] \"Negative, juxta decretum 4 Maii, 1898, vi cujus, foetus et\n  matris vitae, quantum fieri potest serio et opportune providendum\n  est: quod vero tempus, juxta idem decretum, orator meminerit,\n  nullam partus accelerationem licitam esse, nisi perficiatur\n  tempore et modis, quibus ex ordinarie contingentibus, matris ac\n  foetus vitae consulatur.\"\n\nIf the fetus is removed and so killed to avert a threatened danger\nto the maternal life, but not an actually operative destruction of\nher life, this removal or homicide is an evil means used to avert\nthe danger. There is no question of a double effect, that is, of two\neffects, one good and the other evil, coming with equal directness\nfrom the cause, which is the removal or killing of the fetus; but\nof a good effect, the averting of the danger to the mother, issuing\nfrom an evil cause, the removal and death of the fetus. A good effect\ndoes not justify the use of evil means; it is not permitted morally\n_directly_ to kill the fetus, as in this case, to save the mother\nfrom a _threatened_ grave danger.\n\nThe case is not like that of the woman who has an operable cervical\ncancer while she is bearing an inviable fetus. If the cancerous\nuterus is not removed the woman will surely die; if it is removed she\nhas a reasonable chance of cure; but if the inviable ectopic fetus\nis not removed it is by no means certain that the woman will die. In\nthe cancer the uterus is directly removed, the fetus is indirectly\nkilled; in the ectopic case the fetus is directly killed, and the\ndanger to the woman's life is removed as a direct effect of the\nkilling.\n\nAgain, the killing of the inviable ectopic fetus cannot be justified\nby maintaining that the fetus is an unjust aggressor against the life\nof the mother. An aggressor against life may be such formally or\nmaterially. A formally unjust aggressor consciously and voluntarily\nattacks the life of the victim unjustly. This perversion, or evil, in\nthe aggressor's consciously actuated will sets his own right to life\nin juridic inferiority to that of the victim's right to life, and the\nvictim may defend his own life, even unto the indirect death of the\naggressor in necessity.\n\nThe materially unjust aggressor attacks the victim's life unjustly,\nbut whether the aggressor is sane or insane, the attack is not\nvoluntary. When an insane aggressor appears to use his will, such\nuse lacks all moral quality because of the absence of intellect and\nreason; he wills improperly, as a brute is said to will. In either\ncase, nevertheless, there is active aggression directed against the\nvictim's life, which also sets the aggressor in juridic inferiority\nto the victim, and permits the victim to defend his own life to\nextremes. As great an authority as De Lugo holds that in such\ndefence, whether the aggressor is formally or only materially such,\nthe victim may directly kill, but direct killing is never necessary,\nas it is all a matter of intention.\n\nThe ectopic fetus cannot, of course, be a formal aggressor because it\ncannot exercise either intelligence or will. It is not a materially\nunjust aggressor, because the only action it is capable of is to\nincrease in size in obedience to the natural law of growth. It is\nnot trying in any manner to tear the maternal blood-vessels. It has\na right to its own life and a right to grow. Its growth may finally\nbring about a maternal hemorrhage, but just now it is not causing\nthat hemorrhage. An aggressor is such only while there is an actual\nattack going on here and now, directed against the victim's life. The\nfetus is necessarily passive always, never aggressive in any sense\nof the term, until the actual rupture occurs. If it may be deemed\nmaterially aggressive when the actual rupture is taking place, the\nquestion becomes irrelevant, because at that time the fetus may be\nremoved for other reasons altogether. If an insane man is in a room\nwith a loaded revolver which he may not use against me, but which he\nprobably will, I may not kill him in self-defence until he actually\nbegins the aggression. The opinion expressed here is the contrary of\nthe opinion I expressed, in 1906, in _Essays in Pastoral Medicine_.\n\nThe second condition proposed is that the ectopic gestation exists\nwithout symptoms of maternal hemorrhage, but the child is viable. In\nsuch a case it is probably better to remove the fetus at once, but\nonly a skilled abdominal surgeon should attempt the operation because\nit is likely to be difficult from adhesions. A viable ectopic fetus\nis usually deformed. Winckel found 50 per cent. of them deformed--the\nhead in 75 per cent., the pelvic end in 50 per cent., the arms in 40\nper cent. Compression, infraction, hydrocephalus, and meningocele are\ncommon. The longer the fetus is left in, the worse for the mother so\nfar as peritoneal adhesions and danger and difficulty in removing the\nfetus are concerned.\n\nThe third case supposed that the fetus is not viable but the symptoms\nof maternal hemorrhage are slight. The danger to the mother in\nwaiting is greater here than in case one, and the decision must be\nmade in keeping with evidences in the particular case. The surgeon\nwho assumes responsibility is obliged to remain ready for instant\noperation.\n\nWhere there are symptoms of grave hemorrhage in the mother at any\nstage of ectopic gestation the surgeon must operate at once, and\nligate the bleeding vessels to save the woman's life. The ligation\nwill shut off the blood supply to the fetus, and thus indirectly,\npermissively, the fetus must be unavoidably allowed to die. This is a\nclear case of double effect immediately issuing from the same cause,\nand the operation is morally licit. No matter how young the fetus is,\nthe surgeon or an assistant is to baptize it; if it is very young it\nmay be necessary to split the envelopes to get at the fetus.\n\n\n\n\nCHAPTER VII\n\nCESAREAN DELIVERY\n\n\nIn the cesarean delivery (_partus cesareus_, celiohysterotomy) the\ninfant is brought out through an opening made in the abdominal and\nuterine walls. The chief indications for this operation may be a\ncontracted maternal pelvis, an abnormally large fetal head or body,\ndeath of the pregnant mother before delivery, certain forms of\nrigidity of the cervix uteri, some cases of stenosis of the vagina,\nrelative vaginal narrowness, blocking tumors, or a ventrofixed\nuterus. Sometimes abruptio placentae, eclampsia, placenta praevia,\nand other accidents of pregnancy are taken as indications for\ncesarean delivery.\n\nAn abnormal bony pelvic girdle is the most frequent obstruction to\ndelivery of the fetus. The lower part of the pelvis, called the\npelvis minor or true pelvis, supports the muscles of the pelvic\nfloor, and gives shape and trend to the parturient canal. The inlet\nand outlet of the true pelvis are narrower than its middle portion\nand are called the superior and inferior straits. The inlet is\nsomewhat cordate in outline, and normally from front to back, at\nits so-called conjugata vera, it averages 11 centimetres (4-5/16\ninches) in depth; from side to side it measures 13 centimetres (5-1/8\ninches); obliquely from the right posteriorly to the left anteriorly\nit is 12-1/2 centimetres (nearly 5 inches), and the other oblique\nconjugate is 12 centimetres (4-3/4 inches) long. The transverse\ndiameter of the outlet, from right to left, is 11 centimetres; the\ndiameter from front to back, because the coccyx can be pushed back\nin labor, is from 9-1/2 (3-3/4 inches) to 12 cm. Normal fetal head\nmeasurements average from side to side at the widest part, 9-1/2 cm.\n(3-3/4 inches); from the root of the nose to the occiput, 11 cm.;\nfrom the chin to the occiput, 13 cm.; from the vertex to the neck\nbehind, 9-1/2 cm. The size of the fetal head is the most important\nfactor in delivery, so far as the child is concerned, because, as\na rule, when the head is delivered the compressible trunk follows\nreadily. Normally the child presents in delivery with the vertex of\nthe head first; other presentations are transitional, abnormal or\npathologic. In 48,499 cases Karl Braun found vertex presentations in\n95.9 per cent., and Schroeder in 250,000 cases found an average of 95\nper cent. The child's head is \"engaged\" when its largest diameter has\npassed the plane of the inlet.\n\nAn abnormal pelvis may be generally contracted, dwarfed, in all its\ndiameters; it may be flat or narrow from front to back; it may be\ncontracted from side to side; it may be generally contracted and flat\nat the same time; it may be obliquely contracted (N\u00e4geli's pelvis);\nor it may be crowded together irregularly. Rachitis, osteomalacia,\ncurvature of the spine, habit scoliosis, hip dislocation, and similar\npathologic states cause these distortions and contractions.\n\nContraction of the pelvis affects the mother and child in parturition\nin proportion to the degree of the narrowing. Besides this, the\nprognosis depends on the size of the child, its presentation,\nposition, and attitude, the strength of the pains, the skill and\nsurgical cleanliness of the operator, and the presence or absence of\ncomplications. Obstruction may bring about rupture of the uterus,\nsepticemia, exhaustion and shock, pressure narcosis, or tears of the\ncervix or vagina. If the child's head becomes impacted the vagina\nand vulva may become even gangrenous. Pressure may cause areas of\nnecrosis resulting in fistulas into the bladder, rectum, or between\nthe uterus and the vagina. When the contracture is sufficient to let\nthe fetus just engage, pressure may interfere with the placental\ncirculation and kill the child. Compression of the vagus nerve may\nslow the child's pulse and asphyxiate it through lack of oxygen in\nthe blood. The cord may prolapse. The pressure on the child's head\nmay cause fatal intracranial hemorrhage, or effect permanent injury\nto the brain.\n\nOften it is extremely difficult to find out the best plan for\ndelivering a woman who has a contracted pelvis. Where the conjugata\nvera is 9.5 cm. (3-5/8 inches) or above, Ludwig and Savor found that\n75 per cent. were delivered without instrumental help. At 9 cm.\n(3-1/2 inches), 58 per cent. so end; at 8 cm. (3-3/16 inches), 25\nper cent. Should the conjugata vera be less than 5-1/2 cm. (2-3/16\ninches) in a flat pelvis, or 6 cm. (2-3/8 inches) in a generally\ncontracted pelvis, this is an absolutely contracted pelvis according\nto the old standard, and the delivery must be by cesarean section,\nwhether the child is living or dead. The minimal requirements have\nbeen gradually extended. In 1901 Williams of Johns Hopkins University\nadvocated that the absolute indication for cesarean section be\nchanged to 7 cm. in the generally contracted pelvis, and to 7.5 cm.\nin the simple flat pelvis. His opinion was accepted by Webster,\nJewett, Edgar, and others. Now some obstetricians of authority\nextend the measurements to 8 cm. If the woman is seen before labor,\nor early in labor, cesarean delivery alone is done. When the uterus\nis infected it is usually necessary to remove it after taking away\nthe child, because an infected uterus left in place causes death by\nsepsis, as a rule.\n\nText-books on obstetrics have a series of rules, based on pelvic\nmeasurements, concerning the indications for cesarean or other\nmethods of delivery in cases of contracted pelvis, but the problems\nare not so simple and uniform as to be always accurately solved by\nthe data derived from measurements. One woman with a contracted\npelvis may require cesarean delivery; another woman with the same\nmeasurements may have a normal parturition because the child happens\nto be small or its skull compressible. The best pelvic measurement\nis made with the fetal head. A difficult decision as to whether a\ncesarean delivery is necessary or not comes up in the majority of\ncases in primiparae; in multiparae the physician has the experience\nfrom former births to guide him. In over 90 per cent. of primiparae\nthe fetal head normally is found engaged in the pelvis in the last\nweek of gestation, and can be felt by a vaginal examination. In\nmultiparae the head usually is not engaged until labor begins. If the\nfetal head does not engage in a primipara, this fact at once suggests\nan absolutely or relatively narrow pelvis. When labor has begun, if\nthe fetal head cannot be pushed into the true pelvis of a primipara,\nespecially after anesthesia, the necessity for cesarean delivery may\nbe clearly evident.\n\nIn the cases where there is doubt that the child can get through\nthe pelvis, but good reason to think that it can, many obstetrical\nexperts try the effect of labor for two hours or a little more,\nand if there is no real progress they deliver through laparotomy.\nThere is considerable objection now to version or the application of\nhigh forceps, but many skilful men prefer these methods at times.\nWhen version has been done and it fails there is no chance to save\nthe child's life. In the trial of labor, the expectant treatment,\nextraordinary watchfulness is required and a full knowledge of the\nspecial procedure that may be necessary.\n\nIn minor degrees of pelvic contraction the obstetrical practice is\neither to induce premature labor at the thirty-second week, or to\ndeliver by a cesarean operation, or to delay and try labor. In the\nlast event there may be one of the following issues: spontaneous\ndelivery, version and delivery, extraction by high forceps, cesarean\ndelivery, symphyseotomy, hebosteotomy, or craniotomy. Craniotomy on\na living child is never to be considered under any circumstances.\nSymphyseotomy is a cutting of the maternal pelvic girdle through the\nsymphysis pubis, the rigid joint at the front middle part of the\npelvis, and thus letting the bony girdle dilate. Hebosteotomy or\npubiotomy is a sawing through the pelvis near that joint to get the\ndilatation. Symphyseotomy has been replaced by hebosteotomy because\nthe maternal mortality and morbidity are somewhat lessened by the\nlatter method. Schl\u00e4fli in 1908 reported 700 hebosteotomies with a\nmaternal mortality of 4.96 per cent. and a fetal of 9.18 per cent.\nOther operators have a better average; still others a worse. This\noperation is done very seldom of late except in a case where the\nfetal head is caught low in the pelvis, or there is a chin-posterior\nor brow or face presentation, and the cesarean operation would not\ndeliver the child.\n\nThe varieties of the cesarean delivery as practised at present\nare the classic cesarean, called also celiohysterotomy, the Porro\ncesarean, or celiohysterectomy, where the uterus is removed after\nthe extraction of the child, and the two sections in the cervical\nend of the uterus, viz., the extraperitoneal cesarean and the\ntransperitoneal cervical cesarean. Before the days of antiseptic\nsurgery cesarean delivery was practically always fatal to the mother.\nTarnier could not find one successful outcome for the mother in Paris\nduring the nineteenth century up to his own time, and Spaeth said\nthe same for Vienna up to 1877. In 1877 Porro of Pavia advised the\nsupravaginal amputation of the uterus after the child was delivered\nto avoid hemorrhage and peritoneal infection. This operation replaced\nthe classic cesarean until 1882, when S\u00e4nger invented a suture\nwhich would keep the uterine incision shut, and applied antisepsis.\nS\u00e4nger's operation has been improved so much that cesarean delivery,\nwhen performed by skilled obstetricians, has an extremely low\nmortality in cases which have not been infected. Routh, in 1910,\ncollected the statistics of Great Britain, comprising 1282 cases,\nwhich may be taken as a standard for all civilized countries, and he\nfound a steady decrease in the mortality until now it is near 2 per\ncent. in uninfected cases. The dangers in the operation increase with\nevery hour the woman is in labor, but even then the general mortality\nis now down to about 8.1 per cent. This, it must be remembered, is\nthe rate when competent men operate.\n\nWhen the ordinary practitioner in small cities, towns, and country\nplaces operates the mortality is very high. Newell[106] said that\nin four cities of from 25,000 to 40,000 inhabitants within forty\nmiles of Boston he collected the following data: in A no patient on\nwhom cesarean section had been done is known to have recovered--a\nmortality of 100 per cent. In B the mortality is from 60 to 70 per\ncent. In C the operation is invariably fatal when done by the local\nsurgeons. In D the fatality is from 10 to 20 per cent. in average\ncases, but since cesarean section has become popular as a method of\ntreatment for eclampsia the mortality is over 50 per cent.\n\n  [106] _Jour. Amer. Med. Assoc._, February 24, 1917.\n\nIn spite of perfect technic by the best obstetricians, the operation\nhas a high morbidity: fever, peritonitis, pneumonia, dilatation of\nthe stomach, and other bad results are common.\n\nBefore antiseptic surgery began, opening the abdominal cavity was\nalmost always fatal, and some obstetricians tried to get the child\nout of the uterus in cases where cesarean delivery is indicated\nby going in above the pelvis without opening the peritoneum. The\nuterus was incised near its cervical end. This method, called\nextraperitoneal cesarean delivery, has been restored for use in cases\nwhere there is some infection of the uterus and the operator wishes\nto save the child without removing the womb. The technic is more\ndifficult than in the classic cesarean, and the operation was not\nkindly received, but of late some men are having so much success with\nit that it is reviving, and rightly so. Baisch[107] says that the\nfirst eleven women he delivered by extraperitoneal cesarean section\nrecovered more readily than they would from an ordinary laparotomy.\nIn nineteen cases of transperitoneal but cervical section he had\nno trouble, and six of these were infected cases. The technic of\nthis low incision protects the peritoneal cavity better than the\nclassic incision, apparently. Two of the nineteen women were in\nslight fever and the uterine fluids were fetid. Two primiparae forty\nyears of age had been in labor seventy hours. Eight of the women\nwere able to leave the clinic on the tenth day. Only one child was\nlost, and that was a delayed case. Hofmeier[108] compiled 194 cases\nof transperitoneal cervical cesarean section with three deaths.\nK\u00fcstner did 110 extraperitoneal cesarean sections with no mortality.\nThis makes 304 cases of cesarean cervical section, not the classic\noperation, with only three deaths, less than 1 per cent. mortality;\nand fully 50 per cent. of these cases were not surgically clean. From\nthese statistics it is evident that the cervical operation in the\nhands of competent surgeons should be the operation of choice.\n\n  [107] _Zentralblatt f. Gyn\u00e4kologie._ Leipsic, October 30, 1915.\n\n  [108] _M\u00fcnchener medizinische Wochenschrift_, January 4, 1916.\n\nThe ordinary practitioner, however, is utterly unfitted to do a\ncesarean section of any kind. In large cities it is easy to find\na trained surgeon to do the operation, but in small towns and in\ncountry places there is seldom any one available. The physician\nwho chooses to practise medicine in an isolated place knows that\nhe will almost certainly be called upon to do a cesarean section\nsome day, and he should not take up the responsibility of the\ngeneral practitioner in such a place until he is competent to do\nthat operation when life depends upon him. This is as things should\nbe; but unfortunately a man who is trained well enough to do major\nsurgery will not live in a small town if he can get into a large\ncity. The physician in any case should be able at least to make the\ndiagnosis in time, before labor sets in, and have the woman sent to\nthe nearest city, if possible. Dr. Bull[109] reported that he had\ntraveled seventy-five miles to see a woman who was having severe\nhemorrhages at term. He found her in a log cabin, with a centrally\nimplanted placenta (_i.e._, right across the opening of the cervix\nuteri), and she had had three hemorrhages before his arrival. He\nnarcotized her, took her in a train to a hospital, delivered her by\ncesarean section, and saved her and the child. If he had delivered\nher by version in the log cabin, he would almost certainly have lost\nboth the mother and the child.\n\n  [109] _Jour. Amer. Med. Assoc._, September 30, 1916.\n\nThe question of removing the uterus comes up when the uterus is\ninfected, or as a method of sterilizing the woman to avoid the danger\nof a subsequent gestation. Whenever a uterus is gravely infected and\na cesarean delivery is finally necessary, the infection is commonly\ndue to ignorance or carelessness, and the physician or midwife is\nguilty. There should be no such business as that of the midwife who\nactually delivers the patient. The state should provide physicians\nfor the poor. Even the midwife who calls herself \"a practical nurse,\"\nbut who is not a licensed trained nurse, is commonly a public danger,\nalthough some so-called practical nurses are better than the ordinary\ntrained nurses.\n\nSuppose, however, that the uterus is infected unavoidably. If this\ninfection has been done by a competent obstetrician working in a\nhospital with sterile instruments, it may be safe to deliver the\nwoman by an extraperitoneal or cervical trans-peritoneal cesarean\nsection. If the practitioner has tried to deliver the woman at her\nhome with forceps and has failed, especially if repeated attempts\nhave been made by the physician and an assistant or consultant,\nthe uterus should be amputated. It will not do to deliver by a low\ncesarean and await developments, because if the infection is serious\nno subsequent removal of the uterus will save the woman's life. The\ngrave mutilation of removing the uterus is, of course, licit, as it\nis the only means of saving the woman's life. Some moralists hold\nthat a woman from whom the uterus has been removed is impotent, but\nthis question has never been decided authoritatively, as we shall\nshow in the chapter on Vasectomy; and until it has been so decided\nthe woman must be given the benefit of the doubt.\n\nThe question of removing the uterus solely to prevent the danger of\nsubsequent deliveries differs from the condition just considered.\nIf the woman has had a cesarean delivery for an absolutely narrow\npelvis, her subsequent deliveries must be by the same method. After a\ncesarean section there is more or less danger of rupture at the scar\nin other labors. Some think the danger is greater if the placenta\nbecomes implanted on the scar; others think this implantation does\nnot weaken a good scar. If the convalescence after the cesarean\nsection already done has been abnormal, the prognosis for rupture\nis not good. Where there has been an abnormal convalescence, each\nnew pregnancy must be watched closely, and often an early subsequent\ncesarean is indicated to prevent rupture. No matter how well the\nsection has been done, latent gonorrhea may prevent perfect healing\nof the wound. Twins, hydramnios, and overtime gestation are other\ncauses of rupture. The tendency with obstetricians in the future\nwill probably be to do the section toward the cervical end of the\nuterus; and as the uterus is thinnest there, it might be thought\nthat it will be more likely to break, but Spalding[110] found the\ncontrary true--the rupturing was usually in the thick part of the\nuterus. Version, high forceps, uterine tampons, hydrostatic bags,\nand pituitary extract should be avoided where an old cesarean scar\nexists, but Vogt and Kroback have done version a few times without\nrupture. Vogt had one patient with a true conjugate of 6-3/4 cm.\n(2-8/16 inches) to 7 cm. (2-3/4 inches). She was delivered in the\nfirst three labors by craniotomy; in the fourth by version; in the\nfifth and sixth by cesarean section; in the seventh she had twins\none of which was born spontaneously; in the eighth by version and\nperforation of the after-coming head; in the ninth she refused\noperation and was delivered spontaneously. Skilful operators have the\nfewest ruptures after cesarean delivery. Olshausen had one in 120\ncases, Leopold none in 232 cases, Schauta none in 177 cases, K\u00fcstner\nnone in 100 cases. Olshausen, in a series of 29 cases, operated on\ntwo patients twice and upon three patients three times. As early as\n1875, Nancrede of Philadelphia had operated the sixth time on the\nsame woman. In such cases the uterus is commonly so broadly attached\nby adhesions to the belly-wall that it is opened without getting into\nthe peritoneal cavity. In 150 cases of repeated section collected by\nPolak in 1909 the mortality was only 5 per cent.\n\n  [110] _Jour. Amer. Med. Assoc._, December 1, 1917.\n\nA woman may not be sterilized by having the uterus removed, by\nfallectomy, or otherwise, solely to obviate danger or morbidity from\nsubsequent pregnancies and cesarean deliveries. Such a sterilization\nwould be a grave mutilation without a present excusing danger, and\nit would render the primary end of marriage always impossible. Such\nsterilization of a woman is in contravention to the decretal of\nGregory[111] as given in the chapter on Vasectomy. It is also against\nthe bull _Effraenatam_ of Sixtus V., who extended all penalties\nprescribed for abortionists to those who give women drugs which cause\nsterility, and to those who purposely prevent the development of the\nfetus or in any manner abet the deed; and the penalties are to be\napplied to the women themselves who willingly use these means. These\npenalties are enumerated in the chapter on Abortion. The Congregation\nof the Holy Office, May 22, 1895, answered negatively the following\nquestion: \"Si sia lecita la practica sia attiva sia passiva di un\nprocedimento il quale si propone intenzionalmente come fine espresso\nla sterilizatione della donne?\"[112]\n\n  [111] _Corpus Juris_, lib. v, tit. xii, c. 5.\n\n  [112] Is any active or passive procedure licit which is\n  undertaken with the express end of sterilizing a woman?\n\nThe reason for these laws is that any act which deprives one of the\npower to generate, and which prevents conception and makes the semen\nfail of its end, is against the chief intrinsic end of marriage and\nany benefit that arises therefrom, which is the good of offspring.\nThe act is also against the intrinsic end of the semen, which is to\ngenerate; and since the semen cannot possibly effect its end, the\nconjugal act degenerates into an equivalent of onanism. This act of\nsterilization, done not to save the whole body from immediate danger,\nis intrinsically evil, and therefore unjustifiable.\n\nTo say that marriage is also a licit remedy of concupiscence is\nno excuse. Marriage is such only in a secondary sense, and this\nsecondary end is necessarily subordinate to the primary end, and\ncoexistent with that primary end, which is the generation of\nchildren. Even when a surgeon is doing a Porro operation, his main\nintention may not be to sterilize the woman. He must directly intend\nto save her life by removing the infected uterus, and reluctantly\npermit the sterilization as an evil part of the double effect coming\nfrom the causal amputation.\n\n\n\n\nCHAPTER VIII\n\nPLACENTA PRAEVIA AND ABRUPTIO PLACENTAE\n\n\nCesarean delivery is used frequently of late in placenta praevia.\nIt may be necessary also in abruptio placentae, gunshot wounds of\nthe abdomen during pregnancy, sometimes in appendicitis complicating\ngestation, rarely in prolapse of the cord to save the child, and\nwhen twins become interlocked in delivery. Placenta praevia is\na development of the placenta in that part of the uterus which\ndilates at the end of gestation or during delivery. This dilatation,\nwith the mechanical pressure of the child, detaches the placenta\nenough to cause a hemorrhage which may be fatal to the woman if not\nchecked. The hemorrhages begin sometimes as early as the sixth month\nof gestation, but most frequently in the eighth month. Premature\nlabor is a common effect. The position of the placenta may cause\nmalposition of the fetus, prolapse of the cord, weak pains, air\nembolism into the blood, rupture of the uterus, sepsis, profound\nanemia, and other evils. The child may be premature, puny, have\ncollapsed lungs, hemorrhages, and it is very likely to be killed in\ndelivery. The mortality of the women varies, but it averages about 7\nper cent; that of the children averages 61 per cent.\n\nThe tendency with obstetricians is to deliver the child as soon as\nthe diagnosis has been made. When the bleeding is slight, and the\nchild is viable, one may delay delivery provided the woman will\nremain in bed in a good maternity hospital without moving. At home\nthe woman may \"flood\" and bleed to death before a physician can\nreach her. If the woman refuses to go to a hospital, and to permit\nthe induction of labor, any physician who has regard for his own\nreputation will drop the case and leave the woman to her own devices.\n\nThere are various methods of treatment, and much depends on the\nposition of the abnormally placed placenta. The treatments all\nconsist in stopping the hemorrhage for the instant, emptying the\nuterus, insuring permanent hemostasis, and meeting the anemia. The\nBraxton-Hicks version is one method. The child is quickly turned so\nthat the head is upward in the uterus, and a leg is pulled down to\nplug the cervix uteri until there is enough dilatation to extract the\nchild. Very many children are lost by this method. When the placenta\npraevia is marginal to the cervix or lateral in the uterus the child\nhas a better chance when a colpeurynter, or inflatable rubber bag, is\ninserted in the cervix as a plug. Much skill and discrimination is\nrequired in the management of this bag until the child is delivered.\nThe obstetrician may be obliged to sit by the bed and hold on to\nthe bag for from three to twelve hours. Hasty extraction through a\npoorly dilated cervix is a very dangerous process, as a tear cannot\nbe repaired quickly enough, as a rule, to check the hemorrhage, which\nwill be fatal. When version has been done haste may compress the head\nin the tight cervix and asphyxiate the child.\n\nWhen the child is viable a cesarean section is by far the best method\nfor the child, as it lowers the fetal mortality from 61 to about\n5 per cent. The mother, too, has a better chance by the cesarean\nsection, provided it is done by a competent man, early in labor\nbefore infection has set in, and in a hospital.\n\nIf the child is not viable the hemorrhage must be stopped to save the\nwoman's life. As a rule, the hemorrhages are not dangerous before the\nseventh month. In the 128 deaths of M\u00fcller's statistics there was not\none before the seventh month of gestation. Hirst, however, says he\nhas been obliged to empty the uterus at the fifth month for placenta\npraevia. The woman must be kept in bed, the foot of the bed elevated,\nsedatives used, and so on, as in threatened abortion, and the vagina\ntamponed securely with cotton. If it is evident that the fetus is\ndead, it must be extracted as in the case of a viable fetus. If it is\nprobable that the fetus is alive, it is to be treated as in a case\nof inevitable abortion as described in the chapter on Abortion.\nThe tamponing of the vagina to stop the hemorrhage will cause the\nabortion of the fetus indirectly. This is another double-effect case,\nand the tamponing is morally permissible provided the intention is\ncorrect.\n\nAbruptio placentae is a tearing loose of a placenta which is situated\nin the normal position, not abnormally as in placenta praevia. The\ncause may be a disease of the placenta or decidua; for example,\nsyphilis, chronic metritis, traumatism from a blow or fall, jumping\nfrom a carriage-step, and so on. Nephritis is often found where there\nis abruptio placentae. In labor the placenta may be torn loose by a\nversion, by the delivery of the first of a pair of twins, or because\nthe cord is too short.\n\nThere is always profuse hemorrhage, which is usually concealed at\nfirst, but finally external. It is possible at times for a woman\nto bleed to death into her own uterus, when it is distensible. The\nmortality is about 50 per cent. for the women, and where there is\nconcealed hemorrhage about 95 per cent. of the children are lost. A\ndifferential diagnosis is to be made to exclude placenta praevia,\nrupture of the uterus, extrauterine pregnancy, rupture of an\nappendical abscess, gall-stone colic, or intra\u00e4bdominal injury.\n\nIf the child is viable it must be delivered as quickly as possible.\nIf it is dead and the head is developed, craniotomy should be done to\nhasten extraction. When the abruptio takes place before the seventh\nmonth of gestation the fetus will die in about ten minutes, whether\nin the uterus or outside it; no matter what method might be adopted\nto empty the uterus, the child would be dead before delivery. The\ndiagnosis would have to be made and instruments prepared, and this\nwould take up more than the ten minutes of life left to the fetus. It\nis necessary to get the fetus out to stop the bleeding of the open\nsinuses by contraction of the uterus.\n\nThe removal of the fetus here is not like an artificial abortion.\nIn abortion the abortionist separates the placenta from the uterine\nsinuses and so kills the fetus; the removal from the uterus is\nsecondary to that separation which kills. The common notion of\nmoralists that death is caused in abortion by taking the child out\nof the uterus is inexact--tearing loose the placenta is the real\ncause. In a removal of the fetus after an abruptio placentae the\ndeath of the fetus is not caused by the physician at all, but by the\nforce that effected the abruptio. As the child will be dead before\nsufficient dilatation of the cervix to deliver it can be attained,\nthere is no objection to beginning the delivery as soon as the\ndiagnosis is clear.\n\n\n\n\nCHAPTER IX\n\nABDOMINAL TUMORS IN PREGNANCY\n\n\nTumors in or near the uterus may be obstacles to delivery or they may\nthrough malignancy endanger the woman's life. The commonest tumors\ncomplicating pregnancy are fibroids, cancers, and ovarian tumors,\nespecially cysts and dermoids, but tumors of other kinds are not\nfrequently met. Schauta, in 111,112 pregnant women, found fibroids\nin 86, one in 1292 cases; Pinard, in 13,915, found 84, one in 165\ncases; Pozzi, in 12,050, had 83, one in 133 cases; in St. Petersburg,\nin 13,076 deliveries, there were only 4, one in 3269 cases; and in\nthe Charit\u00e9 in Berlin, 6 in 19,052 births, one in 3175 cases. The\novarian cyst in pregnancy is rarer than the fibroid--5 in 17,832\nbirths, one in 3566 cases, in the Berlin Frauenklinik. Cancer of the\ncervix also seldom appears--once in about 2000 cases. Other very rare\nconditions, related to these, are polyps of the cervix, enlarged and\nprolapsed kidneys, extrauterine pregnancy combined with intrauterine,\nechinococcus cysts, parametric abscesses, cancers of the rectum,\nrectal strictures, tumors of the bladder, stones in the bladder,\ntumors of the pelvic bones or cartilages, and tumors of the vagina or\nvulva.\n\nFibroids, called also fibromyomata, fibromata, and myomata, in the\nuterine muscle or adnexa commonly enlarge during pregnancy, and if\nthey are big enough and low in the pelvis may block the parturient\ncanal. These tumors may suppurate, grow gangrenous, or take on red\ndegeneration; they may cause abortion, peritoneal adhesions, pain,\nor hemorrhage; simulate threatened abortion; bring on retroflexion\nof the uterus, placenta praevia, abnormal presentations, sometimes\nweak pains or pains so strong as to rupture the uterus, and they may\ncheck contraction after delivery so as to start hemorrhage. They may\nso kink the uterus as to incarcerate the placenta and cause sepsis.\nThe percentage of degeneration in fibroids taken generally is 22,\naccording to William Mayo.[113]\n\n  [113] _Jour. Amer. Med. Assoc._, March 24, 1917.\n\nMyomata often obscure the diagnosis in pregnancy. The tumor may\nbe mistaken for a twin child, or vice versa. A large symmetrical\ninterstitial myoma may be mistaken for pregnancy, or vice versa.\nSometimes, even after the belly has been opened, it is difficult to\nbe sure whether the condition is pregnancy or a tumor. As eminent a\nsurgeon as Deaver says this diagnosis cannot always be made by any\none no matter what his experience.\n\nWe cannot give a general mortality average for myomata in pregnancy\nbecause only bad cases are reported, but in bad cases the mortality\nis very high--50 per cent. for the mother and about 60 per cent. for\nthe children, with almost 30 per cent. of abortions. The majority of\nwomen who have myomata go on to delivery without trouble. In some\nthere is much pain or hemorrhage, and these conditions may finally\noblige the obstetrician to operate, but the operation should be\ndeferred as long as possible. Where there are signs of necrosis of\nthe tumor, operation is necessary at once to prevent sepsis. Removal\nof a myoma during pregnancy does not always cause abortion. The\nstatistics are that about 83 per cent. of those operated upon are\nremoved without abortion. In the Mayo Clinic[114] fourteen cases of\ndegenerating fibroids in pregnant wombs were removed and the majority\nwent on to term. The removal is always a very bloody operation, and\nit requires great surgical skill. Where enucleation of the tumor\nalone was intended it may finally become necessary to amputate the\nuterus to stop hemorrhage.\n\n  [114] _Ibid._\n\nWhen the case has gone on to labor at term the diagnosis as to\nposition and size of the tumor is to be made, and what the effects\nwill be as to blocking the canal or crushing the tumor so as to\nbring on sloughing. If a tumor blocking the canal cannot be pushed\nup out of the way of the child, a cesarean section should be done\nimmediately. In such an outcome as section the experience of the\noperator must decide whether the tumor is to be removed then or at\na more favorable opportunity. It may be necessary to do cesarean\nsection to liberate an incarcerated placenta.\n\nSometimes the fetus is so involved with a gangrenous myoma that\nenucleation of the tumor will kill or hasten the death of the fetus.\nWhen, in such a complication, it is evident that the life of the\nwoman depends on the immediate removal of the tumor, yet a second but\nevil effect follows from the operation, namely, the unavoidable death\nof the fetus, the removal is morally licit provided the operator has\nthe proper intention. The death of the child as an effect in this\ncase is only indirectly voluntary from the physical point of view,\nand only permissively voluntary from the moral aspect.[115]\n\n  [115] Cf. Ferreres, _Nouvelle Revue Th\u00e9ologique_, September\n  and October, 1912, and the appendix of his book _De Vasectomia\n  Duplici_, Madrid, 1913.\n\nOvarian tumors in pregnancy are, as has been said, rarer than\nmyomata. Such tumors are mostly cysts and dermoids. In 862 cases\ncollected by MacKerron, 68 per cent. were cysts, 23 per cent.\ndermoids, 5 per cent. malignant tumors, and a few were myomata. Cysts\nand dermoids do not, like the myomata, grow bigger during pregnancy,\nbut they may hinder delivery or grow gangrenous and septic. When\ntreated early the mortality in pregnancy is from 2.1 to 5.9 per cent\nfor the women, but delay gives a maternal mortality of from 31 to 39\nper cent. The fetal mortality in Heiberg's statistics of 271 cases\nwas 66 per cent.\n\nMost obstetricians advise the removal of an ovarian tumor in\npregnancy as soon as diagnosed, provided it is of a size to cause\ndifficulty in parturition, but such a removal causes abortion in\nover 20 per cent. of the cases. The expectant treatment causes\nabortion in about 17 per cent. If the child is viable, Fehling,\nMartin, Norris, and De Lee are in favor of the expectant treatment.\nLate operators leave weak scars at labor. When there are symptoms\nof torsion of the pedicle of the tumor, infection, incarceration\nin the pelvis, involvement of the uterine broad ligament, or\noverdistention of the belly, the tumor must be removed immediately.\nWhether vaginal puncture or laparotomy is the better method is to be\ndecided particularly. Dermoid cysts are likely to bring on sepsis\nif they are broken in enucleation, and the diagnosis and operation\nmust be carefully made. When it is necessary to save the life of the\nwoman to remove an ovarian tumor, the risk of abortion may be taken\npermissively.\n\nCancers of the cervix uteri are always malignant and cause death if\nthey are not removed before they have gone on to metastasis. As this\ntumor commonly appears after the child-bearing age, it is rare in\npregnancy; the ordinary ratio is one in 2000 deliveries, but De Lee\nsaw only one in Chicago in 16,000 consecutive labors. Abortion occurs\nin from 30 to 40 per cent. of the cases. Spontaneous rupture of the\nuterus may happen, and placenta praevia is frequent relatively.\nPregnancy hastens the growth and spread of cancer very much. Eight\nper cent. of the women die undelivered, and 43 per cent. die during\nlabor or immediately afterward. Of all uterine cancers, 80 per cent.\nare cervical.\n\nThe diagnosis should be as certain as possible. Rarely nodules which\nare not cancerous appear in the cervix during pregnancy, and these\nare to be examined microscopically. Snipping out of a piece of the\nnodule for examination does not cause abortion. Vaughan of Michigan\nUniversity, who is a skilful and careful observer, said[116] that\nin an investigation of 200 cases of cancer, upon which more than\n30,000 differential blood-counts were made, he discovered a method\nof diagnosing the operability of a cancer as follows: He makes a\nblood-count and then injects intraperitoneally one c.c. of placental\nresidue. The next day he begins a series of blood-counts, and if the\nnumber of polymorphonuclear cells _decreases_ the case is operable,\nno metastasis has occurred; if there is no change in the number\nof the polymorphonuclears, or an _increase_ with a corresponding\ndecrease of the large mononuclears, the case is inoperable,\nmetastasis has begun.\n\n  [116] _Jour. Amer. Med. Assoc._, December 8, 1917.\n\nIn cancer of the cervix operability does not mean curability always.\nInoperability signifies that the woman has no chance at all for life\nand that it is useless to do anything; operability means that she has\none chance in four and that it is worth while taking the chance. The\nfollowing conditions may be met:\n\n1. The case may be operable and the child inviable.\n\n2. The case may be operable and the child viable.\n\n3. The case may be inoperable and the child inviable.\n\n4. The case may be inoperable and the child viable.\n\nIn the first case the supposition is that the case is operable but\nthe child inviable. To save the woman the uterus, with its adnexa,\nmust be removed, and this, of course, kills the fetus. The case\ndiffers from the enucleation of a gangrenous myoma which involves\nthe death of an inviable fetus. In the myoma case the woman has\npractically every chance for her life through operation; in this\ncancer case the woman has only one chance in four, as 75 per cent. of\nsuch operations fail through recurrence of the cancer.\n\nThe child has about one chance in two of going on to viability, owing\nto the tendency to abortion, if no operation is done; but the mother\nloses her chance for life if the operation is not done at once, as\nthe cancer will spread beyond cure. Zweifel has seen such a growth\nextend a finger's breadth in one week. The one chance in four in\nimmediate operation gives the mother a solid ground for hope, and the\nprobability is sufficient, in my opinion, to permit the operation\nwith a permissive loss of the fetus.\n\nIn the second case the cancer is operable and the child is viable.\nThe child should at once be delivered by cesarean section, and the\nuterus with its adnexa removed.\n\nThe third case is that of an inoperable cancer and an inviable child.\nThere the operation should be deferred, if possible, until the child\nbecomes viable.\n\nThe fourth case supposes the cancer is inoperable but the child\nviable. In the interest of the child, immediate cesarean section is\nthe best thing to do; it is much better than waiting until term. At\nterm this operation will have to be done anyhow, and the earlier\nit is done, the better the woman can stand the strain. There is a\nrisk that she will die from the first operation done to deliver\nthe viable child, but she may licitly take this risk, as she might\nlicitly run into a burning house to save a child, even if not her\nown. She may also licitly refuse the first operation.\n\n\n\n\nCHAPTER X\n\nAPPENDICITIS IN PREGNANCY\n\n\nPrimary appendicitis in pregnancy is very rare; recurrent\nappendicitis is not so rare. When appendicitis goes on to suppuration\nand perforative peritonitis the condition is worse in pregnant women\nthan in the non-pregnant. In pregnancy protective adhesions, walling\noff, are less likely to occur; the inflammation is more intense owing\nto increased vascularity; thrombosis and phlebitis are more frequent;\ndrainage may be obstructed and the burrowing of pus widespread;\ntympany, too, causes dyspnoea earlier. About 75 per cent. of the\ncases occur after the third month, and the earlier the appendicitis\nappears, the better the prognosis. During labor the contracting\nuterus sometimes tears open an adhesive appendix, or ruptures a pus\nsac and starts a general peritonitis. This condition may be mistaken\nfor a general sepsis which is puerperal. Acute appendicitis is\nlikely to be confused with an inflammation of a Fallopian tube. When\nthe appendicitis is perforative abortion, infection of the uterine\ncontents and death of the child happen in most cases. Labor is very\npainful when appendicitis is present, and the uterine contractions\nare often weak. After delivery many forms of infection of the uterus\nand its adnexa are possible.\n\nOperation is much less difficult in the first half of gestation\nthan in the latter months. At the beginning of gestation the\noperation does not, as a rule, cause abortion. Late in pregnancy\nappendicitis rapidly goes on to suppuration and perforation, with\na high mortality. Hirst says that where there is reason to suspect\nsuppuration a median incision should be made and the pelvic cavity\nexamined for possible areas of infection. John Deaver says, \"Always\ncut down on the sore spot and do not handle the uterus.\" An infected\nuterus after cesarean section complicated with appendicitis has to be\namputated.\n\nThe diagnosis between appendicitis, ectopic gestation, twisted\novarian tumors, ureteritis, and ureteral stone is to be made. In a\ndiscussion of a paper by Finley on Appendicitis in Pregnancy,[117]\nDr. John Murphy of Chicago, a great authority, advised operation\nas soon as the diagnosis is made, and he was of the opinion that\nthis diagnosis is not difficult to make in pregnancy. Deaver said a\ndiagnosis of catarrhal appendicitis is not seldom very difficult to\nmake. This form is very rare in pregnancy. Deaver is not of the same\nopinion as Murphy as to operating as soon as the diagnosis is made in\nall cases. Where there is a general peritonitis, operation commonly\nonly makes matters worse by spreading infection. The mortality of\ncases of appendicitis in pregnancy left without operation is as high\nas 77 per cent.; where the cases are operated upon within forty-eight\nhours after diagnosis the mortality is 6.7 per cent. and it would be\nbetter if the operation were done within twenty-four hours. Finley\nsays that in the fifteen cases reviewed in his paper the operation\ndid not cause abortion. Deaver tells us the muscular rigidity in\nthe right groin characteristic of appendicitis is often missing in\npregnancy, and that sometimes the pain is on the left side of the\nbelly.\n\n  [117] _Jour. Amer. Med. Assoc._, December 24, 1912.\n\n\n\n\nCHAPTER XI\n\nPUERPERAL INSANITY AND STERILIZATION\n\n\nFrom 8 to 10 per cent. of all insanity in women develops during the\npuerperium--the incidence is about one case to 400 births. Puerperal\ninsanity in nearly 70 per cent. of the cases begins within the first\ntwo weeks after parturition. Next in frequency of occurrence is\nthe period of lactation, especially in multiparae. Insanity during\npregnancy itself is relatively rare, and it begins usually after the\nfourth month.\n\nAs in other forms of insanity, hereditary predisposition is found\nin from 25 to 30 per cent. of the cases. Alcoholism, sepsis, and\nneuroses like hysteria, chorea, and epilepsy, are the predisposing\nelements. The most common immediate exciting cause during pregnancy\nis toxemia from faulty metabolism and excretion. Other frequent\ndirect excitants are mental worry from poverty, desertion, seduction,\nand the like troubles.\n\nProlongation of the lactation period beyond the usual time for\nweaning, from the ninth to the twelfth month, is common among\nignorant and lazy women. Some women prolong lactation in the\nerroneous notion that it prevents renewed impregnation. Such\nlactation is injurious to the child, as a rule. Ploss says\nhyperlactation is frequent in Spain, and that some Japanese,\nChinese, and Armenian women may nurse their children for years, but\nthis practice is undoubtedly injurious, especially among European\nraces. The women get tabes lactea with emaciation, asthenia, anemia,\nbackache, pain in the breasts, neurasthenia, cramps, and blindness.\nThe uterus atrophies in some cases and may be permanently injured.\nInsanity is not unusual.\n\nThe forms of mental disturbance commonest in puerperal insanity are\nmania with or without delirium, melancholia, and dementia. Dementia\nis the final stage in the cases that become chronic. Mania is the\nprevailing type in insanity after labor, and melancholia in insanity\nduring gestation. The melancholy of insanity during gestation is\noften suicidal, and must always be watched. Religious and erotic\nsymptoms are also observed.\n\nThe onset may be very sudden during labor. An outbreak after labor\nmay be suicidal or homicidal. Maniacal puerperal women are dangerous.\nThey have delusions and hallucinations, with very rapid and incessant\nchanges that range from obscenity to prayer. Melancholy in the\npuerperium is likely to be suicidal.\n\nAbout 75 per cent. of puerperal insanity cases recover within five or\nsix months. From 2 to 10 per cent. die from sepsis, exhaustion, or\nintercurrent diseases; the remainder become permanently insane. The\nnearer the delivery the insanity appears, the better the prognosis.\nMenzies found that of cases which began during gestation 56.7 per\ncent. remained insane; of those that began during the puerperium 25\nper cent. did not recover; of those that began during lactation 43.5\nper cent. remained insane. Melancholia is more favorable than mania\nin pregnancy, but after labor mania gives the better prognosis. The\nmaniacal patient is more likely to die, but the melancholic is more\nlikely to remain insane. The older the woman, the greater the number\nof her pregnancies, the more the depression, and the higher the\ntemperature, the worse the prognosis. Alcoholism is an added risk\nalways.\n\nAll puerperal insanities should be treated in sanatoria or asylums\nand not at home. When a woman with puerperal insanity is allowed to\nremain at home she cannot get proper treatment, and is a constant\nmenace to her own life and the lives of her family.\n\nA woman who has had puerperal insanity and has recovered her mental\nhealth is likely to have a recurrence of her malady at subsequent\npregnancies. The question has been asked me a few times, \"Would\nit not be justifiable to sterilize such a woman to prevent this\nrecurrence, with its dangers and terrors?\"\n\nIt would not be justifiable: 1. Because it is not licit to inflict\na grave mutilation to avert a possible or probable future evil.\n2. There are other means to escape the danger: a woman with this\ntendency is justified in denying the debitum. 3. Once crazy, always\ncrazy, is an aphorism with much truth in it, and it is doubtful\nthat sterilization in itself will prevent ultimate insanity. 4. The\nconjugal relation of a sterilized woman would be no better than\nonanistic. 5. The sterilization would fall under the decrees and\npenalties described at the end of the chapter on Cesarean Section.\n\n\n\n\nCHAPTER XII\n\nNEPHRITIS IN PREGNANCY\n\n\nIn pregnancy the kidneys always give evidence of a constant\ncongestion, and the chief symptom of this is the great quantity\nof renal epithelium shed with the urine. This engorgement has\ngiven rise to the term \"kidney of pregnancy.\" There has been much\ndiscussion of this condition, especially as to the possibility of\ndifferentiating it from beginning nephritis. In 227 consecutive cases\nof pregnancy in which the urine was examined at short intervals by\nmyself throughout the entire gestation, there was always an enormous\nquantity of epithelium, and this presence of epithelium is so\nconstant that its absence is a proof that pregnancy does not exist.\nIt is as physiological as any other somatic change in the puerperium.\nVon Leyden and other German observers look upon the degenerative\nalteration in the epithelium of the renal tubules as pathological,\nbut apparently more definite symptoms are necessary to make a\ndiagnosis of significant nephritis.\n\nWilliams[118] says that in the examination of 1000 pregnant women\nat Johns Hopkins Hospital in Baltimore traces of albumin were found\nin 50 per cent. without subsequent serious disturbance, but where\nconsiderable albumin with casts other than hyaline was seen there\nwere symptoms of toxemia later, and several of these went on into\neclampsia. Fisher[119] held that red blood-corpuscles in these cases\nindicate acute nephritis; and granular and epithelial casts, chronic\nnephritis. Like the Johns Hopkins cases, he found albumin in 50 per\ncent. of his patients. Albumin in slight quantities is found to be\nextremely common toward the end of pregnancy. Meyer,[120] in an\nextensive study of the kidney in pregnancy, made at Copenhagen,\nfound albumin in 5.4 per cent. of the women. During the last month of\ngestation 71 per cent. of the women showed albumin. Premature births\noccurred in 8 per cent. of the patients who had had albuminuria, but\nin 21.5 per cent. of the women who had had casts. Delicate tests\nfor albumin are used by men who find these high averages, as a few\nleucocytes from leucorrhoea will give the reaction. Most of these\ncases have no clinical significance.\n\n  [118] _Obstetrics_, p. 456.\n\n  [119] _Praeger medizinische Wochenschrift_, 1892 n. 17.\n\n  [120] _Zeitschrift f\u00fcr Geburtsh\u00fclfe_, bd. 16, n. 2.\n\nIt is usually impossible to differentiate in pregnancy a lighting\nup of an old nephritis from a toxemia. Where there is a history of\nnephritis before the pregnancy, this often clears up the diagnosis.\nNephritis is likely to manifest itself in pregnancy earlier than\ntoxemia; albuminuric retinitis is commoner in nephritis, but these\nfacts are no real help in differentiation.\n\nThe position of the uterus may be a cause of nephritis, according to\nthe _American Text-Book of Obstetrics_; but De Lee and others hold\nthat the growing womb cannot possibly be a cause. Many other origins\nhave been suggested, but without sufficient proof.\n\nThe treatment of the nephritides of pregnancy is that described in\nchap. xiii for eclamptic symptoms. When albuminuric retinitis occurs,\nthe medical tendency is to empty the uterus. All text-books counsel\nthis procedure, but they give no convincing reasons for the advice.\nIf the child is viable the therapeutic abortion might be done when\nnecessary; if the child is not viable the operation is, of course,\nnot licit. In the nephritis of pregnancy it is not certain that\nemptying the uterus artificially, with the entailed shock, is the\nbest method of treatment; but, as a rule, nephritis is made worse\nby pregnancy, and the irritation lessens with the termination of\ngestation in some cases, but not in true chronic nephritis. Eclampsia\nis more toxic than nephritis, and the treatment may differ in\nimportant details: it certainly is doubtful that artificial abortion\nin eclampsia is the method of choice at present. I saw a case of\nalbuminuric retinitis ten years ago, which could not have been worse.\nThe woman was in the seventh month of gestation; she was nearly\nblind and half comatose. The albumin in her urine _always_ was so\ngreat that it would not fully precipitate in a centrifuge tube, and\nevery field under the microscope was covered with large casts in\nsuch enormous quantities that they were felted together. Yet the\nwoman was carried on to term by Dr. Joseph O'Malley and delivered\nof a fully developed child. She since has had two other children at\nterm who are perfectly healthy, and she herself could pass a life\ninsurance examination. This is, of course, only one case, and it is\nexceptional; but it is impossible to say what will happen in any\nparticular case--whether it will go on to death or recovery.\n\nBoth subacute and chronic parenchymatous nephritis show clinically\nmuch albumin, many casts, marked edema (except in very emaciated\ncases), absence of high blood-pressure, and the heart is not\nenlarged. This condition is caused commonly by chronic tuberculosis,\nsyphilis, sepsis, and malignant tumors. With these clinical symptoms\nand the history, we may differentiate the nephritis of pregnancy\nfrom Bright's disease. Again, acute intestinal nephritis or\nglomerulonephritis has urinary findings like the nephritides just\ndescribed, and there may be edema. The heart and the blood-vessels\nare normal. The cause is usually a pus micro\u00f6rganism, and there\nmay be anemia from the sepsis. In subacute glomerulonephritis, or\nintestinal nephritis, the urinary findings are marked (much albumin\nand many casts), anemia is rather constant, the blood-pressure\ngradually goes up to 180 or 200, edema may be marked or absent. The\ncause is usually a pus micro\u00f6rganism. Chronic glomerulonephritis\nshows much epithelium and many casts (sometimes in showers), the\nblood-pressure is high, the heart is usually somewhat enlarged,\nthere is polyuria and some blood, edema is common (but there are\ndry cases), albuminuric retinitis is rare, and anemia is marked\nand secondary. It may be difficult to find the cause of this\nchronic glomerulonephritis, but there is, as a rule, a history of\ntonsillitis, septic rheumatism, endocarditis, a true influenza, or\nthe like infection. Primary arteriosclerotic contracted kidney shows\nhypertension and secondary circulatory disturbance. The urinary\nfindings are comparatively slight and transient, and there is little\nor no anemia. The development is insidious, and the etiology is not\nknown.\n\nThere is evidence of late to find a septic cause for most of the\nnephritides, such as infectious fevers, pyorrhea of the teeth,\nand like bacterial intoxications; in pregnancy the nephritis may\nbe toxemic from sources that are not bacterial. It is extremely\ndifficult, and not seldom impossible, to make any differentiation, as\nhas been said. When the child is viable, whether the uterus should be\nemptied or not must be decided for the individual case; no general\nrule can be set down to cover all conditions.\n\nOne of the kidneys may be dislocated during pregnancy--usually the\nright kidney. If a floating kidney becomes twisted on its pedicle,\nabortion may be a consequence. The torsion may compress the renal\nblood-vessels and bring on acute hydronephrosis with high fever,\ngreat abdominal tenderness, and a peritonic facial expression.\n\nPyelitis of the renal pelvis is not seldom met in pregnancy. The\ngonococcus, colon bacillus, or some other pyogenic bacterium gets a\nnidus after pressure and lowered power of resistance. This condition\nis sometimes mistaken for appendicitis.\n\nCatalepsy is a rare complication of pregnancy, in which the woman\nlies in an unconscious condition. The disease is a neurosis, but it\nmight be mistaken for a toxic or uremic condition by a superficial\nobserver. The infants of such women may be cataleptic, and may die as\na consequence of the condition.\n\n\n\n\nCHAPTER XIII\n\nECLAMPSIA PARTURIENTIUM\n\n\nThe term Eclampsia was first used to describe the sudden exaltation,\nflashing forth (_eklampsis_), of the vital faculties at puberty;\nlater it was applied to convulsions, but now it is restricted to\nconvulsions in pregnancy which sometimes begin suddenly, as in a\nflash. The disease is characterized by a series of violent convulsive\nmovements, loss of consciousness, and coma, and is one of the most\ndangerous complications of gestation. All convulsions and comas in\npregnancy, not due to hysteria, epilepsy, cervical tuberculosis,\napoplexy, pneumonia, phosphorus, strychnia and like poisons, uremia,\nand meningitis, are commonly classed as eclamptic. When the symptoms\nof eclampsia are present with the exception of the convulsions, a\nrare condition, this state also is said to be eclampsia. Reineke[121]\nreported a case like this. After death the heart, kidneys, and liver\nshowed all the signs of eclampsia.\n\n  [121] _M\u00fcnchener medizinische Wochenschrift_, July 30, 1907.\n\nThe eclamptic attack may occur without warning, but almost always\nthere are premonitory symptoms for from a few hours to some weeks.\nThe pre\u00ebclamptic symptoms are headache (commonly frontal), nausea\nand vomiting, vertigo, nervous excitement or somnolence, muscle\ntwitching, occasional delirium, cramps in the calves, disturbances\nof sight, tinnitus, and pain in the epigastrium. Epigastric pain,\nheadache, and disturbances of the optic tract are important symptoms.\nIf these last signs are present in a woman who has some edema and\nnephritis, the eclampsia will certainly occur, if proper means to\nrelieve the condition are not promptly taken. When the prodromata\nappear there is nephritis, as a rule, but exceptions are observed.\n\nWhen the attack comes, if the patient is standing she falls\nunconscious. The pupils dilate, the eyes and head are turned to\nthe side. She opens her mouth, and the jaw is pulled laterally.\nThe woman stiffens, her face is distorted, her arms bent, and the\nwhole body curves sidewise in a tonic spasm. After a few seconds her\njaws chop, and if her tongue is between the teeth it is lacerated;\ntwitching runs down from the face and ends in a violent convulsion\nof the whole body, which may toss the patient from the bed, and she\nmay even fracture her skull or long bones in the fall. The breathing\nstops, the bloodshot eyes stick out, the face swells and darkens, the\nlips become purple. Gradually the convulsions wane, and the woman\nappears to be dying; but after deep sighing she begins to breathe\nstertorously; then she sinks into a coma, or, in favorable cases,\nrevives.\n\nAfter a few minutes to an hour or more another convulsion may\nbefall her, or she may have no more than one. In very grave cases\nconsciousness may never return after the first fit. The convulsions\nmay run up into extraordinary numbers--a hundred or more. There is\na pseudoeclampsia where the convulsions have been as many as two\nhundred. If there are many attacks in the first twenty-four hours\nwith no clear evidence of subsidence, the woman nearly always dies.\nFever begins in such cases, and goes up to 103 or even 107 degrees.\nIn an untreated case Black found a temperature of 110 degrees before\ndeath. The average number of attacks in these cases is from five to\nfifteen, and the convulsions are from a half minute to two or three\nminutes apart. Olshausen had six patients who recovered after having\nhad from twenty-two to thirty-six convulsions, but those who have\nabove fifteen commonly die.\n\nIf the convulsions are severe the woman as a rule aborts, and often\nrapidly. After the child is delivered the eclamptic symptoms may\nsubside, or they may come on again, even a week after labor. Often\nthe fetus dies during the attack; rarely it survives and is carried\nto term; again, it may die and the eclampsia may subside, but the\nfetus remains in the uterus for some time.\n\nIf the woman is to die the eclamptic attacks usually increase in\nfrequency and violence; the temperature runs up very high, or it\nsinks; the pulse becomes weak and running, edema of the lungs comes\non, with rattling and cyanosis, and the urine ceases to flow. The\nwoman may die in a convulsion from apoplexy or heart paralysis. At\ntimes the child is delivered, but the coma deepens and the woman\ndies. In other cases there are coma and death without convulsions.\nRarely there is a condition akin to acute yellow atrophy of the\nliver, with delirium, twitchings, coma, and death.\n\nWomen who have chronic nephritis seldom have convulsions in pregnancy\nunless there happens to be cerebral hemorrhage as an effect, but\nthey suffer the other results of chronic Bright's disease--dropsy,\nuremia, edema of the lungs, paralysis of the heart, and albuminuric\nretinitis; they also are inclined to premature labor, and to\nhemorrhages that loosen the placenta. When acute nephritis happens\nin pregnancy convulsions are quite common, and when there are\nconvulsions as a result of either chronic or acute nephritis it is\nvery difficult to differentiate between these convulsions and genuine\neclampsia.\n\nThe real cause of eclampsia is unknown, but the most plausible\nexplanation of this \"disease of theories,\" as Zweifel of Leipsic\ncalled it, is that it is a toxemia which attacks the liver, and\ndirectly or indirectly the kidneys, and brings on convulsions by\ntoxic action on the anterior cerebral cortex. The great difficulty is\nto explain how these toxins originate. One authority suggests that\nthe poison comes from the liver; another, from the fetus; a third,\nfrom the placenta, the intestines, the general metabolism, disturbed\nglandular balance, bacteria, and so on, but nothing is certain as to\nthe etiology except that it is an intoxication.\n\nOn an average, 20 per cent. of the women who have eclampsia die,--but\nstatistics vary from 5.31 per cent. to 45.7 for the mother and from\n30 to 42 per cent. for the child. Eclampsia occurring ante-partum\nhas the worst mortality; intra-partum, less; post-partum, least.\nAbout half the children die from prematurity, toxemia, asphyxiation,\nnarcotics administered to the mother, or injuries at birth.\n\nIf the patient's pulse remains full and hard and below 120, there\nis no immediate danger of death; but if faster, weaker, and running,\nthe prognosis is bad. High fever is not necessarily fatal to the\nmother, but it is very dangerous to the fetus. Edema of the lungs is\na very grave symptom, but recovery is possible. When the convulsions\nhave gone beyond twenty the prognosis is bad, but there have been\nrecoveries. Deep cyanosis, marked restlessness, anuria, and intense\nalbuminuria are all bad symptoms. Apoplexy is nearly always fatal.\nAfter delivery the recovery of the woman is by no means certain.\nShe may get pneumonia, sepsis, or another eclamptic attack. Hirst\nfinds that if the diastolic pressure does not rise above a ratio of\n1 to 3 times the pulse pressure (_i. e._, the difference between the\nsystolic and diastolic pressures), the prognosis is good.\n\nEvery pregnant woman should be watched to prevent eclampsia, if\npossible, because all are liable to this outcome. The hygienic\nmethods mentioned in the chapter on Abortion are most important here.\nThe family history is of weight--if the women of the patient's family\nhave been eclamptic, if her parents were alcoholic or insane, these\nfacts increase her liability to the disease. If she has had eclampsia\nbefore, if her kidneys are acutely diseased,--especially if injured\nby infections,--if she is inclined to digestive disturbance, she\nis disposed to eclampsia. Albuminuria, diminishing amounts in the\ndaily excretion of urine, and decrease in the total solids of the\nurine, casts or blood in the urine, are serious symptoms. If albumin\nincreases and urea decreases, this is a grave sign.\n\nThe blood should be examined for the various anemias. If the thyroid\ngland is deficient or altered in activity, thyroid extract may be\nindicated--this acts also as a diuretic. Uterine malpositions should\nbe corrected. Treatment should be given where there is any evidence\nof toxemia, as headache, altered secretion and excretion, neuralgia,\nmental eccentricity, increased vasomotor stimulation, high tension,\ndisturbance in the sensory apparatus, obstinate constipation and\njaundice. Toxemia is not necessarily renal in origin.\n\nIn any of these conditions the proteids should be kept low in the\ndiet, so that the kidneys may not be overtaxed. To throw off\ntoxins, the emunctories should be stimulated by laxatives, water\nfor diuresis, tepid bathing. If the symptoms grow threatening, and\nthe kidneys are involved, the woman should be put to bed, on water\nalone. After three days an absolute milk diet should be begun. As she\nimproves, starches are added, then the vegetables containing proteid,\nvegetable oils, and butter. As the improvement goes on, the diet may\nbe vegetables, fruit easy of digestion, and one egg a day. Later\nfish and chicken are used, but never a full meat diet. Beef, mutton,\nveal, and similar heavy meats are not to be eaten. The drink is to be\nwater, buttermilk, or koumiss.\n\nWhen the eclampsia is inevitable the question of inducing labor\narises. If the child is not viable, abortion is out of the question,\nas has been proved in the chapter on Abortion and the general chapter\non Homicide. If the child is viable, there are three opinions: one,\nthat the premature delivery should be effected as soon as possible;\na second, that this delivery should be delayed as long as possible;\nand a third, that it should not be attempted at all. Those who hold\nthat the uterus should be emptied as soon as possible, induce labor\nat the first convulsion, rapidly and under deep narcosis. Chloroform\nis dangerous to the heart in such cases for full anesthesia; ether\nis better. Braun first observed that the convulsions cease or are\nlessened after delivery. D\u00fchrssen found these results in 93.72 per\ncent., Olshausen in 85 per cent., Zweifel in 66 per cent. Peterson\nsaid that in 615 cases of early delivery--as soon as possible after\nthe first convulsion--the maternal mortality was 15.9 per cent., but\n28.9 per cent. in the same maternities under the expectant method.\n\nOlshausen was not in favor of forced delivery. Charpentier[122]\nheld that forced delivery is dangerous and should be absolutely\nproscribed. His statistics of mortality are: after spontaneous labor,\n18.96; after artificial labor, 30.04; after forced delivery, 40.74.\n\n  [122] _Nouvelle Archives d'Obst\u00e9trique et de Gyn\u00e9cologie_, 1893.\n\nLichtenstein[123] reported, from Zweifel's clinic in Leipsic, the\nresults of 400 cases of eclampsia, and he found that the eclamptic\nconvulsions cease in only one-third of the cases after any form of\ndelivery. He says the mortality of induced labor is no better than\nthat after forced delivery, and that the mortality of both methods\ndoes not materially differ from the mortality of a long series of\ncases where there was no such intervention. The difference in the\nmortality between eclampsia without delivery or with delivery seems\nto depend on the relative loss of blood. In 40 per cent. of eclamptic\ncases operated upon, the loss of blood was 500 c.c. above the loss\nin cases of spontaneous delivery. The loss of blood tends to produce\ncollapse when the blood comes from the uterus, although it may be\nbeneficial if removed by venesection before delivery. Five hundred\nc.c. of blood is one-eighth to one-ninth of the entire blood supply\nof the body in a woman of average size. If 500 c.c. of blood is\nwithdrawn before the shock of forced delivery and replaced by an\nequal quantity of normal salt solution, the toxin is thus reduced by\none-fourth or one-third and then diluted by the normal salt solution,\nso that it has less poisonous effect.\n\n  [123] _Archiv f\u00fcr Gyn\u00e4kologie_, 1911, xcv, 1.\n\nLichtenstein[124] describes the expectant treatment by phlebotomy\nand narcotics to replace operative interference, and this method\nhas revolutionized the mortality of the treatment of eclampsia. In\nninety-four cases of eclampsia his mortality was only 5.3 per cent.,\nand none of the deaths could be ascribed to the treatment. The\ninfant mortality was 37.3 per cent., as against his 38.8 per cent.\nin active operative interference during preceding years. Werner, in\nthe Second Gynecological Clinic in the University of Vienna,[125] by\nthis new method in thirty-eight cases of eclampsia had a maternal\nmortality of 5.2, as Lichtenstein had, but his infant mortality was\nonly 14.65 per cent., an enormous advance for the better. Formerly\nthe mortality in the Viennese clinic was 15.8 for the women and 44.3\nfor the children, in a series of 120 cases of eclampsia. A mortality\nof 50 per cent. in the children is common in the old method. In\nLichtenstein's cases there were mental disturbances in 2.1 per cent.\nof the women, as against 6.75 per cent. in the old method. Eclamptics\nmay go insane and kill the child after delivery. Lichtenstein treated\n74 consecutive cases without a single death. In 54 per cent. of his\ncases the convulsions ceased after one venesection, and 42 per cent.\nof the women with ante-partum attacks recovered before labor came\non. Engelmann[126] reported a case where a woman who had had 188\nconvulsions recovered after the third venesection.\n\n  [124] _Monatsschrift f\u00fcr Geburtsh\u00fclfe und Gyn\u00e4kologie_, xxxviii,\n  2. Berlin.\n\n  [125] _M\u00fcnchener medizinische Wochenschrift_, November 23, 1915.\n\n  [126] _Centralbl. f. Gyn\u00e4k._ xxxi, 11.\n\nIn this method the woman is put in a dark, quiet room; 400 to 600\nc.c. of blood are withdrawn by venesection, and 0.002 gm. morphine is\ninjected; two hours later 3 gm. chloral is given in an enema. If the\nfetus presents in a position for prompt delivery it is removed with\nforceps, or by expression to spare the mother; but expression is a\ndangerous process always.\n\nZinke[127] of Cincinnati has a method which reduces the maternal\nmortality, but it has an enormous infantile mortality. He depresses\nthe maternal pulse by veratrum viride, and this depression is\nprobably the cause of the infantile mortality through asphyxia. Veit\nintroduced the use of morphine in eclampsia, and Winckel the use of\nchloral. It has been found that narcotics check the action of toxins\non the nuclei of cells, and in eclampsia the action of narcotics\nmay be of this nature. Baker of Alabama in 1859 first gave veratrum\nviride in eclampsia. The drug lowers arterial tension by depressing\nthe vasomotor centres and the heart itself. In eclampsia it diverts\nblood from the brain and depresses the motor neurons of the spinal\ncord. Aconite has the same effect in acute cerebral congestion\nwithout depressing the vasomotor centres or irritating the stomach as\nveratrum viride does.\n\n  [127] _New York State Journal of Medicine_, xiii, 8.\n\nCesarean delivery is used frequently of late in eclampsia. The\nmortality of the children is lowered somewhat by a cesarean section,\nbut the mortality of the mothers is much worse than in the expectant\nmethod described by Lichtenstein. Eclamptic women usually have\nbadly affected kidneys, and the anesthetic used in the section may\nbe a cause of the raised mortality. Peterson reviewed 500 cases\nof cesarean section for eclampsia[128] done by 259 operators in\nvarious countries. Up to 1908 the maternal mortality was 47.97 per\ncent. in 198 cases; from 1908 to 1913 it was 25.79 per cent. in\n283 cases. Convulsions ceased in only 54.92 per cent. of the women\nafter cesarean delivery, and in those cases in which the convulsions\ncontinued the mortality was 31.53 per cent. In 146 cases where the\nconvulsions ceased the mortality was still 19.8 per cent. for the\nmothers. The fetal mortality was 10.69 per cent., counting all\nchildren who died within three days after delivery by section. The\nmaternal mortality after cesarean section increases with the age of\nthe patient. The cesarean delivery, then, has a maternal mortality of\nlate of 25.79, with a tendency to increase as unskilled men attempt\nit; the expectant method has a maternal mortality of only 5.3 per\ncent. The cesarean delivery has a fetal mortality of 10.69 per cent.;\nthe expectant, 14.65 per cent. The expectant method is preferable.\n\n  [128] _Amer. Jour. Obstetrics and Diseases of Women and\n  Children_, lxix, 6.\n\n\n\n\nCHAPTER XIV\n\nHEART DISEASES IN PREGNANCY\n\n\nOver 20,000 women die in childbirth each year in the United States,\nand about 100,000 infants, and more or less permanent injury from\nparturition is almost general in mothers. The mortality in the\ntrenches during the present great war is 2 per cent.; the mortality\nof infants during the first year is 14 per cent. Very much of this\nmortality and invalidism is attributable to lack of skill in the\nlicensed unfit. We commonly deem parturition merely a physiological\nprocess, and for that reason the state permits ignorant midwives and\nquacks to take upon themselves with impunity the responsibility and\nthe risks of delivery.\n\nIt is difficult to draw the line between normal and abnormal\nparturition, but every labor, as women now are in civilized\ncountries, should be regarded as a grave surgical operation, and\nthe indications that must be met in a surgical operation are likely\nto occur in almost any parturition. The strength of the patient,\nthe condition of the heart, lungs, kidneys, and blood, sepsis and\nantisepsis, the nature and technic of the various operations that\nmay be required, and the complications that may arise, are all to be\nunderstood and met conscientiously. No physician who has any regard\nfor morality and his own reputation now will accept an obstetrical\ncase unless he has had the woman under frequent observation for\nmonths before delivery. If the mother or child dies because of the\nbungling or surgical uncleanness of the physician or midwife,--and\nunfortunately such deaths occur almost hourly,--this physician or\nmidwife is guilty of murder. There may be an abnormality of the\nuterine or abdominal muscles used in parturition, a disproportion\nbetween the parturient canal and the child, or various accidents\nof labor; and these conditions are so frequent in occurrence and\nso grave that their removal requires great medical skill, fine\ndiscernment, quick and exact judgment, and often decidedly courageous\npurpose.\n\nNew methods of treatment frequently appear, and the quack is likely\nto be among the first by which the new is tried. The use and abuse\nof pituitrin is an example of such a method. About 1909, pituitary\nextract as a uterine stimulant was first described and it was\nimmediately taken up by competent men and more frequently, perhaps,\nby the quack. The extract is from the posterior lobe of the pituitary\ngland, and when injected subcutaneously or into a muscle it is a very\npowerful oxytocic. In a few minutes the injection markedly increases\nthe intensity and duration of the pains. The effect lasts for an\nhour or an hour and a half. Whitridge Williams[129] says a judicious\nadministration of the drug will do away with the use of low forceps\nin from one-third to one-half of the cases, but its ignorant use\nplaces the life of the mother and child in jeopardy. Mundell[130]\nfound twelve cases of rupture of the uterus, thirty-four cases of\nfetal death, and forty-one cases of fetal asphyxia pallida in which\nresuscitation was effected only after prolonged and vigorous efforts,\nsometimes for over an hour.\n\n  [129] _Obstetrics_, 4th ed. New York, 1917.\n\n  [130] _Jour. Amer. Med. Assoc._, June 2, 1917.\n\nIf there is any serious obstacle at all to delivery in the parturient\ncanal or in the fetal position, or the like, pituitrin is likely to\ncause rupture of the uterus and asphyxiation of the child. It should\nnever be used when there is the slightest danger of rupture of the\nuterus; or when the child is suffering; or in a shoulder and most\npelvic presentations; or in elderly primiparae with rigid muscles;\nor when the cervix is not fully dilated, lest the undilated cervix\nbe torn off; or where there is inertia after prolonged effort to\novercome an obstacle to delivery. It is never to be used in a normal\ndelivery merely to hasten the birth. Obstetrical cases are tedious,\nand an impatient physician with an atonic conscience is likely to use\npituitrin so that he can get back to his bed.\n\nComparisons between the fetal mortality after the use of pituitrin\nor the forceps are erroneous. Quigley[131] contrasted the fetal\nmortality in these conditions. In 147 pituitrin cases it was 2.7 per\ncent., in about five or six times the number of forceps cases it\nvaried from 5.7 to 15.63 per cent.; but wherever there is any real\nneed at all for the forceps, pituitrin at once is contraindicated\nexcept in easy low forceps deliveries, where in the hands of a\nskilled man pituitrin may safely replace the forceps to avoid\npossible instrumental infection of the uterus. There are contractions\nof the uterus toward the end of gestation, before labor proper sets\nin, which cause what are called False Pains, and these must not be\nmistaken for the beginning of labor, as unnecessary examinations\nand meddlesome interference may bring on great harm. Uterine atony,\nor weak pains, may affect the patient in the first stage of labor,\nin which the cervix of the uterus should be dilated; or the second\nstage, in which the child is delivered; or the third stage, the\npost-partum period, when the placenta is thrown off. Contractions\nof the uterine muscle cause pain, and these contractions themselves\nare called the Pains. In the first stage weak pains may prolong the\ndilatation of the cervix for days and expose the mother to sepsis or\nexhaustion, and the child to consequent danger.\n\n  [131] _Jour. Amer. Med. Assoc._, April 10, 1915.\n\nIn the second stage the abdominal muscles, which push the child\nout of the uterus, fail to work if the pains are weak. Causes of\nunsuccessful pains in the second stage are: an infantile uterus,\nfibroids or other tumors in or near the uterus, peritoneal adhesions,\na full rectum or bladder, abnormal position of the uterus, a\npendulous abdomen, diseases of the uterine wall, scars from past\noperations, chronic metritis or endometritis, primiparity in\nrelatively advanced age, twins, distention of the bag of waters, gas\nin the uterus, abnormal position of the child, contracted pelvis,\nadhesions of the membranes about the os uteri, fatigue of the woman,\nand tetany or stricture of the uterus. The obstetrician must be able\nto diagnose the special cause and treat the indications.\n\nOne of the causes of weak pains is a diseased heart. Systolic murmurs\nat the base of the heart and an accentuated second aortic sound\nare quite common in pregnancy and may not be of grave importance.\nIf there is a genuine cardiac lesion with good compensation, the\nlabor is usually successful and without notable damage to the\nwoman, although obstetricians like De Lee think that such patients\nappear to develop decompensation sooner than do women who are\nnot pregnant. If the heart disease is advanced and the heart is\nin unstable equilibrium, especially if there is myocarditis or\nfatty degeneration, the heart is likely to break down in pregnancy\nor labor. In chronic cardiac lesions, pregnancy, through venous\ncongestion, tends to renal and hepatic disturbance, or to dyspnoea\nand carbonic acid narcosis. The uplifting of the diaphragm by the\nenlarged uterus increases the respiratory difficulty. There may\nbe edema of the lungs, hypostatic pneumonia, dropsy, insomnia,\nalbuminuria, and other serious symptoms.\n\nDuring labor a diseased heart may fail and cause sudden death,\nespecially if the second stage is prolonged. At times there is\ncollapse and death shortly after delivery. The mortality of heart\ndisease in pregnancy varies in the reports on various series from\n4 to 85 per cent. Babcock[132] says that the mortality in mitral\ndisease in pregnancy is 50 per cent.; that in disease of the aortic\nvalve is 23 per cent. These figures are far above those given by\nlater obstetricians of skill. Fellner and Demelin, in ninety-four\nand forty-one cases respectively, had a mortality of only 6.3 and\n5 per cent. Hirst says he never lost a case. Jaschke[133] found a\nmortality of only 4 per cent. in 1548 cases of pregnant cardiopaths.\nA great danger is in treating heart conditions by general rules,\nand in giving digitalis and other drugs without discrimination.\nIn uncompensated heart conditions many of the children die from\nprematurity, abruptio placentae, diseases of the placenta, or\nasphyxiation.\n\n  [132] _Diseases of the Heart._ New York, 1905.\n\n  [133] _Medizin. Klinik_, February 25, 1912.\n\nEven those obstetricians who induce abortion at any stage of\ngestation when they deem the woman's life in danger say that heart\ndisease in itself is not an indication for abortion unless there\nis chronic decompensation with myodegeneration and renal or hepatic\ninsufficiency. Expectancy is the rule. Lusk advises abortion as soon\nas mitral stenosis is discovered.\n\nSurgeons of the Mayo Clinic, in a report[134] on Operative Risk in\nCardiac Disease, hold that a valvular lesion is not a rational basis\nfor judging a cardiopath so far as prognosis in a surgical operation\nis concerned, but this statement is not true for an obstetrical\ncase. If we except angina pectoris and related diseases, the four\ndisorders of the heart's mechanism that surgeons deem the worst risks\nin operation are auricular fibrillation, auricular flutter, impaired\nauriculoventricular conduction, and impaired intraventricular\nconduction. These conditions are usually accompanied by extensive\nlesions of the heart muscle.\n\n  [134] _Jour. Amer. Med. Assoc._, lxix, 24.\n\nIn auricular fibrillation there are rapid inco\u00f6rdinate contractions,\ntwitchings in individual muscle bundles of the auricular wall. The\nauricle loses its power to pump the blood and dilates. The pulse is\ncommonly arhythmic and rapid. A permanent fibrillation is worse than\na paroxysmal state. The condition is found especially in advanced\ncases of exophthalmic goitre. In the Mayo Clinic the operative\nmortality in seventy cases of exophthalmic goitre with auricular\nfibrillation was only 2.8 per cent.\n\nIn auricular flutter, or heart block, there are foci of irritation\nin the auricular wall which cause rapid co\u00f6rdinate contractions.\nThe auricle may contract twice as often as the ventricle, and\nthe pulse may be regular or markedly irregular. The stimulus for\nheart contraction normally reaches the ventricle from the auricle\nby passing along the bridge of primitive tissue which connects\nthe auricle and ventricle. This bridge may be so affected that\nthe stimulus is delayed, or prevented at times from crossing\nover, or completely blocked. One patient with complete heart\nblock was operated upon at the Mayo Clinic three times in eleven\nyears for appendicitis, cancer of the breast, and the excision of\nrecurring skin nodules, and is still alive and reasonably well.\nIn intraventricular block the risk of operation is worth taking,\naccording to the opinion at the Mayo Clinic, where there is\nexophthalmic goitre or tonsillitis.\n\nIn general, where there is question of surgical operation on a\ncardiopath, no such operation should be done unless there is definite\nground to believe that the operation is essential to improve the\nheart condition or restore reasonable health. Extremely severe\ncardiac disease can be relieved or even completely cured by the\nsurgical removal of infectious, mechanical, or toxic sources of heart\ndegeneration, especially goitre. When the myocardial insufficiency\nis so marked that no medical treatment re\u00ebstablishes a reasonable\ncompensation, no surgical operation is permissible. The medical\ntreatment is the only test to learn whether the heart can be put\ninto a condition wherein it will withstand the anesthesia and the\noperation. Life depends on ventricular action, not on auricular, and\nthe ventricular reserve is the standard for judgment in these cases.\n\nFibrillation and heart block are grave conditions when found in\npregnancy, but disease of the mitral valve because of frequency is\nmore important, and when compensation is unstable mitral lesions\nare dangerous. In mitral stenosis the enlarged uterus in the last\nmonths of gestation, by crowding the intestines and diaphragm,\nembarrasses the heart. As the diaphragm cannot descend well, the\nflow of blood out of the right ventricle is not aided by respiration\nas in normal conditions. Pressure on the abdominal veins increases\nthe blood tension and throws greater work on the left ventricle. In\nthe expulsive stage of labor there is danger of the right ventricle\ngiving way under the added strain.\n\nIn mitral regurgitation the left ventricle is dilated, and in\npregnancy the regurgitation is increased by the peripheral resistance\nor obstruction. If the dilated ventricle is also hypertrophied it\nstands the strain much better. In the second stage of labor the\ndanger is the same as in mitral stenosis. In disease of the aortic\nvalve the strain of child-bearing is on the left ventricle, but\npatients in this condition undergo labor more successfully than do\nthose with mitral disease.\n\nLabor in any cardiac disease requires close watching even when the\ncompensation is good. There is always a possibility of collapse in\nthe third stage or during the puerperium. The obstetrician must\nstay by the bedside, and he is to have everything ready for a sudden\nemergency, which is likely to result in death if not instantly met.\nAll the instruments for operative delivery are to be kept sterilized\nand ready for immediate use. When symptoms of imminent collapse\nappear, delivery is to be done at once. If a cardiopath collapses in\nthe early stages of gestation, before the child is viable, the rule\nexplained in the chapter on Abortion holds--the child may not be\nkilled by removal to save the woman's life.\n\nJaschke,[135] in his consideration of 1548 pregnant cardiopaths,\nfound that seven-eighths went to term, and that the women were\nprematurely delivered in only about 9 per cent. of the total number\nof cases. Therapeutic interruption of pregnancy was necessary in\nonly about 1 per cent. The high mortality reported by many good\nobstetricians is a proof that the treatment of cardiac conditions\nrequires an experience in clinical medicine and a skill lacking, as a\nrule, in specialists who are not internists.\n\n  [135] _Loc. cit._\n\nA combined mitral and aortic disease with great enlargement of the\nheart, heaving of the chest wall, and some protrusion makes pregnancy\nvery dangerous. Osler thinks mitral insufficiency in itself not\nvery dangerous. He had one patient with such a condition, a loud\napex systolic murmur, and some enlargement, who bore nine children\nand lived to past sixty years of age. Mitral stenosis is not so\nfavorable, but even in extreme stenosis some women bear several\nchildren without collapse.\n\n\n\n\nCHAPTER XV\n\nHYPEREMESIS GRAVIDARUM\n\n\nHyperemesis Gravidarum, the Pernicious Vomiting of Pregnancy, is\ncommonly classified among the toxemias; but as the etiology is not\nknown definitely, this classification is one of convenience more\nthan exactness. Nausea and vomiting occur so frequently in the early\nmonths of gestation that they are deemed almost physiological,\nbut when these symptoms become very grave and persistent they are\nundoubtedly pathologic, and are said to be pernicious, as they may\nlead to abortion, or to the death of the woman. In 1813, Simmond\nfirst successfully employed artificial abortion to save the woman\nin this condition, and thus added a possible moral quality to the\ndisease. Therapeutic abortion was used in 1608, and Soranus of\nEphesus, in the second century, mentions it.\n\nThe pernicious nausea commonly begins in the second month of\npregnancy, less frequently in the fourth month, but it may be delayed\nuntil the sixth month; if it occurs after the sixth month it is,\nalmost as a rule, an evidence of nephritis. It may last from about a\nmonth and a half to three months, but in toxemic cases it may result\nin death in two weeks. Sometimes remissions occur.\n\nIn 1852, Paul Dubois described the disease, and his division into\nthree stages is still used in articles on pernicious vomiting,\nalthough these stages are not clearly marked clinically. In the\nearly months of gestation the stomach may become unable to retain\nfood, and there is notable loss of appetite; the condition is then\ngrave. There may be retching at the sight of food, at any change of\nposition, or at the entrance of a person into the room. The emesis\nmay recur so often at night as to cause exhaustion from insomnia.\nHiccough, thirst, pain in the stomach, and soreness of the thoracic\nmuscles are frequent and troublesome symptoms. In some cases there is\nsalivation.\n\nThe vomitus is food, mucus, and some bile at first; later mucus and\nbile; finally it contains blood. The blood may come from the mouth,\npharynx, or stomach, and it is serious if it is gastric. The urine is\nscanty, and shows nephritic irritation. At times it contains blood,\nbile, acetone, diacetic acid, indican, and rarely sugar.\n\nIn the second stage of the disease all symptoms are aggravated,\nand the stomach will not retain anything. There is extreme thirst;\nthe patient faints often, and loses weight rapidly. In chronic\ncases there is much emaciation. The mouth is like that in a case of\ntyphoid. Sometimes there is a low fever; again, the temperature is\nsubnormal, with a rise before death. The pulse is rapid and weak, and\nthe post-mortem heart shows fatty degeneration as in a fatal sepsis.\n\nIn the third stage the mind is affected, there is delirium, stupor,\nand coma; the vomiting ceases, the pulse grows more rapid and\nfeebler, and the weakness becomes more and more overwhelming until\nthe patient dies. This third stage is commonly short. In these\nconditions it is too late to empty the uterus, and any attempt to do\nso then only hastens death.\n\nIn some cases the fetus is apparently not affected; in toxic cases it\nis affected, and then there may be miscarriage. If the fetus dies the\nvomiting ceases, as a rule.\n\nThe liver enlarges in the first stage and later diminishes. There\nmay be a general hemorrhagic hepatitis and acute yellow atrophy, or\npartial fatty degeneration around the central lobular veins. Necrosis\nalso occurs. Acute parenchymatous nephritis and hemorrhages into the\nkidneys are often observed.\n\nNeurotic and hysteric women are more liable to this disease than the\nnervously stable. There is a direct communication by the sympathetic\nand vagus nerves between the stomach and the uterus and its adnexa,\nand thus reflex irritations readily pass to the stomach. Through this\npath vomiting is caused by any unusual distention of the uterus,\nas when the fetus grows too rapidly; or when the size of the ovum\nis larger than normal, as in twin pregnancies; or in irritations\nlike hydramnios, displacement of the uterus, acute anteversions,\nretroversions, or flexions which pinch and stretch the nerves.\nInflammations, as metritis, endrometritis, and cervicitis; tumors\nof the uterus; diseases of the adnexa or of the pelvic connective\ntissue or peritoneum are other sources of reflex vomiting. The proof\nthat such are causes is that the vomit ceases when the conditions\nmentioned are cured. Such conditions exist, however, in women who are\nnot pregnant without causing vomit; there is therefore some special\ndisposition in the pregnant.\n\nDiseases which in themselves have vomiting as a symptom will in\npregnancy make the vomit pernicious. Such are chronic gastritis,\ngastric ulcer, enteritis, cancer, helminthiasis, large fecal\nconcretions, enteroptosis, tubercular peritonitis, and gall-stones.\nWhat is apparently pernicious vomiting in pregnancy may be the\nbeginning of acute miliary tuberculosis. Diseases of the air\npassages--hypertrophied turbinates, septal spurs, laryngeal and\napical tuberculosis--seem to cause the vomiting or to dispose to it.\nWhen vomit is associated with uremia, this occurs, as a rule, in the\nlast months of pregnancy.\n\nThe cause, again, may be in the nervous system, from either a\ndemonstrable lesion or a functional imbalance--paresis, locomotor\nataxia, tumors or tubercle of the brain, meningitis, polyneuritis.\nEven when the nervous system is not directly the cause of the emesis,\nthe remote irritant may work through the nervous system. A bad\nneurotic inheritance, as from alcoholic, insane, or weak parents,\ndisposes to neurotic hyperemesis.\n\nToxins from the fetal syncytium appear to be another cause of the\nvomit. The syncytium is a mass of protoplasm without cell demarkation\nbut with nuclei scattered throughout the substance. Sometimes this\nembryological cellular material starts to grow after the manner of\na cancer, and then it is very malignant (_syncytioma malignum_),\nbut its connection with the pernicious vomit of pregnancy is more\ntheoretical than established. In physiological conditions the toxins\nin the blood are neutralized by the secretions of the ductless\nglands of the body, and in pregnancy probably these same glands by\nintensified activity effect the same result. Injection of blood\nserum taken from healthy pregnant women has cured cases of toxemic\npernicious vomit, and this makes the theory much more probable.\n\nTo diagnose the etiology of pernicious vomiting is not always easy.\nWe must decide first whether the emesis is really pernicious or\nnot; secondly, we have to determine whether or not it is due to the\npresence of the fetus; thirdly, we are to differentiate the primary\nand adjuvant causes for intelligent treatment. The age of the fetus\nmust be known to determine whether we may licitly interfere so as to\nremove the fetus from the uterus if necessary, in medical opinion, to\ndo so.\n\nTrousseau emptied the uterus of a woman to stop her pernicious\nvomit, but she died, and at the autopsy he found a cancer of the\nstomach. Caseaux discovered tubercular peritonitis in a woman who had\ndied after a diagnosis of hyperemesis gravidarum; Beau, tubercular\nmeningitis in a like case. Williams of Johns Hopkins University\nstopped a very grave case of pernicious vomiting in a neurotic woman\nmerely by telling her of the dangers of artificial abortion.\n\nThere is no settled mortality percentage in hyperemesis gravidarum\nbecause so much depends on diagnosis and treatment. Braun, in 150,000\nobstetrical cases, never had a death from pernicious vomit; others\nhave a mortality of 40 per cent.\n\nThe treatment is technical, and is given in detail in books like\nDe Lee's _Principles and Practice of Obstetrics_.[136] Suggestion\nand the environment are important elements in the treatment. Local\nanesthetics, mechanical drugs like cerium oxalate and bismuth,\ndepressomotors, external applications, and gastric lavage are\nindicated in the early stages of the disease, but are rather harmful\nthan useful in later stages. Adrenalin, ten drops of a 1:1000\nsolution by mouth, or three drops hypodermically as doses, often\ncures. Sergent and Lian reported six such cases in one paper in\n1913. Hypodermic injection of the extract of corpus luteum in 1\nc.c. doses has been effective in some cases. So has the injection\nof defibrinated serum from a healthy pregnant woman. Curtis\ndescribes the technic in the _Journal of the American Medical\nAssociation_, February 28, 1914. The gynecologist must adjust\nuterine displacements and heal cervical erosions. The oculist,\nlaryngologist, and otologist are to remedy refractive errors and\nremove irritants in the air passages and the ear.\n\n  [136] Philadelphia, 1913.\n\nThe treatment of last resort is to empty the uterus. This will cure\nall cases of neurotic and reflex origin if done early enough. In\nthese cases, if the therapeutic abortion is deferred until very late,\nthe patient will die of exhaustion. Toxemic cases do not react well\nafter therapeutic abortion because of the damage previously done by\nthe circulating poison, especially in the liver. A positive diagnosis\nof toxemia cannot always be made, and many patients in whom the\ndiagnosis has been made correctly recover without abortion. Apart\nfrom moral considerations, it is very difficult to determine the\nproper time to empty the uterus. A test is made of the glycolytic\npower of the liver by giving two ounces of levulose internally;\nand if sugar shows in the urine, this means that the liver is\nunable to act normally, that it has been attacked and disabled by\nthe toxin, and therefore the therapeutic abortion should be done.\nAgain, a marked concentration of the blood, shown by erythrocytosis\nand leucocytosis, indicates starvation. Some obstetricians perform\nabortion when the pulse remains above 100, at the appearance of\nfever, blood from the stomach, jaundice, albuminuria, mellituria,\nacetonuria, indicanuria, or marked loss of weight. Polyneuritis, with\nicterus and bile in the urine, is another indication for abortion;\na patient may die from polyneuritis alone after the hyperemesis has\nceased. Not one but all these facts must be considered, together with\none's own clinical experience.\n\nIn hyperemesis gravidarum, as elsewhere, therapeutic abortion is\nnever permissible, under any circumstances, if the child is not\nviable. If the mother cannot be saved without emptying the uterus,\nthe mother must die; there is no way out of the difficulty. The proof\nthat this doctrine is correct has been given in the introductory\nchapter on Homicide and when considering abortion in general.\n\n\n\n\nCHAPTER XVI\n\nCHOREA GRAVIDARUM AND HYSTERIA\n\n\nRecurring, permanent, localized spasms of facial or other groups\nof muscles, which are often called chorea, are tics,--convulsive\ntic, painful tic, accessorius spasm, and so on. Chorea is also\ncharacterized by various recurrent spasmodic movements, but the\norigin of the disease is commonly an infectious endocarditis,\nrheumatism, tonsillitis, or the like disease. This is Chorea Minor,\nSt. Vitus's Dance, or Infectious Chorea. There is also a common\nchorea, which is not from an infection but from some nervous\nirritation, usually eye-strain, and disappears with the removal\nof the irritation. The chorea of pregnancy is often an infectious\nchorea, and then it is an extremely dangerous condition: the\nmortality in some collections of toxic cases is as high as 22 per\ncent. We meet, too, in pregnancy hysterical chorea, and a form which\nis partly hysterical and partly infectious in origin.\n\nPrimigravidae are more susceptible to infectious chorea in pregnancy\nthan multigravidae. If a woman has not had true rheumatism she very\nrarely gets chorea after the first gestation. Rheumatism in the\npatient or in her immediate ancestors, epilepsy, fright and other\nemotions, and anemia are predisposing causes. The patients are all\nvery neurotic; and if they had chorea in childhood, the condition is\nlikely to recur in pregnancy.\n\nMild cases may be cured without damage to the woman or fetus, but\nmany cases go on to abortion and death in coma and fever. Some severe\ncases result in a mania which may last for months; again, there is\nparalysis and delirium. The earlier in pregnancy the attack, the\ngreater the danger to the fetus.\n\nIt is very important to differentiate infectious chorea from\nhysterical chorea--the latter may or may not be dangerous; chorea\nalways is dangerous. In hysterical chorea the movements are sudden,\nisolated, and sometimes rhythmical, especially in the fingers; there\nare zones of anesthesia, and the perversity of the hysteric soon\nmanifests itself. The movements in hysteria are never so intense as\nto exhaust the patient. In true chorea the movements are irregular,\nspasmodic, and increased by motion and voluntary effort, especially\nif the effort is sustained; they exhaust the patient.\n\nManiacal chorea differs from the mania of the puerperium from other\ncauses: in maniacal chorea the woman is not so sullen, and is more\ngarrulous than the patient with puerperal mania. The prognosis is\nbetter in maniacal chorea as to recovery of reason. Sometimes,\nhowever, the mania of puerperal chorea persists for months, or it may\nbecome even permanent.\n\nIf the fetus is viable and the choreic woman, with a clear toxic\nchorea, shows signs of exhaustion from the spasms and insomnia, or\nif her mania is becoming fixed and her delusions are dangerous (such\nwomen are likely to kill the infant), or if she has endocarditis,\nthe uterus should be emptied, as a rule. If, however, the symptoms\nshow a recession on treatment, the uterus should not be emptied.\nAlbrecht[137] reported a case of chorea cured by an injection of\nserum from a normal pregnant woman. Each case must be judged by its\nown characteristics. The last sacraments should be given as soon as\nthe symptoms grow grave.\n\n  [137] _Zeitschr. f. Geburtsh\u00fclfe u. Gyn\u00e4k._, lxxvi, 3, p. 677.\n  Stuttgart.\n\nHysteria in a woman, even when mild, may grow serious in pregnancy\nwhen it takes the form of melancholia; but it is dangerous when it\npasses into maniacal excitement. In mania there may be exhaustion\nfrom a refusal to take food, and in labor maniacal hysteria may wreak\ngrave injury on both mother and child. Hysterical women should be\ntreated before pregnancy; indeed, the process of avoiding hysteria\nshould have begun in the patient's grandparents.\n\nThe term hysteria has been handed down from the days when physicians\nthought there was a connection between uterine disorders and the set\nof nervous symptoms grouped about the title hysteria. It is now\netymologically meaningless--men also grow hysterical. Briquet found\n11 male to 204 female hysterics, and later statistics increase the\nnumber of males.\n\nThe disease is not readily definable. The patient is usually a young\nemotional woman, oftenest between fifteen and twenty years of age.\nShe commonly has anesthetic spots on her body, concentric limitations\nof the fields of vision and reversals in the color fields,\nhysterogenetic zones, or tender points, which when pressed appear to\ninhibit the hysterical fit. The symptoms enumerated here are not,\nhowever, found in every case of hysteria, and it is difficult at\ntimes to diagnose the case. There is a popular notion that hysteria\nis a disease of malingerers, but it is as real as typhoid fever or\na broken leg, and a much greater affliction than either of these\nconditions. Malingering is only a symptom of the disease.\n\nThe conditions that bring about hysteria are hysteria in a parent, or\ninsanity, alcoholism, or some similar neurotic taint in an ancestor.\nImmediate causes are acute depressive emotions, shocks from danger,\nsudden grief, severe revulsions of feeling, as from disappointment in\nlove or abandonment by a husband; and, secondly, cumulative emotional\ndisturbance, as from worry, poverty, ill treatment, unhappy marriage,\nor religious revivals. Certain diseased conditions, as anemia,\nchronic intoxications, pelvic trouble, start it into activity when\nit is latent. It is also communicated by imitation and it may become\nepidemic.\n\nAfter the great plague, the Black Death, in the fourteenth century,\nthere were very remarkable epidemics of imitative hysteria in Germany\nand elsewhere. In 1374, at Aix-la-Chapelle, crowds of men and women\ndanced together in the streets until they fell exhausted in a\ncataleptic state. These dances spread over Holland and Belgium and\nextended to Cologne and Metz. The \"Dancing Plague\" broke out again,\nin 1418, at Strasburg and in Belgium and along the lower Rhine. In\n1237 there was a similar outbreak among children at Erfurt and many\ndied from exhaustion. The tarantism in Italy from the fifteenth to\nthe eighteenth century is another example of epidemic hysteria. There\nwere epidemics of hysteria in Tennessee, Kentucky, and a part of\nVirginia, which began in 1800 and recurred for a number of years.\nThese outbreaks started in revivals and camp meetings. The majority\nof the cases were in youths from fifteen to twenty-five years of age,\nbut the hysteria was observed in persons from six to sixty years\nold. The muscles affected were those of the neck, trunk, and arms,\nand the convulsions were so strong that the patients were thrown to\nthe ground and often leaped about like a live fish tossed out of the\nwater on a bank.\n\nConvulsions, tremors, paralyses of various forms and degrees are\ncommon in hysteria. In major hysteria the patient falls into a\nconvulsion gently. There is checked breathing, up to apparent danger\nof suffocation. Then follows a furious convulsion, even with a bloody\nfroth at the mouth, but there is a trace of wilfulness or purpose in\nthe movements. Next may come a stage of opisthotonos, in which the\nbody is bent back in a rigid arch until the patient rests on her head\nand heels only, like a wrestler; and this is followed by relaxation\nand a recurrence of the contortions. An ecstatic phase succeeds this\nat times, the so-called crucifix position, with outbursts of various\nemotions, and a final regaining of the normal state. Any of these\nstages, however, may constitute the entire fit. Some major hysterics\ncan simulate demoniacal possession with extraordinary ingenuity.\nIn minor hysteria there is commonly a sensation of a rising ball\nin the throat--the globus hystericus. There may be uncontrollable\nlaughter or weeping, and muscular rigidity is frequent. The patient,\nespecially if she is a child, may mimic dogs and other animals. The\nsnarling, biting, and barking of false rabies are hysterical; such\nsymptoms do not occur at all in real hydrophobia.\n\nThere are innumerable physical symptoms of the disease, but the\nmental phases have most to do with the treatment. The hysterical\nperson is characterized by an overmastering desire to be an object of\nsympathy, interest, admiration, rather than by a tendency to baser\ninstincts. The will is weak, the emotions explosive, the patient is\nimpulsive and lacking in self-control. She readily goes from absurd\nlaughter into floods of tears. She simulates pains and other symptoms\nof disease, and she is always a liar, no matter what her state in\nlife, from nurse-girl to nun.\n\nAcquired hysteria may be cured, but the congenital form is virtually\nhopeless; yet even with this latter kind much can be done by patient\ntraining. Such a girl or boy must be reared carefully and with a firm\nhand. A marked congenital hysteric should not marry. Marriage makes\nthem worse, and they beget other hysterics. When a hysterical girl\ngets one of her fits the chief obstacle to cure is sympathetic visits\nfrom relatives and friends. If a patient in the vapors is taken from\nschool and wept over, she will never come down to earth again. The\ngirl who faints at the communion-rail regularly is always a hysteric,\nand the cure for her is a bucket of cold water in the sacristy, or a\nthreat to turn her over to the police. You will find these fainters\nwith a perfect pulse despite the faint. But there are other cases\nin which rough treatment is harmful, and the only method is patient\ntact. Such persons are objects of great pity and should be dealt with\nas one would deal with any deficient mind.\n\n\n\n\nCHAPTER XVII\n\nACUTE YELLOW ATROPHY OF THE LIVER IN PREGNANCY\n\n\nAcute yellow atrophy of the liver in pregnancy was formerly called\nIcterus Gravis. The disease is not necessarily connected with\npregnancy, but half the cases are in pregnant women, and with them\nit may appear at any time in gestation or shortly after delivery.\nPernicious vomiting, eclampsia, sepsis, chloroform poisoning,\ntyphoid, osteomyelitis, diphtheria, erysipelas, alcoholism, or\nphosphorus poisoning in pregnant women may end in this acute yellow\natrophy. Bendig[138] reported two cases, both fatal, which were\ncaused by syphilis.\n\n  [138] _M\u00fcnchener medizinische Wochenschrift_, August, 1915.\n\nThe liver lessens in size, is friable, yellow-streaked, mottled with\nred; the heart degenerates, and all tissues are stained with bile,\nicteric. If the hepatic atrophy is a consequence of the diseases\nenumerated above, the symptoms of these diseases precede those of the\natrophy. In chloroform poisoning the attack may end fatally within\nsix hours, or it may last for five or six days before death.\n\nIf a pregnant woman has had gastric catarrh with weakness and\nheadache, and then suddenly becomes delirious, begins to toss about\nthe bed with rolling of the head from side to side, is jaundiced,\nshows epigastric tenderness, and a diminution of the liver dullness,\nthe diagnosis is almost certain. The reflexes are exaggerated, there\nare minute petechiae on the trunk, arms, and legs, the tongue is\ndry and brown, the breath is foul, the pulse is fast and weak, the\ntemperature is usually high (102-104 degrees), and the urine shows\nnephritis.\n\nThe prognosis is always bad. The fetus nearly always dies. If the\nfetus is viable the uterus should be emptied at once even if the\nwoman is so near death that the procedure appears useless: it may at\nleast give a chance to baptize the infant. Suppose in a particular\ncase a consultant or the physician in charge holds that the mother is\nso ill that therapeutic abortion will only hasten her death, yet the\nfetal heart-sounds can be heard through her abdominal wall. In that\ncase I should be in favor of performing the abortion to baptize the\ninfant, reluctantly permitting the chance of hastening the mother's\ndeath. But this hastening is by no means certain.\n\nWhen a diagnosis of acute yellow atrophy has been made the patient\nshould receive the last sacraments as soon as possible.\n\n\n\n\nCHAPTER XVIII\n\nINFECTIOUS DISEASES IN PREGNANCY\n\n\nAny of the acute infections, as typhoid, typhus, smallpox, measles,\nscarlatina, and the others, attacks a pregnant woman as readily\nas one who is not pregnant. Pregnancy, as a rule, lessens the\nresistance to the infection, and the infection is likely to cause\nabortion. The toxin of the infection is added to the physiological\ntoxins of pregnancy, the kidneys often are overwhelmed, and there\nis a tendency to hemorrhage. After the exhaustion from the disease,\ndelivery, whether premature or at term, is liable to end in collapse,\nespecially if the heart or lungs have been injured. Puerperal sepsis,\neither general or local, is a common effect of these bacterial\ndiseases. In smallpox there is infection from the pustules and the\nvirus itself; in typhoid the typhoid bacillus and the streptococci\nin Peyer's patches get into the blood; in influenza, pneumonia,\nerysipelas, and diphtheria the bacteria directly cause sepsis, and in\nscarlatina the pus organisms from the throat are found in the septic\nfoci.\n\nIn these infections the fetus may be killed by the high temperature;\nit may die from asphyxia brought on by feeble maternal blood-pressure\nand consequent stagnation of the circulation in the uterine sinuses;\nit may be overwhelmed by maternal hemorrhage; by deoxidation of the\nmaternal blood, as in pneumonia; by a hemorrhage in the placenta, and\na consequent separation of the placenta itself from the uterine wall;\nby fatty degeneration of the fetal villi, which renders respiration\nof gases impossible. Again, the child may be infected by the disease\nof the mother, or it may be killed by the toxins in the maternal\ncirculation.\n\nThe communication between the fetal and the maternal blood systems\nis as indirect as that between the air in a man's lungs and his\nblood. The communication between mother and fetus is by osmosis, but\ncertain toxins, drugs, and bacteria may also pass from the maternal\nto the fetal circulation through the placenta. Strychnia injected\ndirectly into the embryos of animals by Savory and Gussarow killed\nthe mother after passing to her through the placenta. There is no\ndirect communication (except by osmosis) between the fetal chorionic\nvilli and the maternal intervillous blood spaces. In the first half\nof pregnancy fetal and maternal blood are separated by the syncytium,\nLanghan's layer of cells, the stroma of the villi, and the walls of\nthe fetal capillaries; in the second half of gestation Langhan's\nlayer gradually disappears. In the fetal blood-vessels are found\nmany nucleated red corpuscles, but these are lacking in the maternal\nintervillous spaces. S\u00e4nger also discovered that in pernicious\nleucemia the leucocytes of the mother are not present in the fetal\ncirculation.\n\nThat gaseous substances pass through the fetal barrier of tissues\nwas proved by Zweifel, Cohnstein, and Zuntz. Zweifel showed that\nchloroform administered to the mother rapidly reaches the fetus. As\nearly as 1817, Mayer proved the passage of cyanide of potassium.\nSince then we have been made certain of the transmission of iodide\nand ferrocyanide of potassium, salicylic acid, bichloride of mercury,\nmethylene blue, and many other substances. Kr\u00f6nig and Futh, in 1901,\ndetermined that the maternal and the fetal blood freeze at the same\ntemperature, which indicates that they possess equal osmotic power,\nand that osmosis may occur in either direction.\n\nSome bacteria do not get through to the fetus, but a few do get in.\nTubercle bacilli were found in the fetus by Birch-Hirschfeld[139]\nin 1891, and Schmorl[140] demonstrated them in 50 per cent. of the\nplacentas in one series of examinations. Bar and Renon[141] found\nthem in the blood of the umbilical cord in two of five cases. Actual\ncongenital tuberculosis is possible, though very exceptional: the\nbacteria either pass through the wall between mother and fetus,\nor destroy this wall and then get in. Smallpox, measles, and\nscarlatina, the causes of which have not yet been demonstrated;\ntyphoid, cholera Asiatica, pneumonia, bubonic plague, erysipelas,\npus infection, anthrax, syphilis, febris recurrens, and malaria\nhave already been demonstrated in the fetus. Lynch of Johns Hopkins\ncollected sixteen cases of typhoid in the fetus. I found the typhoid\nbacillus in the liver and kidneys of a still-born fetus whose mother\nwas ill with typhoid fever; this case was not among those collected\nby Lynch.\n\n  [139] _Arbeiten d. pathologisch. Instit. zu Leipsig._ Jena, 1891.\n\n  [140] _M\u00fcnchener medizinische Wochenschrift_, 1904, vol. li, p.\n  1676.\n\n  [141] _L'Obst\u00e9trique_, vol. i, p. 69.\n\nThe majority of writers give unfavorable prognoses for typhoid in\npregnancy. Abortion or premature labor is extremely common, with\ngreat danger to the mother's life. When labor begins in these cases\nthe last sacraments should be administered early. Therapeutic\nabortion in typhoid is very likely to cause death, yet a number of\nwomen recover after abortion. As regards the woman's life, cases\nof premature labor have a worse prognosis than early abortion. The\ngreatest danger is while the fever is high, and abortion is commoner\nin the first week of fever than in the second or third. In protracted\ntyphoid abortion is likely to occur in the fourth week or later.\nAfter defervescence the prognosis is better, but there is always\ndanger. Different physicians have markedly varying results. There is\nno medical condition where skill in the physician counts more than\nin typhoid; it is the supreme test of the therapeutist. Sacquin[142]\ncollected from various sources the statistics of 233 cases of\npregnancy during typhoid, and abortion or premature labor occurred\nin 150 of these, with death in 16 per cent. Many skilful men have\na mortality as low as 3 per cent. in typhoid not complicated with\npregnancy.\n\n  [142] _Th\u00e8se._ Nancy, 1885.\n\nThe subject of typhoid is too vast for complete treatment here:\nthe article on Typhoid in the American edition of Nothnagel's\n_Encyclopedia of Practical Medicine_ covers 472 large octavo pages.\nA very important point is not to mistake typhoid for a septicemia\nin its early stage. A Widal reaction should be made in apparently\nseptic cases to exclude typhoid. Sometimes, however, a streptococcic\ninfection will give a positive Widal, and there may be a mixed\ntyphoid and streptococcic infection.\n\nSmallpox in pregnancy causes abortion or premature labor in the\nmajority of cases, and the child usually dies. The child may be born\nin the eruptive stage, or pockmarked. Franklin reported a case where\na vaccinated woman was delivered of a child while her husband was in\nthe house ill with smallpox. The mother did not take the infection,\nbut the child was born dead of smallpox: the contagion had passed\nto the child through the unaffected mother. Vaccinated women at\ntimes bear children which are after birth immune to vaccinia and\nsmallpox--vaccinia, in the commonly held opinion at present, is an\nattenuated smallpox. Pregnant women should be vaccinated, when there\nis smallpox in their neighborhood, to protect themselves and their\nchildren, unless they have been successfully vaccinated within four\nor five years.\n\nVaccination prevents smallpox in more than 90 per cent. of the\nexposures to the disease. The death-rate was 58 per cent. in\nthe unvaccinated cases and 16 per cent. in the vaccinated in a\ngroup of 5000 cases of smallpox studied by Welch in 1894. During\nthe eighteenth century, according to Bernouilli's calculation,\none-twelfth of all the children born succumbed to this disease. In\n1707, in Iceland, 18,000 of the entire population of 50,000 died\nof smallpox. As late as 1885, 3164 persons died of the disease in\nMontreal in one epidemic brought on at a time when vaccination had\nbeen neglected. In Prussia, from 1851 to 1860, without compulsory\nvaccination for civilians, there were 36,577 deaths from smallpox; in\nthe Prussian army during the same time, with compulsory vaccination,\nthere were only fourteen deaths. During the war of 1870 the French\narmies, without vaccination, lost 23,469 men from smallpox; the\nGerman armies lost only 459 men and there was a great epidemic of the\ndisease in Germany at the time.\n\nThe efficiency and necessity of vaccination against smallpox, which\nis as virulent now as it ever was, is so certainly established\nthat a parent or guardian who neglects or refuses to have children\nvaccinated when exposed to the disease is guilty of homicide through\nneglect if an unvaccinated child under his care dies of smallpox.\nRevaccination is necessary every eighth year if smallpox reappears.\nAgitation against vaccination is not mere ignorance: it is a\ndangerous crime, exactly like loosing a mad dog; and it is combined\nwith the insolence of ignorance. Persons who have seen smallpox\nare very much afraid of it, because it is one of the most dreadful\nafflictions humanity is exposed to; those who have not seen it, yet\nsay they are not afraid of it, are mere fools.\n\nA pregnant woman who is infected with smallpox should receive the\nlast sacraments as soon as possible. If she aborts she may die very\nquickly in collapse. If she is evidently in _articulo mortis_ and the\nfetal heart can be heard, her cervix should be forcibly dilated, the\nchild turned, and delivered for baptism. If the physician waits for\ndeath, the child will be dead also, and sectional delivery will be\ntoo late for any good.\n\nPneumonia in pregnancy is a rare but very dangerous disease.\nIn one series of 13,611 pregnancies there were 120 cases of\npneumonia--eight-tenths of one per cent.; in another series of 1842\npregnancies two and three-tenths had pneumonia. Wallich,[143] in\na study of the mortality of this condition, found that pneumonia\ncauses abortion in one-third of the cases that occur during the\nfirst six months of gestation, and in two-thirds of the cases that\nhappen between the sixth month and term. On the third day of the\npneumonia the abortions are most likely to occur. The maternal\nmortality varies between 50 and 100 per cent. in the groups studied,\nand the fetal mortality is 80 per cent. in general, but about 40 per\ncent. for viable fetuses. The large size of the uterus in the last\nmonths of pregnancy interferes with the descent of the diaphragm\nin respiration, and the heart is likely to fail. The more advanced\nthe pregnancy, the greater the danger to both mother and child\nfrom pneumonia. Among the dangers to the child is the imperfect\noxygenation of its blood, and in a few cases the pneumococci reach\nthe fetus.\n\n  [143] _Annales de Gyn\u00e9cologie._ June, 1889\n\n  Randall, in a study of 190 pregnant women who had pneumonia,\n  found a somewhat lower mortality than that observed by Wallich.\n  In Randall's series 70 died (36.7 per cent.); of 118 who did\n  not abort, only 12 died (10.7 per cent.). In a second group of\n  352 cases abortion happened in 58.8 per cent. Of 144 patients in\n  the first six months of gestation, 22.08 per cent. died, but of\n  those that aborted 52.08 per cent. died. Again, of 164 cases in\n  the last three months, 30.49 per cent. died, but 70.12 per cent.\n  died of those that aborted during these three months. Of 82 that\n  aborted, 87.8 per cent. died. The mortality in women under 25\n  years of age was 13.33 per cent.; in women from 25 to 35 years,\n  23.2 per cent.; over 35, 22 per cent.\n\n  Pneumonia in pregnancy is made worse by the mechanical\n  interference with respiration brought about by the enlargement\n  of the uterus, and the heart, which is overburdened in ordinary\n  pneumonia, is still more exhausted by the additional strain\n  of pregnancy in the pneumonia of gestation; moreover, the\n  lungs, which are obliged to do enhanced labor in pregnancy\n  in eliminating, are clogged by the pneumonia; it would seem,\n  then, that, if the fetus is viable, the womb should be emptied\n  to give the mother a better chance for recovery. Statistics,\n  however, are against therapeutic abortion. The evacuation of\n  the uterus determines blood to the inflamed lungs, which are\n  already overburdened. The exhaustion of labor weakens the\n  patient, and makes her liable to general septic infection.\n  Matton[144] found that in eighteen cases where pregnancy was\n  artificially interrupted, nine women died (50 per cent.); while\n  in twenty cases where no interference was attempted, only one\n  woman died. This comparison is not exact, perhaps, because we\n  do not know the gravity of the infection in each group, but\n  in any consideration the difference is remarkable. In a group\n  studied by Chatelain[145] the results in natural and artificial\n  delivery were virtually the same. Inasmuch as therapeutic\n  abortion at the best is no better than non-interference, there\n  is no justification for therapeutic abortion, unless in unusual\n  circumstances.\n\n  [144] _Jour. de M\u00e9d. de Bruxelles_, 1872, p. 412.\n\n  [145] _Ibid._, 1870, vol. l, pp. 430, 516, and vol. li, p. 11.\n\nPneumonia is an infectious disease, and a pregnant woman should,\nfor her own sake and the sake of the fetus, avoid exposure to\ninfection. When the disease is present the last sacraments should not\nbe deferred, as it may be impossible to make a confession when near\ndeath.\n\nInfluenza in pregnancy is more severe than it is in the non-gravid\nstate. By the laity, and sometimes even by physicians, influenza\nis confused with la grippe, but there is an influenza vera and an\ninfluenza nostras, or la grippe, and this latter is not nearly\nso serious a disease. The real influenza is caused by a specific\nbacillus; it appears in epidemics which have a tendency to become\npandemic, and then the disease disappears for a generation. La grippe\nis a bronchitis or coryza with some fever and muscle-soreness. True\ninfluenza (the name is Italian, _influenza di freddo_) is very\ninfectious. The pandemic of 1889-90 started in Turkestan in June,\n1889, and by October, 1890, influenza had gone westward and encircled\nthe earth along the trade routes. The preceding pandemic occurred in\n1847-48.\n\nThere is no clear proof that pregnant women are especially liable\nto infection by influenza, but there is always a notable fall in\nthe birth-rate after marked epidemics of the disease. This has been\nobserved in France, Germany, and Switzerland. When it does occur in\npregnancy it is likely to cause abortion. Pasquier, as early as 1410,\nnoticed this fact. The disease is likely to cause hemorrhage from\nthe uterus in non-gravid women, especially in those who are past the\nclimacteric, and menorrhagia in younger women who are not pregnant.\nMoeller[146] found abortion or premature labor in 28.3 per cent. of\ntwenty-one severe cases. In severe influenza where there is diffuse\ncapillary bronchitis, pleuropneumonia, or spasmodic cough, abortion\nis most likely to occur, and such abortion is always dangerous. The\nhemorrhages in abortions from influenza are often alarmingly profuse.\n\n  [146] _Deutsch. med. Wochensch._, 1900, No. 28.\n\nIn threatened respiratory or cardiac failure in influenza\ncomplicating pregnancy there may be question of therapeutic abortion,\nbut in such an event great care must be taken to avoid exhaustion and\nshock. The child should be extracted; the woman should not be made to\nlabor. One of the important moral considerations in this matter of\ninfluenza and pregnancy is that the woman commits grave sin if she\nneedlessly exposes herself to infection, because of the danger to\nthe child's life and the risk of its loss without baptism, and also\nbecause of the danger to her own life.\n\nScarlatina (Italian _scarlattina_, Low Latin _febris scarlatina_),\nor Scarlet Fever, is very rare in pregnancy. Popularly, scarlatina\nis used for a light form of scarlet fever, as varioloid is used\nfor a light attack of smallpox; but physicians do not make this\ndistinction between scarlatina and scarlet fever: they use the terms\nsynonymously. In Nothnagel's _Encyclopedia of Practical Medicine_\nJuergensen has an elaborate discussion on the differentiation between\ngenuine scarlet fever in the puerperium and the relatively frequent\nseptic erythema found in that state, but the received opinion now is\nthat real scarlet fever is very rare in pregnancy. Those who report\nlarge numbers of scarlet fever cases in pregnancy err in diagnosis.\n\nThe mortality in the scarlatina of pregnancy may be very high--52 per\ncent. in some epidemics; and if the infection happens immediately\nafter delivery, the mortality is still higher. A septic rash is\nsometimes mistaken for scarlatina, but where the genuine disease is\npresent the pregnant woman is gravely obliged to avoid exposure to\nit, both for her own sake and for that of the fetus. In the early\nmonths of gestation scarlatina commonly causes abortion.\n\nMeasles in pregnancy is also very rare, but when it does occur it\nis a serious disease. Gestation is interrupted in 55 per cent. of\nthe cases, and the mortality is 15 per cent. for the women. The same\nmoral and related conditions that obtain in scarlatina are found in\nmeasles. There is a marked tendency to hemorrhage and pneumonia. Of\neleven cases reported by Klotz,[147] nine aborted.\n\n  [147] _Archiv. f. Gyn._, vol. xxix, p. 448.\n\nIn epidemics of Asiatic cholera the mortality among pregnant women\nis extremely high. In the Hamburg epidemic of 1897, fifty-seven per\ncent. of the pregnant women affected died. Abortion is very frequent\nbecause of the hemorrhagic endometritis. The mortality for all\npatients in Asiatic cholera is very great--almost 50 per cent. at\nthe beginning of the epidemic.\n\nTyphus fever is the ship or famine fever of 1847. It is very rare\nnow. When it does occur it is about three times as fatal as typhoid.\nIt is a disease of poverty and war, and is spread largely by the\nbody-louse, as happened in Serbia in 1915. Skilled hygiene, however,\nsoon gains control of the epidemic.\n\nErysipelas in pregnancy is rare, but not infrequent after delivery.\nIn the puerperium it appears commonly as a septic infection in\nabrasions about the parturient canal. When it starts on the face,\nscalp, or breast the prognosis is relatively favorable, but even then\nit causes death; when it starts on the genitalia it has a mortality\nof 43 per cent. Erysipelas causes abortion. As it begins from pus\nbacteria, it is not seen so frequently now as formerly, owing to\ngreater attention to asepsis. In the puerperium it is often an\ninfection brought on by dirty midwives or physicians.\n\nMalaria, if severe, may interrupt gestation through fever or\ncachexia. During labor in such cases the uterine action is feeble,\nand hemorrhages are common after delivery. By proper treatment during\npregnancy these evils can be averted. The infection is spread from\none malaria patient to another by a mosquito (_Anopheles_), as yellow\nfever is spread by another mosquito (_Stegomyia fasciata_).\n\nPulmonary tuberculosis in pregnancy is somewhat frequent; the\nestimate is that about 32,000 tubercular women become pregnant\nannually in the United States; and obstetricians incline to the\nopinion that pregnancy commonly, though not always, makes the\ntuberculosis worse. Nearly all agree that the combined effect of\npregnancy, the puerperium, and lactation is a grave burden on the\nconsumptive and lowers the power of resistance.\n\nTrembley of the Saranac Lake Sanitarium reported that 63 per cent.\nof 240 tubercular married women under his observation gave a history\nwhich showed that the disease was first recognized during pregnancy\nor the puerperium. Schauta's clinic found such origins in 29 per\ncent. Fisberg, Funk, Jacob, Panwitz, and other observers, in a series\nof 1100 cases, said 39 per cent. of these women thought the disease\nbegan during pregnancy or the puerperium.\n\nSome tubercular women during pregnancy give no clinical evidence\nof an aggravation of the pulmonary disease, but these cases are\nexceptional. Tubercular women who apparently improve during pregnancy\nare likely to have a subsequent detrimental reaction. As tubercular\ncases, however, are prone to show exacerbations even if not pregnant,\nit is not possible to say that pregnancy is the sole cause of\nthe progressive lesions in particular instances. Where there are\nno wide or deep areas of infection, there may be no recognizable\ndamage from pregnancy, but advanced and active tuberculosis, with\nfever or cavity formation, does badly, especially if the throat is\ninvolved. The pressure of the enlarged uterus causes dyspnoea; the\ncough and fever may bring on miscarriage. Miscarriage, however,\nis rare in tuberculosis; it is more common in cardiac and renal\ndiseases. Bernheim, in a series of 315 tubercular pregnancies, found\nthat abortion occurred in 23 per cent. The later in gestation the\ntuberculosis becomes florid, the more likely it is that abortion will\nhappen. Conception may take place at any stage of the tuberculosis,\nalthough women in the final stage are commonly sterile. Sometimes\na woman will give birth to a sound child and die herself of\ntuberculosis a few days after the parturition.\n\nPregnancy in consumptive women is not necessarily detrimental to\neach particular patient, nor is it, as a rule, a justification\nfor emptying the uterus of even the viable fetus. Even when the\ntubercular condition grows worse during pregnancy it is not always\npossible to prove that the pregnancy itself is the cause of the\ndeterioration. If the woman conceives in the final stage of pulmonary\ntuberculosis she will die, whether she goes on to term or not.\nBonney[148] describes three cases of advanced pulmonary tuberculosis\nwhich were cured during pregnancy, by the bodily changes peculiar to\nthat condition, but such results are altogether exceptional.\n\n  [148] _Pulmonary Tuberculosis_, p. 550. Philadelphia, 1908.\n\nArtificially induced premature labor sometimes causes more damage\nthan normal parturition at term. Much depends upon the methods\nused for the induction of the abortion. The insertion of bougies,\ncatheters, or sounds is always contraindicated in advanced\ntuberculosis. Hirst of the University of Pennsylvania[149] thinks\nthe notion that tubercular women improve in pregnancy is \"a\nsuperstition,\" and that such women should neither marry nor have\nchildren. De Lee[150] holds that tubercular women should not marry\nbecause the woman is likely to infect her husband and children. He\nthinks the disease grows worse in pregnancy, and that hemorrhage is\nfrequent except in chronic ulcerative tuberculosis. In this last\ncondition pregnancy does not ordinarily aggravate the condition.\nIn tubercular laryngitis complicating pregnancy, K\u00fcttner found the\nmortality to be 90 per cent. Such laryngitis is usually fatal,\nwhether pregnancy is present or not. When there is a miscarriage\nin tuberculosis, the infection often becomes florid and resembles\npneumonia. Advanced cases have a tedious and dangerous labor, with\ndyspnoea and occasionally hemorrhage or cardiac exhaustion. Edema of\nthe lungs is not infrequent.\n\n  [149] _A Text-book of Obstetrics_, p. 427. Philadelphia, 1912.\n\n  [150] _The Principles and Practice of Obstetrics_, p. 480.\n  Philadelphia, 1913.\n\nWilliams of Johns Hopkins University, in the 1903 edition of his\n_Obstetrics_, tells of a woman who died of tuberculous peritonitis a\nshort time after parturition. The uterus was studded with tubercles\nand its interior was covered with tuberculous ulcers. The tubercle\nbacillus had been found in cultures taken from the interior of the\nuterus during life. Her child was born perfectly healthy and remained\nso. Williams says in the same place that the induction of premature\nlabor because of tuberculosis is justifiable only in the interests\nof the child, and this only in those rare cases in which the woman\nis so ill that she probably will die before term. Norris[151] of\nPhiladelphia agrees with Williams that induction of premature labor\nis useless, and he says all authorities unite in this opinion.\n\n  [151] _Pennsylvania Medical Journal_, February, 1916.\n\nA tubercular woman should not nurse her infant because she will\ninfect it and exhaust herself. Infants are very susceptible to\ntuberculosis. Birch-Hirschfeld, in 1891, first demonstrated\ntuberculosis in the fetus, and Schmorl found it in the placenta in\n50 per cent. of a series of cases that he examined. Infection of the\nchild _in utero_, however, is extremely rare even by the placental\nway. There is a high death-rate from tuberculosis among infants,\nbut the infection is postnatal. Dietrich of Berlin found that the\ndeath-rate from tuberculosis among children in Prussia is higher\nduring the first year of life than in any other year.\n\nThe moral conclusion is that artificial abortion in pregnancy\ncomplicated with tuberculosis is never indicated except when the good\nof the child is at stake in the last stage of gestation.\n\n\n\n\nCHAPTER XIX\n\nSYPHILIS IN PREGNANCY AND MARRIAGE\n\n\nSyphilis in pregnancy at times assumes peculiar malignancy. The\nvirulence depends on the patient's power of resistance, and whether\nor not there are septic micro\u00f6rganisms mixed with the syphilitic\nspirochetes. There are, moreover, varying strains of spirochetes\nwhich differ in virulence, or there are familial idiosyncrasies.\nTropical syphilis is worse than northern infections, and syphilis of\nthe nervous system is often incurable. Fournier was of the opinion\nthat a syphilitic woman who becomes pregnant is more likely to abort\nthan a pregnant woman who becomes syphilitic. The percentage of\nfetal deaths is also greater in the first class than in the second.\nThe longer a woman has been syphilitic, provided she has not been\ntreated for the disease, the worse the prognosis for the duration of\nthe pregnancy and the life of the fetus. The earlier in pregnancy\nthe syphilis appears, the worse the prognosis for gestation. General\nfetal mortality in syphilis under the best circumstances is 75 per\ncent. Syphilis should be looked for in every case where the cause\nof an abortion is not evident. Ruge holds that in 83 per cent.\nof repeated abortions syphilis is at fault; late abortions are\ncharacteristic of this disease.\n\nInoculation with syphilis before conception almost always results\nin abortion. In 130 women studied by Le Pileur there were 3.8 per\ncent. still-births before infection by syphilis, but 78 per cent.\nafter infection. In premature labor the child is, as a rule, born\ndead; less frequently it is born syphilitic; still less frequently\nit is born apparently sound, but the syphilis appears later; in\na few cases, when the maternal syphilis is old, the child may be\nborn normal. Interruption of gestation is the commonest symptom in\nsyphilis complicating pregnancy. The labor itself is affected: the\npains are weak and tardy. Abnormal presentations occur frequently\nwhen the fetus is dead. Chancres on the cervix may cause obstruction,\nand there may be indurations so dense as to necessitate cesarean\ndelivery. The perineum may become so friable as to tear, as De Lee\nsays, \"like wet paper.\"\n\nWhen the mother is infected at the time of conception the child is\nalways syphilitic. If the mother is infected early in pregnancy the\nchild is almost always infected. If she is infected late in pregnancy\nthe child may escape infection. Men with tertiary syphilis have\nbegotten children without, to all clinical appearance, inoculating\nthe wife. In such a case the mother may nurse the child with safety\nto herself, but the child will infect a wet nurse other than its\nown mother, and in very rare instances mothers in this condition\nhave been floridly infected. The condition here described is called\nColles's Law.[152] The doctrine of Colles's Law has fallen into\ndisuse because we can now demonstrate by the Wassermann reaction that\nalmost all apparently healthy mothers of this class are in reality\ninfected. The term now used is \"Syphilis by Conception.\"[153] The\nvirus passes through the fetal placenta to the mother, although\nimmunizing substances are held back by the placenta. A fetus cannot\nmake immunizing bodies before its eighth month, and on that account\nthe earlier the fetus is infected, the more likely it is to die.\nRecently, however, some scanty testimony has been collected which\nsustains Colles's Law in a few cases. Ledermann reported three\ncases, and Nonne others, in which the wives of men with tabes or\nparalysis bore syphilitic children and yet never responded positively\nthemselves to the Wassermann test, or showed any symptoms suggesting\nsyphilis. To this list Kroon[154] adds a case corresponding fully\nto the requirements of Colles's Law. A woman of twenty-eight years\nwho had had eight abortions was delivered of a child with undoubted\ncongenital syphilis. The child's father had been infected with\nsyphilis twelve years before. The woman showed no signs of syphilis,\ntwo Wassermann tests were negative, and she nursed the child without\ninjury to herself.\n\n  [152] From Abraham Colles, Dublin, 1837.\n\n  [153] Wolff, 1879.\n\n  [154] _Nederlandisch Tijdschrift voor Geneeskunde_, i, 9.\n\nShould the husband have florid primary or secondary syphilis, and\ninfect his wife at impregnation, abortion is the rule. The commonest\ncases are those where the husband has been treated for syphilis\nmore or less thoroughly before marriage. Even if at the time of\nimpregnation the husband has no apparent infective lesion, the\nchild is usually syphilitic, or it may show signs of the disease\nlater in life. Ibsen's _Ghosts_ is founded on a case like this. If\nthe syphilis is recent, or uncured, the child dies, macerates, and\nis expelled. These conditions recur in pregnancy after pregnancy,\nuntil the virus is removed by time or drugs. As the nucleus of the\nspermatozo\u00f6n is too small to carry the spirochete of syphilis, the\ninfection is through the semen in a manner not yet clear to us.\n\nWolff[155] studied a group of nine syphilitic women and their\nchildren. There were sixty-six pregnancies, but only thirty-three\nviable children were born. Of these last fourteen died in childhood,\nthree committed suicide at twelve, twenty, and twenty-eight years\nof age; and of the thirteen still living only two were normal. The\nothers are all feeble-minded, epileptic, hysteric, or otherwise\nneurotic. Post[156] tabulated the mortality in thirty syphilitic\nfamilies in which there were 168 pregnancies. Of these fifty-three\nended in still-birth or miscarriage and there were forty-four early\ndeaths--a total loss of 57 per cent. Of the children that were born\nalive 38 per cent. are now dead, and of the seventy-one that are\nalive only thirty-nine are apparently healthy. There are very many\ncases of diseased children and adults with serious lesions of obscure\netiology, and in a great number of instances of anemia, malnutrition,\nextreme nervousness, aortitis, bone diseases, vague pain, and similar\nconditions, the origin is congenital syphilis. Stoll,[157] in\nsixty-eight such cases, found a positive luetin syphilitic reaction,\nand a positive Wassermann in 17 per cent.\n\n  [155] _Zeitschr. f. klinisch. Med._, vol. lxxvi. Berlin.\n\n  [156] _Boston Med. and Surg. Jour._, vol. clvii, n. 4.\n\n  [157] _Jour. Amer. Med. Assoc._, October 31, 1914.\n\nGottheil,[158] professor of dermatology and syphilography in Fordham\nUniversity, holds that if a man has gone through a modern treatment\nfor syphilis, given by a competent physician and extended over\nthree years, and if during the fourth year, without treatment, he\nrepeatedly shows a negative Wassermann reaction, he may marry. That\nis the common opinion of physicians, but it is decidedly erroneous.\n\n  [158] _Forchheimer's Therapeusis of Internal Diseases_, vol. ii,\n  p. 421. New York, 1913.\n\nIn one series of 562 cases of hereditary syphilis observed by the\ngreat syphilographer Fournier, sixty children, or over 10 per\ncent., were infected more than six years after the primary parental\ninoculation. He tells of one woman who had nineteen consecutive\nstill-births from syphilis. Gowers[159] says: \"There is no evidence\nthat the disease ever is or ever has been cured, the word 'disease'\nbeing here used to designate that which causes the various\nmanifestations of the malady.\" This statement is too sweeping, but it\nis very near the truth.\n\n  [159] _Syphilis and the Nervous System_, 1892.\n\nBruhns recently reported the outcome of the Wassermann test repeated\nabout yearly from 1908 to 1915 in one hundred private cases infected\nwith syphilis ten or more years before the time of the report.\nIn forty-two the test was constantly negative; in thirty-two,\npositive at first but negative later; in seven, constantly positive\nnotwithstanding repeated courses of treatment; in three, positive at\nfirst, then long negative, but finally changing to positive again; in\neight, negative at first, then positive, and finally negative; and in\neight, negative at first but finally positive. The last three groups\nare particularly significant. In some the long negative reaction, for\nfive or six years, indicated cure, and physicians would pronounce\nsuch cases positively cured; but suddenly they changed to a positive\nreaction without any clinical manifestations showing at the time.\nAfter renewed courses of treatment in the following two years the\nreaction became negative. Among the cases with constant negative\nreaction there were some who developed brain syphilis, or tabes,\nproving that they were not cured despite the absence of clinical\nmanifestations of the disease and the negative Wassermann reactions.\nProfessor Blaschko of Berlin, at the seventeenth International\nMedical Congress in 1913, in the presence of Ehrlich, Wassermann and\nHata, said no one could even talk of a cure of syphilis until an\ninterval of ten years without symptoms had occurred. Where a blood\nWassermann is negative a spinal fluid reaction may be positive.\n\nIn from 60 to 75 per cent. of all cases of tabes or paresis members\nof the family other than the patient have shown infection. The\nproportion of infections in the families of tabetics and paretics is\nfar larger than that found in families in which the syphilis does not\ngo on to these extremes. Tabes is also called locomotor ataxia. It is\na degeneration of a part of the spinal cord, with unsteadiness and\ninco\u00f6rdination of motion, lightning pains, disorders of vision, and\nother symptoms. Paresis is softening of the brain, with insanity and\ndeath.\n\nThese and other facts strongly indicate that the form of syphilis\nwhich ends in tabes or paresis remains infectious over a much longer\ntime than ordinary syphilis does. No one has cured either tabes or\nparesis. Raven reported in 1914 an investigation of ninety families\nin each of which a case of metalues had developed. The interval\nbetween the date of infection and the marriage was known in about\nhalf of these, and it was four years in two families, five years\nin one, and from _six to twenty-one years_ in ten! Fournier, in\n4400 cases of syphilis, saw three cases where the tertiary symptoms\nappeared fifty years after infection, and in one case fifty-five\nyears after infection. Bonnet[160] reported such a case which came to\nhim for treatment fifty-four years after infection. The man had no\nchildren.\n\n  [160] _Lyon Med._, November 7, 1907.\n\nSyphilis that affects the nervous system as in tabes and paresis is\nan incurable syphilis, and there is no means whereby any physician,\nno matter how skilful he may be, can tell whether or not a given\npatient has such an infection. The physician, then, who tells a\nsyphilitic that he or she is cured and lets such a person marry\nis responsible for all the evils that result from his rashness.\nOnce a syphilitic, not necessarily always a syphilitic; but once a\nsyphilitic, _possibly_ and probably always a syphilitic, and that no\nmatter what the treatment or the lack of clinical symptoms. Damaged\ngoods of this kind are to be looked upon as damaged goods forever.\n\nAny man or woman, then, who has ever had a clear case of syphilis\n(and the diagnosis is easy, as a rule) is likely to be for\nthe remainder of life a source of syphilitic infection. There\nis even question of late of spirochete-carriers, as there are\ntyphoid-carriers and diphtheria-carriers, who may infect others while\nnot suffering themselves. If one who has been a syphilitic marries\nwithout informing the other party to the contract of the condition,\nthe injustice is, without doubt, very grave. I should call such\nconcealment a mortal sin, and a condition exposing the sacrament to\nsacrilege.\n\nSuppose the second party is informed of the old infection and is\nthen foolish enough to risk the marriage. No one but an experienced\nphysician has any notion of the indescribable horror that may come\nof taking this risk, and no one has the right to expose his own body\nto infection by syphilis for the advantage of marriage. There is no\napproach to a juridic equilibrium between these two conditions. If\nin such a marriage children are begotten and infected, (1) embryos\nwill die without baptism; (2) later possible children will be born\nwho will die of congenital syphilis; (3) possible children who will\nescape syphilis; (4) children who may have to pass through tabes or\nparesis to death, after begetting other degenerates.\n\nA syphilitic embryo which dies without baptism is better than\nno child at all. It will live in a state of natural happiness\nafter abortion. A baptized child which has congenital syphilis is\nimmeasurably better off than a sound child that lacks baptism.\nEugenics as a prudent investigation of conditions before marriage\nis a good thing; eugenics as the drivel of agitators, who cannot\ntell the difference between a gentleman and a corn-fed hog, is quite\nanother thing. The marriage, therefore, of a person who has been\nsyphilitic to one who knows or does not know of this condition gets\nits mortality chiefly from the damage to one of the contracting\nparties which is imminent. It is difficult to estimate the morality\nof the act as it refers to the children infected congenitally, and to\nsociety.\n\nThe natural order, charity, justice, and related principles give\nevery child the right to be born with bodily health, if such an event\nis possible. If it is not possible in particular circumstances, then\n_melius esse quam non esse_, and the decision in each case depends on\nits own qualities.\n\nIf a physician knows that a person who has been infected with\nsyphilis is about to marry, should the physician warn the innocent\nparty?\n\nThere are several conditions: (1) the infected person about to marry\nmay be actively infectious; (2) the person may be probably infective,\nas any one is who has once had syphilis; (3) the physician may\nknow the fact of the infection officially or unofficially; (4) the\ninfective person may have gone to the physician for treatment for a\ncondition not connected with the syphilis--say, for a bronchitis or a\nbroken bone--and the physician in the examination discovers syphilis.\n\nAgain, there are various kinds of secrets. St. Alphonsus Liguori[161]\nclassifies secrets in three groups: (1) natural; (2) promised;\n(3) entrusted secrets. A natural secret is one which obliges us\nin justice to observe it if divulging it will gravely injure any\none in reputation or possessions. We are not obliged to observe\na secret of this kind at the risk of our lives unless the damage\nfrom the divulging would affect the community gravely. A promised\nsecret obliges to silence either gravely or lightly, according to\nthe intention of the promiser. Where reasonable doubt exists as\nto grave obligation, such obligation does not exist. A promise to\nsecrecy made even under oath is not binding if one is obliged in\njustice to reveal the secret; therefore we must testify to the crime\nof another when a judge legitimately demands our testimony, even if\nwe have promised not to tell anything. If a secret is entrusted to\none, and divulging would cause grave damage, but justice, or similar\ncircumstances, do not oblige us to reveal it, we are bound to observe\nit even when questioned by legitimate authority. Then we may answer\nwe know nothing about it, at least for revelation. St. Alphonsus's\ntext is: \"Potes respondere te nihil scire, scilicet ad revelandum.\"\nHis meaning seems to be: \"You may say you know nothing about the\nmatter inquired into.\" Any other signification would be futile.\nTo say literally, \"I do not know anything I may tell,\" would only\nexpose one to punishment for contempt. He seems to make the answer\na conventional denial, like the \"not guilty\" of a criminal. A judge\nmay not abrogate the natural right by which an entrusted secret is\nprotected, unless the secret is already known in some other way, or\nthere is a just cause for revealing it.[162]\n\n  [161] _Theologia Moralis_, iv, n. 970 et seq.\n\n  [162] Cf. De Lugo, _De Justitia et Jure_, disp. 14, n. 141.\n\nWhen an entrusted secret, however, which is also called a strict\nor absolutely natural secret, is imparted expressly or tacitly,\nsay, to physicians, lawyers, or priests, and becomes a professional\nsecret, it obliges more strictly than any other. There are four\nconditions under which such an entrusted secret may be revealed, at\nleast without mortal sin (except by a confessor): (1) If we have the\npresumed consent of the principal. (2) If the material of the secret\nis trivial, or if it is known from another source, or is already\npublic. Is it a mortal sin to divulge a grave entrusted secret to\na responsible person who is under the same bond? St. Alphonsus,\nDe Lugo, and others say probably it is not, provided the secret\nis not divulged to the particular person from whom the principal\nwished it to be concealed. The term _probably_ here is technical\nand refers more to the absolute truth of an assertion than to its\npractical application. (3) One might reveal such a secret without\nmortal sin, through inadvertence or thoughtlessness, or under the\nsupposition that it is not a grave secret. Some moralists hold,\nhowever, that to excuse from mortal sin, the revealer must be certain\nthat the matter of the secret is not grave. (4) Such a secret may\nbe revealed if keeping it would cause public injury, or injury to\nan innocent person, or injury to the person to whom the secret has\nbeen entrusted; then the law of charity demands that it be revealed.\nTherefore, even if one has bound himself under oath, he may reveal\nthe secret--always excepting a priest or confessor. This is the\ncommon doctrine of moral theologians. It is for the common good of\nhuman society that entrusted secrets be absolutely kept unless so\ngrave a damage befalls another from such observance that it becomes\nmore conducive to the public good to reveal than to conceal. To let\nan infective syphilitic, for example, spread his contagion merely\nbecause an entrusted secret should be kept is a much greater damage\nto the public than a good.\n\nBarrett[163] says a physician may not divulge the diseases of a\nfamily to an insurance company unless the family assents; he may\nnot tell the man before marriage that the woman had been operated\nupon, say, for ovariotomy, unless the woman gives permission; nor\nmay he let the woman know, before marriage, of those diseases of the\nman which are not contagious. Ho says further that if a man has had\nsyphilis and is now completely cured, the physician may not reveal\nthis previous condition to the woman.\n\n  [163] Sabetti-Barrett, _Compend. Theol. Moral._, n. 565. New\n  York, 1915.\n\nThat doctrine about ovariotomy, if it includes double ovariotomy, is\ndisputed by physicians because, they say, such a woman is sterile\nand she knowingly is going to deprive the man of his chances of\nhaving children; secondly, a woman upon whom double ovariotomy\nhas been performed is almost always a neurasthenic invalid with a\nmarked tendency to insanity, and it is a grave injustice to any man\nto saddle such a degenerate upon him for life by treachery. The\nprospective injury to the man is so great that the physician should\nfirst try to induce the woman to divulge her condition, and if she\ndoes not, the physician at least _may_ divulge it.\n\nSecondly, I deny most emphatically that any physician can tell that\na man who once has had syphilis is completely cured and is not a\nsource of infection. The facts I have cited in this chapter prove\nconclusively that once a syphilitic always probably a syphilitic,\nand the risk is always so great that the physician is obliged first\nto insist that the man does not marry, and if the man persists the\nphysician may let the woman know. If preparations for the marriage\nhave been made publicly, the physician will, as a rule, for his pains\nfrom the woman and her family get only a rebuff and the woman will\nlater get her syphilis more or less certainly. If the man is actively\ninfective the physician is bound to let the woman know, through\nher confessor if no other way presents, provided the man cannot be\nfrightened out of his scoundrelism. If nothing else avails, the\nphysician would be justified in reporting such a man to the Board\nof Health or the sanitary police. Barrett says the physician may be\nexcused from divulging that the man has infective syphilis if such a\nrevelation would cause the physician to lose the confidence of his\npatients. It never does have such an effect, although physicians\nconstantly expose such cases in the interests of humanity. Because\na man who is apparently cured of syphilis may or may not infect the\nwoman, this doubt probably excuses the physician from the strict\nobligation of divulging the condition, although he _may_ tell her if\nhe wishes to do so, _salvo meliore consilio_, as far as the release\nfrom strict obligation to divulge is concerned.\n\nIf a patient with syphilis goes to a physician for the treatment\nof some other physical disability, and the physician discovers the\nsyphilis in the course of the examination, this knowledge of the\nsyphilis would be a tacitly entrusted secret. Whether, however, a\nsecret that a man is actively infective or very probably infective is\nentrusted either tacitly or directly, it is not a privileged secret\nowing to the danger or certainty of extraordinary calamity to the\ninnocent second party.\n\nThe fact that in these cases of active or latent syphilis the disease\nhas been acquired criminally does not in itself affect the state of\nthe question one way or another--a criminal syphilitic has a right to\nhis reputation and goods despite his moral condition; but even where\nthe disease has been acquired without moral guilt the syphilitic is\nalways a formally or materially unjust aggressor in a prospective\nmarriage to an innocent and uninfected woman, and is to be treated\naccordingly. If a woman may kill an unjust aggressor in defence\nof her chastity, and if _quod liceat per se licet per alium_, her\nnatural protectors, kin, physician, and so on, may at least divulge\nthe secret of the man's condition in defence of her from a fate which\nin many respects is worse than rape.\n\nIn keeping with this matter of entrusted secrets it is worth noting\nthat physicians should remember that the case histories they leave\nafter them at death, or which they leave unguarded in their offices,\nare likely to be read by some third party who has no right to the\nsecrets they contain. Case histories which the patients would not\nhave divulged should be kept in cipher so far as proper names and\naddresses are concerned.\n\n\n\n\nCHAPTER XX\n\nGONORRHEA IN MARRIAGE\n\n\nGonorrhea is caused by the gonococcus discovered by Neisser in 1879.\nThe name was given to the disease in the second century by Galen,\nwho supposed that the condition is a spermatorrhea. The infection\nbegins as a surface inflammation and gradually penetrates more or\nless deeply into the underlying tissues. In the male, gonorrhea may\naffect any part of the body; and when the disease is chronic it is a\nsource of infection for years. If a man who has had gonorrhea wishes\nto marry after careful treatment, most physicians will permit him to\ndo so if he passes the customary tests which indicate cure, but he\nis always dangerous. The tests are: (1) the microscopic and cultural\nexaminations of the centrifugalized morning urine--the washings\nfrom the urethra must be negative after repeated trials and over a\nspace of months; (2) the microscopic and cultural examinations of\nurethral spontaneous and artificial discharges must be negative in\nthe same manner; (3) the microscopic and cultural findings of the\nsecretion expressed from the prostate and seminal vesicles must be\nnegative in the same manner; (4) urethroscopic examinations of the\nanterior and posterior urethra must show no unhealed lesions; (5) the\ncomplement fixation test is to be repeatedly negative. The complement\nfixation test is like a Wassermann reaction, but the antigen should\nbe polyvalent. This test does not give a positive reaction where no\ngonorrhea is present, but it is often negative where the gonococcus\nis present. Hence a positive result has value, but a negative result\nhas little or no value. All these tests are to be tried repeatedly,\nand if negative for months, the physician may say the man is\n_probably_ cured, but no physician can guarantee the cure so as to\ntake the responsibility of the decision. Not one physician in five\nhundred can make these tests himself, because physicians in general\nlack the special training and the means to make them. As the effects\nof gonorrheic infection in a woman are so appalling, any woman who\nwittingly marries a man who has had gonorrhea is very rash, and the\nman who takes the risk of infecting such a woman is a rascal.\n\nA physician is obliged to let a woman who innocently is about to\nmarry a \"cured\" gonorrheic know of the man's condition, as in a\ncase of supposedly cured syphilis. Taber Johnson, Noble, and other\nauthorities, say no one can tell when a gonorrheic is absolutely\ncured.\n\nIn women infection of the cervix uteri occurs in about 80 per\ncent. of the cases of acute gonorrhea, and in 95 per cent. of all\nchronic cases. The infection may extend up into the uterus at the\nmenstrual period or just after parturition. In the cervix, owing\nto the histologic formation, the disease tends to chronicity,\nbut the inflammation within the uterus is much more likely to\nsubside naturally. Chronic gonorrhea of the endometrium is usually\naccompanied by tubular infection. The infection of the uterus may be\nsuperficial or it may extend down into the underlying myometrium.\n\nThe inflammation extends from the endometrium to the Fallopian\ntubes and beyond, causing salpingitis, pyosalpinx, hydrosalpinx,\ntubo\u00f6varian abscess, tubo\u00f6varian cysts, and pelvic peritonitis. The\nmost frequent form of tubal gonorrhea is pyosalpinx, or pus tube.\n\nIn the acute stage of tubal infection the tubes become elongated\nand swollen, and the mucous surfaces within are covered with\na seropurulent exudate. This condition is called salpinx or\nsalpingitis. When the condition advances so far that the external\nabdominal ostium of the tube is closed, a pyosalpinx forms. The\npyosalpinx may be quite large. A hydrosalpinx is like a pyosalpinx,\nwith both tubal ends sealed, except that its content is a serous or\nwatery fluid. When infected material escapes through the distal end\nof the tube, perio\u00f6phoritis develops, and the ovary becomes adherent\nto the tube and other adnexa. More commonly only the surface of\nthe ovary is affected, but frequently the infection gets into the\nbody of the ovary and causes o\u00f6phoritis. The ovary then swells and\nthere is a tendency to the formation of retention and other cysts,\nor an abscess of the ovary. A tubo\u00f6varian cyst is a hydrosalpinx\nin communication with an ovarian retention cyst, and a tubo\u00f6varian\nabscess is a like formation.\n\nGonorrhea, especially in women, is likely to be very chronic. Emil\nNoeggerath, who in 1872 published a book[164] which changed the\nmedical doctrine on the disease, said of women, \"Once infected,\nalways infected.\" Norris[165] reports a case where the gonococcus was\nlatent in a man for twenty years, and he then infected his wife and\nwished to divorce her until he found that he himself was at fault.\nSax[166] reported an infection after fourteen years; MacMunn,[167]\none after fifteen years. These are exceptional durations in the male\nfor virulence, though not for continuance of the diplococcus.\n\n  [164] _Die latente Gonorrhoea in weib. Geschlect._ Bonn.\n\n  [165] _Gonorrhea in Women_, p. 123. Philadelphia, 1913.\n\n  [166] _Trans. Amer. Urological Assoc._, vol. iii.\n\n  [167] _Lancet_, November 24, 1906.\n\nNeisser, who discovered the cause of gonorrhea, holds that, with\nthe exception of measles, gonorrhea is the most widespread of all\nmaladies. By sterilizing men and women and by abortion it holds down\nthe birth-rate more than any other disease. The number of deaths\nfrom the consequences of gonorrhea (pelvic abscess, peritonitis,\nsepticemia, endocarditis, and so on) is enormous. Norris thinks that\n12,000 prostitutes die annually from the effects of gonorrhea alone.\nWoodruff[168] holds that 60,000 is nearer the truth. The estimate,\ntoo, is that 50 per cent. of all pelvic inflammatory diseases in\nwomen is gonorrheic; and Neisser, Bumm, and F\u00fcrbinger hold that from\n20 to 50 per cent. of childless marriages are due to gonorrhea.\nProbably more than 20 per cent. of all the blindness in the world\nis from the same cause. The Committee of Seven,[169] in 1901, after\nexamining most of the hospital records in New York and hearing from\n4750 physicians, estimated that there were more than 220,000 venereal\npatients in New York City. Bierhoff[170] reckoned that in 1910 there\nwere about 800,000 gonorrheics in that city. In 1906, in Baltimore,\nthere were 3310 cases of the infectious diseases like measles,\ndiphtheria, scarlet fever, and tuberculosis combined, but 9450 cases\nof venereal diseases. In New York City, in round numbers, there\nare annually about 41,000 cases of infectious diseases, excluding\nthe venereal group, but 243,000 cases of venereal diseases--over\nfive times more cases of venereal diseases than of all the other\ninfectious diseases together. Of 12,000,000 persons insured in\nGermany, 750,000 annually are infected with venereal diseases. In the\nUnited States navy between 1904 and 1908, with an average of 43,165\nmen in the navy and marine corps, there were 32,852 admissions to\nthe hospitals for venereal diseases, and of these 11,526 were cases\nof gonorrhea. This report is far below the actual numbers, as only\nmen incapacitated for work are included in the list. In the English\nnavy in 1906 the daily number of men rendered inefficient by venereal\ndiseases was 867. In the total relative number of venereal diseases\nthe American army and navy, before the present war, were the worst in\nthe world, the Japanese navy next, the English army and navy next.\n\n  [168] _Expansion of Races._ New York, 1909.\n\n  [169] _Medical News_, December 21, 1909.\n\n  [170] _New York Med. Jour._, November 12,\n  1910.\n\nSullivan and Spaulding[171] reported on the prevalence and effects\nof gonorrhea in 522 women and girls in a Massachusetts reformatory\nfor women. Of these women 75.7 per cent. had gonorrhea by positive\ndiagnosis. The average length of time the infection had existed when\ndiagnosed was four years and five months, but one woman had had the\ndisease for twenty-six years, and seven had had it for over twenty\nyears. In 82.7 per cent. there had been no cessation of the clinical\nsymptoms from the time of infection to the time of diagnosis. Of the\ntotal number 68 per cent. had pelvic inflammation on one side, and 27\nper cent. had it on both sides. There were 41 per cent. of the cases\nwhich had had surgical operations or which required such treatment.\n\n  [171] _Jour. Amer. Med. Assoc._, January 8, 1916.\n\nOf 63 women committed for alcoholism 52.4 per cent. had gonorrhea,\n42.8 per cent. had syphilis, and 9.6 per cent. had doubtful\nsyphilis; but of 400 women who had been at some time prostitutes 98.2\nper cent. had gonorrhea, 65.5 per cent. had syphilis, and 9.5 per\ncent. had doubtful syphilis. Of 119 mental defectives among these\nwomen, 90.8 per cent. had gonorrhea, 61.3 per cent. had syphilis, and\n6.7 per cent. had doubtful syphilis.\n\nDr. Thomas Haines[172] reported on 365 cases of boys and girls under\neighteen years of age committed to an Ohio reformatory, and of these\n20.8 per cent. had syphilis, and it was mostly acquired syphilis, not\ncongenital--over one-fourth of the boys were so affected. McNeil[173]\nexamined 1200 adult negroes in Galveston, Texas, for syphilis and\nfound the disease in 30 per cent. of the 1200.\n\n  [172] _Jour. Amer. Med. Assoc._, January 8, 1916.\n\n  [173] _Jour. Amer. Med. Assoc._, September 30, 1916.\n\nHoward Kelly[174] estimated that venereal diseases cost the United\nStates three billion dollars annually, and Norris thinks this\nestimate too low. The ravages of the disease are so frightful,\nphysically and morally, that any one who spreads it by infection,\nespecially of an innocent woman, is guilty of the gravest moral\ninjustice. Morrow[175] thinks that 250,000 married women in the\nUnited States are suffering from gonorrhea. As most of these\nunfortunate women are infected by immoral husbands, and as the\ninvalidism and suffering they undergo are indescribable and cure is\noften impossible, the physician who permits a gonorrheic to marry\nwithout a protest is responsible for the evil as an accomplice; and,\nas has been said, once a gonorrheic, probably always a gonorrheic.\n\n  [174] _Jour. Amer. Med. Assoc._, October 6, 1912.\n\n  [175] _Social Diseases and Marriage_, 1904.\n\nPelvic inflammatory disease includes in the uterus and its adnexa\nalone metritis, salpingitis, o\u00f6phoritis, pelvic peritonitis,\ncellulitis, lymphangitis, and perimetritis. Pus may rupture into the\npelvic cavity and set up local or general peritonitis or septicemia.\nIt may burrow through from behind the uterus into the vagina, rectum,\nor other parts of the intestines, or into the bladder, and leave\nfistulas. Pus has been known to get through the abdominal wall\nitself. When the disease advances beyond the tubes there is, as a\nrule, invalidism until after the menopause, although the woman may\nbe cured by surgery. Even skilled surgery does not always cure,\nbecause it is practically impossible to get rid of the gonococcus\nonce it has been fixed in the tissues.\n\nIn cases where the gonorrheic or other bacterial infection has been\nchronic in the uterine adnexa, palliative treatment will in a certain\npercentage of cases make surgical intervention unnecessary, and\nwhen such treatment does not avail we must decide between the total\nremoval of organs and the partial removal. Partial removal is called\nconservative surgery, and the term conservative is used as a synonym\nof preservative. Prochownick[176] reported 420 cases where pus in\nthe tubes or ovaries was let out extraperitoneally, and no organs\nwere removed. Of these cases, one hundred and sixty, or 38 per cent.,\nwere permanently cured. Fourteen of the one hundred and sixty who\nhad received only one treatment subsequently gave birth to children,\nand three aborted. After a second treatment twenty-seven remained\nwell and three became pregnant, of whom one aborted. Olshausen,[177]\na great authority in gynecology, used the palliative treatment, and\nhe commonly waited for nine months after the infection and until the\ntemperature was normal. Goth[178] reported excellent results in seven\nhundred cases of pelvic disease treated by the palliative method.\nThe chief objections to this method are the time required to get the\nresult, and the difficulty of controlling the patients and their\nchronically diseased husbands, who reinfect them despite the medical\nprohibition of marital intercourse.\n\n  [176] _Monatschrift f. Geburt. u. Gyn\u00e4._, 1909, n. 20.\n\n  [177] _Zeitschr. f. Geb. u. Gyn._, 1907, vol. lix, n. 1.\n\n  [178] _Archiv. f. Gyn._, vol. xcii, n. 2.\n\nIn cases of chronic pelvic peritonitis the question comes up\nfrequently whether the womb and both tubes and ovaries should be\nremoved wholly or in part. The text-books decide the question without\nany heed whatever to the notion of the morality of mutilation as\nsuch. They take into account the age of the patient, whether she has\nchildren or is desirous of maternity, whether or not she supports\nherself by manual labor, her temperament and character, and the\nresults attained by men who have tried various methods of operating.\n\nThe conservative surgery of the uterus and its adnexa in gonococcal\npelvic peritonitis was for many years looked upon with disfavor\nby surgeons. These conservative operations often failed or later\nrequired secondary intervention. Preliminary palliative treatment\nas now used greatly lessened the number of failures. Operations\nin peritonic conditions are dangerous because they may let loose\nencysted bacteria and start up a general septic peritonitis, which\nmay be fatal. By delay and palliative treatment the virulence of\nthe bacteria subsides, except where the woman is reinfected by her\nhusband. In any case the blood-count should have been normal for\nat least a month and a half before any surgical interference is\nattempted. Olshausen waited nine months to let nature disinfect the\npus.\n\nThe removal of a part of a tube is called salpingotomy; the taking\nout of the whole tube is salpingectomy; the opening up of a shut\ntube is salpingostomy. The presence of pus in a tube is absolute\nindication for removal according to the gynecologists at present.\nHoward Kelly and others have succeeded at times in such cases with\nconservative surgery, yet such treatment is now deemed obsolete--the\ndangers and failures seem to overbalance the little good effected.\nThe end of conservative surgery is to try to restore function without\npain, to preserve menstruation and ovulation, to put the organs in a\ncondition to make pregnancy possible, and to preserve the internal\nsecretion of the ovaries. The ovaries, so far as the woman's health\nis concerned, are the most important of her generative organs. If a\nwoman is at the end of her child-bearing age there is no reason to\npreserve the tubes when they are affected, and conservation is likely\nto fail; but the ovaries should always be preserved, wholly or in\npart, when possible.\n\nIf one tube is infected from the uterus many gynecologists are\ninclined to remove both tubes. When a single tube is affected the\ncause is seldom the gonococcus, but some other bacteria which are\nnot persistent. When both tubes are affected the cause is commonly\nthe gonococcus, and attempts at preservation then fail, as a rule.\nNorris, who is a reliable authority, holds that \"the only cases\nin which a salpingostomy is justifiable is on old, non-active\nhydrosalpinges, and in those cases of tubal occlusion or phimosis\nresulting from extratubal inflammation, such as sometimes result from\nappendicitis or ectopic pregnancies.\"[179] When a tube is shut, if\nit can be opened the opening tends to close again. A few cases of\nsubsequent pregnancy have occurred after salpingostomy, but such a\nresult is exceptional, because the origin is usually the gonococcus,\nwhich destroys tissue and is very persistent.\n\n  [179] _Gonorrhea in Women_, p. 285. Philadelphia, 1913.\n\nThe ovary corresponds to the testicle, and the Fallopian tube to\nthe vas deferens. Removal of the ovaries, or removal or closure of\nthe Fallopian tubes, renders the woman sterile, but removal of the\novaries has other profound effects beside sterility. Loss of the\novaries brings on suppression of ovulation, menstruation, pregnancy,\nand ovarian internal secretion, various neuroses, and a tendency to\ninsanity in certain cases.\n\nThe testicles and prostate gland produce an internal secretion\ncontaining spermin, and the ovaries a similar nitrogenous base called\novarin, which acts like spermin. The suprarenal glands secrete\nepinephrin; the thyroid gland and the pituitary body also make\ninternal secretions, and these secretions sustain the tone of the\nblood-vessels and effect immunity against those toxins that arise\nfrom metabolic waste substances while these are in the body before\nelimination. If there is a hypersecretion from one or more of these\nglands, the excess causes congestion of the cerebrum and cerebellum\nand of the nerve centres there, and one effect may then be a sexual\nerethism that leads to masturbation and similar deordination.\n\nCastration in the male or ovariotomy in the female stops all\nproduction of spermin and ovarin. In man the prostate gland also\nceases its function after castration, and vasectomy lessens the\nproduction of spermin. In castration or spaying, again, when we\nremove the power of producing spermin or ovarin, that function of the\ntestes and ovaries whereby the body is immunized against poisoning\nby its own effete material is also inhibited, and evil effects arise\nfrom this waste material. These toxins act just as would an excess of\nspermin or ovarin--they congest the cranial nerve centres, excite\nfever, neuroses, or temporary sexual erethism. This excitement may\ngradually subside as equilibrium is restored and neutralization\neffected, through a compensatory overproduction of the internal\nsecretions by the other glands remaining in the body. Cimoroni[180]\nfound after ovariotomy an increase in size of the pituitary body\nwith dilatation of the blood-vessels. Goldstein[181] reported a\ncase of gigantism from overactivity of the pituitary gland after\ncastration. Acromegaly in cases where there was no castration has\nbeen accompanied by atrophy of testicles and ovaries. Cecca[182]\nfound like effects in the thyroid, and several have observed these\neffects in the adrenals. All these results have also been produced\nexperimentally on animals.\n\n  [180] _Policlinico_, 1907, p. 16.\n\n  [181] _M\u00fcnchener medizinische Wochenschrift_, April 8, 1913.\n\n  [182] _Soc. Med.-Chir. de Bologne_, 1904.\n\nWomen at the menopause frequently are observed who have become\nneurasthenic from the irritation of waste material intoxication which\nis not neutralized because the ovaries are ceasing to function.\nOvariotomy in younger women produces this menopause artificially and\nsuddenly; and women from whom both ovaries have been removed, as a\nrule, become neurotic invalids with a tendency to insanity if they\nare unstable in character or have a bad inheritance. If the whole\nthyroid gland is removed, death results from intoxication. Extreme\nobesity is an effect of undersecretion by the glands and a consequent\nlack of oxidation. Fat children have deficient glands, as a rule, and\neunuchs grow fat as capons do. Removal of the ovaries before puberty\narrests or prevents the development of the uterus; removal after\npuberty stops menstruation, the breasts atrophy, and there is an\narrest of general physical growth.\n\nGordon[183] reported on 112 cases of o\u00f6phorectomy. Of these\nthirty-four had had before operation various symptoms of\nneurasthenia, hysteria, or psychasthenia, and vague abdominal\ndisturbances. Surgeons in each of these thirty-four cases blamed\nthe ovaries for the symptoms; and although these organs were not\ndiseased in any degree, the surgeons removed them. In twenty-five\nof these cases there was no improvement whatever; in the remaining\nnine there was improvement for a few weeks, but complete relapse\nlater, and finally their symptoms grew worse. The obsessions became\npermanent and expanded. Those women in the group who had hysterical\nparoxysms began to have stronger and more frequent attacks. Several\npsychasthenics had to be confined in asylums for the insane. Three\nof the women who had complained merely of vague nervous symptoms, as\npain in the abdomen, head, or back, or of constipation or diarrhea,\nafter o\u00f6phorectomy grew irritable, highly nervous, quarrelsome,\nfickle, restless, showed a tendency to travel about, to complain of\nothers; finally there was insomnia, and loss of appetite or voracity.\nIn the remaining seventy-five cases one or both the ovaries were\ndiseased, but both ovaries were completely removed. All these women\ndeveloped symptoms like those described above, but several grew\nmuch worse in their mental condition than the psychasthenics among\nthe first thirty-four women. The generally observed symptoms are:\nrestlessness with a tendency to move from place to place; loss of\nself-control; dissatisfaction with all persons and things; want of\ninterest in work; indolence; pessimism. Sometimes there are outbursts\nof anger, with a tendency to attack. The mental conditions do not, as\na rule, become clearly developed melancholias or manias, although a\nfew do grow definitely insane. The morbid symptoms, however, persist\nobstinately. After ten years' observation Gordon found no improvement\nin some of these psychasthenics.\n\n  [183] _Jour. Amer. Med. Assoc._, October 17, 1914.\n\nWhen the ovaries must be removed for diseases like cystic\ndegeneration or abscess, the surgeon leaves, if possible, part of an\novary, or he engrafts part of an ovary in the abdominal wound, under\nthe skin, or elsewhere. This grafting is beneficial in many cases,\nbut it has little or no effect in many others. The graft is absorbed\nand it disappears in a year or two, but before it is absorbed it\nmakes the onset of the surgical menopause gradual and thus prevents\nmuch suffering. In thirty-two cases reported by Chalfant[184] the\ngraft gave evidence of functioning in five of seventeen women from\nwhom the uterus and ovaries had been removed; in others it acted\nfor months and then failed; in others it lessened the unfavorable\nsymptoms; in others it had no effect at all. Stocker[185] reported\ntwo successful implantations of ovarian grafts and one testicular\ngraft.\n\n  [184] _Surgery, Gynecology, and Obstetrics_, November, 1915.\n  Chicago.\n\n  [185] _Correspondenz-Blatt f. Schweizer Aerzte_, February 12,\n  1916.\n\nGiles[186] says that in his series of 157 cases of double\no\u00f6phorectomy severe mental depression occurred in various groups in\nfrom 10 to 33 per cent., and two women became insane. Sex instinct\nwas abolished in 16 per cent. Dickinson[187] found, in 200 cases\nwhere one or both ovaries had been removed, that not more than 20\nper cent. fell into the surgical menopause even when the uterus\nhad been taken out; but Giles, in 50 removals of one ovary, found\nirregularity, diminution, or cessation of the menses in 16 per\ncent. Carmichael, Valtorta, and McIlroy[188] discovered in animals\na compensatory hypertrophy of the remaining ovary after one ovary\nhad been removed. The internal function and nutrition seem to depend\nupon the ovarian secretion, as atrophy occurs after bilateral\no\u00f6phorectomy. In all operations upon or near the ovaries there is\nlikelihood of interference with the blood supply of the ovary, either\nby including ovarian arteries in the ligatures, or by tension of\nthese vessels, which occludes them, or by malposition and prolapse of\nthe ovary, which kinks them: these accidents result in degeneration\nor retention cysts. In most cases of pelvic peritonitis the uterus is\nretrodisplaced, and this position prevents cure until it is corrected.\n\n  [186] _Jour. Obstet. and Gynecol. of Brit. Empire_, March and\n  April, 1910.\n\n  [187] _Trans. Amer. Gyn. Soc._, vol. xxxvi, p. 324.\n\n  [188] Norris, _Gonorrhea in Women_, p. 289.\n\nWhen there is pus in the ovary, resection, in the opinion of\ngynecologists at present, is not an advisable operation; the ovary\nshould be removed. Watkins,[189] however, says he resects small\novarian abscesses in young women with good results. In resection the\nblood supply is, as has been said, usually disturbed, and the cause\nfor the operation is, as a rule, the gonococcus, and both these\ncircumstances make the prognosis bad. The stitches necessarily used\nin resection operations are an additional source of irritation.\nTuretta[190] speaks in favor of resection in certain cases. A single\nretention cyst may be resected, especially when pedunculated.\nBoldt[191] had only one bad result in forty-five resections where a\npart of the ovary was saved. If the blood supply after the resection\nis evidently to be poor, resection is useless. Skill in surgical\ntechnic has much to do with success in all these cases. When the\nuterus is removed because of tumors, even near the time of the\nmenopause, if one or both ovaries can be left in, this should be\ndone. In such conservative operations Dickinson found 80 per cent.\nof the patients free from nervous disturbance at the time of the\nmenopause.\n\n  [189] _Jour. Amer. Med. Assoc._, January, 1913.\n\n  [190] _Il Policlinico_, January 3, 1919.\n\n  [191] _Trans. Amer. Gynecol. Soc._, vol. xxxiv, p. 327.\n  Philadelphia, 1909.\n\nPolak[192] describes an operation for the preservation of the\nmenstrual function in double suppurative disease of the tubes\nand chronic metritis. He maintains that even if only one tube is\ninfected, both should be removed because this apparently sound\nsecond tube will later, almost as a rule, show infection--probably\nby extension from the fundus of the uterus inside. Ordinarily\ninflammation of the tubes happens to be bilateral. Owing to the\npersistence of the gonococcus in the uterine muscle, surgeons are\ninclined to the removal of the whole uterus and both tubes. After\nsuch an operation menstruation ceases, and in the removal of the\nuterus the blood supply to the ovary is interfered with so that\nthe ovaries degenerate. The consequent artificial menopause has\na decidedly injurious effect on the woman's general physical and\nmental health. The parts of the uterus permanently infected by\nchronic gonorrhea are the cervical region, the fundus and the partes\ninterstitiales of the Fallopian tubes. Polak advises that in cases\nwhere surgeons usually remove the tubes and the whole uterus they\nshould instead cure the cervical infection by the cautery and take\nout the tubes, but in place of the removal of the whole uterus\nthey should cut out a wedge including the fundus and the partes\ninterstitiales of the tubes. This leaves the body of the uterus\nand does not injure the circulation to the ovaries. In the last\nseventeen cases thus operated upon by him he had success.\n\n  [192] _Jour. Amer. Med. Assoc._, December 8, 1917.\n\nWhen it is necessary to remove both ovaries and tubes an opinion very\ncommon now is that it is better to take out the uterus also, because\nin such cases the uterus and vagina atrophy and this condition later\ncauses trouble. Giles came upon such trouble in 11 per cent. of\nsixty-two cases. As the uterus is useless after the removal of the\novaries and tubes, there is no reason why it should not be removed.\nThe danger of atrophy is sufficient reason for the mutilation. In\noperations for pelvic peritonitis it is well to remove also the\nappendix, because it is nearly always diseased, or it will give\ntrouble from adhesions later and cause a secondary operation. It has\nno function we know of at present.\n\nIn conservative surgery of the uterus and adnexa for pelvic\ninflammatory diseases, the results attained by four skilled surgeons\nare: Giles cured 90 per cent. of 132 cases; Polak cured 35 per\ncent. of 300 cases; Robins cured 100 per cent. of 20 cases; Norris\ncured 73 per cent. of 191 cases. Polak's patients became pregnant\nafter operation much oftener than those of the other operators.\nSeventeen per cent. of his patients, from whom he removed one\novary and resected the other, became pregnant. Giles found that of\nhis married patients under fifty years of age at the time of the\noperation 25 per cent. became pregnant and went to term. They bore\ntwenty-five children. Five of these also miscarried. In sixty-eight\nof Morris's cases seventeen were delivered of living children after\nthe operation; three had two children each, one had three children,\nand there were seven miscarriages. In one of his cases where he\nremoved one ovary and _both_ tubes, the woman bore a healthy\nfull-term child two years after the operation. Dudley[193] found that\nabout 10 per cent. of 2168 cases of resection became pregnant after\noperation. Ectopic gestation is likely to occur in a few cases after\nconservative operations. Giles had seven such cases in his series of\n132 operations, Polak one, and Norris two.\n\n  [193] _Jour. Amer. Med. Assoc._, vol. xli, n. 24.\n\nWhen it is necessary to remove the uterus, the choice between\nsupravaginal hysterectomy, where the cervix is left in after the\ndestruction of its mucosa, and panhysterectomy, where the cervix and\nthe body of the uterus are removed, offers no moral problem except\nthe necessity of deciding upon what will be best for the woman.\nRupture of a pus tube is a very dangerous accident--all the patients\nsuffering from such a rupture die if not operated upon, and fifty per\ncent. die even after operation. A physician may do this damage by\nignorant or careless examination, and he may be morally responsible\nfor the death. The accident happens not unfrequently from marital\ncongress, and if the husband has been warned by a physician but does\nnot heed this warning, he is guilty of murder if the woman dies after\nrupture of the pus tube.\n\nPregnant women are more liable to infection by the gonococcus than\nnon-gravid women, because of the increased blood supply to the\ngenerative organs in gestation, and the softening of these organs.\nFor the same reason, latent gonorrhea is likely to become active and\nto spread during pregnancy. A like activity and extension of latent\ngonorrhea often occurs during menstruation. Women with gonorrhea\nare commonly sterile--this is the chief reason why prostitutes are\nusually sterile. In married women gonorrhea may cause dyspareunia; it\nmay bring on abortion through endometritis; it may shut the tubes and\nprevent conception; it may destroy the ovaries.\n\nThe disease is extremely frequent during pregnancy. Gurd[194]\nisolated the gonococcus in 52 of 113 pregnant women who came to his\ndispensary service because of pelvic pain. Leopold, Stephenson,\nFruhinholtz, and many others estimated that about 20 per cent. of all\npregnant women have gonorrhea, but more recent observers think that\nfrom 5 to 10 per cent. is nearer the truth.\n\n  [194] _Montreal Med. Jour._, vol. xxxvii.\n\nWhen a pregnant woman has gonorrhea great care must be taken in\ntreatment to prevent abortion. Powerful antiseptics in the cervix,\nor dilatation of the cervix, are not permissible, and operative\ninterference is to be delayed as long as possible--in each instance\nto avoid abortion. The vaginal douche as a routine treatment is not\nused now by obstetricians in these cases. When the gonorrhea is in\nthe uterus douches of hot bichloride solution, 1 to 10,000, are\nused twice daily during the last few weeks of gestation, with the\nintention of saving the infant's eyes from infection during delivery.\nAfter delivery the cavity of the uterus should not be entered with\ninstruments lest infection be carried in, unless absolute necessity\nrequires this instrumental procedure. Post-partum gonorrheal sepsis\nis differentiated from other septic conditions chiefly by the history\nof gonorrhea in the husband, by bacteriological examinations, and by\nthe technical differentiation of symptoms.\n\nThe moral guilt of a person who infects another with gonorrhea\nis affected by the extent of the physical injury done. Gonorrhea\ncauses, besides the effects already described: (1) chronic cystitis,\nwith all the suffering, loss of work, and danger of renal infection\nin such a condition; (2) lymphadenitis of the inguinal canal, and\nrarely of other places; (3) proctitis, or inflammation of the rectum,\nespecially in women and young children; (4) ophthalmia, vaginitis,\nand proctitis in infants and children, and metastatic conjunctivitis;\n(5) stomatitis or inflammation of the mouth in adults and children;\n(6) nasal gonorrhea (a doubtful condition); (7) gonorrheal\nsepticemia, bacteremia, or toxemia, which may affect any organ\nin the entire body; (8) bone and joint lesions: (_a_) gonorrheal\narthritis in any joint in the body (this condition may be fatal,\nor it may leave permanent disability, or it may disappear); (_b_)\ntenosynovitis, or pain, swelling, and edema along affected tendon\nsheaths; (_c_) gonorrheal periostitis, where the bone and periosteum\nnear a joint are affected; (_d_) perichondritis and chondritis, a\nrare condition, where cartilage is attacked; (9) endocarditis, or\ninflammation of the lining membrane of the heart (one of the most\nfrequent secondary lesions of gonorrhea); (10) pericarditis, or\ninflammation of the sac which contains the heart; (11) myocarditis,\nan inflammation of the heart muscle itself, usually as an extension\nof endocarditis; (12) aortitis, or inflammation of the aorta--a rare\ncondition; (13) phlebitis, an inflammation of the veins--a very\nrare condition; (14) thrombosis, or blocking of a blood-vessel by\nexudate (this may be fatal); (15) skin lesions, as erythema, erythema\nnodosum, bullous and hemorrhagic eruptions, hyperceratosis, and\nulcers; (16) gonorrhea of the lungs in septicemia; (17) gonorrheal\npleurisy in septicemia; (18) gonorrheal nephritis, which is frequent\nin gonorrheal septicemia--the condition is often fatal; (19)\nperinephritis, a very rare condition; (20) gonorrhea of the nervous\nsystem, as neuritis or neuralgia, or neuroses, which vary from slight\nmelancholia to severe mental disturbances; (21) parotiditis, a very\nrare condition; (22) otitis, or inflammation of the middle ear, a\nvery rare condition; (23) suppuration in muscles, or under the skin;\n(24) wound septicemia; (25) venereal warts; and (26) epididymitis,\nwhich often causes not only sterility but impotence.\n\nCampbell[195] reported a gonorrheal infection of a compound fracture\nat the ankle--it required four months to get the wound free of the\ninfection. Gonorrheal obliterating epididymitis is quite common.\nDelbet and Chevassu[196] found 114 cases of male sterility in\n131 cases of epididymitis. More than half of such cases are left\npermanently sterile, and if the function of the testicle cannot be\nrestored by the surgeon the patient is impotent, and any marriage he\nwould make, ... is rendered void. These two surgeons have restored\nfunction in six such cases by uniting the vas with the epididymis\nby Martin's operation. It is much easier to restore function after\nvasectomy than after obliterating epididymitis.\n\n  [195] _New York Medical Journal_, February 22, 1908.\n\n  [196] _Canadian Presse M\u00e9dic._, July, 1908.\n\nThere are frequent cases of arthritic rheumatism in which the source\nof the infection is a chronic gonorrhea of the seminal vesicles.\nFuller[197] has done 101 vesiculotomies for this condition, and\nof these twenty-three were gonorrheal. In these twenty-three\nthe excision of the infected vesicles cured the rheumatism. In\nvesiculotomy great care must be taken not to cut the vas deferens. If\nit is cut the man is impotent until the vas is restored, and it would\nbe a very difficult operation to reunite the vas if cut near the\nvesicles.\n\n  [197] _New York Medical Journal_, May 30, 1908.\n\nOf all the gonorrheal affections of the body the most dangerous and\nimportant are the cardiac inflammations and ophthalmia neonatorum.\nThis ophthalmia is a purulent infection of the external parts of the\neye in infants. It may be caused by many kinds of toxic bacteria,\nbut the worst cases are from the diphtheria bacillus (a very rare\ncondition) and the gonococcus (a very frequent condition). Before\n1881, when Cred\u00e9 introduced prophylactic treatment for ophthalmia\nneonatorum, every maternity hospital had a department isolated for\nthe care of babies suffering with this disease. At the present\nday, however, despite the precautions taken, this disease is quite\ncommon. Pennsylvania and New York alone spent $242,000 annually\nfor the support of asylums for the blind, and about 40 per cent.\nof the children in these institutions were blinded by gonorrheal\nophthalmia. The United States spends $1,800,000 yearly on victims of\nophthalmia neonatorum. Stephenson[198] tells us that in the practice\nof forty-one oculists who reported to him the gonococcus was found in\n67.14 per cent. of their 1658 cases of ophthalmia. Mayou found the\ngonococcus in 63.5 per cent. of 1483 cases.\n\n  [198] _Ophthalmia Neonatorum._ London. 1907.\n\nThere is an infection of the child's eyes by gonococci possible even\nwhile the child is in the womb, but this is very exceptional; the\ninfection happens in the vagina during delivery, as a rule. When\nthe child's head is born its lids and eyelashes should be cleansed\nwith vaseline, or 1 to 5000 bichloride, or carbolized oil, before\nthe eyes are opened to put in the silver nitrate solution. This\nsolution should be made from a pure drug or it will injure the eyes.\nA one per cent. solution is strong enough for routine work, but if\nthe gonococcus is suspected, or if it is known that the mother has\ngonorrhea, then the lids of the infant must be everted and touched\neverywhere with a five per cent. solution of silver nitrate. This is\nneutralized with a salt solution and washed out before the lids are\nturned back. It is rash to trust any of the albuminoid preparations\nof silver, like argyrol, silvol, or protargol, in gonorrhea or\nsuspected gonorrhea of the eyes.\n\nIf the child develops ophthalmia the treatment should be turned over\nto an oculist when possible. When a child can have a day and a night\nnurse, this method should be adopted, but ordinarily there is no\nnurse except some woman about the house or the mother. In such cases\none eye, commonly the right, does better than the other because\nthe first eye treated is opened readily, but after the infant has\nbeen irritated it shuts the eyes so strongly that it is difficult to\nopen them at all. The first eye treated is habitually the same. The\nnurse should begin to treat the eyes alternately on this account, or\nwait to treat the second eye until after the baby has quieted down.\nIced compresses should be used, but not so long as to chill the eye\nvery much--five to ten minutes at a time is enough. If the physician\nhimself makes the applications of silver nitrate, the nurse should\nuse some silver salt like argyrol. Three to eight grains of zinc\nsulphate to eight ounces of boric solution is a good regular eye-wash\nin these cases. Atropine must also be instilled to protect the iris.\nIf only one eye is affected, the other eye should be protected under\na watch glass sealed over it. All persons who have gonorrhea, or\nwho treat gonorrhea, must be warned of the danger they are in of\ninfecting their own eyes.\n\nA new treatment of gonorrhea is described by Weiss.[199] The\ngonococci are killed by a temperature of 107.6 degrees Fahrenheit,\nand in eleven cases Weiss subjected men to a hot bath for forty to\nfifty-five minutes, with the temperature of the water gradually\nincreased from 104 to 110 degrees Fahrenheit. In one instance the\nbody temperature was raised to 108.5 degrees F. in a forty-minute\nbath and the gonococci disappeared at once. In the other cases the\nbody temperature did not go up so high, but the vitality of the\ngonococcus was evidently reduced, and under a few local injections\nthey all disappeared.\n\n  [199] _M\u00fcnchener medizinische Wochenschrift_, November 2, 1915.\n\n\n\n\nCHAPTER XXI\n\nDIABETES IN PREGNANCY\n\n\nDiabetes Mellitus is rare in pregnancy, but when it does occur the\ndisease is fatal in three-fourths of the children, and it hastens the\ndeath of the woman, according to the common opinion of obstetricians,\nbut this opinion is disputed. In making the diagnosis we must exclude\nlactosuria and other pseudodiabetic conditions. A sugar reaction\nwhich is often mistaken for the glycosuria of true diabetes is from\nlactose in excessive milk secretion. This lactosuria is harmless.\nAgain, when women are taking tonics or cough mixtures containing\nderivatives of wild cherry their urine may give a sugar reaction\nfrom the phloridzin of the wild cherry. The phloridzin so acts on\nthe epithelium of the kidneys that it lets the blood-sugar escape\ninto the urine. Medical writers who report diabetes in large numbers\nof pregnant women mistake these reactions for the reaction of true\nglycosuria.\n\nIn the genuine diabetes of pregnancy there is a high mortality.\nOffergeld,[200] in sixty cases, found that the women died within\ntwo and a half years, and that 76 per cent. of the children were\nlost. Diabetics commonly are sterile from atrophy of the uterus and\novaries: in a series of 114 diabetic married women, Lacorch\u00e9 found\nonly seven pregnancies. In a third of such as do become pregnant\nabortion or premature labor occurs. Coma happens in 30 per cent. of\nthese pregnancies, and it is almost always fatal. Delivery frequently\ncauses collapse, coma, or sudden death. The liver in any gestation\nhas more work than it has in the unimpregnated state, but a diabetic\nliver is unfit for almost any normal function. If albuminuria is\nfound the prognosis becomes very bad. Diabetic women have poor\nresistance against a tubercular infection. Half their children are\nstill-born, and 10 per cent. more die within a few days after birth\n(many of these children are diabetic).\n\n  [200] _Archiv. f. Gyn._, bd. 86, n. 1.\n\nThere is some evidence of heredity in diabetes--it is likely \"to\nrun in a family.\" Heiberg[201] reported one family in which five\nof thirteen children had diabetes; in another, four of eight\nchildren, the mother, two of the mother's brothers, and the maternal\ngrandfather had diabetes. In another, two brothers, the father, and\ngrandfather died of it. I know of a case where the only two sons and\nthe father in a family died of it. Heiberg did not find any essential\ndifference in the histology between the hereditary cases and those\nwhich were not hereditary.\n\n  [201] _Deutsche medizinische Wochenschrift_, xlii, 9.\n\nJoslin[202] reported seven cases of diabetes associated with\npregnancy. Four of the seven are now dead, one by suicide, one from\nuremia, one from coma, one from tuberculosis. Of the three living one\nis in good condition, one is not well and she has lost two of three\nchildren, and one is very ill with diabetes. In persons beyond middle\nage diabetes with proper treatment may go on for from ten to fifteen\nyears before it is fatal, but it quickly kills young patients. A\nyoung woman at the marriageable age who has diabetes will die anyhow\nin two or three years, and if she marries and becomes pregnant she\nwill die very probably in her first pregnancy.\n\n  [202] _Boston Medical and Surgical Journal_, November 25, 1915.\n\nWhen the child is viable, and the diabetic mother shows albuminuria,\nprogressive weakness, or diacetic acid in marked quantity, it may\nbe necessary to perform therapeutic abortion; but if this is done\nno anesthetic may be used, and great precautions should be taken to\navert physical and mental shock. Even ergot acts badly with these\ncases. The last sacraments should be given in good time, especially\nif coma threatens. When labor begins in a diabetic and everything\nappears to be normal the sacraments should be given, because there is\nalways danger of sudden collapse and death.\n\n\n\n\nCHAPTER XXII\n\nCHILDBIRTH IN TWILIGHT SLEEP\n\n\nA method of effecting painless childbirth through the use of\nscopolamine and morphine was first used in 1902 by Steinbuechel,\nand in 1906 Gauss, of the University of Freiburg in Baden, reported\na series of five hundred obstetrical cases in which scopolamine\nand morphine had been used. The woman's condition was called\nin Freiburg a _D\u00e4mmerschlaf_, a Twilight Sleep, because she is\nsomnolent and forgetful of pain. In 1903 the chief obstetricians\nin several of the leading American and German universities tried\nthe drugs, but they quickly abandoned the method because they found\nit dangerous and unscientific. The process was exploited here by\n_McClure's Magazine_,[203] _The Ladies' Home Journal_, and other\nlay periodicals. The articles in these magazines were written by\npersons who are not physicians, and their erroneous statements are\nmisleading. _The Ladies' Home Journal_, however, while favoring\nthe method, published letters from several leading obstetricians\nin the United States, all of whom are opposed to the use of these\ndrugs during parturition because they had tried them and found them\nunscientific. The method is illicit morally, and it is unscientific.\n\n  [203] June, 1911.\n\nObstetricians divide a parturition into three stages. In most\nprimiparae and many multiparae there is a prodromal stage, in which\nfalse labor pains (_dolores praesagientes_) are the most evident\nsymptom. When the real labor sets in there are rhythmic uterine\ncontractions about every fifteen minutes, which cause pain to the\nwoman by the pressure of the fetus on the uterine nerves--_dolores\npraeparantes_. From the time the pains become rhythmic, and are\neffective in dilating the neck and mouth of the womb, until the\nmouth of the womb is completely stretched and flush with the vaginal\nwall, thus completing the continuous parturient canal, is the first\nstage of labor. The fetal enveloping membranes (the \"bag of waters\")\nusually rupture at the end of this stage, but sometimes the bag\nbursts before the end, or as late as the second stage of labor. The\nfirst period is the stage of dilatation.\n\nThe second stage extends from the end of the dilatation until the\nexpulsion of the child is completed. This is the stage of expulsion.\n\nThe third stage lasts from the delivery of the child until after the\nexpulsion of the placenta and membranes and the retraction of the\nuterus has ended--the period of the afterbirth.\n\nNormal parturition is always painful to the woman. As the labor\nprogresses the pains gradually grow more intense, and the interval\nbetween them shorter. After a few hours the pain is strong enough\nto cause the woman to cry out, but there is a great variety in the\nendurance of these pains, as the women's characters differ. Neurotic\nwomen begin to scream and act hysterically even in the early part of\nthe first stage. When the pains are fully developed each lasts about\nhalf a minute.\n\nIn most cases the infant comes out head first, but almost any part of\nits body may present. Before the advancing child part of the _liquor\namnii_ within the fetal enveloping membranes is forced down into the\nneck of the womb, and causes dilatation. In primiparae especially the\nbag of waters may rupture prematurely and thus cause what is called\na dry labor, which is commonly tedious and painful. Often operative\ninterference is required in dry labors.\n\nIn the second stage the pains are stronger, recur every two or three\nminutes, and are expulsive. The woman then strives to expel the\nchild. She strains violently with the abdominal muscles--literally\nlabors; her pulse is high, the veins of her neck stand out, her face\nis turgid, and her body is covered with sweat. When at last the head\nof the child is driven out the woman feels as if she were being torn\nasunder in the _dolores conquassantes_. The pain is so great that the\nwoman may faint from it, but that is not the rule. After a pause the\nshoulders are forced out, and then the trunk in one long convulsive\neffort. The umbilical cord is tied and cut, and the child is born.\n\nAfter from five to twenty minutes the womb begins to contract again,\nbut the pains (_dolores ad secundum partum_) are not nearly so\nintense as they were during labor. Then in from fifteen minutes to\nabout three hours the placenta is expelled.\n\nThe pains of labor are so evident that the expulsive contractions of\nthe uterus, of which the pains are symptoms, are themselves called\n\"the pains.\" These pains in all scientific exactness of statement\nare, as has been said, agonizing. \"In dolore paries filios\" is a\nvery literal text. The scopolamine-morphine method was devised with\nthe intention of mitigating them, or mercifully rendering the woman\nunconscious of them during at least a part of the labor. If she is\nunconscious of pain she is thus saved also from shock and depression,\nwhich render her susceptible to infection. Such results certainly are\nimmeasurably valuable if attainable without taint of moral evil, but\nas the method stands just now, they are not free from that taint.\n\nScopolamine hydrobromide, one of the drugs used in this method, is\nan alkaloid obtained from the roots of _Scopolia_ (or _Scopola_)\n_carniolica_, and it cannot be differentiated chemically from\nhyoscine hydrobromide, which is made from henbane and other plants of\nthe _Solanaceae_ group. Rusby was of the opinion that scopolamine is\nreally a mixture of hyoscine, hyoscyamine, and atropine: one-tenth\nhyoscine and nine-tenths hyoscyamine and atropine. Cushny and others\nfind different proportions of these alkaloids. As the leaves of\n_Scopolia_ are used to adulterate the belladonna leaves from which\natropine is derived, hyoscine and scopolamine are substituted for\neach other--if, indeed, there is an any real difference between\nthem. Some of the largest drug-houses in Germany before the war\nsupplied hyoscine and scopolamine from the same stock bottle--the\nname depended on the asker. Even in a pure state hyoscine and\nscopolamine have the same chemical formula (C{17}H{21}NO{4}),\nand their physiological action is the same. Each can exist in three\nisomeric forms, and in one of these forms they turn polarized light\nto the left, in another to the right, while in a third form they do\nnot affect the light at all. The higher the rotatory power of the\ndrugs, the more active they are physiologically. The levorotatory\nscopolamine has, according to Cushny, Peebles, and Hug, double\nthe action of the inactive scopolamine on the cardiac inhibitory\nfibres of the vagus, but the levoactive and the inactive scopolamine\nproduce the same effect on the central nervous system. The drug on\nthe market is usually composed of a mixture of the levoactive and\nthe inactive forms, and as one or the other predominates the results\ndiffer: the rotatory power of a given specimen should be known. Old\nsolutions of scopolamine decompose and give rise to toxic substances.\nGauss attributed post-partum hemorrhages in the women and asphyxia\nin infants to these decomposition products, but he avoided these\nuntoward effects somewhat by cutting down the morphine dose. He had\nfive infant deaths before he cut down the morphine, and 25 per cent.\nof the children were intoxicated. The chief action of scopolamine\nor hyoscine is upon the cerebral cortex, producing sleep, which is\naccompanied often by a low delirium. They depress the centre of\nrespiration, and have a depressant effect also on that part of the\nspinal cord which governs the motions of the body. They intensify the\naction of morphine and other narcotics.\n\nMorphine, which is used to prevent pain, is the chief drug in the\ntwilight sleep method, and it is greatly intensified in action by the\npresence of scopolamine. When, however, morphine and scopolamine are\ngiven to a pregnant woman hypodermically, these drugs are at once\ncarried by the blood to the fetus. Children for years after birth all\nwithstand the action of morphine badly, and a fetus _in utero_ may be\noverwhelmed by it. Just in this fact lies the chief moral crux in the\nuse of the twilight sleep method of obstetrical delivery. The woman\nmay go on to the end more or less safely in competent hands, but if\nconstant watch is not kept at the bedside by a skilled observer the\ninfant is liable to be killed, and the danger comes to it not solely\nfrom the drug directly--it may be drowned in the amniotic fluid, its\ncondition may be masked by the restlessness of the mother, which\nprevents proper observation: when a woman is plunging all over the\nbed, as is extremely common in twilight sleep, the pulse-rate of the\nbaby cannot be properly watched.\n\nIf the mother happens to be particularly susceptible to scopolamine\nor morphine, the first will cause delirium and the second coma; or\nthe respirations may become arhythmic and be reduced to only five or\nsix a minute. The kidneys may be affected by the morphine so as to\nbring on total suppression of urine. Labor is prolonged, and it may\nbe very much prolonged. In some women uterine atony is induced by\nthe morphine, with very dangerous consequent post-partum hemorrhage.\nMorphine relaxes all musculature, and it relaxes the muscle of the\narterial walls and so disposes to hemorrhage. There is little or no\npremonitory symptom of these idiosyncrasies (except in the case of\nan injured kidney) to inform the physician that he should avoid the\nscopolamine-morphine treatment.\n\nDr. Polak, professor of obstetrics at the Long Island College\nHospital, reported[204] on 155 cases of the twilight sleep method,\nand he is in favor of it under several restrictions. He uses the\ndrugs from ampules which contain one two-hundredth of a grain of\nscopolamine and half a grain of narcophin, which is a proprietary\ndrug said to be composed of the meconate of morphine with the\nmeconate of narcotin in molecular proportion. Morphine itself is a\ntribasic meconate, and narcotin, of course, another opium derivative.\nThe American Council on Pharmacy and Chemistry was unable to accept\nthe claims made for narcophin.[205] Polak says he finds no difference\nbetween morphine and narcophin.\n\n  [204] _Long Island Medical Journal_, December, 1914, and\n  _American Journal of Obstetrics_, May, 1915.\n\n  [205] _Jour. Amer. Med. Assoc._, November 21, 1914.\n\nIn the twilight sleep treatment the patient, especially if she is\na primipara, should be definitely in labor before any injection\nis given. She should have pains occurring at regular intervals,\npreferably every four or five minutes, before the first injection of\nscopolamine and morphine is administered; that is, the first stage of\nlabor should be well advanced. Gauss gives one-sixth of a grain of\nmorphine at the first injection, and Polak nearly three-fourths of a\ngrain of narcophin, with one two-hundredth of a grain of scopolamine.\nIf the woman is a multipara, Polak begins the treatment at the very\nbeginning of the pains. The patient is kept in bed, in a darkened\nroom, removed from all noise and excitement. Some stop the ears and\nblindfold the patient, and, according to Baer of Chicago, the women\nare put into restraining sheets as a routine practice in certain\nclinics to keep them from infecting themselves. The ordinary practice\nis to give a half dose of scopolamine an hour after the first dose\nand about every two hours thereafter, according to the indications.\nThe morphine may be discontinued, or used approximately every six\nhours in a long labor. Smaller doses are required if the first is\ngiven early in the labor, and larger if the pains have been well\ndeveloped. In these latter cases the danger to the child is, of\ncourse, greater.\n\nThe condition of the patient's pulse, respiration, pupillary\nreaction, and the frequency and character of the uterine contractions\nare constantly watched, to guard against poisoning. Fonyo[206]\nreported two fatal poisonings by the scopolamine-morphine method\nas used in surgery. Both were operations for the delivery of\nwomen by laparotomy, and in each case the centre of respiration\nwas overwhelmed. In each of these operations only one-hundredth\nof a grain of scopolamine and one-third of a grain of morphine\nhad been used, but chloroform was administered later. Robinson\nrecently reported the fatal poisoning of a negress by scopolamine,\nand Chandler of Philadelphia two more where one thirty-third of a\ngrain of scopolamine had been used. One-ninetieth of a grain given\nhypodermically has caused severe toxic disturbance which lasted\nfor twenty-eight hours, and Root[207] reported a case where one\nthree-hundredth of a grain given by mouth poisoned violently.\n\n  [206] _Zentralblatt f. Gyn\u00e4kologie_, September 19, 1914. Leipsic.\n\n  [207] _Therapeutic Gazette_, vol. ii.\n\nIn Freiburg, Gauss tests the consciousness of the women about every\nhalf hour by showing them some object, and if they remember having\nseen this object he gives an additional dose of scopolamine. Polak\nsays this memory test is not necessary: even if the patient gives\noutward evidence of pain by cries and motion, she is apparently but\nvery dimly conscious in his opinion.\n\nThe progress of the delivery must be constantly watched by repeated\nextra\u00e4bdominal or rectal examinations, following the fetal shoulder\nas it rotates--and not by vaginal examinations--to avoid sepsis. The\nfetal heart must be auscultated every half hour at most, between\nand during the pains. If the child's pulse grows arhythmic or slow\nbetween pains, these are bad prognostic signs. All use of the drugs\nis to be discontinued, and the child is to be delivered at once to\nsave its life, by the most suitable method and route.\n\nPolak holds that the solutions of the drugs must be absolutely pure,\nand that hyoscine cannot be substituted for scopolamine, but that\nnarcophin is no better than morphine: the American preparations\nhave produced delirium. As I have shown, no one can possibly tell\nthe difference between hyoscine and scopolamine, even by chemical\nanalysis. All we can do is to take the druggist's word that the drug\nat hand was made from _Scopolia_ and not from _Hyoscyamus niger_. It\ndoes not make any difference which is the source of the supply.\n\nPolak says the morphine shortens the first stage of labor by\nsoftening the cervix, but that the treatment lengthens the second\nstage. Other observers have not found that it shortens the first\nperiod. He tells us that if this second stage--that is, the time from\nthe full dilatation of the os until the delivery of the child--lasts\nover an hour in multiparae, or over two hours in primiparae, delivery\nmust be effected by the Kristeller expression or by low forceps. In\nthe Kristeller expression the child is pushed out of the canal by\nthe hands of the physician applied to the fundus uteri. It should be\na method of last resort, because there is danger of rupturing the\nuterus, of tearing the placenta loose, or of crushing an ovary.\n\nIn his report Polak says he has had no failures; the patients had\nno recollection of the labor; in the first series of fifty-one the\nchildren showed no sign of asphyxiation or even cyanosis except\nin two cases. In this first series one patient had a long second\nstage and the child had to be resuscitated. There were, he said,\nno post-partum hemorrhages; no low forceps; the placentas were\ndelivered without difficulty; none of the women showed signs of\ntire or exhaustion the next day; in fact, they were better off\nthan the women who have normal labor. This report is different from\nthat made by other men just as competent, and in exactly the same\ncircumstances; even Gauss confesses many failures. The lay journals\nsay Gauss had no failures, but he himself should know. In April,\n1915, I was told in New York City that there had been no failures\nthere, yet in May, Dr. Broadhead, professor of obstetrics at the\nPostgraduate School of Medicine in that city, after observing\nseventy-two cases confessed[208] several failures where the child was\nconcerned. One Catholic woman, a member of the executive committee in\na Twilight Sleep League of married and unmarried women, was killed in\nBrooklyn by the method in the summer of 1915.\n\n  [208] _The Postgraduate_, May, 1915.\n\nDr. Charles M. Green, professor of obstetrics in Harvard University,\ntells us:[209] \"My own observations, published in 1903, led me at\nthe time to favor this therapeutic means of producing the 'Twilight\nSleep,' and removing the consciousness of pain, or at least\npreventing all remembrance of it. I have long since abandoned this\nagent, however, for two reasons: First, because it has apparently\nbeen the cause, occasionally, of fetal asphyxia. Second, because the\neffect of the drug on the mother is often uncertain, and unless used\nwith great care may cause unfavorable or dangerous results. Moreover,\nwe have other and safer measures for the relief of pain in labor. So\nI have given up teaching the use of scopolamine in my lectures.\"\n\n  [209] _Ladies' Home Journal._\n\nDr. Williams, professor of obstetrics in Johns Hopkins University,\nand the author of a book on obstetrics which is very valuable,\nsays:[210] \"We have used the scopolamine treatment of childbirth in\ntwo separate series of cases at the Johns Hopkins Hospital, but in\nneither series were the results satisfactory, nor did they in any way\napproach the claims made for the treatment. We expect to do more with\nit next year.\" In the fourth edition of his _Obstetrics_, published\nin 1917, he thinks that the twilight sleep method will fall into\ndisuse, or at least that its use will be restricted to a small group\nof neurotic patients. From his experience, he says, the method is\nnot adapted for private practice.\n\n  [210] _Ibid._\n\nDr. Hirst, professor of obstetrics in the University of Pennsylvania,\ntried the scopolamine treatment in the maternity hospital of the\nuniversity in about 300 cases at three different times. He tried it\nfirst in 1903, but he found that if sufficient morphine is given\nto abolish pain there is danger of hemorrhage in the mother and\nof asphyxia in the child. At a meeting of the Obstetrical Society\nof Philadelphia[211] Hirst, commenting on a paper by Polak, said:\n\"I am sorry to say I cannot agree with my friend Dr. Polak in his\nconclusions ... I had to discontinue morphia and scopolamine because\nthere were too many cases of post-partum hemorrhage, too many cases\nin which forceps had to be used, too many asphyxiated babies. So I am\nnot an enthusiast for 'twilight sleep.'\"\n\n  [211] Proceedings printed in _American Journal of Obstetrics_,\n  May, 1915.\n\nDr. Joseph B. De Lee, professor of obstetrics in the Northwestern\nUniversity Medical School, Chicago, and the author of a book on\nobstetrics which is now one of the best we have in English, tells\nus[212] that the impressions he received from studying ten cases of\nchildbirth in Professor Kr\u00f6nig's clinic at Freiburg were \"decidedly\nunfavorable to the method of 'Twilight Sleep.'\" In all the ten cases,\nhe testifies, the birth pains were weakened, and labor prolonged--in\ntwo instances for forty-eight hours. In three cases pituitrin, which\nis in itself a dangerous drug to use before the uterus has been\nalmost emptied, had to be given to save the child from imminent\nasphyxia. In five of the cases forceps had to be used owing to the\nparalyzing effects of the drug, and all these forceps cases were\nextensively lacerated. Several of the women became so delirious and\nviolent that ether had to be used to quiet them, with the result that\nthe infants were born \"narcotized and asphyxiated to a degree.\" One\nchild had convulsions for several days.\n\n  [212] _Ladies' Home Journal._\n\nThe complete failure in these ten cases is so obvious as to be a\nscandal, although De Lee does not say so. He abandoned the use of\nthe method twelve years ago, and in 1913 he visited the maternities\nat Berlin, Vienna, Munich, and Heidelberg, and found that all had\ntried the method and had rejected it.\n\nSeveral so-called detoxicated substitutes for morphine, like\n\"tocanalgine\" and \"analgine,\" have been tried; but these turned\nout to be morphine, and to be equal in strength to morphine as\nwe ordinarily have it. These were the drugs that were advocated\nin the _Cosmopolitan Magazine_ as \"having nothing to do with the\nmorphine-scopolamine treatment originating some years ago in\nFreiburg.\" They are morphine treacherously disguised, and the\nassertions in the _Cosmopolitan_ were never retracted when attention\nwas called to the untruth by the _Journal of the American Medical\nAssociation_. In the _American Journal of Obstetrics_ for May, 1915,\nis a full description of these drugs (page 772).\n\nDr. Joseph Baer reported[213] sixty cases of the morphine-scopolamine\ntreatment at the Michael Reese Maternity Hospital in Chicago, and\nhis results were diametrically opposed to those Dr. Polak himself\nobtains. The rooms used were large, and had cork-lined sound-proof\nwalls and doors; obstetricians and specially trained nurses were\npresent day and night. The circumstances, then, were the best that\ncould be had.\n\n  [213] _Jour. Amer. Med. Assoc._, May 22, 1915, lxiv, 21, p. 1723.\n\nHe used Merck's scopolamine at first, and later a solution made up\nafter the formula of Straub of Freiburg, which is more stable. His\ndoses of morphine were from one-eighth to one-fourth of a grain;\nGauss uses one-eighth to one-sixth of a grain; Polak, as much as\nthree-fourths of a grain of narcophin for his first dose.\n\nBaer's series ended on February 5, 1915, and of his sixty cases\nonly five were successful. Three of the successful cases received\none-fiftieth of a grain of scopolamine in all, and some of the\nunsuccessful cases got as high as one-sixteenth of a grain, with only\nwild delirium as a result.\n\nThe labor was lengthened by about seven hours over untreated cases.\nAs to the amnesia, in twenty-six cases the memory was not dulled at\nall, although they received more scopolamine than thirty-nine cases\nin which the memory was cloudy.\n\nThirty-two women had unbearable thirst throughout the labor, and\nnothing would slake this thirst. Their incessant cries for water\nwere very distressing to the attendants. Headache was present in\ntwenty-seven cases and vertigo in thirty-one, and the headache,\nwhich was very intense in some women, lasted for several days after\ndelivery.\n\nPain was diminished in thirty-nine cases, absent in one, as severe\nas in the average untreated woman in nineteen, and increased in one.\nThat is, only one woman in sixty did not suffer the pain for which\nthe treatment was devised. The reason evidently is that his dose of\nmorphine was too small, yet if he went above this dose he ran the\nrisk of post-partum hemorrhage and of narcotizing the baby. As it\nwas, he had seven post-partum hemorrhages, but in a series of sixty\nunselected normal delivery cases he had only one hemorrhage.\n\nRestlessness was present in eighteen cases, and delirium in nine; six\nof these women had to be wrapped in restraining sheets, and one had\nto be shackled for four days after she had overpowered a nurse in an\neffort to jump out of a window. It took three attendants to get her\ninto the strait-jacket. Chandler of Philadelphia saw a woman in a\nlike delirium who was shackled only after six attendants together had\ntackled her. Two physicians in the Chicago maternity were severely\nbeaten by women in a twilight sleep delirium.\n\nBaer says the serious risk of self-infection during labor through the\nuncontrollable motion of these women is a source of constant anxiety.\nThey sit cross-legged, and the heel infects them with coli communis\nfrom the expressed feces. The dazed women constantly try to get at\nthe vague pain with their hands, and on this account, according to\nBaer, some clinics that practise the twilight sleep method keep all\nthe women in strait-jackets, but they omit to publish this fact.\n\nOne of Baer's patients died from a ruptured uterus, and her dead\nbaby was taken from her belly-cavity. The drug will mask symptoms in\na case like this. Sudden cessation of puerperal pain as a symptom\nof rupture, and the peculiar pain of a premature loosening of\nthe placenta, are both covered from observation by the drugs, the\ndarkening of the room, and the tossing of the patient, which prevent\nproper examinations.\n\nOne patient had a mitral insufficiency and myocarditis. This should\nbe an ideal case for the treatment, according to the twilight sleep\nmen. The woman, however, after three doses of the scopolamine\ndeveloped pulmonary edema. Her child was delivered in asphyxia\npallida and resuscitated with difficulty.\n\nThirteen of the children did not breathe at delivery, six were\nasphyctic, and two cases relapsed into asphyxia. One child was\nkilled, as we said, when the mother's uterus ruptured. Avarffy[214]\nhad one fatal case in fifty, and Chrobak one in one hundred and seven.\n\n  [214] _Gyn\u00e4kol. Rundschau_, 1909, iii.\n\nEight of the women had blurred vision after delivery, which lasted\nfor over twenty-four hours; two had marked delirium for from two\nto four days after childbirth. As to exhaustion after labor, Baer\nsays he found no difference between the twilight sleep women and the\nnormal cases.\n\nSome advocates of the twilight sleep method say that there is less\nuse of the forceps in this method than in normal delivery. At\nFreiburg, for example, operative delivery has been \"reduced\" to six\nor seven per cent. Six per cent., as a matter of truth, is two per\ncent. above the normal average for forceps delivery in eighteen\nGerman maternities. In 95,025 deliveries in these hospitals the\naverage forceps delivery was 4.5 per cent., and some were small\nteaching hospitals where the forceps were used on any provocation\nfor class demonstration. The twilight sleep method has a much higher\noperative delivery, and this varies, of course, according to the\nskill and judgment of the operators.\n\nHolmes, one of the first in Chicago to try the newly revived\nmethod, says[215] that in July, 1914, before the great war broke\nout, there were twenty-five malpractice suits pending in one German\ncity as a result of the morphine-scopolamine fad. He quotes a noted\nobstetrician on this subject: \"If you will use the method, have the\npatient in the best hospital possible, with all the appurtenances\nrequisite for the revival of the child; if you do not know, learn\nat once the differences between asphyxia, oligoapneia, and narcotic\npoisoning, and the methods of treating them; get the best and the\nmost reliable product called scopolamine; and then be sure you\nare in a position to be adequately defended by a lawyer versed in\nmalpractice suits.\"\n\n  [215] _American Journal of Obstetrics_, May, 1915.\n\nThis is the state of the question. Two or three men in the best\ncircumstances say they get one hundred perfect results; other men,\nequally or far more skilled and in equally favorable circumstances,\nget one hundred results which are anything but successful, often\na disgrace to science, and undoubtedly immoral. They are immoral\nbecause they risk human life in an attempt to ease a physiological\npain, and this is not a sufficient reason; moreover, these attempts\nfail oftener than they succeed. The second group of practitioners\nhave no motive except honesty to induce them to make their\nunfavorable reports of failure. The reports of the two groups are\ndirectly contradictory, and the judgment is thus a matter of motives.\nTestimony from women who have gone through the process is not to be\ntaken into account. They were dazed, and in any case they are not\ncompetent to judge a matter which is wholly technical.\n\nWe know the limitation of morphine and scopolamine and we cannot\nimprove their use. If enough is given to still pain, we take a\ncriminal risk; if we do not give enough to remove the sense of pain,\nwhy not use the safer nitrous oxide, ether, and chloroform? If\nenough morphine and scopolamine are administered early in labor to\na multipara, the labor is commonly stopped; if this dosage is given\nafter the pains are developed, the baby is born, as a rule, before\nthey take effect.\n\n\n\n\nCHAPTER XXIII\n\nVASECTOMY, OR STERILIZATION, BY STATE LAW\n\n\nThe State of Indiana in 1907 enacted a vasectomy law which obliges\nthe superintendents of some prisons and asylums to appoint two\nsurgeons whose office is to sterilize sexually criminals, idiots,\nimbeciles, and similar persons, if these surgeons, in consultation\nwith the chief physician of the institution, deem the propagation\nof children by such so-called degenerates detrimental to society.\nThe same law has been incorporated in the statutes by New York, New\nJersey, Washington, Iowa, Nevada, Wisconsin, Connecticut, California,\nUtah, Kansas, Oregon, and Minnesota. The law has been proposed\nseveral times in the Legislature of Pennsylvania, but it was vetoed\ntwice and held up once in the Assembly.\n\nIn New Jersey there was question of sterilizing an epileptic girl,\nand the Supreme Court of that State[216] decided in 1913 that the\nlaw is contrary to the State and Federal constitutions. In 1916\nProbate Judge Lapeer of Michigan declared the law as passed in his\nState in 1913 unconstitutional, but the State appealed against this\ndecision. The Supreme Court of Washington[217] decided in favor\nof the law in a case where a man convicted of rape was sentenced\nby the trial judge to life imprisonment and to vasectomy as a\npunishment. The constitutionality of the Iowa law is on appeal to the\nUnited States Supreme Court after a Federal judge had declared it\nunconstitutional. The law in Indiana was put into effect in hundreds\nof cases, but Governor Marshall set the law in abeyance. Two Federal\njudges in Kansas said the law is unconstitutional and granted an\ninjunction against its application in a particular case. In 1808\nthe superintendent of a Kansan institution for the feeble-minded\ncastrated forty-eight boys. Up to April, 1916, about twenty-five\nfeeble-minded boys in the Wisconsin institution at Chippewa Falls\nwere sterilized, and the authorities then said they intended to\nsterilize the girls. The law has been advocated by alienists in\nSwitzerland, and French and English physicians have advocated it.\n\n  [216] _Smith vs. Board of Examiners of the Feeble-minded, 88 alt.\n  R. 963._\n\n  [217] _State vs. Feilen, 126 Pac. R. 75._\n\nThe reason given by the advocates of this law is the alarming\nprevalence of feeble-mindedness with its tendency to criminality; and\nas, they say, heredity accounts for 65 per cent. of feeble-mindedness,\nthe feeble-minded should be prevented from propagating their kind.\nSweden, with 5,500,000 inhabitants, has 18,000 insane, 14,000 idiots,\n20,000 imbeciles, and 7,000 epileptics. Much of this degeneracy is\ndue to the notorious alcoholism of the Swedes, which only lately\nhas been brought under some control. Pennsylvania had about 17,000\nfeeble-minded in 1913. In a single county almshouse in that State\nwere 105 women who had given birth to 101 defective children. One\nfeeble-minded couple in the same State had 19 defective children;\ntwo other families had 9 imbeciles and 7 idiots. In New Jersey the\nhistory of 480 individuals of the famous \"Kallikak\" family (a\npseudonym), descended from a feeble-minded woman who lived at the\ntime of the Revolutionary War, has been traced out, and of these\ndescendants only 40 were normal. New York State has 32,000 known\nfeeble-minded persons. One State school for the feeble-minded in\nIndiana in 1908 had 1054 inmates. There are 6000 mentally defective\nchildren in the schools of Chicago. An investigation made in Illinois\nabout 1907 brought out the conclusion that all the defectives and\ndelinquents in that State at the time could be traced to 150\nfamilies. Poehlmann of Bonn traced the descendants of one female\ndrunkard through six generations in 800 individuals, and of these\n107 were illegitimate, 102 were beggars, 181 were prostitutes, 76\nwere criminals in a grave degree, 7 were murderers, and they had\ncost the State $1,206,000. The Jukes sisters, two illegitimate\nprostitutes in New York State, in five generations bred 709\ncriminals. Fifty-two per cent. of the women were prostitutes,\nwhereas the ordinary ratio of prostitutes to other women is 1.66\nper cent. Alcoholics engender degenerates. In three generations\nof 215 French alcoholic families, Legrand found that 60 per cent.\nof the children were degenerates. Bourneville found that 62\nper cent. of 1000 idiotic, epileptic, and feeble-minded children in\nParis had alcoholic parents.\n\nHereditary transmission is certainly a cause also of many diseases\nof the nervous system. Friedrich's ataxia is hereditary. It is an\nincurable progressive inco\u00f6rdination of the limbs, tongue, larynx,\nand eyes, which attacks commonly between the tenth and the twentieth\nyear, and the patient dies from some intercurrent disease, usually\nan infection. Progressive muscular dystrophy is also hereditary\nand incurable. The legs and trunk atrophy, and death comes from\nan intercurrent disease. Related to this malady are hereditary\nprogressive neurotic muscular atrophy, progressive spinal muscular\natrophy in infants, and progressive spinal amyotrophy in adults.\nAmaurotic (_amaurosis_, blindness) family idiocy is hereditary,\nand the child dies at about two years of age. Huntington's chorea\nappears in every generation of an affected family. Its symptoms show\nbetween the ages of thirty and forty years, and it progresses from\nchoreic and ataxic signs to dementia and death. The death is often\nby suicide. In eastern Long Island, southwestern Connecticut, and\neastern Massachusetts 962 cases were all traced back to six persons,\nthree of whom were probably brothers, who came to America in the\nseventeenth century. In the 3000 relatives of these choreics were\n39 cases of epilepsy, 51 cases of cerebral inflammation, 41 cases\nof hydrocephaly, 73 feeble-minded children, and other evidences of\nneuroses. The heredity in this disease is apparently Mendelian.\nBesides the diseases enumerated here, there are several pathologic\nconditions of the eyes which are hereditary--presenile cataract,\nstationary night blindness, and retinitis pigmentosa. If the persons\nwho have these diseases are sexually sterile, evidently the heredity\nso far as they are concerned will be cut across; hence the advocates\nof legal sterilization wish to have these patients sterilized to\nprotect society.\n\nThe surgical operation by which the man is sterilized according to\nthe State laws mentioned above is an interruption of the continuity\nof the vasa deferentia near the testicles. This interruption may be\na severing of each vas, a cutting out of a part of each vas, or a\nligation of the vasa. The term vasectomy is now used loosely to cover\nall these methods. The vas deferens, or seminal duct, passes from the\ntesticle up along the groin on each side, in through the belly-wall\nby the inguinal canal, down along the pelvis and under the bladder,\nwhere it opens into the bottom of the urethra a short distance in\nfront of the bladder exit. Each vas is about two feet in length, and\nit has a diameter of one-tenth of an inch throughout the greater part\nof its length, but its lumen is extremely narrow.\n\nThere are two essential parts in the semen, the spermatozoa and\nthe carrying liquid. The spermatozoa, which fructify the ovum, are\nformed in the testicle; the liquid, which is the essential vehicle\nof the spermatozoa, and without which the spermatozoa are inert and\nsterile, is secreted, except a few drops from the testicles, at the\ndistal end of the vasa deferentia under the base of the bladder, in\nthe seminal vesicles, the prostate gland, and Cowper's and Littr\u00e9's\nglands. The semen is made up of 90 per cent. water and 10 per cent.\nsolids, and in these solids is the nitrogenous base called spermin,\nwhich is produced by the interstitial cells of the testicles and the\nprostate gland. Ovarin, secreted from the ovaries, corresponds in the\nwoman to spermin in the man. The ductless glands, and some that have\nducts, produce secretions which sustain the tone of the blood-vessels\nand neutralize the toxins from waste substances while these are in\nthe body before excretion. An excess of spermin or ovarin causes\ncongestion of the cerebrum and cerebellum and the nerve centres\nthere, with consequent sexual erethism. When there is a pathologic\nsexual erethism from an excess of spermin or ovarin, vasectomy,\ncastration, spaying, or the menopause cuts off this excess and the\nerethism disappears. Sometimes the waste product toxins excite the\npatient when the spermin or ovarin has been eliminated, just as the\nexcess of spermin or ovarin excites, and the neurotic disturbance\nor sexual erethism continues until compensation by other glands\nneutralizes the irritating substance.\n\nThe testicles in man are by no means the sole organ of generation.\nThere are at least seventeen distinct organs in the male generative\nsystem. The seminal vesicles with the prostate gland are as necessary\nin generation as the testicles, as their removal sterilizes the\nspermatozoa and prevents the formation of the liquid vehicle.\nCastration effects an atrophy of several parts of the generative\ntract, and an irremediable degeneration; vasectomy cuts off the\nspermatozoa but causes no atrophy or degeneration, and the condition\nis remediable. Dr. Edward Martin of Philadelphia found active living\nspermatozoa in a testicle that had been ligated off for twenty years.\n\nRunning along the vasa deferentia, within the sheath of the two\nspermatic cords, are the spermatic arteries, the pampiniform plexus\nof veins, and the deferential arteries. These vessels, with the vas\ndeferens and the sheath enveloping the bundle, make up the spermatic\ncord. In vasectomy, under local anesthesia, a slit is made through\nthe skin of the scrotum behind, the sheath of the spermatic cord\nis opened, and the vas is isolated and tied or cut. The skin wound\nis left to heal. This operation is repeated on the second vas. If\nthe blood-vessels in the cord are ligated or cut with the vas,\nthe testicle will atrophy; if the vas alone is operated upon, the\ntesticle is not injured. The person upon whom vasectomy has been done\nis conscious of no change. The semen is discharged as before the\noperation, but in a slightly less quantity, and it is, of course,\nsterile from the lack of spermatozoa.\n\nDr. Carrington of Virginia reported, in 1910,[218] twelve cases of\nvasectomy on convicts. He said ten of this dozen had been confirmed\nmasturbators, and all were cured by vasectomy. One masturbating\nepileptic was cured of both conditions. Two dangerous homicides were\nrendered harmless and peaceable. One of these two homicides was a\nnegro under a long sentence for murder. He grew insane in prison,\nand while insane killed a second person. A confirmed masturbator and\nsodomist, and a dangerous savage, he became lucid and relapsed into\ninsanity several times. A year after vasectomy he was \"a sleek, fat,\ndocile, intelligent fellow, a trusty about the yard.\"\n\n  [218] _Virginia Medical Semi-monthly_, vols. xiv, xv.\n\nDr. Sharp of Indianapolis, after ten years' experience with the\noperation, during which time he did 456 vasectomies, says:[219]\n\"There is no atrophy of the testicle, no cystic degeneration, no\ndisturbed mental or nervous condition following.\" He says, further,\nthat 176 men in the Indiana Reformatory asked him to perform the\noperation on them. Vasectomy tends to check masturbation, and the\nminds of the masturbators frequently improve after the operation.\n\n  [219] _Jour. Amer. Med. Assoc._, December 4, 1909.\n\nIf a man has been sterilized by vasectomy, restoration of function\nand removal of the sterility seems practically always possible. If\na ligature has been used, releasing the ligature restores function.\nDr. William T. Belfield of Chicago[220] restored function fully by\nremoving the ligature eight weeks after it had been applied. In a\nletter to me, Dr. Belfield said: \"My observation accords with the\ngeneral experimental and clinical experience that the restoration of\nthe lumen after vasectomy or ligation, or both, is more certain than\nthe lasting occlusion of the vasa by these measures. The perseverance\nof natural forces in restoring the lumen of the vas--and the success\nachieved over such obstacles as silk ligatures--is surprising until\none reflects upon the natural factors favoring such restoration. In\none case I tied a waxed (to avoid cutting through) silk ligature\n_tightly_ around the sheath of each vas; a specimen examined a month\nlater was devoid of sperms; one six months later contained plenty of\nthem. I cut down upon the ligatures, found them in place and neatly\nencysted, and removed them. Evidently the pressure from behind had\nsqueezed a passage on at least one side. The gynecologists have\nlearned that ligatures around the Fallopian tubes are apt to cut\nthrough, whereupon the tubal lumen is restored, though pressure\nmust be less than in the vas. Even when a piece of the vas has been\nexcised cases of spontaneous restoration have been observed in men\nand dogs.\"[221]\n\n  [220] _Jour. Amer. Med. Assoc._, October 19, 1912.\n\n  [221] _Belfield, loc. cit._\n\nWhen the ends of a cut vas are released from cicatricial tissue,\nthese ends may be sutured together; but as the lumen of the vas is\nextremely small, there is sometimes obliteration by occlusion at\nthe juncture. Christian and Sanderson[222] described a method of\npreventing this obliteration. A piece of No. 0 twenty-day catgut is\ninserted three-eighths of an inch into each end of the vas, and these\nends are brought together by two catgut sutures, leaving the inserted\ncatgut in the canal. The ends heal together and the catgut in the\ncanal is absorbed. This method has been used successfully to join the\ncut end of a Fallopian tube.\n\n  [222] _Jour. Amer. Med. Assoc._, December 13, 1913.\n\nGemelli[223] did vasectomy on eleven dogs and seven cats; about\nsix months later he reunited the cut ends, and on dissection found\nrestoration perfect, anatomically and functionally, in the eighteen\nanimals. The vas deferens in these animals is smaller than in man;\nand therefore offers greater difficulty in the suturing. He used no\ninserted catgut, but told me he employed the method Carrel applies in\njoining cut arteries. In one case, where the dissection was broad,\nhe successfully inserted a piece of a vas taken from another animal.\nWhether there is occlusion or not after end-to-end suturing depends\nlargely on the skill of the surgeon.\n\n  [223] _La Scuola Cattolica_, November, 1911.\n\nDr. Edward Martin of the Pennsylvania University[224] and Delbet[225]\nhave removed sterility by effecting a patulous anastomosis between\nthe vas and the epididymis, and this method is applicable after\nvasectomy by cutting, but it is not successful, as a rule. It has\nbeen done effectively where the vas had no stricture. McKenna,[226]\nin five attempts on men, succeeded once. F\u00fcrbringer[227] said that\nin his experience with a thousand cases of double epididymis, the\ncondition is incurable in 80 per cent. of the gonorrheal infections.\n\n  [224] _University of Pennsylvania Medical Bulletin_, 1902, p.\n  388; 1903, xv, 2; _Therapeutic Gazette_, December 15, 1909.\n\n  [225] _Revue de Th\u00e9rapeutique M\u00e9dico-chirurgicale_, January 15,\n  1912.\n\n  [226] _Journal Amer. Med. Assoc._, January 26, 1915.\n\n  [227] _Deutsche med. Wochenschrift_, xxxix, 29.\n\nApart from the so-called vasectomy law, gynecologists quite\nfrequently sterilize women who have chronic heart disease,\ntuberculosis, nephritis, diabetes, or hereditary mental taints.\nSome men, like Spinelli, Cramer, Polak, and others, would sterilize\nalso in chronic anemia, persistent albuminuria, epilepsy, syphilis,\ncontracted pelvis, diseases of metabolism, infections, and\ncirrhosis of the liver. There are several methods of sterilizing\nwomen--removal of the ovaries, ligation of the Fallopian tubes,\nresection of portions of the tubes, resection of the whole tube on\neach side, cutting the tubes and burying the cut end in the tissues\nby various methods, and destruction of the lining of the uterus by\nvaporization or the thermocautery. De Tarnowsky[228] describes the\nvarious methods. Some ligations and short resections have failed\nto sterilize. When the ovaries or uterus are removed, or the major\npart of the tubes are resected, or the lining of the uterus has\nbeen destroyed, the sterilization is permanent. Almost certainly\nfunction could be restored where the resection of the tubes is not\ntoo destructive. Apart from the matter of mutilation, the effects of\ndouble o\u00f6phorectomy are very grave,[229] and removal of the uterus\nor the ovaries merely for sterilization is not only immoral, but\naltogether unjustifiable scientifically.\n\n  [228] _Jour. Amer. Med. Assoc._, April 19, 1913.\n\n  [229] See the chapter on Gonorrhea.\n\nA phase of this subject which is important and has occasioned much\ndiscussion is whether vasectomy causes sexual impotence or not.\nFrom a medical point of view, there is no question of impotence;\nphysicians would say it causes sterility only. Most canonists,\nhowever, hold that the condition after vasectomy is technically\nimpotence in the canonical sense. Ferreres of Tortosa, a leading\nSpanish canonist, in several articles in the _Ecclesiastical Review_,\nin _Razon y Fe_ (xxviii, 376; xxxi, 496), and in his book _De\nVasectomia Duplici_ (Madrid, 1913), opposed my opinion published in\n1912 and 1913, which then was that vasectomy does not cause canonical\nimpotence. De Smet of Bruges[230] holds that it causes impotence.\nSo do Ojetti,[231] Ren\u00e9 Michaud,[232] Wouters,[233] Eschbach,[234]\nCapello,[235] Stucchi,[236] De Becker, Vermeersch, De Villers,\nand Salsmans of the University of Louvain, and others. Gemelli of\nMilan[237] agreed with me. The weight of authority is certainly\nin favor of the notion of impotence, but the arguments are by no\nmeans convincing, as virtually every canonist who has discussed the\nquestion has made gross misstatements of the physical facts in the\ncase.\n\n  [230] _Ecclesiastical Review_, September, 1912.\n\n  [231] _Synopsis Rerum Moralium et Juris Pontificii_, 31st ed., n.\n  2425.\n\n  [232] _Nouvelle Revue Th\u00e9ologique._\n\n  [233] _Nederlandische Katholische Stemmen_, January 15, 1911.\n\n  [234] _Analecta Ecclesiastica_, September, 1911, and _La Scuola\n  Cattolica_, February, 1912.\n\n  [235] _La Scuola Cattolica_, February, 1912.\n\n  [236] _Ibid._, November, 1911.\n\n  [237] _Ibid._, November, 1911.\n\nIf a man or woman is impotent, the disability is an _impedimentum\njuris naturalis_, and as such it would nullify any marriage, no\nmatter what the dispensation. There are two opinions among moralists\nas to the essence of canonical impotence.\n\nI. Some hold that any permanent obstruction to fecundation, no matter\nin what stage of the physiological process or in what part of the\ngenital tract it occurs, constitutes impotence. They maintain that a\nwoman whose ovaries or uterus have been removed is impotent. Roman\nCongregations have promulgated several decrees in peculiar cases\npermitting the marriage of spayed women; but, these moralists say,\nit is not clear that in those special cases the entire ovary on each\nside of the whole uterus was taken out; they hold there is doubt as\nto the fact. And, since there is disagreement of moralists, the Holy\nOffice or other congregations would give the same decision because of\nthe _dubium juris_.\n\nApril 2, 1909, the Congregation on the Discipline of the Sacraments\ndecreed that the marriage of a Spanish woman, from whom, according to\nthe physician in charge of the case, the uterus and both ovaries had\ncertainly been removed, should not be prevented.\n\nFebruary 3, 1887, the Holy Office made the same decree in the case of\na woman from whom the uterus and both ovaries had been removed.\n\nJuly 23, 1890, the Holy Office made the like decree under the same\nconditions.\n\nJuly 31, 1895, the Holy Office permitted the marriage of a woman from\nwhom both ovaries had been removed.\n\nAnother case, in 1902, in which the physician was not certain that\nthe whole ovary on each side had been removed, was decided in the\nsame manner.\n\nThere have been, then, four decisions so far permitting the marriage\nof women who lacked both ovaries, and three of these women lacked the\nuterus also. The Congregation of the Council has made four decisions\nin recent time forbidding the marriage of women because of impotence;\nMarch 21, 1863, a case in which there was neither vagina nor uterus;\nJanuary 24, 1871, a case in which the vagina was only two inches in\ndepth; September 7, 1895, a case in which the vagina was obliterated\nin greater part; December 16, 1899, a case in which the vagina was\nonly five centimetres in depth.\n\nThat a woman who certainly lacks both ovaries is canonically impotent\nis the opinion of Antonelli,[238] Lehmkuhl,[239] Rosset,[240]\nAlberti,[241] Bucceroni,[242] and others. These men meet the\ndecisions of the congregations concerning the spayed women by saying\nit is not certain the whole ovarian tissue or the entire uterus\nwas removed, although as a matter of fact the physician in one\ncase testified explicitly that both ovaries and the whole uterus\nwere undoubtedly removed. That a woman lacking both ovaries is not\nimpotent is the opinion of Gasparri, D'Annibale, G\u00e9nicot, Berardi,\nAertnys, Tanquerey, Ojetti, De Smet, and others.[243]\n\n  [238] _Medicina Pastoralis_, vol. ii, n. 43.\n\n  [239] _Theologia Moralis_, 8th ed., ii, n. 744.\n\n  [240] _De Matrimonio._\n\n  [241] _Theologia Pastoralis_, p. iv, n. 88.\n\n  [242] _Theologia Moralis_, ii, n. 994.\n\n  [243] See Ferreres, _De Vasectomia Duplici necnon de Matrimonio\n  Mulieris Excisae_, p. 110. Madrid, 1913.\n\nII. The second opinion on impotence is that this condition is caused\nexclusively by those permanent disabilities which exist in the copula\nitself. If the sexual act contains in itself all that is essential\nto generation, if the copula is _de se apta ad generationem_,\nprescinding from all antecedent and subsequent, temporary or\npermanent, obstructions to generation, there is no impotence. In\nthis opinion the woman without ovaries is not impotent, but the\nvasectomized man is; in the first opinion both the _mulier excisa_\nand the vasectomized man are impotent. The second group says the\nvasectomized man is incapable of performing an act _de se apta ad\ngenerationem_ because his semen lacks the essential spermatozoa. If\none objects that the spayed woman, who is not impotent according to\nsome moralists that so interpret the decisions of the congregations,\nlacks the essential ovum, so that she cannot perform an act _de se\napta ad generationem_ because she has nothing to generate with,\nthey answer that her copula is _per se apta_, that there happens in\nit everything which takes place in a copula from which generation\nactually follows. The vasectomized man cannot go through the form\nof the act with all the elements which, _so far as the act is\nconcerned_, are required and sufficient for generation because he\nlacks the spermatozoa, but the _mulier excisa_ can. His inability is\nintrinsic to the act, it vitiates the very substance of the act; her\ninability to present ova is not intrinsic to the act, they say. All\nthat is necessary in her case is that she be capable of receiving the\nsemen.\n\nMarriage was instituted to beget children; that is the proper end of\nthe contract, its basic justification. Whenever the debitum is used\nit must be with the intention of generating children. Even the use\nof marriage as a remedy of concupiscence is so secondary an end that\nit alone is not enough to legitimize marriage. Because a woman does\nnot always have ova present in the tubes,--and there is no means\nof knowing just when the ova are present,--it is justifiable to\nrepeat the conjugal act until the woman is impregnated; secondarily\nand dependently, the repetition may be a remedy of concupiscence.\nThe sexual act does not form either the spermatozoa or the ova;\nthese pre-exist. The spermatozoa are always released in a normal\nsexual act; the ova are not always present when the spermatozoa are\nreleased. A copula which is perfectly _de se apta ad generationem_\nsupposes not at the time the presence of both sperm and ovum, but\nit does suppose the possibility of the ovum, otherwise generation\nis utterly impossible; and every copula becomes justifiable solely\nbecause there is a hope that it may be present. It is a mere\nquibble to say that an act is _de se apta ad generationem_ if by\nno possibility generation ever can take place; nevertheless the\ncongregations in four cases have apparently judged to the contrary.\nIn these special decisions, however, Rosset, Antonelli, Bucceroni,\nand Palmieri hold there was a doubt in the minds of the members of\nthe congregation as to the complete removal of the ovaries or uterus.\nBucceroni expressly states[244] that the Cardinal Secretary of the\nHoly Office told him personally the members of the congregation\nsupposed in the particular cases that generation could follow.\nTherefore these decisions do not say that the _mulier excisa_ in\ngeneral is not impotent or potent; they merely gave the women of\nthese cases the benefit of the doubt. Tho question is entirely open\nso far as these decisions are concerned.\n\n  [244] _Theologia Moralis_, 5th ed., vol. ii, p. 391, n. 994.\n\nThose who hold that vasectomy causes canonical impotence say also\nthe constitution of Sixtus V. forbidding the marriage of eunuchs is\napplicable necessarily to the vasectomized man, because the semen\nfrom the vasectomized man, inasmuch as it lacks spermatozoa, is not\ngenuine semen, and Sixtus V. said eunuchs cannot produce true semen.\nThe relevant passage in the constitution is: \"Cum frequenter in istis\nregionibus eunuchi et spadones, qui utroque teste carent, et ideo\ncertum ac manifestum est eos verum semen emittere non posse; quia\nimpura carnis tentigine atque immundis complexibus cum mulieribus\nse comiscent, et humorem forsan quemdam similem semini, licet ad\ngenerationem et ad matrimonii causam minime aptam, effundunt,\nmatrimonium ... contrahere praesumant ... mandamus ut conjugia per\ndictos et alios quoscumque eunuchos ... contrahi prohibeas.\"\n\nSixtus V. says here: (1) that eunuchs \"who lack both testicles\ncertainly and evidently cannot emit true semen\"; (2) that \"although\neunuchs may perhaps produce a kind of liquid resembling semen,\nthis is by no means fit for generation or marriage\"; (3) therefore\neunuchs are forbidden to marry. The effects of castration in the\neunuch are: (_a_) that all spermatozoa are absent; (_b_) that, as a\nconsequence of the absence of the testicles, the power of penetration\nis lost; (_c_) that, as another consequence, the _liquor seminis_,\nwhich normally is formed in the seminal vesicles, the prostate and\nother glands, is no longer secreted. The eunuch, then, is completely\nimpotent, in the full sense of the term. Ferreres is of the opinion,\nerroneously, that eunuchs, as a rule, have the power of penetration\nand of emitting a _humor semini similis_, and that amputation of the\npenis is requisite to cause impotence in eunuchs. There are only five\nauthentic cases of temporary apparent potence in eunuchs in modern\nmedical records, and these are explicable as cases of erethism from\nwaste-product intoxication.\n\nThe canonists who hold that the vasectomized man is impotent\ninterpret the words of Sixtus V. to fit their opinion, although the\nvasectomized man has all the sexual potency of the normal man except\nthat his spermatozoa are occluded. The _potestas coeundi_ is not\nlost in any degree; neither he nor the woman is conscious of any\nchange whatever. Only the microscope can tell that the spermatozoa\nare absent if the fact that he has been vasectomized is not told.\nMoreover, if vasectomy has been done by mere cutting without\nconsiderable resection, and especially if the vasa have been shut by\nligation alone, no one can be certain that the occlusion is either\ncertain or permanent. There is always doubt that the spermatozoa\nare present if the microscope is not used, and these canonists\nall disclaim the use of the microscope in such circumstances. The\nargument Ferreres uses, to the effect that the absence of spermatozoa\nis seriously injurious to the woman, is a supposition of his own\narising from an erroneous notion of potency in the vasectomized. This\nabsence is not injurious to her, but it is probably injurious to the\nvasectomized man because of the partial ejaculation. Onanism, which\nis different, is decidedly injurious to both the man and the woman.\n\nOnanism, _coitus interruptus_, or withdrawal before ejaculation,\nwhich takes place _extra vas_, is intended to prevent impregnation.\nIn the normal sexual act the male genital tract suddenly becomes\ncongested with blood through nervous action of centres in the\nlumbar cord and the cerebrum. Cowper's and Littr\u00e9's glands secret\nan alkaline fluid which neutralizes the acid urine in the urethra\nand thus prevents killing of the spermatozoa. Muscular peristaltic\naction presses out the spermatozoa and the secretions of the seminal\nvesicles and the prostate. When the act is normal there is a complete\nemptying of the tract of semen and of the blood engorgement; in\n_coitus interruptus_ there is incomplete ejaculation and only\npartial deplethorization. The seminal vesicles remain distended,\nand this distention, with the congestion of the prostate, causes\ncontinual excitation of the sexual centres without relief. There is\nirritability and exhaustion of the centres, and this state brings on\npremature ejaculation and final _impotentia coeundi_. Other common\neffects are tenesmus of the urinary bladder, incontinence of urine,\nnocturnal pollutions, sexual neurasthenia, pain in the legs, over the\neyes, and in almost any part of the body, general weakness, headache,\nvertigo, cardiac palpitation, neurotic dyspepsia, and a train of\npsychic symptoms which not seldom end in suicide.\n\nIn the woman there is the like blood engorgement and a pouring\nout of the secretions of Bartholin's and the other glands, but\ndeplethorization takes place later in the woman than in the man, and\nfor this reason the woman suffers more from _coitus interruptus_ than\nthe man does. In onanism, as in masturbation, after the diseased\nconditions have been established it is extremely difficult to induce\nthe patient to resist the almost overwhelming irritation.\n\nThe canonists have interpreted the text of Sixtus V. to the effect\nthat the eunuch is impotent precisely and solely because he cannot\nproduce semen \"_elaboratum in testibus_.\" No man produces semen\n_elaboratum in testibus_--more than 93 per cent. of the semen is\nproduced entirely outside the testicle; nothing but the spermatozoa\nand two or three drops of a lubricating fluid are produced in the\ntesticles. The eunuch really is impotent because the removal of the\ntesticles and their nervous system so breaks the genital circuit,\nwhich consists of at least seventeen distinct parts, that erection is\nprevented, the formation of spermatozoa is impossible, the secretion\nof the essential vehicle of the sperm and of the fluids which render\nit fertile is cut off. The eunuch cannot penetrate and he cannot form\nany semen; he is impotent; the vasectomized man can penetrate, and he\nforms a semen which is sterile.\n\nI think now the vasectomized man is really impotent for the reason\nthat I think the _mulier excisa_ is impotent, but he is not impotent\nbecause of the constitution of Sixtus V., which is not relevant at\nall to his case.\n\nIf the vasectomized man is impotent, the following cases are also\nimpotent:\n\n     1. A man whose germ-cells have been destroyed by the action of\n     the X-ray.\n\n     2. A man with double permanent occluding epididymitis.\n\n     3. A man whose vasa deferentia open into the ureters and not\n     into the urethra.\n\n     4. A man whose vasa are shut by surgical operations for stone,\n     or cysts of the prostate, or seminal vesicles.\n\n     5. A man whose seminal vesicles are shut by concretions, cysts,\n     or tumors.\n\n     6. A man with bilateral cryptorchidism.\n\n     7. A man with a tuberculous condition of the testicles.\n\n     8. A man with absolute neurotic aspermia.\n\n     9. A man with congenital lack of development of the testicles or\n     vasa.\n\nSterility in the male would exist only in advanced diabetes, general\ntuberculosis, senility, or in cases of absent or diseased prostate\ngland or seminal vesicles.\n\nHere it is worth noting that since the copula must be natural, fit\nfor generation in the natural manner, artificial impregnation by the\nuse of instruments is immoral, and forbidden by a decree of the Holy\nOffice, promulgated March 24, 1897. Artificial impregnation does not\neffect a copula which is by its nature proper to generation, but is\nan act contrary to nature, one from which generation does not follow\nin a natural manner, _secundum communem speciem actus_. It supposes\ndeliberate pollution and semination outside the vagina, both of which\nactions are intrinsically evil.\n\nIn discussing the morality of vasectomy the following points must be\nconsidered:\n\n1. In what degree of mutilation is vasectomy?\n\n2. Vasectomy may be done either at the request or by the permission\nof the vasectomized person; or by order of the State.\n\n     (_a_) If done by the request or permission of the vasectomized\n         person, it may be either (1) as a means to use the debitum\n         without the inconvenience of having children; or (2) as a\n         therapeutic measure to cure some malady.\n\n     (_b_) If done by order of the State, it may be (1) a punishment;\n         or (2) a prophylactic measure to avert physical or moral evil\n         in society.\n\nIf vasectomy causes canonical impotence, that fact adds a special\nmoral quality. The weight of authority is on the side that it does\ncause canonical impotence, as has already been mentioned.\n\nA slight mutilation, in the sense of the term as commonly used, can\nbe any permanent effect of a wound, bruise, or similar cause, from a\nmere scar to an amputation or other injury whereby any member of the\nbody is rendered unfit for normal action. That the causal wound or\ninjury is trivial in itself, apart from its effect, as in vasectomy,\nhas little or no direct bearing on the morality of the mutilation.\nIt is possible to have a very gross mutilation without extensive\nwounding. We can blind a man permanently by putting the point of a\nfine cambric needle one-twentieth of an inch within the pupil.\n\nVasectomy is a grave mutilation because (1) it removes from the\nman the power of generation; (2) it inhibits the function of the\ntesticle, which is an important organ of the body. Although they\nare not the entire organ of generation, the testicles are together\na complete organ in themselves, the function of which is to produce\nthe spermatozoa essential to the procreation of the human species.\nIf by a wound one inhibits the function of the testicles, he gravely\nmutilates the human body, for a grave mutilation is nothing but an\ninhibition of the function of a distinct organ through a wound.\n\nA mutilation of this kind, since it frustrates the production and\naction of the human generative semen and prevents generation, is\nwhat is technically called a mortal sin against nature, unless\nthere is sufficient cause to necessitate the frustration, such as\nto save life, to restore as a sole means the health of the whole\nbody, to protect society, or a similar reason. What is said here of\nvasectomy is true for fallectomy or other methods of sterilizing the\nwoman. Fallectomy, however, is in itself a dangerous operation, and\no\u00f6phorectomy is never justifiable as a mere method of sterilization\nbecause of its very injurious effects on the whole body and mind of\nthe woman.\n\nAmong the decretals of Gregory in _Corpus Juris_ (lib. v, tit.\nxii, c. 5) is the following canon: \"If any one, for the sake of\nindulging lust, or through revenge, does anything to a man or woman,\nor gives them anything to drink, whereby they cannot generate, or\nconceive, or bear children, he is to be treated as a homicide.\" Any\none who sterilizes a man by vasectomy or a woman by fallectomy or\no\u00f6phorectomy, for an improper motive, _ipso facto_ falls under this\ndecree, and is before the canon law classed in the same category as\na murderer; that is, the agent is deemed guilty of a grave crime\nagainst nature.\n\nIf a man has vasectomy done upon himself, his intention may be (1) to\nuse the debitum without the inconvenience of having children; or (2)\nto avert from a wife with a narrow pelvis the dangers of the cesarean\nsection or other obstetrical operation to herself and the child; or\n(3) to avoid the transmission to possible offspring of a hereditary\ndisease like Huntington's chorea or one of the others mentioned at\nthe beginning of this chapter; or (4) to cure himself of some malady.\n\n1. If vasectomy is done merely to be able to use the debitum without\nthe inconvenience of having children, it is evidently illicit. It is\nin that condition the same as onanism; it is contrary to the basic\njustification of marriage; it is a frustration of nature; and so on.\n\n2. If it is done to safeguard a wife with a narrow pelvis it is\na means, evil in itself, used directly to effect a good end; and\na good end, or any end or effect, never justifies a direct evil\nmeans or cause. There is in reality no such thing as a good effect\nfrom an evil means or cause; the evil means or cause essentially\nand substantially vitiates the effect. There is no question here of\na double effect, one good and one evil, wherein the good effect is\nintended and the evil permitted, both coming with equal directness\nfrom the single causal act. On the contrary, from the vasectomy\nhere there is the single direct effect that the man is sterilized,\nand then directly from this sterility comes the desired effect, the\nprotection of the wife. For exactly the same reason, vasectomy done\nto prevent the transmission of a hereditary disease is illicit; it is\nan evil means used directly to effect an end intended. In artificial\nabortion when the fetus is inviable the act done is to empty the\nuterus, and this act itself kills the fetus, which is not an unjust\naggressor, and is murder. This murder may save the mother's life,\nbut the end does not justify the means. The vasectomy to protect the\nmother's life or to avert an evil heredity is a parallel case.[245]\n\n  [245] See the chapter on General Principles concerning Mutilation\n  for an explanation of the act with a double effect.\n\nThe fourth case supposes that the vasectomy was done to cure the man\nof some malady. If there were a malady that endangered the patient's\nlife, or destroyed the health of the body and it could be cured by\nvasectomy, the operation would of course be licit for the reasons\ngiven in the chapter on General Principles concerning Mutilation.\nDr. Carrington tells us[246] that he did vasectomy on an epileptic\nconvict and cured him. Such a cure is doubtful as to permanence. He\ndescribes two dangerous insane negro homicides who were rendered\nharmless by vasectomy. In cases like those of the homicides any\none responsible for them would probably be justified in having the\noperation done, although these two cases are the only direct ones on\nrecord. Epileptics sometimes show a homicidal tendency, but it is\ndoubtful that vasectomy would help them. The operation of vasectomy\nas a cure for bodily ill has a very limited field. There are very\nmany conditions in women where it is necessary to remove the ovaries\nor the tubes to save life, or to cure chronic invalidism of an\nunbearable nature. These conditions are discussed in the chapter on\nGonorrhea. There is no objection to the removal of a tube or an ovary\nwhen such removal is absolutely necessary, but the necessity must be\nclearly evident. There is a tendency in some surgeons to mutilate\nwomen in this manner without sufficient reason or to follow out a\ntherapeutic theory.\n\n  [246] _Virginia Medical Semi-monthly_, vols, xiv, xv.\n\nMen, like Sharp, who have done hundreds of vasectomies, say the\noperation commonly removes the inclination to masturbation.\nMasturbation is, as a rule, a moral condition, but it can, like\nalcoholism, come to have a large physical element. Idiots almost\nunexceptionally have this vice, and in them there is no morality\npossible. If by vasectomy they can be cured of this vice, which\ninjures their health and is a social indecency and a source of sin\nin observers, the operation would be licit in their case. When the\npatient is morally responsible vasectomy would not be licit, as there\nis no adequation between a physical evil like sterilization and a\nmoral vice. There are cases of pathological sexual erethism which\nare so violent that the patients must be put into strait-jackets to\nprevent constant masturbation. The semen of such patients is usually\ndevoid of spermatozoa. If the patient is confined in a strait-jacket\nhe will die, and vasectomy, according to Sharp, will quiet such a\nman. Vasectomy would be permissible in these circumstances.\n\nThe question has arisen in the case of a sane masturbator who is\nneurotic, weak-willed, and a confirmed addict to his vice, whether\nor not his vasa might be tied off by ligatures, temporarily, with\nthe intention of removing the ligature later and restoring function.\nI think not. Even temporary sterilization is sterilization, a grave\nmutilation, while it lasts, and the condition is really moral\nfundamentally, and therefore not a fitting object for physical\nremedies.\n\nWhen vasectomy is done by the State, it is done either as a penal\nor as a prophylactic measure. As a general statement we can say\nthe State in certain conditions has the right to kill or mutilate\na criminal in defence of the social order; but even then any\npunishment, to be justifiable, must be effective and necessary,\nand it has to be either reformative, exemplary, or reparative in\nregard to the crime for which it is inflicted. Capital punishment\nand mutilation are effective usually, and are necessary for the\npreservation of society. The natural law permits the State to\npreserve itself against the unjust encroachments of individuals by\ncurtailing their rights in so far as that curtailment is effective\nand necessary: since the natural law requires the existence of civil\nsociety, it must allow what is necessary for the preservation of that\nsociety. There is no question here of a good end justifying evil\nmeans; the means which otherwise would be evil in these conditions\nbecome good. Homicide and mutilation are not mere killing or mere\nmaiming, but unjust killing or unjust maiming. Killing or maiming is\nnot intrinsically wrong under all circumstances, as lying, blasphemy,\nand some other crimes are; nevertheless, as a punishment by maiming,\nvasectomy is ordinarily wrong, and therefore a law making it an\nordinary mode of punishment for certain whole classes of criminals,\nor all criminals, is unjust.\n\nIt is wrong because as a punishment it is neither effective nor\nnecessary nor reformatory nor exemplary nor reparative--it lacks\nevery quality of a justifiable punishment. In Dr. Sharp's list\nof vasectomies done in Indiana prisons, 176 operations were done\non men who voluntarily asked for vasectomy. There is no pain, no\ninconvenience caused by the operation, no sexual change perceptible,\nbut a fitting of the criminal to indulge his lust without the various\ninconveniences of impregnation. Instead of being reformatory,\nit is conducive to crime. I find only one man who objected to\nvasectomy.[247] In this man vasectomy was added to life imprisonment\nas a punishment for rape.\n\n  [247] _State of Washington vs. Feilen, 126 Pac. R. 75._\n\nThe legislators in the States which have passed the vasectomy law\nall seem to have been influenced by the pseudoscientific notion that\ncriminality is a hereditary condition, a physical disease, and not\na matter of volition. This Lombrosan absurdity is now held by no\nphysical scientist, and from an ethical point of view it is nonsense.\nMoreover, if the State vasectomized all the criminals in the jails,\nthis method would not appreciably affect the supply of criminals, nor\nreach an appreciable minority of the criminal class, as the most\ndangerous criminals are not in jails.\n\nThe operation is not a punishment to the men upon whom it is done,\nbut it is an unnecessary deprivation of an essential right of these\nmen, an excessive, ill-ordered attack on a primary right of man,\nand an act of violence against human nature and its Author without\nadequate reason. The law is against the natural order because it\ndirectly deprives a man, and that against his will, of functions\nwhich are at times a moral necessity to him, and puts him into the\noccasion of sin. Vasectomy does not remove his venereal desires, but\ngives opportunity to lust; it turns the conjugal relation into mere\nonanism and degrades marriage into a crime. Other conditions, like\nmilitary service, in which necessity obliges the State to place its\ncitizens and thus prevent the conjugal relation, cause an indirect\ntemporary prevention, reluctantly permitted, not directly intended.\nVasectomy is an evil directly intended.\n\nIt is to the interest of the State to prevent the transmission of\nhereditary disease, and in doing so it may to a certain degree\ncurtail the natural liberty of its citizens. When the peril is great,\nas in a plague, the State may isolate infected individuals, and thus\nindirectly, but temporarily, prevent a natural right--namely, the\nconjugal relation. It may even perpetually isolate, as in leprosy.\nVasectomy, however, is a direct prevention without reason, and it is\ndone as a direct evil means to effect a so-called end which it never\nattains.\n\nA man with Huntington's chorea, if married and if he has children,\nwill surely transmit the disease to some of these children, and they\nto their children. Vasectomy on him will prevent a propagation of\nhis kind but will cure no disease. Moreover, he is not a criminal\nand not amenable to punishment. The bad effect, sterilization, must\nbe perpetual in his case or it is foolish, but the sterilization is\nnot a punishment, nor a means of saving the health of the patient.\nWhatever good comes of the act comes out of an evil cause. If such a\nman persists in marrying, his marriage might be prevented, but that\nis different from mutilating him.\n\nThe State has no _direct dominion_ over the lives or members of its\ncitizens, nor are citizens naturally mere instruments for the good of\nthe government; on the contrary, the government exists solely for the\ngood and utility of the citizen. The State may not take the life of\nan innocent person, nor mutilate him, unless these acts are necessary\neither (1) to protect the life or rights of individuals; or (2) to\npreserve the social life of the commonwealth. Now, neither of these\ntwo requisites is present when there is question of vasectomizing a\nman.\n\nThe right or life of no individual is at stake. The rights of the\npossible children, yet unborn, are not injured, because, as these\nchildren are not in existence, they have no rights. Should they come\ninto being, it is always better to be, even though diseased, than not\nto be. The methods of cattle-breeders in dealing with human beings is\nnot a virtue in the State, but an outrage and a degradation of human\nnature.\n\nThe rights of the wife are not injured, because she personally\nreceives no injury; and if her possible children have chorea, for\nexample, she either voluntarily took that risk when she married, or\nif she did not, through ignorance, there are other means to avoid\nthe trouble than the evil of sterilization, which in itself would\nrender the use of marriage onanistic. If the husband has syphilis,\ngonorrhea, leprosy, tuberculosis, or any other infectious disease,\nvasectomy is no protection for the wife.\n\nMay a physician employed by the State in a prison, an institution\nfor the feeble-minded, or a like place, do vasectomy at the command\nof the law? Certainly he may not, except in those rare cases where\nvasectomy is permissible as described above.\n\nThe advocates of freakish legislation harp on the assertion that\ninsanity and imbecility are increasing alarmingly, and as a\nconsequence the entire nation is degenerating. To cure this evil we\nare to mutilate certain criminals and the mentally defective. It is\nnot true that insanity and mental imbecility are increasing in a very\nmarked degree in the United States. The number of inhabitants in this\ncountry is increasing rapidly, and as there are more people here than\nthere were a few years ago, the number of the insane and the mentally\ndefective has increased _pari passu_, but the percentage does\nnot increase to any degree that calls for immoral and ineffective\nlegislation. Only of late years have the State governments begun to\nclassify, diagnose, and gather up the insane and the imbecile, whom\nwe always have had with us, and these processes have brought the\ndefectives into the light.\n\nOur late immigrants are not equal in race, in mental and moral\nstrength, to the old northern European immigrants. In Philadelphia\nthe foreign-born population is 24.7 per cent. of the whole, but\nthat foreign-born population gives us 44 per cent. of the indigent\ninsane. In New York State 27 per cent. of the registered insane are\nnot American citizens. What we need here is not sterilization, but a\nbetter control of the immigrant, a keeping out of the unfit. Again,\nour insanity percentage is increased avoidably by the undoubted\nincrease of insanity among negroes. We are accountable for this\nbecause we do not care for our helpless negroes. These people are\nprevented by trades-unions from learning and working at elevating\ntrades, and they are thus forced unjustly into a poverty and\ndegradation which lead to vice and mental deterioration. The cure is\nnot a jail surgeon's scalpel, evidently.\n\nA system of education that ignores the will, upon which morality\nand virtue are based, and substitutes a sham intellectuality as\nelaborated by ignorant boards of education and administered by\nemotional, half-educated women, together with a lack of genuine\nreligion, is a prolific source of mental and moral deterioration and\nconsequent degeneracy in the physical and moral orders. Our American\npublic-school system is such, and its deity is the unwashed and\ncrassly depraved god Demos, whose bible is the evening newspaper.\nIf we could civilize our schools, we should have no mention of\nlegislation by vagary.\n\n\nBIBLIOGRAPHY\n\n     Ecclesiastical Review, vols, xlii, xliii, xliv, xlvi, xlvii,\n     xlviii, _passim_. Philadelphia.\n\n     Gemelli. La Scuola Cattolica, November, 1911. Milan.\n\n     Stucchi. _Ibid._\n\n     Eschbach. _Ibid._, February, 1912; Analecta Ecclesiastica,\n     September and October, 1911.\n\n     Capello. La Scuola Cattolica, February, 1912.\n\n     Michaud. Nouvelle Revue Th\u00e9ologique. Paris, 1914.\n\n     Schmidt. Zeitschrift f\u00fcr katholische Theologie, nn. 1 and 4,\n     1911.\n\n     Ferreres. De Vasectomia Duplici necnon de Matrimonio Mulieris\n     Excisae. Madrid, 1913.\n\n     De Smet. Collationes Brugenses, December, 1910.\n\n     Wouters. Nederlandische kathol. Stemmen, January 15, 1911.\n\n     Waffelaert. De Virtutibus Cardinalibus, vol. ii. Bruges, 1889.\n\n     Sharp. Journal of the American Medical Association, December 4,\n     1909. This is the article which started the entire vasectomy\n     controversy.\n\n     Barker. Maryland Medical Journal, April, 1910.\n\n     Bell. Hereditary Criminality. Medico-Legal Journal, vol. xvii.\n     New York.\n\n     Desfosses. Presse M\u00e9d., vol. xviii.\n\n     Rentoul. St. Thomas Hospital Gazette, vol. xx. London.\n\n     Swift. Maine Medical Association Journal, December, 1914.\n\n     Lydston. Medical Record, November 8, 1913. New York.\n\n\n\n\nCHAPTER XXIV\n\nTHE ETHICS OF BIRTH CONTROL\n\n\nA corollary of the doctrine which treats of the destruction in\nmedical practice of existent human life, is a consideration of what\nis called Birth Control, or the criminal prevention of possible human\nlife by onanistic contraceptive methods. There has been an agitation\nfor several years past in western and northwestern Europe and in the\nUnited States to bring about the repeal of laws which forbid the\nspreading of information on the methods of preventing conception.\nThe laws which the agitators wish to have abrogated declare that\ncontraceptive information is indecent and should be classed with\nthe circulation of obscene literature, pornographic pictures, and\ninstruction in abortion. The birth control advocates pay no attention\nto accusations like those expressed in the laws, or to those made by\npersons who have accurate notions of morality and common decency, but\nassert that the spread of contraceptive information tends to benefit\nthe individual and human society.\n\nBirth control as advocated by its perpetrators is intrinsically\ncontrary to the natural law, and therefore immoral; it mentally and\nphysically debases those that are guilty of the practice; it does not\nbenefit the poor as its advocates claim it does; the arguments urged\nby its supporters are foolish and frequently deliberate untruths;\nand it is destructive of society and the state. Broadly speaking the\nnatural law rests on the principle that order, reason, justice, what\nis congruous with the nature of a being or faculty and tends to its\nperfection in being or action, should prevail, and that disorder,\nunreason, injustice, the unnatural, must be avoided. The right\norder of nature as established by the Supreme Creator of nature is\nthe standard of action; what is contrary to that order is evil,\nwrong, destructive, criminal, injurious, or the like, in different\ncircumstances, but altogether these deordinate conditions must be\nremoved, not accepted. Morality also depends on these facts. Morality\nis merely the observance of the natural law, and immorality is revolt\nagainst that law.\n\nSince the natural law evidently prescribes that man must live in\nsociety and that the human race which constitutes this society,\nis to be preserved by the generation of new human beings who will\nreplace those that die, or are made useless by disease or other\naccident, whatever tends to this sustention of humanity according to\nthe natural law, and in the proper conditions, is good, and whatever\ntends to the destruction of humanity is evil and to be avoided.\n\nThe generation of new replacing human beings must take place only in\nthe state of marriage, because thus solely the wife and the child\nare protected, the children are educated physically, mentally and\nmorally, and the degradation and bestiality of promiscuous sexual\nrelationship are averted. The first and principal end of marriage is\nthe procreation of children. That end of marriage must be the end on\nwhich is founded primarily the natural necessity for this contract,\nbut the natural necessity for the contract is the propagation of the\nhuman kind through lawful generation and education. Marriage, too, in\nits very nature is fitted for that chief end, and for that end it was\ninstituted by the Author of nature--a stable, perpetual association\nof the sexes for the attainment of what is requisite for the\npropagation of mankind. There are secondary ends of marriage, such\nas a reciprocal love and help of the husband and wife, and also that\naspect of marriage which makes it a restraint upon promiscuous lust.\nThese last, however, are not enough to justify marriage in themselves\nwithout the first or chief end, which is the procreation of children.\n\nWhatever is subversive of the end of marriage, and that is the\npropagation of mankind, is subversive of the very foundation of human\nsociety, is contrary to the nature of man, frustrates the primal\nfunction of nature, and is therefore essentially and always evil,\nas bestiality, sodomy, or incest are evil. Such is birth control as\nordinarily practised. Birth control if it is effective through a\nreciprocal consent of a wedded couple, for grave reason, and solely\nby mutual abstention from the _debitum_ may be in certain conditions\nan indifferent act morally. If, however, birth control is effected\nby contraceptive drugs, or like methods, it is a crime against\nnature, and always a crime which no circumstance can excuse, no\nmore than no circumstance can excuse bestiality, sodomy, or incest.\nSecondly, marriage, which was instituted primarily to perpetuate the\ncreative act of God, when such practices prevail degenerates to mere\nconcubinage, a gratification of lust protected from the police. Such\npractices, moreover, lower man and woman below the brutes, because\nbrutes do not frustrate the natural law except in the case of the\nmale rat and a few other low grade rodents and boar pigs. Onan is the\npatron of Birth Control advocates. The Book of Genesis said Onan, the\nson of Judah, \"did a detestable thing, therefore the Lord slew him.\"\n\nThese are the fundamental reasons those of us recognize who do not\nwish that the ignorant and vicious should be taught to act contrary\nto the natural law. Furthermore, there is always another way out\nof the difficulties, mostly imaginary, the birth control advocates\nconjure up. Granting that all the difficulties from multiple births\nare real, no end justifies essentially evil means, and a subversion\nof the natural law is always essentially evil. War, homicide, and\nlike acts are not always evil; under certain circumstances both\nwar and homicide may be holy deeds; but to act contrary to nature\nis never justifiable in any condition. If I owe a man a large sum\nof money it may be to the advantage of myself or my children that\nthis man be removed, but that good end does not justify murder;\nno more does any condition of poverty justify a contraceptive act\nagainst nature, especially when such an act is never the sole means\nof evasion. We must protect the married state, but in America we\nare destroying it. Human society had its origin in marriage, and it\ndepends on marriage for its preservation, but our American divorce\nlaws have made marriage a travesty. In New York alone in 1916 there\nwere 74,893 women divorced, nearly twenty-eight times as many as\nwere divorced in England and Wales in that year, and over forty-nine\nper cent. of these women were childless, very significantly. Probably\nninety-five per cent. of the childless women had used contraceptive\nmethods, yet there are few forces better able to hold the marriage\nknot tied as it should be tied than a child's fingers. In England and\nWales, too, in 1916, forty per cent. of the divorced couples were\nalso birth controllers, at least they had no children. Pennsylvania\nis much more shameless than New York in granting divorces for no\nreason at all.\n\nAmong the arguments used by those in favor of spreading contraceptive\ninformation is that large families keep the laboring classes down\nto low living standards, and it would be better for those families\nand the state that these children were not born. Large families\nas such do not keep the laboring classes down to low standards of\nliving; bad legislation which allows profiteering, which criminally\npermits extortion in the prices of food, clothing, in taxes, rents,\nthe cost of coal, and the like, which does not force employers to\ngive laborers an honest price for labor, or check the extortions\nof monopolists, and a hundred similar economic deeds of injustice,\ntogether with a parental shiftlessness, unthrift, alcoholism, lack of\neducation through neglect, and so on indefinitely, are the causes.\nBig families have more wages than small families, and as a rule they\ndo better than the small families when the children are old enough\nto work. Society is at fault, not the size of the family; the active\nand the passive selfish are at fault, not the babies; the liars,\nhypocrites, and the buttoned pockets are at fault, not the holy\ninnocents; the professional meddlers in the business of better folk\nare the nuisance, not the blessed children, who are the brightest\nthings in this darkened world until we spoil them, and make them like\nourselves instead of better. One decent mother is worth a hundred\nshirkers who raise nothing but lap dogs.\n\nThe children of large families, the birth controllers say, are more\nafflicted by infectious diseases than those of small families. I\nwas for years in charge of the infectious diseases Bureau of the\nWashington Health Department, and I have had ample opportunity\nhere and in Europe to study this matter. Large families in proper\neconomic positions are not different from small families as regards\nthe infectious diseases. These diseases spread among the poor\nbecause the houses of the poor are commonly owned by land sharks and\npoliticians who laugh at health regulations; our health departments\ncan not get enough money away from the political ringleaders in power\nto employ capable sanitary experts; our laws for the regulation of\nmedical practice and education are a disgrace to our civilization,\nand every town is swarming with quacks who can not recognize even\nsmallpox when they see it. The fault here is in ourselves not in the\nlarge families. Control the professional politicians and quacks and\nthere will be no occasion for foolish talk about birth control.\n\nAgain, the children of poor but large families, we are told, have\nslight or no chance to rise in the social order. Benjamin Franklin,\nhowever, one of the greatest men America has produced, was the\nyoungest of seventeen children in a poor family; Lyman Beecher, a\npoor man, had eleven children, and every man and woman among them\nbecame famous; Theodore Schwann, the father of the cell doctrine\nand of all modern biology, was one of thirteen poor children; John\nMueller, one of the greatest of modern scientists, and the Father\nof German medicine, was one of five children of a very poor family;\nEmerson was one of five sons, so was Farragut; John Wesley the\nfounder of Methodism, was the eighteenth child of his parents;\nIgnatius Loyola was the eighth; Saint Catherine of Sienna, among the\ngreatest women intellectually and morally that Europe ever produced,\nwas the twenty-fourth child of her parents. This list can be extended\nindefinitely from the biographical dictionaries. Every enormous\nfortune made in America was built up originally by a man who arose\nfrom the depths--Rockefeller, Carnegie, Vanderbilt, Astor, Ryan,\nHavemeyer, Schwab, Ford, Gould, and so on. Poverty is a necessary\nfoundation for a great fortune. The great soldiers of the world\nalmost without exception rose from the ranks of poverty--Napoleon,\nWashington, Sheridan, Grant, Sherman, Pershing, De Lacy in Russia,\nPrim in Spain, O'Higgins in Chili, Stonewall Jackson, and others. The\npowerful Dukes of Tetuan in Spain came from an Irish adventurer, the\nfifth of eight sons of a poor man. Big families make for strength\nof character in the struggle for existence; the solitary child in a\nfamily is pampered, spoiled.\n\nAdvocates of birth control say that Holland has had a Neomalthusian\nLeague openly operative since 1881, with fifty-two clinics where\ncontraceptive information is publicly given. As a direct consequence,\nand solely from the work of this League, Holland has a dropping death\nrate and an increase in population, and even the stature of the Dutch\nhas increased four inches since 1881. The main objection to these\nstatements about Holland is that they are absolutely false in every\nparticular except that the population of Holland has increased--from\nother causes. Before the great war every civilized nation had a\ndropping death rate and an increase in population except France\nwhere birth control worked against the increase made by the progress\nof preventive medicine and a diffusion of sanitary methods. The\nassertion about the fifty-two clinics in Holland was investigated. An\narmy officer sent out by the committee searched fourteen days before\nhe could find even one secret birth control propaganda station. The\npresent prime minister of Holland, de Beerenbrouk, is an earnest\nCatholic man, and if anyone talks birth control in Holland during\nhis administration he guarantees them a long term in jail. There\nwas really a Neomalthusian League with 6,704 members, now greatly\ndecreased in number, in the northern Protestant provinces of Holland.\nAs a matter of fact just where this league exists the birth rate\ndecreased and the death rate increased and where it did not exist\nthe direct opposite is true. As to the increase of four inches in\nstature--since this is a physical impossibility the spinner of the\noriginal yarn was an ignorant romancer, lacking plausibility in\nhis untruth. Where there is birth control there are no children\nto increase or maintain the population, but the New York birth\ncontroller who invented the Dutch story says that in Holland where\nthere are no children born through birth control the population\nincreases through birth control.\n\nThe birth control movement assumes that the world suffers from\noverpopulation. It does not; it suffers from incorrect distribution\nof populations, and no doctrine of birth control will ever affect\nthis fact. All the authorities on the statistics of population tell\nus it requires an average of four children to each family to keep\nthe population even stationary, not to talk of overcrowding. Two\nchildren reaching maturity replace their parents, and because of the\nhigh mortality in infancy, and the large number of the unmarried and\nthe birth controllers and abortionists, four children are needed to\na family to make a new generation as large as the old. An average\nof one, two, or even three children to a family means a loss in\npopulation, unless the loss is supplied, as in the United States, by\nimmigration. An average of five or six children means an increase in\nthe population. Having none or two children to a family and relying\non immigration to preserve the nations means political annihilation,\nas can be readily shown. In New York State in 1919 instead of the\nrequired four children to keep the population stationary, as far as\nthe native Americans are concerned, there was one child to every ten\nfamilies.\n\nThe American nation was founded and built up wholly by Nordic races,\nimmigrants from Great Britain and Ireland, Germany, and a few from\nFrance, Holland and Sweden. All our national traditions are from\nthese Nordic immigrants, our notions of self government, our peculiar\ndemocracy, our constitution, our language and literature. These\nNordic peoples are dying out here in appalling numbers for two chief\nreasons, one of which is birth control and the other is the American\nclimate. The civilization which affects us has always existed along a\ngeographical belt reaching from the British Isles to above Rome, and\ncovering Great Britain, Ireland, France, Spain, middle and western\nGermany, and Italy to below Florence. The Grecian civilization was\nnot indigenous, but the result of a Nordic occupation, and it ceased\ncenturies before Christ. Huntington of Yale and several others have\nshown, by studying the production of thousands of piece workers and\nstudents over a long time, that man does his best work physically\nand mentally under four climatic conditions: a mean temperature\nof about sixty-two degrees Fahrenheit for physical work and about\nforty degrees for mental work; secondly, there must be a humidity\nof about seventy-five per cent.; thirdly, the climate must be\nvariable, be that of the belt of cyclonic storms; fourthly, there\nmust be a quantity of sunlight such as that found in the European\nracial habitat of the person considered. These conditions are found\ncuriously in exactly these degrees in the civilized parts of Europe\nand not elsewhere. Above and below that area they are lacking and\nthere has never been any civilization where they are wanting. The\nreason physical and mental productivity lessen annually with us in\nDecember, January, and February is because these climatic conditions\nare absent during these three months.\n\nAgain, men are differentiated into races, thrive, develop, and\nreach and maintain mental and physical perfection within well\ndefined climatic areas. Nature preserves the race that has acquired\nthrough countless ages acclimatization in a given environment, and\nkills off very quickly immigrants coming from far north or south\nof the given latitudes. The natural geographical position for the\nblack man is from the equator to the thirtieth parallel of north\nor south latitude. The thirtieth parallel in America runs through\nupper Florida, southern Louisiana, and the lowest third of Texas.\nFrom the thirtieth to the thirty-fifth parallel is the zone of the\nbrown man, like the Malay. The thirty-fifth parallel runs along the\nsouthern border of North Carolina and Tennessee, through the middle\nof Arkansas, New Mexico, Arizona, and the lowest third of California.\nFrom the thirty-fifth to the forty-fifth parallel is the zone of\nthe brune Mediterranean races. The forty-fifth parallel passes near\nHalifax, Bangor in Maine, Ogdensburg, Ottawa, and St. Paul. In\nEurope it runs near Bordeaux, Turin, Bosnia, and the Crimea. New\nYork is as far south as Naples, Philadelphia is sixty miles south of\nNaples, and has the sun of southern Italy. The Nordic races that we\nare interested in as our origins all live above the United States,\nand the summer temperatures they have been accustomed to are above\nthe United States. An immigrant coming from northern Ireland to\nPhiladelphia moves southward a thousand miles; a Norwegian going to\nTexas moves southward two thousand miles, and his family disappears\nas a rule in two generations.\n\nIn historic times there have been sudden movements southward\nof European races for about seven hundred miles and all ended\ndisastrously. The Lombards went south from upper Prussia to middle\nItaly at the level of Boston and disappeared in two hundred years.\nThe Teutonic Goths went from the Baltic to Italy and Spain. They\nlasted sixty-two years in Italy. Eighty thousand Vandals with their\nfamilies went down from Brandenburg to North Africa at the level\nof Virginia. They were annihilated by the climate in one hundred\nand eight years. The Burgundians disappeared in sixty years from\nGreece, as the Celts who had carried the Homeric sagas to Greece also\ndisappeared. Rome was great while the Nordic Cisalpine Celt ruled it,\nand died forever with the Celt. Italian art ended at Florence, the\nsouthern boundary of Cisalpine Gaul. The Slav disappeared the same\nway from southeastern Europe and left only language traces to the\nTuranian and Semite there. No European race of pure blood has ever\nhad grandchildren in the tropics.\n\nThe northern races of Europe die out with amazing rapidity in the\nnorthern United States. The Irish death rate at the level of New\nYork is double the death rate in Ireland under much worse economic\nconditions; the death rate of the southern Italian and the southern\nRussian is much better in New York than it is in their European\nracial habitats.\n\nIn 1910 our English immigration was only six per cent. of the whole,\nand the Irish immigration is now negligible because there are no more\npeople in Ireland to leave it, but we have seven million Slavs who\ncame in during the ten years before the war. We have three million\nsouthern Italians, three million Poles, and hundreds of thousands\nof nondescript folk from all the back alleys of the old world. At\nan army camp in Massachusetts during the late war there were thirty\nlanguages other than English spoken, and seven thousand men there\nnever had heard the term Anglo-Saxon. The extreme southern, eastern,\nand southeastern European hordes are overwhelming us, and these\nhordes never knew a single political principle that even remotely\nresembles what we understand as American principles. They come of\nraces who were ruled, if they had any rule at all, by despots, but\nwe shall make \"Anglo-Saxons,\" Americans, or whatever you like to\ncall the final metamorphosis we effect, out of these barbarians.\nNever! Even in a millenium. Centuries from today the Slav here will\nbe a Slav, the Sicilian a Sicilian, the Russian a Russian, all\nwith a veneer of American slang on the tongue of an eternal racial\ncharacter. Whole counties of Pennsylvania are filled with Germans\nwho have been here since before the Revolution and they have not so\nmuch as learned English yet. The Nordic peoples die out here. Only\nthe dark-skinned southern Germans last with us; the sun kills out the\nred and blond in two or three generations. I recently went over fifty\nIrish families which I knew perfectly, and they have degenerated\neighty-six per cent. numerically and otherwise in my own lifetime:\nkilled off by the climate which keeps our southern states empty of\nwhite men. By two American censuses and one English we know that\nfifty per cent. of Washington's army was born in Ireland, but there\nare no Irish in the revolutionary societies because the Revolutionary\nIrish have disappeared.\n\nIf there is any chance at all for our civilization, flimsy as it\nis, this world must be ruled by the Nordic European races, not by\nthe southern, eastern and southeastern European barbarian Semite.\nWe must rule for our own sake and for their sake; they can not rule\nanything. If we do not rule them, then welcome the final curtain\nas soon as possible. How can we rule America, not to think of the\nrest of the world, unless we have Nordic children to take our place,\nand how can we have such children if we let sex-brained misfits\nrun about spreading contraceptive drivel? The rascal that preaches\nsuch doctrine is a traitor to America, the worst enemy our country\never has had, more treacherous than any spy that sneaked in among\nus during the war just past. The French have had their lesson in\nbirth control, and we should learn from their misfortune. In the\nfirst six months of 1914 when Europe was still at peace the total\nnumber of births in France was 381,398; a decrease of 4,000 on the\nyear 1913. At the same time the deaths increased 20,845. Thus the\npopulation of France during the first six months of 1914 decreased\n24,816. For the past thirty years the birth rate of that country has\nsteadily decreased by contraceptive methods, while the death rate\nhas increased proportionately to the number of inhabitants. January,\n1916, found France with about seven hundred thousand less people than\nshe had in January, 1914, and then came the horrible carnage of the\ngreat war. No matter what change of heart war may bring to France\nno increase in her population can be expected for many years yet to\ncome. She is daily crying out to the world for treaties to protect\nher from Germany, despite the prostration of Germany, because she\nknows Germany had a birth rate of two males for her one, and for\ntwenty years to come Germany probably can put twice as many men into\nthe field as France can. If France will give over her unclean birth\ncontrol she will not need to whine for protection.\n\nThe advocates of birth control assert that it lessens venereal\ndiseases. It does not; it increases the spread of venereal disease.\nThe more reasonable among the birth control propagandists are anxious\nlest their public talks suggest temptation to the young. There is at\npresent for youth the deterrent of the natural consequences of lust;\nwith birth control knowledge spread broadcast that check is removed\nand promiscuity will become more general, because safer socially.\nVenereal diseases will spread also as incontinence spreads. Nowhere\nin the world has the crime of birth control been practised as in\nFrance nor for a longer time, and in that country together with the\nlowest birth rate in the world there is the highest death rate from\nvenereal diseases according to Dr. Dublin the statistician of the\nNew York Metropolitan Life Insurance Company. Not long ago one of\nthe leading medical writers of France, Doyen, said in the Academy\nof Medicine in Paris that syphilis is the chief cause of death in\nFrance. France now asserts she has given over birth control, but that\nis a hard disease to cure after it has been established. Unchastity\nis its own punishment, and if France goes the way of those nations\nthat have died along the pathway of civilization, and great would be\nthe pity, she has nothing to blame for it but this abominable moral\nleprosy, birth control. She is as striking an example of the insanity\nof birth control as Russia is of the insanity of communism.\n\n\n\n\nINDEX\n\n\n  Abnormal pelves, 133, 134, 135\n\n  Abortion, 91\n    after fifth month, 102\n    agents of, 117\n    American law on, 119\n    causes of, 92\n    civil law on, 121\n    Council of Lerida on, 115\n    Council of Worms on, 115\n    decretal of Gregory on, 115\n    direct, 109\n    excommunication for, 116, 117\n    Gregory XIV on, 116\n    habitual, 98\n    Holy Office decrees on, 118\n    homicide in, 110\n    incomplete, 101\n    inevitable, 101\n    irregularity and, 117\n    morality of, 109-114\n    morphine in, 101\n    paternal causes of, 95\n    Pius IX on, 116\n    precautions against, 105, 106\n    prognosis after, 100\n    sepsis after, 105\n    Sixtus V on, 115\n    statistics of, 97, 98\n    symptoms of, 99\n    syphilis and, 107\n    tampon, use of, 103\n    therapeutic, 107, 109\n    threatened, 99\n    treatment of, 102\n    violence and, 94\n\n  Abruptio placentae, 144\n    causes of, 144\n    effects of, 144\n\n  Acute yellow atrophy of the liver, 186\n\n  Aggressor, 17, 19\n\n  Amnion, 52\n\n  Amphiaster, 44\n\n  Anaesthesia and the fetus, 93\n\n  Analgine, 240\n\n  Animal heat, 71\n\n  Animal life, 48\n\n  Animation, 33, 39\n    Aristotle on, 39\n    biologists on, 49\n    Conklin on, 73\n    Fienus on, 35\n    Greek fathers on, 33\n    Greek philosophers on, 33\n    St. Alphonsus on, 39\n    St. Anselm on, 35\n    St. Augustine on, 34\n    St. Gregory of Nyssa on, 35\n    St. Thomas on, 35\n    Zacchias on, 36\n\n  Aortic stenosis in pregnancy, 175\n\n  Apparent death, 82\n\n  Appendicitis in pregnancy, 152\n\n  Archenteron, 50\n\n  Artificial impregnation, 258\n\n  Attraction sphere, 40\n\n\n  Baer on twilight sleep, 240\n\n  Baptism of monsters, 80\n\n  Beginning of life, 33\n\n  Blameless defence, 18\n\n  Blastocyst, 50\n\n  Blastulas, 50\n\n  Braxton-Hicks version, 143\n\n  Bright's disease in pregnancy, 157\n\n  Broad ligament, 124\n\n\n  Cancers in pregnancy, 149\n    morality of operation, 150\n\n  Canonical irregularity, 23, 24, 25\n\n  Capital punishment, 31\n\n  Carrington's vasectomies, 248\n\n  Catalepsy, 85\n    in pregnancy, 160\n\n  Cell, 40\n    bridges, 60\n    differentiation, 67, 68\n    division, 41, 42\n    heredity, 45\n    life, 48\n    motion, 70\n    reduction, 45\n    union, 65, 66\n\n  Centrosome, 40\n\n  Cesarean delivery, 132\n    amputation of the uterus after, 138\n    indications for, 132\n    morality of, 136, 137\n    repeated sections, 140\n    sterilizations and, 139, 140, 141\n\n  Chemico-vital changes, 70, 71\n\n  Cholera in pregnancy, 195\n\n  Chorea gravidarum, 181\n\n  Chorion, 51\n\n  Chromosome, 42\n    numbers of, 43\n\n  Chromatin, 41\n\n  Circumstances, 3\n\n  Citizen as member of the State, 31\n\n  Coelom, 51\n\n  Coition in gestation, 95, 96, 97\n\n  Congenital tuberculosis, 189\n\n  Conscience, 12\n\n  Constitution _Effraenatam_, 115\n\n  Contingent being, 1\n\n  Contracted pelves, 133\n\n  Craniotomy and excommunication, 117\n\n\n  _D\u00e4mmerschlaf_, 231\n\n  Death, signs of, 89, 90\n\n  De Lugo on the State, 31\n\n  Development of the body, 56\n\n  Diagnosis, percentage of correct, 21\n\n  Diabetes in pregnancy, 229\n\n  Differentiation by position, 68, 69\n\n  Division, direct and indirect, 42\n\n  Double effects, 18, 26\n\n  Double monsters, 78, 79\n\n  Dry labor, 109\n\n\n  Eclampsia parturientium, 161\n    abortion in, 165\n    expectant treatment of, 166\n    forced delivery in, 165\n    mortality, 163, 168\n    Lichtenstein's method in, 166\n    precautions against, 164\n    symptoms of, 161\n    veratrum viride in, 167\n\n  Ectoderm, 50\n    derivatives of, 51\n\n  Ectopic gestation, 123\n    decrees of the Holy Office on, 128, 129\n    diagnosis of, 126, 127\n    morality of operations, 129, 130\n\n  Effects of an action, 6\n\n  Egg shell, 47\n\n  Embryo, 33\n    growth of, 50\n    stages of, 52\n\n  End of an action, 4\n\n  End of life, 82\n\n  Endoderm, 50\n\n  Endometritis, 93\n\n  Entelechy, 60\n\n  Erysipelas in pregnancy, 196\n\n  Eunuchs, 255, 256\n\n  Euthanasia, 1\n\n\n  Fallopian tubes, 123\n\n  Fecundation, 124\n\n  Fetus, 33\n    and the dead mother, 87\n    at term, 54\n    months, 53, 54, 55\n    stages, 53\n\n  Fibrillation, 174\n\n  Fibroids, 146\n\n  Fission theory, 77\n\n  Form, 60\n\n\n  Gemmule theory, 58\n\n  Germ cells, 44\n\n  God's existence, 2\n\n  Gonorrhoea in marriage, 211\n    abortion and, 224\n    blindness and, 226\n    conservative surgery for, 217\n    effects, 212, 213, 215, 216, 225, 226\n    operations for, 216\n    professional secret and, 212\n    tests of cure, 211\n    treatment by heat, 228\n\n  Good, 3\n\n  Grippe, 194\n\n\n  Happiness, 2\n\n  Hastening of death, 111\n\n  Hebosteotomy, 135\n\n  Heart beat, 83\n\n  Heart block, 173\n\n  Heart diseases in labor, 172, 174\n\n  Heart diseases in pregnancy, 169\n    Mayo clinic on, 173\n\n  Heart, origin of, 52\n\n  Homicide, 13\n    accidental, 19\n    arguments against, 14, 15, 16, 17\n    bibliography of, 22\n    direct and indirect, 13\n    self-defence and, 17, 18, 19\n\n  Human terata, 78\n\n  Hyperemesis gravidarum, 176\n\n  Hysteria,\n    imitative, 183\n    major and minor, 184\n    marriage and, 185\n    in pregnancy, 181, 182, 183\n\n\n  Icterus gravis, 186\n\n  Impotence, 258\n    opinions on, 252\n\n  Infectious diseases in pregnancy, 188\n\n  Influenza in pregnancy, 194\n\n  Insanity,\n    puerperal, 154\n    spread of, 266\n\n\n  Kant on morality, 29\n\n  Karyokinesis, 41\n\n\n  La grippe in pregnancy, 194\n\n  Law, definition of, 28\n\n  Life in separated tissues, 73, 74\n\n\n  Malaria in pregnancy, 196\n\n  Male generative system, 248\n\n  Male pronucleus, 49\n\n  Maniacal chorea, 182\n\n  Marriage, end of, 254\n\n  Mayhem, 23\n\n  Means of an action, 5\n\n  Measles in pregnancy, 195\n\n  Mesoderm, 50\n\n  Metabolism of the cell, 69, 70, 72\n\n  Metaphases of mitosis, 44\n\n  Midwives, 138\n\n  Mignonette case, 113\n\n  Mitosis, 41\n\n  Miscarriage, 91\n\n  Mitral regurgitation in pregnancy, 174\n\n  Monsters, 75\n    by displacement, 78\n    multiple, 76\n\n  Morality, 3\n    determinants of, 3\n\n  Morphine,\n    effects on fetus, 234\n    effects in labor, 234, 235\n\n  Morula, 50\n\n  Mutilation, 23\n    argument against, 26, 27\n    argument for, 27\n    civil law on, 23\n    direct and indirect, 26\n    Molina on, 24\n    St. Alphonsus on, 25\n    State and, 28, 29, 30, 31, 32\n    self-mutilation, 26\n    Suarez on, 24\n\n  Myomata in pregnancy, 146\n    effects of, 147\n    fetus and, 148\n    mortality of, 147\n\n\n  Natural law, 2, 12\n\n  Necessary being, 1\n\n  Nephritis in pregnancy, 157\n    treatment of, 158\n    varieties of, 158\n\n  Nervous system, 51\n\n  Nucleus, 40, 46\n\n\n  Object of an action, 3\n\n  Onanism, 256\n\n  Operations during pregnancy, 94\n\n  Operative risk in cardiopaths, 173\n\n  Ophthalmia neonatorum, 226, 227, 228\n\n  Organs, origin of, 51\n    of the body, 64\n\n  Ovaries,\n    removal of, 218, 223\n    resection of, 221\n\n  Ovarian tumors in pregnancy, 148\n\n  Ovarian, 247\n\n  Ovariotomy,\n    decrees of the Holy Office on, 252, 253\n    effects of, 219\n    impotence and, 252, 254, 255\n    psychoses after, 219, 220, 221\n\n  Ovum, 33, 47\n\n  Oxidation, 72\n\n\n  Pangens, 68\n\n  Paresis, 204\n\n  Parturition, 169, 231, 232, 233\n\n  Partus cesareus, 132\n\n  Pathogenesis, 48, 49\n\n  Pelvic diameters, 132\n\n  Penal law, 31\n\n  Pernicious vomit of pregnancy, 176\n    abortion for, 180\n    causes and symptoms, 177\n    diagnosis of, 179\n    treatment, 179\n\n  Pituitrin, 170\n\n  Placental infection, 188\n\n  Placental osmosis, 189\n\n  Placenta praevia, 142\n\n  Plastid, 40\n\n  Pneumonia in pregnancy, 192, 193\n\n  Polak's operation on the tubes, 222\n\n  Polar body, 46\n\n  Porro's operation, 136\n\n  Preformationists, 56\n\n  Premature infants, 55\n\n  Premature labor, 98, 108\n\n  Probabilism, 6\n\n  Prophases of mitosis, 44\n\n  Protoplasmic bridges, 67\n\n  Puerperal insanity, 154\n    prognosis, 155\n    sterilization and, 154\n\n  Pyelitis in pregnancy, 160\n\n\n  Quacks, 22\n\n\n  Resuscitation, 83, 84\n    methods of, 88\n\n  Right and wrong, 3\n\n  Rupture of Fallopian tube, 125\n\n\n  Sacraments in apparent death, 82\n\n  Salpingectomy, 217\n\n  Salpingostomy, 217\n\n  Salpingotomy, 217\n\n  Scarlatina in pregnancy, 195\n\n  Scopolamine, 233\n\n  Secrets, 206, 207\n\n  Segmentation cavity, 50\n\n  Segmentation nucleus, 49\n\n  Self-defence, 17, 18\n\n  Semen, 247\n\n  Sixtus V, bull of, 255\n\n  Smallpox in pregnancy, 191\n\n  Soul, 60\n\n  _Spaltungstheorie_, 76\n\n  Spermatozo\u00f6n, 46, 47, 48\n\n  Spermin, 247\n\n  Spindle, 44\n\n  Spireme, 43\n\n  State,\n    citizen and, 30\n    dominion of, 28, 29\n    end of, 29\n\n  Sterilization of women, 251\n\n  Substantial form, 60, 62, 75\n\n  Suicide, 7\n    arguments against, 7-12\n\n  Suspended animation, 85\n\n  Syncytium, 52, 66\n\n  Symphyseotomy, 135\n\n  Syphilis,\n    abortion in, 200\n    curability of, 203\n    fetal, 201\n    incurability of, 204\n    marriage and, 205\n    nervous system affections, 204\n    pregnancy in, 200, 202\n    professional secret in, 206\n\n\n  Tabes, 204\n\n  Telophases in mitosis, 44\n\n  Terata, 75\n\n  Tetrads, 46\n\n  Tocanalgine, 240\n\n  Tonics, 48\n\n  Traducianism, 34\n\n  Trophoblast, 50\n\n  Tubal abortion, 125\n\n  Tuberculosis in pregnancy, 196, 197, 198\n\n  Tumors in pregnancy, 146\n\n  Tumors and premature labor, 109\n\n  Twilight sleep, 231\n    authorities opposed to, 238, 239\n    effects of, 240, 241, 242, 243\n    methods used, 235, 236, 237\n\n  Twins, 76\n\n  Two-celled stage of the embryo, 65\n\n  Typhoid in the fetus, 190\n\n  Typhoid in pregnancy, 196\n\n  Typhus in pregnancy, 196\n\n\n  Unity of the soul, 65\n\n  Uterine adnexa, 123\n\n  Uterus, abnormalities of, 124\n    anatomy of, 123\n\n\n  Vaccination, 191\n\n  Vas deferens, restoration of, 249, 250\n\n  Vasectomy, 244\n    arguments against, 260-265\n    bibliography, 266, 267\n    bull of Sixtus V and, 255, 256\n    effects of, 248, 249\n    grave mutilation, 259\n    hereditary disease and, 264\n    impotence and, 251\n    morality of, 259\n    not a punishment, 263, 264\n    operation for, 247\n    reasons for the operation, 245, 246\n    State and, 244\n    State surgeon and, 265\n\n  Venereal diseases,\n    prevalence of, 213, 214, 215\n\n  _Verwachsungstheorie_, 76\n\n  Viability of the fetus, 54, 114\n\n  Vital principle, 58, 61\n\n  Vital processes, 69\n\n\n  Weak pains, 171\n\n  Weismann's theories, 49, 56\n\n\n  Yellow atrophy of the liver, 186\n\n  Yolk sac, 52\n\n\n\n\n                        (\"Think\")\n\n\"_Thoughts are the Masters and the Thinkers are the\n                  Doers._\"--_Confucius._\n\nOne of the most successful of teachers is a Montreal\nPrincipal--successful because she insistently teaches undergraduates\nto THINK. Force of thought is better than force of will. A triphammer\nis all force, but unless guided by a THINKER strikes a pile or\na cream-puff with equal power. Then there is the nagger with a\ntongue-will of poiseless perpetual power but--thought-proof.\n\n     Do you as host, hostess or guest want a spur to cleverness of\n     thought, wit and repartee?\n\n     Do you fail in clearness of thought and expression--especially\n     in conversation?\n\n     Do you teach, preach--or lecture?\n\n     Do you dictate at home(?) at office--or both?\n\n     Do you want to give straight-to-the-point advice to your\n     children, your friends, your employees and YOURSELF?\n\n     If an employer you will commend KEYSTONES OF THOUGHT to your\n     employees--surely to the stenographers.\n\n     If easily discouraged, a victim of worry, fear, the blues,\n     \"Keystones\" is your prescription.\n\n     Is Christianity a Failure? Have you an active or passive grouch\n     against the clergy (a now fashionable disease usually confined\n     to the middle aisle) because of \"what they say and do and\n     because of the way they live\"?\n\nDo you want something to \"crib\" for public dinners and other\noccasions? The \"greatest after-dinner speaker in the world\" is a\nNew Yorker. Never lengthy, always aphoristic, he says more in five\nminutes than all the \"wax-works\" on the dais drone or spout in hours.\n\n\n                           THEN READ\n\n                     KEYSTONES _of_ THOUGHT\n\n               By AUSTIN O'MALLEY, M.D., Ph.D., LL.D.\n\nThe only book of original and genuine aphorisms in English. Written\n   by \"the World's master of aphoristic thought and expression.\"\n\n     \"_The successful aphorist is about ten thousand times scarcer\n     than the successful essayist, or story teller, or Assyriologist.\n     Humor without effort, wit without bitterness, philosophy without\n     pretension! Dr. O'Malley has written a book that is worth\n     possessing._\"--_From a review of the book written by the editor\n     of the N. Y. Sun himself._\n\n               Special gift book edition, su\u00e8de, gold\n     edges, in box--a very useful ornament for Den, Desk, or Drawing\n     Room, $4.00 net, Postpaid. Cloth, gold letters and design, $2.00\n                            net, Postpaid.\n\nNOTE: Whether young or old, Sage or Seer, Poet, Philosopher, or\nwhat-not, if you think YOU can match KEYSTONES OF THOUGHT in\naphoristic originality, in depth, deftness, wit, wisdom and humor--in\ntonic-cheer for all of life's worries, troubles and adversities, you\nare welcome to try. If successful The Devin-Adair Company will send\nyou a check for an acceptable but well-earned sum, and your work will\nbe promptly published.\n\n\n                THE DEVIN-ADAIR COMPANY, Publishers\n\n                   437 FIFTH AVENUE, NEW YORK\n\n\n\n\n       *       *       *       *       *\n\n\n\n\nTranscriber's note:\n\nVariations in spelling, punctuation and hyphenation have been\nretained except in obvious cases of typographical error.\n\nThe symbol of a Maltese cross precedes \"JOHN CARDINAL FARLEY\".\n\nPage 151: \"3. The case may be inoperable and the child inviable.\"\nThe word \"be\" was added by the transcriber.\n\nPage 194: Footnote 145 \"_Ibid._, 1970, vol. l, pp. 430, 516,\nand vol. li, p. 11.\" The transcriber has changed 1970 changed to 1870.\n\nPage 215: A missing anchor was added by the transcriber for Footnote\n170 \"_New York Med. Jour._, November 12, 1910.\"\n\nPage 222 Footnote 185 \"_Correspondenz-Blatt f. Schweizer Aertze_\"\nThe transcriber has changed \"Aertze\" to \"Aerzte\".","title":"The Ethics of Medical Homicide and Mutilation","tradition":"philosophy-ethics","translated_text":null,"word_count":100873}