MUTILATION***


E-text prepared by Dianna Adair, Julia Neufeld, and the Online Distributed
Proofreading Team (http://www.pgdp.net) from page images generously made
available by Internet Archive/Canadian Libraries
(http://archive.org/details/toronto)



Note: Project Gutenberg also has an HTML version of this
      file which includes the original illustrations.
      See 42764-h.htm or 42764-h.zip:
      (http://www.gutenberg.org/files/42764/42764-h/42764-h.htm)
      or
      (http://www.gutenberg.org/files/42764/42764-h.zip)


      Images of the original pages are available through
      Internet Archive/Canadian Libraries. See
      http://archive.org/details/theethicsofmedic00omaluoft


Transcriber's note:

      Text enclosed by underscores is in italics (_italics_).

      Small capital text has been replaced with all capitals.

      The text (page 234) contains one chemical formula in
      which the numbers enclosed in curly braces are subscripted
      (C{17}H{21}NO{4}).





THE ETHICS OF MEDICAL HOMICIDE AND MUTILATION

by

AUSTIN O'MALLEY, M.D., PH.D., LL.D.







[Illustration: printer logo]

New York
The Devin-Adair Company
1922



Nihil obstat
Arthur J. Scanlan, S.T.D.
_Censor Librorum_

Imprimatur

[see Transcriber's note below] JOHN CARDINAL FARLEY
Archbishop of New York

Copyright, 1919, by
The Devin-Adair Company

All Rights Reserved by
The Devin-Adair Company

Third Printing

Printed in U.S.A.




CONTENTS


  CHAPTER I

  GENERAL PRINCIPLES CONCERNING SUICIDE AND HOMICIDE

                                                                  PAGE

  There is a Supreme Being who alone is master of life. The
  Natural Law. The nature and determinants of morality.
  Probabilism. Permissive suicide. Suicide is illicit.
  Conscience. Homicide, direct and indirect. Self-defence.
  Formal and material aggressors. Legalized homicide.
  Bibliography                                                    1-22


  CHAPTER II

  GENERAL PRINCIPLES CONCERNING MUTILATION

  Mutilation. Canonical irregularity. Self-mutilation. The
  double effect in morality. Direct and indirect mutilation.
  The State and mutilation. The dominion of the State            23-32


  CHAPTER III

  WHEN DOES HUMAN LIFE BEGIN?

  Ancient and modern opinions. The fetus is animated at the
  moment of conception. The single cell as the primal
  life-organ. Cell growth and division. Germ cells. The
  development of the embryo. Fetal viability. Theories
  of development. The Aristotelian and Thomistic opinions.
  The formal principle. A soul exists. The primordial
  cell is a sufficient organ for the soul. Metabolism
  in the cell. Cell motion. Animal heat and energy.
  Life in separated tissues. The soul in monsters                33-82


  CHAPTER IV

  WHEN DOES HUMAN LIFE END?

  The heart and life. Resuscitation after apparent death. The
  last sacraments in apparent death. Suspended animation.
  The living fetus in the womb of a dying or dead
  mother. Methods of resuscitation. Signs of death               83-91


  CHAPTER V

  ABORTION

  Abortion and miscarriage. Causes of abortion, fetal,
  maternal and paternal. Surgical operations and abortion.
  The debitum in pregnancy. Premature labor. Threatened,
  inevitable, and incomplete abortions. Treatment. The
  use of the tampon. Precautions against abortion. Therapeutic
  abortion. Methods of inducing abortion. Artificial
  abortion of an inviable fetus is never licit. Decrees
  of the church concerning abortion. The civil law
  on abortion                                                   92-123


  CHAPTER VI

  ECTOPIC GESTATION

  Ectopic gestation or extrauterine pregnancy. Anatomy of the
  uterus and its adnexa. Place of fecundation. The abnormal
  uterus. Tubal rupture and tubal abortion. Diagnosis.
  Decrees of the church on ectopic gestation. Removal
  of an inviable ectopic fetus except in present
  peril of life is illicit                                     124-132


  CHAPTER VII

  CESAREAN DELIVERY

  Indications for cesarean delivery. Abnormal pelves.
  Symphyseotomy. Varieties of cesarean delivery. Morality.
  Amputation of the uterus after cesarean delivery.
  Precautionary sterilization of a cesarean case is illicit    133-142


  CHAPTER VIII

  PLACENTA PRAEVIA AND ABRUPTIO PLACENTAE

  Nature and effects of placenta praevia. Treatment. Morality
  and methods of treatment. Abruptio placentae. Morality
  of fetal removal                                             143-146


  CHAPTER IX

  ABDOMINAL TUMORS IN PREGNANCY

  Tumors blocking parturition. Fibroids or myomata. Ovarian
  tumors. Cancer. Effects and morality of operation            147-152


  CHAPTER X

  APPENDICITIS IN PREGNANCY

  Occurrence. Time of operation. Diagnosis                     153-154


  CHAPTER XI

  PUERPERAL INSANITY AND STERILIZATION

  Causes. Varieties. Prognosis. Precautionary sterilization
  of puerperal psychopaths is illicit                          155-157


  CHAPTER XII

  NEPHRITIS IN PREGNANCY

  Frequency. Effects. Abortion as a treatment. Varieties of
  nephritis. Pyelitis. Catalepsy                               158-161


  CHAPTER XIII

  ECLAMPSIA PARTURIENTIUM

  Definition. Symptoms. Prognosis. Causes. Precautions
  against eclampsia. Forced delivery. The expectant
  treatment. Relative mortality and morality of the
  methods. Cesarean delivery as a treatment. The expectant
  treatment is apparently the best                             162-169


  CHAPTER XIV

  HEART DISEASES IN PREGNANCY

  Factors in abnormal gestation. The use of pituitrin. Weak
  pains and the diseased heart. The diseased heart in
  actual parturition. Operative risk in cardiopaths. Heart
  block and mitral regurgitation in labor. Prognosis           170-176


  CHAPTER XV

  HYPEREMESIS GRAVIDARUM

  Pernicious vomiting. Occurrence. Symptoms. Stages. Effects.
  Causes. Therapeutic abortion in pernicious vomiting.
  Treatment                                                    177-181


  CHAPTER XVI

  CHOREA GRAVIDARUM AND HYSTERIA

  Varieties of chorea. Differentiation. Prognosis. Hysteria.
  Causes. Epidemics of hysteria. Symptoms. Prognosis           182-186


  CHAPTER XVII

  ACUTE YELLOW ATROPHY OF THE LIVER IN PREGNANCY

  Icterus gravis. Causes. Symptoms. Prognosis                  187-188


  CHAPTER XVIII

  INFECTIOUS DISEASES IN PREGNANCY

  Effects on mother and fetus. Abortions in infectious
  diseases. Placental permeability. Typhoid. Smallpox.
  Pneumonia. Influenza. Scarlatina. Measles. Cholera.
  Tuberculosis. Artificial abortion in tuberculosis            189-200


  CHAPTER XIX

  SYPHILIS IN PREGNANCY AND MARRIAGE

  Prognosis. Abortion. Infection of mother and fetus. Colles'
  Law. Erroneous notions on the curability of syphilis.
  Once a syphilitic probably always a syphilitic. The
  professional secret in syphilis. Nature of secrets. The
  physician may warn an innocent person                        201-211


  CHAPTER XX

  GONORRHOEA IN MARRIAGE

  The cause of gonorrhoea. Tests of cure. Effects on a woman.
  Chronicity. Prevalence. Surgical treatment in women.
  Morality of the surgical treatment. Conservative surgery.
  Salpingotomy. Ovariotomy. Evil effects of
  ovariotomy. Internal secretion of the ovary. Results of
  various operations. Pregnancy after operation. Morality
  of infection. General effects of gonorrhoea. Ophthalmia
  neonatorum and gonorrhoea                                    212-229


  CHAPTER XXI

  DIABETES IN PREGNANCY

  Fatality of diabetes in pregnancy. Diagnosis. Sterility
  of diabetics. Prognosis. Heredity in diabetes. Therapeutic
  abortion in diabetes                                         230-231


  CHAPTER XXII

  CHILDBIRTH IN TWILIGHT SLEEP

  Twilight sleep to avert pain in parturition. Stages of labor.
  Drugs used. Scopolamine and morphine. Danger in
  the use of these drugs in labor. Contradictory report
  of physicians on twilight sleep. Eminent authorities opposed
  to the methods. Baer's report on the evil effects.
  The methods are morally illicit and useless                  232-244


  CHAPTER XXIII

  VASECTOMY, OR STERILIZATION, BY STATE LAW

  The States that have this law. Reasons for the law. Hereditary
  transmission of certain diseases. The operation.
  Its effects. Restoration of the function of the interrupted
  vas deferens. Vasectomy and impotence. Onanism.
  Vasectomy effects impotence from the moral
  point of view. Other conditions in the male that effect
  moral impotence. Immorality of artificial impregnation.
  Vasectomy a grave mutilation. Vasectomy as ordinarily
  practised is illicit. The State and vasectomy.
  The limitations of the State's dominion. The State surgeon
  and vasectomy. Bibliography                                  245-268


  CHAPTER XXIV

  THE ETHICS OF BIRTH CONTROL                                      269

  Index                                                            281




PREFACE


In this book is discussed the morality involved in the ordinary cases
of medical homicide and mutilation. Craniotomy has been omitted
because this operation on the living child is never morally licit,
and when done on the dead fetus it has no moral quality that requires
explanation.

The articles may seem to be intended for Catholic physicians and
spiritual directors alone, but the desire in writing them was to
reach all practitioners, to the end that the Natural Law which
binds every man may be observed. Morality is not made such in
its fundamental principles by any religious creed, but by the
requirements of Divine Order, which finally prevails no matter what
the opposition. Killing and maiming without sufficient extenuation
did not become unlawful solely by the establishment of Christianity.
Practically, however, physicians who have no religion, or a religion
which is so illogical as to pay no attention to dogma, or even to
rail at it as obtrusive, necessarily gravitates to the emotional in
morality, and the principles of this book will not even interest
them. Dogmas are abstract propositions, and all human society rests
on abstract propositions. The most vital facts in morality, the basic
distinction between crime and all that is virtuous or indifferent
morally, is in abstract principle alone, but physicians and pastors
who are not trained in philosophy and rational religion cannot
appreciate an abstract principle--they are influenced only by the
concrete.

Obstetrical text-books, unfortunately, are written by such emotional
men; by men who lack all training in ethics other than that
inculcated in childhood out of the mental vagaries of the women in
the household; and these authors prescribe therapeutic homicide as
if it were a drug in the American Pharmacopœia. The reader is told
that if the patient is a Catholic he is to respect her religious
"prejudices"; if she is not a Catholic one need not bother about
moral scruples when it is necessary to take a life to stop fits.
Since the civil law does not prosecute a physician for therapeutic
abortion on an inviable child, most physicians deem such an act
not only permissible but scientific, and they hold that if a man's
conscience will not let him kill a fetus to alleviate maternal
distress he is guilty of malpractice.

Decrees of the Catholic Church are cited in these pages, not because
morality is an asset of the Catholic Church alone, but because
it alone pronounces officially on these medical subjects after
careful consideration by competent specialists. This Church has
made decisions in comparatively few medico-moral cases, and the
questions still undecided authoritatively are very numerous. They
are quite difficult, too, because judgment supposes a knowledge
of both medicine and ethics, a combination seldom found in one
person. As physicians do not know ethics, and moralists do not know
medicine, there is often trouble in getting at even a statement of
the questions at issue between them. In the preface to _Essays in
Pastoral Medicine_, in 1906, I mentioned a noted case of this kind,
and in 1911 a similar incident occurred in a discussion of the
morality involved in the sterilization of criminals and the defective
by the state. This dispute was taken up by the leading canonists and
moral theologians in the United States, Belgium, Holland, Austria,
Spain, Italy and France, and for nearly two years these men wrote
article after article based upon utterly erroneous physical data.

The books we have on medico-moral subjects are either obsolete at
present, or insufficient; or, more commonly, they are the work of
amateurs in medicine. These last are worthless when they are not
harmful. If, however, I may judge from the questions sent to me for
answer by clergymen and physicians from all parts of the country,
our theological seminaries and medical schools are in grave need of
courses on the morality of medical practice. In this book, to the
preparation of which I have given years of anxious thought because of
the extreme responsibility involved in its decisions, the data for
the most important parts of such courses are presented.

  AUSTIN O'MALLEY.




THE ETHICS OF

MEDICAL HOMICIDE AND MUTILATION




THE ETHICS OF MEDICAL HOMICIDE AND MUTILATION




CHAPTER I

GENERAL PRINCIPLES CONCERNING SUICIDE AND HOMICIDE


A Discussion of euthanasia through the use of narcotics in cases of
incurable diseases periodically recurs, and the opinions of those in
favor of putting the patient out of his misery are expressions of
mere sentimentality, as in Maeterlinck's essay, _Our Eternity_. They
think either that the passing of a law by a legislature removes all
moral difficulty, or that morality is a trifle which should never
stand in the way of expediency. Those who oppose this method of
euthanasia base their argument, first, on the fact that many patients
supposed by even clever diagnosticians to be incurable recover
health; and, secondly, on the fact that the giving power of life and
death to physicians is liable to grave abuse. This side misses the
central truth and argues from accidental and secondary premises.
Whether it is expedient, humane, or impolitic to kill incurable
patients are almost irrelevant considerations: the fundamental
question to be answered here is, Is there a Supreme Being who alone
is master of life, to give it or to take it?

By its very definition such a Being is necessary (as opposed to
contingent), self-existent; its essence always has been and always
will be actualized into existence, and that from itself alone; it is
an individual substance of an intelligent nature, and therefore a
person. A contingent being is one that happens to be (_contingere_);
it is of necessity neither existent nor non-existent; it has no
logical aversion to existence, but in itself it has no more than
a possibility of actuality. A necessary Being, on the contrary,
essentially must be; it cannot not be; it is absolutely and
essentially its own existence.

There must be such a Necessary Being. If there were not, all things
would be contingent, which is an absurdity. The absurdity arises
from the fact that if all things were contingent nothing would be
actual, nothing could ever come into existence, because there would
be nothing to bring the primitive potentiality of the contingent
beings into actual existence. The sufficient reason for the existence
of contingent beings is either in themselves or in something outside
themselves. It cannot be in themselves, because as they do not yet
exist they are nothing; therefore it is in a Being which is not
contingent, but whatever is not contingent is necessary. Therefore
the existence of contingent beings absolutely requires the existence
of a Necessary Being, which always was in existence. The ordinary
name for this Necessary Being is God. Contingent beings are all
creatures, all organic and inorganic beings without exception. There
is, then, a God, the first cause or creator of all contingent beings,
among whom is man; and since God created man wholly, this creature is
wholly subservient to God, under the dominion of God, and his life is
owned solely by God; God alone is the master of life and death, and
he alone can delegate such mastery.

From the relation between the Creator and the creatures arises the
natural law. Violation of this law is the source of all moral evil
in the world, and of much of the physical evil. Reason shows us
this law, and the method of observing it; and reason and unreason,
observance or disregard, of the order fixed by the natural law are
the foundation of happiness and unhappiness. Whatever a human being
is or does, he must seek happiness; that is an essential quality
of his being. Happiness is the satisfying of our desires; but as
our desires are limitless, only infinite good can satisfy them. The
sole sufficient good that sates all human longing is the infinite
Necessary Being, and to be happy we must be united with that Being.
Obviously the only possible method of possessing this infinite
God is through mental union, by undisturbable contemplation of his
infinite truth, goodness, being, beauty, and his other attributes. If
perfect, everlasting happiness is not in that, in what can it be? Is
it in human fame, honor, riches, science, art, man, woman, or child?
None of these can give _lasting_ happiness, and no other happiness is
real happiness.

Now, the only means we have to obtain union with infinite good is to
follow out the condition inexorably placed by God, which is to act
in life in keeping with right reason, to obey the law. Man's supreme
honor is in freedom from the tyranny of unreason, and in a full
obedience to external and immovable order, with the belief that his
chief duty is to apprehend and to conform thereto.

This is morality. From the beginning men have held that certain
acts are wrong and to be avoided, and that others are to be done.
What is wrong, moreover, is such of its own nature, not from our
will: we deem the fulfillment of duty, obedience to law, the first,
highest, and last necessity of life. If we deny this truth we let in
chaos. What is right or wrong is one or the other on its own merits,
prescinding from its pleasurableness or pain.

We must seek good whether we will or not. Good is the sole object
upon which the will operates, it is the raw material of the will's
business. The ultimate standard of this good is God himself as its
exemplary cause, but proximately the standard of moral good is our
rational nature. Through our reason we judge whether a thing is good
or bad; that is, whether it perfects or injures us; and as it is good
or bad for us our will's tendency toward it is good or bad. Many acts
are indifferent in themselves, but take on a good or bad quality from
our intention; others are good or bad in themselves apart from our
volition: charity is good, lying is bad, whether they are willed by
us or not.

The morality of any action is determined (1) by the object of the
action; (2) by the circumstances that accompany the action; (3) by
the end the agent had in view.

1. The term _object_ has various meanings, but here it means the
deed performed in the action, the thing which the will chooses. That
deed by its very nature may be good, or it may be bad, or it may
be indifferent morally. To help the afflicted is in itself a good
action, to blaspheme is a bad action, to walk is an indifferent
action. Some bad actions are absolutely bad; they never can become
good or indifferent--blasphemy or adultery, for example; others, as
stealing, are evil because of a lack of right in the agent: these
may become indifferent or good by acquiring the missing right.
Others are evil because of the danger necessarily connected with
their performance,--the danger of sin connected with them, or the
unnecessary peril to life. An action, to have a moral quality, must
be voluntary, deliberate; and mere repugnance in doing an act does
not in itself make the act involuntary.

2. Circumstances sometimes, though not always, may add a new element
of good or evil to an action. The circumstances of an action are
the Agent, the Object, the Place in which the action is done, the
Means used, the End in view, the Method observed in using the means,
and the Time in which the deed is done. If a judge in his official
capacity tells a sheriff to hang a criminal, and a private citizen
gives the same command, the actions are very different morally
because of the circumstance of the agent giving the command. The
object--it changes the morality of the deed whether one steals a
cent or a thousand dollars. The place--what might be an offensive
action in a residence might be a sacrilege in a church. The means--to
support a family by labor or thievery. The end in view--to give alms
in obedience to divine command or to give them to buy votes. The
method used in employing the means--kindly, say, or cruelly. The
time--to do manual labor on Sunday or on Monday. Some circumstances
aggravate the evil in a deed, others excuse or attenuate it. Others
may so color the deed that they specify it, make it some special
virtue or vice. The circumstance that a murderer is the son of the
man he kills specifies the deed as parricide.

3. The end also determines the morality of an action. Since the
end is the first thing in the intention of the agent, he passes
from the object wished for in the end to choosing the means for
obtaining it. Without the end the means cannot exist as such. There
are occasions when an end is only a circumstance: for example, if
it is a concomitant or extrinsic end. When this extrinsic end is in
keeping with right reason or when it is discordant thereto, it may
become a determinant of morality. In every voluntary, or human, act
there is an interior and exterior act of the will, and each of these
acts has its own object. The end is the proper object of the interior
act of the will; the exterior object acted upon is the object of
the exterior act of the will; both specify the morality, but the
interior object or end specifies more importantly, as a rule, than
the exterior object does. The will uses the body as an instrument on
the external object, and the action of the body is connected with
morality only through the will. We judge the morality of a blow not
by the physical stroke, but from the intention of the striker. The
exterior object of the will is, in a way, the matter of the morality,
and the interior object of the will, or the end, is the form.
Aristotle said: "He that steals to be able to commit adultery is more
of an adulterer than a thief."[1] The thievery is a means to the
principal end, and this principal end chiefly specifies or informs
the action.

  [1] _Ethics_, v, c. 2.

The means used to obtain an end are very important in a consideration
of the morality of an act. There are four classes of means--the
good, bad, indifferent, and excusable. Good means may be absolutely
good, but commonly they are liable to become vitiated by
circumstances,--almsgiving is an example. Some means are bad always
and inexcusable--lying, for instance. The excusable means are those
which are bad, but justifiable through circumstances. To save a man's
life by cutting off his leg is an excusable means. The end sometimes
may vitiate or hallow indifferent means, but it does not in itself
justify all means. Means, like other circumstances, are accidents
of an action, but they are in the action just as much as color is
in a man. Color is not of a man's essence, but we cannot have a man
without color.

The effect of an action, the result or product of an effective cause
or agency, may in itself be an end or an object or a circumstance,
and it has influence in the determination of morality. Sometimes
an act has two immediate effects, one good and the other bad. For
example, ligating the blood-vessels going to the uterus to stop a
hemorrhage and so save a woman's life, a good effect, has also in
ectopic gestation while the fetus is living another immediate effect,
namely, to shut off the blood supply from the fetus and so kill it, a
bad effect. To make such a double-effect action licit there are four
conditions which are explained in the chapter on Mutilation.

The doctrine of Probabilism is very important in morality. Any law
must be promulgated before it really becomes a law, and promulgation
in a rational conscience is sufficient. Sometimes there is rational
doubt of the existence, the interpretation, or the application of a
law in a given case. Here probability is the only rule we can follow.
A law which is doubtful after honest and capable investigation has
not been sufficiently promulgated, and therefore it cannot impose a
certain obligation because it lacks an essential element of a law.
When we have used such moral diligence as the gravity of the matter
calls for, but still the applicability of the law is doubtful in
the action in view, the law does not bind; and what a law does not
forbid it leaves open. Probabilism is not permissible where there is
question of the worth of an action as compared with another, or of
issues like the physical consequences of an act. If a physician knows
a remedy for a disease that is certainly efficacious and another that
is doubtfully efficacious, he may not choose this probable cure.
Probabilism has to do only with the existence, interpretation, or
applicability of a law, not with the differentiation of actions.
The term probable means provable, not guessed at, not jumped at
without reason. The doubt must be positive, founded on reason, not
a matter of mere ignorance, suspicion, emotional bias. The opinion
against a law to permit probabilism must be solid. It must rest upon
an intrinsic reason from the nature of the case, or an extrinsic
reason from authority, always supposing the authority is really an
authority. The probability is to be comparative also. What seems to
be a very good reason when standing alone may be weak when compared
with reasons on the other side. When we have weighed the arguments
on both sides, and we still have a good reason for holding our
opinion in a doubtful case, our opinion is probable. The probability
is, moreover, to be practical. It must have considered all the
circumstances of the case.

There is, then, a Supreme Being whom we _must_ obey, who created
and owns human life primarily; there is also a moral law. On these
facts rests the argument relating to the destruction of human life.
How far, then, has a human being dominion over his own life, and,
secondly, over the life of any one else?

St. Thomas,[2] Lessius,[3] and others offer as one argument to prove
suicide is not licit, that it is an injury to society or the state
of which the suicide is part, and to which the use and profit of
his service rightly belong. Lessius, while developing this proof,
acknowledges its weakness.

  [2] _Summa Theologica_, 1, 2, q. 64, a. 5.

  [3] _De Justitia et Jure_, lib. 2, cap. 9.

If there were only one man in the world, and no society or state,
suicide would still be illicit, because its basic deordination lies
deeper than society or the state. If suicide were a moral evil solely
because it deprives the state of the suicide's life, then for the
same reason no one might become a citizen of another state, emigrate,
nor might man abandon society and live as a recluse. Moreover, if a
man were detrimental to the state rather than beneficial, in this
point of view that fact alone would justify suicide, and the state
would then be justified in permitting or even commanding suicide; and
we shall show later that the state has not this power.

It is true that the injury done the state or society by loss of use
and profit, by scandal and similar evils, is a solid argument against
suicide, as such injury aggravates the deordination of suicide,
but in itself the injury done to the state and society is not the
fundamental reason against suicide.

St. Thomas[4] argues against suicide because it is contrary to
the charity a human being should have for himself. This is true
ordinarily, and suicide takes on part of its guilt just because it
is an offence against the rational regard a person should have for
himself; yet this argument is not basic. We are told that if one sins
against charity in killing his neighbor, _a fortiori_ he sins in
killing himself. Yet suppose just what the advocates of euthanasia
suggest, viz., that a neighbor is in great agony and incurable: then
the act of killing him takes on a quality of charity rather than
of uncharity. And so for the suicide: if the patient is willing to
be killed, there would be no uncharity; if he were unwilling, then
homicide in any form would be uncharitable and unjust. The argument
from charity, therefore, is too narrow to fit the whole case; and its
very weakness is a source of error for the advocates of euthanasia.

  [4] _Ibid._

Still another argument is often advanced against suicide, viz., that
a man is obliged to love his own life, since it is the foundation, or
the necessary condition, to him, of all good and every virtue, and
this circumstance makes the destruction of that life unlawful. That
argument has solid truth, but if it held absolutely it would prevent
us from desiring death in any case, and no one denies that there are
conditions in which a desire for death is fully legitimate. No desire
for death, however, can give the slightest justification for the
destruction of life.

Again, the argument that suicide is cowardice is not broad enough.
Fortitude is a mean between fear and rashness, and this argument
maintains that the suicide sins against fortitude by rashness. If we
have good reason it is not rash to expose ourselves to death; the
soldier may do so, the person struggling to save a neighbor's life,
and so on; it may be the highest form of fortitude thus to expose
oneself to death. If the suicide can persuade himself that by his act
he is seeking greater good than the life he possesses he would have
reason for his act, and at least be above cowardice. This argument is
one that can be turned at times so as to cut the fingers of the man
that uses it. The fundamental reason that suicide is not lawful is
that man cannot be master of his own life, and therefore he may not
dispose of it as he pleases.

Suicide is the direct killing of oneself on one's own authority.
A killing is _direct_ when death is intended as an end, or chosen
as a means to an end. Direct killing is positive by commission, or
negative by omission. In such cases the will directly rests in the
death as a voluntary and free act. A killing is _indirect_ when the
act of which death is the effect by its nature and the intent of the
agent is directed toward another end, but concomitantly, or as a
consequence, results in death. In such case death is an accidental
effect, and comes indirectly from the activity of the will--it is not
necessarily voluntary. If one has a right to do that other deed, or
if it is his duty to do it, and there is a proportion between it and
his life, he may do the deed and permit the consequent death.

A direct homicide may be done on one's own authority, or on that
of another person. It is done on one's own authority if the agent
assumes a natural individual dominion over life, and by virtue of
such dominion directly kills himself or another; it is done on the
authority of another when a man directly kills himself or another
by the mandate of a positive divine or human law, and in the name
and on the authority of a positive divine or human legislator. It is
evident that God, as Creator, has supreme dominion over human life,
and therefore by his positive authority he may command a man directly
to kill himself. God, however, does not by the natural law confer on
man the right thus to kill. The question here is of the natural duty
or right which comes from the natural law alone.

Direct suicide on one's own authority may happen in two ways:
positively, that is, by doing an act which is directly homicidal;
or negatively, by omitting an act necessary for the preservation of
life. That a negative homicide be direct, death must be intended as
an end or means. If, however, one voluntarily intends an end or a
means, but for the sake of antecedent good or evil omits some act
necessary to preserve life, his suicide is indirect, _per accidens_,
and not always illicit unless there is a precept against just such
an omission. Man has no dominion over his own life, he has only
the use of it; and the natural law obliges us while using a thing
which is under the dominion of another not to omit ordinary means
for its preservation. We are not, however, held to extraordinary
means. His own death is criminally imputable to him who negatively
and indirectly kills himself by omitting the ordinary means for
preserving his life, because the precept he is under to preserve his
own life makes his act voluntary. If he omits extraordinary means,
the death is not criminally imputable to him because there is no
precept obliging such means. Certain circumstances may by accident
oblige one to use extraordinary means to preserve one's own life--a
dependent family, a public office in perilous times, or the like. The
proposition, then, is: The natural law does not give a man absolute
dominion over his own life.

I. The natural law gives no rights except such as are finally founded
in human nature itself; but human nature cannot give a title to
dominion over one's own life; therefore the natural law does not give
man such a right.

Every natural right is either congenital or acquired. The title to
a congenital right is human nature itself; the title to an acquired
right is some act consequent to the exercise of human activity. The
right to such exercise is, in turn, congenital and founded in human
nature.

If nature established the title to dominion over one's own life it
would thereby establish the power of destroying that life, and thus
of removing the fundamental title to all rights; but nature exists
as the foundation for rights, not for the subversion of rights;
therefore human nature cannot give a final title to dominion over our
own life.

Again, this minor of the first argument is confirmed by the fact that
if nature even remotely established the power of self-destruction
there should be in nature itself some natural tendency to such
destruction, but the direct contrary is the fact.

II. The natural law cannot grant a right to man which is not a means
to the common end of human life; but absolute dominion over one's own
life is not such a means, therefore the natural law cannot give one
dominion over his own life.

The natural law is only an ordination of man to that common end of
human life and to the means toward that end. As regards the minor of
this second argument, an absolute dominion over his own life would
give man power to stop all his human activity, yet the common end of
human life is attainable only by man's activity. The stopping, or the
power of stopping, all activity cannot be a means to that end.

III. The natural law cannot give man a power which is opposed to the
essential needs of human nature itself; but that a man should have
absolute dominion over his own life is opposed to an essential need
of human nature itself, therefore the natural law cannot give such a
power.

Dominion over his own life implies the power in man of rebelling
against the subjection which he owes to God; but human nature
essentially demands that man be in subjection to God, since dominion
over one's own life and subjection to God are contradictory.

Again, if man had absolute dominion over his own life he could stand
aloof from all influx of the natural law and avoid every duty arising
from that law. A law, however, cannot give a power which nullifies
itself.

The objection that suicide is licit because no injury can be done
a man by an act if the man is willing to submit to the act, is
irrelevant. The injury in suicide is not to man at all, but to God.

There is also nothing in the objection that a gratuitous gift may be
renounced. Life is not a gratuitous gift; it is an onerous gift with
obligations inseparably affixed thereto which forbid the destruction
of the gift.

IV. Destruction is an act proper to a master alone. Man cannot be
master of his own life; he can have dominion of things that are
outside himself, distinguishable from himself, but not of the very
existence of himself, which is not really distinguishable from
himself. The definition of dominion supposes relation. The offices
of master, father, magistrate, are relative conditions which suppose
superiority over _another_ person, not over oneself. Even God is not
a superior over himself, although he has all perfection. For this
reason a man cannot sell himself; he can sell only his labor.

God, who should have absolute dominion over all creatures, and who
has, wills to confine these creatures to certain lines of action
in keeping with the creature's nature. This is the law underlying
even the moral law when it touches humanity; it is the eternal law
coeternal with God's decree of creation, but not necessary as God is.
When this law exists in the mind of God it is the eternal law; when
it exists in the minds of creatures it is the natural law, governing
the free acts of intellectual creatures. When the natural law becomes
a motive to the human will, obliging but not forcing it, a law
through knowledge within the consciousness of a man regulating his
behavior, it is called the law of conscience.

Conscience is an act, a practical judgment on one's own action in
some particular case. It testifies, accuses, excuses, restrains,
urges. It is a rational faculty, not an emotional, sentimental power.
Emotion blinds its judgments. Yet mere emotion, and that foolish
deordination of emotion called sentimentality, are promptings which
the ignorant mistake for conscience and obey. Conscience is the
enlightened eye of the heart, not the vagary of any appetite that
blunders into action. It must be educated; left to itself, it is
guilty of all the perversions of the streets.

The natural law is immutable, not subject to recall by every rascal
under the goad of the flesh. In morality what was, is; what was once
right because reasonable, always will be right and reasonable. Since
opposition to the natural law as applied to man is repugnant to human
nature, no power can make opposition to that law licit. For the same
reason this law is not subject to evolution. Truth in morality is
eternal. What is ugly now was ugly a millennium ago; what was immoral
yesterday was immoral in the sixth century. If our ancestors thought
permissible what we know to be illicit, our ancestors were ignorant;
the fact has not changed. It was as immoral to steal, lie, or murder
in the day of Abraham as it is to-day.

The ultimate tendency of man is toward happiness, and, of course,
happiness, or any other perfection, is impossible without existence;
hence the instinctive recoil from the destruction of our life, which
is the requisite condition for happiness. Even those that abnormally
destroy their own life do so with horror for the destruction
itself, and act thus unreasonably to escape evil, not to escape
life; or they seek what they think will be a better life. We can do
no other injury to a man so great as the depriving him of his life,
for that deprivation destroys every right and possession he has. He
can recover from all other evil, or hold his soul above every other
evil, but death is the absolute conqueror. No matter how debased or
how diseased a man's body may be, no one may dissociate that body
from its soul, except in defence of individual or social life under
peculiarly abnormal conditions; but even such defence is permissible
only while the defender respects other human life and the social
life, while he is innocent, has done no harm to society commensurate
with the loss of his own life.

        "The weariest and most loathed worldly life
    That age, ache, penury, and imprisonment
    Can lay on nature is a paradise
    To what we fear of death."

Existence, no matter how sordid, is immeasurably better than
non-existence, for non-existence is nothing; and when we consider
eternal life after separation from the body, even as a probability,
that raises existence to infinite possibilities above the void
of non-existence. A human life, even in an Australian Bushman,
in a tuberculous pauper, in the vilest criminal, is in itself so
stupendously noble a thing that the whole universe exists for its
upholding toward betterment. The raising of human life toward a
higher condition has been the sole tendency of all the magnificent
charity, sacrifice, patriotism, and heroism the best men and women of
the world since time began have striven in. The necessary first cause
itself is life, and life is by far the most sacred thing possible for
the first cause to effect. Eternal life is the greatest reward of the
just.

It is not permissible under any possible circumstance _directly_ to
kill an innocent human being. By killing directly is meant either (1)
as an end desirable in itself, as when a man is killed for revenge;
or (2) as a means to an end. By an innocent human being is meant
a person who has not by any voluntary act of his own done harm
commensurate with the loss of his own life.

To kill a human being is to destroy human nature, by separating the
vital principle from the body; to destroy anything is to subordinate
and sacrifice that thing absolutely to the purposes of the slayer;
but (1) no one has a right so to subordinate another human being,
because man and his life are solely under the dominion of God. If
a man may not kill himself, as we proved above, because he is not
master of his own life, he surely may not kill another to whom he is
no more closely related as master than he is to himself. (2) No man
has a right to subordinate another human being as is done in slaying
him, because this other human being is a person, an intelligent
nature, and consequently free, independent, referring its operations
solely to itself as to their centre. This very freedom differentiates
man from brutes and inanimate things. These are not independent;
they are rightly possessed by man; but man may be possessed by no
one except God. Even extrinsic human slavery is abhorrent to us as a
corollary of the intrinsic freedom of man, which is absolute. This
intrinsic freedom is such that we may not under any circumstances
lawfully resign it to another's possession. This is one of the chief
moral objections to oath-bound secret societies which exact blind
obedience. All morality depends on that freedom, all peace in life,
all civilization, and society itself.

The end of our struggles, toil, fortitude, temperance, thrift, is
freedom,--freedom to do and to hold, freedom from the thraldom of
vice and barbarity. The rational endeavor of every civilized nation
is that it be free; and this means solely that every citizen thereof,
from the highest to the lowest, is made secure in his rights as a
human being. It intends that justice should prevail. Nearly all the
unhappiness, crime, moral misery, and much of the physical misery in
the world are due to a disregard for liberty, for the safeguarding
of men in their inalienable rights. Give every man his bare rights
as a man and all troubles of capital and labor, all race problems
would cease, the prisons would be empty, war would be unknown. Our
struggle toward justice, toward the protection of the rights of man,
toward liberty, must go on, or anarchy and social destruction will
ensue. Now, as there is nothing greater and nobler than liberty, the
freedom of the sons of God to do what they have a right to do, and as
every human being has a right to that liberty, so there is nothing
baser than its contrary, the destruction of that liberty; and no
destruction is so final as that of killing the man, no usurpation
so abhorrent to human nature and all liberty. Abhorrence for such
a destruction is the primal instinct of all human beings; even the
irrational reflexes of our bodies react quickest in protecting us
from that destruction.

Justice and order must prevail; that is a fundamental natural law
to which all other laws are subordinate. Justice, moreover, is a
moral equation, and whenever one right transcends another it must be
superior to the right it holds in abeyance. The right an innocent
human being has to his life, however, is so great that no other human
right can be superior to it while he remains innocent. Subversion
of this right by creatures is intrinsically evil, as blasphemy and
perjury are evil, although not in exactly the same degree.

There are occasions upon which it is permissible to kill,
_indirectly_, innocent persons. An effect is brought about indirectly
when it is neither intended as an end for its own sake, nor chosen as
means toward an end, but is attached as a circumstance to the end or
the means. Means help to an end, circumstances often do not, although
they may affect the morality of an act.

Suppose two swimmers, Peter and Paul, are trying to save Thomas, who
dies in the water; as he dies Thomas grips Peter and Paul so tightly
that they cannot shake the corpse off. Peter is weak, and he will
soon sink and drown, owing to his weakness and the weight of the
corpse; Paul also will go down later, owing to the weight of Peter
and Thomas. Peter, however, cuts his own clothing loose from the grip
of the corpse and is saved; but Paul immediately is drowned, owing
to the fact that the full weight of the corpse comes upon him. Is
Peter justified in cutting himself loose? Certainly he is. This is an
example of indirect killing, a case of double effect, one good, the
saving of Peter's life, the other evil, the loss of Paul's life, both
proceeding immediately and equally from the causal act, the cutting
loose of the clothing. The good effect is intended, the bad effect is
reluctantly permitted.

Again, let us set the same condition for Peter, Paul, and Thomas; but
Peter is not able to cut himself loose. John, a fourth person, can
cut Peter loose and save him, but can do no more; he must let Paul go
down with the corpse of Thomas. May John cut Peter loose? Certainly
he may, on the principle _quod liceat per se licet per alium_. This
is another case of double effect, with the extenuating circumstances
as above.

Suppose, however, Peter represents a living infant in the womb
of Ann, and that she is in labor; further, this infant cannot be
delivered owing to the contraction of Ann's pelvis. May John, a
physician, cut away Peter by craniotomy and so save Ann's life?
Certainly he may _not_. John here _directly_ brains Peter to save
Ann, although Peter is not an unjust aggressor; he does a murder to
get a good effect, and the end does not justify the means. There are
two effects, but the good effect follows from the bad one, and not
immediately from the causal act.

Take another example: Peter is a swimmer disabled by cramps and about
to drown; Paul, going to save Peter, is seized by Peter, and both
are now in danger of drowning; John goes to help Peter and Paul.
He cannot get Peter's grip loose by ordinary means, and he sees he
can save only one man, either Peter or Paul. May John knock Peter
senseless to loosen his grip from Paul, bring in Paul, and thus leave
Peter to drown? Certainly he may. You have the double effect here
also. Moreover, Peter is a materially unjust aggressor; he is like a
maniac trying to kill Paul. In the craniotomy case the child is not
a materially or formally unjust aggressor, it is not doing anything
at all. It is where the mother put it, and it has a full right to its
position and its life.

John most probably might also knock Paul senseless and save Peter,
if through affection or similar motive he preferred this course.
He would then be justified by the double-effect principle alone,
although Paul is in no sense an aggressor. The intention of the blow
would have to be solely to loosen Paul's hold.

In a just war a commander may shell an enemy's works and indirectly
thereby kill non-combatants. The gunners that cause the death of the
non-combatants do not intend this death; they permit it as the evil
effect which comes immediately with the good effect (the capture of
the works) from the causal act of firing the guns.

If we keep within the bounds of a just defence we may protect
ourselves against an unjust aggressor to the effusion of his blood,
or even, if need be, to killing him. An aggressor is any one who
does injury to us contrary to our rights and the ordination of
right. A formally unjust aggressor is a sane intelligent person who
intentionally attacks us; a materially unjust aggressor is one who
is not intelligent, not responsible, as an insane person, a child,
or a sane person who is injuring us unintentionally. This question
is important in medicine because the fetus _in utero_ is often
erroneously called an unjust aggressor.

It is a primary law of nature that every human being should and will
strive to resist injury and destruction. Justice requires a moral
equation, and if one right prevails over another it must be superior
to the right it supersedes. At the outset both the aggressor and
the intended victim have equal rights to life, but the fact that
the aggressor uses his own life for the destruction of a fellow man
sets the aggressor in a condition of juridic inferiority to the
victim. The moral power of the aggressor here is equal to his inborn
right to life, _less_ the unrighteous use he makes of it; while the
moral power of the intended victim remains in its integrity, and has
therefore a higher juridic value.

The right of self-defence is not annulled by the fact that the
aggressor is irresponsible. The absence of knowledge saves him
from moral guilt, but it does not alter the character of the act
considered objectively; it is yet an unjust aggression, and in the
conflict the life assailed has still a superior juridic value. In
any case the right of wounding or of killing in self-defence is
not based on the ill will of the aggressor, but on the illegitimate
character of the aggression.

The condition's of a blameless defence (_moderamen inculpatae
tutelae_) are: (1) that the aggressor really threatens the defender's
life, and there is no means of offsetting that violence except like
violence; (2) that no more violence is used than is adequately
required: if the aggression can be stopped by wounding the aggressor
the defender is not to kill him; (3) that the violence in the defence
is used with the intention of defence, not in revenge, hatred, anger,
or the like motives.

We may do an act good in itself from which a double effect
immediately follows, one good, to which the agent has a right, and
the other bad, which the agent is not obliged to omit if permitted
by him and not intended; but in the case of a necessary defence of
life against an unjust aggressor, made even with the death of the
aggressor, the defence is such an act, provided the moderation of a
blameless defence is observed.

The evil effect here is not a means to the good effect, nor does it
more immediately follow from the act done. The evil effect is an
effect _per accidens_, and thus not directly voluntary, either in
itself, because it is not intended, or in its cause. It lacks the
condition necessary to make it voluntary in cause as regards the
accidental effect since the act is not prohibited precisely because
this accidental effect follows.

The act in the case is good in itself; it is an application of
physical force in defence of a proper right, and any right supposes
a compulsive power. The two effects of this double-effect act are:
(_a_) the preservation of the defender's life, and (_b_) the death of
the aggressor. The first effect is good because the defender has a
right to his own life; the other effect is evil, not only physically
for the one who dies, but morally inasmuch as the death conflicts
with the dominion of God. This death, however, is an accidental
effect of the act, because in general the defensive act is not
directed by its nature to that death but to the preservation of the
defender's life; nor does the death follow more immediately than the
preservation. Thus it is not a means of the defence. Finally, the
defensive act is not prohibited precisely lest that death follow: not
in justice, for there is no justice in any right of the aggressor
which requires from the defender an omission of defence unto the loss
of life; there is no obligation in charity, since charity does not
oblige us to love another more than ourselves, or to exalt the good
of another above our own.

In an aggression which is merely material--say, in an attack by an
insane man--the defender has a right to the infliction of such damage
as is necessary and proportionate to an efficacious defence. The
right of the aggressor yields to the superior right of the defender,
not through the fault of the aggressor but through his misfortune.
There is a collision where both rights cannot be exercised at the
same time, and there is no reason obliging the defendant to forego
his own right.

We may defend another against an unjust aggressor because we can
assume that the attacked person communicates to us the use of his
own coactive right. If the aggressor is our own father, mother, son,
or daughter, or in general any one to whom charity obliges us more
than to the person attacked, we are not permitted to kill our own kin
because charity does not oblige us to prefer the good of an alien
to the good of one of our blood. Ordinarily we are not obliged in
justice or charity to defend another at the risk of our own life.

We may kill an unjust aggressor, _servatis servandis_, in defence
of good equivalent in value to life: for example, to prevent life
imprisonment, the loss of reason, a mutilation which would render us
useless, the loss of a woman's chastity.

There are cases of _accidental_ homicide, in medicine and elsewhere,
which have an element of guilt in them. If a death follows
accidentally upon an act which in itself is licit, and the agent
uses all proper precautions, he is not morally guilty in case of
an accidental death following his act. This is true even if the
agent foresaw a probable death but did not intend it. If, however,
the agent's primary act is illicit in itself, and an accidental
death follows from this act, the agent may be guilty of homicide,
provided the first act in itself is naturally likely to cause
homicide. Should the first act be always dangerous, such that
death commonly follows from it, like rocking a row-boat, aiming a
supposedly unloaded gun at a person and pulling the trigger, striking
a pregnant woman, drinking whiskey and then overlying an infant in
the bed, throwing building material from a roof to a street, racing
an automobile through a crowded thoroughfare, sending a crew out in
a rotten ship, and so on, the accidental homicide that follows is
imputable to the agent no matter how much precaution he may say he
has used to avert such a death.

Suppose, secondly, the original act of the agent is illicit but such
that accidental death rarely follows from it; then if he takes due
precaution he is not ordinarily guilty of homicide. He has, say,
stolen an automobile, and is going along the street leisurely, when a
careless child runs off the sidewalk under the machine and is killed.

1. No person, then, may hasten his own death or permit any one else
to hasten it.

2. No physician may in any possible condition kill a patient merely
to effect euthanasia.

3. The state has no more right than the physician to permit the
killing of patients to bring about euthanasia.

Were such permission given to physicians it would immediately be
abused by men with even the best intentions. In all countries and
in the largest cities the medical profession is swarming with
quacks. What is done in crass ignorance by licensed physicians and
specialists every day in the name of medicine is appalling. Professor
Orth of the Pathologic Institute in Berlin makes the statement that
of all the appendices that have been submitted to him for microscopic
examination after removal by conservative and supposedly skilled
physicians, 17 per cent. showed no disease at all, and should
not have been removed. In this country the percentage of normal
appendices removed because of vague abdominal pains is much larger.

The _Journal of the American Medical Association_ (June 7, 1913)
gave a list of post-mortem examinations where the diagnosis made
by men with a reputation for fair work had been correct in only the
following ratios:

                                   Diagnosis     Diagnosis
                                    correct.     incorrect.
                                    Per cent.     Per cent.
  Diabetes Mellitus                    95             5
  Typhoid Fever                        92             8
  Aortic Regurgitation                 84            16
  Cancer of Colon                      74            26
  Lobar Pneumonia                      74            26
  Chronic Glomerular Nephritis         74            26
  Cerebral Tumor                       72.8          27.2
  Tuberculous Meningitis               72            28
  Gastric Cancer                       72            28
  Mitral Stenosis                      69            31
  Brain Hemorrhage                     67            33
  Septic Meningitis                    64            36
  Aortic Stenosis                      61            39
  Phthisis, Active                     59            41
  Miliary Tuberculosis                 52            48
  Chronic Interstitial Nephritis       50            50
  Thoracic Aneurism                    50            50
  Hepatic Cirrhosis                    39            61
  Acute Endocarditis                   39            61
  Peptic Ulcer                         36            64
  Suppurative Nephritis                35            65
  Renal Tuberculosis                   33.3          66.7
  Bronchopneumonia                     33            66
  Vertebral Tuberculosis               23            77
  Chronic Myocarditis                  22            78
  Hepatic Abscess                      20            80
  Acute Pericarditis                   20            80
  Acute Nephritis                      16            84

Pneumonia is a very common disease, extremely dangerous, and by
skilful treatment it is very often cured, yet of these 100 cases 66
were not diagnosed. I recently saw a severe case of double pneumonia
which a physician was treating as "indigestion," and he was giving
pepsin tablets for the supposed indigestion. There is such a thing
as extraordinary scientific precision in medical work, but it is
rare; the ordinary physician treats symptoms without knowing the
cause of the symptoms; that is, the symptom-treater is a quack,
and if euthanasia were legalized thousands of such quacks would
be permitted to murder with an overdose of morphine any querulous
old man or woman who might fall into their hands. Osteopaths and
chiropractors are masseurs, and they know very little of massage, but
they are licensed by legislatures to practise medicine, and some of
them even try obstetrical malpractice. They, too, would be licensed
to inflict euthanasia. Pure homeopathy is little more than a name at
present; it is faith-healing without prayer. It attenuates its drugs
100 per cent. for thirty repetitions, to a degree expressible by one
with sixty ciphers. Consequently it gives sugar of milk or alcohol
in minute quantities plus a label, and one cannot make much of an
impression on any disease with a label. Such practitioners also would
come under the euthanasia act.


BIBLIOGRAPHY

     Cardinal John de Lugo. Disputationes Scholasticae et Morales,
     vol. vi; De Justitia et Jure, disputatio x.

     St. Augustine. I Contra Petilianum, cap. 24; Ad Marcellianum
     Comitem, cap. 21; De Civitate Dei, cap. 17 to 28.

     Aristotle. III Ethicorum, cap. 7, and lib. v, cap. ii. Plato.
     Phaedo.

     Cicero. Quaestiones Tusculanae. I, lib. v; De Somno Scipionis.

     Lessius. De Justitia et Jure, lib. ii, c. 9, dub. 6, 7.

     Molina. De Justitia et Jure, vol. i, tr. 2, disp. 119; vol. iv,
     tr. 3, disp. 1 and 9.

     St. Thomas Aquinas. Summa Theologica, 2, 2, q. 64, a. 5, 7.

     St. Alphonsus Liguori. Theologia Moralis, vol. iv, tr. 4. See
     this book for opposed opinions and a bibliography.

     Costa-Rossetti. Philosophia Moralis, thesis 120.

     Ferretti. Philosophia Moralis, theses xci, xciv.

     Macksey. De Ethica Naturali, theses xxxiv _et seq._




CHAPTER II

GENERAL PRINCIPLES CONCERNING MUTILATION


The members of the human body may be injured (1) by a blow, which
without bloodshed causes pain or a bruise; (2) by a wound, which
breaks the continuity of the tissues; (3) by mutilation, which,
without killing, removes some member requisite for the integrity
of the body. The term Mutilation as applied to the human body has
various meanings. In the civil law mutilation of a person is called
Mayhem, an old form of the word Maim, and is defined by Blackstone[5]
as "such hurt of any part of a man's body as renders him less able in
fighting to defend himself or annoy his adversary." By statute in the
United States and Great Britain the scope of the offence has been so
extended as to include injuries to a person which merely disfigure or
disable. Mutilation in the civil law now implies the taking away of
some part of a legal instrument, as a will, contract, or the like, by
any one who has no right to make this alteration.

  [5] _Commentary_, bk. iv, p. 205.

In canon law mutilation is like malicious or accidental mayhem in
the civil law, and it has also a technical phase in relation to
irregularity as affecting the reception of ecclesiastical orders.
The mutilation requisite to irregularity as affecting the reception
of Holy Orders may differ from mutilation in its purely moral and
accidental aspects. Broadly, an irregularity is a canonical and
permanent impediment to the reception and exercise of ecclesiastical
orders. It does not exist unless it is actually promulgated in some
canon, and it is not necessarily grounded on corporal deformity.
Defects of the body that cause canonical irregularity are such as
would render the public ministration of a clergyman either impossible
or indecent.

Molina, treating of mutilation, says[6] it does not exist unless
there is an amputation or shortening (_detruncatio_) of a member.
When a foot or hand is so weakened without amputation that it cannot
exercise its function the person is said to be maimed or lame, not
mutilated. He holds that a finger, and _a fortiori_ a phalanx of
a finger, are not properly members. In defining mutilation as a
cause of canonical irregularity[7] he contends that the weakening
of a member so that it cannot perform its function is not a true
mutilation canonically. He does not agree[8] with Cajetan, de Soto,
and others who hold that an important part of a whole member is
equivalent to a member so far as technical canonical mutilation is
concerned. Molina says that a part of the body as a member to fulfil
the requirements of the law on mutilation as a cause of irregularity
must have a distinct, complete function of its own, not be a mere
part conducing to the function. Ballerini[9] agrees with Molina,
but he draws attention to a decretal of Innocent I. which makes an
amputation by oneself of even a part of one's own finger a full
canonical irregularity, because of the unnatural quality of the act.

  [6] _De Justitia et Jure_, disp. 19, tr. 3.

  [7] _Ibid._, disp. 68, tr. 3.

  [8] _Ibid._, n. 69.

  [9] _Theol. Moral._ vol. vii.

Suarez defines mutilation thus: "Mutilare significat proprie membrum
aliquod abscindere"[10]--to mutilate means, strictly speaking, to
cut off any member. He holds with Cajetan that an important part of
a member is in itself equivalent to a member. A reason he offers
for his opinion is that a eunuch is enumerated among those who are
canonically mutilated, but the eunuch, he tells us, "does not lack
any member which in itself has a function in the body independent of
all other organs." This is not true. The testicles, which the eunuch
lacks, have two distinct functions, independent of other organs--they
make the spermatozoa and an important internal glandular secretion.
These facts were not known in Suarez's time (1548-1617). Suarez adds
this remark: "There can be a grave sin in a marring [_diminutio_] of
any chief member, although there may be no grave mutilation; as,
for example, to cut off a part of a finger is undoubtedly a mortal
sin, yet, in the opinion of all moralists, it is not enough to cause
irregularity."

  [10] _De Censuris_, etc., disp. 44, sec. 2, 2.

St. Alphonsus Liguori defines mutilation thus: "Mutilation here
signifies that some principal member be separated from the body; that
is, a part of the body that has in itself a distinct function, as a
foot, hand, eye, ear, etc."[11] He says[12] canonical irregularity
as a punishment is not incurred by a person who cuts off another
man's finger, thumb, lips, nose, auricle, or who knocks out teeth,
because these are supposed by canonists not to be properly members
of the body, but parts of members. To blind a man in one eye is
not enough to cause canonical irregularity; the eye must be taken
out.[13] All these injuries are of course mutilations in the moral
sense of the term. To blind a man without removing the eye, to cut
out his spleen in the treatment of Banti's disease, to remove a
woman's ovary or uterus, to cut off part of the point of a finger,
to crop the top of an auricle, to knock out a tooth, and any other
permanent marring of the body, even to cause an unsightly scar across
the face, are all mutilations in the moral sense of the term. A
physician, midwife, nurse, or parent who neglects an infant's eyes,
and so permits ophthalmia neonatorum to blind the child, is guilty of
grave mutilation. In the year 1914, in the Chicago schools, 45,176
children were found suffering from various defects, and 35,425 were
advised by the examining physicians to seek treatment; in each of
these cases the parents were informed of the nature of the disease
and the necessity for treatment, but only 40 per cent. of the parents
paid any attention to the notices. Of 5754 cases of diseased tonsils,
which are likely to affect the heart permanently, only 4 per cent.
were treated; of 1254 cases of discharging ears only 10 per cent.
were treated, although such a condition may go on to deafness if not
attended to. These parents were criminally guilty of grave neglect
in permitting the mutilation of the heart and ears.

  [11] _Theol. Moral._, lib. 7, cap. 5, disp. 4, n. 365.

  [12] _Ibid._, n. 378.

  [13] _Ibid._, n. 382.

Any notable mutilation inflicted upon oneself is akin to the
malice of suicide, and when perpetrated on another it is related
to homicide. The dominion over the members of the body, as over
the whole body, belongs to God alone. Man is constituted by his
parts, members, taken together, and if he were master of his members
he would be master of himself. Again, each member of the body is
naturally united to that body and ordained for determined organic
functions; so it is wrong to render these members unfit for their
natural function or to separate them from the body, unless such
actions are necessary for the preservation of life itself. Although
man is not master of himself, he is the administrator of himself;
and therefore when the amputation of any member is necessary for the
preservation of the life of the whole body it is licit to subordinate
this part to the good of the whole.

A direct mutilation is one intended as an end, or as a means to an
end; it is a voluntary and free act. An indirect mutilation is one
in which the mutilation is the natural effect of the act, but the
intention of the agent is directed toward another end. The mutilation
follows indirectly from the activity of the will, but there is a
satisfying proportion between the accidental effect (the mutilation)
and the end intended. In such an act there are two effects which
follow the causal act _aeque immediate_, or directly (not indirectly,
that is, not all from the other effect, but each immediately from
this cause): one effect is good (to save life, avoid unbearable pain,
or the like), and the other evil (the mutilation), but the good
effect is the end intended, the evil effect is reluctantly permitted.
Such an act is licit provided the usual conditions of the double
effect are present, that is:

1. The action that is the cause of the good and bad effects must be
itself good or indifferent morally.

2. The good and the bad effects must each be an immediate result of
the causal act; the good effect may be not so subordinated to the
evil effect as to be obtainable only through the evil effect.

3. The bad effect must not be intended, either immediately or
remotely; it may at most be tolerated as unavoidable.

4. There must be a sufficiently grave reason for the act.

Indirect mutilation may be licit when the evil to be avoided is
proportional to the mutilation. Direct mutilation, where there is one
direct effect of, say, the surgical operation, namely, to remove the
somatic organ, is not licit, except for the good of the whole body;
and that good to the whole body must be juridically equivalent to
the damage done the body by the mutilation. There is to be a direct
effect in such mutilation, which is the good of the whole body. It is
not permitted to kill directly to save the life of another, but it
is permissible to mutilate directly to save the whole body. Direct
mutilation, however, is never unavoidable because the agent can
always correctly order his intention before the operation.

All direct mutilation, unless for the good of the whole body, implies
deordination: it offends against the supreme dominion of God, who
reserves to himself, as Creator, ownership of human life and its
organs. As we may not destroy life, which belongs to God, we may not
amputate a member to suppress any vital function. The exception which
permits us to mutilate a member or organ is, as has been said, the
adequate good of the whole body. The reason for this is that man is
the administrator of his members, to the good of the whole person.
Each member is not for itself but for the whole body.

The good of the body is the sole cause that renders direct mutilation
licit. The members of the body by their nature are not immediately
subordinate to anything except the conservation of the total
natural good, or that of the body. Therefore direct mutilation is
not permissible to effect immediately spiritual good, or the good
of the soul. We may not castrate a man, or do vasectomy on him, to
preserve his continence, because there is no immediate subordination
and connection between the members of the body and the salvation
of the soul. Moreover, as St. Thomas says,[14] "Spiritual health
can always be preserved by means other than amputation of bodily
members," that is, through moderating by the will the use of these
members. If a mutilation that immediately conduces to the good of the
whole body, happens also to do good to the soul, this second effect
is then legitimate. (The various mutilations of the body by surgical
operations will be considered separately hereafter.)

  [14] 2, 2, q. lxv, a. 1, ad 3.

May the state, then, sterilize criminals, and persons afflicted with
dangerous hereditary diseases, to prevent the propagation of moral
and physical defectives? This question is considered specially in
another chapter.

There is an error gradually infecting all nations of late which is
that the state, as such, is above morality; that what the civil
authority permits or orders is by that fact alone made licit or
obligatory. Hence the interference with individual liberty, with the
rights of man, shown by laws for the mutilation of the physically
degenerate, laws conferring privileges on one part of the community
to the detriment of another, meddling in parental rights, and so on.
Political error has come to such a pass that the men on the street
think any majority is justified, solely because it is a majority,
in recalling a judge or a law, in overriding authority for the
satisfaction of appetite. The sovereign people tries to be subject
and sovereign at the same time, and it deems its rulers mere hired
men who may be discharged at will like cooks.

A law is a rule and standard of action; a just, permanent, and
rational ordination for the good of the community, promulgated by one
who has charge of that community. Dominion is the power of claiming
a thing as one's own, the right of ownership; and if this possessor
has created the object, his dominion may be absolute. A governor,
lawgiver, judge, has power or jurisdiction for the good of the
governed. The business of government, of the state, is to protect
each citizen in the pursuit of temporal happiness, to develop his
natural faculties, establish and preserve social order, wherein each
citizen is secured in his natural and legal rights, and is held up
to the fulfilment of his own duties so far as they bear on the good
of the community as such; and also to put within the reach of all
citizens, as far as possible, a fair allowance of means to acquire
temporal happiness, or external peace and prosperity. This is the
whole business of the state. The state is for the people, and it may
not transgress an inch beyond its proper limits, which are as hard
and fast as those that bind the individual citizen. The citizen is
not to be treated solely as an industrial or military unit; nor are
material progress and military power, or even sheer intellectual
civilization, to be the sole aim of the state. The state should
develop a man's entire nature, physical, mental, and moral.

We must obey civil authority, but we are not slaves or chattels of
that authority. The state's authority over us is not dominative; it
is only a power for our good and utility. The civil authority has no
more right to invade the rights of its meanest citizen than it has
to lie or to blaspheme. God gives civil authority to the established
community, and the community entrusts this to its ruler; authority
is a divine institution, rulers are directly a human institution and
only indirectly divine. When the ruler has once been set up, has had
authority entrusted to him, obedience must be given to him while he
acts in keeping with his contract. Kant and his followers erroneously
separate the juridic from the moral order; they deny that beyond the
state there are any rights preeminent to the state's rights, yet they
say there is an innate liberty which belongs to every human being
equally and inalienably. The moral order comprehends all factors that
are necessary to make the free activity of man in every respect well
disposed, and among these factors is the juridic order itself. Man is
naturally social, and whatever means are necessary to preserve human
society are also naturally befitting man. Such means are to preserve
for each man what are his, and to abstain from injuring other men.
Now, so to act, that is, to abstain from murder, theft, and the like,
to fulfil contracts, are strictly juridic duties, and at the same
time moral duties. Therefore the moral order comprehends the juridic
order.

The end of the state, then, is not the public good considered as an
end in itself. The individual citizen is not his own end in life, and
so no mere multitude of men ever can become their own end. If the end
of the state is the public good, then private good is subordinate
to this, and the public good becomes man's final end, which is
subversive of human dignity and is despotism.

A clear definition of the power of the state to interfere with the
rights to life and limb of the individual citizen is very important,
because, as has been said, of late there is an alarming tendency
on the part of the civil authority to override the rights of
private citizens, even in the most democratic forms of government.
Encroachment on the liberty of the individual is characteristic of
unchristian political societies, and all states are now receding from
Christianity. A striking example of this tyranny is the laws recently
passed in ten American states for the mutilation of degenerates. This
definition is more readily made by considering concrete examples of
public conduct.

Suppose an enemy demands from a city the surrender for execution
of an innocent man on pain of the burning of the city and the
destruction of its inhabitants. May the city cut off that member for
the safety of the whole body politic, as a person may cut off his own
hand to save his life? The state has not dominion over the life of a
citizen, nevertheless it may kill a citizen in punishment of crime,
because the punishment is useful to the whole people, is for the
common good, is preservative of the social life. Why, however, should
the state be permitted to kill a criminal rather than an innocent
man, since it has no dominion over the life of either, and we suppose
the death of each is necessary for the public good? If you answer by
saying a man may cut off a diseased member but not a sound one to
save his body, and the state in like manner may cut off a criminal,
unsound member, but not an innocent one, this answer does not remove
the difficulty: we may cut off even a sound member to save the body.
Suppose, for example, a man caught by the arm and in danger of death
from a flood; he might sever a sound arm to escape death if no other
means presented. In like manner the state might cut off an innocent,
sound member to save its life from the enemy, as described above.

This reasoning, however, is open to objection. The state has no
dominion over the life of its members, and there is a vast difference
between the members of the human body and those of a body politic.
A member of a human body has no right in itself against the other
members; nor is it capable of natural injury, since it is not
separable from the whole suppositum, or person. The suppositum, or
person, has a right to the use of the members; it alone is injured
when a member is amputated; and the members are solely for the
utility of the suppositum. Therefore we may licitly destroy a member
to save the suppositum for which this member exists.

The state, however, is not a suppositum in this sense; it may not
wrest the life of its members to its own utility, because the
citizens are not for the state; on the contrary, the state is for
them and their utility. That a rational being should be for the
utility of another person or a society makes him a slave and supposes
dominion in the user. A slave is differentiated from a subject
by the fact that the subject is only politically governed--that
is, governed for his own utility and good; the slave is governed
despotically--that is, for the utility and good of his master. The
state may not, as a master, use the life of a subject for its own
utility alone. Although the suppositum does not own its members,
yet since the members are not separable from the man, are not
self-centred as are the citizens in a state, the man may use them for
his own utility. They are as slaves under a master, not as subjects
in a body politic; therefore they may be sacrificed for the good of
the suppositum.

This is the argument used by De Lugo; Molina follows the same line of
thought; but both authorities finally reach the conclusion, in the
case of the enemy and the citizen whose life is required, that the
state may at least drive this citizen out of the city to save its own
existence. Molina also draws attention to the fact that there is a
great difference between a member of a body politic and a member of
the human body; this identification, if pushed far enough, becomes
an analogical quibble.

Some hold that a judge or the civil authority in general may kill
or maim a criminal by gubernatorial power alone, prescinding from
dominative power, and this not to the utility of the criminal but for
the utility of society. The killing of a criminal, these objectors
say, is not for the good of the criminal; it is a deterrent, a
protective act, for the good of society. This is not true. The penal
law which the criminal breaks was not made solely for society; it was
intended also for the utility of the person who becomes a criminal.
The law was made and the punishment established that all subjects
indiscriminately should be helped to live honestly and blamelessly,
and to this end it was necessary to decree and inflict punishment as
affecting all offenders. The obligation to receive punishment is in
a manner essential to man. As he naturally requires direction and
government unto virtue in his political and social life, he has a
connatural obligation to endure punishment when he violates the law
made for his advantage--one condition cannot exist without the other.
Hence punishment really is to the utility of the criminal.




CHAPTER III

WHEN DOES HUMAN LIFE BEGIN?


By the embryologists from the moment the spermatozoön joins the
nucleus of the ovum until the end of the second week of gestation
the product of conception is called the _Ovum_; from the end of the
second week to the end of the fourth week it is the _Embryo_; from
the end of the fourth week to birth it is the _Fetus_. At what moment
during these three stages does the human soul, the substantial form
of a man in the full comprehension of the term, enter the product of
conception? When does the thing become a human being?

The question is evidently one of the greatest importance. If the
rational soul does not enter until the ovum has developed into
an embryo, or only after the embryo has passed on into the fetal
condition, the destruction of this ovum, by artificial abortion
or otherwise, would be a very different act morally from such
destruction after the soul had turned the new growth into a living
man. If the product of conception has first only a vegetative vital
principle, and this is later replaced by a vital principle that is
merely sensitive, and this again is finally superseded by a rational
vital principle, the destruction by abortion or otherwise of the
vegetative or sensitive life would not be a destruction of a rational
life. In this hypothesis the killing of the embryo would be a great
crime, because the embryo would be in potency for the reception of
human life, but the act would not be murder.

The discussion concerning the moment the human soul enters the body
is older than Christianity, and it was taken up by many of the early
Greek and Latin Fathers of the Church, and revived again and again
down to the present day. Plato thought the soul enters at birth;
Asclepias, Heraclites, and the Stoics held it is not infused until
the time of puberty; Aristotle[15] said the soul is infused in the
male fetus about the fortieth day after conception, and into the
female fetus about the eightieth day.

  [15] _IX, De Animalibus_.

Tertullian,[16] Apollinaris, and a few others advocated
Traducianism,[17] or a transmission of the spiritual soul by the
parents. He said souls are carried over by conception and by the
parents, so that the soul of the father is the soul of the son, and
from one man comes the whole overflow of souls. St. Augustine used
the metaphor, one soul lit from another as flame from flame, without
decay in either. Augustine was in doubt as to the origin of the
soul, and inclined to traducianism, because it seemed to him better
to explain the doctrine of the transmission of original sin. "Tell
me," he wrote to St. Jerome in 415,[18] "if souls are created singly
for each person born to-day, when do infants sin so that they need
remission in the sacrament of Christ, sin in Adam from whom the flesh
of sin is propagated?... Since we cannot say that God makes of souls
sinners, or punishes the innocent, nor may we hold that souls even of
infants which without baptism leave the body are saved, I ask you how
that opinion can be defended which thinks that all souls are not made
from the single soul of the first man, yet as that soul was one to
one man, these are particular to particular individuals."

  [16] _De Anima_, cap. 27.

  [17] From _tradux_, a planted vine-shoot made to take root.

  [18] Migne, vol. xxxiii, col. 720.

Again, St. Augustine said:[19] "I do not know how the soul came into
my body; he knows who gave it, whether he drew it [_traxerit_] from
my father, or created it new as in the first man." In the _Book of
Retractions_,[20] speaking of the articles he had written against the
Academicians before he was a bishop, he says: "As to the origin of
the soul, how it is set in the body--whether it is from that one man
who first was created ... or, as in his case, is made particularly
for each particular individual, I did not then know, and I do not
know now." St. Gregory the Great also said he could not tell whether
the human soul descends from Adam or is given particularly to each
man.

  [19] _De Anima et ejus Origine_, i, xv.

  [20] I, cap. i, n. 3.

St. Gregory of Nyssa, however, who died about 385, thirty years
before St. Augustine wrote the letter to St. Jerome, held that the
soul is infused into the body at the moment of conception, and he
argues with absolute precision for his opinion.[21] St. Maximus the
Theologian, who was martyred in 662, inveighs[22] against the notion
that the soul is vegetative at first, then sensitive, and finally
intellectual, and he thinks the assertion of Aristotle that the fetus
is not animated before the fortieth day is altogether untrue.

  [21] Migne, _Patrologia Graeca_, vols. xliv and xlvi.

  [22] Migne, _Ibid._, vol. xci, col. 1335.

St. Anselm, who died in 1109, very dogmatically denied that the fetus
is animated at conception,[23] and after his time the doctrine of
Aristotle, which is commonly called the Thomistic opinion, became
almost general. Vincent of Beauvais, however, a contemporary of St.
Thomas, opposed the Thomistic doctrine. Albertus Magnus[24] had the
same opinion as St. Thomas, and probably taught it to St. Thomas. In
the middle ages all held that each soul is directly created by God,
and is infused into the embryo, not at the instant of conception,
but when the embryo is sufficiently formed to receive it, which, as
Aristotle said, happens at about the fortieth day in males and the
eightieth day in females. The Thomists maintained the succession of
the three souls; many others opposed this particular opinion.

  [23] _De Conceptione Virginis_, cap. xii.

  [24] _Summa, De Homine_, q. xvi, art. 3.

Thomas Fienus, a physician and a professor in the University of
Louvain, in 1620 published a book[25] in which he held that the soul
is infused about the third day after conception, and his argument
for the early advent of the soul is very sound. As a result of
Fienus's revolutionary argument, Florentinus in 1658 brought out a
book at Lyons, called _De Hominibus Dubiis Baptizandis_, in which he
held that no matter what the age of the aborted fetus, if it could
be differentiated from a mole it should be baptized. This book was
brought before the Congregation of the Index. The congregation did
not condemn the book, but the author was forbidden to teach that his
doctrine holds _sub gravi_. The book went through many editions and
was approved by the faculties of the principal universities and the
theologians of the leading religious orders.

  [25] _De Vi Formatrice Foetus Liber._

Zacchias, chief physician to Innocent X., in 1661 published his
_Questiones Medico-Legales_, and in this he maintained that "the
human fetus has not at any time any kind of soul other than a
rational, and this is created by God at the first moment of
conception, and is then infused."[26] By 1745 the opinion of
Zacchias as to the moment life begins was virtually general among
physicians, and has since remained the doctrine of physicists. Modern
discoveries by biologists have confirmed the fact that human life
exists in the impregnated ovum exactly as it does in all stages of
life, and no scientist holds any other opinion. There are, however,
a few moralists at the present day who incline to the old Thomistic
doctrine or to modifications of it.

  [26] Tom. ii, lib. ix, tr. 1.

St. Alphonsus Liguori[27] was a follower of the Thomistic opinion.
He affirmed: "They are wrong that say the fetus is animated at the
instant of conception, because the fetus certainly is not animated
before it is formed, as is proved from Exod. xxi: 22, where in the
Septuagint version we find: 'He that strikes a gravid woman and
causes abortion, will give life for life if the child was formed;
if it was not formed, he will be fined.'" This argument by St.
Alphonsus is invalid apart from any facts that may bear upon either
the Thomistic or the modern opinion concerning the quickening of
the fetus. The text from the Septuagint Exodus is (1) too doubtful
in itself to be the basis of any argument; but (2) even if it were
authentic just as it stands, the conclusion St. Alphonsus draws from
it is not warranted by the premises. The Septuagint text differs
from the Vulgate and the Hebrew texts. The Vulgate has it thus: "Si
rixati fuerint viri et percusserit quis mulierem praegnantem, et
abortum quidem fercerit, sed ipsa vixerit, subjacebit damno quantum
maritus mulieris expetierit et arbitri judicaverint; sin autem mors
fuerit subsecuta, reddit animam pro anima, oculum pro oculo, dentem
pro dente, manum pro manu, pedem pro pede, adustionem pro adustione,
vulnus pro vulnere, livorem pro livore."[28] This version has nothing
whatever to say about the _foetus formatus_ or _non formatus_; it is
merely an application of the Semitic Lex Talionis, and the form of
the law is clearly corrupt and inaccurate.

  [27] _Theologia Moralis_, lib. iv, tr. 4, n. 594.

  [28] If men quarrel, and one strike a woman with child, and she
  miscarry indeed, but live herself, he shall be answerable for so
  much damage as the woman's husband shall require and as arbiters
  shall award. But if her death ensue thereupon, he shall render
  life for life, eye for eye, tooth for tooth, hand for hand, foot
  for foot, burning for burning, wound for wound, stripe for stripe.

The passage quoted by St. Alphonsus as that of the Septuagint is not
exact even as the Septuagint has it. The full text is: "If two men
fight, and one strike a woman that hath [a child] in the womb, and
her babe come forth not yet fully formed,[29] in a fine he shall
be mulcted; whatsoever the husband layeth upon him he shall give
according to decision [_i.e._, of the judges]. But if it [the babe]
be fully formed he will give life for life, eye for eye, tooth for
tooth, hand for hand, foot for foot, burning for burning, wound for
wound, stripe for stripe."

  [29] καὶ ἐξέλθη παιδίον αὐτῆσ μὴ ἐξεικονισμένον--not moulded out
  into form; ἐξεικονίζειν, to mould out into form: εἰκων, an icon,
  image, likeness.

This is (1) evidently nothing but an application of the Lex Talionis,
with no thought whatever of the biological animation, as such, of
the fetus. It means that if a fully formed fetus be aborted, either
no real damage is done, as such a child is viable; or the formed
child may be maimed, and then the Lex Talionis is to be applied. If
the fetus is not fully formed it is not a fit subject of the Lex
Talionis since it cannot lose an eye, a tooth, and so on, because it
lacks these organs and therefore the law of retaliation is not to be
enforced.

(2) Suppose, however, the writer of the text as the Septuagint has
it did think with St. Alphonsus that the formed fetus is animated,
and the unformed is not animated, even then the conclusion drawn
by St. Alphonsus is not warranted by the text. The laws of Exodus
do not teach embryology, physiology, or any other part of physical
science; and no authority worth a hearing holds that the Scriptures
were intended to be infallible treatises on obstetrics or astronomy.
Like the other parts of the Bible, the laws of Exodus presuppose the
unscientific biological, astronomical, and other physical notions of
the time in which they were written--the moral truth is the matter
the Scripture is dealing with; there no inaccuracy is to be found.
St. John (1:13) speaks of those who believe in Christ's name, "Qui
non _ex sanguinibus_, neque ex voluntate carnis, neque ex voluntate
viri, sed ex Deo nati sunt." Here he expresses the contemporary
notion, which is also the Thomistic opinion, that men are generated
from the specialized blood of their parents. He was interested
solely in conveying the truth that those who received Christ were
regenerated by him, not through heredity; and he does so, although
the biology is inexact. If St. Alphonsus's conclusion is valid as
from the text of Exodus, then men are generated _ex sanguinibus_, and
so on indefinitely.

The Massoretic text of this passage seems to be the best preserved:
"If men fight, and one hurt a woman who is with child, and her child
come forth, yet there is no mischief, he [who struck her] shall be
mulcted in a fine; whatsoever the husband of the woman layeth upon
him he shall pay according to the judges. But if there be mischief,
then he shall give life for life, eye for eye, tooth for tooth, hand
for hand, foot for foot, burning for burning, wound for wound, stripe
for stripe." Here the Hebrew text follows the Lex Talionis exactly.
If, in a brawl, a man's pregnant wife is struck and abortion results,
the offender pays the penalty. If the abortion does not kill or maim
the child, the culprit is fined by the Sanhedrim; if the child is
killed or maimed, then the penalty is according to the Lex Talionis.
In the Hebrew text also there is no mention of a distinction between
a _foetus formatus_ and _non formatus_.

Whether the fetus is animated at conception or some time later,
there is no foundation whatever for the notion that the female is
quickened later than the male. As was said before, Aristotle held
that the human male fetus is animated at the fortieth day, the female
at the ninetieth day, and the old moralists accepted his statement.
At the fortieth day, however, no one can differentiate sex unless
the microscope is used, and this particular use of the microscope is
altogether modern--the knowledge requisite for such use was not in
existence sixty years ago. At the twentieth day, with the microscope
and a stained specimen, a biologist can recognize whether the
primordial ova are present or absent and thus determine sex. Only at
the eighty-fourth day can sex now be differentiated without the aid
of the microscope, but then the embryo must be dissected: nothing can
be told from its external appearance. Sex can first be distinguished
by the external appearance only at about the one hundred and twelfth
day, the end of the fourth month of gestation. Therefore when
Aristotle said the male fetus is animated at the fortieth day, and
the female at the eightieth or ninetieth day, he was romancing.

The question, then, narrows to this: Is any human fetus animated
immediately at conception, or from forty to eighty days after
conception? The reason given by the followers of Aristotle for
deferring animation is that the vital principle requires organs in
the receptive material, but the embryo in the early stages, they say,
lacks these organs. This notion, however, as to the lack of organs
is altogether erroneous, and the rational soul enters the embryo
in the oval stage, immediately after the pronuclei unite: there is
organization in that stage of human life sufficient to receive the
substantial form or soul. We do not know how long after insemination
the pronuclei unite, but the proposition here is that as soon as
they unite the human soul enters. Fecundation usually occurs after a
menstruation, but not necessarily so; the spermatozoön may live in
the tube for seventeen days awaiting the ovum.

The human body is made up of billions of microscopic living cells,
all of which are derived by fission and differentiation from the
two original single germ-cells, the ovum and the spermatozoön.
Some nerve-cells have long processes running along the white
fibres through the entire length of the body, but they cannot be
differentiated except by the microscope. In the body are also
various liquids which are not cellular, as water, saliva, tears,
urine, blood and lymph plasma, and the gastric, intestinal, and
glandular juices, and these are secreted or excreted by the somatic
cells. The cells assimilate nutritive material carried to them by
the blood, excrete refuse substances, secrete glandular products,
and are the media for all human operations below certain acts of the
intellect.

A typical animal cell is commonly spherical in shape, but it
may take a great variety of forms through compression. It has a
cell-body or protoplasm, which is called also cytoplasm, especially
when contrasted with the nuclear karyoplasm, and a nucleus. A few
cells, like fat-cells and the human ovum, have an external covering
membrane, or cell-wall. There is a part called the Centrosome
observable in many cells, and this is made up of one or two minute
dots surrounded by a radiating aster called the Attraction-Sphere.
The centrosome is concerned in the process of cell-division and
in the fertilization of the ovum; it is an important organ in the
production of cell from cell, though its full nature and function
are not yet known. The Plastid, or Protoplast, is another less
important part found in certain cells; and in this by enlargement
and differentiation are formed starch, pigment, and in some cases
chlorophyl. Vacuoles are seen in cells; and there is an opinion that
these may be a special kind of plastid: some vacuoles pulsate.

The Nucleus is the most important part of a cell, the centre of
its activity. The specific qualities of organism in origin and
development are based upon nuclei, so far as the material element
of the living cells is concerned. Vital stimuli pass through the
nucleus into the surrounding protoplasm, and these stimuli control
metabolism. The nutritive cytoplasm assimilates, but the vital
principle energizes this assimilation through the nucleus, for a
part of a cell deprived of the nucleus may live for a time, but it
cannot repair itself. Constructive metabolism ceases when the nucleus
is lost. A toxic disease like diphtheria kills by disintegrating
cellular nuclei.

In the nucleus are several elements, the chief among which is
Chromatin. Chromatin takes various forms, but commonly it is an
irregular network. From the chromatin are derived the Chromosomes
in the prophases of indirect cell-division which is the process of
cell-division in the human body, except in lymph-cells and white
blood-corpuscles, which split directly, or by Amitosis. Indirect
cell-division is called Mitosis or Karyokinesis. In the male and
female chromosomes, according to a common opinion of biologists,
all the elements of parental and phyletic physical heredity are
transmitted to the embryo.

[Illustration: Fig. I

A CELL.

Throughout the Cytoplasm is a mesh containing numerous minute
granules called Microsomes.]

The production of cell from cell is accomplished either by direct
splitting of the nucleus and cytoplasm into two new cells, or by
indirect division through a series of stages. In a typical direct,
or amitotic, division the nucleus is constricted in the middle
and divides into two daughter-nuclei. These by amoeboid movements
withdraw to the poles of the cell; the cell finally divides between
them, and thus two cells are formed. These, again, split into four,
the four into eight, and so on. An amoeba by direct division can
separate into two distinct new animals in ten minutes.

Heredity here is simple. In unicellular organisms, such as Rhizopoda
and Infusoria, each individual grows to a certain stage, and
then divides into two parts, which are exactly alike in size and
structure, so that it is not possible to decide whether one is older
or younger than the other. These organisms reduce the size of their
overgrown bodies by division. Each individual of any such unicellular
species is a part split off serially from an organism which started
into life ages ago. Some of them have come down in uninterrupted
life from geological epochs that passed away eons before the first
man was created. Many of these unicellular plants and animals have
immeasurably the most ancient form of life on earth. Heredity with
them depends upon the fact that each offspring is merely half of its
parent. In some cases the division has a sexual quality: two cells in
_Paramecium_, and, like Infusoria fuse and then divide if they come
into contact; they can, however, split without this sexual process.

Multicellular plants and animals do not reproduce by simple division,
and the half of the parental body does not pass over into the
progeny. Sexual reproduction is the chief means of multiplication in
multicellular organisms, and in no case is it completely wanting; in
most it is the only method of reproduction. In multicellular animals
the power of reproduction is in the germ-cells, which differ from
the somatic cells. Germ-cells do not maintain individual life as
the body-cells do, but the germ-cells alone preserve the species.
From two of these germ-cells under certain conditions is developed a
complete bodily organism of the same species as the parents. These
two cells are in a sense the undying cells; the somatic cells die.

Multicellular animals--Man, for example--grow embryologically by
Mitosis or Indirect Division. As in Direct Division, typically,
the nucleus in mitosis splits first and the cytoplasm secondly;
but before the nucleus divides its content undergoes a series of
changes. The chromatin loses its reticular arrangement and gives
rise to a definite number of separate bodies, usually rod-shaped,
known as Chromosomes. In this process the chromatin becomes a
convoluted thread, called the Skein or Spireme. The thread thickens
and opens out somewhat, and finally breaks transversely to form
the chromosomes, which may be rods, straight, curved, ovoid, and
sometimes annular. Commonly the nuclear material fades away and
leaves the chromosomes in the cell-plasm. (Fig. II, 2 and 3.)

[Illustration: Fig. II

DIAGRAM OF MITOSIS.

1. Cell with resting Nucleus. 2. Prophase: Chromatin in
thickened convoluted threads, beginning of Spindle. 3. Prophase:
Chromosomes. 4. Prophase: Spindle in long axis of the Nucleus,
Chromosomes dividing. 5. Anaphase: Chromosomes moving toward
the Centrosomes. 6. Chromosomes at the poles forming the
Diaster, beginning splitting of the Cell-body. 7. Telophase,
Daughter-Nuclei returning to resting state. 8. Daughter-Nuclei
showing Monaster below. 9. The two new Cells.]

It is almost an established fact that each species of animal and
plant has a fixed and characteristic number of chromosomes, which
regularly recurs in the division of all its cells. In forms arising
by sexual production the number is even. The number of chromosomes
in the human cell is said to be forty-eight. There are, according
to some observers, forty-seven chromosomes in man and forty-eight in
woman. There seem to be twice as many chromosomes in white men as
in negroes. Wilson gives the number[30] of specific chromosomes for
seventy-four animals and plants. Germ-cells as differentiated from
the somatic cells have in the perfected cell always half the number
of chromosomes found in a somatic cell.

  [30] _The Cell in Development and Inheritance_, p. 207.

While these changes are going on in the chromatin the Amphiaster
forms. This consists of a fibrous spindle-shaped body, the Spindle,
at either pole of which is an Aster made up of rays. In the centre of
each aster is a Centrosome, and this may have a Centrosphere about
it. As the amphiaster grows the centrosomes are grouped in a plane at
the equator of the spindle, forming the Equatorial Plate. (Fig. II,
No. 4.) The process so far makes up the Prophases of the Mitosis.

In the Metaphases of the Karyokinesis begins the actual division of
the cell. Each chromosome splits lengthwise into exactly similar
halves, and these, in the Anaphases of the mitosis, drift out to the
opposite poles of the spindle to form the daughter-nuclei of the new
cells. The daughter-nuclei receive precisely equivalent portions of
chromatin from the mother-nucleus, and this is an important fact in
mitosis. As the chromosomes go toward the poles the cell-body begins
to constrict at the equator.

In the final phases, the Telophases, the cell divides in a plane
passing through the equator of the spindle, and each daughter-cell
receives half the chromosomes, half the spindle, and one of the
asters with its centrosome. A daughter-nucleus is reconstructed
in each cell from the chromosomes. The aster commonly disappears
and the centrosome persists, usually outside the new nucleus, but
sometimes within it. Every phase of mitosis is subject to variation
in different kinds of cells, but the outline of the division given
here is the fundamental method.

The germ-cells differ from the body-cells in general by containing
half the number of chromosomes characteristic of a given animal
or plant. If the body-cell has, say, twenty-four chromosomes, the
spermatozoön of the animal or plant from which the cells are taken
will have twelve chromosomes and the ovum will have twelve. When
the nuclei of these two cells unite in fertilization the resulting
primordial cell will have the twenty-four chromosomes restored,
the specific number for this plant or animal. In oögenesis and
spermatogenesis the phases of "Reduction," wherein the ovum and
spermatozoön get rid of half the chromosomes during the stages of
maturation of these germ-cells, are somewhat similar for both sexes.
The process is very complicated, but it is of importance in the
theories of inheritance. All the physical characteristics in a human
being that come to him from his parents and remoter ancestors are
supposed, by the biologists, to reach him through the chromosomes in
the nuclei of the single parental germ-cells. The maternal physical
heredity is handed on through the chromosomes in the ovum. The fetus
in the womb is a parasite, autocentric, feeding at the start from
the deutoplasm, or yolk, in the ovum, and later from the supplies
brought to it by the maternal blood. The physical material it gets
directly from the mother is very probably all in the chromosomes
of the fecundated ovum. Some weeks elapse, and the embryo is quite
advanced before it begins to draw food from the mother at all. So far
as the father is concerned, there is no doubt whatever that every
physical and pathological characteristic that can be handed down--and
there are many such qualities--must come through the chromosomes
of the paternal spermatozoön. Certain physical characteristics
are passed on for centuries in a family--the Norseman's body in
northeastern Ireland, the skin-pigment in the American negro, and so
on indefinitely--and these qualities cannot come down except through
the chromosomes. The germ-plasm has come to us from the first man,
and it will be passed on to the last person of the race--we are all
literally uterine brothers.

In the reduction of the germ-cells, if the primordial cell that
finally produces the ovum has, say, four chromosomes, these four
chromosomes first split longitudinally and reduce into two tetrads,
or two groups of four chromosomes. Outside the nucleus is a spindle
toward which the two tetrads move; they pass out of the nucleus and
become the equatorial plane of the spindle; each tetrad divides into
dyads (pairs of chromosomes), and one pair of these dyads remains in
the ovum, while the other pair leaves the ovum entirely and becomes
the nucleus of an abortive cell, called the First Polar Body. Later
a second polar body forms and carries another dyad (two chromosomes)
out of the ovum, leaving only one dyad, or two chromosomes, in the
germ-cells; that is, half the number of chromosomes that were in the
primordial cell.

The reduction-division in spermatozoa is similar, but the end process
leaves four active spermatozoa, whereas in the ovum the final
result is one ovum and three practically inert and cast-off polar
bodies. The reduction-division in both ovum and spermatozoön is in
reality far more complicated than the broad summary given here. In
parthenogenetic insects and animals a polar body takes the place of
the spermatozoön, and fuses with the egg-nucleus to start mitosis.

In general, the new nuclei in the cells formed by division are not
made _de novo_, but arise from the splitting of the nucleus in the
mother-cell. The new nucleus assimilates material, grows to maturity,
and divides again into two daughter-nuclei. Whatever be the number
of chromosomes that enter a new nucleus as it forms, the same number
issues from it in mitosis. Boveri said,[31] "We may identify every
chromatic element arising from a resting nucleus with a definite
element that enters into the formation of that nucleus, from which
the remarkable conclusion follows that in all cells derived in the
regular course of division from the fertilized egg, one half of
the chromosomes are of strictly paternal origin, the other half of
maternal." It is not strictly true to say that the germ-nuclei fuse:
they send in two sets of chromosomes that lie side by side, as has
been frequently demonstrated since 1892[32] in many of the lower
forms of life, and this law almost certainly extends also to man.

  [31] _Jenaische Zeitschrift_, 1891, p. 410.

  [32] See Wilson, _op. cit._, p. 299.

The primordial germ-cells appear in the human fetus about the
twentieth day and finally mature at puberty. Then an ovum at
menstruation breaks out through the surface of the ovary, and is
taken by the fimbriae of the Fallopian tube into the lumen of this
tube. Fecundation happens near the outer or ovarian end of the
Fallopian tube, and the fecundated ovum finally is passed on to
fasten on the wall of the uterus. The spermatozoön is a ciliated cell
with the power of locomotion, through the movement of the tail of the
cell. It can move 0.05 to 0.06 mm., or its own length, in a second.
It thus passes up through the uterus and out through the Fallopian
tube, against the cilary motion of the tubal cells, until it meets
the ovum.

A human ovum is a typical cell, but it has a covering membrane, and
a minute quantity of deutoplasm or yolk, which is not alive, and
is food for the growing embryo before the embryo begins to draw
sustenance through the placenta. The eggs of birds have a large
quantity of food stored in the yolk, since their embryos live in
the ovum and draw food therefrom during the entire period which
corresponds to the time of gestation in mammals. The "white" and the
calcareous shell of a hen's egg are adventitious parts, added in the
oviduct after the egg leaves the ovary.

The spermatozoön is a complicated organism. The head is partly
covered with a thin protoplasmic cap, and it contains the nucleus
with the chromatin. In the neck are two centrosomes. The tail
is in three parts with an axial filament throughout, which is a
bundle of extremely minute fibrils. In the middle part the axial
filament is surrounded by an inner sheath; outside this sheath
is a spiral filament lying in a clear substance; and outside the
spiral filament is a finely granular layer of protoplasm, called the
Mitochondria. This organism is a living animal cell, and it can live
in an incubator, or in the Fallopian tube for two or three weeks,
altogether removed from the living male body that produced it. Sir
John Lubbock[33] says he kept a queen ant alive for thirteen years.
This ant, which died in 1888, had been fertilized in 1874, and never
afterward. She laid fertile eggs for thirteen years; that is, the
spermatozoa in her oviduct retained their vitality for thirteen years.

  [33] _Journal of the Linnean Society_, vol. xx, p. 133.

The human spermatozoön is a living cell: it has (1) the requisite
structure; (2) the chemical composition of an organic being;
(3) a figure in keeping with its species; (4) an origin from a
living progenitor; (5) the _explicatio naturae_; (6) the power
of assimilation; (7) the _duratio viventium_; (8) the power of
reproduction; (9) motion and locomotion. As soon as the ovum breaks
through the surface of the ovary it has all the qualities of the
spermatozoön except locomotion. These two cells are animal cells,
not vegetable; just as single-celled protozoa, like Actinophrys,
Actinosphaerium, Closterium, Stentor, and the Amoebas are animals,
not plants. It is not possible in our present knowledge sharply to
differentiate ultimate forms of plants from animals. To say that
animals have the qualities of plants plus a sentient vital principle
is not enough. It is very doubtful that even the so-called sensitive
plants feel, and it is practically certain that many low forms of
animal life do not feel--they have no sentient mechanism. Plants have
the qualities enumerated above plus the power of drawing nutriment
directly from inorganic material, while animals can draw nutriment
directly only from organic material; yet some fungi, bacteria
for example, will grow and thrive only on organic material, and
animals will take up mineral drugs. It is questionable, however,
that minerals which thus find a way into animal cells are really
assimilated. They excite or irritate these cells into intenser
action, and thus cause growth, rather than affect development by
direction. The so-called mineral tonics used in medicine act by
irritation.

This irritation or stimulation by drugs can in certain very low forms
of animal life start mitosis in the unfertilized ovum, and thus build
up part, at the least, of a specific embryo parthenogenetically:
here probably a polar body takes the place of the spermatozoön.
Loeb, by treating the unfertilized egg of Arbacia (a sea-urchin) with
magnesium chloride, started mitosis that resulted, it is said, in a
perfect Pluteus larva.[34]

  [34] _American Journal of Physiology_, 1899, iii, 3.

The human ovum is about half the size of a period in the type of this
page, and two hundred and fifty spermatozoa will fit side by side
along the horizontal diameter of the lowercase letter _o_ here. The
nuclei of these cells are extremely minute: they must be stained and
be observed with a high-power objective on the microscope before they
become visible. This small nucleus of the spermatozoön penetrates
the covering membrane of the ovum, enlarges, and becomes the male
pronucleus. The pronucleus unites permanently with the pronucleus of
the ovum, and together they form the Cleavage or Segmentation Nucleus
of the fertilized ovum. This new nucleus gives rise by division to
the innumerable myriads of nuclei in the growing body. Hence every
nucleus of the child apparently contains nuclear material derived
from both parents, as has been said.

The two perfected germ-cells before fecundation are in a state of
nuclear rest after the numerous mitotic changes that have taken
place in the maturation of these cells. When these nuclei unite in
the ovum an intense activity at once is set up. Biologists offer
very many theories to explain this awakening force. Herbert Spencer,
Herting, and others held that protoplasm when perfected tends to
pass into a state of stable equilibrium and consequent lessened
activity, but fertilization restores it to a labile state. This and
similar theories are verbose amplifications of the obvious fact that
the cells start to divide and the biologists do not know the cause.
The soul, of course, cannot have anything to do with the matter,
because you cannot smell a soul. "Senescence and rejuvenescence" is
another sonorous explanation that does not explain, used by Minot,
Engelmann, and Hansen. Weismann rejects these theories for his own
"Fertilization as a Source of Variation." Anyhow, the fertilized cell
starts to divide regardless of the biologists. Adult cells may be
stimulated to divide by chemical irritation, by mechanical pressure
as in the formation of calluses, traumatism, by any agency that
brings about an abnormal condition of the body, but this fact does
not explain the normal fission of the fecundated ovum.

In about fifteen days from the date of fertilization the ovum passes
through the following stages:

1. The ovum, with a full series of mitotic changes of the ordinary
somatic type described above, divides, subdivides, and grows within
the cell-wall until a rounded mass of cells is formed, which is
called the Morula or Blastula--the original cell-wall, of course,
stretches to hold these new cells. They are of unequal size, and they
divide at unequal rates.

2. An albuminous fluid collects within the morula, and thus the
Vesicle or Blastocyst is formed. The blastocyst is called more
commonly the Cleavage Cavity or the Segmentation Cavity. As this
cavity widens the cells are seen to be arranged in two groups--(_a_)
an enveloping layer, the epiblast, from the outermost plate of which
develops later the Trophoblast, or the nourishing and protecting
covering of the embryo; (_b_) an Inner Cell Mass, made up of granular
cells, attached to the epiblastic layer at the Embryonic Pole of the
Vesicle. These two stages probably take place in the Fallopian tube,
and thereafter the embryo is in the cavity of the uterus.

3. In the third stage the Inner Cell-Mass separates into two layers
derived from the inner cell-plate of the blastula. The mass flattens
and spreads peripherally, until finally it is divided into two
layers. The outer is the Ectoderm and the inner is the Endoderm or
Hypoblast. The three steps just described have not yet been seen in
the human species by any one, but they are inferred very confidently
from what is well known of the development in mammals most closely
resembling man in physical formation.

4. By the conversion of the one-layered blastula into two layers of
cells, the Gastrula stage of the embryo is attained. The Gastrula
consists of two layers of cells surrounding a central cavity, which
is the Archenteron, or the body-cavity that will hold the intestines.
During the past twelve years many specimens of human gastrulas have
been observed. The earliest form was that seen in 1908 by Teacher
and Boyce.[35] This embryo was 1.95 mm. in length by 0.95 mm. in
width, about twice the size of a pin-head. It showed on section the
endoderm, the ectoderm, and the beginning mesoderm, enclosed in a
spherical mass of trophoblastic cells. The mesoderm is a plate of
cells lying between the endodermic and ectodermic plates. When the
mesoderm develops into two plates, a cavity, called the Primitive
Coelom, appears between the plates. The Coelom becomes the space
between the viscera and the body-walls in later development.

  [35] _Contributions to the Study of the Early Development and
  Embedding of the Human Embryo._ Glasgow, 1911.

From the primary embryonic layers of cells, the ectoderm, the
endoderm, and mesoderm, all the parts of the body are built up. From
the ectoderm are produced the skin, nails, hair, the epithelium of
the sebaceous, sweat, and mammary glands, the epithelium of the mouth
and salivary glands, the teeth-enamel, the epithelium of the nasal
tract, of the ear, of the front of the eye, and the whole spinal cord
and the brain, with their outgrowths.

From the endoderm come the epithelium of the respiratory tract,
of most of the digestive tract with the liver and pancreas, the
epithelium of the thyroid body, the bladder, and other minor parts.

From the mesoderm are developed bone, dentine, cartilage, lymph,
blood, fibrous and alveolar tissues, muscles, all endothelial cells,
as of joint-cavities, blood-vessels, the pleura and peritoneum, the
spleen, kidneys and ureters, and the reproductive bodies.

The epiblast now with its mesoblastic lining begins to form the
Chorion, an embryonic intrauterine appendage; and the endoderm
encloses the Archenteron or primitive gut. Before the end of the
second week of gestation the heart is indicated as two tubes in the
mesoderm, and the blood-vessels begin to be produced in the yolk-sac.
About the twelfth day the mouth-pit shows, and the gut-tract is
partly separated from the yolk-sac. The medullary plate of the
nervous system is laid down about the fourteenth day, and the nasal
area is observable. The maternal blood escapes into spaces about
the embryo enclosed by masses of embryonic cells, which have not
separated from one another, but which are known collectively as
Syncytium.

5. With the third week the stage of the embryo, technically so
called, begins. During this week the body of the embryo is indicated.
There are three layers of cells, already mentioned, the ectoderm,
mesoderm, and endoderm, and these lie on the floor of the enveloping
Amnion. The amnion is a loose fluid-filled sac (the caul) enveloping
the fetus to protect it from jarring. The fluid in it is the "waters"
that escape in parturition when the infant breaks through the caul.
The archenteron in the third week shows the beginning of a division
into two parts: the part that will go to the body proper of the
embryo, and the part outside the body of the embryo which will form
the yolk-sac, or umbilical vesicle, from which the embryo will draw
sustenance until the placental vessels have been formed. The part of
the archenteron that remains within the embryo proper begins in this
third week to be moulded into the head-cavity. The forepart of the
archenteron will later make the alimentary tract from the mouth to
the middle of the duodenum, or small intestine beyond the stomach.
The other part of the archenteron wall make the Allantois, the hind
gut and the bladder. The allantois becomes a part of the fetal
umbilical cord after the formation of the placenta.

During this third week the dorsal outline of the embryo is concave;
the heart has a single cavity, which will begin to divide during
the fourth week; the vitelline blood circulation begins, and the
blood-vessels of the visceral arch are laid down. The digestive
system is advanced to a gut-tract, which is a straight tube connected
with the yolk-sac. The liver evagination is present and the oral
pit is a five-sided fossa. The respiratory system is represented by
the _anlage_ of the lungs, a longitudinal protrusion of the ventral
wall of the esophagus. The genito-urinary system begins as the
Wolffian bodies. The mesoderm starts to segment to form the skin,
and the neural canal (from which develop the spinal cord and brain)
for the nervous system forms. The fourth ventricle of the brain is
indicated, and the vesicles of the fore brain, mid brain, and hind
brain are recognizable. The ears, nose, and eyes, muscular system,
skeleton, and limbs are also beginning to be recognizable. At about
the sixteenth or eighteenth day of gestation the various parts of the
embryo rapidly differentiate.

In the fourth week all these parts advance. The atrium cavity of
the heart begins to divide; the alimentary tract shows the pharynx
and esophagus, stomach, and gut; the pancreas starts, the liver
diverticulum divides, and the bile-ducts appear. The lung _anlage_
bifurcates and the primitive trachea is seen. The ventral roots
of the spinal nerves appear, the interior ear is indicated, and
the eye is deeper. The buds of the legs and arms appear about the
twenty-first day--by the thirty-second day even the fingers are
present. The four heart-cavities are formed, the intestinal canal is
nearly closed, the first indications of the liver and kidneys appear.
The child now has reached the fetal stage, and its living body is
made up of myriads of cells all derived from the original fertilized
ovum. The fetus is then one centimetre, or two-fifths of an inch, in
length--about the length of the word "fetus" here.

At the end of the second month the fetus is two and a half
centimetres long. The ears appear, and the tail-like process at the
lower end of the spine disappears. The arms show the three parts,
arm, forearm, and hand; and a little later the thigh, leg, and foot
are differentiated. The navel begins to close, the liver develops,
the abdomen is yet partly open.

At the end of the third lunar month the fetus is seven to nine
centimetres long. The intestinal canal is formed and contains
bile. The body resembles that of a human being, but the head is
proportionately very large. Bony tissue begins to appear.

[Illustration: FIG. III.

The Development of the Fetus.]

At the end of the fourth lunar month the fetus is ten to seventeen
centimetres long. Some muscles are movable. The heart-beat is strong.
Sex is distinguishable externally. The skin is bright red, and so
transparent that the blood-vessels are visible through it.

Toward the close of the fifth lunar month the head is about the size
of a hen's egg. The skin is somewhat less transparent. There are
indications of hair and nails. The eyelids are closed. Parts of the
brain and spinal cord are formed. Such a fetus may live for five or
ten minutes if removed from the womb, and it may make attempts at
respiration.

At the end of the sixth lunar month the fetus, if born, may live
for several hours under favorable circumstances. Its respiratory,
digestive, and related organs are not developed, and no artificial
feeding will keep such a child alive. The brain cortex, the organ of
consciousness, begins to laminate into three strata of nerve-cells at
the beginning of the sixth month.

Here the time of fetal viability outside the womb may be considered.
Langstein, of the Augusta Victoria Hospital in Berlin, reported[36]
a study of the growth and nutrition of 250 prematurely born infants,
and he found that a weight of 1000 grammes (2-1/5 pounds) and a full
body length of 34 centimetres (13-3/5 inches) are the lowest limits
for viability under proper circumstances. A fetus 1000 grammes in
weight and 34 centimetres in length has completed the sixth solar
month, or the sixth and a half lunar month; that is, it is viable at
the _beginning_ of its seventh month, _servatis servandis_.

  [36] _Berliner klinische Wochenschrift_, June 14, 1915.

The child at term, as a rough average, is from 48 to 52 centimetres
(19 to 20-1/2 inches) in length, and it weighs from about 6-3/5 to
7-1/2 pounds. It is impossible, however, to obtain the sizes and
weights of infants _in utero_ with scientific accuracy, because the
date of conception cannot be determined with absolute certainty, and
individual fetuses vary as do infants after birth. A full-term infant
sometimes may weigh only 3-1/2 pounds when the mother is diseased,
and again an eight-month fetus will weigh as much as 8 pounds. Large
muscular and fat women have large babies; women of the well-to-do
classes have larger babies than do the poor; women who work during
gestation bear smaller babies than do those women that rest. Mothers
who work in tobacco, lead, or phosphorus have puny babies; white
children are larger at birth than negro children; boys at term are 3
to 5 ounces heavier than girls.

Langstein says that prematurely born infants weighing from 900
grammes (31-1/2 ounces) to 1500 grammes (3-1/2 pounds)--that is,
all born before the seventh solar month--must be kept in hot-water
incubators in a room with ordinary ventilation. Babies weighing 2000
grammes (4-1/2 pounds) or more get along in an ordinary crib if they
are kept surrounded with hot-water bags. Such children are to be fed
with human milk through a catheter passed into the mouth or they
die of inanition. Only a few of them are strong enough to suck from
a bottle, and these give up the effort after a few days and die.
They cannot utilize fat, even from milk; and all artificial food is
dangerous.

Most of the prematurely born become rachitic, and even human milk
is not preventive of this condition. Rachitis is a constitutional
disease, characterized by impaired nutrition of the bones and
changes in their shape. In the third or fourth month craniotabes is
frequent--that is, an atrophy of the skull bones with the formation
of small conical pits. These infants show also a morbid tendency
to convulsions--spasmophilia. Such diseases are caused by a lack
of mineral salts, which normally are carried to the fetus by the
placental blood during the last two months of gestation. Because of
this lack premature infants require the administration of lime salts
in their food; they also need iron because they are anemic.

A fetus, then, of six calendar, or solar, months (not lunar) is
viable if treated in a hospital by competent physicians. Otherwise
it is not viable, except in a strictly technical sense; it will not
live more than a few days or weeks. Reports of infants younger than
six months as having been successfully reared are not credible--it is
easy to make an error in the reckoning.

A full seven-months infant may be reared with proper feeding and
skilled care; a six-months infant may be reared (with difficulty) in
a hospital with skilled care. If it is certain that the removal of a
six-months fetus will here and now save the life of a mother (a very
difficult matter to judge by the best diagnosticians), this removal
may be done, provided the infant is delivered in circumstances where
skilled care, incubator, and proper food are obtainable; otherwise
the removal is not justifiable. That the ordinary physician says it
is necessary to empty the uterus is not a sufficient reason, as he is
likely to act from ill-digested information set forth by professorial
pagans, who place no value whatever on human life in an infant.

A most important and essential circumstance in the matter of
inducing abortion at the end of the sixth month of gestation to
save a mother's life is that in practically every case requiring
such interference the diseased condition of the mother has checked
the growth of the fetus, and the fetus therefore is really not a
six-months child in development. Such an undeveloped fetus is not
viable. Eclamptic women, and those who have nephritis, are most
likely to have undeveloped fetuses. In cases of this kind the seventh
month should be completed before interference.

How is this human body in all its complexity developed from the
microscopic germ-cells? There has been a vast deal of ink spilled in
striving to solve this mystery, but we come out empty by the same
door wherein we went. The early Preformationists guessed that the
ovum contains an embryo fully formed in miniature, and development
is a mere unfolding of what had already existed. The biologists of
to-day mention the Preformationists with superior scorn, and then
present Preformationism under other names. Weismann's theory is the
most fashionable at present.

In a paper read at the Darwinian Memorial Congress in 1909, Weismann
said: "With others I regard the minimal amount of substance which
is contained within the nucleus of the germ-cells in the form of
rods, bands, or granules, as the _germ-substance_, or _germ-plasm_,
and I call the individual granules[37] _ids_. There is always a
multiplicity of such _ids_ present in the nucleus, either occurring
individually or united in the forms of rods and bands (chromosomes).
Each _id_ contains the primary constituents of the _whole_
individual, so that several _ids_ are concerned in the development
of a new individual." Actually there are such things as chromosomes,
and when these are stained and are under the highest power of the
microscope they appear to be granular. These granules Weismann calls
_ids_. Beyond the fact that there are such granules, all else is
sheer guessing.

  [37] _Id_ is a word derived from Nägeli's term idioplasm, which
  means the chromosome granule.

He says further: "In every complex structure thousands of primary
constituents must go to make up a single _id_; these I call
_determinants_, and I mean by this name very small individual
particles, far beyond the limit of microscopic visibility, vital
units, which feed, grow, and multiply by division. These determinants
control the parts of the developing embryo,--in what manner need not
here concern us."

There is some truth here. The _id_ is made up of molecules and atoms,
ions and electrons, and in some manner, of course, these have to do
with the development of the embryo; but as to the manner we have not
the slightest knowledge, and just this knowledge is what we need
to make the theory anything more dignified than a child's game at
guessing. There is a structural differentiation in the unsegmented
ovum, with all the embryonal axes foreshadowed in it, but this tells
us nothing more than that the egg contains the man in germ.

He goes on: "The determinants differ among themselves; those of a
muscle are differently constituted from those of a nerve-cell or a
glandular cell, etc., and each determinant is in its turn made up of
minute vital units, which I call _biophors_, or the bearers of life."

That these so-called determinants differ among themselves may be
true, if they exist at all, which is just the point to be proved.
Giving Greek names to inventions does not turn invention into fact.
These supposed determinants, he says, "may vary quantitatively if
the elements of which they are composed vary; they ... and their
variations may give rise to _corresponding_ variations of the organ,
cell, or cell-group which they determine." Professor Dwight said:[38]
"This is what is palmed off on us for science!" Weismann assures us
we _must_ admit this farrago of clumsy fiction, otherwise we should
be forced "to assume the help of a principle of design."[39] In the
name of common sense, then, admit a principle of design, and be done
with it!

  [38] _Thoughts of a Catholic Anatomist_, p. 48.

  [39] _Contemporary Review_, September, 1893.

Darwin's Gemmule Theory is the same guessing; and Weismann rejects it
because he did not think of it first. As a theory the gemmule plot
is just as good and just as bad scientifically as Weismann's. The
chief objection to such imagining is that after its authors have put
it into print a few times they lose all sense of humor, and mistake
phantasms for facts.

Up to the present time we have discovered no living organism lower in
grade than the cell. If life ever originated from inorganic matter,
it appeared in an organized cell. The Weismann ids, biophors, and
the rest, supposing they existed outside his own imagination, are
not more capable of independent life than is a chromatin granule. In
any event, these biophors could not have originated spontaneously
in the first living being; and if they could not so have come into
existence, life could never have begun. However primitive any
organism is, it must be able to nourish itself and to develop into
a higher specific form; but such a variety of functions supposes
differentiated structure, composed of unstable chemical substances,
a correlation of parts, a purposeful anticipation of ends. Inorganic
substances, crystals, and the like are characteristically stable,
not unstable; and these could not have been brought into the organic
state on an earth burnt to a cinder and devoid of chlorophyl, which
itself presupposes organic cells. Whence came also the absolutely
essential form of energy, directive of vegetative life? The only
possible explanation is that life was created, not evolved by a
stranger miracle from a lump of lava.

We know the successive steps in the growth of the embryo from the
time of fertilization to the end of gestation, but how this vital
process is effected is not so evident. What we are certain of is
that there is a vital principle of some kind from the beginning,
and this is the matter of real importance in the present discussion.
The old moralists held that this principle in the human being is
at first vegetative; after a while that vegetative vital principle
is expelled by a sensitive principle; and finally this sensitive
soul is expelled by the rational vital principle, or human soul.
St. Thomas[40] says: "Some tell us the vital acts that appear in
the embyro are not from its soul, but from the soul of the mother,
or from the primitive force in the semen. Both these statements are
false. Vital operations, as sensation, nutrition, growth, cannot come
from an extrinsic principle; therefore it must be admitted that a
soul preëxisted in the embryo, nutritive at first, then sensitive,
and finally intellectual." After showing that an intellectual soul
cannot be evolved from lower forms, he concludes: "Therefore we say
that since the generation of one thing is always the corruption of
another, in man as in other animals, when a more perfect form comes
in this supposes the corruption of any precedent form; so, however,
that the sequent form has all perfection that was in the destroyed
forms, and something in addition: and thus through many generations
and corruptions the final substantial form is attained in man and
other animals. This is apparent to the senses in animals generated
from putrefaction. Therefore the intellectual soul is created by God
at the end of human generation, and this soul is both sensitive and
nutritive, all precedent forms having been destroyed."

  [40] I, q. 118, a. 2, ad 2.

There is no such thing as the generation of any animal or other
living being from putrefaction; but that is irrelevant. St. Thomas's
argument proves conclusively that _if_ man has first a merely
vegetative soul, and secondly a merely sensitive soul, which includes
the power of the vegetative soul, and thirdly an intellectual soul,
which does the work of all three, that this final intellectual
soul is not an evolution of the first two, but a new form that
replaces these after they have served their purpose and have been
annihilated. It does not even attempt to prove that man really has
first a merely vegetative soul, and secondly a sensitive, and lastly
an intellectual soul; it supposes all this. It starts out with the
erroneous Aristotelian theory and takes it for granted. The reason
for this statement is that the rational substantial form requires
disposed matter to work upon, and the Thomists suppose (again
erroneously) that in the human embryo during the period immediately
after conception there is not enough matter to be a receptacle for
the rational soul.

The soul according to the Thomists, who use the Aristotelian
definition, is the first entelechy of a natural organic body that has
life in potency.[41] It is the determination that gives the body its
specific and substantial being; the primal actuation of a body or
matter, since only in matter is there a distinction between potency
for substantial being and substantial actuality. An entelechy is a
realization, actuality, full perfection; sight, for example, is the
entelechy of the eye. This body is natural, not merely instrumental;
it is energized by an immanent principle, not moved by an external
force like a tool. The body is also organic; it must have organs,
faculties, parts destined to perform definite functions. To say the
entelechy has life in potency means that since life, or the operation
of the soul, is an immanent act, there must be a receptacle within
which it can be immanent, and the soul is the primal actualization
of that organic body, which is in potency to produce those immanent
actions in which life consists. A body might be in potency while it
still has no principle of operation, or, secondly, while it has such
a principle but is not using it. In the second condition the human
body is in potency for life at the moment of actualization.

  [41] ἡ ψυχή ἐστιν ἐντελέχεια ἡ πρώτη σώματος ψυσικοῦ ὀργανικοῦ
  δυνάμει ζωὴν ἔχοντοσ (_De Anima_, ii, 1).

A form fixes a thing in its prχοντοσoper species, and the rational
soul is such a form for the human body. This substantial form is the
completion, perfection, in operability and existence, of the matter
that receives it. It is the formal cause of man, not the efficient
cause, although it is the efficient cause of subsequent vital
operations. An efficient cause makes something numerically different
from itself by its own real and physical action; a formal cause and
a material cause do not make anything different from themselves
numerically, but they intrinsically constitute the effect--they are
intrinsic causes.

The human soul as the substantial form virtually contains vegetative
and sensory faculties, and through these lower organic capacities it
informs and animates the body. That form, together with the matter,
the body, does the vital acts of the composite human nature. The
rational soul enters the body at the beginning, and first uses its
vegetative faculty until the fetus is far enough advanced to be a
subject for the action of the sensory faculty of the soul. Later,
some time after the birth of the child, when the body is sufficiently
formed, the intellectual faculty comes into use.

The nature of a vital principle is that in which it normally
issues. If it issues as a rational substantial form, as in man, it
was rational from the beginning. If it was not rational from the
beginning, a rational principle replaced a sensory vital principle,
and that sensory vital principle replaced a vegetative vital
principle. The only reason for these replacements would be that the
early human embryo, as has been said, lacks organization sufficient
to sustain a form higher than a vegetative principle. If this were
sufficient reason for deferring the advent of the rational soul, then
a baby six months after birth would have no rational soul because
it certainly lacks the supposedly requisite organs. However, as the
rational soul is whole in each part of the adult body in the totality
of its essence and perfection, but not in the totality of its virtue,
because certain organs are lacking in particular parts of the
body, it is in the embryo whole in the totality of its essence and
perfection, but not in its virtue because certain organs are not yet
formed, and it is thus from the moment of conception.

As to the soul itself, Kant held that the soul is not a real, but
only a logical substance. The Pantheists, Transcendentalists, and
Neo-Hegelians try to identify the soul with the divine consciousness.
The Associationists (Hume, Davis, Höffding, Sully) say that the soul
is a mere group of sensations. The Agnostics and Positivists (Locke,
Herbert Spencer, James, Comte) write volume after volume on the
soul to prove that they know nothing about it. Then the Materialists
assert that there is no soul of any kind; that we secrete thought
as a mule secretes sweat. Yet the vital operations of man are
inexplicable as resultants of the physical and chemical properties
of matter. There is an intrinsic energy that unifies the actions
of man, directs processes, controls the tendency of organic matter
to pass into the fixity of the inorganic, and effects metabolism.
This intrinsic energy is the entelechy, substantial form, or what is
popularly called the soul.

In any organic body there is a formal principle. We know that there
are activities that proceed from organic bodies, and a formal
principle of such activity is a substantial entity whence the
organism derives basically its own kind of action, which determines
and orders the activity. There are acts of perception in animals
such that an external object becomes so internal to the organism of
these animals that it is known by one expressed and immanent image,
not only as something objectively existing but as good or hurtful to
the perceiving animal. The innate and elicited appetites by which
the animal tends toward or away from the object are recognized, as
are the spontaneous motions which are directed by that knowledge.
There must be a principle whence these actions proceed, and this is
either an accident of matter or something substantial. It is not an
accident of matter, because action can never arise from an accident;
it must proceed from a substance. If you say this principle whence
these actions arise is not an accident of matter, but matter itself,
you would have an extended, composite, inert mass acting; but even if
such thing could act, it could never effect a simple immanent image
of an object or group of objects external to itself.

No mere machine can build up itself, can make any remote approach
to metabolism as an organized body can; and the principle of this
immanent action is not matter itself, because it uses, makes,
subordinates matter to itself. That principle is positively one, not
one by continuity as matter is. Matter as in a crystal grows by mere
aggregation, an organism grows by assimilation; a crystal loses
force in formation and growth, an organism accumulates force.

The theory that denies the existence of this formal principle does
not explain the phenomena of life in organic beings. Uniformity
of tendency toward an end is not a characteristic of mere matter;
neither is a harmonious interaction of parts, nor the dependence of
parts on the unit, nor motion, nor the reproduction of the species.

Moreover, most of the greatest physical scientists strongly maintain
that there must be a formal substantial principle in all living
things. Among these are Wallace, Nägeli, Askenasy, Preyer, Fechner,
Agassiz, von Baer, E. de Beaumont, Blanchard, A. Braun, Brongniart,
Bronn, Burmeister, Delff, Milne-Edwardes, Flourens, Goeppert,
Griesbach, Heer, Koelliker, Mivart, Quatrefages, Quenstedt, Spiers,
Volger, R. Wagner, Liebig, and Joseph Hyrtl.

The formal principle which coexists with matter in the organic
body is really though not perfectly distinguished from matter. A
formal principle which is necessary for sensation should be either
perfectly simple, or at the least so one that its parts together
make up one essence: matter, however, cannot have such unity, and
as a consequence the formal principle must be distinct from matter.
Anything is like its operation, and the parts of any sensitive
activity always result in an activity that is essentially one. If we
touch a table, by that single touch we at once know that the object
is one, wooden, hard, angular, smooth, extended, and so on, and we
also know that one subject perceives all these varied qualities.
One eye can convey knowledge at once of a thousand objects miles
apart, and these objects can be brought into one perception only by a
simple subject. An extended complex subject like matter would get one
impression (if it could perceive any impression) on one side, one on
another, and so on, but it could not unite these.

The formal principle which is in organic bodies is a true substantial
form, actuating the body both as to its nature and substance.
Together with the body, this principle makes a being one in itself,
such that the matter and the form separably are incomplete as
regards operation and being. Now, a form is that principle through
which anything is established in its own species; light, for example,
is the form of a luminous body, heat of a hot substance. A body,
however, is established in the human species by receiving a rational
soul, and this soul, then, is its form. It is also a substantial form
because the soul itself is a substance, not an accident dependent
upon another subject. Moreover, from its union with the body another
substance--man--arises, and not a thing added to a substance. Man's
body is alive, therefore it is a living substance; but life in its
secondary actuality is an operation; in its primary actuality it is
an essence. The body is made a living substance, not from itself, but
from the soul which is added to it. When the soul departs the body is
no longer alive. Now, a principle which by a communication of itself
determines the body in its essence and differentiates it as a living
substance from everything else, is a substantial form. A substantial
form, then, or a soul, exists.

The soul, however, must have disposed matter for most of its
operations; it cannot exist as a substantial form _bombinans in
vacuo_; but it does not need a human organism complete in all its
parts as a necessary condition for its indwelling. There is organized
matter enough in the first cell that comes into existence after the
fusion of the germ-nuclei to hold this rational form, or soul, as
perfectly as it needs to be held in this first stage of human life.

To inform the embryo any principle, whether it is the rational soul
or a force derived from the parental organism, must have organs; and
if organs are present, then the embryo is fit to receive the human
soul, as the only objection to its presence is a supposed lack of
organs. To use other principles when the human soul itself could be
present would be a _multiplicatio entium sine necessitate_, which is
a condition repugnant to the universal method of the Creator.

It has been said that the vital activity in the fertilized ovum does
not proceed from the rational soul because, "in the first place, it
results from the fusion of two vital activities, neither of which is
rational; secondly, it results in the formation, by fission, and
differentiation, of two distinct and separate living cells, each
containing within itself a principle of vital activity. Now this
principle of vital activity cannot be a rational soul, for each cell
has its own principle of activity, and in man there is but one soul."

In the first place, that vital activity does _not_ result from the
fusion of two vital activities neither of which is rational. It
results _after_ the nuclei come together, by particular creation,
and replaces their activity--the generation of the last vital force
is the corruption of the first that existed in the separate nuclei,
not a derivative of that first force. Again, when the embryo is
in the two, four, eight cell stage, and so on, there are not two,
four, eight vital principles present, but one. Substantial unity is
essential to life of any kind, no matter how low its grade; and if
each cell had an independent vital principle, any form of resultant
life in the mass would be impossible. An aggregation has no unity of
substance; there would be as many substances or natures as there are
individual beings in the aggregate, no matter whether ordered or in a
mob, consequently no life at all as a life.

The embryo in the two-cell stage is not made up of two independent
organisms, any more than the right and left halves of an adult man
are two independent organisms. The cells in the two-cell stage
of the embryo are the right and left halves of the body, not two
individuals, as has been proved repeatedly by biologists. Roux[42]
punctured with a hot needle one of the cells in the two-cell stage
of a frog embryo without killing the embryo, and it grew into a
half-frog larva. Analogous results were obtained by operating in
the four-cell stage. Later, Pflüger, Schultze, Enders, and Morgan
corroborated the work of Roux. Newport[43] discovered this fact sixty
years ago.

  [42] Virchow's Archiv (1888), 114.

  [43] _Phil. Trans._, 1854.

In analyzing the structure and functions of the individual cell we
regard it as an independent elementary organic unit, but this view is
solely a matter of convenience, almost a convention. All the billions
of cell's in an adult man are inseparable parts of the single living
person. No cell exists as an independent organism in multicellular
animals, except the germ-cells, and these only after separation from
the gland of origin. Indeed, the biological theory of heredity,
already mentioned here, wherein the germ-cell is supposed to carry
forward the entire heredity, is now changing toward the view which
makes all the somatic cells influence the germ-cells; that is, the
body-mass of cells sends on heredity through the germ-cell as the
instrument. Adult organisms do not make cells _de novo_. New cells
are formed by division from preëxisting cells, but some biologists
think the body-cells so affect the new germ-cells as to influence
heredity.

The cells are organs, nodal points, of a single formative power
which pervades the mass of cells as a whole. The protoplasm of each
cell is not only in direct apposition with its neighbors, but nearly
all biologists are now inclining to the opinion, which Heitzmann
proposed in 1873, that division of cell from cell is incomplete
in nearly all forms of tissue; and that even where cell-walls are
present (an exceptional condition in mammals) they are traversed by
strands of protoplasm, by means of which the cells are in organic
continuity. The whole body, he contended, is thus a syncytium (a
mass of continuous protoplasm stippled with nuclei), with the cells
as mere nodal points in an almost homogeneous protoplasmic mass.
There are cell-bridges between the sieve-tubes of plants. In 1879
Tangl discovered such connection between the endosperm cells of
plants, and later Gardiner, Kienitz-Gerloff, A. Meyer, and many
others demonstrated that in nearly all plant tissues the cell-walls
are connected by intracellular bridges. Ranvier, Bizzozero, Retzius,
Fleming, Pfitzner, and many other observers have found these
protoplasmic bridges in animal epithelium. In the skin of a larval
salamander they are quite conspicuous. They are known to occur also
in smooth muscle-fibre, in cartilage cells, in connective-tissue
cells, and in some nerve-cells. Harrison found, in 1908, that in
frogs the nerve-fibres develop out of these intracellular bridges.
Dendy in 1888, Retzius in 1889, and Palladino in 1890 have shown
that the follicle cells of the ovary are connected by protoplasmic
bridges, not only with one another, but also with the ovum; and
similar connection between somatic cells and germ-cells has been
found in a number of plants. Thus even the germ-cell is not
independent until it has actually broken away from the gland. A.
Meyer holds that both the plant and animal individual are continuous
masses of protoplasm, in which the cytoplasmic substance forms a
morphological unit, no matter what the cell is. That opinion is
not finally settled as regards the animal after the fetal stage,
but it is much stronger as regards embryos. In the early stages of
many arthropods it is certain that the whole embryo is at first
an unmistakable syncytium. This is almost established also for
Amphioxus, the Echinoderm Volvox, and other animals. Adam Sedgwick
holds that it is true for vertebrates up to a late embryonic stage.
Mitosis, then, is a form of growth of a mass, not a generation of new
individuals.

Whether chromatin or any other element in the germ-cell be the
idioplasm in which heredity inheres, differentiation is a progressive
transformation, through physical and chemical changes, of the
substance of the ovum, and this transformation occurs in a definite
order and a definite distribution in the ovum. The changes result in
a cleavage of the egg into cells, the boundaries of which sharply
mark the areas of differentiation. These cells take on specific
characters. In the four-celled stage of an annelid egg these four
cells contribute equally to the formation of the alimentary canal
and the cephalic nervous system, but only one of them, the left-hand
posterior cell, gives rise to the nervous system of the trunk and to
the muscles, connective tissues, and germ-cells. The relation between
the four original cells, or blastomeres, and the adult parts arising
from them, is not fixed, because in some eggs these relations may
be artificially changed. A portion of the egg which normally would
develop into a fragment of the body will, if split off from the
others, give rise to an entire body of a diminished size.

Conklin says[44] that in the ascidian Styela "there are four or
five substances in the egg which differ in color, so that their
distribution to different regions of the egg and to different
cleavage cells may be easily followed, and even photographed, while
in the living condition. The peripheral layer of protoplasm is yellow
and it gathers at the lower pole of the egg, where the sperm enters,
forming a yellow cap. This yellow substance then moves, following the
sperm nucleus, up to the equator of the egg on the posterior side,
and there forms a yellow crescent extending around the posterior side
of the egg. On the anterior side of the egg a gray crescent is formed
in a somewhat similar manner, and at the lower pole between these two
crescents is a slate-blue substance, while at the upper pole is an
area of colorless protoplasm. The yellow crescent goes into cleavage
cells which become muscle and mesoderm, the gray crescent into cells
which become nervous system and notochord, the slate-blue substance
into endoderm cells, and the colorless substance into ectoderm cells.
Thus within a few minutes after the fertilization of the egg, and
before or immediately after the first cleavage, the anterior and
posterior, dorsal and ventral, right and left poles are clearly
distinguishable, and the substances which will give rise to ectoderm,
endoderm, mesoderm, muscles, notochord, and nervous system are
plainly visible in their characteristic positions." Conklin followed
these cells in every division until the embryo was developed, making
a complete genealogy up to the ovum proper.

  [44] _Heredity and Environment_, p. 123, Oxford Press.

De Vries[45] assumed that the character of each cell is determined
by "Pangens" that migrate from the nucleus into the protoplasm.
Driesch and Oscar Hertwig held that the peculiar development of a
given blastomere is a result of its relation to the remainder of the
cell-mass, an outcome of the action upon it by the whole system of
cells of which it is a part. Hertwig said:[46] "Each of the first
two blastomeres contains the formative and differentiating forces
not simply for the production of a half-body, but for the entire
organism; the left blastomere develops into the left half of the
body only because it is placed in relation to a right blastomere."
Wilson[47] and Driesch[48] came to the same conclusion about the
time Hertwig wrote. Driesch said:[49] "The relative position of a
blastomere in the whole determines in general what develops from it;
if its position be changed it gives rise to something different; in
other words, its prospective value is a function of its position."

  [45] _Intracelluläre Pangenesis._ Jena, 1889.

  [46] _Jenaische Zeitschrift_, 1892, 1.

  [47] _Journal of Morphology_, 1893, 1894.

  [48] _Studien_, iv, p. 25.

  [49] _Ibid._, p. 39.

A discussion of this matter will be found in Wilson,[50] but the many
experiments made in the study of this subject show conclusively that
the cells, singly, grouped, and in mass, are a morphological unit,
not an aggregation of distinct individuals. They are not, of course,
absolutely homogeneous, because such a body could not have organs.
The substantial form, therefore, is not confined to the first cell.

  [50] _The Cell in Development and Inheritance_, pp. 413 _et seq._
  New York, 1906.

The cell-mass, then, has a unity sufficient to be the receptacle of
a human vital principle; again, the basic vital operation of the
human body at any age is metabolism, and this is actually carried on
in the first somatic cell of the embryo as in the cells of the adult
man. In the development of the human body in the embryonal stage
the energy of cell-division is most intense in the early cleavage
stage, and this diminishes as the limit of growth approaches because
further division is not needed. When that limit is attained a more
or less definite equilibrium is established. Some of the cells in
the fully formed body cease to divide, the nerve-cells, for example;
others divide under special conditions, as the blood-cells, the
connective-tissue cells, gland-cells, epithelial and muscle cells;
others continue to divide throughout life and thus replace worn-out
cells of the same tissue, as the Malpighian layer of the skin.
Cells grow, divide, function, reproduce themselves, and so on, all
through their vital activity, sustained by the material brought to
them by the blood. Weismann[51] and other biologists think that the
vital processes of the higher animals are accompanied by a renewal
of the morphological elements in most tissues. The material is
carried to the fetus in the womb by various agents, but mostly by the
maternal blood after the embryo uses up the yolk; and when the fetal
circulation has been established the nutritive material is taken from
the maternal blood into the fetal circulation through the placenta,
and then carried to the cells by the fetal circulation itself. After
the child has been born the stomach and intestines take in the food.
The stomach does very little with it except in a preparatory manner;
the intestines further prepare it, pass it into the body, where it
is again modified by other organs, and finally it is carried by the
blood to the cells. The cells really use it; the other organs are
the farmers, grocers, railways, and the like; the cells are the
consumers. So far as the essential processes are concerned, the
embryological cells act as do the adult cells.

  [51] _The Duration of Life._

The first cell has contractility, protoplasmic motion; it can absorb
perfectly all food-stuffs necessary for it from the deutoplasm of
the ovum, and the water that passes in from without to the ovum. In
a few days the embryonic cells have used up the deutoplasm and are
taking up food from the maternal blood as perfectly as any adult cell
does, and are exercising their function of building up and sustaining
whatever part of the body they are destined for; and this with all
the complicated metabolism of the adult cell. Cell metabolism is the
fundamental, chief, organic act of any human body at any age. That
the embryo does this impelled by the _virtus formativa_ transmitted
from the parents is a mere gratuitous assumption to fit the theory
that the embryonic cell lacks organic power. The fundamental organ
that conserves the body in its very existence under the government
of the soul is the apparatus which effects metabolism. Incessant
chemico-vital change is a characteristic of all living substances,
from the single cell up to the adult man; and in all cases this
activity has to do with a transformation of the complex molecules
which build up the protoplasm or are associated with its operations.
The totality of the chemical changes, or exchanges, in living cells,
the transformation of unorganized food materials so that these may be
assimilated, and the chemical processes in the tissues themselves,
all are metabolism. Growth and repair (anabolism) occur side by side
with the destruction of elementary tissue substance (katabolism),
and the duration of life rests on these processes; and all are mere
cell activities. Food-stuffs (water, inorganic salts, proteids,
albuminoids, carbohydrates, and fats) undergo more or less combustion
or oxidation. Oxygen unites with carbon to form carbon dioxide, and
with hydrogen to form water; the nitrogen of the highly complex
proteid substances reappears in combination with carbon, hydrogen,
and oxygen as urea, uric acid, and other compounds; and other ingesta
are thus transformed through oxidation. All maintain the temperature
of the body, replace outworn parts, and accomplish the body's work.
Oxidation occurs to a slight extent in the blood, but the specific
reactions are intracellular. Even when nothing exists but the cells
and the blood, as in the beginning embryo, the cells really do the
work, and they do the work as they do in the adult.

The cells also from the very beginning are the organs that make the
animal heat necessary for life. Rubner[52] proved that the source of
at least 90 per cent. of the animal heat in the body is a result of
the chemical changes--oxidation--in the food ingested: the other 10
per cent. is caused by muscular contractions, the flow of blood, the
friction of joints, and like motions. This oxidation is more active
in young animals than in adults, and in each it is, of course, a
cellular process.

  [52] _Zeitschrift f. Biologie_, 1893, bd. 30, p. 73.

Living matter contains hydrogen, oxygen, sulphur, chlorine, iodine,
fluorine, nitrogen, phosphorus, carbon, silicon, potassium,
sodium, calcium, magnesium, and iron. The removal of one of these
elements causes the death of the body. They must be arranged in a
definite, prescribed order to constitute cellular protoplasm, and
any disarrangement of this order causes intoxication, disease,
or death. Hydrogen is a constant product in the putrefaction of
animal matter, of animal food, and is present in the intestinal
tract. Oxygen is found dissolved in water and loosely combined in
blood as oxyhemoglobin. All the elements, except fluorine, combine
with oxygen, forming oxides, and the process is called oxidation.
The production of heat and all vital motion depend on oxidation,
decomposition of matter. In the nuclei of cells there is a so-called
"oxygen-carrier," a nucleo-proteid, which contains iron, and this
appears to be the chief oxidizing agent in the body. Chlorine, which
in hydrochloric acid is essential to digestion, is ingested as
chloride, and leaves the body chiefly through the urine and sweat.
Iodine is a necessary part of the thyroid gland, an indispensable
vital organ. Fluorine is found in all cells. Nitrogen goes into the
body combined in proteids; and phosphorus, combined in the alkalies
and alkaline earths of the foods. Carbon occurs in all cells and
leaves them through the lungs as carbon dioxide.

The amount of energy set in action in the body in the decomposition
of any food is equal to the energy that had been expended in the
synthesis of that food from its organic elements, and the liberated
energy set free in the body appears as heat, work, and nervous
impulse. In a plant the chlorophyl and the sun's rays combine water
and the carbon dioxide of the air into sugar and free oxygen. This
sugar is changed in a plant into starch, cellulose, and fat, and
also, when combined with some nitrogen, into proteid. An animal eats
this plant, which contains starch, cellulose, fat, and proteid, and
it either adds these ingredients to its own substance or oxidizes
them so as to prevent the destruction of its own substance. These are
the ends of all food. Broadly speaking, plants synthesize elements;
animals analyze them, reduce them into simpler bodies.

Such processes, and those of the other elements of the body, which
have to do with the changing constituents of the human organism,
are all cellular processes--metabolism. Hence the chief organic
act of the body is metabolic; the basic organ of man is the cell.
Arms, legs, heart, brain, stomach, and similar organs are secondary,
though some of the latter are essential for certain operations. Now,
one cell is an organ amply sufficient for metabolism, for the chief
organic act of the body; hence it is a fitting receptacle for a
substantial form, a soul. Therefore there is no reason why the soul
may not be present in the one-cell stage of the embryo; and since
there is no reason why it should not be present, but many why it
should, it is present.

Conklin says:[53] "The fertilized egg of a star-fish, or frog, or
man is not a different individual from the adult form into which it
develops, rather it is a star-fish, a frog, or a human being in the
one-celled stage. This fertilized egg fuses with no other cells,
it takes into itself no living substance, but manufactures its own
protoplasm from food substances; it receives food and oxygen from
without and it gives out carbonic acid and other waste products;
it is sensitive to certain alterations in the environment, such
as thermal, chemical, and electrical changes--it is, in short, a
distinct living thing, an individuality. Under proper environmental
conditions this fertilized egg-cell develops, step by step, without
the addition of anything from the outside except food, water, oxygen,
and such other raw materials as are necessary to the life of any
adult animal, into the immensely complex body of a star-fish, a frog,
or a man. At the same time, from the relatively simple reactions
and activities of the fertilized egg there develop, step by step,
without the addition of anything from without except raw materials
and environmental stimuli, the multifarious activities, reactions,
instincts, habits, and intelligence of the mature animal."

  [53] _Heredity and Environment._

An objection to the opinion that the soul is in the embryo from
the beginning is made from a consideration of the facts that there
appears to be an aptitude for life in certain animal cells and
tissues after removal from the original host, or after the death
of the host; and, secondly, that in other separated tissues life
is undoubtedly made evident under proper conditions. Some parts of
the human body can be grafted upon another human body, and human
sarcomatous cells have been made to grow _in vitro_. Hair often
lengthens after the death of a person, if no embalming fluid has been
injected. Dr. Alexis Carrel[54] substituted a piece of a popliteal
artery, taken from an amputated human leg and kept in cold storage
for twenty-four days, for a part of the aorta of a small bitch,
and the dog lived for four years afterward and died in parturition.
Magitot of Paris, in 1911, took a piece of the cornea from an
extirpated human eye, and with it replaced a part of an opaque cornea
on another man, and this second man could see through the new cornea.
Surgeons now remove skin, bone, and other tissues from still-born
infants and accident cases, preserve these, for weeks if necessary,
in petrolate and Ringer's solution in cold storage, and then graft
them on patients to repair lesions in skin, bone, cartilage, or other
parts of the body.

  [54] _Journal of the American Medical Association_, vol. lix, n.
  7, p. 523.

If these separated tissues are alive, what is the origin and nature
of the life? Again, if there is a low form of life in these separated
tissues, remaining after the departure of the human soul, why could
not such a low form of life precede in the embryo the advent of the
human soul?

What is the nature of the "life" in the parasitic sarcomatous tissue
which has been seen to proliferate for a short time _in vitro_? We
do not know, nor is it relevant to the question. That there is life
of any kind in the cold-storage graft of bone and skin is certainly
not evident; rather every evidence points to the absence of all life.
When taken out of cold storage, and the ordinary forces which corrupt
a dead body are permitted to work, these grafts corrupt exactly as
any part of a corpse does. That there is life of any kind in these
grafts is a gratuitous assumption. In cold storage they are kept
ready for assimilation into the body as food may be kept. Bone and
skin grafting is merely a peculiar form of assimilation. Food taken
into the body through the stomach and entrails is prepared in the
body and assimilated into the substance of the bones or skin or other
tissues; the graft is ready for assimilation without this preparation
because it is already bone or skin.

The vital principle in a man, or in anything else, is at the end,
when it normally issues, of the same nature as it was in the
beginning. If it is at perfection a substantial primary form, it
always was such--a substantial form cannot issue from an accidental
form. If the substantial form is the form of the cells in the
completed organism, it was such before that organism was perfected,
unless it replaced a lower substantial form; but there is, we repeat,
absolutely no need for such a secondary form at the beginning. If
the cells of the embryo (not the infused germ-cells, which are
not the embryo) had a _forma corporeitatis_, or _cellularis_, or
whatever you wish to call it, the human soul when it did come would
not confer primal existence, would not be a _forma substantialis_,
but an accidental form. "In proof of which," says St. Thomas,[55]
"we must consider that a substantial form differs from an accidental
form in this, that an accidental form does not give being simply, but
such or such being; as heat does not give being simply, but heated
being. So when an accidental form comes in, a thing is not said to
come into existence or to be generated, simply, but to become such or
such an object, or to find itself in such or such a condition. So,
also, when an accidental form disappears, a thing is not said to be
destroyed simply, but only to a certain degree. A substantial form,
however, gives being simply; and therefore by its advent a thing is
said to be generated simply, and by its recession to be destroyed
simply. If, therefore, it happened that any substantial form other
than the intellectual soul preëxisted in matter, by which the subject
of that soul would come into actual being, it would follow that
the soul would not confer being simply, and therefore would not
be a substantial form; also that the coming of the soul would not
be a generation simply, but only _secundum quid_--all of which is
evidently false." Again, St. Thomas says:[56] "Some tell us the vital
acts that appear in the embryo are not from the soul, but from the
soul of the mother, or from the primitive force in the semen. Both
these statements are false."

  [55] I, q. 76, corp.

  [56] Ia, q. 118, a. 2, ad 2.

An application of the opinion offered here--that is, that the human
soul is infused at the instant of conception--to multiple and
monstrous embryos offers no real difficulty. There are two kinds of
human twins--those from two distinct ova and those from one ovum. Two
ova may come from one or different ovaries, or even from one Graafian
follicle, be fertilized at the same time and develop synchronously.
If the ova are placed at some distance apart in the uterus, two
placentas appear; if the ova are near each other the placentas may
fuse, but their circulations do not. Each child will have its own
fetal envelope.

In twins from two distinct ova there is no difficulty in seeing that
the souls are placed in these in the same manner as the soul is put
in the normal single embryo. When the twins come from one ovum the
condition is not so simple. The oval nucleus is the essential part
that goes from the maternal side, and human ova at times contain
two nuclei, as occasionally hens' eggs do; a double-yoked hen's egg
has two nuclei, and two nuclei have been found in a single yolk.
Kölliker, Stöckel, and von Franque have observed double germinal
vesicles in single human ova. In such a condition two spermatozoa
could fecundate the two nuclei and the development go on as in the
case of twins from distinct ova.

There is a theory which holds that homologous twins (uni-oval)
can develop from a single germinal vesicle which splits into two
primitive streaks and two gastrulas. According to this opinion, if
the germinal vesicle divide entirely, two fetuses develop which are
always of the same sex, and which resemble each other so closely in
appearance that it is very difficult to differentiate them. This
theory holds also that should the germinal vesicle not split fully,
the lack of fission causes the various kinds of double monsters. The
germinal vesicle that supposedly splits into two is not fecundated by
two spermatozoa, they say, because where there is only one nucleus in
the beginning, the entrance of a second spermatozoön commonly kills
the ovum. This last assertion has been disproved of late.

Some followers of the splitting theory hold that double monsters
arise from the union of two originally separate primitive traces
(_Verwachsungstheorie_). Others say that a single primitive trace
of blastoderm cleaves more or less thoroughly and makes the double
monster (_Spaltungstheorie_). The earliest human double monster
(Ahlfeld's case) was in the fourth week of gestation; therefore
whatever is held in these theories as regards human monsters is only
through analogy with lower animals.

Gerlach[57] saw bifurcation at the cephalic end of a chicken embryo
sixteen hours old. In this case the first change was a broadening of
the anterior end of the primitive streak; next a forked divergence
appeared, and by the twenty-sixth hour the bifurcation was half as
long as the undivided posterior part. Whether this was a case of two
nuclei or not is not known.

  [57] _U. d. Entstchungsweise der vordern Verdoppelung. Deutsch.
  Archiv. f. klin. Med._, 1887.

What seems to make for the fission theory is that in non-parasitic
double terata, no matter how unequally nourished or how variable in
extent, the union between the halves of double monsters is symmetric,
and the same part of each twin is joined. This fact is used as a
reason to exclude a fortuitous growing together of dissimilar areas
of cell-masses, at least in non-parasitic cases. Born,[58] in a study
of fish ova, found that eggs which produce double monsters begin
with a segmentation like that of the simple normal ovum. Composite
spermatozoa have been observed with two and three heads and one body
and tail-piece, but the significance of these abnormal cells is not
known.

  [58a] _U. d. Furchung des Eies bei Doppelbildungen. Breslauer
  Aertzliche Zeitschrift_, 1887.

Embryos of sea-urchins in the two-cell and four-cell stages can be
separated by shaking into isolated blastomeres, and the segments will
grow into full though dwarfed larvae. The same division with the
growth of dwarfed larvae has been made in Amphioxus, in the teleost
Fundulus, in Triton, in a number of Hydromedusae and several other
low forms of life. When the division is not made completely double
monsters result.

Up to a certain stage of development the blastomeres of the Medusa
embryo are totipotent, or capable of developing into any part of
the body. The limitation of development in a particular case lies
in the cytoplasm rather than in the nuclei of the cells. If frogs'
eggs are fastened in abnormal positions, inverted or on the side, a
rearrangement of the egg material results, wherein the nucleus and
cytoplasm rise and the deutoplasm sinks. This change of axis shifts
the embryo. If an egg is turned upside down in the two-cell stage,
a whole embryo, or half a double embryo, may arise from each of the
two blastomeres, instead of a normal half-embryo. A half-embryo or
a whole dwarf may arise according to the artificial position of the
blastomere. Each of the two blastomeres contains all the materials
potentially for the formation of the whole body, and these materials
build up a whole body or a half body according to the grouping they
take on. Primarily the egg cytoplasm, in low forms of animal life,
is totipotent; it has no fixed relation with the parts to which it
gives rise, and may be artificially modified or differentiated.
These effects, from position and traumatic dislocation, suggest
explanations for teratic forms in higher animals.

Human terata are now commonly classified in four groups: (1)
Hemiteratic; (2) Heterotaxic; (3) Hermaphroditic; and (4) Monstrous.
Hemiterata are giants, dwarfs, persons showing anomalies in shape,
color, closure of embryonal clefts, in absence or excess of digits,
or like defects. The Heterotaxic group are persons whose left or
right organs are reversed in position. A true Hermaphrodite would
have the complete reproductive organs of both sexes, but such an
individual has not been observed. There is never any question of
double personality in hermaphrodites.

Terata more properly so called may be single, double, or triple;
and single monsters may be autositic or independent of another
fetus, or they may be omphalositic, dependent upon another which is
commonly well developed and which supplies blood for both through
the umbilical vessels. There are four genera of autositic single
monsters, with eight species and thirty-four varieties. Of the
_monstra per defectum_ the commonest are caused by a failure of
closure in the embryonal medullary canal, which leaves part of
the brain and spinal cord or their bony covering lacking. Some
terata, as the Acephalia, have no brain or spinal cord, but they
die in the fetal stage. The Anencephalia may have a spinal cord, a
medulla oblongata, and parts of the basal ganglia, but the cerebral
hemispheres are wanting. Such monsters are sometimes born at term
and live for several days: they cry, suckle, show some reflexes and a
sense of pain, and move the arms and legs.

I described the various kinds of terata in _Essays in Pastoral
medicine_,[58b] and of these the most important in the matter under
discussion here are the double and triple monsters. Many of the
double monsters evidently were two persons. There is only one well
authenticated case of a triple human monster, and this happened in
Italy in 1831. It had a single broad body with three distinct heads
and two necks, and was killed in delivery. There is no proof as to
whether it was one or more persons. The standard of judgment in such
cases as regards the presence of one or two souls in the monster
is the evidence of one or more distinct consciousnesses. A monster
double from the navel or breast downward (_terata anadidyma_) is,
I think, one person. There was an example of a monster in this
group which was divided from the foreheads downward; or better,
the distinct twins were united by their foreheads only; but such a
form is very exceptional. In my article on "Human Terata and the
Sacraments," in _Essays in Pastoral Medicine_, in 1906, I expressed
the opinion that a monster which is single to the navel and double
below is composed of two persons, but I now am of the opinion that
such a monster is only one person, because there is apparently only
one consciousness. There are about eight cases of two-headed monsters
known which were evidently two persons in each case, and several
terata kata-anadidyma, divided above and below but joined at the
sternum, abdomen or sacrum. Several ischiopagic twins, joined at the
pelvis with the heads at the opposite ends of the double body, are
grouped with either the katadidyma or kata-anadidyma. It is commonly
not difficult to recognize individuality or duality of personality in
monsters, but it is not easy to explain the origin of life, to point
out the moment the _second_ soul enters these fused or undivided
twins.

  [58b] Chap. vi, p. 69. New York, 1906.

  We can artificially obtain double embryos of frogs by inverting
  the blastomeres in the two-cell stage.[58c] We thus get united
  twins with heads turned in opposite directions, twins united back
  to back like the Blazek Sisters, twins united by their ventral
  sides, and double-headed tadpoles, but we have no knowledge of
  how similar doubling in human monsters takes place; we must guess
  vaguely from analogy. There was one soul, at least, present from
  the one-cell stage of the human monster; when the second soul
  is created and infused we do not know, but the moment of the
  creation of this second soul has no practical significance in
  this discussion.

  [58c] See Wilson, _op cit._., p. 421.

  The presence of certain kinds of monsters in the uterus can
  be diagnosed before labor, but double monsters are mistaken
  for ordinary twins. A woman who has given birth to a monster
  is likely to have subsequent monstrous fetuses. Where the
  intrauterine existence of a single monster is suspected the X-ray
  will at times clear up the diagnosis. Women gravid with monsters
  commonly abort early in pregnancy, but even united twins may go
  on to term. Those monsters that offer an obstacle to delivery
  by the abnormal bulk of one or the other end are mostly twins
  joined above or below the navel; those joined at the middle are
  easier of delivery. Monsters that are joined at the pelves are
  commonly in a straight line, and may not be difficult to deliver.
  Most double monsters cannot be delivered alive except by cesarean
  section, and the fact that the content of the uterus is monstrous
  is, as a rule, not diagnosed until it is impossible to attempt
  cesarean section without killing the mother through infection.
  In such a condition the double monster would, in the ordinary
  medical practice, be delivered by craniotomy, exenteration,
  cleidotomy, or the like operation.

  The _Rituale Romanum Pauli V_[59] gives the following directions
  for the baptizing of human terata:

  "18. In monstris vero baptizandis, si casus eveniat, magna
  cautio, adhibenda est, de quo si opus fuerit, ordinarius loci,
  vel alii periti consulantur, nisi mortis periculum immineat.

  "19. Monstrum, quod humanam speciem non praeseferat baptizari non
  debet; de quo si dubium fuerit, baptizatur sub hac conditione;
  _Si tu es homo ego te baptizo_, etc.

  "20. Illud vero, de quo dubium est, una ne, aut plures sint
  personae non baptizetur, donee id discernatur: discerni autem
  potest si habeat unum vel plura capita, unum vel plura pectora;
  tune enim totidem erunt corda et animae, hominesque distincti, et
  eo casu singuli seorsim sunt baptizandi, unicuique dicendo: _Ego
  te baptizo_, etc. Si vero periculum mortis immineat, tempusque
  non suppetat, ut singuli separatim baptizentur, poterit minister
  singulorum capitibus aquam infundens omnes simul baptizari,
  dicendo: _Ego vos baptizo in nomine Patris, et Filii, et Spiritus
  Sancti_. Quam tamen formam in iis solum, et in aliis similibus
  mortis periculis, ad plures simul baptizandos, et ubi tempus non
  patitur, ut singuli separatim baptizentur, aliis nunquam, licet
  adhibere.

  "21. Quando vero non est certum in monstro duas esse personas, ut
  quia duo capita et duo pectora non habet distincta; tune debet
  primus unus absolute baptizari, et postea alter sub conditione,
  hoc modo: _Si non es baptizatus, ego te baptizo in nomine Patris,
  et Filii, et Spiritus Sancti_."

  [59] Tit. ii, cap. 1, nn. 18, 19, 20, 21.

Any kind of monster coming from the human womb, if it is only a
head and lacks a body (Acardiacus Acormus), or is a body and lacks
a head and heart (Acardiacus Acephalus), or is a Foetus Anideus,
which is a shapeless mass of flesh covered with skin, should be
baptized, provided _it shows signs of life_. Number 19 in the Ritual
would be liable to an interpretation which is too narrow if it were
not that very monstrous fetuses, which appear to a lay observer to
be not human, are as a rule delivered dead. Here it may be worth
while to mention that a hybrid between a human being and a lower
animal is impossible. As to number 20, the rule for differentiating
unity or duality of personality is not the number of heads, but the
number of evident consciousnesses, and this differentiation commonly
cannot be made at birth. There have been examples of two-headed
monsters delivered alive, which were single as to soul because the
consciousness evidently was one.




CHAPTER IV

WHEN DOES HUMAN LIFE END?


The moment human life begins in the human fetus is a subject of
dispute, but the moment human life ends is a mystery--we have no
method of determining exactly just when the soul leaves the body.
Daily throughout the world the priest reaches a patient who has just
died. Conditional absolution, extreme unction, baptism might have
been administered if there were signs of life, but the heart and
lungs are still, "the patient is dead," and the priest leaves without
doing anything. Yet it is always probable that the patient does not
die at once even in a case of decapitation.

Bichat, at the beginning of the last century, called the brain,
lungs, and heart "the tripod of life," and from time immemorial we
have based our judgment of the presence of somatic death on the lack
of consciousness, respiration, and circulation in the patient. The
heart, however, beats after consciousness and respiration cease (and
sometimes respiration continues after the pulse cannot be felt), and
this cardiac activity may go on for more than a half hour after all
the normal clinical signs of death have appeared--after respiration
has quit, when no heart-sounds can be heard by the stethoscope and
muscular relaxation indicates death.

The stimulus of the heart-beat probably starts at the juncture
of the superior vena cava with the right auricle of the heart.
Some biologists think that in this spot life takes its last stand
before the final retreat, but that fact is disputed of late. In
the hospital of the Rockefeller Institute for Medical Research in
New York, Dr. G. Canby Robinson[60] made records from about eight
patients before and during the actual stopping of the heart, using
the electrocardiograph, which can be employed without disturbing
the patient. He thus found--only in one case, however--that the
heart may beat for a half hour after all vascular and circulatory
sounds have ceased to be audible. In a letter to me Dr. Robinson
said: "Undoubtedly the heart continues to show activity sufficient
to be recorded by the string galvanometer very frequently after
respiration has ceased, both in man and the lower animals; but this
does not necessarily mean that it continues to be an efficient pump,
maintaining the circulation. Undoubtedly also in other instances the
cardiac activity ceases before the respiration, but I have never
obtained electrocardiographic records of such cases."

  [60] _A Study with the Electrocardiograph of the Mode of Death of
  the Human Heart. Journal of Experimental Medicine_, 1912, xvi,
  291.

Crile's experiments upon dogs show that it is possible to resuscitate
these animals after they have been apparently dead for periods of
time up to seven and a half minutes. The cessation of the blood
circulation causes degenerations in the nerve cells and fibres, and
these lesions may last even if the animal has been resuscitated.
Crile thinks the human respiratory centre may survive anemia from
thirty to fifty minutes; the vasomotor and cardiac centres, about
twenty to thirty minutes; the spinal cord, eight to ten minutes; the
motor cortex, eight to ten minutes; the portion of the brain used in
conscious activity as such, six to seven minutes. The higher neurons
have been stimulated into reflex activity twenty-five minutes after
complete clinical cardiac cessation of activity.

In any attempt to resuscitate a person apparently dead the
maintenance of the blood circulation is the chief end. If,
however, the blood is not oxygenated the circulation will not go
on automatically. Artificial respiration is used, and the active
principle of the adrenal gland is injected to stimulate the heart.
If the heart has stopped in diastole,--that is, when distended with
blood,--this distention must be relieved by cardiac massage, commonly
through an opening in the thoracic wall. Intratracheal insufflation
of oxygen is also to be employed, as a rule.

In _Essays in Pastoral Medicine_[61] I mentioned several cases of
resuscitation after what had appeared to be certain death. Two of
these had been "dead" for forty-five minutes before they were revived
temporarily. Wayne Babcock[62] reported a number of new cases of his
own. One was a resuscitation which lasted for forty-three hours, and
which was begun twenty-five minutes after respiration had ceased.
The patient was a very fat negress who had collapsed after the use
of scopolamine. A man whose arm had been torn off died from shock in
the operating-room. After fifteen minutes of artificial respiration
the circulation started again, and he was kept alive for six hours
in this manner, but he died as soon as the artificial respiration
was discontinued. An exactly similar case was kept alive for seven
hours by artificial respiration. One of Babcock's cases was a woman
of eighty-seven years of age, who apparently died on the table during
an operation for strangulated hernia. After ten minutes of cardiac
and respiratory cessation she was revived. She died four days later
of peritonitis. A man fifty-six years of age undergoing the same
operation ceased breathing and his heart stopped. He was completely
revived and cured.

  [61] New York, 1906, p. 164.

  [62] _Proceedings of the American Therapeutic Society_, 1912.

Father Juan Ferreres[63] holds that aborted and newly born children
should be baptized, although they give no sign of life, if they show
no clear evidence of putrefaction. This opinion is mine also, but the
word maceration should be substituted as more exact. Eschbach[64]
says: "Infantes recenter natos et in vitae discrimine positos, aut
foetus abortivos plane formatos, cum vel levissimus in eis motus
apprehenditur, absolute baptizari oportet: cum autem sine motu et
sensu iidem videantur neque tamen adhuc corrupti aut putrefacti sint,
sine mora baptizentur conditionate: _Si vivis, ego te baptizo_, etc."
These quotations give the common opinion of moralists at present,
and this opinion is fully safe. Eschbach, however, would have the
fetus "plane formatus," which is erroneous and an echo of the old
Aristotelian notion. If the fetus is visible at all, open the
membranes and baptize it conditionally, even if it is not as big as a
pea.

  [63] _La Muerte Real y Apparente_, 4th ed., p. 21. Madrid, 1911.

  [64] _Quaestiones Physiologicae-Theologicae_, disp. 3, p. 2, c.
  3, a. 3.

An infant born apparently dead may be resuscitated after a delay
very much longer than would be possible in an older person, provided
always the infant has not begun to breathe.

Ferreres mistakes cases of catalepsy which have recovered
consciousness for cases of apparent somatic death. In these
cataleptic conditions the blood circulation does not completely
cease--if it did the nervous centres would be disintegrated. The case
he reports on p. 26,[65] of the woman resuscitated by Rigaudeaux in
1748, was one of catalepsy, if it ever happened. The same is true
of the case from Gaspar de los Reyes,[66] which probably had some
foundation in a condition of catalepsy, but which more probably is a
sheer invention by Reyes. It looks like an anecdote from a medieval
Florentine _novella_.

  [65] P. 30 in the English translation.

  [66] P. 35; p. 39, English translation.

Old writers speak of cessation of the pulse for long periods.
Ballonius[67] mentions a person in whom there was no pulse for
fourteen days before death; Ramazzini[68] describes a cessation of
the pulse for four days before dissolution; Schenck[69] tells of a
disappearance of the pulse for three days, with recovery. These all
were apparently cataleptic cases, where the circulation was very
feeble and the radial pulse was not palpable. Cheyne gives an account
of a Colonel Townsend who had the power of apparently dying at will.
He could so suspend the heart action that no pulse could be felt,
and after a short while the circulation would become normal again.
The longest period in which he remained in this condition was about
thirty minutes. St. Augustine mentions a priest named Rutilutus who
had a power like that of Colonel Townsend, and Caillé[70] reported a
similar case.

  [67] _Opera Medica Omnia._ Geneva, 1762.

  [68] _Epistolae_, 1692.

  [69] _Observationum Medicarum_, etc. Frankfort, 1600.

  [70] _New Orleans Medical and Surgical Journal_, xvi.

The fakirs of India carry this power to great lengths. Braid,[71]
on the authority of a Sir Claude Wade, says a fakir was buried
unconscious at Lahore in 1837, and the grave was guarded day and
night by sentinels from an English regiment. Six weeks after the
burial the man was dug up and he presented all the appearance of
a corpse. The legs and arms were shrunken and stiff, and the head
reclined on the shoulder, as happens in corpses. There was no
perceptible circulation anywhere, yet he revived.

  [71] _Treatise on Human Hibernation_, 1850.

Honigberger, a German physician in the service of Runjeet Singh,
described[72] a fakir of the Punjaub who was put into a sealed vault
for forty days, and the seal of Runjeet Singh was on the coffin.
Grain was sown above the vault and it was well above the ground
when the man was taken out of the vault and resuscitated. Sir Henry
Lawrence testified to the truth of this story. The fakir's chin was
shaved, Honigberger says, before the burial, and the beard did not
grow while he was in the vault.

  [72] _Medical Times and Gazette_, vol. i. London, 1870.

In keeping with these stories are many curious accounts of recovery
after hanging. These are frequent in writings of the sixteenth
and seventeenth centuries, when hanging was almost an every-day
occurrence. These narratives are much more authentic than the
anecdotes told of recovery after premature burial, which are as old
as literature. Paul Zacchias[73] tells of a young man who died of
the plague and was set out with the corpses for burial. He revived
and was taken back to the pest-house. He "died" again and was again
prepared for the grave, but he came to a second time. The stock story
in these premature burial cases is that of the woman who is revived
by a thief who cuts her finger in an effort to steal the rings buried
with her.

  [73] _Quaestiones Medico-Legales_, 1701.

The important fact, however, is that in any case of death the exact
moment in which the soul leaves the body is not knowable by any
means we have at present, and where there is question of giving the
sacraments the person apparently dead should have the benefit of the
doubt. He is to receive conditional baptism, absolution, or extreme
unction (preferably by the short method), in case these sacraments
are required. For a whole hour after apparent death the probability
that the soul has not departed is so strong that, in my opinion, a
priest who does not give the necessary sacraments is virtually as
guilty as if he neglected to administer them to a person evidently
alive. Crile, one of the best medical authorities on this matter of
somatic death, holds that the human respiratory system may survive
anemia for from thirty to fifty minutes. How long after the hour a
priest may administer the sacraments is not known, but a second hour,
or even a third, are not unreasonable periods of time during which
the sacraments may be administered conditionally. The sacraments
are for man, and there is no irreverence if they are administered
conditionally and the priest explains to the bystanders the reason he
has for his action.

If a pregnant woman dies slowly, the fetus in her womb is likely to
die owing to lack of oxygen; if she dies suddenly, the child may
live for variable periods in various cases. Brotherton reported
a case where a living child was taken from a woman twenty-three
minutes after the death of the mother. Tarnier, the noted French
obstetrician, told of a remarkable incident which happened in Paris
during the rioting by the Commune after the war of 1870. The rioters
fired on a maternity hospital, and a pregnant woman sitting on a bed
in a ward was instantly killed by a bullet through her head. After a
while she was discovered dead, and Tarnier was sent for to save the
fetus, as its heart-sounds could be heard through the abdominal wall.
When he began the operation the hospital was fired upon again, and
it was necessary to carry the corpse to the cellar of the building.
There Tarnier, an hour and three quarters at least after the death
of the women, extracted a living child from the corpse. Hirst[74]
tells of another case which was narrated to him by an American naval
surgeon who saw it in the harbor of Rio Janeiro during the revolution
at the beginning of the present republic of Brazil. A woman near term
was killed instantly by a piece of shell. As soon as she fell to the
ground a Brazilian surgeon, who was standing near by, cut open her
abdomen with a penknife and drew out the child, but it was already
dead.

  [74] _A Textbook of Obstetrics_, 7th ed., p. 643. Philadelphia,
  1912.

Mack[75] was called to a pregnant woman, and he found she had died
suddenly about five minutes before he arrived. He at once opened the
uterus with a small lancet and extracted a child which was beyond
the livid stage and had no heart-sound. He worked on the child for
forty minutes, using the ordinary methods for reviving asphyxiated
children, but got no sign of life. Then he injected a hypodermic
syringeful of a 1:1000 epinephrin solution through the umbilical cord
into the abdomen and continued the reviving motions. In ten minutes
the child was crying vigorously, and it was a healthy baby afterward.

  [75] _Journal of the American Medical Association_, August 28,
  1915.

Gunn and Martin,[76] in experiments on rabbits poisoned by chloroform
and apparently dead, found they could resuscitate about 70 per cent.
of the animals if treatment was begun within ten minutes after the
heart ceased beating. They started artificial respiration through a
tube in the trachea, then injected epinephrin into the pericardium,
and afterward massaged the heart through an opening in the abdomen.
The rate of compression of the heart in this massage must be somewhat
less than half that of the normal beat, and at short intervals the
massage is to be stopped to allow the spontaneous beats to develop.
Compression should be gradual and the relaxation abrupt. The massage
is applied by one of these four methods, and they are arranged
here in the order of their efficiency: (1) by direct compression
of the heart through an opening in the thorax; (2) by compression
above the diaphragm through an opening in the belly-wall; (3) by
simple compression of the abdomen; (4) by simple compression of the
thorax. Epinephrin, or pituitary extract, is used as an adjuvant
intravenously to increase the cardiac movement after it has been
started. The same methods will probably be effective in man, and have
been used successfully.

  [76] _Journal of Pharmacology and Experimental Therapeutics._
  Baltimore, July, 1915.

       *       *       *       *       *

When a woman is _in articulo mortis_ with a living fetus in her womb,
one should not wait for her death. If one waits, he will nearly
always lose the child. The cervix should be dilated forcibly, the
child turned and delivered. Even if this forcible delivery should
happen to hasten somewhat the mother's death, the action would be
morally licit. It would be a double-effect action; the two effects
would proceed immediately and equally from the act, which is
indifferent morally; one effect, the good one, is to save the child
for baptism at least, and possibly permanently; the second, evil but
reluctantly permitted, is the possible hastening of the maternal
death. I should be willing even to slit the cervix, if necessary,
provided the diagnosis were certain, with the possibility of tearing
the uterus, in a case where the dilatation of the cervix would be too
slow a method; but this supposition is scarcely practical.

Zsako[77] gives a method for determining the interval since death
by muscular phenomena. Tapping with a percussion hammer on certain
muscles of the body excites a reflex contraction up to from an hour
and a half to two hours after death. The contraction may be elicited
in the same manner on the living, but it is more evident on a cadaver
owing to the absence of antagonistic tonus in the muscles. Some
muscles may move for four hours after death. Tapping along the radius
from the elbow downward, he says, a point is found where the stroke
causes extension of the hand; tapping along the radius above the
wrist makes the thumb bend; tapping on the spaces between the bones
of the hand closes up the corresponding fingers; tapping on the back
of the foot extends the toes, on the leg adducts the foot, on the
tibia along the middle third extends the leg. When the lower third
of the thigh is tapped across the muscles move, and if the back is
struck between the scapula and the spine the shoulder blades move
toward each other. If there is no response the person must be dead
from two to four hours. I have had no experience with this method.

  [77] _Münchener medizinische Wochenschrift_, January 18, 1916.

Satre[78] reported that many soldiers brought into the
dressing-stations apparently dead from shock, head or spinal wounds,
or gas asphyxiation, were revived after artificial respiration
had been applied, sometimes for even six hours before results were
obtained. Two tests were used to find out whether the patient was
alive or not. In such cases ten c.c. of a 20 per cent. alkaline
solution of fluorescine is injected subcutaneously, and if there is
any circulation this dye will be carried to the eye and turn the
conjunctiva green. The second test is to push a fine puncture-needle
into the spleen or liver and thus remove a particle of the pulp.
This pulp is put on blue litmus-paper and drawn free from blood. If
the litmus-paper turns red the man is dead; if it remains blue he
is alive. The reaction of the living pulp is alkaline, blue; this
becomes acid, red, a half-hour after death; an hour after death the
acid reaction is quite marked.

  [78] _Presse Médicale_, Paris, xxiv, 66.




CHAPTER V

ABORTION


Abortion, as the term is used by physicians, in its widest sense
is the ejection or extraction of a fetus from the womb at any time
before term. The word is popularly contrasted with miscarriage, where
the fetus is ejected through disease or accident; abortion in the
lay sense supposes artificial, and commonly criminal, extraction of
the fetus. Abortion (from _aboriri_, to perish) etymologically has
an association with destruction of life, but the name is given by
physicians to a removal of any premature fetus, even if it is viable.
Strictly, however, abortion is an interruption of pregnancy before
the fetus is viable, and premature labor is such an interruption
after the fetus is viable. Throughout this chapter the words are used
in this sense.

Abortion as a medical and moral consideration may be considered from
several points of view.

First, involuntary pathologic and accidental interruptions of
pregnancy are to be averted, if it is possible to do so, to save the
life of the child; and when the abortion is inevitable the treatment
has moral qualities which involve the physician and the mother.

Secondly, voluntary and therapeutic abortion has peculiar moral
and medical qualities arising (_a_) from the period of gestation
or the viability of the child; (_b_) from the truth or error in
the diagnosis as regards the necessity for interference, and the
advantage or damage resulting from the interference.

Thirdly, the technical skill or ignorance of the physician, and the
methods he employs may in themselves in any case avert or cause
the death of the mother or grave injury to her, and in the forced
delivery of premature infants may save, kill, or maim the child.

Fourthly, voluntary criminal abortion has a special malice of its
own, which makes it somewhat more criminal than the therapeutic
removal of an inviable infant.

Fifthly, there are positive canonical and civil penalties against
abortion as it affects the inviable infant.

Pathologic abortions, and those arising from accident or
carelessness, are extremely common. Hegar estimated that there is
one of these abortions to every eight normal parturitions, and
specialists in obstetrics find as many as one abortion to four
deliveries at term. These abortions are most frequent from the eighth
to the twelfth week of gestation, because the ovum is then not
firmly attached to the uterus, and it readily succumbs to external
influence. Moreover, the woman is not certain she is pregnant and
neglects precautions. Many women, again, are under the error that
there is no moral evil in getting rid of the ovum before quickening,
and they think quickening occurs only when they feel the fetal
movements. Others, erroneously again, fancy that abortion in the
early months is not dangerous or injurious to themselves.

The causes of pathologic and accidental abortion are very numerous
and often interactive. They may arise from the fetus, the mother, the
father, or from violence. The death of the fetus, or diseases of the
fetus itself or of its appendages, cause abortion. Weakness of the
fetus from alcoholism in the parents, anemia, carbon monoxide and
lead poisoning, tobacco poisoning in women who are cigar-makers, and
similar conditions in one or both parents, will bring on abortion.
Monsters rarely go on to term. Acute or chronic affections in the
mother, as typhoid, malaria, smallpox, cholera, scarlatina, measles,
tuberculosis, and the like, and syphilis in the mother or father,
effect abortion. Other abnormal states that bring on abortion are low
blood-pressure in maternal anemia, shock, syncope; hemorrhages into
the placenta in maternal nephritis; hemorrhages between the placenta
and uterus from diseases of the placenta and decidua, or from
traumatism, which detach the placenta; sun or heat stroke; sudden
high temperature in fever; toxemias, as in some forms of hyperemesis
gravidarum, eclampsia, chorea, hepatic autolysis, and impetigo
herpetiformis.

Chronic endometritis, or inflammation of the lining membrane of
the uterine cavity, is the commonest maternal cause of abortion,
especially of habitual abortion. In this condition hemorrhages in
the decidua, or uterine fold that holds the fetus, kill the fetus,
or force the ovum off the uterine wall, or excite expulsive uterine
contractions. Without hemorrhage endometritis prevents a firm
fixation of the ovum, or it may bring about a malposition of the
placenta, called placenta praevia. Endometritis at the decidua may
cause hydrorrhoea gravidarum, and the accumulated serous secretions
from this source are likely to start uterine contraction. Chronic
metritis, or inflammation of the deeper tissues of the uterus, is
commonly found with endometritis, and it prevents the expansion of
the uterine muscle. This condition is more likely to cause abortion
than endometritis alone.

Acute gonorrhea, inflammations of the Fallopian tubes, and
appendicitis sometimes interrupt pregnancy. Other causes are
malformations and diseases of the uterus, infantilism, fibroids,
polyps, uterine horns, lacerations and amputation of the cervix, and
retroversions and retroflexions of the uterus. At times a replacement
of the uterus will avert an abortion.

When the mother has an infectious disease like typhoid, smallpox,
cholera, or typhus, the infection may reach the fetus and kill it,
or may cause an endometritis with a hemorrhagic tendency. Maternal
sepsis may kill the fetus directly or secondarily, and this is
true also of maternal syphilis. A sudden rise in temperature may
excite expulsive uterine contraction. In pneumonia the excess of
carbon dioxide in the blood may bring on abortion. Like pneumonia,
anesthesia may kill the fetus if kept up for a long time, or if
marked by cyanosis. Prolonged nitrous-oxide anesthesia is especially
dangerous to a fetus, but a brief nitrous-oxide anesthesia for the
extraction of a tooth may not bring on abortion. The worst tooth
stump can be extracted painlessly after local injection of novocain,
with no danger to the fetus. The gums remain somewhat sore for a day
or two after novocain infiltration, but this inconvenience is a much
less evil than total anesthesia, even when there is no pregnancy. It
is probable that total anesthesia is morally unjustifiable for the
extraction of a single tooth if the tooth is not wedged in.

Violence, accidental or intentional, is a frequent primary or
secondary cause of abortion. Sometimes a slight jar, a misstep on
a stairway, a nervous shock, a jump from a carriage-step, lifting
weights, running sewing-machines, sea-bathing, a rough automobile
ride, will bring on an abortion where there is a predisposition.
Often in healthy women, on the other hand, extreme violence does
not interrupt pregnancy. Surgical operations are classed here with
violence. In a neurotic woman a slight operation on an organ not
directly connected with the uterus will start expulsive contractions.
Again, 66 per cent. of operations on ovarian tumors during pregnancy
have left the uterus undisturbed. De Lee says he has removed fibroids
from the pregnant uterus, once even exposing the chorion, and has
amputated the cervix of a gravid uterus, without interrupting
pregnancy. Several cases have occurred where both ovaries have
been removed during pregnancy without abortion. The breast has
been amputated and a kidney removed from a pregnant woman[79]
without disturbing the pregnancy. Wiener[80] did eleven operations
for ovarian tumors during pregnancy with only two abortions. Von
Holst[81] removed a myoma weighing two and a half pounds from the
uterus at the seventh month of gestation without abortion. Davis
of Birmingham, Alabama, reported[82] that a woman three and a half
months pregnant was shot in the abdomen. The rifle bullet made
twenty-five perforations in her intestines. She was taken eighty-five
miles, and then Davis cut out five feet of the intestine. She
recovered and gave birth to a living child at term.

  [79] Cronk, _Oklahoma State Med. Assoc. Jour._, July, 1816.

  [80] _Amer. Jour. Obstet._, August, 1915.

  [81] _Upsala Läkareforenings Förhandlingar_, xxi, 8.

  [82] _Journal Amer. Med. Assoc._, October 28, 1916.

Double ovariotomy brings on abortion in the early months of
pregnancy oftener than in the later, probably from the loss of the
corpus luteum, which, it appears, is necessary for the growth of
the uterus. Appendicitis and appendectomy are especially likely
to interrupt gestation, apparently as a result of infection and
because pregnant women are prone to defer operation. The traumatism
of criminal abortion, punctures and lacerations from bougies and
curettes, and the exhibition of drugs like ergot and cantharides,
are sources and results of abortion. Drugs will not empty the uterus
unless they are given in poisonous doses which endanger the woman's
life.

In the father, syphilis, tuberculosis, general paresis, general
debility from alcoholism, unchastity, and senility, and septic
conditions of the generative tract, may cause abortion. Many men
who work with lead, phosphorus, mercury, or X-rays are sterile, and
before they become totally sterile their condition appears to cause
debility in the fetus which leads to abortion. In paternal lead
poisoning there is a reduction of about 20 per cent. in the weight
of the infants at birth, and a general weakness and retardation of
the child. The children of lead-poisoned fathers are frequently
permanently under weight.

Coition during gestation is a cause of abortion, and the fault here,
as a rule, lies with the husband. St. Thomas[83] said: "St. Jerome
protests against the sexual approach of the husband to his gravid
wife, not that in this condition such an act is always a mortal sin,
unless there is probable danger of abortion." St. Alphonsus[84]
says if there is danger of abortion the use of the debitum is a
grave sin. In n. 924 he again teaches that while it is true that
if by the use of the debitum the life or formation of the fetus is
endangered or checked the right to the use of the debitum is, in such
circumstances, lost, yet he thinks that in pregnancy there is little
danger of abortion from this cause, especially near term.

  [83] _In. 4, dist. 81._

  [84] _Theologia Moralis_, n. 943.

Sabetti-Barrett[85] says the wife is excused from the debitum
conjugale if the husband is drunk, or if there is a rational dread of
grave injury, or grave danger to health. Genicot[86] thinks that in
pregnancy it "can scarcely be shown that there is a notable danger of
abortion." Lehmkuhl[87] holds that a married person is not obliged to
grant the debitum if there is great danger of abortion; but, he adds,
"Even then, if there is a grave danger of incontinence I do not think
it certain that there is an absolute obligation to abstain."

  [85] _Theologia Moralis_, n. 936.

  [86] _Theologiae Moralis Institutiones_, vol. ii, n. 544.

  [87] _Compendium Theologiae Moralis_, n. 1114.

Unlike Lehmkuhl, moralists agree that if there is real danger of
abortion from marital congress, such an act is illicit, but they are
inclined to think that there is little or no danger of abortion,
especially at the end of gestation. Authorities on obstetrics, on
the contrary, say that one of the causes of abortion in the early
months of pregnancy is marital congress; and one of the sources
of sepsis in women, which may result in the death of both mother
and child, is certainly congress at the end of gestation. This
causation of abortion is found especially in neurotic irritable
women, in such as have diseases of the generative tract, or a
tendency to habitual abortion. Whenever a woman shows any tendency
to bleeding during gestation the use of the debitum is undoubtedly
contraindicated, because of the proximate danger of both abortion
and septic infection. Toward the end of pregnancy the danger from
sexual commerce is the risk of infecting the woman's vagina with
bacteria which may bring on sepsis through the abrasions incident
to parturition. The staphylococcus pyogenes albus, a dangerous
septic microörganism, exists as a saprophyte in 50 per cent. of
male urethras, and the bacillus coli communis is another source of
infection from the father during pregnancy. De Lee saw two cases
of sepsis that killed both mother and child from such an infection
shortly before term. If a physician now examines a woman before
delivery without using all the precautions known to prevent sepsis,
such as wearing a sterile rubber glove, he is guilty of malpractice;
yet certain moralists are inclined to let a husband do what he likes.
Moralists talk about the fetus as protected in the membranes. That is
nonsense, because it has no relevancy to the question. It can have
the slight relevancy of untruth when the woman is rendered septic,
because then the membranes are no protection at all.

The mortality statistics of the United States Census Bureau show
that a little more than 42 per cent. of the infants who died in the
registration area in 1911 did not last throughout the first month of
extrauterine life, and of these babies almost seven-tenths died of
prenatal and delivery abnormalities. In 1912, in the registration
area, which then took in 63.2 per cent. of our population, the
total death-rate of infants under a year old was 9035, and of these
3905 died of puerperal infection. In the entire country a very
conservative estimate of the annual number of deaths of infants from
puerperal sepsis is 5000; and about 15,000 women die here yearly
from this etiology alone. Of course most of these deaths are caused
by unclean midwives and quacks, but a large number of them are
brought about by incontinent husbands. Invalidism from puerperal
sepsis happens many times 15,000. Moreover, one-third of all the
blindness in the world is caused by septic infection of the eyes at
birth and virtually all this septic infection of the eyes is carried
in by diseased husbands, although not necessarily by coitus during
gestation.

Coition during pregnancy is unnatural because it necessarily fails
of the end of coition, which is procreation. Curiously, too, all
the lower animals instinctively appear to avoid this act during
pregnancy. Men should be told that marriage has restraints as well
as celibacy. Women are reminded of the law of the debitum, but not
of the occasions when they are even obliged to deny it. If a man
cannot keep continent in the presence of his pregnant wife, let him
live in another part of the house. Regard for the woman is lacking
in many ways. Young girls often marry without having the faintest
notion of sexual life, and they are panic-stricken when assaulted.
I have known two who were frightened into insanity. Priests should
tell young married men that they are human beings, not animals; that
they should act like rational beings when they are first married; and
that after the wife has become pregnant the husband should not be the
cause of abortion in the first three months, nor of puerperal sepsis
in the last three months. Priestley,[88] in 2325 pregnancies, found
one abortion in every four pregnancies; Guillemot and Devilliers in
France, Hirst in Philadelphia, and others report the same proportion.
These are natural, not criminal, abortions. If, then, in normal
pregnancies about one child in five is lost before birth, husbands
should be taught a continence which would to some degree avert this
calamity. Superfetation has occurred by coition during pregnancy, and
this results commonly in abortion and the death of both fetuses.

  [88] _Pathology of Intrauterine Death._ London, 1887.

Premature labor in cases where the child is viable is produced by
the same agencies that interrupt gestation in the early months.
Obstetricians think that syphilis is the commonest cause of premature
labor, and they estimate that from 50 to 80 per cent. of these
premature births are due to syphilis. In a series of 705 fetal deaths
in Johns Hopkins Hospital, 26.4 per cent. were due to syphilis. After
syphilis the cause of premature labor next in frequency is nephritis
with placental hemorrhages and infarcts. Twins are not seldom
delivered prematurely because of lack of room in the uterus. For the
same reason any tumor of the uterus or abdomen may cause an abortion.

When successive pregnancies are interrupted prematurely the abortion
is said to be habitual, and again the commonest cause is syphilis.
In this disease, as the virulence of the infection decreases, the
gestation is prolonged until a child is born infected with congenital
syphilis. This child commonly dies, and later a child strong enough
to live appears. Correct treatment of the parents will avert this
slaughter of the innocents. Sometimes the syphilis is latent so
far as clinical symptoms are concerned, but we may find a positive
Wassermann reaction. Hubert reported[89] that 8.8 per cent. of 8652
patients in a clinic at Munich where all were subjected to the
Wassermann test had latent syphilis, and in 52 per cent. of these
cases in men, and 75 per cent. in women, the infection was altogether
unknown to the patients.

  [89] _Münchener medizinische Wochenschrift_, lxii, 39.

Chronic endometritis, where there is no syphilis, will permit
habitual abortion, and each abortion makes the condition worse.
Nephritis, diabetes, and other constitutional diseases cause habitual
abortion.

In the first two months of gestation the decidual fold which
holds the ovum against the uterine wall is thick, vascular, and
friable. The contracting uterus in abortion expels the decidua with
considerable difficulty, but the ovum containing the fetus may slip
out easily and be lost. A fetus two months old is about three-fourths
of an inch in length. If a physician, nurse, or other person finds
the ovum, no matter how small it is, they should open it at once with
a scalpel or scissors and baptize the fetus conditionally, even if
no sign of life is perceptible. If the fetus is unmistakably dead--a
diagnosis not easily made--there is no use in attempting baptism;
but always give the fetus the benefit of the doubt. In the first six
or eight weeks the whole ovum is usually born developed in decidual
tissue; sometimes the ovum will slip out of the decidua and be
covered only with shaggy villi, suggestive of a chestnut burr.

During the third and fourth months there may be (1) an abortion
of the whole ovum; or (2) the membranes may rupture, the fetus be
expelled, and the secundines remain in the uterus, and these may have
to be removed by instrument or finger; or (3) the decidua reflexa
and the chorion may split and let out the fetus into the amniotic
sac: here again the remaining secundines, if they do not come away
spontaneously, must be removed. Abortion after the fifth month is
like a regular labor at term, but not so energetic.

An abortion may be threatened, inevitable, or incomplete. In each of
these conditions there is uterine pain and hemorrhage. In inevitable
and incomplete abortions we find softening and dilatation of the
cervix, and a presentation or expulsion of part or all of the ovum.

In pregnancy uterine hemorrhage and uterine pain are symptoms of a
threatened abortion, but not certain symptoms. Fromme found that
17.9 per cent. of 157 women who had these signs in the early months
went on to term. If the fact of pregnancy is not known it is not
always easy to differentiate a threatened abortion from other
uterine conditions, like chronic metritis, ectopic gestation, a
fibroid or other tumor, hemorrhage from cervical erosions or varices,
or malposition of the uterus. If the abortion is inevitable the
diagnosis is made more readily. The cervix is then more or less
dilated and the ovum is palpable. There is rather profuse hemorrhage,
flooding, and painful uterine contractions are evident. The rupture
of the bag of waters may be simulated by the escape of secretions
in hydrorrhoea gravidarum, or the escape of waters may be a primary
symptom of graviditas exochorialis. Hydrorrhoea gravidarum is an
intermittent discharge of clear or bloody fluid from a catarrhal
endometritis under the decidua. It occurs in anemic, weak women,
especially multiparae. In graviditas exochorialis the fetus is left
within the womb but outside the ruptured chorion, and it may remain
there for some time.

When an abortion is incomplete it is absolutely necessary to learn
whether the entire ovum and decidual tissue have been expelled or
not. When a part or all of the dead ovum is retained the consequences
are so grave that they may result in the death of the woman or cause
chronic invalidism. Sepsis may result, a placental polyp may form,
and even syncytioma malignum may start--this fatal tumor, however,
is not so common after incomplete abortion as after hydatid mole
formation.

The prognosis as regards health is worse after abortion than after
normal pregnancy. The involution of the uterus is slower than in
full-term cases, and if infection has occurred there is great
likelihood of a chronic endometritis and metritis. The woman may be
rendered sterile, or she may become a chronic invalid to be cured
only by capital operations.

In threatened abortion examination is to be avoided unless it is
absolutely necessary for diagnosis, and then great gentleness is
required so as not to excite uterine contractions. The woman is to
rest in bed, not so much as raising her head to take a drink of water
(which is given to her through a tube), and she is morally obliged
to submit to this inconvenience. If she refuses she is accountable
for the death of the fetus. If there is bleeding the foot of the
bed should be elevated as in hemorrhage in typhoid fever. The
routine practice is to quiet the woman and the uterine irritability
with morphine and other opium derivatives. Children are readily
overwhelmed by opium because their circulation is not sufficient to
neutralize the deoxidizing effects of the drug up to safety. While
the embryo is connected with the maternal circulation through the
placenta the mother's circulation often safeguards the fetus from the
effects of the opium. The danger to the child in such cases begins
from the opium remaining in its circulation after the child has been
separated from the mother. Often, however, fetuses in cases where
scopolamine and morphine have been used on the mother during labor
are born badly, and even fatally narcotized, despite the connection
with the maternal circulation. Nevertheless, even if there is some
real danger to the fetus from the use of morphine in a threatened
abortion, the cautious use of this drug would be morally justifiable.
Should the threatened abortion go on to actual abortion, the fetus
will certainly be killed, but the use of morphine on the woman is
the best and virtually the only means we have to avert a threatened
abortion and so save the fetal life. The immediate double effect from
the morally indifferent act of giving a dose of morphine is, on the
good side, the saving of the fetal life, and on the other, the evil
side, the danger of fetal narcosis, which is not at all certain to
follow. Evidently, the good intended effect far overbalances the evil
and somewhat hypothetical effect.

After about five days, if the bleeding ceases, the woman may be
permitted to go back to her ordinary routine of life, but with
extreme caution, and she must return to bed at the slightest show of
blood. Morphine is used at the beginning to quiet the patient and the
irritable uterus. If the cervix is eroded, applications of a 10 per
cent. nitrate of silver solution are made. The bowels are kept locked
for three days and a softening enema of olive-oil is used before
emptying the bowel.

If the bleeding starts again every time the woman goes about her
duties, the abortion may be inevitable. When the cervix is shortened
and dilated so that the ovum is palpable and pieces of the decidua
or ovum are expelled, the hemorrhage is more or less profuse, and
especially if the bag of waters has ruptured and uterine contractions
show, the abortion is deemed inevitable. In such a case the fetus
may be alive, or it may be dead; and, again, conditions which
show all the classic symptoms of inevitable abortion sometimes,
though rarely, do not go on to abortion. It is extremely difficult,
and often impossible, to tell whether an early fetus is dead or
alive. A high, lasting fever sometimes kills the child; so do low
blood-pressure, profuse hemorrhages, deoxidation of the blood in
pneumonia, separation of the placenta, fatty degeneration of the
placenta, and the severe infections--in such cases there is always
strong probability that the child is dead when the abortion shows
its symptoms. If the fetal tissues that appear indicate maceration,
or if the discharge is fetid or purulent, the fetus is dead. Should
the fetus be alive, tamponing the vagina to check the hemorrhage
often separates the fetus from the uterus by the dissecting force of
the blood dammed back, or in any case tamponing is almost certain to
excite uterine contractions; thus there is an indirect killing of the
fetus.

The treatment of inevitable abortion after the fifth month differs
very much from the methods used in the early months. The prime
principle is, never interfere until forced to do so. When the
hemorrhage is dangerously profuse, so that the woman's life is
endangered (an exceptional condition), the uterine cervix and the
vagina must be tamponed with sterile gauze and cotton to check the
bleeding, but this is a last resort. If the fetus is alive, or
probably alive, nothing short of a necessity to save the woman's life
by this means justifies the use of the tampon. De Lee advises the
routine use of the tampon in threatened abortion, but this doctrine
is erroneous medically and altogether false morally. If the physician
knows the fetus is dead, he should, of course, tampon at once to get
rid of the fetus. The tampon excites uterine contractions and causes
destruction of a living fetus by dissecting it loose from the uterine
wall through the dammed blood. Elevation of the foot of the bed and
the use of morphine will, as a rule, check the bleeding.

When the woman is bleeding _to the risk of her life_, the tampon is
put in to check the bleeding and so save her life. The double effect
immediately following this indifferent act is on one side good,
the saving of her life; on the other side evil, the killing of the
fetus. The good effect is intended, the evil effect is reluctantly
permitted. Such a procedure is morally licit.

Where a tampon must be put in, it is left in from sixteen to
twenty-four hours, even if the temperature goes up. During this
time there are painful contractions of the uterus, as a rule, and
these are expulsive. No drug is to be given to allay these pains if
the intention is to have a dead or viable fetus expelled. If the
pains cease suddenly, this is usually a sign that the fetus has been
expelled above the tampon. When the tampon is removed and the entire
ovum is found, it is best for the ordinary physician not to meddle
with the uterus in any manner. Some advise that the physician should
go over the uterine lining with a half-sharp curette to make certain
that nothing has been left behind, but this is dangerous advice to
any one who is not an expert obstetrician. Should the temperature
remain above 100 degrees, the uterus must be cleaned out, and
flushing with uterine catheters is not enough: if the gloved finger
cannot remove the secundines, the curette is needed.

If, when the tampon has been removed, no ovum is found and the
cervix is still closed, another tampon is to be put in for another
twenty-four hours, supposing the removal of the ovum is licit.
Forcible dilatation of the cervix is always a dangerous operation,
and should never be employed when avoidable. Steel dilators have
ruptured the uterus and killed the patients again and again even
when used by experts. Laminaria tents are not to be recommended; the
tamponade is enough.

When the retained ovum cannot be removed by the finger or squeezed
out, the free portion of the ovum is to be grasped by an ovum forceps
and gently drawn out. The operator should be sure he has a part of
the ovum in the forceps and not a part of the uterine wall. If he
bites into the uterine wall (a common catastrophe), he may pull a
hole in that wall, and then the woman will probably die unless the
rent can be closed immediately after opening the belly. When the
abdominal cavity has been opened in such an event, the uterus is
also to be opened, cleansed, and sutured. This method is safer than
curetting where there is a rent. If one is certain the gut has not
been injured--and it is extremely difficult to be certain--vaginal
anterior hysterotomy may be substituted. Sometimes perforations,
when the uterus is not septic and the instruments are clean, are
not dangerous. Rest in bed, ice-bags, ergot, and opium cure without
operation.

Physicians who are called into an abortion case should always be
certain that no one has attempted to pass sounds, curettes, or
similar instruments, because a perforation may have been made by the
meddler which will be charged to the second man himself.

If a uterus is flexed it is easy to poke a curette or like instrument
through it at the bend, especially if the uterus is thin or friable
from sepsis. Again, the placental site is raised, it feels rough, and
the furrows in it lead one to think part of the placenta is still
adherent, whereas all has been removed. Repeated scraping, due to
this error, may dig a hole through the uterine wall. Perforation
in a septic case is practically always fatal to the woman. The use
of the curette supposes a special technic, and no physician should
presume to try its use unless he has been carefully and practically
instructed.

In inevitable abortion after the third month it may be very difficult
to get the embryo out. The cervix, in primiparae especially, may be
long, thick, and hard. If the fetus is dead, it may then be removed
by _morcellement_--_i. e._, by cutting and breaking it into pieces,
and then taking out these pieces with an ovum or stone forceps.
Sometimes, though rarely, the operator may find it impossible to get
the entire fetus away. Then the uterus is packed with weak iodine
gauze, and after twenty-four hours the fetal remains are expelled.

In every abortion the presence or absence of extrauterine pregnancy
is to be made out. If there is an extrauterine pregnancy, curettage
will cause rupture of the sac.

When the interior of the aborting uterus has become septic the old
treatment was to empty the uterus at once, but now the treatment is
expectant, because the traumatism of the curetting makes the sepsis
worse. The commonest and worst infections are of the streptococcus
putridus, a pus staphylococcus, and the bacterium coli communis.
Curettage lets these microörganisms enter the circulation. The
cause of this condition is often unskilful attempts at artificial
abortion. When the womb contains decomposing material bleeding
usually obliges tamponing, and thus often the uterine contents come
away in twenty-four hours with the gauze. If there is no hemorrhage
there should be no tamponing: it is then better to get dilatation by
packing and drain the uterus with gauze. The curette should not be
used at all.

Where there is habitual abortion the cause must be found. During
gestation syphilis and displacements of the uterus, as causes,
may be treated. Endometritis can be cured only when the uterus is
empty. Rest in bed at the time when these abortions usually occur,
and at the time when menstruation customarily appears, is required.
Treatment of the husband is often necessary, as he is virtually
always the source of luetic infection.

Attention or inattention to the mother's own hygiene during
pregnancy has great effect on the fetus, and care of hygiene may
avert abortion. The woman's dress should be simple and warm enough
to prevent congestion from changes in temperature. Congestions are
likely to affect the kidneys, and care of the renal function is
always one of the most important facts connected with pregnancy. No
circular constrictions of the trunk by lacing or stiff corsets should
be attempted. The corset forces the uterus and child downward into
the pelvis and against the lower abdominal wall, causing congestion
of the pelvic veins and strain on the abdominal muscles. Tight
corsets, preventing the expansion of the uterus and the growth of
the fetus, may cause mutilations like club-foot and wry-neck, or
even kill the child. The woman who would "preserve her figure" by
corsets, to the mutilation, weakening, or killing of her unborn
infant, and this is an every-day evil, is either a criminal fool or
an unmitigated scoundrel. Tight lacing to conceal pregnancy is a
method of murder. High-heeled shoes are somewhat injurious because
of the constrained position into which they throw the woman. X-ray
photographing of pregnant women is very likely to cause abortion.

The woman's diet should be simple. She must abstain from all
alcoholic liquors even if she has been accustomed to their use at
meals. She should not overeat on the supposition that she has to
feed two persons. Some popular books advise a special diet to reduce
the bone-salts and thus get a smaller baby and one more easily
delivered. Such advice is criminal. The constipation of pregnancy is
not to be treated by strong cathartics like Epsom salt. The kidneys
are to be watched; therefore the urine should be examined every
three weeks up to the seventh month, then oftener. If there is any
suspicion of toxemia or nephritis, the urine should be examined
daily. Obstetricians who have any regard for their own conscience and
reputation will have nothing to do with a woman who refuses to take
this precaution.

Physical exercise should be gentle--say, walking, up to two miles in
the daytime. The vast majority of women are too lazy to take physical
exercise as a hygienic duty at any time, and during pregnancy their
aversion to all effort to overcome indolence is so great they make
even themselves believe they cannot. Just as most professional men
think they think, most women think they work. There are thousands of
women who have servants, yet make not only their families and friends
but themselves believe they are worked to death, and their work is
the spreading of four or five beds, and the ordering of groceries
over the telephone. When these women are pregnant they quit even the
bed-making.

Cold and hot baths, Turkish and Russian baths, hot sitz-baths and
ocean bathing are not permissible during gestation. Tepid baths and
spongings are to be substituted. Near term the bath-tub is not safe
because of danger of uterine infection from unclean water. Then
shower-baths are better, but these are dangerous if the woman must
step over an enameled bath-tub side to take them, because she may
slip and fall. Vaginal douches are not to be used in pregnancy except
in certain diseased conditions, under the direction of a competent
physician.

Therapeutic abortion and therapeutic induction of premature labor are
employed in five chief groups of conditions: (1) contracted pelvis;
(2) diseases caused by pregnancy; (3) diseases coincident with
pregnancy; (4) habitual death of the child after viability but before
term; (5) prolonged pregnancy. There is no such act as therapeutic
abortion of an inviable child; all abortions of inviable children,
when direct, are criminal, and nothing criminal is therapeutic. The
consideration of narrow pelvis, and the diseases caused by pregnancy
and coincident therewith, will be treated in detail.

When the child dies after viability but before term the cause is
most commonly syphilis. In such cases a Wassermann reaction should
be made from both parents; and even if it is negative, and no other
definite cause for the fetal death can be found, syphilitic treatment
should be tried on the father and mother. Bright's disease, even when
scarcely diagnosable, anemia, diabetes, adiposity, and hypothyroidism
are other lethal causes of habitually still-born infants. Not seldom
the cause is in the husband. If he is an alcoholic (and two or
three drinks of whiskey a day make any man an alcoholic), if he is
especially susceptible to the toxin of tobacco (and tobacco alone may
render some men not only sterile but impotent), if he is a worker in
poisonous metals, an X-ray operator, a user of narcotics, exhausted
with overwork and worry, affected with weakening systemic disease,
his germ-cells are unfit for their function. Such men are not
technically sterile, but they are practically sterile.

Some women carry the child beyond term, with the effect that the baby
is overgrown for normal delivery. The head is harder and more angular
than it should be, the long bones stiffer and less pliable, the
muscles tenser. All these changes make the delivery so difficult that
the overgrown child may be fatally injured at birth. Physicians must
be cautious in believing histories of enormous children at previous
births at which they were not present. Mothers and nurses are likely
to exaggerate the size of infants.

In cases where the children die at a particular time before term,
premature labor should be induced to save the child, and when the
child has been carried over term it may be necessary to induce labor.
In the first condition labor is not to be induced a week earlier than
is necessary. We talk so much of a seven months' child as viable
that we forget that any child born before the thirtieth week of
gestation has very small chance for survival. From 30 to 60 per cent.
of all prematurely delivered infants die. The maternal passages do
not dilate normally and the child is unformed; its bones fracture
readily; it cannot sustain pressures and strains. All induced labors
are dangerous to the mother by shock and possible infection, and only
very grave necessity justifies any such procedure.

In inducing necessary premature labor the technical method may take
on a moral quality. There are over a score of methods, and many of
these, although used, are dangerous and should be obsolete. A very
common method, begun in 1855, is to insert one or two elastic solid
bougies into the uterus between the membranes and the uterine wall.
This is a dangerous method and should be obsolete. Other dangerous
and obsolete methods are the puncture of the membranes with a trocar
high up in the uterus; intrauterine injections of hot or cold
water, glycerine, milk, and other liquids; vaginal tamponade alone;
irrigation of the vagina with carbon-dioxide water; a stream of hot
water directed against the cervix, electricity, X-ray, dilatation of
the vagina with a rubber bag, irritation of the nipples, the use of
drugs like quinine, cimicifuga, ergot, or cantharides.

If haste is not necessary, packing the cervical canal and the lower
uterine segment antiseptically with a strip of gauze three to
five yards long and three inches wide and leaving it in for about
twenty-four hours is one of the best methods. Where rapid delivery
is required, cesarean section must be employed. In cases of somewhat
less urgency the membranes are first punctured and balloon dilators
are used. In any case puncture of the membranes is the most certain
method to start labor, but it has many bad disadvantages. A dry
labor in a primipara with an undilated cervix is a grave condition.
If the fetal head is not engaged in the pelvis, puncture must not
be attempted. When the head is not engaged in the pelvis like a
ball-valve, the cord will prolapse, be pinched, and thus the blood
supply will be cut off from the child and the loss will kill it.
For the same reason, the waters must not be run off too quickly.
Many operators insert a bag, dilate, and so start the labor, without
puncturing the membranes, where there is no reason for haste.

Therapeutic abortion, as has been said, is never permissible, under
any circumstances, if the child is not viable. In certain conditions,
say, when a uterine tumor clearly threatens the life of the pregnant
woman, or if in extrauterine gestation there is a rupture of the
tube, an operation may be permissible, or even obligatory, which has
for its direct end the removal of the tumor or the stopping of the
hemorrhage. If such a removal or ligation, under these conditions,
indirectly causes the abortion of the inviable fetus, or its death
from a lack of blood, these indirect effects may be reluctantly
permitted. They are cases of an equally immediate double effect,
one good and one evil, where all the requirements are fulfilled.
A _direct_ abortion of an inviable fetus, however, is never licit
even to save the mother's life, and in abortion the killing is
_direct_ because it is used as a means to an end. In a ruptured
ectopic gestation the primary effect of the physical operation is
to ligate the torn arteries to save the woman's life here and now;
the secondary effect is the permitted death of the fetus from the
shutting off of the blood supply. In the abortion of a premature
fetus the primary effect of the operation is to separate the placenta
from the uterus, to cut off the child's blood supply, and as a direct
consequence of this act, which is essentially evil, the woman's life
is saved. The original act in this abortion is evil, and evil may not
be done even if good follows. Even in self-defence against an unjust
aggressor one may not kill a man to save his own life--he tries to
save his own life and reluctantly permits the death of the aggressor.
In a killing in self-defence there are two distinct effects; in
abortion there is only one effect, and the killing is a means to this
one effect. That you may kill an irresponsible insane man who is
attacking your life, or the life of one entrusted to your care, is no
reason that you may attack a fetus in the womb. There is no parity.
The insane man is a materially unjust aggressor; the fetus is not an
aggressor at all. The mother placed it where it is; and if any one is
an aggressor, she is. In the abortion you directly kill the fetus and
indirectly save the woman's life, and this indirection uses the death
of the fetus as a means to the end of saving the woman's life. In
killing the insane aggressor you directly save the life of yourself
or your ward, and reluctantly permit the death of the aggressor. The
proofs of the essential immorality of direct homicide have already
been established in the general chapter on Homicide.

The assertion that an undeveloped fetus in the womb is not as
valuable as the mother of a family is beside the question, and in
certain vital distinctions it is untrue. Any human life, as such,
whether in a fetus or an adult, is as valuable as another, inasmuch
as no one but God has any authority to destroy it, except when it has
lost its right to existence through culpable action. Secondly, the
quality of motherhood is an accidental addition to a mother's life,
not substantial as is the life itself. This quality of motherhood
does not create any juridic imbalance of values which justifies the
destruction of the rights inherent in the fetus. That the fetus may
not be able to enjoy these rights if the mother dies is, again,
an irrelevant consideration. There is no question of a comparison
of values. A life is a life, whether in mother or fetus, and the
destruction of an innocent life by any one except its creator, God,
is essentially an evil thing, like blasphemy. An innocent fetus
an hour old may not be directly killed to save the lives of all
the mothers in the world. Insisting on such comparisons supposes
ignorance and sentimental opposition to truth. It is a good deed
to save a mother's life; but such saving by killing an innocent
human being ceases to be good and becomes indescribably evil, an
enormous subversion of the order of the natural law, as it is a
usurpation of the dominion over life possessed by God alone. If I
owe a man a vast sum of money and the payment of this debt will ruin
me and my children, it would be a good thing for me and them to
have this creditor put out of the way by death, but that fact is no
justification whatever for me to kill the man. The fetus in the womb
in a case where there is question of therapeutic abortion is like
this creditor: it would be well for the mother to have this fetus out
of the way, but that is no justification whatever for her to kill
the fetus, or to let it be killed by a physician. The physician who
kills such a fetus is exactly like a hired bravo who assassinates a
troublesome creditor for a fee, except that the physician does the
nasty job for less money.

To hasten even an inevitable death is homicide, and that quality
of merely hastening adds nothing for extenuation: every murder is
merely a hastening of inevitable death. To give a dying man a fatal
dose of morphine "to put him out of misery" is as criminal a murder
as to blow out his brains while he is walking the streets in health;
to ease pain is not commensurate with the horrible deordination of
taking a human life. This subversion of the moral law in the interest
of mawkish sentimentality is one of the gravest evils of modern
social ignorance. Physicians are constantly mistaking inclination, or
the mental vagaries of the nurses who influenced their childhood, for
rules of moral conduct. A physician is not a public executioner, nor
a judge with the power of life and death: his business is solely to
save human life, never to destroy it.

If there were anything in the objection that refusal to do abortion
opposes the life of a useless fetus to that of a useful mother of a
family, where would such false logic stop? If it held for the taking
of life in an unpleasant condition, it would hold _a fortiori_ in
every other less unpleasant condition where a life would not be at
stake. When a note that you had given falls due and it would bankrupt
you to pay it, does this inconvenience let you out of the difficulty
in honor, in the moral law, or in the civil law? It certainly does
not; but it should if the doctrine of the sentimentalists on
abortion were true. An eclamptic woman, or one with hyperemesis
gravidarum, conceived the child, got into the difficulty, and she and
her physician have no right to tear up the note they have given to
the Creator, especially when such tearing implies murder. Suppose,
again, a woman has done a deed for which she has in due process
of just law been condemned to death; suppose, also, there is only
one man available to put her to death, and if this man were killed
she could escape. Would her physician be permitted to shoot that
executioner to let her out of the difficulty? Certainly not. That,
however, is just what the physician does who empties an eclamptic
uterus of an unviable fetus. You may not do essential evil that
anything under the sun, good, bad, or indifferent, may come of it.

If I may kill a so-called "useless fetus" to save a useful mother, do
gross evil to effect great good, why should I stop there? Why, then,
may I not rob a church to make my children rich, murder a useless
miser to employ his money in founding orphanages, shoot any oppressor
of the poor, kick out of doors my senile and bothersome father,
reject all my most sacred promises whenever their observance makes
me suffer? Where will the sentimental moralist draw the line? That
the civil law permits therapeutic abortion is no excuse at all; it is
merely a disgrace of the civil law. The American civil law permits
many things that are contrary to morality and the law of God: it
absolves bankrupts even if they afterward become solvent; it permits
the marriage of divorced persons; it levies unjust school taxes; it
gives unjust privileges; it squanders the money of the citizens; and
so on.

If a woman marries in good faith a man she deemed a gentleman, but
who turns out to be a syphilitic sot who disgraces her and makes her
life a perpetual misery, immeasurably worse than the condition of
any eclamptic woman, no greater blessing could come to her and her
children than his death. Would she therefore be justified before any
tribunal of God or man in murdering him to get rid of her trouble?
No; she must bear with her evil for the sake of social order and of
eternal right. So must the eclamptic woman.

If it is murder to kill a child outside the womb, and mere
therapeutics to kill it inside the womb, then it is murder to shoot a
man on the street, and mere good marksmanship to shoot him to death
inside his house, especially if he is an undesirable citizen. All
reputable physicians deem a fetus in a _normal_ pregnancy so good
that they will not dream of destroying this fetus. They absolutely
refuse to effect an abortion to get rid of a fetus which may disgrace
an unmarried woman and her family, and they are perfectly right in
this refusal. They talk and write with genuine indignation of race
suicide. The only reason they have for the refusal to do what they
call criminal abortion is that the disgrace or inconvenience of the
woman is not commensurate with the destruction of a human life.
They observe the natural human instinctive repugnance to murder in
this special speech and writing, and then go home and get their
obstetrical bags and complacently murder the first baby they find
in the womb of a _married_ matron who has a disturbed stomach or
kidneys. They show here the fine intellectual acumen and reasoning
ability of a chronic lunatic. The first fact in the social order is
that justice, law, order, should prevail, no matter what the cost.
It might be better that the fetus should _die_ than that the mother
should die, though that is not always true. It is not better that an
unbaptized fetus should die than that a mother in the state of grace
should die. But these are irrelevant considerations. It is never
better that the fetus should be _killed_ than that the mother should
die. That is a very different matter.

The _Mignonette_ case in 1884, tried in England by Lord Coleridge,
is a good example of evaluation of lives as in therapeutic abortion,
which came to grief. A ship called the _Mignonette_ foundered 1600
miles from the Cape of Good Hope, and three of its crew, with a boy,
were for a long time at sea in an open boat without provisions. When
they were almost starved the boy lay on the bottom of the boat,
asleep or half conscious from weakness. Two of the men plotted to
kill the boy for therapeutic purposes; they needed his flesh to save
their own lives. They killed the poor lad just as the therapeutic
abortionist kills a fetus. They got his uncooked flesh for four days.
Later Lord Coleridge got them and he sentenced both of them to death.
Another Lord will get the therapeutic abortionists.

What, then, is the physician to do who meets a case that imperatively
calls for therapeutic abortion according to the common medical
practice? He can do nothing. The law may seem hard in certain
circumstances to those who cannot see beyond the physical; yet that
fact does not abrogate the law, which is one of essential morality.

May the physician call in a physician who, he knows, will not scruple
to perform the therapeutic abortion on an unviable fetus? If he does,
he is as much a murderer as if he did the deed himself. He may not so
much as suggest the name of some one who will do the deed. He simply
tells the family he can do nothing. If they insist on the abortion he
withdraws from the case.

In this connection it is necessary to mention again the question of
viability. Langstein reported[90] a study of the growth and nutrition
of 250 prematurely born infants, and he found a confirmation of what
was already known, that a weight of 1000 grammes (2-1/5 pounds) and
a full body length of 34 centimetres (13-3/5 inches) are the lowest
limits for viability under proper circumstances. A fetus 1000 grammes
in weight and 34 centimetres in length has completed the sixth
solar or calendar month, or the sixth and a half lunar month--it is
beginning its seventh month, not ending it, yet it is viable under
proper conditions.

  [90] _Berliner klinische Wochenschrift_, June 14, 1915.

The child at term, on a rough average, is from 48 to 52 centimetres
(19 to 20-1/2 inches) in length, and it weighs from about 6-3/5 to
7-1/2 pounds. It is impossible, however, to obtain the sizes and
weights of infants _in utero_ with scientific accuracy, because the
date of conception cannot be determined with absolute certainty, and
infants _in utero_ vary as they do after birth. A full-term infant
sometimes may weigh only 3-1/2 pounds when the mother is diseased,
and at times an eight-months fetus will weigh as much as 8 pounds.

As was said in Chapter III, a fetus of six completed calendar or
solar months (not lunar--the duration of gestation is often reckoned
in lunar months by obstetricians) is viable provided it is cared for
by competent physicians in a hospital. Otherwise it is not viable,
except in a strictly technical sense; it will not live more than a
few days or weeks.

A full seven-months infant may be reared with proper feeding and
skilled care; a six-months infant may be reared (with difficulty) in
a hospital with skilled care. If it is certain that the removal of a
six-months fetus will here and now save the life of a mother (a very
difficult matter to judge by the best diagnosticians), this removal
may be done, provided the infant is delivered in circumstances where
skilled care, incubator, and proper food are obtainable; otherwise
the removal is not justifiable.

The Council of Lerida, in Catalonia, in the year 524, decreed that
abortionists of any kind must do penance all their lives, and if
they are clerics they are to be suspended perpetually from all
ecclesiastical ministration.

The Council of Worms, under Hadrian II., in the year 868,[91] also
judged women who procure abortion as certainly guilty of murder.

  [91] Cap. 35.

In the _Corpus Juris_,[92] among the decretals of Gregory, there is
the following law: "If any one, through lust or hatred, does anything
to a man or woman, or gives them any drug, so that they cannot either
generate or conceive, or bear children, he is to be treated as a
murderer."

  [92] Lib. v, tit. xii, c. 5.

Sixtus V., in the Constitution _Effraenatam_, October 29, 1588,
mentions a decree of the Sixth Synod of Constantinople, in session
in 680 and 681, which subjects those who perform abortion, or kill a
fetus, to the punishment inflicted on murderers. Sixtus then decreed
that any one who effects the abortion, directly or indirectly, of an
immature fetus, whether the fetus is animated, formed, or not, either
by blows, poison, drugs, or potions, or tasks of hard labor imposed
on pregnant women, or any other method, however subtle or obscure
it be, is guilty of murder, and is to be punished accordingly.
He recalls all ecclesiastical privileges from clerics who cause
abortion, and says that they are to be reckoned as murderers
according to the decree of the Council of Trent,[93] and he makes a
law that abortionists may never be promoted to orders.

  [93] Session xiv, _De Reformatione_, cap. 7.

In the fifth paragraph he says: "Moreover, we decree that the same
penalties are incurred (1) by those who give potions and poisons to
women to induce sterility or prevent conception, or who cause these
drugs to be administered, and (2) by the women themselves who freely
and consciously take these drinks."

In paragraph seventh he decrees that any one, man or woman,
cleric or lay, who procures abortion by counsel, favor, drinks,
letters of advice, signs, or in any way whatever, are _ipso facto_
excommunicated, and the excommunication is reserved to the Pope
himself.

Gregory XIV., in the constitution _Sedes Apostolica_, May 31, 1591,
gave to priests who have special faculties for the purpose from the
bishop, permission to absolve from this excommunication, but only _in
foro conscientiae_. Sixtus V. and Gregory XIV. used the term _foetus
animatus_, in keeping with the old Aristotelian notion of animation.

Pius IX., in the constitution _Apostolicae Sedis Moderationi_,
deleted the epithet _animatus_, and extended the excommunication
to all abortions, no matter at what time of the gestation they
occur. He ordered that only the actual physical abortionist is to
be excommunicated, not those who counsel the crime. Some moralists
hold that those who order abortion are direct abortionists and fall
under this excommunication; other moralists oppose this opinion. Pius
IX.[94] excommunicates procurators of abortion if actual abortion is
effected, and this excommunication is reserved to the bishops, not to
the Pope.

  [94] Sect, iii, cap. ii.

In this decree occur the words "_Procurantes abortum, effectu_
_secuto_," and there has been considerable discussion of the
question who are the _procurantes_, the agents who fall under the
excommunication? Again, are craniotomy, cephalotrypsis, decapitation,
embryotomy, and exenteration, when performed on the living child,
abortions in the sense of the decree, and thus matter of the
excommunication?

Those who do abortion are the principal agents who _physically_,
immediately, of themselves, in their own name, or who _morally_,
through others, perform an abortion. The common opinion of moralists
is that all those who of themselves or through others bring on an
abortion are excommunicated, but that assistants, although guilty of
crime, are not excommunicated.

Many eminent moralists are of the opinion that the mother herself who
seeks an abortion does not fall under the excommunication because
Sixtus V. does not explicitly mention her in this penal law, and a
penal law is to be interpreted literally. If a pregnant woman goes to
an abortionist and persuades him by speech and pay to do an abortion,
she is the direct moral cause of that abortion. If it were not for
her, the abortion would not take place. Virtually all abortions done
on married women are effected morally by the woman herself. In my
opinion, and the new canon law states this explicitly, the woman who
procures an abortion on herself or on another woman is excommunicated.

Sabetti-Barrett[95] holds that craniotomy on a living child and
the removal of an inviable extrauterine fetus are not abortion in
the scope of this excommunication, because as a penal law these
operations are not specifically mentioned. All mutilating operations,
like craniotomy and the others enumerated above, first kill the
fetus, then extract its body from the womb; abortion first extracts
the fetus and then lets its die. The result is the same, but the
operations differ technically, and a penal law is _ad literam_. A
cleric who procures abortion of an inviable fetus at any time of
gestation falls under the excommunication and suspension _a sacris_
perpetually, although he probably is not technically irregular
canonically if he procures the abortion before the Aristotelian date
of animation. The bull _Effraenatam_ makes the canonical irregularity
at the Aristotelian date obsolete practically.

  [95] _Compendium Theologiae Moralis_, 1915, n. 1009.

In the church the Holy Office (that is, the Inquisitors-General
in matters of faith and morals) is the official authority which
interprets, under the approval of the Pope, the morality of acts like
abortion and related operations. In 1895 the following difficulty was
proposed to the Holy Office for solution:

A physician is treating a woman with a disease which will certainly
be fatal to her unless cured medically, and the disease is due to the
presence of a fetus in her womb. To save her it is necessary to empty
the uterus, but the fetus is not yet viable. The question is, May the
physician perform therapeutic abortion in such circumstances?

On July 24, 1895, the Holy Office answered: "The Inquisitors-General
in matters of faith and morals, with the vote of their Consultors,
decree: _Negatively_, in accord with the other decrees of May 28,
1884, and August 19, 1888."

In May, 1898, the following questions were proposed to the Holy
Office:

I. Is the induction of premature labor licit when a contracted
maternal pelvis prevents the birth of a child at term?

II. If the maternal pelvis is so narrow that premature delivery is
impossible, is it licit to perform abortion, or to effect _cesarean_
delivery at the proper time?

III. Is laparotomy in extrauterine gestation licit?

May 4, 1898, the Holy Office answered, with the assent of Leo XIII:

I. Premature labor in itself is not illicit, provided it is done for
sufficient reason, and at the time and by such methods as will under
ordinary circumstances preserve the life of the mother and the fetus.

II. As to the first part, the answer is negative, according to the
decree of July 24, 1895, on the unlawfulness of abortion. As to the
second part, there is no objection to the cesarean delivery at the
proper time.

III. In a case of necessity, a laparotomy to remove an ectopic fetus
from the mother is licit, provided the lives of both mother and fetus
are, so far as is possible, carefully and opportunely preserved.[96]

  [96] "Dummodo et foetus et matris vitae serio et opportune
  provideatur."

March 5, 1902, this question was asked the Holy Office: "Is it ever
licit to remove an ectopic fetus from the mother while the fetus is
under six months of age from the time of conception?"

The answer was: "_Negatively_, in accord with the decree of May 4,
1898, by which the lives of the fetus and mother, as far as possible,
are carefully and opportunely preserved. As to the time, the
questioner is reminded by the same decree that no premature delivery
is licit unless effected at the time and by the methods which, under
ordinary circumstances, will preserve the lives of mother and fetus."

The English civil law concerning abortion[97] is:

"Whoever shall unlawfully supply or procure any poison or other
noxious thing, or any instrument or thing whatsoever, knowing that
the same is intended to be unlawfully used or employed with intent to
procure the miscarriage of any woman, whether she be or be not with
child, shall be guilty of a misdemeanor, and being convicted thereof
shall be liable, at the discretion of the court, to be kept in penal
servitude for the term of three years, or to be imprisoned for any
term not exceeding two years, with or without hard labor."

  [97] Statutes 24 and 25, Victoria, cap. 100, sec. 59.

Alfred Susaine Taylor,[98] commenting on this law, said: "Strictly
speaking, there is no such thing as justifiable abortion; the law
recognizes no such possibility. A medical man must always remember
this when he contemplates emptying a pregnant uterus.

  [98] _Principles and Practice of Medical Jurisprudence._ London,
  1905.

"It is obvious that the only reasons that can be thought of by an
honorable man as justifying the induction of labor are (1) to save
the life of the mother; (2) to save the life of the child. (Some
religions will not contemplate the first reason, but that we are not
now concerned with.) It cannot be done for the sake of family honor
nor for any similar ethical reason....

"The golden rule is never to empty a uterus without first having a
second professional opinion as to its necessity; if this opinion be
adverse, do not do it; if it be favorable, it is well to get it in
writing, and it is well also to get the written or attested consent
of the woman and her husband, and then proceed to do it with all the
skill and care possible. The death of the fetus is at any time the
most certain means of causing the womb to empty itself, but after
the sixth month the operation is performed necessarily with a view
to preserving this life, and steps must be taken accordingly." Coke,
about 1615, judged that to kill a child in the womb is not murder,
but if it is expelled by violence and dies after it leaves the womb,
that is murder.

The law in Pennsylvania[99] is: "If any person, with intent to
procure the miscarriage of any woman, shall unlawfully administer to
her any poison, drug, or substance whatsoever, or shall unlawfully
use any instrument, or other means whatsoever, with the like intent,
such person shall be guilty of felony, and being thereof convicted,
shall be sentenced to pay a fine not exceeding five hundred dollars,
and undergo an imprisonment, by separate or solitary confinement
at labor, not exceeding three years." It makes no difference in
Pennsylvania law whether the child is quickened or not.

  [99] _Laws of Pennsylvania_, Act of March 31, 1860, sec. 88. p.
  404.

The New Jersey, Massachusetts, and Wisconsin laws are like the
Pennsylvania law. The law in Iowa[100] is: "If any person, with
intent to procure the miscarriage of any pregnant woman, wilfully
administer to her any drug or substance whatever, or, with such
intent, use any instrument or other means whatever, unless such
miscarriage shall be necessary to save her life, he shall be
imprisoned in the penitentiary for a term not exceeding five years,
and be fined in a sum not exceeding one thousand dollars." To the
same effect are the laws in Connecticut, Maine, New York, Ohio,
Michigan, Minnesota, Colorado, Texas, and Maryland.

  [100] _Laws of 1897_, Iowa Code, 4759.

Frank Winthrop Draper, professor of legal medicine in Harvard
University,[101] commenting on the Massachusetts law of October,
1903, cap. 212, secs. 15, 16, says: "It is important to recognize the
fact that the law does not make any exception or formal recognition
in favor of justifiable operations to procure premature labor. The
statute is general in its application. It is, of course, obvious
that the best sentiment of the medical profession and of obstetric
teachers is favorable to interference of pregnancy, (1) whenever
there is such anatomical deviation or mechanical obstruction in the
mother's pelvis that the birth of a child is impossible; or (2)
whenever the mother is suffering from such grave disease that her
life is in imminent peril and can be saved only by the arrest of
gestation. Under such conditions the physician is not only warranted
in inducing premature labor, but is required to do so by a sense of
duty to his patient, with a view thereby to save one life at least,
and, if possible, the lives of both mother and offspring.

  [101] _Legal Medicine_, 1905.

"Nevertheless, as the law now stands, a prudent practitioner will not
expose himself to any risk, if a few precautions will save him. In
the event of the death of the mother and child in such an emergency,
the attending physician might find himself in jeopardy, with the
imputation of gross carelessness and criminal neglect hanging over
him, an imputation which requires years to remove. So the attending
physician should never undertake to do an instrumental operation
without these precautions: 1. The consent of the patient, with that
of her husband or family. 2. Especially, a consultation with some
other physician or physicians in whom there is full confidence.
Attention to these simple and sensible safeguards, by making the
conduct appear by its candor and openness in the strongest possible
contrast with the secret methods of the abortionist, may save great
embarrassment."

The ethics of this doctrine is, of course, absurd, as has been
shown, and it is cited here only to show how the civil law considers
abortion. Wharton and Stille[102] give the same information in a
more technical manner. "It is a general rule," they say, "independent
of statute, that the act of a physician in aiding a miscarriage is
not unlawful, where the miscarriage was the inevitable result of
other causes. And the act is justified where the circumstances were
such as to induce in the mind of a competent person the belief that a
miscarriage was necessary to preserve the life of the mother. And the
statutes of many of the States penalize the causing, or attempting
to cause, an abortion, unless necessary to preserve the life of the
woman, or unless advised by a designated number of physicians to be
necessary for such purpose, the absence of both the necessity and
the advice being an essential ingredient in the crime. The physician
by whom the deed is done, however, cannot act as his own adviser in
the matter. And an indictment under the statute must not only allege
that the act was not necessary to preserve the woman's life, but must
also negative the advice of physicians; and such averments cannot be
inserted as an amendment after demurrer.

  [102] _Medical Jurisprudence_, vol. iii, sec. 526.

"The burden of proof rests with the state to show that the means used
were not necessary to preserve the life of the woman in question;
and the absence of necessity may be determined from circumstantial
evidence. But the burden of proof as to the advice of physicians
would not fall within the rule controlling the production of proof
as to negative matters in general, and would rest with the accused;
though it may be proved by a preponderance of the evidence and need
not be established beyond a reasonable doubt. But either that the
act was necessary to preserve the life of another, or that it was
advised by physicians to be necessary for that purpose, is of equally
good defence; and the destruction of the child need not have been
both necessary and advised by physicians. And statutes of this class
apply only in cases in which the death of the mother could reasonably
be expected to result from natural cause, unless the child was
destroyed, and do not apply to a case in which the mother threatened
suicide unless she was relieved from her trouble."




CHAPTER VI

ECTOPIC GESTATION


Ectopic Gestation, called also extrauterine pregnancy, is gestation
outside the uterus in the adnexa or the peritoneal cavity. Pregnancy
in the horn of an abnormal or rudimentary uterus is classed with
ectopic gestation because the effects are similar, although pregnancy
at times in a rudimentary uterus goes on to term normally. The uterus
is in the pelvic cavity, between the bladder and the rectum, and
above the vagina, into which it opens. It is a hollow, pear-shaped,
muscular organ, somewhat flattened, and about three inches long, two
inches broad, and an inch thick. The fundus or base is upward, and
the neck is downward. Passing horizontally out from the corners or
horns of the uterus, which are at the fundus, are the two Fallopian
tubes, one on either side. These are about five inches in length
and somewhat convoluted. They are true tubes, opening into the
uterus, and they are about one-sixteenth of an inch in diameter
throughout the greater part of their extent. The ends farthest from
the uterus are fringed and funnel-shaped; and this funnel end,
called the Infundibulum or Fimbriated Extremity, opens into the
abdominal or peritoneal cavity. Near the Fimbriated Extremity of each
tube is an Ovary, an oval body about one and a half inches long by
three-quarters of an inch in width. For convenience in description,
each tube is divided into four parts: (1) the Uterine Portion, which
is that part included in the wall of the uterus itself: it extends
from the outer end of the horn into the upper angle of the uterine
cavity, and its lumen is so small that it will admit only a very fine
probe; (2) the Isthmus, or the narrow part of the tube which lies
nearest the uterus: it gradually widens into the broader part called
(3) the Ampulla; (4) the Infundibulum, or the funnel-shaped end of
the Ampulla. One of the fimbriae, the Fimbria Ovarica, is longer than
the others, and it forms a shallow gutter which extends to the ovary.

The uterus, tubes, and ovaries lie in a septum which reaches across
the pelvis from hip to hip. This septum is called the Broad Ligament.
If a man's soft hat, of the style called "Fedora," is inverted, the
fold along the crown coming up into the cavity of the hat is like the
broad ligament. As the crown is held downward the uterus would be in
the middle, its fundus upward, and outside the hat, representing the
pelvic cavity, but in the crown fold. The tubes and ovaries would
also be in the crown fold, or broad ligament, and the fimbriated
extremities would open into the interior of the pelvic cavity through
holes. The ovum breaks through the surface of the ovary into the
pelvic cavity, passes, probably on a capillary layer of fluid, into
the fimbria ovarica and thence into the infundibulum, whence it moves
along slowly into the uterus.

Ovulation and menstruation occur about the same time ordinarily, and
if the ovum produced is not fecundated it gradually shrivels and
passes off through the uterus and vagina. Fecundation of the ovum
rarely occurs in the uterus, but ordinarily in the Fallopian tube.
After fecundation the ovum is pushed on through the Fallopian tube
into the uterus in from five to seven days, where it fastens to the
wall and develops normally. Hyrtl described an ovum which appeared
to reach the uterus in three days. If from some abnormal condition
of the Fallopian tube the fecundated ovum is blocked and held in the
tube, the embryo grows where the ovum stopped, and we have a case
of Ectopic Gestation. In normal pregnancy in the uterus, the uterus
grows with the embryo, but a tube does not. In the latter condition,
when the ovum is big enough it bursts the tube or slips out through
the ampulla, causing hemorrhage or other pathological symptoms.

There are certain rare abnormalities of the uterus through imperfect
embryological development, and pregnancy in such a uterus may result
in symptoms like those of ectopic gestation. Normally the uterus and
vagina are formed by the fusion of the two Müllerian ducts. When
these ducts do not fuse perfectly, or when one develops partly, the
various kinds of abnormal wombs and vaginas are the results. There
may be a double uterus with a single or double vagina, a uterus with
a complete or partial septum down the middle, a uterus with one
horn, a uterus with a developed horn and a rudimentary horn, and the
rudimentary horn may be open or shut, and so on. In many of these
conditions the ovum becomes blocked and rupture follows as in ectopic
gestation.

When the ectopic ovum begins to develop in the Fallopian tube the
placental villi erode the tubal wall and the blood-vessels. At length
the ovum slips out of the ampulla--the common result--or the tube
bursts. The break may be traumatic in origin, from jarring or a like
accident, or it may be spontaneous. If the rupture is through the
tube there is hemorrhage into the pelvic cavity; if the ovum slips
out of the ampulla the tubal abortion causes hemorrhage as in uterine
abortion. In either case the blood with peritoneal fibrin forms a
hematocele, and this, with the ovum, may be finally absorbed; or the
woman may bleed to death unless the hemorrhage is checked surgically;
or the child may live for varying periods up to term. The tube rarely
ruptures into the fold of the broad ligament.

The fetus usually dies after rupture or tubal abortion, and if it
has not advanced beyond the eighth week it is absorbed. Sometimes
it lives. When the rupture or abortion does not tear the placental
site the fetus may develop in the abdominal cavity. Between 1889
and 1896 Haines[103] found 40 operations for ectopic gestation done
after the seventh month of pregnancy with 10 maternal deaths. Of the
children, 27 survived the operation from a few moments to fifteen
years. Sittner, in 1903, compiled from the medical reports 142 cases
of viable ectopic fetuses, and Essen found 25 additional cases. Since
Essen's article more have been reported, about 173 to my knowledge,
but the number is considerably larger.

  [103] Kelly's _Operative Gynaecology_. New York, 1898.

Hirst says an experienced obstetrical specialist sees from 12 to 24
cases of ectopic pregnancy annually. Küstner himself operated on 105
cases in five years. About 78 per cent. of all ectopic gestations
result in tubal abortion and 22 per cent. in rupture.

Many specialists now are of the opinion that the diagnosis of ectopic
gestation ordinarily is not difficult, but most physicians find it
very difficult. Before rupture of the tube or a hemorrhage diagnosis
is hardly ever made by any one, and no pelvic condition gives rise
to more diagnostic errors. When there is rupture or tubal abortion
the symptoms may lead the physician to mistake the condition for
uterine abortion. In uterine abortion the onset of the symptoms is
quiet, with gradually intensifying and regular pains, resembling
labor, in the lower abdomen. In ectopic pregnancy the symptoms of a
rupture or tubal abortion arise quickly, with irregular and colicky
or very violent pains, localized on one side. In uterine abortion the
external hemorrhage is more or less profuse, with clots; in ectopic
gestation the external hemorrhage is slight or absent; the shock
in the latter case is out of proportion to the visible blood loss.
Parts of the ovum, or the presence of the whole ovum, as uterine,
are found in ordinary abortion, but in the ectopic condition the
ovum proper does not appear. An intrauterine angular pregnancy, or
pregnancy in a uterine horn, causing the upper corner of the womb to
bulge sidewise, may be mistaken for ectopic gestation. Pregnancy in a
retroflexed uterus, tumors of the adnexa, the twisted pedicle of an
ovarian tumor, a burst pyosalpinx, an appendicitis in pregnancy, or
a combined intrauterine and ectopic gestation, also may confuse the
diagnosis. When there is a dangerous hemorrhage from rupture or tubal
abortion the diagnosis is usually made without difficulty from the
collapse and other signs.

The diagnosis as to whether the fetus in the pelvis is dead or alive
may be made (1) from the absence or presence of symptoms of tubal
rupture during the second and third months, or of mild symptoms
indicating only slight bleeding; (2) from the continuation and
progress of the evidences of pregnancy, as nausea, mammary changes,
fetal movements, or audibility of the fetal heart; (3) from the
presence of a loud uterine blood souffle; (4) from the absence of
toxemia or suppuration; (5) from a growth of the uterus and a
softening of the cervix; (6) from a gradual increase in the size of
the suspected ectopic fetal tumor. In making the diagnosis great
caution must be observed, as roughness in manipulation may start
hemorrhage or rupture a thinned tube.

The diagnosis may be made: (1) that ectopic gestation exists without
symptoms of maternal hemorrhage, and the fetus is not viable; (2)
that the same maternal condition may be present, but the fetus is
viable; (3) that there may be symptoms of slight bleeding, and the
fetus is inviable; (4) that there may be symptoms of grave maternal
hemorrhage at any stage of the gestation.

The ordinary medical doctrine in the text-books is that as soon as
a diagnosis of ectopic gestation is made laparotomy should be done
and the sac with the ectopic fetus removed. If the fetus is alive
and inviable this procedure will, of course, kill it. Only a few
obstetricians of authority advise an expectant treatment. Schauta
found 75 recoveries and 166 maternal deaths in 241 cases treated
expectantly--a mortality of 69 per cent.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  [104] "In a case of necessity, it is licit to do a laparotomy
  for the removal of an ectopic gestation sac from the maternal
  pelvis, provided the life of both fetus and mother be carefully
  safeguarded."

  [105] "Negative, juxta decretum 4 Maii, 1898, vi cujus, foetus et
  matris vitae, quantum fieri potest serio et opportune providendum
  est: quod vero tempus, juxta idem decretum, orator meminerit,
  nullam partus accelerationem licitam esse, nisi perficiatur
  tempore et modis, quibus ex ordinarie contingentibus, matris ac
  foetus vitae consulatur."

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

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

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

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

The ectopic fetus cannot, of course, be a formal aggressor because it
cannot exercise either intelligence or will. It is not a materially
unjust aggressor, because the only action it is capable of is to
increase in size in obedience to the natural law of growth. It is
not trying in any manner to tear the maternal blood-vessels. It has
a right to its own life and a right to grow. Its growth may finally
bring about a maternal hemorrhage, but just now it is not causing
that hemorrhage. An aggressor is such only while there is an actual
attack going on here and now, directed against the victim's life. The
fetus is necessarily passive always, never aggressive in any sense
of the term, until the actual rupture occurs. If it may be deemed
materially aggressive when the actual rupture is taking place, the
question becomes irrelevant, because at that time the fetus may be
removed for other reasons altogether. If an insane man is in a room
with a loaded revolver which he may not use against me, but which he
probably will, I may not kill him in self-defence until he actually
begins the aggression. The opinion expressed here is the contrary of
the opinion I expressed, in 1906, in _Essays in Pastoral Medicine_.

The second condition proposed is that the ectopic gestation exists
without symptoms of maternal hemorrhage, but the child is viable. In
such a case it is probably better to remove the fetus at once, but
only a skilled abdominal surgeon should attempt the operation because
it is likely to be difficult from adhesions. A viable ectopic fetus
is usually deformed. Winckel found 50 per cent. of them deformed--the
head in 75 per cent., the pelvic end in 50 per cent., the arms in 40
per cent. Compression, infraction, hydrocephalus, and meningocele are
common. The longer the fetus is left in, the worse for the mother so
far as peritoneal adhesions and danger and difficulty in removing the
fetus are concerned.

The third case supposed that the fetus is not viable but the symptoms
of maternal hemorrhage are slight. The danger to the mother in
waiting is greater here than in case one, and the decision must be
made in keeping with evidences in the particular case. The surgeon
who assumes responsibility is obliged to remain ready for instant
operation.

Where there are symptoms of grave hemorrhage in the mother at any
stage of ectopic gestation the surgeon must operate at once, and
ligate the bleeding vessels to save the woman's life. The ligation
will shut off the blood supply to the fetus, and thus indirectly,
permissively, the fetus must be unavoidably allowed to die. This is a
clear case of double effect immediately issuing from the same cause,
and the operation is morally licit. No matter how young the fetus is,
the surgeon or an assistant is to baptize it; if it is very young it
may be necessary to split the envelopes to get at the fetus.




CHAPTER VII

CESAREAN DELIVERY


In the cesarean delivery (_partus cesareus_, celiohysterotomy) the
infant is brought out through an opening made in the abdominal and
uterine walls. The chief indications for this operation may be a
contracted maternal pelvis, an abnormally large fetal head or body,
death of the pregnant mother before delivery, certain forms of
rigidity of the cervix uteri, some cases of stenosis of the vagina,
relative vaginal narrowness, blocking tumors, or a ventrofixed
uterus. Sometimes abruptio placentae, eclampsia, placenta praevia,
and other accidents of pregnancy are taken as indications for
cesarean delivery.

An abnormal bony pelvic girdle is the most frequent obstruction to
delivery of the fetus. The lower part of the pelvis, called the
pelvis minor or true pelvis, supports the muscles of the pelvic
floor, and gives shape and trend to the parturient canal. The inlet
and outlet of the true pelvis are narrower than its middle portion
and are called the superior and inferior straits. The inlet is
somewhat cordate in outline, and normally from front to back, at
its so-called conjugata vera, it averages 11 centimetres (4-5/16
inches) in depth; from side to side it measures 13 centimetres (5-1/8
inches); obliquely from the right posteriorly to the left anteriorly
it is 12-1/2 centimetres (nearly 5 inches), and the other oblique
conjugate is 12 centimetres (4-3/4 inches) long. The transverse
diameter of the outlet, from right to left, is 11 centimetres; the
diameter from front to back, because the coccyx can be pushed back
in labor, is from 9-1/2 (3-3/4 inches) to 12 cm. Normal fetal head
measurements average from side to side at the widest part, 9-1/2 cm.
(3-3/4 inches); from the root of the nose to the occiput, 11 cm.;
from the chin to the occiput, 13 cm.; from the vertex to the neck
behind, 9-1/2 cm. The size of the fetal head is the most important
factor in delivery, so far as the child is concerned, because, as
a rule, when the head is delivered the compressible trunk follows
readily. Normally the child presents in delivery with the vertex of
the head first; other presentations are transitional, abnormal or
pathologic. In 48,499 cases Karl Braun found vertex presentations in
95.9 per cent., and Schroeder in 250,000 cases found an average of 95
per cent. The child's head is "engaged" when its largest diameter has
passed the plane of the inlet.

An abnormal pelvis may be generally contracted, dwarfed, in all its
diameters; it may be flat or narrow from front to back; it may be
contracted from side to side; it may be generally contracted and flat
at the same time; it may be obliquely contracted (Nägeli's pelvis);
or it may be crowded together irregularly. Rachitis, osteomalacia,
curvature of the spine, habit scoliosis, hip dislocation, and similar
pathologic states cause these distortions and contractions.

Contraction of the pelvis affects the mother and child in parturition
in proportion to the degree of the narrowing. Besides this, the
prognosis depends on the size of the child, its presentation,
position, and attitude, the strength of the pains, the skill and
surgical cleanliness of the operator, and the presence or absence of
complications. Obstruction may bring about rupture of the uterus,
septicemia, exhaustion and shock, pressure narcosis, or tears of the
cervix or vagina. If the child's head becomes impacted the vagina
and vulva may become even gangrenous. Pressure may cause areas of
necrosis resulting in fistulas into the bladder, rectum, or between
the uterus and the vagina. When the contracture is sufficient to let
the fetus just engage, pressure may interfere with the placental
circulation and kill the child. Compression of the vagus nerve may
slow the child's pulse and asphyxiate it through lack of oxygen in
the blood. The cord may prolapse. The pressure on the child's head
may cause fatal intracranial hemorrhage, or effect permanent injury
to the brain.

Often it is extremely difficult to find out the best plan for
delivering a woman who has a contracted pelvis. Where the conjugata
vera is 9.5 cm. (3-5/8 inches) or above, Ludwig and Savor found that
75 per cent. were delivered without instrumental help. At 9 cm.
(3-1/2 inches), 58 per cent. so end; at 8 cm. (3-3/16 inches), 25
per cent. Should the conjugata vera be less than 5-1/2 cm. (2-3/16
inches) in a flat pelvis, or 6 cm. (2-3/8 inches) in a generally
contracted pelvis, this is an absolutely contracted pelvis according
to the old standard, and the delivery must be by cesarean section,
whether the child is living or dead. The minimal requirements have
been gradually extended. In 1901 Williams of Johns Hopkins University
advocated that the absolute indication for cesarean section be
changed to 7 cm. in the generally contracted pelvis, and to 7.5 cm.
in the simple flat pelvis. His opinion was accepted by Webster,
Jewett, Edgar, and others. Now some obstetricians of authority
extend the measurements to 8 cm. If the woman is seen before labor,
or early in labor, cesarean delivery alone is done. When the uterus
is infected it is usually necessary to remove it after taking away
the child, because an infected uterus left in place causes death by
sepsis, as a rule.

Text-books on obstetrics have a series of rules, based on pelvic
measurements, concerning the indications for cesarean or other
methods of delivery in cases of contracted pelvis, but the problems
are not so simple and uniform as to be always accurately solved by
the data derived from measurements. One woman with a contracted
pelvis may require cesarean delivery; another woman with the same
measurements may have a normal parturition because the child happens
to be small or its skull compressible. The best pelvic measurement
is made with the fetal head. A difficult decision as to whether a
cesarean delivery is necessary or not comes up in the majority of
cases in primiparae; in multiparae the physician has the experience
from former births to guide him. In over 90 per cent. of primiparae
the fetal head normally is found engaged in the pelvis in the last
week of gestation, and can be felt by a vaginal examination. In
multiparae the head usually is not engaged until labor begins. If the
fetal head does not engage in a primipara, this fact at once suggests
an absolutely or relatively narrow pelvis. When labor has begun, if
the fetal head cannot be pushed into the true pelvis of a primipara,
especially after anesthesia, the necessity for cesarean delivery may
be clearly evident.

In the cases where there is doubt that the child can get through
the pelvis, but good reason to think that it can, many obstetrical
experts try the effect of labor for two hours or a little more,
and if there is no real progress they deliver through laparotomy.
There is considerable objection now to version or the application of
high forceps, but many skilful men prefer these methods at times.
When version has been done and it fails there is no chance to save
the child's life. In the trial of labor, the expectant treatment,
extraordinary watchfulness is required and a full knowledge of the
special procedure that may be necessary.

In minor degrees of pelvic contraction the obstetrical practice is
either to induce premature labor at the thirty-second week, or to
deliver by a cesarean operation, or to delay and try labor. In the
last event there may be one of the following issues: spontaneous
delivery, version and delivery, extraction by high forceps, cesarean
delivery, symphyseotomy, hebosteotomy, or craniotomy. Craniotomy on
a living child is never to be considered under any circumstances.
Symphyseotomy is a cutting of the maternal pelvic girdle through the
symphysis pubis, the rigid joint at the front middle part of the
pelvis, and thus letting the bony girdle dilate. Hebosteotomy or
pubiotomy is a sawing through the pelvis near that joint to get the
dilatation. Symphyseotomy has been replaced by hebosteotomy because
the maternal mortality and morbidity are somewhat lessened by the
latter method. Schläfli in 1908 reported 700 hebosteotomies with a
maternal mortality of 4.96 per cent. and a fetal of 9.18 per cent.
Other operators have a better average; still others a worse. This
operation is done very seldom of late except in a case where the
fetal head is caught low in the pelvis, or there is a chin-posterior
or brow or face presentation, and the cesarean operation would not
deliver the child.

The varieties of the cesarean delivery as practised at present
are the classic cesarean, called also celiohysterotomy, the Porro
cesarean, or celiohysterectomy, where the uterus is removed after
the extraction of the child, and the two sections in the cervical
end of the uterus, viz., the extraperitoneal cesarean and the
transperitoneal cervical cesarean. Before the days of antiseptic
surgery cesarean delivery was practically always fatal to the mother.
Tarnier could not find one successful outcome for the mother in Paris
during the nineteenth century up to his own time, and Spaeth said
the same for Vienna up to 1877. In 1877 Porro of Pavia advised the
supravaginal amputation of the uterus after the child was delivered
to avoid hemorrhage and peritoneal infection. This operation replaced
the classic cesarean until 1882, when Sänger invented a suture
which would keep the uterine incision shut, and applied antisepsis.
Sänger's operation has been improved so much that cesarean delivery,
when performed by skilled obstetricians, has an extremely low
mortality in cases which have not been infected. Routh, in 1910,
collected the statistics of Great Britain, comprising 1282 cases,
which may be taken as a standard for all civilized countries, and he
found a steady decrease in the mortality until now it is near 2 per
cent. in uninfected cases. The dangers in the operation increase with
every hour the woman is in labor, but even then the general mortality
is now down to about 8.1 per cent. This, it must be remembered, is
the rate when competent men operate.

When the ordinary practitioner in small cities, towns, and country
places operates the mortality is very high. Newell[106] said that
in four cities of from 25,000 to 40,000 inhabitants within forty
miles of Boston he collected the following data: in A no patient on
whom cesarean section had been done is known to have recovered--a
mortality of 100 per cent. In B the mortality is from 60 to 70 per
cent. In C the operation is invariably fatal when done by the local
surgeons. In D the fatality is from 10 to 20 per cent. in average
cases, but since cesarean section has become popular as a method of
treatment for eclampsia the mortality is over 50 per cent.

  [106] _Jour. Amer. Med. Assoc._, February 24, 1917.

In spite of perfect technic by the best obstetricians, the operation
has a high morbidity: fever, peritonitis, pneumonia, dilatation of
the stomach, and other bad results are common.

Before antiseptic surgery began, opening the abdominal cavity was
almost always fatal, and some obstetricians tried to get the child
out of the uterus in cases where cesarean delivery is indicated
by going in above the pelvis without opening the peritoneum. The
uterus was incised near its cervical end. This method, called
extraperitoneal cesarean delivery, has been restored for use in cases
where there is some infection of the uterus and the operator wishes
to save the child without removing the womb. The technic is more
difficult than in the classic cesarean, and the operation was not
kindly received, but of late some men are having so much success with
it that it is reviving, and rightly so. Baisch[107] says that the
first eleven women he delivered by extraperitoneal cesarean section
recovered more readily than they would from an ordinary laparotomy.
In nineteen cases of transperitoneal but cervical section he had
no trouble, and six of these were infected cases. The technic of
this low incision protects the peritoneal cavity better than the
classic incision, apparently. Two of the nineteen women were in
slight fever and the uterine fluids were fetid. Two primiparae forty
years of age had been in labor seventy hours. Eight of the women
were able to leave the clinic on the tenth day. Only one child was
lost, and that was a delayed case. Hofmeier[108] compiled 194 cases
of transperitoneal cervical cesarean section with three deaths.
Küstner did 110 extraperitoneal cesarean sections with no mortality.
This makes 304 cases of cesarean cervical section, not the classic
operation, with only three deaths, less than 1 per cent. mortality;
and fully 50 per cent. of these cases were not surgically clean. From
these statistics it is evident that the cervical operation in the
hands of competent surgeons should be the operation of choice.

  [107] _Zentralblatt f. Gynäkologie._ Leipsic, October 30, 1915.

  [108] _Münchener medizinische Wochenschrift_, January 4, 1916.

The ordinary practitioner, however, is utterly unfitted to do a
cesarean section of any kind. In large cities it is easy to find
a trained surgeon to do the operation, but in small towns and in
country places there is seldom any one available. The physician
who chooses to practise medicine in an isolated place knows that
he will almost certainly be called upon to do a cesarean section
some day, and he should not take up the responsibility of the
general practitioner in such a place until he is competent to do
that operation when life depends upon him. This is as things should
be; but unfortunately a man who is trained well enough to do major
surgery will not live in a small town if he can get into a large
city. The physician in any case should be able at least to make the
diagnosis in time, before labor sets in, and have the woman sent to
the nearest city, if possible. Dr. Bull[109] reported that he had
traveled seventy-five miles to see a woman who was having severe
hemorrhages at term. He found her in a log cabin, with a centrally
implanted placenta (_i.e._, right across the opening of the cervix
uteri), and she had had three hemorrhages before his arrival. He
narcotized her, took her in a train to a hospital, delivered her by
cesarean section, and saved her and the child. If he had delivered
her by version in the log cabin, he would almost certainly have lost
both the mother and the child.

  [109] _Jour. Amer. Med. Assoc._, September 30, 1916.

The question of removing the uterus comes up when the uterus is
infected, or as a method of sterilizing the woman to avoid the danger
of a subsequent gestation. Whenever a uterus is gravely infected and
a cesarean delivery is finally necessary, the infection is commonly
due to ignorance or carelessness, and the physician or midwife is
guilty. There should be no such business as that of the midwife who
actually delivers the patient. The state should provide physicians
for the poor. Even the midwife who calls herself "a practical nurse,"
but who is not a licensed trained nurse, is commonly a public danger,
although some so-called practical nurses are better than the ordinary
trained nurses.

Suppose, however, that the uterus is infected unavoidably. If this
infection has been done by a competent obstetrician working in a
hospital with sterile instruments, it may be safe to deliver the
woman by an extraperitoneal or cervical trans-peritoneal cesarean
section. If the practitioner has tried to deliver the woman at her
home with forceps and has failed, especially if repeated attempts
have been made by the physician and an assistant or consultant,
the uterus should be amputated. It will not do to deliver by a low
cesarean and await developments, because if the infection is serious
no subsequent removal of the uterus will save the woman's life. The
grave mutilation of removing the uterus is, of course, licit, as it
is the only means of saving the woman's life. Some moralists hold
that a woman from whom the uterus has been removed is impotent, but
this question has never been decided authoritatively, as we shall
show in the chapter on Vasectomy; and until it has been so decided
the woman must be given the benefit of the doubt.

The question of removing the uterus solely to prevent the danger of
subsequent deliveries differs from the condition just considered.
If the woman has had a cesarean delivery for an absolutely narrow
pelvis, her subsequent deliveries must be by the same method. After a
cesarean section there is more or less danger of rupture at the scar
in other labors. Some think the danger is greater if the placenta
becomes implanted on the scar; others think this implantation does
not weaken a good scar. If the convalescence after the cesarean
section already done has been abnormal, the prognosis for rupture
is not good. Where there has been an abnormal convalescence, each
new pregnancy must be watched closely, and often an early subsequent
cesarean is indicated to prevent rupture. No matter how well the
section has been done, latent gonorrhea may prevent perfect healing
of the wound. Twins, hydramnios, and overtime gestation are other
causes of rupture. The tendency with obstetricians in the future
will probably be to do the section toward the cervical end of the
uterus; and as the uterus is thinnest there, it might be thought
that it will be more likely to break, but Spalding[110] found the
contrary true--the rupturing was usually in the thick part of the
uterus. Version, high forceps, uterine tampons, hydrostatic bags,
and pituitary extract should be avoided where an old cesarean scar
exists, but Vogt and Kroback have done version a few times without
rupture. Vogt had one patient with a true conjugate of 6-3/4 cm.
(2-8/16 inches) to 7 cm. (2-3/4 inches). She was delivered in the
first three labors by craniotomy; in the fourth by version; in the
fifth and sixth by cesarean section; in the seventh she had twins
one of which was born spontaneously; in the eighth by version and
perforation of the after-coming head; in the ninth she refused
operation and was delivered spontaneously. Skilful operators have the
fewest ruptures after cesarean delivery. Olshausen had one in 120
cases, Leopold none in 232 cases, Schauta none in 177 cases, Küstner
none in 100 cases. Olshausen, in a series of 29 cases, operated on
two patients twice and upon three patients three times. As early as
1875, Nancrede of Philadelphia had operated the sixth time on the
same woman. In such cases the uterus is commonly so broadly attached
by adhesions to the belly-wall that it is opened without getting into
the peritoneal cavity. In 150 cases of repeated section collected by
Polak in 1909 the mortality was only 5 per cent.

  [110] _Jour. Amer. Med. Assoc._, December 1, 1917.

A woman may not be sterilized by having the uterus removed, by
fallectomy, or otherwise, solely to obviate danger or morbidity from
subsequent pregnancies and cesarean deliveries. Such a sterilization
would be a grave mutilation without a present excusing danger, and
it would render the primary end of marriage always impossible. Such
sterilization of a woman is in contravention to the decretal of
Gregory[111] as given in the chapter on Vasectomy. It is also against
the bull _Effraenatam_ of Sixtus V., who extended all penalties
prescribed for abortionists to those who give women drugs which cause
sterility, and to those who purposely prevent the development of the
fetus or in any manner abet the deed; and the penalties are to be
applied to the women themselves who willingly use these means. These
penalties are enumerated in the chapter on Abortion. The Congregation
of the Holy Office, May 22, 1895, answered negatively the following
question: "Si sia lecita la practica sia attiva sia passiva di un
procedimento il quale si propone intenzionalmente come fine espresso
la sterilizatione della donne?"[112]

  [111] _Corpus Juris_, lib. v, tit. xii, c. 5.

  [112] Is any active or passive procedure licit which is
  undertaken with the express end of sterilizing a woman?

The reason for these laws is that any act which deprives one of the
power to generate, and which prevents conception and makes the semen
fail of its end, is against the chief intrinsic end of marriage and
any benefit that arises therefrom, which is the good of offspring.
The act is also against the intrinsic end of the semen, which is to
generate; and since the semen cannot possibly effect its end, the
conjugal act degenerates into an equivalent of onanism. This act of
sterilization, done not to save the whole body from immediate danger,
is intrinsically evil, and therefore unjustifiable.

To say that marriage is also a licit remedy of concupiscence is
no excuse. Marriage is such only in a secondary sense, and this
secondary end is necessarily subordinate to the primary end, and
coexistent with that primary end, which is the generation of
children. Even when a surgeon is doing a Porro operation, his main
intention may not be to sterilize the woman. He must directly intend
to save her life by removing the infected uterus, and reluctantly
permit the sterilization as an evil part of the double effect coming
from the causal amputation.




CHAPTER VIII

PLACENTA PRAEVIA AND ABRUPTIO PLACENTAE


Cesarean delivery is used frequently of late in placenta praevia.
It may be necessary also in abruptio placentae, gunshot wounds of
the abdomen during pregnancy, sometimes in appendicitis complicating
gestation, rarely in prolapse of the cord to save the child, and
when twins become interlocked in delivery. Placenta praevia is
a development of the placenta in that part of the uterus which
dilates at the end of gestation or during delivery. This dilatation,
with the mechanical pressure of the child, detaches the placenta
enough to cause a hemorrhage which may be fatal to the woman if not
checked. The hemorrhages begin sometimes as early as the sixth month
of gestation, but most frequently in the eighth month. Premature
labor is a common effect. The position of the placenta may cause
malposition of the fetus, prolapse of the cord, weak pains, air
embolism into the blood, rupture of the uterus, sepsis, profound
anemia, and other evils. The child may be premature, puny, have
collapsed lungs, hemorrhages, and it is very likely to be killed in
delivery. The mortality of the women varies, but it averages about 7
per cent; that of the children averages 61 per cent.

The tendency with obstetricians is to deliver the child as soon as
the diagnosis has been made. When the bleeding is slight, and the
child is viable, one may delay delivery provided the woman will
remain in bed in a good maternity hospital without moving. At home
the woman may "flood" and bleed to death before a physician can
reach her. If the woman refuses to go to a hospital, and to permit
the induction of labor, any physician who has regard for his own
reputation will drop the case and leave the woman to her own devices.

There are various methods of treatment, and much depends on the
position of the abnormally placed placenta. The treatments all
consist in stopping the hemorrhage for the instant, emptying the
uterus, insuring permanent hemostasis, and meeting the anemia. The
Braxton-Hicks version is one method. The child is quickly turned so
that the head is upward in the uterus, and a leg is pulled down to
plug the cervix uteri until there is enough dilatation to extract the
child. Very many children are lost by this method. When the placenta
praevia is marginal to the cervix or lateral in the uterus the child
has a better chance when a colpeurynter, or inflatable rubber bag, is
inserted in the cervix as a plug. Much skill and discrimination is
required in the management of this bag until the child is delivered.
The obstetrician may be obliged to sit by the bed and hold on to
the bag for from three to twelve hours. Hasty extraction through a
poorly dilated cervix is a very dangerous process, as a tear cannot
be repaired quickly enough, as a rule, to check the hemorrhage, which
will be fatal. When version has been done haste may compress the head
in the tight cervix and asphyxiate the child.

When the child is viable a cesarean section is by far the best method
for the child, as it lowers the fetal mortality from 61 to about
5 per cent. The mother, too, has a better chance by the cesarean
section, provided it is done by a competent man, early in labor
before infection has set in, and in a hospital.

If the child is not viable the hemorrhage must be stopped to save the
woman's life. As a rule, the hemorrhages are not dangerous before the
seventh month. In the 128 deaths of Müller's statistics there was not
one before the seventh month of gestation. Hirst, however, says he
has been obliged to empty the uterus at the fifth month for placenta
praevia. The woman must be kept in bed, the foot of the bed elevated,
sedatives used, and so on, as in threatened abortion, and the vagina
tamponed securely with cotton. If it is evident that the fetus is
dead, it must be extracted as in the case of a viable fetus. If it is
probable that the fetus is alive, it is to be treated as in a case
of inevitable abortion as described in the chapter on Abortion.
The tamponing of the vagina to stop the hemorrhage will cause the
abortion of the fetus indirectly. This is another double-effect case,
and the tamponing is morally permissible provided the intention is
correct.

Abruptio placentae is a tearing loose of a placenta which is situated
in the normal position, not abnormally as in placenta praevia. The
cause may be a disease of the placenta or decidua; for example,
syphilis, chronic metritis, traumatism from a blow or fall, jumping
from a carriage-step, and so on. Nephritis is often found where there
is abruptio placentae. In labor the placenta may be torn loose by a
version, by the delivery of the first of a pair of twins, or because
the cord is too short.

There is always profuse hemorrhage, which is usually concealed at
first, but finally external. It is possible at times for a woman
to bleed to death into her own uterus, when it is distensible. The
mortality is about 50 per cent. for the women, and where there is
concealed hemorrhage about 95 per cent. of the children are lost. A
differential diagnosis is to be made to exclude placenta praevia,
rupture of the uterus, extrauterine pregnancy, rupture of an
appendical abscess, gall-stone colic, or intraäbdominal injury.

If the child is viable it must be delivered as quickly as possible.
If it is dead and the head is developed, craniotomy should be done to
hasten extraction. When the abruptio takes place before the seventh
month of gestation the fetus will die in about ten minutes, whether
in the uterus or outside it; no matter what method might be adopted
to empty the uterus, the child would be dead before delivery. The
diagnosis would have to be made and instruments prepared, and this
would take up more than the ten minutes of life left to the fetus. It
is necessary to get the fetus out to stop the bleeding of the open
sinuses by contraction of the uterus.

The removal of the fetus here is not like an artificial abortion.
In abortion the abortionist separates the placenta from the uterine
sinuses and so kills the fetus; the removal from the uterus is
secondary to that separation which kills. The common notion of
moralists that death is caused in abortion by taking the child out
of the uterus is inexact--tearing loose the placenta is the real
cause. In a removal of the fetus after an abruptio placentae the
death of the fetus is not caused by the physician at all, but by the
force that effected the abruptio. As the child will be dead before
sufficient dilatation of the cervix to deliver it can be attained,
there is no objection to beginning the delivery as soon as the
diagnosis is clear.




CHAPTER IX

ABDOMINAL TUMORS IN PREGNANCY


Tumors in or near the uterus may be obstacles to delivery or they may
through malignancy endanger the woman's life. The commonest tumors
complicating pregnancy are fibroids, cancers, and ovarian tumors,
especially cysts and dermoids, but tumors of other kinds are not
frequently met. Schauta, in 111,112 pregnant women, found fibroids
in 86, one in 1292 cases; Pinard, in 13,915, found 84, one in 165
cases; Pozzi, in 12,050, had 83, one in 133 cases; in St. Petersburg,
in 13,076 deliveries, there were only 4, one in 3269 cases; and in
the Charité in Berlin, 6 in 19,052 births, one in 3175 cases. The
ovarian cyst in pregnancy is rarer than the fibroid--5 in 17,832
births, one in 3566 cases, in the Berlin Frauenklinik. Cancer of the
cervix also seldom appears--once in about 2000 cases. Other very rare
conditions, related to these, are polyps of the cervix, enlarged and
prolapsed kidneys, extrauterine pregnancy combined with intrauterine,
echinococcus cysts, parametric abscesses, cancers of the rectum,
rectal strictures, tumors of the bladder, stones in the bladder,
tumors of the pelvic bones or cartilages, and tumors of the vagina or
vulva.

Fibroids, called also fibromyomata, fibromata, and myomata, in the
uterine muscle or adnexa commonly enlarge during pregnancy, and if
they are big enough and low in the pelvis may block the parturient
canal. These tumors may suppurate, grow gangrenous, or take on red
degeneration; they may cause abortion, peritoneal adhesions, pain,
or hemorrhage; simulate threatened abortion; bring on retroflexion
of the uterus, placenta praevia, abnormal presentations, sometimes
weak pains or pains so strong as to rupture the uterus, and they may
check contraction after delivery so as to start hemorrhage. They may
so kink the uterus as to incarcerate the placenta and cause sepsis.
The percentage of degeneration in fibroids taken generally is 22,
according to William Mayo.[113]

  [113] _Jour. Amer. Med. Assoc._, March 24, 1917.

Myomata often obscure the diagnosis in pregnancy. The tumor may
be mistaken for a twin child, or vice versa. A large symmetrical
interstitial myoma may be mistaken for pregnancy, or vice versa.
Sometimes, even after the belly has been opened, it is difficult to
be sure whether the condition is pregnancy or a tumor. As eminent a
surgeon as Deaver says this diagnosis cannot always be made by any
one no matter what his experience.

We cannot give a general mortality average for myomata in pregnancy
because only bad cases are reported, but in bad cases the mortality
is very high--50 per cent. for the mother and about 60 per cent. for
the children, with almost 30 per cent. of abortions. The majority of
women who have myomata go on to delivery without trouble. In some
there is much pain or hemorrhage, and these conditions may finally
oblige the obstetrician to operate, but the operation should be
deferred as long as possible. Where there are signs of necrosis of
the tumor, operation is necessary at once to prevent sepsis. Removal
of a myoma during pregnancy does not always cause abortion. The
statistics are that about 83 per cent. of those operated upon are
removed without abortion. In the Mayo Clinic[114] fourteen cases of
degenerating fibroids in pregnant wombs were removed and the majority
went on to term. The removal is always a very bloody operation, and
it requires great surgical skill. Where enucleation of the tumor
alone was intended it may finally become necessary to amputate the
uterus to stop hemorrhage.

  [114] _Ibid._

When the case has gone on to labor at term the diagnosis as to
position and size of the tumor is to be made, and what the effects
will be as to blocking the canal or crushing the tumor so as to
bring on sloughing. If a tumor blocking the canal cannot be pushed
up out of the way of the child, a cesarean section should be done
immediately. In such an outcome as section the experience of the
operator must decide whether the tumor is to be removed then or at
a more favorable opportunity. It may be necessary to do cesarean
section to liberate an incarcerated placenta.

Sometimes the fetus is so involved with a gangrenous myoma that
enucleation of the tumor will kill or hasten the death of the fetus.
When, in such a complication, it is evident that the life of the
woman depends on the immediate removal of the tumor, yet a second but
evil effect follows from the operation, namely, the unavoidable death
of the fetus, the removal is morally licit provided the operator has
the proper intention. The death of the child as an effect in this
case is only indirectly voluntary from the physical point of view,
and only permissively voluntary from the moral aspect.[115]

  [115] Cf. Ferreres, _Nouvelle Revue Théologique_, September
  and October, 1912, and the appendix of his book _De Vasectomia
  Duplici_, Madrid, 1913.

Ovarian tumors in pregnancy are, as has been said, rarer than
myomata. Such tumors are mostly cysts and dermoids. In 862 cases
collected by MacKerron, 68 per cent. were cysts, 23 per cent.
dermoids, 5 per cent. malignant tumors, and a few were myomata. Cysts
and dermoids do not, like the myomata, grow bigger during pregnancy,
but they may hinder delivery or grow gangrenous and septic. When
treated early the mortality in pregnancy is from 2.1 to 5.9 per cent
for the women, but delay gives a maternal mortality of from 31 to 39
per cent. The fetal mortality in Heiberg's statistics of 271 cases
was 66 per cent.

Most obstetricians advise the removal of an ovarian tumor in
pregnancy as soon as diagnosed, provided it is of a size to cause
difficulty in parturition, but such a removal causes abortion in
over 20 per cent. of the cases. The expectant treatment causes
abortion in about 17 per cent. If the child is viable, Fehling,
Martin, Norris, and De Lee are in favor of the expectant treatment.
Late operators leave weak scars at labor. When there are symptoms
of torsion of the pedicle of the tumor, infection, incarceration
in the pelvis, involvement of the uterine broad ligament, or
overdistention of the belly, the tumor must be removed immediately.
Whether vaginal puncture or laparotomy is the better method is to be
decided particularly. Dermoid cysts are likely to bring on sepsis
if they are broken in enucleation, and the diagnosis and operation
must be carefully made. When it is necessary to save the life of the
woman to remove an ovarian tumor, the risk of abortion may be taken
permissively.

Cancers of the cervix uteri are always malignant and cause death if
they are not removed before they have gone on to metastasis. As this
tumor commonly appears after the child-bearing age, it is rare in
pregnancy; the ordinary ratio is one in 2000 deliveries, but De Lee
saw only one in Chicago in 16,000 consecutive labors. Abortion occurs
in from 30 to 40 per cent. of the cases. Spontaneous rupture of the
uterus may happen, and placenta praevia is frequent relatively.
Pregnancy hastens the growth and spread of cancer very much. Eight
per cent. of the women die undelivered, and 43 per cent. die during
labor or immediately afterward. Of all uterine cancers, 80 per cent.
are cervical.

The diagnosis should be as certain as possible. Rarely nodules which
are not cancerous appear in the cervix during pregnancy, and these
are to be examined microscopically. Snipping out of a piece of the
nodule for examination does not cause abortion. Vaughan of Michigan
University, who is a skilful and careful observer, said[116] that
in an investigation of 200 cases of cancer, upon which more than
30,000 differential blood-counts were made, he discovered a method
of diagnosing the operability of a cancer as follows: He makes a
blood-count and then injects intraperitoneally one c.c. of placental
residue. The next day he begins a series of blood-counts, and if the
number of polymorphonuclear cells _decreases_ the case is operable,
no metastasis has occurred; if there is no change in the number
of the polymorphonuclears, or an _increase_ with a corresponding
decrease of the large mononuclears, the case is inoperable,
metastasis has begun.

  [116] _Jour. Amer. Med. Assoc._, December 8, 1917.

In cancer of the cervix operability does not mean curability always.
Inoperability signifies that the woman has no chance at all for life
and that it is useless to do anything; operability means that she has
one chance in four and that it is worth while taking the chance. The
following conditions may be met:

1. The case may be operable and the child inviable.

2. The case may be operable and the child viable.

3. The case may be inoperable and the child inviable.

4. The case may be inoperable and the child viable.

In the first case the supposition is that the case is operable but
the child inviable. To save the woman the uterus, with its adnexa,
must be removed, and this, of course, kills the fetus. The case
differs from the enucleation of a gangrenous myoma which involves
the death of an inviable fetus. In the myoma case the woman has
practically every chance for her life through operation; in this
cancer case the woman has only one chance in four, as 75 per cent. of
such operations fail through recurrence of the cancer.

The child has about one chance in two of going on to viability, owing
to the tendency to abortion, if no operation is done; but the mother
loses her chance for life if the operation is not done at once, as
the cancer will spread beyond cure. Zweifel has seen such a growth
extend a finger's breadth in one week. The one chance in four in
immediate operation gives the mother a solid ground for hope, and the
probability is sufficient, in my opinion, to permit the operation
with a permissive loss of the fetus.

In the second case the cancer is operable and the child is viable.
The child should at once be delivered by cesarean section, and the
uterus with its adnexa removed.

The third case is that of an inoperable cancer and an inviable child.
There the operation should be deferred, if possible, until the child
becomes viable.

The fourth case supposes the cancer is inoperable but the child
viable. In the interest of the child, immediate cesarean section is
the best thing to do; it is much better than waiting until term. At
term this operation will have to be done anyhow, and the earlier
it is done, the better the woman can stand the strain. There is a
risk that she will die from the first operation done to deliver
the viable child, but she may licitly take this risk, as she might
licitly run into a burning house to save a child, even if not her
own. She may also licitly refuse the first operation.




CHAPTER X

APPENDICITIS IN PREGNANCY


Primary appendicitis in pregnancy is very rare; recurrent
appendicitis is not so rare. When appendicitis goes on to suppuration
and perforative peritonitis the condition is worse in pregnant women
than in the non-pregnant. In pregnancy protective adhesions, walling
off, are less likely to occur; the inflammation is more intense owing
to increased vascularity; thrombosis and phlebitis are more frequent;
drainage may be obstructed and the burrowing of pus widespread;
tympany, too, causes dyspnoea earlier. About 75 per cent. of the
cases occur after the third month, and the earlier the appendicitis
appears, the better the prognosis. During labor the contracting
uterus sometimes tears open an adhesive appendix, or ruptures a pus
sac and starts a general peritonitis. This condition may be mistaken
for a general sepsis which is puerperal. Acute appendicitis is
likely to be confused with an inflammation of a Fallopian tube. When
the appendicitis is perforative abortion, infection of the uterine
contents and death of the child happen in most cases. Labor is very
painful when appendicitis is present, and the uterine contractions
are often weak. After delivery many forms of infection of the uterus
and its adnexa are possible.

Operation is much less difficult in the first half of gestation
than in the latter months. At the beginning of gestation the
operation does not, as a rule, cause abortion. Late in pregnancy
appendicitis rapidly goes on to suppuration and perforation, with
a high mortality. Hirst says that where there is reason to suspect
suppuration a median incision should be made and the pelvic cavity
examined for possible areas of infection. John Deaver says, "Always
cut down on the sore spot and do not handle the uterus." An infected
uterus after cesarean section complicated with appendicitis has to be
amputated.

The diagnosis between appendicitis, ectopic gestation, twisted
ovarian tumors, ureteritis, and ureteral stone is to be made. In a
discussion of a paper by Finley on Appendicitis in Pregnancy,[117]
Dr. John Murphy of Chicago, a great authority, advised operation
as soon as the diagnosis is made, and he was of the opinion that
this diagnosis is not difficult to make in pregnancy. Deaver said a
diagnosis of catarrhal appendicitis is not seldom very difficult to
make. This form is very rare in pregnancy. Deaver is not of the same
opinion as Murphy as to operating as soon as the diagnosis is made in
all cases. Where there is a general peritonitis, operation commonly
only makes matters worse by spreading infection. The mortality of
cases of appendicitis in pregnancy left without operation is as high
as 77 per cent.; where the cases are operated upon within forty-eight
hours after diagnosis the mortality is 6.7 per cent. and it would be
better if the operation were done within twenty-four hours. Finley
says that in the fifteen cases reviewed in his paper the operation
did not cause abortion. Deaver tells us the muscular rigidity in
the right groin characteristic of appendicitis is often missing in
pregnancy, and that sometimes the pain is on the left side of the
belly.

  [117] _Jour. Amer. Med. Assoc._, December 24, 1912.




CHAPTER XI

PUERPERAL INSANITY AND STERILIZATION


From 8 to 10 per cent. of all insanity in women develops during the
puerperium--the incidence is about one case to 400 births. Puerperal
insanity in nearly 70 per cent. of the cases begins within the first
two weeks after parturition. Next in frequency of occurrence is
the period of lactation, especially in multiparae. Insanity during
pregnancy itself is relatively rare, and it begins usually after the
fourth month.

As in other forms of insanity, hereditary predisposition is found
in from 25 to 30 per cent. of the cases. Alcoholism, sepsis, and
neuroses like hysteria, chorea, and epilepsy, are the predisposing
elements. The most common immediate exciting cause during pregnancy
is toxemia from faulty metabolism and excretion. Other frequent
direct excitants are mental worry from poverty, desertion, seduction,
and the like troubles.

Prolongation of the lactation period beyond the usual time for
weaning, from the ninth to the twelfth month, is common among
ignorant and lazy women. Some women prolong lactation in the
erroneous notion that it prevents renewed impregnation. Such
lactation is injurious to the child, as a rule. Ploss says
hyperlactation is frequent in Spain, and that some Japanese,
Chinese, and Armenian women may nurse their children for years, but
this practice is undoubtedly injurious, especially among European
races. The women get tabes lactea with emaciation, asthenia, anemia,
backache, pain in the breasts, neurasthenia, cramps, and blindness.
The uterus atrophies in some cases and may be permanently injured.
Insanity is not unusual.

The forms of mental disturbance commonest in puerperal insanity are
mania with or without delirium, melancholia, and dementia. Dementia
is the final stage in the cases that become chronic. Mania is the
prevailing type in insanity after labor, and melancholia in insanity
during gestation. The melancholy of insanity during gestation is
often suicidal, and must always be watched. Religious and erotic
symptoms are also observed.

The onset may be very sudden during labor. An outbreak after labor
may be suicidal or homicidal. Maniacal puerperal women are dangerous.
They have delusions and hallucinations, with very rapid and incessant
changes that range from obscenity to prayer. Melancholy in the
puerperium is likely to be suicidal.

About 75 per cent. of puerperal insanity cases recover within five or
six months. From 2 to 10 per cent. die from sepsis, exhaustion, or
intercurrent diseases; the remainder become permanently insane. The
nearer the delivery the insanity appears, the better the prognosis.
Menzies found that of cases which began during gestation 56.7 per
cent. remained insane; of those that began during the puerperium 25
per cent. did not recover; of those that began during lactation 43.5
per cent. remained insane. Melancholia is more favorable than mania
in pregnancy, but after labor mania gives the better prognosis. The
maniacal patient is more likely to die, but the melancholic is more
likely to remain insane. The older the woman, the greater the number
of her pregnancies, the more the depression, and the higher the
temperature, the worse the prognosis. Alcoholism is an added risk
always.

All puerperal insanities should be treated in sanatoria or asylums
and not at home. When a woman with puerperal insanity is allowed to
remain at home she cannot get proper treatment, and is a constant
menace to her own life and the lives of her family.

A woman who has had puerperal insanity and has recovered her mental
health is likely to have a recurrence of her malady at subsequent
pregnancies. The question has been asked me a few times, "Would
it not be justifiable to sterilize such a woman to prevent this
recurrence, with its dangers and terrors?"

It would not be justifiable: 1. Because it is not licit to inflict
a grave mutilation to avert a possible or probable future evil.
2. There are other means to escape the danger: a woman with this
tendency is justified in denying the debitum. 3. Once crazy, always
crazy, is an aphorism with much truth in it, and it is doubtful
that sterilization in itself will prevent ultimate insanity. 4. The
conjugal relation of a sterilized woman would be no better than
onanistic. 5. The sterilization would fall under the decrees and
penalties described at the end of the chapter on Cesarean Section.




CHAPTER XII

NEPHRITIS IN PREGNANCY


In pregnancy the kidneys always give evidence of a constant
congestion, and the chief symptom of this is the great quantity
of renal epithelium shed with the urine. This engorgement has
given rise to the term "kidney of pregnancy." There has been much
discussion of this condition, especially as to the possibility of
differentiating it from beginning nephritis. In 227 consecutive cases
of pregnancy in which the urine was examined at short intervals by
myself throughout the entire gestation, there was always an enormous
quantity of epithelium, and this presence of epithelium is so
constant that its absence is a proof that pregnancy does not exist.
It is as physiological as any other somatic change in the puerperium.
Von Leyden and other German observers look upon the degenerative
alteration in the epithelium of the renal tubules as pathological,
but apparently more definite symptoms are necessary to make a
diagnosis of significant nephritis.

Williams[118] says that in the examination of 1000 pregnant women
at Johns Hopkins Hospital in Baltimore traces of albumin were found
in 50 per cent. without subsequent serious disturbance, but where
considerable albumin with casts other than hyaline was seen there
were symptoms of toxemia later, and several of these went on into
eclampsia. Fisher[119] held that red blood-corpuscles in these cases
indicate acute nephritis; and granular and epithelial casts, chronic
nephritis. Like the Johns Hopkins cases, he found albumin in 50 per
cent. of his patients. Albumin in slight quantities is found to be
extremely common toward the end of pregnancy. Meyer,[120] in an
extensive study of the kidney in pregnancy, made at Copenhagen,
found albumin in 5.4 per cent. of the women. During the last month of
gestation 71 per cent. of the women showed albumin. Premature births
occurred in 8 per cent. of the patients who had had albuminuria, but
in 21.5 per cent. of the women who had had casts. Delicate tests
for albumin are used by men who find these high averages, as a few
leucocytes from leucorrhoea will give the reaction. Most of these
cases have no clinical significance.

  [118] _Obstetrics_, p. 456.

  [119] _Praeger medizinische Wochenschrift_, 1892 n. 17.

  [120] _Zeitschrift für Geburtshülfe_, bd. 16, n. 2.

It is usually impossible to differentiate in pregnancy a lighting
up of an old nephritis from a toxemia. Where there is a history of
nephritis before the pregnancy, this often clears up the diagnosis.
Nephritis is likely to manifest itself in pregnancy earlier than
toxemia; albuminuric retinitis is commoner in nephritis, but these
facts are no real help in differentiation.

The position of the uterus may be a cause of nephritis, according to
the _American Text-Book of Obstetrics_; but De Lee and others hold
that the growing womb cannot possibly be a cause. Many other origins
have been suggested, but without sufficient proof.

The treatment of the nephritides of pregnancy is that described in
chap. xiii for eclamptic symptoms. When albuminuric retinitis occurs,
the medical tendency is to empty the uterus. All text-books counsel
this procedure, but they give no convincing reasons for the advice.
If the child is viable the therapeutic abortion might be done when
necessary; if the child is not viable the operation is, of course,
not licit. In the nephritis of pregnancy it is not certain that
emptying the uterus artificially, with the entailed shock, is the
best method of treatment; but, as a rule, nephritis is made worse
by pregnancy, and the irritation lessens with the termination of
gestation in some cases, but not in true chronic nephritis. Eclampsia
is more toxic than nephritis, and the treatment may differ in
important details: it certainly is doubtful that artificial abortion
in eclampsia is the method of choice at present. I saw a case of
albuminuric retinitis ten years ago, which could not have been worse.
The woman was in the seventh month of gestation; she was nearly
blind and half comatose. The albumin in her urine _always_ was so
great that it would not fully precipitate in a centrifuge tube, and
every field under the microscope was covered with large casts in
such enormous quantities that they were felted together. Yet the
woman was carried on to term by Dr. Joseph O'Malley and delivered
of a fully developed child. She since has had two other children at
term who are perfectly healthy, and she herself could pass a life
insurance examination. This is, of course, only one case, and it is
exceptional; but it is impossible to say what will happen in any
particular case--whether it will go on to death or recovery.

Both subacute and chronic parenchymatous nephritis show clinically
much albumin, many casts, marked edema (except in very emaciated
cases), absence of high blood-pressure, and the heart is not
enlarged. This condition is caused commonly by chronic tuberculosis,
syphilis, sepsis, and malignant tumors. With these clinical symptoms
and the history, we may differentiate the nephritis of pregnancy
from Bright's disease. Again, acute intestinal nephritis or
glomerulonephritis has urinary findings like the nephritides just
described, and there may be edema. The heart and the blood-vessels
are normal. The cause is usually a pus microörganism, and there
may be anemia from the sepsis. In subacute glomerulonephritis, or
intestinal nephritis, the urinary findings are marked (much albumin
and many casts), anemia is rather constant, the blood-pressure
gradually goes up to 180 or 200, edema may be marked or absent. The
cause is usually a pus microörganism. Chronic glomerulonephritis
shows much epithelium and many casts (sometimes in showers), the
blood-pressure is high, the heart is usually somewhat enlarged,
there is polyuria and some blood, edema is common (but there are
dry cases), albuminuric retinitis is rare, and anemia is marked
and secondary. It may be difficult to find the cause of this
chronic glomerulonephritis, but there is, as a rule, a history of
tonsillitis, septic rheumatism, endocarditis, a true influenza, or
the like infection. Primary arteriosclerotic contracted kidney shows
hypertension and secondary circulatory disturbance. The urinary
findings are comparatively slight and transient, and there is little
or no anemia. The development is insidious, and the etiology is not
known.

There is evidence of late to find a septic cause for most of the
nephritides, such as infectious fevers, pyorrhea of the teeth,
and like bacterial intoxications; in pregnancy the nephritis may
be toxemic from sources that are not bacterial. It is extremely
difficult, and not seldom impossible, to make any differentiation, as
has been said. When the child is viable, whether the uterus should be
emptied or not must be decided for the individual case; no general
rule can be set down to cover all conditions.

One of the kidneys may be dislocated during pregnancy--usually the
right kidney. If a floating kidney becomes twisted on its pedicle,
abortion may be a consequence. The torsion may compress the renal
blood-vessels and bring on acute hydronephrosis with high fever,
great abdominal tenderness, and a peritonic facial expression.

Pyelitis of the renal pelvis is not seldom met in pregnancy. The
gonococcus, colon bacillus, or some other pyogenic bacterium gets a
nidus after pressure and lowered power of resistance. This condition
is sometimes mistaken for appendicitis.

Catalepsy is a rare complication of pregnancy, in which the woman
lies in an unconscious condition. The disease is a neurosis, but it
might be mistaken for a toxic or uremic condition by a superficial
observer. The infants of such women may be cataleptic, and may die as
a consequence of the condition.




CHAPTER XIII

ECLAMPSIA PARTURIENTIUM


The term Eclampsia was first used to describe the sudden exaltation,
flashing forth (_eklampsis_), of the vital faculties at puberty;
later it was applied to convulsions, but now it is restricted to
convulsions in pregnancy which sometimes begin suddenly, as in a
flash. The disease is characterized by a series of violent convulsive
movements, loss of consciousness, and coma, and is one of the most
dangerous complications of gestation. All convulsions and comas in
pregnancy, not due to hysteria, epilepsy, cervical tuberculosis,
apoplexy, pneumonia, phosphorus, strychnia and like poisons, uremia,
and meningitis, are commonly classed as eclamptic. When the symptoms
of eclampsia are present with the exception of the convulsions, a
rare condition, this state also is said to be eclampsia. Reineke[121]
reported a case like this. After death the heart, kidneys, and liver
showed all the signs of eclampsia.

  [121] _Münchener medizinische Wochenschrift_, July 30, 1907.

The eclamptic attack may occur without warning, but almost always
there are premonitory symptoms for from a few hours to some weeks.
The preëclamptic symptoms are headache (commonly frontal), nausea
and vomiting, vertigo, nervous excitement or somnolence, muscle
twitching, occasional delirium, cramps in the calves, disturbances
of sight, tinnitus, and pain in the epigastrium. Epigastric pain,
headache, and disturbances of the optic tract are important symptoms.
If these last signs are present in a woman who has some edema and
nephritis, the eclampsia will certainly occur, if proper means to
relieve the condition are not promptly taken. When the prodromata
appear there is nephritis, as a rule, but exceptions are observed.

When the attack comes, if the patient is standing she falls
unconscious. The pupils dilate, the eyes and head are turned to
the side. She opens her mouth, and the jaw is pulled laterally.
The woman stiffens, her face is distorted, her arms bent, and the
whole body curves sidewise in a tonic spasm. After a few seconds her
jaws chop, and if her tongue is between the teeth it is lacerated;
twitching runs down from the face and ends in a violent convulsion
of the whole body, which may toss the patient from the bed, and she
may even fracture her skull or long bones in the fall. The breathing
stops, the bloodshot eyes stick out, the face swells and darkens, the
lips become purple. Gradually the convulsions wane, and the woman
appears to be dying; but after deep sighing she begins to breathe
stertorously; then she sinks into a coma, or, in favorable cases,
revives.

After a few minutes to an hour or more another convulsion may
befall her, or she may have no more than one. In very grave cases
consciousness may never return after the first fit. The convulsions
may run up into extraordinary numbers--a hundred or more. There is
a pseudoeclampsia where the convulsions have been as many as two
hundred. If there are many attacks in the first twenty-four hours
with no clear evidence of subsidence, the woman nearly always dies.
Fever begins in such cases, and goes up to 103 or even 107 degrees.
In an untreated case Black found a temperature of 110 degrees before
death. The average number of attacks in these cases is from five to
fifteen, and the convulsions are from a half minute to two or three
minutes apart. Olshausen had six patients who recovered after having
had from twenty-two to thirty-six convulsions, but those who have
above fifteen commonly die.

If the convulsions are severe the woman as a rule aborts, and often
rapidly. After the child is delivered the eclamptic symptoms may
subside, or they may come on again, even a week after labor. Often
the fetus dies during the attack; rarely it survives and is carried
to term; again, it may die and the eclampsia may subside, but the
fetus remains in the uterus for some time.

If the woman is to die the eclamptic attacks usually increase in
frequency and violence; the temperature runs up very high, or it
sinks; the pulse becomes weak and running, edema of the lungs comes
on, with rattling and cyanosis, and the urine ceases to flow. The
woman may die in a convulsion from apoplexy or heart paralysis. At
times the child is delivered, but the coma deepens and the woman
dies. In other cases there are coma and death without convulsions.
Rarely there is a condition akin to acute yellow atrophy of the
liver, with delirium, twitchings, coma, and death.

Women who have chronic nephritis seldom have convulsions in pregnancy
unless there happens to be cerebral hemorrhage as an effect, but
they suffer the other results of chronic Bright's disease--dropsy,
uremia, edema of the lungs, paralysis of the heart, and albuminuric
retinitis; they also are inclined to premature labor, and to
hemorrhages that loosen the placenta. When acute nephritis happens
in pregnancy convulsions are quite common, and when there are
convulsions as a result of either chronic or acute nephritis it is
very difficult to differentiate between these convulsions and genuine
eclampsia.

The real cause of eclampsia is unknown, but the most plausible
explanation of this "disease of theories," as Zweifel of Leipsic
called it, is that it is a toxemia which attacks the liver, and
directly or indirectly the kidneys, and brings on convulsions by
toxic action on the anterior cerebral cortex. The great difficulty is
to explain how these toxins originate. One authority suggests that
the poison comes from the liver; another, from the fetus; a third,
from the placenta, the intestines, the general metabolism, disturbed
glandular balance, bacteria, and so on, but nothing is certain as to
the etiology except that it is an intoxication.

On an average, 20 per cent. of the women who have eclampsia die,--but
statistics vary from 5.31 per cent. to 45.7 for the mother and from
30 to 42 per cent. for the child. Eclampsia occurring ante-partum
has the worst mortality; intra-partum, less; post-partum, least.
About half the children die from prematurity, toxemia, asphyxiation,
narcotics administered to the mother, or injuries at birth.

If the patient's pulse remains full and hard and below 120, there
is no immediate danger of death; but if faster, weaker, and running,
the prognosis is bad. High fever is not necessarily fatal to the
mother, but it is very dangerous to the fetus. Edema of the lungs is
a very grave symptom, but recovery is possible. When the convulsions
have gone beyond twenty the prognosis is bad, but there have been
recoveries. Deep cyanosis, marked restlessness, anuria, and intense
albuminuria are all bad symptoms. Apoplexy is nearly always fatal.
After delivery the recovery of the woman is by no means certain.
She may get pneumonia, sepsis, or another eclamptic attack. Hirst
finds that if the diastolic pressure does not rise above a ratio of
1 to 3 times the pulse pressure (_i. e._, the difference between the
systolic and diastolic pressures), the prognosis is good.

Every pregnant woman should be watched to prevent eclampsia, if
possible, because all are liable to this outcome. The hygienic
methods mentioned in the chapter on Abortion are most important here.
The family history is of weight--if the women of the patient's family
have been eclamptic, if her parents were alcoholic or insane, these
facts increase her liability to the disease. If she has had eclampsia
before, if her kidneys are acutely diseased,--especially if injured
by infections,--if she is inclined to digestive disturbance, she
is disposed to eclampsia. Albuminuria, diminishing amounts in the
daily excretion of urine, and decrease in the total solids of the
urine, casts or blood in the urine, are serious symptoms. If albumin
increases and urea decreases, this is a grave sign.

The blood should be examined for the various anemias. If the thyroid
gland is deficient or altered in activity, thyroid extract may be
indicated--this acts also as a diuretic. Uterine malpositions should
be corrected. Treatment should be given where there is any evidence
of toxemia, as headache, altered secretion and excretion, neuralgia,
mental eccentricity, increased vasomotor stimulation, high tension,
disturbance in the sensory apparatus, obstinate constipation and
jaundice. Toxemia is not necessarily renal in origin.

In any of these conditions the proteids should be kept low in the
diet, so that the kidneys may not be overtaxed. To throw off
toxins, the emunctories should be stimulated by laxatives, water
for diuresis, tepid bathing. If the symptoms grow threatening, and
the kidneys are involved, the woman should be put to bed, on water
alone. After three days an absolute milk diet should be begun. As she
improves, starches are added, then the vegetables containing proteid,
vegetable oils, and butter. As the improvement goes on, the diet may
be vegetables, fruit easy of digestion, and one egg a day. Later
fish and chicken are used, but never a full meat diet. Beef, mutton,
veal, and similar heavy meats are not to be eaten. The drink is to be
water, buttermilk, or koumiss.

When the eclampsia is inevitable the question of inducing labor
arises. If the child is not viable, abortion is out of the question,
as has been proved in the chapter on Abortion and the general chapter
on Homicide. If the child is viable, there are three opinions: one,
that the premature delivery should be effected as soon as possible;
a second, that this delivery should be delayed as long as possible;
and a third, that it should not be attempted at all. Those who hold
that the uterus should be emptied as soon as possible, induce labor
at the first convulsion, rapidly and under deep narcosis. Chloroform
is dangerous to the heart in such cases for full anesthesia; ether
is better. Braun first observed that the convulsions cease or are
lessened after delivery. Dührssen found these results in 93.72 per
cent., Olshausen in 85 per cent., Zweifel in 66 per cent. Peterson
said that in 615 cases of early delivery--as soon as possible after
the first convulsion--the maternal mortality was 15.9 per cent., but
28.9 per cent. in the same maternities under the expectant method.

Olshausen was not in favor of forced delivery. Charpentier[122]
held that forced delivery is dangerous and should be absolutely
proscribed. His statistics of mortality are: after spontaneous labor,
18.96; after artificial labor, 30.04; after forced delivery, 40.74.

  [122] _Nouvelle Archives d'Obstétrique et de Gynécologie_, 1893.

Lichtenstein[123] reported, from Zweifel's clinic in Leipsic, the
results of 400 cases of eclampsia, and he found that the eclamptic
convulsions cease in only one-third of the cases after any form of
delivery. He says the mortality of induced labor is no better than
that after forced delivery, and that the mortality of both methods
does not materially differ from the mortality of a long series of
cases where there was no such intervention. The difference in the
mortality between eclampsia without delivery or with delivery seems
to depend on the relative loss of blood. In 40 per cent. of eclamptic
cases operated upon, the loss of blood was 500 c.c. above the loss
in cases of spontaneous delivery. The loss of blood tends to produce
collapse when the blood comes from the uterus, although it may be
beneficial if removed by venesection before delivery. Five hundred
c.c. of blood is one-eighth to one-ninth of the entire blood supply
of the body in a woman of average size. If 500 c.c. of blood is
withdrawn before the shock of forced delivery and replaced by an
equal quantity of normal salt solution, the toxin is thus reduced by
one-fourth or one-third and then diluted by the normal salt solution,
so that it has less poisonous effect.

  [123] _Archiv für Gynäkologie_, 1911, xcv, 1.

Lichtenstein[124] describes the expectant treatment by phlebotomy
and narcotics to replace operative interference, and this method
has revolutionized the mortality of the treatment of eclampsia. In
ninety-four cases of eclampsia his mortality was only 5.3 per cent.,
and none of the deaths could be ascribed to the treatment. The
infant mortality was 37.3 per cent., as against his 38.8 per cent.
in active operative interference during preceding years. Werner, in
the Second Gynecological Clinic in the University of Vienna,[125] by
this new method in thirty-eight cases of eclampsia had a maternal
mortality of 5.2, as Lichtenstein had, but his infant mortality was
only 14.65 per cent., an enormous advance for the better. Formerly
the mortality in the Viennese clinic was 15.8 for the women and 44.3
for the children, in a series of 120 cases of eclampsia. A mortality
of 50 per cent. in the children is common in the old method. In
Lichtenstein's cases there were mental disturbances in 2.1 per cent.
of the women, as against 6.75 per cent. in the old method. Eclamptics
may go insane and kill the child after delivery. Lichtenstein treated
74 consecutive cases without a single death. In 54 per cent. of his
cases the convulsions ceased after one venesection, and 42 per cent.
of the women with ante-partum attacks recovered before labor came
on. Engelmann[126] reported a case where a woman who had had 188
convulsions recovered after the third venesection.

  [124] _Monatsschrift für Geburtshülfe und Gynäkologie_, xxxviii,
  2. Berlin.

  [125] _Münchener medizinische Wochenschrift_, November 23, 1915.

  [126] _Centralbl. f. Gynäk._ xxxi, 11.

In this method the woman is put in a dark, quiet room; 400 to 600
c.c. of blood are withdrawn by venesection, and 0.002 gm. morphine is
injected; two hours later 3 gm. chloral is given in an enema. If the
fetus presents in a position for prompt delivery it is removed with
forceps, or by expression to spare the mother; but expression is a
dangerous process always.

Zinke[127] of Cincinnati has a method which reduces the maternal
mortality, but it has an enormous infantile mortality. He depresses
the maternal pulse by veratrum viride, and this depression is
probably the cause of the infantile mortality through asphyxia. Veit
introduced the use of morphine in eclampsia, and Winckel the use of
chloral. It has been found that narcotics check the action of toxins
on the nuclei of cells, and in eclampsia the action of narcotics
may be of this nature. Baker of Alabama in 1859 first gave veratrum
viride in eclampsia. The drug lowers arterial tension by depressing
the vasomotor centres and the heart itself. In eclampsia it diverts
blood from the brain and depresses the motor neurons of the spinal
cord. Aconite has the same effect in acute cerebral congestion
without depressing the vasomotor centres or irritating the stomach as
veratrum viride does.

  [127] _New York State Journal of Medicine_, xiii, 8.

Cesarean delivery is used frequently of late in eclampsia. The
mortality of the children is lowered somewhat by a cesarean section,
but the mortality of the mothers is much worse than in the expectant
method described by Lichtenstein. Eclamptic women usually have
badly affected kidneys, and the anesthetic used in the section may
be a cause of the raised mortality. Peterson reviewed 500 cases
of cesarean section for eclampsia[128] done by 259 operators in
various countries. Up to 1908 the maternal mortality was 47.97 per
cent. in 198 cases; from 1908 to 1913 it was 25.79 per cent. in
283 cases. Convulsions ceased in only 54.92 per cent. of the women
after cesarean delivery, and in those cases in which the convulsions
continued the mortality was 31.53 per cent. In 146 cases where the
convulsions ceased the mortality was still 19.8 per cent. for the
mothers. The fetal mortality was 10.69 per cent., counting all
children who died within three days after delivery by section. The
maternal mortality after cesarean section increases with the age of
the patient. The cesarean delivery, then, has a maternal mortality of
late of 25.79, with a tendency to increase as unskilled men attempt
it; the expectant method has a maternal mortality of only 5.3 per
cent. The cesarean delivery has a fetal mortality of 10.69 per cent.;
the expectant, 14.65 per cent. The expectant method is preferable.

  [128] _Amer. Jour. Obstetrics and Diseases of Women and
  Children_, lxix, 6.




CHAPTER XIV

HEART DISEASES IN PREGNANCY


Over 20,000 women die in childbirth each year in the United States,
and about 100,000 infants, and more or less permanent injury from
parturition is almost general in mothers. The mortality in the
trenches during the present great war is 2 per cent.; the mortality
of infants during the first year is 14 per cent. Very much of this
mortality and invalidism is attributable to lack of skill in the
licensed unfit. We commonly deem parturition merely a physiological
process, and for that reason the state permits ignorant midwives and
quacks to take upon themselves with impunity the responsibility and
the risks of delivery.

It is difficult to draw the line between normal and abnormal
parturition, but every labor, as women now are in civilized
countries, should be regarded as a grave surgical operation, and
the indications that must be met in a surgical operation are likely
to occur in almost any parturition. The strength of the patient,
the condition of the heart, lungs, kidneys, and blood, sepsis and
antisepsis, the nature and technic of the various operations that
may be required, and the complications that may arise, are all to be
understood and met conscientiously. No physician who has any regard
for morality and his own reputation now will accept an obstetrical
case unless he has had the woman under frequent observation for
months before delivery. If the mother or child dies because of the
bungling or surgical uncleanness of the physician or midwife,--and
unfortunately such deaths occur almost hourly,--this physician or
midwife is guilty of murder. There may be an abnormality of the
uterine or abdominal muscles used in parturition, a disproportion
between the parturient canal and the child, or various accidents
of labor; and these conditions are so frequent in occurrence and
so grave that their removal requires great medical skill, fine
discernment, quick and exact judgment, and often decidedly courageous
purpose.

New methods of treatment frequently appear, and the quack is likely
to be among the first by which the new is tried. The use and abuse
of pituitrin is an example of such a method. About 1909, pituitary
extract as a uterine stimulant was first described and it was
immediately taken up by competent men and more frequently, perhaps,
by the quack. The extract is from the posterior lobe of the pituitary
gland, and when injected subcutaneously or into a muscle it is a very
powerful oxytocic. In a few minutes the injection markedly increases
the intensity and duration of the pains. The effect lasts for an
hour or an hour and a half. Whitridge Williams[129] says a judicious
administration of the drug will do away with the use of low forceps
in from one-third to one-half of the cases, but its ignorant use
places the life of the mother and child in jeopardy. Mundell[130]
found twelve cases of rupture of the uterus, thirty-four cases of
fetal death, and forty-one cases of fetal asphyxia pallida in which
resuscitation was effected only after prolonged and vigorous efforts,
sometimes for over an hour.

  [129] _Obstetrics_, 4th ed. New York, 1917.

  [130] _Jour. Amer. Med. Assoc._, June 2, 1917.

If there is any serious obstacle at all to delivery in the parturient
canal or in the fetal position, or the like, pituitrin is likely to
cause rupture of the uterus and asphyxiation of the child. It should
never be used when there is the slightest danger of rupture of the
uterus; or when the child is suffering; or in a shoulder and most
pelvic presentations; or in elderly primiparae with rigid muscles;
or when the cervix is not fully dilated, lest the undilated cervix
be torn off; or where there is inertia after prolonged effort to
overcome an obstacle to delivery. It is never to be used in a normal
delivery merely to hasten the birth. Obstetrical cases are tedious,
and an impatient physician with an atonic conscience is likely to use
pituitrin so that he can get back to his bed.

Comparisons between the fetal mortality after the use of pituitrin
or the forceps are erroneous. Quigley[131] contrasted the fetal
mortality in these conditions. In 147 pituitrin cases it was 2.7 per
cent., in about five or six times the number of forceps cases it
varied from 5.7 to 15.63 per cent.; but wherever there is any real
need at all for the forceps, pituitrin at once is contraindicated
except in easy low forceps deliveries, where in the hands of a
skilled man pituitrin may safely replace the forceps to avoid
possible instrumental infection of the uterus. There are contractions
of the uterus toward the end of gestation, before labor proper sets
in, which cause what are called False Pains, and these must not be
mistaken for the beginning of labor, as unnecessary examinations
and meddlesome interference may bring on great harm. Uterine atony,
or weak pains, may affect the patient in the first stage of labor,
in which the cervix of the uterus should be dilated; or the second
stage, in which the child is delivered; or the third stage, the
post-partum period, when the placenta is thrown off. Contractions
of the uterine muscle cause pain, and these contractions themselves
are called the Pains. In the first stage weak pains may prolong the
dilatation of the cervix for days and expose the mother to sepsis or
exhaustion, and the child to consequent danger.

  [131] _Jour. Amer. Med. Assoc._, April 10, 1915.

In the second stage the abdominal muscles, which push the child
out of the uterus, fail to work if the pains are weak. Causes of
unsuccessful pains in the second stage are: an infantile uterus,
fibroids or other tumors in or near the uterus, peritoneal adhesions,
a full rectum or bladder, abnormal position of the uterus, a
pendulous abdomen, diseases of the uterine wall, scars from past
operations, chronic metritis or endometritis, primiparity in
relatively advanced age, twins, distention of the bag of waters, gas
in the uterus, abnormal position of the child, contracted pelvis,
adhesions of the membranes about the os uteri, fatigue of the woman,
and tetany or stricture of the uterus. The obstetrician must be able
to diagnose the special cause and treat the indications.

One of the causes of weak pains is a diseased heart. Systolic murmurs
at the base of the heart and an accentuated second aortic sound
are quite common in pregnancy and may not be of grave importance.
If there is a genuine cardiac lesion with good compensation, the
labor is usually successful and without notable damage to the
woman, although obstetricians like De Lee think that such patients
appear to develop decompensation sooner than do women who are
not pregnant. If the heart disease is advanced and the heart is
in unstable equilibrium, especially if there is myocarditis or
fatty degeneration, the heart is likely to break down in pregnancy
or labor. In chronic cardiac lesions, pregnancy, through venous
congestion, tends to renal and hepatic disturbance, or to dyspnoea
and carbonic acid narcosis. The uplifting of the diaphragm by the
enlarged uterus increases the respiratory difficulty. There may
be edema of the lungs, hypostatic pneumonia, dropsy, insomnia,
albuminuria, and other serious symptoms.

During labor a diseased heart may fail and cause sudden death,
especially if the second stage is prolonged. At times there is
collapse and death shortly after delivery. The mortality of heart
disease in pregnancy varies in the reports on various series from
4 to 85 per cent. Babcock[132] says that the mortality in mitral
disease in pregnancy is 50 per cent.; that in disease of the aortic
valve is 23 per cent. These figures are far above those given by
later obstetricians of skill. Fellner and Demelin, in ninety-four
and forty-one cases respectively, had a mortality of only 6.3 and
5 per cent. Hirst says he never lost a case. Jaschke[133] found a
mortality of only 4 per cent. in 1548 cases of pregnant cardiopaths.
A great danger is in treating heart conditions by general rules,
and in giving digitalis and other drugs without discrimination.
In uncompensated heart conditions many of the children die from
prematurity, abruptio placentae, diseases of the placenta, or
asphyxiation.

  [132] _Diseases of the Heart._ New York, 1905.

  [133] _Medizin. Klinik_, February 25, 1912.

Even those obstetricians who induce abortion at any stage of
gestation when they deem the woman's life in danger say that heart
disease in itself is not an indication for abortion unless there
is chronic decompensation with myodegeneration and renal or hepatic
insufficiency. Expectancy is the rule. Lusk advises abortion as soon
as mitral stenosis is discovered.

Surgeons of the Mayo Clinic, in a report[134] on Operative Risk in
Cardiac Disease, hold that a valvular lesion is not a rational basis
for judging a cardiopath so far as prognosis in a surgical operation
is concerned, but this statement is not true for an obstetrical
case. If we except angina pectoris and related diseases, the four
disorders of the heart's mechanism that surgeons deem the worst risks
in operation are auricular fibrillation, auricular flutter, impaired
auriculoventricular conduction, and impaired intraventricular
conduction. These conditions are usually accompanied by extensive
lesions of the heart muscle.

  [134] _Jour. Amer. Med. Assoc._, lxix, 24.

In auricular fibrillation there are rapid incoördinate contractions,
twitchings in individual muscle bundles of the auricular wall. The
auricle loses its power to pump the blood and dilates. The pulse is
commonly arhythmic and rapid. A permanent fibrillation is worse than
a paroxysmal state. The condition is found especially in advanced
cases of exophthalmic goitre. In the Mayo Clinic the operative
mortality in seventy cases of exophthalmic goitre with auricular
fibrillation was only 2.8 per cent.

In auricular flutter, or heart block, there are foci of irritation
in the auricular wall which cause rapid coördinate contractions.
The auricle may contract twice as often as the ventricle, and
the pulse may be regular or markedly irregular. The stimulus for
heart contraction normally reaches the ventricle from the auricle
by passing along the bridge of primitive tissue which connects
the auricle and ventricle. This bridge may be so affected that
the stimulus is delayed, or prevented at times from crossing
over, or completely blocked. One patient with complete heart
block was operated upon at the Mayo Clinic three times in eleven
years for appendicitis, cancer of the breast, and the excision of
recurring skin nodules, and is still alive and reasonably well.
In intraventricular block the risk of operation is worth taking,
according to the opinion at the Mayo Clinic, where there is
exophthalmic goitre or tonsillitis.

In general, where there is question of surgical operation on a
cardiopath, no such operation should be done unless there is definite
ground to believe that the operation is essential to improve the
heart condition or restore reasonable health. Extremely severe
cardiac disease can be relieved or even completely cured by the
surgical removal of infectious, mechanical, or toxic sources of heart
degeneration, especially goitre. When the myocardial insufficiency
is so marked that no medical treatment reëstablishes a reasonable
compensation, no surgical operation is permissible. The medical
treatment is the only test to learn whether the heart can be put
into a condition wherein it will withstand the anesthesia and the
operation. Life depends on ventricular action, not on auricular, and
the ventricular reserve is the standard for judgment in these cases.

Fibrillation and heart block are grave conditions when found in
pregnancy, but disease of the mitral valve because of frequency is
more important, and when compensation is unstable mitral lesions
are dangerous. In mitral stenosis the enlarged uterus in the last
months of gestation, by crowding the intestines and diaphragm,
embarrasses the heart. As the diaphragm cannot descend well, the
flow of blood out of the right ventricle is not aided by respiration
as in normal conditions. Pressure on the abdominal veins increases
the blood tension and throws greater work on the left ventricle. In
the expulsive stage of labor there is danger of the right ventricle
giving way under the added strain.

In mitral regurgitation the left ventricle is dilated, and in
pregnancy the regurgitation is increased by the peripheral resistance
or obstruction. If the dilated ventricle is also hypertrophied it
stands the strain much better. In the second stage of labor the
danger is the same as in mitral stenosis. In disease of the aortic
valve the strain of child-bearing is on the left ventricle, but
patients in this condition undergo labor more successfully than do
those with mitral disease.

Labor in any cardiac disease requires close watching even when the
compensation is good. There is always a possibility of collapse in
the third stage or during the puerperium. The obstetrician must
stay by the bedside, and he is to have everything ready for a sudden
emergency, which is likely to result in death if not instantly met.
All the instruments for operative delivery are to be kept sterilized
and ready for immediate use. When symptoms of imminent collapse
appear, delivery is to be done at once. If a cardiopath collapses in
the early stages of gestation, before the child is viable, the rule
explained in the chapter on Abortion holds--the child may not be
killed by removal to save the woman's life.

Jaschke,[135] in his consideration of 1548 pregnant cardiopaths,
found that seven-eighths went to term, and that the women were
prematurely delivered in only about 9 per cent. of the total number
of cases. Therapeutic interruption of pregnancy was necessary in
only about 1 per cent. The high mortality reported by many good
obstetricians is a proof that the treatment of cardiac conditions
requires an experience in clinical medicine and a skill lacking, as a
rule, in specialists who are not internists.

  [135] _Loc. cit._

A combined mitral and aortic disease with great enlargement of the
heart, heaving of the chest wall, and some protrusion makes pregnancy
very dangerous. Osler thinks mitral insufficiency in itself not
very dangerous. He had one patient with such a condition, a loud
apex systolic murmur, and some enlargement, who bore nine children
and lived to past sixty years of age. Mitral stenosis is not so
favorable, but even in extreme stenosis some women bear several
children without collapse.




CHAPTER XV

HYPEREMESIS GRAVIDARUM


Hyperemesis Gravidarum, the Pernicious Vomiting of Pregnancy, is
commonly classified among the toxemias; but as the etiology is not
known definitely, this classification is one of convenience more
than exactness. Nausea and vomiting occur so frequently in the early
months of gestation that they are deemed almost physiological,
but when these symptoms become very grave and persistent they are
undoubtedly pathologic, and are said to be pernicious, as they may
lead to abortion, or to the death of the woman. In 1813, Simmond
first successfully employed artificial abortion to save the woman
in this condition, and thus added a possible moral quality to the
disease. Therapeutic abortion was used in 1608, and Soranus of
Ephesus, in the second century, mentions it.

The pernicious nausea commonly begins in the second month of
pregnancy, less frequently in the fourth month, but it may be delayed
until the sixth month; if it occurs after the sixth month it is,
almost as a rule, an evidence of nephritis. It may last from about a
month and a half to three months, but in toxemic cases it may result
in death in two weeks. Sometimes remissions occur.

In 1852, Paul Dubois described the disease, and his division into
three stages is still used in articles on pernicious vomiting,
although these stages are not clearly marked clinically. In the
early months of gestation the stomach may become unable to retain
food, and there is notable loss of appetite; the condition is then
grave. There may be retching at the sight of food, at any change of
position, or at the entrance of a person into the room. The emesis
may recur so often at night as to cause exhaustion from insomnia.
Hiccough, thirst, pain in the stomach, and soreness of the thoracic
muscles are frequent and troublesome symptoms. In some cases there is
salivation.

The vomitus is food, mucus, and some bile at first; later mucus and
bile; finally it contains blood. The blood may come from the mouth,
pharynx, or stomach, and it is serious if it is gastric. The urine is
scanty, and shows nephritic irritation. At times it contains blood,
bile, acetone, diacetic acid, indican, and rarely sugar.

In the second stage of the disease all symptoms are aggravated,
and the stomach will not retain anything. There is extreme thirst;
the patient faints often, and loses weight rapidly. In chronic
cases there is much emaciation. The mouth is like that in a case of
typhoid. Sometimes there is a low fever; again, the temperature is
subnormal, with a rise before death. The pulse is rapid and weak, and
the post-mortem heart shows fatty degeneration as in a fatal sepsis.

In the third stage the mind is affected, there is delirium, stupor,
and coma; the vomiting ceases, the pulse grows more rapid and
feebler, and the weakness becomes more and more overwhelming until
the patient dies. This third stage is commonly short. In these
conditions it is too late to empty the uterus, and any attempt to do
so then only hastens death.

In some cases the fetus is apparently not affected; in toxic cases it
is affected, and then there may be miscarriage. If the fetus dies the
vomiting ceases, as a rule.

The liver enlarges in the first stage and later diminishes. There
may be a general hemorrhagic hepatitis and acute yellow atrophy, or
partial fatty degeneration around the central lobular veins. Necrosis
also occurs. Acute parenchymatous nephritis and hemorrhages into the
kidneys are often observed.

Neurotic and hysteric women are more liable to this disease than the
nervously stable. There is a direct communication by the sympathetic
and vagus nerves between the stomach and the uterus and its adnexa,
and thus reflex irritations readily pass to the stomach. Through this
path vomiting is caused by any unusual distention of the uterus,
as when the fetus grows too rapidly; or when the size of the ovum
is larger than normal, as in twin pregnancies; or in irritations
like hydramnios, displacement of the uterus, acute anteversions,
retroversions, or flexions which pinch and stretch the nerves.
Inflammations, as metritis, endrometritis, and cervicitis; tumors
of the uterus; diseases of the adnexa or of the pelvic connective
tissue or peritoneum are other sources of reflex vomiting. The proof
that such are causes is that the vomit ceases when the conditions
mentioned are cured. Such conditions exist, however, in women who are
not pregnant without causing vomit; there is therefore some special
disposition in the pregnant.

Diseases which in themselves have vomiting as a symptom will in
pregnancy make the vomit pernicious. Such are chronic gastritis,
gastric ulcer, enteritis, cancer, helminthiasis, large fecal
concretions, enteroptosis, tubercular peritonitis, and gall-stones.
What is apparently pernicious vomiting in pregnancy may be the
beginning of acute miliary tuberculosis. Diseases of the air
passages--hypertrophied turbinates, septal spurs, laryngeal and
apical tuberculosis--seem to cause the vomiting or to dispose to it.
When vomit is associated with uremia, this occurs, as a rule, in the
last months of pregnancy.

The cause, again, may be in the nervous system, from either a
demonstrable lesion or a functional imbalance--paresis, locomotor
ataxia, tumors or tubercle of the brain, meningitis, polyneuritis.
Even when the nervous system is not directly the cause of the emesis,
the remote irritant may work through the nervous system. A bad
neurotic inheritance, as from alcoholic, insane, or weak parents,
disposes to neurotic hyperemesis.

Toxins from the fetal syncytium appear to be another cause of the
vomit. The syncytium is a mass of protoplasm without cell demarkation
but with nuclei scattered throughout the substance. Sometimes this
embryological cellular material starts to grow after the manner of
a cancer, and then it is very malignant (_syncytioma malignum_),
but its connection with the pernicious vomit of pregnancy is more
theoretical than established. In physiological conditions the toxins
in the blood are neutralized by the secretions of the ductless
glands of the body, and in pregnancy probably these same glands by
intensified activity effect the same result. Injection of blood
serum taken from healthy pregnant women has cured cases of toxemic
pernicious vomit, and this makes the theory much more probable.

To diagnose the etiology of pernicious vomiting is not always easy.
We must decide first whether the emesis is really pernicious or
not; secondly, we have to determine whether or not it is due to the
presence of the fetus; thirdly, we are to differentiate the primary
and adjuvant causes for intelligent treatment. The age of the fetus
must be known to determine whether we may licitly interfere so as to
remove the fetus from the uterus if necessary, in medical opinion, to
do so.

Trousseau emptied the uterus of a woman to stop her pernicious
vomit, but she died, and at the autopsy he found a cancer of the
stomach. Caseaux discovered tubercular peritonitis in a woman who had
died after a diagnosis of hyperemesis gravidarum; Beau, tubercular
meningitis in a like case. Williams of Johns Hopkins University
stopped a very grave case of pernicious vomiting in a neurotic woman
merely by telling her of the dangers of artificial abortion.

There is no settled mortality percentage in hyperemesis gravidarum
because so much depends on diagnosis and treatment. Braun, in 150,000
obstetrical cases, never had a death from pernicious vomit; others
have a mortality of 40 per cent.

The treatment is technical, and is given in detail in books like
De Lee's _Principles and Practice of Obstetrics_.[136] Suggestion
and the environment are important elements in the treatment. Local
anesthetics, mechanical drugs like cerium oxalate and bismuth,
depressomotors, external applications, and gastric lavage are
indicated in the early stages of the disease, but are rather harmful
than useful in later stages. Adrenalin, ten drops of a 1:1000
solution by mouth, or three drops hypodermically as doses, often
cures. Sergent and Lian reported six such cases in one paper in
1913. Hypodermic injection of the extract of corpus luteum in 1
c.c. doses has been effective in some cases. So has the injection
of defibrinated serum from a healthy pregnant woman. Curtis
describes the technic in the _Journal of the American Medical
Association_, February 28, 1914. The gynecologist must adjust
uterine displacements and heal cervical erosions. The oculist,
laryngologist, and otologist are to remedy refractive errors and
remove irritants in the air passages and the ear.

  [136] Philadelphia, 1913.

The treatment of last resort is to empty the uterus. This will cure
all cases of neurotic and reflex origin if done early enough. In
these cases, if the therapeutic abortion is deferred until very late,
the patient will die of exhaustion. Toxemic cases do not react well
after therapeutic abortion because of the damage previously done by
the circulating poison, especially in the liver. A positive diagnosis
of toxemia cannot always be made, and many patients in whom the
diagnosis has been made correctly recover without abortion. Apart
from moral considerations, it is very difficult to determine the
proper time to empty the uterus. A test is made of the glycolytic
power of the liver by giving two ounces of levulose internally;
and if sugar shows in the urine, this means that the liver is
unable to act normally, that it has been attacked and disabled by
the toxin, and therefore the therapeutic abortion should be done.
Again, a marked concentration of the blood, shown by erythrocytosis
and leucocytosis, indicates starvation. Some obstetricians perform
abortion when the pulse remains above 100, at the appearance of
fever, blood from the stomach, jaundice, albuminuria, mellituria,
acetonuria, indicanuria, or marked loss of weight. Polyneuritis, with
icterus and bile in the urine, is another indication for abortion;
a patient may die from polyneuritis alone after the hyperemesis has
ceased. Not one but all these facts must be considered, together with
one's own clinical experience.

In hyperemesis gravidarum, as elsewhere, therapeutic abortion is
never permissible, under any circumstances, if the child is not
viable. If the mother cannot be saved without emptying the uterus,
the mother must die; there is no way out of the difficulty. The proof
that this doctrine is correct has been given in the introductory
chapter on Homicide and when considering abortion in general.




CHAPTER XVI

CHOREA GRAVIDARUM AND HYSTERIA


Recurring, permanent, localized spasms of facial or other groups
of muscles, which are often called chorea, are tics,--convulsive
tic, painful tic, accessorius spasm, and so on. Chorea is also
characterized by various recurrent spasmodic movements, but the
origin of the disease is commonly an infectious endocarditis,
rheumatism, tonsillitis, or the like disease. This is Chorea Minor,
St. Vitus's Dance, or Infectious Chorea. There is also a common
chorea, which is not from an infection but from some nervous
irritation, usually eye-strain, and disappears with the removal
of the irritation. The chorea of pregnancy is often an infectious
chorea, and then it is an extremely dangerous condition: the
mortality in some collections of toxic cases is as high as 22 per
cent. We meet, too, in pregnancy hysterical chorea, and a form which
is partly hysterical and partly infectious in origin.

Primigravidae are more susceptible to infectious chorea in pregnancy
than multigravidae. If a woman has not had true rheumatism she very
rarely gets chorea after the first gestation. Rheumatism in the
patient or in her immediate ancestors, epilepsy, fright and other
emotions, and anemia are predisposing causes. The patients are all
very neurotic; and if they had chorea in childhood, the condition is
likely to recur in pregnancy.

Mild cases may be cured without damage to the woman or fetus, but
many cases go on to abortion and death in coma and fever. Some severe
cases result in a mania which may last for months; again, there is
paralysis and delirium. The earlier in pregnancy the attack, the
greater the danger to the fetus.

It is very important to differentiate infectious chorea from
hysterical chorea--the latter may or may not be dangerous; chorea
always is dangerous. In hysterical chorea the movements are sudden,
isolated, and sometimes rhythmical, especially in the fingers; there
are zones of anesthesia, and the perversity of the hysteric soon
manifests itself. The movements in hysteria are never so intense as
to exhaust the patient. In true chorea the movements are irregular,
spasmodic, and increased by motion and voluntary effort, especially
if the effort is sustained; they exhaust the patient.

Maniacal chorea differs from the mania of the puerperium from other
causes: in maniacal chorea the woman is not so sullen, and is more
garrulous than the patient with puerperal mania. The prognosis is
better in maniacal chorea as to recovery of reason. Sometimes,
however, the mania of puerperal chorea persists for months, or it may
become even permanent.

If the fetus is viable and the choreic woman, with a clear toxic
chorea, shows signs of exhaustion from the spasms and insomnia, or
if her mania is becoming fixed and her delusions are dangerous (such
women are likely to kill the infant), or if she has endocarditis,
the uterus should be emptied, as a rule. If, however, the symptoms
show a recession on treatment, the uterus should not be emptied.
Albrecht[137] reported a case of chorea cured by an injection of
serum from a normal pregnant woman. Each case must be judged by its
own characteristics. The last sacraments should be given as soon as
the symptoms grow grave.

  [137] _Zeitschr. f. Geburtshülfe u. Gynäk._, lxxvi, 3, p. 677.
  Stuttgart.

Hysteria in a woman, even when mild, may grow serious in pregnancy
when it takes the form of melancholia; but it is dangerous when it
passes into maniacal excitement. In mania there may be exhaustion
from a refusal to take food, and in labor maniacal hysteria may wreak
grave injury on both mother and child. Hysterical women should be
treated before pregnancy; indeed, the process of avoiding hysteria
should have begun in the patient's grandparents.

The term hysteria has been handed down from the days when physicians
thought there was a connection between uterine disorders and the set
of nervous symptoms grouped about the title hysteria. It is now
etymologically meaningless--men also grow hysterical. Briquet found
11 male to 204 female hysterics, and later statistics increase the
number of males.

The disease is not readily definable. The patient is usually a young
emotional woman, oftenest between fifteen and twenty years of age.
She commonly has anesthetic spots on her body, concentric limitations
of the fields of vision and reversals in the color fields,
hysterogenetic zones, or tender points, which when pressed appear to
inhibit the hysterical fit. The symptoms enumerated here are not,
however, found in every case of hysteria, and it is difficult at
times to diagnose the case. There is a popular notion that hysteria
is a disease of malingerers, but it is as real as typhoid fever or
a broken leg, and a much greater affliction than either of these
conditions. Malingering is only a symptom of the disease.

The conditions that bring about hysteria are hysteria in a parent, or
insanity, alcoholism, or some similar neurotic taint in an ancestor.
Immediate causes are acute depressive emotions, shocks from danger,
sudden grief, severe revulsions of feeling, as from disappointment in
love or abandonment by a husband; and, secondly, cumulative emotional
disturbance, as from worry, poverty, ill treatment, unhappy marriage,
or religious revivals. Certain diseased conditions, as anemia,
chronic intoxications, pelvic trouble, start it into activity when
it is latent. It is also communicated by imitation and it may become
epidemic.

After the great plague, the Black Death, in the fourteenth century,
there were very remarkable epidemics of imitative hysteria in Germany
and elsewhere. In 1374, at Aix-la-Chapelle, crowds of men and women
danced together in the streets until they fell exhausted in a
cataleptic state. These dances spread over Holland and Belgium and
extended to Cologne and Metz. The "Dancing Plague" broke out again,
in 1418, at Strasburg and in Belgium and along the lower Rhine. In
1237 there was a similar outbreak among children at Erfurt and many
died from exhaustion. The tarantism in Italy from the fifteenth to
the eighteenth century is another example of epidemic hysteria. There
were epidemics of hysteria in Tennessee, Kentucky, and a part of
Virginia, which began in 1800 and recurred for a number of years.
These outbreaks started in revivals and camp meetings. The majority
of the cases were in youths from fifteen to twenty-five years of age,
but the hysteria was observed in persons from six to sixty years
old. The muscles affected were those of the neck, trunk, and arms,
and the convulsions were so strong that the patients were thrown to
the ground and often leaped about like a live fish tossed out of the
water on a bank.

Convulsions, tremors, paralyses of various forms and degrees are
common in hysteria. In major hysteria the patient falls into a
convulsion gently. There is checked breathing, up to apparent danger
of suffocation. Then follows a furious convulsion, even with a bloody
froth at the mouth, but there is a trace of wilfulness or purpose in
the movements. Next may come a stage of opisthotonos, in which the
body is bent back in a rigid arch until the patient rests on her head
and heels only, like a wrestler; and this is followed by relaxation
and a recurrence of the contortions. An ecstatic phase succeeds this
at times, the so-called crucifix position, with outbursts of various
emotions, and a final regaining of the normal state. Any of these
stages, however, may constitute the entire fit. Some major hysterics
can simulate demoniacal possession with extraordinary ingenuity.
In minor hysteria there is commonly a sensation of a rising ball
in the throat--the globus hystericus. There may be uncontrollable
laughter or weeping, and muscular rigidity is frequent. The patient,
especially if she is a child, may mimic dogs and other animals. The
snarling, biting, and barking of false rabies are hysterical; such
symptoms do not occur at all in real hydrophobia.

There are innumerable physical symptoms of the disease, but the
mental phases have most to do with the treatment. The hysterical
person is characterized by an overmastering desire to be an object of
sympathy, interest, admiration, rather than by a tendency to baser
instincts. The will is weak, the emotions explosive, the patient is
impulsive and lacking in self-control. She readily goes from absurd
laughter into floods of tears. She simulates pains and other symptoms
of disease, and she is always a liar, no matter what her state in
life, from nurse-girl to nun.

Acquired hysteria may be cured, but the congenital form is virtually
hopeless; yet even with this latter kind much can be done by patient
training. Such a girl or boy must be reared carefully and with a firm
hand. A marked congenital hysteric should not marry. Marriage makes
them worse, and they beget other hysterics. When a hysterical girl
gets one of her fits the chief obstacle to cure is sympathetic visits
from relatives and friends. If a patient in the vapors is taken from
school and wept over, she will never come down to earth again. The
girl who faints at the communion-rail regularly is always a hysteric,
and the cure for her is a bucket of cold water in the sacristy, or a
threat to turn her over to the police. You will find these fainters
with a perfect pulse despite the faint. But there are other cases
in which rough treatment is harmful, and the only method is patient
tact. Such persons are objects of great pity and should be dealt with
as one would deal with any deficient mind.




CHAPTER XVII

ACUTE YELLOW ATROPHY OF THE LIVER IN PREGNANCY


Acute yellow atrophy of the liver in pregnancy was formerly called
Icterus Gravis. The disease is not necessarily connected with
pregnancy, but half the cases are in pregnant women, and with them
it may appear at any time in gestation or shortly after delivery.
Pernicious vomiting, eclampsia, sepsis, chloroform poisoning,
typhoid, osteomyelitis, diphtheria, erysipelas, alcoholism, or
phosphorus poisoning in pregnant women may end in this acute yellow
atrophy. Bendig[138] reported two cases, both fatal, which were
caused by syphilis.

  [138] _Münchener medizinische Wochenschrift_, August, 1915.

The liver lessens in size, is friable, yellow-streaked, mottled with
red; the heart degenerates, and all tissues are stained with bile,
icteric. If the hepatic atrophy is a consequence of the diseases
enumerated above, the symptoms of these diseases precede those of the
atrophy. In chloroform poisoning the attack may end fatally within
six hours, or it may last for five or six days before death.

If a pregnant woman has had gastric catarrh with weakness and
headache, and then suddenly becomes delirious, begins to toss about
the bed with rolling of the head from side to side, is jaundiced,
shows epigastric tenderness, and a diminution of the liver dullness,
the diagnosis is almost certain. The reflexes are exaggerated, there
are minute petechiae on the trunk, arms, and legs, the tongue is
dry and brown, the breath is foul, the pulse is fast and weak, the
temperature is usually high (102-104 degrees), and the urine shows
nephritis.

The prognosis is always bad. The fetus nearly always dies. If the
fetus is viable the uterus should be emptied at once even if the
woman is so near death that the procedure appears useless: it may at
least give a chance to baptize the infant. Suppose in a particular
case a consultant or the physician in charge holds that the mother is
so ill that therapeutic abortion will only hasten her death, yet the
fetal heart-sounds can be heard through her abdominal wall. In that
case I should be in favor of performing the abortion to baptize the
infant, reluctantly permitting the chance of hastening the mother's
death. But this hastening is by no means certain.

When a diagnosis of acute yellow atrophy has been made the patient
should receive the last sacraments as soon as possible.




CHAPTER XVIII

INFECTIOUS DISEASES IN PREGNANCY


Any of the acute infections, as typhoid, typhus, smallpox, measles,
scarlatina, and the others, attacks a pregnant woman as readily
as one who is not pregnant. Pregnancy, as a rule, lessens the
resistance to the infection, and the infection is likely to cause
abortion. The toxin of the infection is added to the physiological
toxins of pregnancy, the kidneys often are overwhelmed, and there
is a tendency to hemorrhage. After the exhaustion from the disease,
delivery, whether premature or at term, is liable to end in collapse,
especially if the heart or lungs have been injured. Puerperal sepsis,
either general or local, is a common effect of these bacterial
diseases. In smallpox there is infection from the pustules and the
virus itself; in typhoid the typhoid bacillus and the streptococci
in Peyer's patches get into the blood; in influenza, pneumonia,
erysipelas, and diphtheria the bacteria directly cause sepsis, and in
scarlatina the pus organisms from the throat are found in the septic
foci.

In these infections the fetus may be killed by the high temperature;
it may die from asphyxia brought on by feeble maternal blood-pressure
and consequent stagnation of the circulation in the uterine sinuses;
it may be overwhelmed by maternal hemorrhage; by deoxidation of the
maternal blood, as in pneumonia; by a hemorrhage in the placenta, and
a consequent separation of the placenta itself from the uterine wall;
by fatty degeneration of the fetal villi, which renders respiration
of gases impossible. Again, the child may be infected by the disease
of the mother, or it may be killed by the toxins in the maternal
circulation.

The communication between the fetal and the maternal blood systems
is as indirect as that between the air in a man's lungs and his
blood. The communication between mother and fetus is by osmosis, but
certain toxins, drugs, and bacteria may also pass from the maternal
to the fetal circulation through the placenta. Strychnia injected
directly into the embryos of animals by Savory and Gussarow killed
the mother after passing to her through the placenta. There is no
direct communication (except by osmosis) between the fetal chorionic
villi and the maternal intervillous blood spaces. In the first half
of pregnancy fetal and maternal blood are separated by the syncytium,
Langhan's layer of cells, the stroma of the villi, and the walls of
the fetal capillaries; in the second half of gestation Langhan's
layer gradually disappears. In the fetal blood-vessels are found
many nucleated red corpuscles, but these are lacking in the maternal
intervillous spaces. Sänger also discovered that in pernicious
leucemia the leucocytes of the mother are not present in the fetal
circulation.

That gaseous substances pass through the fetal barrier of tissues
was proved by Zweifel, Cohnstein, and Zuntz. Zweifel showed that
chloroform administered to the mother rapidly reaches the fetus. As
early as 1817, Mayer proved the passage of cyanide of potassium.
Since then we have been made certain of the transmission of iodide
and ferrocyanide of potassium, salicylic acid, bichloride of mercury,
methylene blue, and many other substances. Krönig and Futh, in 1901,
determined that the maternal and the fetal blood freeze at the same
temperature, which indicates that they possess equal osmotic power,
and that osmosis may occur in either direction.

Some bacteria do not get through to the fetus, but a few do get in.
Tubercle bacilli were found in the fetus by Birch-Hirschfeld[139]
in 1891, and Schmorl[140] demonstrated them in 50 per cent. of the
placentas in one series of examinations. Bar and Renon[141] found
them in the blood of the umbilical cord in two of five cases. Actual
congenital tuberculosis is possible, though very exceptional: the
bacteria either pass through the wall between mother and fetus,
or destroy this wall and then get in. Smallpox, measles, and
scarlatina, the causes of which have not yet been demonstrated;
typhoid, cholera Asiatica, pneumonia, bubonic plague, erysipelas,
pus infection, anthrax, syphilis, febris recurrens, and malaria
have already been demonstrated in the fetus. Lynch of Johns Hopkins
collected sixteen cases of typhoid in the fetus. I found the typhoid
bacillus in the liver and kidneys of a still-born fetus whose mother
was ill with typhoid fever; this case was not among those collected
by Lynch.

  [139] _Arbeiten d. pathologisch. Instit. zu Leipsig._ Jena, 1891.

  [140] _Münchener medizinische Wochenschrift_, 1904, vol. li, p.
  1676.

  [141] _L'Obstétrique_, vol. i, p. 69.

The majority of writers give unfavorable prognoses for typhoid in
pregnancy. Abortion or premature labor is extremely common, with
great danger to the mother's life. When labor begins in these cases
the last sacraments should be administered early. Therapeutic
abortion in typhoid is very likely to cause death, yet a number of
women recover after abortion. As regards the woman's life, cases
of premature labor have a worse prognosis than early abortion. The
greatest danger is while the fever is high, and abortion is commoner
in the first week of fever than in the second or third. In protracted
typhoid abortion is likely to occur in the fourth week or later.
After defervescence the prognosis is better, but there is always
danger. Different physicians have markedly varying results. There is
no medical condition where skill in the physician counts more than
in typhoid; it is the supreme test of the therapeutist. Sacquin[142]
collected from various sources the statistics of 233 cases of
pregnancy during typhoid, and abortion or premature labor occurred
in 150 of these, with death in 16 per cent. Many skilful men have
a mortality as low as 3 per cent. in typhoid not complicated with
pregnancy.

  [142] _Thèse._ Nancy, 1885.

The subject of typhoid is too vast for complete treatment here:
the article on Typhoid in the American edition of Nothnagel's
_Encyclopedia of Practical Medicine_ covers 472 large octavo pages.
A very important point is not to mistake typhoid for a septicemia
in its early stage. A Widal reaction should be made in apparently
septic cases to exclude typhoid. Sometimes, however, a streptococcic
infection will give a positive Widal, and there may be a mixed
typhoid and streptococcic infection.

Smallpox in pregnancy causes abortion or premature labor in the
majority of cases, and the child usually dies. The child may be born
in the eruptive stage, or pockmarked. Franklin reported a case where
a vaccinated woman was delivered of a child while her husband was in
the house ill with smallpox. The mother did not take the infection,
but the child was born dead of smallpox: the contagion had passed
to the child through the unaffected mother. Vaccinated women at
times bear children which are after birth immune to vaccinia and
smallpox--vaccinia, in the commonly held opinion at present, is an
attenuated smallpox. Pregnant women should be vaccinated, when there
is smallpox in their neighborhood, to protect themselves and their
children, unless they have been successfully vaccinated within four
or five years.

Vaccination prevents smallpox in more than 90 per cent. of the
exposures to the disease. The death-rate was 58 per cent. in
the unvaccinated cases and 16 per cent. in the vaccinated in a
group of 5000 cases of smallpox studied by Welch in 1894. During
the eighteenth century, according to Bernouilli's calculation,
one-twelfth of all the children born succumbed to this disease. In
1707, in Iceland, 18,000 of the entire population of 50,000 died
of smallpox. As late as 1885, 3164 persons died of the disease in
Montreal in one epidemic brought on at a time when vaccination had
been neglected. In Prussia, from 1851 to 1860, without compulsory
vaccination for civilians, there were 36,577 deaths from smallpox; in
the Prussian army during the same time, with compulsory vaccination,
there were only fourteen deaths. During the war of 1870 the French
armies, without vaccination, lost 23,469 men from smallpox; the
German armies lost only 459 men and there was a great epidemic of the
disease in Germany at the time.

The efficiency and necessity of vaccination against smallpox, which
is as virulent now as it ever was, is so certainly established
that a parent or guardian who neglects or refuses to have children
vaccinated when exposed to the disease is guilty of homicide through
neglect if an unvaccinated child under his care dies of smallpox.
Revaccination is necessary every eighth year if smallpox reappears.
Agitation against vaccination is not mere ignorance: it is a
dangerous crime, exactly like loosing a mad dog; and it is combined
with the insolence of ignorance. Persons who have seen smallpox
are very much afraid of it, because it is one of the most dreadful
afflictions humanity is exposed to; those who have not seen it, yet
say they are not afraid of it, are mere fools.

A pregnant woman who is infected with smallpox should receive the
last sacraments as soon as possible. If she aborts she may die very
quickly in collapse. If she is evidently in _articulo mortis_ and the
fetal heart can be heard, her cervix should be forcibly dilated, the
child turned, and delivered for baptism. If the physician waits for
death, the child will be dead also, and sectional delivery will be
too late for any good.

Pneumonia in pregnancy is a rare but very dangerous disease.
In one series of 13,611 pregnancies there were 120 cases of
pneumonia--eight-tenths of one per cent.; in another series of 1842
pregnancies two and three-tenths had pneumonia. Wallich,[143] in
a study of the mortality of this condition, found that pneumonia
causes abortion in one-third of the cases that occur during the
first six months of gestation, and in two-thirds of the cases that
happen between the sixth month and term. On the third day of the
pneumonia the abortions are most likely to occur. The maternal
mortality varies between 50 and 100 per cent. in the groups studied,
and the fetal mortality is 80 per cent. in general, but about 40 per
cent. for viable fetuses. The large size of the uterus in the last
months of pregnancy interferes with the descent of the diaphragm
in respiration, and the heart is likely to fail. The more advanced
the pregnancy, the greater the danger to both mother and child
from pneumonia. Among the dangers to the child is the imperfect
oxygenation of its blood, and in a few cases the pneumococci reach
the fetus.

  [143] _Annales de Gynécologie._ June, 1889

  Randall, in a study of 190 pregnant women who had pneumonia,
  found a somewhat lower mortality than that observed by Wallich.
  In Randall's series 70 died (36.7 per cent.); of 118 who did
  not abort, only 12 died (10.7 per cent.). In a second group of
  352 cases abortion happened in 58.8 per cent. Of 144 patients in
  the first six months of gestation, 22.08 per cent. died, but of
  those that aborted 52.08 per cent. died. Again, of 164 cases in
  the last three months, 30.49 per cent. died, but 70.12 per cent.
  died of those that aborted during these three months. Of 82 that
  aborted, 87.8 per cent. died. The mortality in women under 25
  years of age was 13.33 per cent.; in women from 25 to 35 years,
  23.2 per cent.; over 35, 22 per cent.

  Pneumonia in pregnancy is made worse by the mechanical
  interference with respiration brought about by the enlargement
  of the uterus, and the heart, which is overburdened in ordinary
  pneumonia, is still more exhausted by the additional strain
  of pregnancy in the pneumonia of gestation; moreover, the
  lungs, which are obliged to do enhanced labor in pregnancy
  in eliminating, are clogged by the pneumonia; it would seem,
  then, that, if the fetus is viable, the womb should be emptied
  to give the mother a better chance for recovery. Statistics,
  however, are against therapeutic abortion. The evacuation of
  the uterus determines blood to the inflamed lungs, which are
  already overburdened. The exhaustion of labor weakens the
  patient, and makes her liable to general septic infection.
  Matton[144] found that in eighteen cases where pregnancy was
  artificially interrupted, nine women died (50 per cent.); while
  in twenty cases where no interference was attempted, only one
  woman died. This comparison is not exact, perhaps, because we
  do not know the gravity of the infection in each group, but
  in any consideration the difference is remarkable. In a group
  studied by Chatelain[145] the results in natural and artificial
  delivery were virtually the same. Inasmuch as therapeutic
  abortion at the best is no better than non-interference, there
  is no justification for therapeutic abortion, unless in unusual
  circumstances.

  [144] _Jour. de Méd. de Bruxelles_, 1872, p. 412.

  [145] _Ibid._, 1870, vol. l, pp. 430, 516, and vol. li, p. 11.

Pneumonia is an infectious disease, and a pregnant woman should,
for her own sake and the sake of the fetus, avoid exposure to
infection. When the disease is present the last sacraments should not
be deferred, as it may be impossible to make a confession when near
death.

Influenza in pregnancy is more severe than it is in the non-gravid
state. By the laity, and sometimes even by physicians, influenza
is confused with la grippe, but there is an influenza vera and an
influenza nostras, or la grippe, and this latter is not nearly
so serious a disease. The real influenza is caused by a specific
bacillus; it appears in epidemics which have a tendency to become
pandemic, and then the disease disappears for a generation. La grippe
is a bronchitis or coryza with some fever and muscle-soreness. True
influenza (the name is Italian, _influenza di freddo_) is very
infectious. The pandemic of 1889-90 started in Turkestan in June,
1889, and by October, 1890, influenza had gone westward and encircled
the earth along the trade routes. The preceding pandemic occurred in
1847-48.

There is no clear proof that pregnant women are especially liable
to infection by influenza, but there is always a notable fall in
the birth-rate after marked epidemics of the disease. This has been
observed in France, Germany, and Switzerland. When it does occur in
pregnancy it is likely to cause abortion. Pasquier, as early as 1410,
noticed this fact. The disease is likely to cause hemorrhage from
the uterus in non-gravid women, especially in those who are past the
climacteric, and menorrhagia in younger women who are not pregnant.
Moeller[146] found abortion or premature labor in 28.3 per cent. of
twenty-one severe cases. In severe influenza where there is diffuse
capillary bronchitis, pleuropneumonia, or spasmodic cough, abortion
is most likely to occur, and such abortion is always dangerous. The
hemorrhages in abortions from influenza are often alarmingly profuse.

  [146] _Deutsch. med. Wochensch._, 1900, No. 28.

In threatened respiratory or cardiac failure in influenza
complicating pregnancy there may be question of therapeutic abortion,
but in such an event great care must be taken to avoid exhaustion and
shock. The child should be extracted; the woman should not be made to
labor. One of the important moral considerations in this matter of
influenza and pregnancy is that the woman commits grave sin if she
needlessly exposes herself to infection, because of the danger to
the child's life and the risk of its loss without baptism, and also
because of the danger to her own life.

Scarlatina (Italian _scarlattina_, Low Latin _febris scarlatina_),
or Scarlet Fever, is very rare in pregnancy. Popularly, scarlatina
is used for a light form of scarlet fever, as varioloid is used
for a light attack of smallpox; but physicians do not make this
distinction between scarlatina and scarlet fever: they use the terms
synonymously. In Nothnagel's _Encyclopedia of Practical Medicine_
Juergensen has an elaborate discussion on the differentiation between
genuine scarlet fever in the puerperium and the relatively frequent
septic erythema found in that state, but the received opinion now is
that real scarlet fever is very rare in pregnancy. Those who report
large numbers of scarlet fever cases in pregnancy err in diagnosis.

The mortality in the scarlatina of pregnancy may be very high--52 per
cent. in some epidemics; and if the infection happens immediately
after delivery, the mortality is still higher. A septic rash is
sometimes mistaken for scarlatina, but where the genuine disease is
present the pregnant woman is gravely obliged to avoid exposure to
it, both for her own sake and for that of the fetus. In the early
months of gestation scarlatina commonly causes abortion.

Measles in pregnancy is also very rare, but when it does occur it
is a serious disease. Gestation is interrupted in 55 per cent. of
the cases, and the mortality is 15 per cent. for the women. The same
moral and related conditions that obtain in scarlatina are found in
measles. There is a marked tendency to hemorrhage and pneumonia. Of
eleven cases reported by Klotz,[147] nine aborted.

  [147] _Archiv. f. Gyn._, vol. xxix, p. 448.

In epidemics of Asiatic cholera the mortality among pregnant women
is extremely high. In the Hamburg epidemic of 1897, fifty-seven per
cent. of the pregnant women affected died. Abortion is very frequent
because of the hemorrhagic endometritis. The mortality for all
patients in Asiatic cholera is very great--almost 50 per cent. at
the beginning of the epidemic.

Typhus fever is the ship or famine fever of 1847. It is very rare
now. When it does occur it is about three times as fatal as typhoid.
It is a disease of poverty and war, and is spread largely by the
body-louse, as happened in Serbia in 1915. Skilled hygiene, however,
soon gains control of the epidemic.

Erysipelas in pregnancy is rare, but not infrequent after delivery.
In the puerperium it appears commonly as a septic infection in
abrasions about the parturient canal. When it starts on the face,
scalp, or breast the prognosis is relatively favorable, but even then
it causes death; when it starts on the genitalia it has a mortality
of 43 per cent. Erysipelas causes abortion. As it begins from pus
bacteria, it is not seen so frequently now as formerly, owing to
greater attention to asepsis. In the puerperium it is often an
infection brought on by dirty midwives or physicians.

Malaria, if severe, may interrupt gestation through fever or
cachexia. During labor in such cases the uterine action is feeble,
and hemorrhages are common after delivery. By proper treatment during
pregnancy these evils can be averted. The infection is spread from
one malaria patient to another by a mosquito (_Anopheles_), as yellow
fever is spread by another mosquito (_Stegomyia fasciata_).

Pulmonary tuberculosis in pregnancy is somewhat frequent; the
estimate is that about 32,000 tubercular women become pregnant
annually in the United States; and obstetricians incline to the
opinion that pregnancy commonly, though not always, makes the
tuberculosis worse. Nearly all agree that the combined effect of
pregnancy, the puerperium, and lactation is a grave burden on the
consumptive and lowers the power of resistance.

Trembley of the Saranac Lake Sanitarium reported that 63 per cent.
of 240 tubercular married women under his observation gave a history
which showed that the disease was first recognized during pregnancy
or the puerperium. Schauta's clinic found such origins in 29 per
cent. Fisberg, Funk, Jacob, Panwitz, and other observers, in a series
of 1100 cases, said 39 per cent. of these women thought the disease
began during pregnancy or the puerperium.

Some tubercular women during pregnancy give no clinical evidence
of an aggravation of the pulmonary disease, but these cases are
exceptional. Tubercular women who apparently improve during pregnancy
are likely to have a subsequent detrimental reaction. As tubercular
cases, however, are prone to show exacerbations even if not pregnant,
it is not possible to say that pregnancy is the sole cause of
the progressive lesions in particular instances. Where there are
no wide or deep areas of infection, there may be no recognizable
damage from pregnancy, but advanced and active tuberculosis, with
fever or cavity formation, does badly, especially if the throat is
involved. The pressure of the enlarged uterus causes dyspnoea; the
cough and fever may bring on miscarriage. Miscarriage, however,
is rare in tuberculosis; it is more common in cardiac and renal
diseases. Bernheim, in a series of 315 tubercular pregnancies, found
that abortion occurred in 23 per cent. The later in gestation the
tuberculosis becomes florid, the more likely it is that abortion will
happen. Conception may take place at any stage of the tuberculosis,
although women in the final stage are commonly sterile. Sometimes
a woman will give birth to a sound child and die herself of
tuberculosis a few days after the parturition.

Pregnancy in consumptive women is not necessarily detrimental to
each particular patient, nor is it, as a rule, a justification
for emptying the uterus of even the viable fetus. Even when the
tubercular condition grows worse during pregnancy it is not always
possible to prove that the pregnancy itself is the cause of the
deterioration. If the woman conceives in the final stage of pulmonary
tuberculosis she will die, whether she goes on to term or not.
Bonney[148] describes three cases of advanced pulmonary tuberculosis
which were cured during pregnancy, by the bodily changes peculiar to
that condition, but such results are altogether exceptional.

  [148] _Pulmonary Tuberculosis_, p. 550. Philadelphia, 1908.

Artificially induced premature labor sometimes causes more damage
than normal parturition at term. Much depends upon the methods
used for the induction of the abortion. The insertion of bougies,
catheters, or sounds is always contraindicated in advanced
tuberculosis. Hirst of the University of Pennsylvania[149] thinks
the notion that tubercular women improve in pregnancy is "a
superstition," and that such women should neither marry nor have
children. De Lee[150] holds that tubercular women should not marry
because the woman is likely to infect her husband and children. He
thinks the disease grows worse in pregnancy, and that hemorrhage is
frequent except in chronic ulcerative tuberculosis. In this last
condition pregnancy does not ordinarily aggravate the condition.
In tubercular laryngitis complicating pregnancy, Küttner found the
mortality to be 90 per cent. Such laryngitis is usually fatal,
whether pregnancy is present or not. When there is a miscarriage
in tuberculosis, the infection often becomes florid and resembles
pneumonia. Advanced cases have a tedious and dangerous labor, with
dyspnoea and occasionally hemorrhage or cardiac exhaustion. Edema of
the lungs is not infrequent.

  [149] _A Text-book of Obstetrics_, p. 427. Philadelphia, 1912.

  [150] _The Principles and Practice of Obstetrics_, p. 480.
  Philadelphia, 1913.

Williams of Johns Hopkins University, in the 1903 edition of his
_Obstetrics_, tells of a woman who died of tuberculous peritonitis a
short time after parturition. The uterus was studded with tubercles
and its interior was covered with tuberculous ulcers. The tubercle
bacillus had been found in cultures taken from the interior of the
uterus during life. Her child was born perfectly healthy and remained
so. Williams says in the same place that the induction of premature
labor because of tuberculosis is justifiable only in the interests
of the child, and this only in those rare cases in which the woman
is so ill that she probably will die before term. Norris[151] of
Philadelphia agrees with Williams that induction of premature labor
is useless, and he says all authorities unite in this opinion.

  [151] _Pennsylvania Medical Journal_, February, 1916.

A tubercular woman should not nurse her infant because she will
infect it and exhaust herself. Infants are very susceptible to
tuberculosis. Birch-Hirschfeld, in 1891, first demonstrated
tuberculosis in the fetus, and Schmorl found it in the placenta in
50 per cent. of a series of cases that he examined. Infection of the
child _in utero_, however, is extremely rare even by the placental
way. There is a high death-rate from tuberculosis among infants,
but the infection is postnatal. Dietrich of Berlin found that the
death-rate from tuberculosis among children in Prussia is higher
during the first year of life than in any other year.

The moral conclusion is that artificial abortion in pregnancy
complicated with tuberculosis is never indicated except when the good
of the child is at stake in the last stage of gestation.




CHAPTER XIX

SYPHILIS IN PREGNANCY AND MARRIAGE


Syphilis in pregnancy at times assumes peculiar malignancy. The
virulence depends on the patient's power of resistance, and whether
or not there are septic microörganisms mixed with the syphilitic
spirochetes. There are, moreover, varying strains of spirochetes
which differ in virulence, or there are familial idiosyncrasies.
Tropical syphilis is worse than northern infections, and syphilis of
the nervous system is often incurable. Fournier was of the opinion
that a syphilitic woman who becomes pregnant is more likely to abort
than a pregnant woman who becomes syphilitic. The percentage of
fetal deaths is also greater in the first class than in the second.
The longer a woman has been syphilitic, provided she has not been
treated for the disease, the worse the prognosis for the duration of
the pregnancy and the life of the fetus. The earlier in pregnancy
the syphilis appears, the worse the prognosis for gestation. General
fetal mortality in syphilis under the best circumstances is 75 per
cent. Syphilis should be looked for in every case where the cause
of an abortion is not evident. Ruge holds that in 83 per cent.
of repeated abortions syphilis is at fault; late abortions are
characteristic of this disease.

Inoculation with syphilis before conception almost always results
in abortion. In 130 women studied by Le Pileur there were 3.8 per
cent. still-births before infection by syphilis, but 78 per cent.
after infection. In premature labor the child is, as a rule, born
dead; less frequently it is born syphilitic; still less frequently
it is born apparently sound, but the syphilis appears later; in
a few cases, when the maternal syphilis is old, the child may be
born normal. Interruption of gestation is the commonest symptom in
syphilis complicating pregnancy. The labor itself is affected: the
pains are weak and tardy. Abnormal presentations occur frequently
when the fetus is dead. Chancres on the cervix may cause obstruction,
and there may be indurations so dense as to necessitate cesarean
delivery. The perineum may become so friable as to tear, as De Lee
says, "like wet paper."

When the mother is infected at the time of conception the child is
always syphilitic. If the mother is infected early in pregnancy the
child is almost always infected. If she is infected late in pregnancy
the child may escape infection. Men with tertiary syphilis have
begotten children without, to all clinical appearance, inoculating
the wife. In such a case the mother may nurse the child with safety
to herself, but the child will infect a wet nurse other than its
own mother, and in very rare instances mothers in this condition
have been floridly infected. The condition here described is called
Colles's Law.[152] The doctrine of Colles's Law has fallen into
disuse because we can now demonstrate by the Wassermann reaction that
almost all apparently healthy mothers of this class are in reality
infected. The term now used is "Syphilis by Conception."[153] The
virus passes through the fetal placenta to the mother, although
immunizing substances are held back by the placenta. A fetus cannot
make immunizing bodies before its eighth month, and on that account
the earlier the fetus is infected, the more likely it is to die.
Recently, however, some scanty testimony has been collected which
sustains Colles's Law in a few cases. Ledermann reported three
cases, and Nonne others, in which the wives of men with tabes or
paralysis bore syphilitic children and yet never responded positively
themselves to the Wassermann test, or showed any symptoms suggesting
syphilis. To this list Kroon[154] adds a case corresponding fully
to the requirements of Colles's Law. A woman of twenty-eight years
who had had eight abortions was delivered of a child with undoubted
congenital syphilis. The child's father had been infected with
syphilis twelve years before. The woman showed no signs of syphilis,
two Wassermann tests were negative, and she nursed the child without
injury to herself.

  [152] From Abraham Colles, Dublin, 1837.

  [153] Wolff, 1879.

  [154] _Nederlandisch Tijdschrift voor Geneeskunde_, i, 9.

Should the husband have florid primary or secondary syphilis, and
infect his wife at impregnation, abortion is the rule. The commonest
cases are those where the husband has been treated for syphilis
more or less thoroughly before marriage. Even if at the time of
impregnation the husband has no apparent infective lesion, the
child is usually syphilitic, or it may show signs of the disease
later in life. Ibsen's _Ghosts_ is founded on a case like this. If
the syphilis is recent, or uncured, the child dies, macerates, and
is expelled. These conditions recur in pregnancy after pregnancy,
until the virus is removed by time or drugs. As the nucleus of the
spermatozoön is too small to carry the spirochete of syphilis, the
infection is through the semen in a manner not yet clear to us.

Wolff[155] studied a group of nine syphilitic women and their
children. There were sixty-six pregnancies, but only thirty-three
viable children were born. Of these last fourteen died in childhood,
three committed suicide at twelve, twenty, and twenty-eight years
of age; and of the thirteen still living only two were normal. The
others are all feeble-minded, epileptic, hysteric, or otherwise
neurotic. Post[156] tabulated the mortality in thirty syphilitic
families in which there were 168 pregnancies. Of these fifty-three
ended in still-birth or miscarriage and there were forty-four early
deaths--a total loss of 57 per cent. Of the children that were born
alive 38 per cent. are now dead, and of the seventy-one that are
alive only thirty-nine are apparently healthy. There are very many
cases of diseased children and adults with serious lesions of obscure
etiology, and in a great number of instances of anemia, malnutrition,
extreme nervousness, aortitis, bone diseases, vague pain, and similar
conditions, the origin is congenital syphilis. Stoll,[157] in
sixty-eight such cases, found a positive luetin syphilitic reaction,
and a positive Wassermann in 17 per cent.

  [155] _Zeitschr. f. klinisch. Med._, vol. lxxvi. Berlin.

  [156] _Boston Med. and Surg. Jour._, vol. clvii, n. 4.

  [157] _Jour. Amer. Med. Assoc._, October 31, 1914.

Gottheil,[158] professor of dermatology and syphilography in Fordham
University, holds that if a man has gone through a modern treatment
for syphilis, given by a competent physician and extended over
three years, and if during the fourth year, without treatment, he
repeatedly shows a negative Wassermann reaction, he may marry. That
is the common opinion of physicians, but it is decidedly erroneous.

  [158] _Forchheimer's Therapeusis of Internal Diseases_, vol. ii,
  p. 421. New York, 1913.

In one series of 562 cases of hereditary syphilis observed by the
great syphilographer Fournier, sixty children, or over 10 per
cent., were infected more than six years after the primary parental
inoculation. He tells of one woman who had nineteen consecutive
still-births from syphilis. Gowers[159] says: "There is no evidence
that the disease ever is or ever has been cured, the word 'disease'
being here used to designate that which causes the various
manifestations of the malady." This statement is too sweeping, but it
is very near the truth.

  [159] _Syphilis and the Nervous System_, 1892.

Bruhns recently reported the outcome of the Wassermann test repeated
about yearly from 1908 to 1915 in one hundred private cases infected
with syphilis ten or more years before the time of the report.
In forty-two the test was constantly negative; in thirty-two,
positive at first but negative later; in seven, constantly positive
notwithstanding repeated courses of treatment; in three, positive at
first, then long negative, but finally changing to positive again; in
eight, negative at first, then positive, and finally negative; and in
eight, negative at first but finally positive. The last three groups
are particularly significant. In some the long negative reaction, for
five or six years, indicated cure, and physicians would pronounce
such cases positively cured; but suddenly they changed to a positive
reaction without any clinical manifestations showing at the time.
After renewed courses of treatment in the following two years the
reaction became negative. Among the cases with constant negative
reaction there were some who developed brain syphilis, or tabes,
proving that they were not cured despite the absence of clinical
manifestations of the disease and the negative Wassermann reactions.
Professor Blaschko of Berlin, at the seventeenth International
Medical Congress in 1913, in the presence of Ehrlich, Wassermann and
Hata, said no one could even talk of a cure of syphilis until an
interval of ten years without symptoms had occurred. Where a blood
Wassermann is negative a spinal fluid reaction may be positive.

In from 60 to 75 per cent. of all cases of tabes or paresis members
of the family other than the patient have shown infection. The
proportion of infections in the families of tabetics and paretics is
far larger than that found in families in which the syphilis does not
go on to these extremes. Tabes is also called locomotor ataxia. It is
a degeneration of a part of the spinal cord, with unsteadiness and
incoördination of motion, lightning pains, disorders of vision, and
other symptoms. Paresis is softening of the brain, with insanity and
death.

These and other facts strongly indicate that the form of syphilis
which ends in tabes or paresis remains infectious over a much longer
time than ordinary syphilis does. No one has cured either tabes or
paresis. Raven reported in 1914 an investigation of ninety families
in each of which a case of metalues had developed. The interval
between the date of infection and the marriage was known in about
half of these, and it was four years in two families, five years
in one, and from _six to twenty-one years_ in ten! Fournier, in
4400 cases of syphilis, saw three cases where the tertiary symptoms
appeared fifty years after infection, and in one case fifty-five
years after infection. Bonnet[160] reported such a case which came to
him for treatment fifty-four years after infection. The man had no
children.

  [160] _Lyon Med._, November 7, 1907.

Syphilis that affects the nervous system as in tabes and paresis is
an incurable syphilis, and there is no means whereby any physician,
no matter how skilful he may be, can tell whether or not a given
patient has such an infection. The physician, then, who tells a
syphilitic that he or she is cured and lets such a person marry
is responsible for all the evils that result from his rashness.
Once a syphilitic, not necessarily always a syphilitic; but once a
syphilitic, _possibly_ and probably always a syphilitic, and that no
matter what the treatment or the lack of clinical symptoms. Damaged
goods of this kind are to be looked upon as damaged goods forever.

Any man or woman, then, who has ever had a clear case of syphilis
(and the diagnosis is easy, as a rule) is likely to be for
the remainder of life a source of syphilitic infection. There
is even question of late of spirochete-carriers, as there are
typhoid-carriers and diphtheria-carriers, who may infect others while
not suffering themselves. If one who has been a syphilitic marries
without informing the other party to the contract of the condition,
the injustice is, without doubt, very grave. I should call such
concealment a mortal sin, and a condition exposing the sacrament to
sacrilege.

Suppose the second party is informed of the old infection and is
then foolish enough to risk the marriage. No one but an experienced
physician has any notion of the indescribable horror that may come
of taking this risk, and no one has the right to expose his own body
to infection by syphilis for the advantage of marriage. There is no
approach to a juridic equilibrium between these two conditions. If
in such a marriage children are begotten and infected, (1) embryos
will die without baptism; (2) later possible children will be born
who will die of congenital syphilis; (3) possible children who will
escape syphilis; (4) children who may have to pass through tabes or
paresis to death, after begetting other degenerates.

A syphilitic embryo which dies without baptism is better than
no child at all. It will live in a state of natural happiness
after abortion. A baptized child which has congenital syphilis is
immeasurably better off than a sound child that lacks baptism.
Eugenics as a prudent investigation of conditions before marriage
is a good thing; eugenics as the drivel of agitators, who cannot
tell the difference between a gentleman and a corn-fed hog, is quite
another thing. The marriage, therefore, of a person who has been
syphilitic to one who knows or does not know of this condition gets
its mortality chiefly from the damage to one of the contracting
parties which is imminent. It is difficult to estimate the morality
of the act as it refers to the children infected congenitally, and to
society.

The natural order, charity, justice, and related principles give
every child the right to be born with bodily health, if such an event
is possible. If it is not possible in particular circumstances, then
_melius esse quam non esse_, and the decision in each case depends on
its own qualities.

If a physician knows that a person who has been infected with
syphilis is about to marry, should the physician warn the innocent
party?

There are several conditions: (1) the infected person about to marry
may be actively infectious; (2) the person may be probably infective,
as any one is who has once had syphilis; (3) the physician may
know the fact of the infection officially or unofficially; (4) the
infective person may have gone to the physician for treatment for a
condition not connected with the syphilis--say, for a bronchitis or a
broken bone--and the physician in the examination discovers syphilis.

Again, there are various kinds of secrets. St. Alphonsus Liguori[161]
classifies secrets in three groups: (1) natural; (2) promised;
(3) entrusted secrets. A natural secret is one which obliges us
in justice to observe it if divulging it will gravely injure any
one in reputation or possessions. We are not obliged to observe
a secret of this kind at the risk of our lives unless the damage
from the divulging would affect the community gravely. A promised
secret obliges to silence either gravely or lightly, according to
the intention of the promiser. Where reasonable doubt exists as
to grave obligation, such obligation does not exist. A promise to
secrecy made even under oath is not binding if one is obliged in
justice to reveal the secret; therefore we must testify to the crime
of another when a judge legitimately demands our testimony, even if
we have promised not to tell anything. If a secret is entrusted to
one, and divulging would cause grave damage, but justice, or similar
circumstances, do not oblige us to reveal it, we are bound to observe
it even when questioned by legitimate authority. Then we may answer
we know nothing about it, at least for revelation. St. Alphonsus's
text is: "Potes respondere te nihil scire, scilicet ad revelandum."
His meaning seems to be: "You may say you know nothing about the
matter inquired into." Any other signification would be futile.
To say literally, "I do not know anything I may tell," would only
expose one to punishment for contempt. He seems to make the answer
a conventional denial, like the "not guilty" of a criminal. A judge
may not abrogate the natural right by which an entrusted secret is
protected, unless the secret is already known in some other way, or
there is a just cause for revealing it.[162]

  [161] _Theologia Moralis_, iv, n. 970 et seq.

  [162] Cf. De Lugo, _De Justitia et Jure_, disp. 14, n. 141.

When an entrusted secret, however, which is also called a strict
or absolutely natural secret, is imparted expressly or tacitly,
say, to physicians, lawyers, or priests, and becomes a professional
secret, it obliges more strictly than any other. There are four
conditions under which such an entrusted secret may be revealed, at
least without mortal sin (except by a confessor): (1) If we have the
presumed consent of the principal. (2) If the material of the secret
is trivial, or if it is known from another source, or is already
public. Is it a mortal sin to divulge a grave entrusted secret to
a responsible person who is under the same bond? St. Alphonsus,
De Lugo, and others say probably it is not, provided the secret
is not divulged to the particular person from whom the principal
wished it to be concealed. The term _probably_ here is technical
and refers more to the absolute truth of an assertion than to its
practical application. (3) One might reveal such a secret without
mortal sin, through inadvertence or thoughtlessness, or under the
supposition that it is not a grave secret. Some moralists hold,
however, that to excuse from mortal sin, the revealer must be certain
that the matter of the secret is not grave. (4) Such a secret may
be revealed if keeping it would cause public injury, or injury to
an innocent person, or injury to the person to whom the secret has
been entrusted; then the law of charity demands that it be revealed.
Therefore, even if one has bound himself under oath, he may reveal
the secret--always excepting a priest or confessor. This is the
common doctrine of moral theologians. It is for the common good of
human society that entrusted secrets be absolutely kept unless so
grave a damage befalls another from such observance that it becomes
more conducive to the public good to reveal than to conceal. To let
an infective syphilitic, for example, spread his contagion merely
because an entrusted secret should be kept is a much greater damage
to the public than a good.

Barrett[163] says a physician may not divulge the diseases of a
family to an insurance company unless the family assents; he may
not tell the man before marriage that the woman had been operated
upon, say, for ovariotomy, unless the woman gives permission; nor
may he let the woman know, before marriage, of those diseases of the
man which are not contagious. Ho says further that if a man has had
syphilis and is now completely cured, the physician may not reveal
this previous condition to the woman.

  [163] Sabetti-Barrett, _Compend. Theol. Moral._, n. 565. New
  York, 1915.

That doctrine about ovariotomy, if it includes double ovariotomy, is
disputed by physicians because, they say, such a woman is sterile
and she knowingly is going to deprive the man of his chances of
having children; secondly, a woman upon whom double ovariotomy
has been performed is almost always a neurasthenic invalid with a
marked tendency to insanity, and it is a grave injustice to any man
to saddle such a degenerate upon him for life by treachery. The
prospective injury to the man is so great that the physician should
first try to induce the woman to divulge her condition, and if she
does not, the physician at least _may_ divulge it.

Secondly, I deny most emphatically that any physician can tell that
a man who once has had syphilis is completely cured and is not a
source of infection. The facts I have cited in this chapter prove
conclusively that once a syphilitic always probably a syphilitic,
and the risk is always so great that the physician is obliged first
to insist that the man does not marry, and if the man persists the
physician may let the woman know. If preparations for the marriage
have been made publicly, the physician will, as a rule, for his pains
from the woman and her family get only a rebuff and the woman will
later get her syphilis more or less certainly. If the man is actively
infective the physician is bound to let the woman know, through
her confessor if no other way presents, provided the man cannot be
frightened out of his scoundrelism. If nothing else avails, the
physician would be justified in reporting such a man to the Board
of Health or the sanitary police. Barrett says the physician may be
excused from divulging that the man has infective syphilis if such a
revelation would cause the physician to lose the confidence of his
patients. It never does have such an effect, although physicians
constantly expose such cases in the interests of humanity. Because
a man who is apparently cured of syphilis may or may not infect the
woman, this doubt probably excuses the physician from the strict
obligation of divulging the condition, although he _may_ tell her if
he wishes to do so, _salvo meliore consilio_, as far as the release
from strict obligation to divulge is concerned.

If a patient with syphilis goes to a physician for the treatment
of some other physical disability, and the physician discovers the
syphilis in the course of the examination, this knowledge of the
syphilis would be a tacitly entrusted secret. Whether, however, a
secret that a man is actively infective or very probably infective is
entrusted either tacitly or directly, it is not a privileged secret
owing to the danger or certainty of extraordinary calamity to the
innocent second party.

The fact that in these cases of active or latent syphilis the disease
has been acquired criminally does not in itself affect the state of
the question one way or another--a criminal syphilitic has a right to
his reputation and goods despite his moral condition; but even where
the disease has been acquired without moral guilt the syphilitic is
always a formally or materially unjust aggressor in a prospective
marriage to an innocent and uninfected woman, and is to be treated
accordingly. If a woman may kill an unjust aggressor in defence
of her chastity, and if _quod liceat per se licet per alium_, her
natural protectors, kin, physician, and so on, may at least divulge
the secret of the man's condition in defence of her from a fate which
in many respects is worse than rape.

In keeping with this matter of entrusted secrets it is worth noting
that physicians should remember that the case histories they leave
after them at death, or which they leave unguarded in their offices,
are likely to be read by some third party who has no right to the
secrets they contain. Case histories which the patients would not
have divulged should be kept in cipher so far as proper names and
addresses are concerned.




CHAPTER XX

GONORRHEA IN MARRIAGE


Gonorrhea is caused by the gonococcus discovered by Neisser in 1879.
The name was given to the disease in the second century by Galen,
who supposed that the condition is a spermatorrhea. The infection
begins as a surface inflammation and gradually penetrates more or
less deeply into the underlying tissues. In the male, gonorrhea may
affect any part of the body; and when the disease is chronic it is a
source of infection for years. If a man who has had gonorrhea wishes
to marry after careful treatment, most physicians will permit him to
do so if he passes the customary tests which indicate cure, but he
is always dangerous. The tests are: (1) the microscopic and cultural
examinations of the centrifugalized morning urine--the washings
from the urethra must be negative after repeated trials and over a
space of months; (2) the microscopic and cultural examinations of
urethral spontaneous and artificial discharges must be negative in
the same manner; (3) the microscopic and cultural findings of the
secretion expressed from the prostate and seminal vesicles must be
negative in the same manner; (4) urethroscopic examinations of the
anterior and posterior urethra must show no unhealed lesions; (5) the
complement fixation test is to be repeatedly negative. The complement
fixation test is like a Wassermann reaction, but the antigen should
be polyvalent. This test does not give a positive reaction where no
gonorrhea is present, but it is often negative where the gonococcus
is present. Hence a positive result has value, but a negative result
has little or no value. All these tests are to be tried repeatedly,
and if negative for months, the physician may say the man is
_probably_ cured, but no physician can guarantee the cure so as to
take the responsibility of the decision. Not one physician in five
hundred can make these tests himself, because physicians in general
lack the special training and the means to make them. As the effects
of gonorrheic infection in a woman are so appalling, any woman who
wittingly marries a man who has had gonorrhea is very rash, and the
man who takes the risk of infecting such a woman is a rascal.

A physician is obliged to let a woman who innocently is about to
marry a "cured" gonorrheic know of the man's condition, as in a
case of supposedly cured syphilis. Taber Johnson, Noble, and other
authorities, say no one can tell when a gonorrheic is absolutely
cured.

In women infection of the cervix uteri occurs in about 80 per
cent. of the cases of acute gonorrhea, and in 95 per cent. of all
chronic cases. The infection may extend up into the uterus at the
menstrual period or just after parturition. In the cervix, owing
to the histologic formation, the disease tends to chronicity,
but the inflammation within the uterus is much more likely to
subside naturally. Chronic gonorrhea of the endometrium is usually
accompanied by tubular infection. The infection of the uterus may be
superficial or it may extend down into the underlying myometrium.

The inflammation extends from the endometrium to the Fallopian
tubes and beyond, causing salpingitis, pyosalpinx, hydrosalpinx,
tuboövarian abscess, tuboövarian cysts, and pelvic peritonitis. The
most frequent form of tubal gonorrhea is pyosalpinx, or pus tube.

In the acute stage of tubal infection the tubes become elongated
and swollen, and the mucous surfaces within are covered with
a seropurulent exudate. This condition is called salpinx or
salpingitis. When the condition advances so far that the external
abdominal ostium of the tube is closed, a pyosalpinx forms. The
pyosalpinx may be quite large. A hydrosalpinx is like a pyosalpinx,
with both tubal ends sealed, except that its content is a serous or
watery fluid. When infected material escapes through the distal end
of the tube, perioöphoritis develops, and the ovary becomes adherent
to the tube and other adnexa. More commonly only the surface of
the ovary is affected, but frequently the infection gets into the
body of the ovary and causes oöphoritis. The ovary then swells and
there is a tendency to the formation of retention and other cysts,
or an abscess of the ovary. A tuboövarian cyst is a hydrosalpinx
in communication with an ovarian retention cyst, and a tuboövarian
abscess is a like formation.

Gonorrhea, especially in women, is likely to be very chronic. Emil
Noeggerath, who in 1872 published a book[164] which changed the
medical doctrine on the disease, said of women, "Once infected,
always infected." Norris[165] reports a case where the gonococcus was
latent in a man for twenty years, and he then infected his wife and
wished to divorce her until he found that he himself was at fault.
Sax[166] reported an infection after fourteen years; MacMunn,[167]
one after fifteen years. These are exceptional durations in the male
for virulence, though not for continuance of the diplococcus.

  [164] _Die latente Gonorrhoea in weib. Geschlect._ Bonn.

  [165] _Gonorrhea in Women_, p. 123. Philadelphia, 1913.

  [166] _Trans. Amer. Urological Assoc._, vol. iii.

  [167] _Lancet_, November 24, 1906.

Neisser, who discovered the cause of gonorrhea, holds that, with
the exception of measles, gonorrhea is the most widespread of all
maladies. By sterilizing men and women and by abortion it holds down
the birth-rate more than any other disease. The number of deaths
from the consequences of gonorrhea (pelvic abscess, peritonitis,
septicemia, endocarditis, and so on) is enormous. Norris thinks that
12,000 prostitutes die annually from the effects of gonorrhea alone.
Woodruff[168] holds that 60,000 is nearer the truth. The estimate,
too, is that 50 per cent. of all pelvic inflammatory diseases in
women is gonorrheic; and Neisser, Bumm, and Fürbinger hold that from
20 to 50 per cent. of childless marriages are due to gonorrhea.
Probably more than 20 per cent. of all the blindness in the world
is from the same cause. The Committee of Seven,[169] in 1901, after
examining most of the hospital records in New York and hearing from
4750 physicians, estimated that there were more than 220,000 venereal
patients in New York City. Bierhoff[170] reckoned that in 1910 there
were about 800,000 gonorrheics in that city. In 1906, in Baltimore,
there were 3310 cases of the infectious diseases like measles,
diphtheria, scarlet fever, and tuberculosis combined, but 9450 cases
of venereal diseases. In New York City, in round numbers, there
are annually about 41,000 cases of infectious diseases, excluding
the venereal group, but 243,000 cases of venereal diseases--over
five times more cases of venereal diseases than of all the other
infectious diseases together. Of 12,000,000 persons insured in
Germany, 750,000 annually are infected with venereal diseases. In the
United States navy between 1904 and 1908, with an average of 43,165
men in the navy and marine corps, there were 32,852 admissions to
the hospitals for venereal diseases, and of these 11,526 were cases
of gonorrhea. This report is far below the actual numbers, as only
men incapacitated for work are included in the list. In the English
navy in 1906 the daily number of men rendered inefficient by venereal
diseases was 867. In the total relative number of venereal diseases
the American army and navy, before the present war, were the worst in
the world, the Japanese navy next, the English army and navy next.

  [168] _Expansion of Races._ New York, 1909.

  [169] _Medical News_, December 21, 1909.

  [170] _New York Med. Jour._, November 12,
  1910.

Sullivan and Spaulding[171] reported on the prevalence and effects
of gonorrhea in 522 women and girls in a Massachusetts reformatory
for women. Of these women 75.7 per cent. had gonorrhea by positive
diagnosis. The average length of time the infection had existed when
diagnosed was four years and five months, but one woman had had the
disease for twenty-six years, and seven had had it for over twenty
years. In 82.7 per cent. there had been no cessation of the clinical
symptoms from the time of infection to the time of diagnosis. Of the
total number 68 per cent. had pelvic inflammation on one side, and 27
per cent. had it on both sides. There were 41 per cent. of the cases
which had had surgical operations or which required such treatment.

  [171] _Jour. Amer. Med. Assoc._, January 8, 1916.

Of 63 women committed for alcoholism 52.4 per cent. had gonorrhea,
42.8 per cent. had syphilis, and 9.6 per cent. had doubtful
syphilis; but of 400 women who had been at some time prostitutes 98.2
per cent. had gonorrhea, 65.5 per cent. had syphilis, and 9.5 per
cent. had doubtful syphilis. Of 119 mental defectives among these
women, 90.8 per cent. had gonorrhea, 61.3 per cent. had syphilis, and
6.7 per cent. had doubtful syphilis.

Dr. Thomas Haines[172] reported on 365 cases of boys and girls under
eighteen years of age committed to an Ohio reformatory, and of these
20.8 per cent. had syphilis, and it was mostly acquired syphilis, not
congenital--over one-fourth of the boys were so affected. McNeil[173]
examined 1200 adult negroes in Galveston, Texas, for syphilis and
found the disease in 30 per cent. of the 1200.

  [172] _Jour. Amer. Med. Assoc._, January 8, 1916.

  [173] _Jour. Amer. Med. Assoc._, September 30, 1916.

Howard Kelly[174] estimated that venereal diseases cost the United
States three billion dollars annually, and Norris thinks this
estimate too low. The ravages of the disease are so frightful,
physically and morally, that any one who spreads it by infection,
especially of an innocent woman, is guilty of the gravest moral
injustice. Morrow[175] thinks that 250,000 married women in the
United States are suffering from gonorrhea. As most of these
unfortunate women are infected by immoral husbands, and as the
invalidism and suffering they undergo are indescribable and cure is
often impossible, the physician who permits a gonorrheic to marry
without a protest is responsible for the evil as an accomplice; and,
as has been said, once a gonorrheic, probably always a gonorrheic.

  [174] _Jour. Amer. Med. Assoc._, October 6, 1912.

  [175] _Social Diseases and Marriage_, 1904.

Pelvic inflammatory disease includes in the uterus and its adnexa
alone metritis, salpingitis, oöphoritis, pelvic peritonitis,
cellulitis, lymphangitis, and perimetritis. Pus may rupture into the
pelvic cavity and set up local or general peritonitis or septicemia.
It may burrow through from behind the uterus into the vagina, rectum,
or other parts of the intestines, or into the bladder, and leave
fistulas. Pus has been known to get through the abdominal wall
itself. When the disease advances beyond the tubes there is, as a
rule, invalidism until after the menopause, although the woman may
be cured by surgery. Even skilled surgery does not always cure,
because it is practically impossible to get rid of the gonococcus
once it has been fixed in the tissues.

In cases where the gonorrheic or other bacterial infection has been
chronic in the uterine adnexa, palliative treatment will in a certain
percentage of cases make surgical intervention unnecessary, and
when such treatment does not avail we must decide between the total
removal of organs and the partial removal. Partial removal is called
conservative surgery, and the term conservative is used as a synonym
of preservative. Prochownick[176] reported 420 cases where pus in
the tubes or ovaries was let out extraperitoneally, and no organs
were removed. Of these cases, one hundred and sixty, or 38 per cent.,
were permanently cured. Fourteen of the one hundred and sixty who
had received only one treatment subsequently gave birth to children,
and three aborted. After a second treatment twenty-seven remained
well and three became pregnant, of whom one aborted. Olshausen,[177]
a great authority in gynecology, used the palliative treatment, and
he commonly waited for nine months after the infection and until the
temperature was normal. Goth[178] reported excellent results in seven
hundred cases of pelvic disease treated by the palliative method.
The chief objections to this method are the time required to get the
result, and the difficulty of controlling the patients and their
chronically diseased husbands, who reinfect them despite the medical
prohibition of marital intercourse.

  [176] _Monatschrift f. Geburt. u. Gynä._, 1909, n. 20.

  [177] _Zeitschr. f. Geb. u. Gyn._, 1907, vol. lix, n. 1.

  [178] _Archiv. f. Gyn._, vol. xcii, n. 2.

In cases of chronic pelvic peritonitis the question comes up
frequently whether the womb and both tubes and ovaries should be
removed wholly or in part. The text-books decide the question without
any heed whatever to the notion of the morality of mutilation as
such. They take into account the age of the patient, whether she has
children or is desirous of maternity, whether or not she supports
herself by manual labor, her temperament and character, and the
results attained by men who have tried various methods of operating.

The conservative surgery of the uterus and its adnexa in gonococcal
pelvic peritonitis was for many years looked upon with disfavor
by surgeons. These conservative operations often failed or later
required secondary intervention. Preliminary palliative treatment
as now used greatly lessened the number of failures. Operations
in peritonic conditions are dangerous because they may let loose
encysted bacteria and start up a general septic peritonitis, which
may be fatal. By delay and palliative treatment the virulence of
the bacteria subsides, except where the woman is reinfected by her
husband. In any case the blood-count should have been normal for
at least a month and a half before any surgical interference is
attempted. Olshausen waited nine months to let nature disinfect the
pus.

The removal of a part of a tube is called salpingotomy; the taking
out of the whole tube is salpingectomy; the opening up of a shut
tube is salpingostomy. The presence of pus in a tube is absolute
indication for removal according to the gynecologists at present.
Howard Kelly and others have succeeded at times in such cases with
conservative surgery, yet such treatment is now deemed obsolete--the
dangers and failures seem to overbalance the little good effected.
The end of conservative surgery is to try to restore function without
pain, to preserve menstruation and ovulation, to put the organs in a
condition to make pregnancy possible, and to preserve the internal
secretion of the ovaries. The ovaries, so far as the woman's health
is concerned, are the most important of her generative organs. If a
woman is at the end of her child-bearing age there is no reason to
preserve the tubes when they are affected, and conservation is likely
to fail; but the ovaries should always be preserved, wholly or in
part, when possible.

If one tube is infected from the uterus many gynecologists are
inclined to remove both tubes. When a single tube is affected the
cause is seldom the gonococcus, but some other bacteria which are
not persistent. When both tubes are affected the cause is commonly
the gonococcus, and attempts at preservation then fail, as a rule.
Norris, who is a reliable authority, holds that "the only cases
in which a salpingostomy is justifiable is on old, non-active
hydrosalpinges, and in those cases of tubal occlusion or phimosis
resulting from extratubal inflammation, such as sometimes result from
appendicitis or ectopic pregnancies."[179] When a tube is shut, if
it can be opened the opening tends to close again. A few cases of
subsequent pregnancy have occurred after salpingostomy, but such a
result is exceptional, because the origin is usually the gonococcus,
which destroys tissue and is very persistent.

  [179] _Gonorrhea in Women_, p. 285. Philadelphia, 1913.

The ovary corresponds to the testicle, and the Fallopian tube to
the vas deferens. Removal of the ovaries, or removal or closure of
the Fallopian tubes, renders the woman sterile, but removal of the
ovaries has other profound effects beside sterility. Loss of the
ovaries brings on suppression of ovulation, menstruation, pregnancy,
and ovarian internal secretion, various neuroses, and a tendency to
insanity in certain cases.

The testicles and prostate gland produce an internal secretion
containing spermin, and the ovaries a similar nitrogenous base called
ovarin, which acts like spermin. The suprarenal glands secrete
epinephrin; the thyroid gland and the pituitary body also make
internal secretions, and these secretions sustain the tone of the
blood-vessels and effect immunity against those toxins that arise
from metabolic waste substances while these are in the body before
elimination. If there is a hypersecretion from one or more of these
glands, the excess causes congestion of the cerebrum and cerebellum
and of the nerve centres there, and one effect may then be a sexual
erethism that leads to masturbation and similar deordination.

Castration in the male or ovariotomy in the female stops all
production of spermin and ovarin. In man the prostate gland also
ceases its function after castration, and vasectomy lessens the
production of spermin. In castration or spaying, again, when we
remove the power of producing spermin or ovarin, that function of the
testes and ovaries whereby the body is immunized against poisoning
by its own effete material is also inhibited, and evil effects arise
from this waste material. These toxins act just as would an excess of
spermin or ovarin--they congest the cranial nerve centres, excite
fever, neuroses, or temporary sexual erethism. This excitement may
gradually subside as equilibrium is restored and neutralization
effected, through a compensatory overproduction of the internal
secretions by the other glands remaining in the body. Cimoroni[180]
found after ovariotomy an increase in size of the pituitary body
with dilatation of the blood-vessels. Goldstein[181] reported a
case of gigantism from overactivity of the pituitary gland after
castration. Acromegaly in cases where there was no castration has
been accompanied by atrophy of testicles and ovaries. Cecca[182]
found like effects in the thyroid, and several have observed these
effects in the adrenals. All these results have also been produced
experimentally on animals.

  [180] _Policlinico_, 1907, p. 16.

  [181] _Münchener medizinische Wochenschrift_, April 8, 1913.

  [182] _Soc. Med.-Chir. de Bologne_, 1904.

Women at the menopause frequently are observed who have become
neurasthenic from the irritation of waste material intoxication which
is not neutralized because the ovaries are ceasing to function.
Ovariotomy in younger women produces this menopause artificially and
suddenly; and women from whom both ovaries have been removed, as a
rule, become neurotic invalids with a tendency to insanity if they
are unstable in character or have a bad inheritance. If the whole
thyroid gland is removed, death results from intoxication. Extreme
obesity is an effect of undersecretion by the glands and a consequent
lack of oxidation. Fat children have deficient glands, as a rule, and
eunuchs grow fat as capons do. Removal of the ovaries before puberty
arrests or prevents the development of the uterus; removal after
puberty stops menstruation, the breasts atrophy, and there is an
arrest of general physical growth.

Gordon[183] reported on 112 cases of oöphorectomy. Of these
thirty-four had had before operation various symptoms of
neurasthenia, hysteria, or psychasthenia, and vague abdominal
disturbances. Surgeons in each of these thirty-four cases blamed
the ovaries for the symptoms; and although these organs were not
diseased in any degree, the surgeons removed them. In twenty-five
of these cases there was no improvement whatever; in the remaining
nine there was improvement for a few weeks, but complete relapse
later, and finally their symptoms grew worse. The obsessions became
permanent and expanded. Those women in the group who had hysterical
paroxysms began to have stronger and more frequent attacks. Several
psychasthenics had to be confined in asylums for the insane. Three
of the women who had complained merely of vague nervous symptoms, as
pain in the abdomen, head, or back, or of constipation or diarrhea,
after oöphorectomy grew irritable, highly nervous, quarrelsome,
fickle, restless, showed a tendency to travel about, to complain of
others; finally there was insomnia, and loss of appetite or voracity.
In the remaining seventy-five cases one or both the ovaries were
diseased, but both ovaries were completely removed. All these women
developed symptoms like those described above, but several grew
much worse in their mental condition than the psychasthenics among
the first thirty-four women. The generally observed symptoms are:
restlessness with a tendency to move from place to place; loss of
self-control; dissatisfaction with all persons and things; want of
interest in work; indolence; pessimism. Sometimes there are outbursts
of anger, with a tendency to attack. The mental conditions do not, as
a rule, become clearly developed melancholias or manias, although a
few do grow definitely insane. The morbid symptoms, however, persist
obstinately. After ten years' observation Gordon found no improvement
in some of these psychasthenics.

  [183] _Jour. Amer. Med. Assoc._, October 17, 1914.

When the ovaries must be removed for diseases like cystic
degeneration or abscess, the surgeon leaves, if possible, part of an
ovary, or he engrafts part of an ovary in the abdominal wound, under
the skin, or elsewhere. This grafting is beneficial in many cases,
but it has little or no effect in many others. The graft is absorbed
and it disappears in a year or two, but before it is absorbed it
makes the onset of the surgical menopause gradual and thus prevents
much suffering. In thirty-two cases reported by Chalfant[184] the
graft gave evidence of functioning in five of seventeen women from
whom the uterus and ovaries had been removed; in others it acted
for months and then failed; in others it lessened the unfavorable
symptoms; in others it had no effect at all. Stocker[185] reported
two successful implantations of ovarian grafts and one testicular
graft.

  [184] _Surgery, Gynecology, and Obstetrics_, November, 1915.
  Chicago.

  [185] _Correspondenz-Blatt f. Schweizer Aerzte_, February 12,
  1916.

Giles[186] says that in his series of 157 cases of double
oöphorectomy severe mental depression occurred in various groups in
from 10 to 33 per cent., and two women became insane. Sex instinct
was abolished in 16 per cent. Dickinson[187] found, in 200 cases
where one or both ovaries had been removed, that not more than 20
per cent. fell into the surgical menopause even when the uterus
had been taken out; but Giles, in 50 removals of one ovary, found
irregularity, diminution, or cessation of the menses in 16 per
cent. Carmichael, Valtorta, and McIlroy[188] discovered in animals
a compensatory hypertrophy of the remaining ovary after one ovary
had been removed. The internal function and nutrition seem to depend
upon the ovarian secretion, as atrophy occurs after bilateral
oöphorectomy. In all operations upon or near the ovaries there is
likelihood of interference with the blood supply of the ovary, either
by including ovarian arteries in the ligatures, or by tension of
these vessels, which occludes them, or by malposition and prolapse of
the ovary, which kinks them: these accidents result in degeneration
or retention cysts. In most cases of pelvic peritonitis the uterus is
retrodisplaced, and this position prevents cure until it is corrected.

  [186] _Jour. Obstet. and Gynecol. of Brit. Empire_, March and
  April, 1910.

  [187] _Trans. Amer. Gyn. Soc._, vol. xxxvi, p. 324.

  [188] Norris, _Gonorrhea in Women_, p. 289.

When there is pus in the ovary, resection, in the opinion of
gynecologists at present, is not an advisable operation; the ovary
should be removed. Watkins,[189] however, says he resects small
ovarian abscesses in young women with good results. In resection the
blood supply is, as has been said, usually disturbed, and the cause
for the operation is, as a rule, the gonococcus, and both these
circumstances make the prognosis bad. The stitches necessarily used
in resection operations are an additional source of irritation.
Turetta[190] speaks in favor of resection in certain cases. A single
retention cyst may be resected, especially when pedunculated.
Boldt[191] had only one bad result in forty-five resections where a
part of the ovary was saved. If the blood supply after the resection
is evidently to be poor, resection is useless. Skill in surgical
technic has much to do with success in all these cases. When the
uterus is removed because of tumors, even near the time of the
menopause, if one or both ovaries can be left in, this should be
done. In such conservative operations Dickinson found 80 per cent.
of the patients free from nervous disturbance at the time of the
menopause.

  [189] _Jour. Amer. Med. Assoc._, January, 1913.

  [190] _Il Policlinico_, January 3, 1919.

  [191] _Trans. Amer. Gynecol. Soc._, vol. xxxiv, p. 327.
  Philadelphia, 1909.

Polak[192] describes an operation for the preservation of the
menstrual function in double suppurative disease of the tubes
and chronic metritis. He maintains that even if only one tube is
infected, both should be removed because this apparently sound
second tube will later, almost as a rule, show infection--probably
by extension from the fundus of the uterus inside. Ordinarily
inflammation of the tubes happens to be bilateral. Owing to the
persistence of the gonococcus in the uterine muscle, surgeons are
inclined to the removal of the whole uterus and both tubes. After
such an operation menstruation ceases, and in the removal of the
uterus the blood supply to the ovary is interfered with so that
the ovaries degenerate. The consequent artificial menopause has
a decidedly injurious effect on the woman's general physical and
mental health. The parts of the uterus permanently infected by
chronic gonorrhea are the cervical region, the fundus and the partes
interstitiales of the Fallopian tubes. Polak advises that in cases
where surgeons usually remove the tubes and the whole uterus they
should instead cure the cervical infection by the cautery and take
out the tubes, but in place of the removal of the whole uterus
they should cut out a wedge including the fundus and the partes
interstitiales of the tubes. This leaves the body of the uterus
and does not injure the circulation to the ovaries. In the last
seventeen cases thus operated upon by him he had success.

  [192] _Jour. Amer. Med. Assoc._, December 8, 1917.

When it is necessary to remove both ovaries and tubes an opinion very
common now is that it is better to take out the uterus also, because
in such cases the uterus and vagina atrophy and this condition later
causes trouble. Giles came upon such trouble in 11 per cent. of
sixty-two cases. As the uterus is useless after the removal of the
ovaries and tubes, there is no reason why it should not be removed.
The danger of atrophy is sufficient reason for the mutilation. In
operations for pelvic peritonitis it is well to remove also the
appendix, because it is nearly always diseased, or it will give
trouble from adhesions later and cause a secondary operation. It has
no function we know of at present.

In conservative surgery of the uterus and adnexa for pelvic
inflammatory diseases, the results attained by four skilled surgeons
are: Giles cured 90 per cent. of 132 cases; Polak cured 35 per
cent. of 300 cases; Robins cured 100 per cent. of 20 cases; Norris
cured 73 per cent. of 191 cases. Polak's patients became pregnant
after operation much oftener than those of the other operators.
Seventeen per cent. of his patients, from whom he removed one
ovary and resected the other, became pregnant. Giles found that of
his married patients under fifty years of age at the time of the
operation 25 per cent. became pregnant and went to term. They bore
twenty-five children. Five of these also miscarried. In sixty-eight
of Morris's cases seventeen were delivered of living children after
the operation; three had two children each, one had three children,
and there were seven miscarriages. In one of his cases where he
removed one ovary and _both_ tubes, the woman bore a healthy
full-term child two years after the operation. Dudley[193] found that
about 10 per cent. of 2168 cases of resection became pregnant after
operation. Ectopic gestation is likely to occur in a few cases after
conservative operations. Giles had seven such cases in his series of
132 operations, Polak one, and Norris two.

  [193] _Jour. Amer. Med. Assoc._, vol. xli, n. 24.

When it is necessary to remove the uterus, the choice between
supravaginal hysterectomy, where the cervix is left in after the
destruction of its mucosa, and panhysterectomy, where the cervix and
the body of the uterus are removed, offers no moral problem except
the necessity of deciding upon what will be best for the woman.
Rupture of a pus tube is a very dangerous accident--all the patients
suffering from such a rupture die if not operated upon, and fifty per
cent. die even after operation. A physician may do this damage by
ignorant or careless examination, and he may be morally responsible
for the death. The accident happens not unfrequently from marital
congress, and if the husband has been warned by a physician but does
not heed this warning, he is guilty of murder if the woman dies after
rupture of the pus tube.

Pregnant women are more liable to infection by the gonococcus than
non-gravid women, because of the increased blood supply to the
generative organs in gestation, and the softening of these organs.
For the same reason, latent gonorrhea is likely to become active and
to spread during pregnancy. A like activity and extension of latent
gonorrhea often occurs during menstruation. Women with gonorrhea
are commonly sterile--this is the chief reason why prostitutes are
usually sterile. In married women gonorrhea may cause dyspareunia; it
may bring on abortion through endometritis; it may shut the tubes and
prevent conception; it may destroy the ovaries.

The disease is extremely frequent during pregnancy. Gurd[194]
isolated the gonococcus in 52 of 113 pregnant women who came to his
dispensary service because of pelvic pain. Leopold, Stephenson,
Fruhinholtz, and many others estimated that about 20 per cent. of all
pregnant women have gonorrhea, but more recent observers think that
from 5 to 10 per cent. is nearer the truth.

  [194] _Montreal Med. Jour._, vol. xxxvii.

When a pregnant woman has gonorrhea great care must be taken in
treatment to prevent abortion. Powerful antiseptics in the cervix,
or dilatation of the cervix, are not permissible, and operative
interference is to be delayed as long as possible--in each instance
to avoid abortion. The vaginal douche as a routine treatment is not
used now by obstetricians in these cases. When the gonorrhea is in
the uterus douches of hot bichloride solution, 1 to 10,000, are
used twice daily during the last few weeks of gestation, with the
intention of saving the infant's eyes from infection during delivery.
After delivery the cavity of the uterus should not be entered with
instruments lest infection be carried in, unless absolute necessity
requires this instrumental procedure. Post-partum gonorrheal sepsis
is differentiated from other septic conditions chiefly by the history
of gonorrhea in the husband, by bacteriological examinations, and by
the technical differentiation of symptoms.

The moral guilt of a person who infects another with gonorrhea
is affected by the extent of the physical injury done. Gonorrhea
causes, besides the effects already described: (1) chronic cystitis,
with all the suffering, loss of work, and danger of renal infection
in such a condition; (2) lymphadenitis of the inguinal canal, and
rarely of other places; (3) proctitis, or inflammation of the rectum,
especially in women and young children; (4) ophthalmia, vaginitis,
and proctitis in infants and children, and metastatic conjunctivitis;
(5) stomatitis or inflammation of the mouth in adults and children;
(6) nasal gonorrhea (a doubtful condition); (7) gonorrheal
septicemia, bacteremia, or toxemia, which may affect any organ
in the entire body; (8) bone and joint lesions: (_a_) gonorrheal
arthritis in any joint in the body (this condition may be fatal,
or it may leave permanent disability, or it may disappear); (_b_)
tenosynovitis, or pain, swelling, and edema along affected tendon
sheaths; (_c_) gonorrheal periostitis, where the bone and periosteum
near a joint are affected; (_d_) perichondritis and chondritis, a
rare condition, where cartilage is attacked; (9) endocarditis, or
inflammation of the lining membrane of the heart (one of the most
frequent secondary lesions of gonorrhea); (10) pericarditis, or
inflammation of the sac which contains the heart; (11) myocarditis,
an inflammation of the heart muscle itself, usually as an extension
of endocarditis; (12) aortitis, or inflammation of the aorta--a rare
condition; (13) phlebitis, an inflammation of the veins--a very
rare condition; (14) thrombosis, or blocking of a blood-vessel by
exudate (this may be fatal); (15) skin lesions, as erythema, erythema
nodosum, bullous and hemorrhagic eruptions, hyperceratosis, and
ulcers; (16) gonorrhea of the lungs in septicemia; (17) gonorrheal
pleurisy in septicemia; (18) gonorrheal nephritis, which is frequent
in gonorrheal septicemia--the condition is often fatal; (19)
perinephritis, a very rare condition; (20) gonorrhea of the nervous
system, as neuritis or neuralgia, or neuroses, which vary from slight
melancholia to severe mental disturbances; (21) parotiditis, a very
rare condition; (22) otitis, or inflammation of the middle ear, a
very rare condition; (23) suppuration in muscles, or under the skin;
(24) wound septicemia; (25) venereal warts; and (26) epididymitis,
which often causes not only sterility but impotence.

Campbell[195] reported a gonorrheal infection of a compound fracture
at the ankle--it required four months to get the wound free of the
infection. Gonorrheal obliterating epididymitis is quite common.
Delbet and Chevassu[196] found 114 cases of male sterility in
131 cases of epididymitis. More than half of such cases are left
permanently sterile, and if the function of the testicle cannot be
restored by the surgeon the patient is impotent, and any marriage he
would make, ... is rendered void. These two surgeons have restored
function in six such cases by uniting the vas with the epididymis
by Martin's operation. It is much easier to restore function after
vasectomy than after obliterating epididymitis.

  [195] _New York Medical Journal_, February 22, 1908.

  [196] _Canadian Presse Médic._, July, 1908.

There are frequent cases of arthritic rheumatism in which the source
of the infection is a chronic gonorrhea of the seminal vesicles.
Fuller[197] has done 101 vesiculotomies for this condition, and
of these twenty-three were gonorrheal. In these twenty-three
the excision of the infected vesicles cured the rheumatism. In
vesiculotomy great care must be taken not to cut the vas deferens. If
it is cut the man is impotent until the vas is restored, and it would
be a very difficult operation to reunite the vas if cut near the
vesicles.

  [197] _New York Medical Journal_, May 30, 1908.

Of all the gonorrheal affections of the body the most dangerous and
important are the cardiac inflammations and ophthalmia neonatorum.
This ophthalmia is a purulent infection of the external parts of the
eye in infants. It may be caused by many kinds of toxic bacteria,
but the worst cases are from the diphtheria bacillus (a very rare
condition) and the gonococcus (a very frequent condition). Before
1881, when Credé introduced prophylactic treatment for ophthalmia
neonatorum, every maternity hospital had a department isolated for
the care of babies suffering with this disease. At the present
day, however, despite the precautions taken, this disease is quite
common. Pennsylvania and New York alone spent $242,000 annually
for the support of asylums for the blind, and about 40 per cent.
of the children in these institutions were blinded by gonorrheal
ophthalmia. The United States spends $1,800,000 yearly on victims of
ophthalmia neonatorum. Stephenson[198] tells us that in the practice
of forty-one oculists who reported to him the gonococcus was found in
67.14 per cent. of their 1658 cases of ophthalmia. Mayou found the
gonococcus in 63.5 per cent. of 1483 cases.

  [198] _Ophthalmia Neonatorum._ London. 1907.

There is an infection of the child's eyes by gonococci possible even
while the child is in the womb, but this is very exceptional; the
infection happens in the vagina during delivery, as a rule. When
the child's head is born its lids and eyelashes should be cleansed
with vaseline, or 1 to 5000 bichloride, or carbolized oil, before
the eyes are opened to put in the silver nitrate solution. This
solution should be made from a pure drug or it will injure the eyes.
A one per cent. solution is strong enough for routine work, but if
the gonococcus is suspected, or if it is known that the mother has
gonorrhea, then the lids of the infant must be everted and touched
everywhere with a five per cent. solution of silver nitrate. This is
neutralized with a salt solution and washed out before the lids are
turned back. It is rash to trust any of the albuminoid preparations
of silver, like argyrol, silvol, or protargol, in gonorrhea or
suspected gonorrhea of the eyes.

If the child develops ophthalmia the treatment should be turned over
to an oculist when possible. When a child can have a day and a night
nurse, this method should be adopted, but ordinarily there is no
nurse except some woman about the house or the mother. In such cases
one eye, commonly the right, does better than the other because
the first eye treated is opened readily, but after the infant has
been irritated it shuts the eyes so strongly that it is difficult to
open them at all. The first eye treated is habitually the same. The
nurse should begin to treat the eyes alternately on this account, or
wait to treat the second eye until after the baby has quieted down.
Iced compresses should be used, but not so long as to chill the eye
very much--five to ten minutes at a time is enough. If the physician
himself makes the applications of silver nitrate, the nurse should
use some silver salt like argyrol. Three to eight grains of zinc
sulphate to eight ounces of boric solution is a good regular eye-wash
in these cases. Atropine must also be instilled to protect the iris.
If only one eye is affected, the other eye should be protected under
a watch glass sealed over it. All persons who have gonorrhea, or
who treat gonorrhea, must be warned of the danger they are in of
infecting their own eyes.

A new treatment of gonorrhea is described by Weiss.[199] The
gonococci are killed by a temperature of 107.6 degrees Fahrenheit,
and in eleven cases Weiss subjected men to a hot bath for forty to
fifty-five minutes, with the temperature of the water gradually
increased from 104 to 110 degrees Fahrenheit. In one instance the
body temperature was raised to 108.5 degrees F. in a forty-minute
bath and the gonococci disappeared at once. In the other cases the
body temperature did not go up so high, but the vitality of the
gonococcus was evidently reduced, and under a few local injections
they all disappeared.

  [199] _Münchener medizinische Wochenschrift_, November 2, 1915.




CHAPTER XXI

DIABETES IN PREGNANCY


Diabetes Mellitus is rare in pregnancy, but when it does occur the
disease is fatal in three-fourths of the children, and it hastens the
death of the woman, according to the common opinion of obstetricians,
but this opinion is disputed. In making the diagnosis we must exclude
lactosuria and other pseudodiabetic conditions. A sugar reaction
which is often mistaken for the glycosuria of true diabetes is from
lactose in excessive milk secretion. This lactosuria is harmless.
Again, when women are taking tonics or cough mixtures containing
derivatives of wild cherry their urine may give a sugar reaction
from the phloridzin of the wild cherry. The phloridzin so acts on
the epithelium of the kidneys that it lets the blood-sugar escape
into the urine. Medical writers who report diabetes in large numbers
of pregnant women mistake these reactions for the reaction of true
glycosuria.

In the genuine diabetes of pregnancy there is a high mortality.
Offergeld,[200] in sixty cases, found that the women died within
two and a half years, and that 76 per cent. of the children were
lost. Diabetics commonly are sterile from atrophy of the uterus and
ovaries: in a series of 114 diabetic married women, Lacorché found
only seven pregnancies. In a third of such as do become pregnant
abortion or premature labor occurs. Coma happens in 30 per cent. of
these pregnancies, and it is almost always fatal. Delivery frequently
causes collapse, coma, or sudden death. The liver in any gestation
has more work than it has in the unimpregnated state, but a diabetic
liver is unfit for almost any normal function. If albuminuria is
found the prognosis becomes very bad. Diabetic women have poor
resistance against a tubercular infection. Half their children are
still-born, and 10 per cent. more die within a few days after birth
(many of these children are diabetic).

  [200] _Archiv. f. Gyn._, bd. 86, n. 1.

There is some evidence of heredity in diabetes--it is likely "to
run in a family." Heiberg[201] reported one family in which five
of thirteen children had diabetes; in another, four of eight
children, the mother, two of the mother's brothers, and the maternal
grandfather had diabetes. In another, two brothers, the father, and
grandfather died of it. I know of a case where the only two sons and
the father in a family died of it. Heiberg did not find any essential
difference in the histology between the hereditary cases and those
which were not hereditary.

  [201] _Deutsche medizinische Wochenschrift_, xlii, 9.

Joslin[202] reported seven cases of diabetes associated with
pregnancy. Four of the seven are now dead, one by suicide, one from
uremia, one from coma, one from tuberculosis. Of the three living one
is in good condition, one is not well and she has lost two of three
children, and one is very ill with diabetes. In persons beyond middle
age diabetes with proper treatment may go on for from ten to fifteen
years before it is fatal, but it quickly kills young patients. A
young woman at the marriageable age who has diabetes will die anyhow
in two or three years, and if she marries and becomes pregnant she
will die very probably in her first pregnancy.

  [202] _Boston Medical and Surgical Journal_, November 25, 1915.

When the child is viable, and the diabetic mother shows albuminuria,
progressive weakness, or diacetic acid in marked quantity, it may
be necessary to perform therapeutic abortion; but if this is done
no anesthetic may be used, and great precautions should be taken to
avert physical and mental shock. Even ergot acts badly with these
cases. The last sacraments should be given in good time, especially
if coma threatens. When labor begins in a diabetic and everything
appears to be normal the sacraments should be given, because there is
always danger of sudden collapse and death.




CHAPTER XXII

CHILDBIRTH IN TWILIGHT SLEEP


A method of effecting painless childbirth through the use of
scopolamine and morphine was first used in 1902 by Steinbuechel,
and in 1906 Gauss, of the University of Freiburg in Baden, reported
a series of five hundred obstetrical cases in which scopolamine
and morphine had been used. The woman's condition was called
in Freiburg a _Dämmerschlaf_, a Twilight Sleep, because she is
somnolent and forgetful of pain. In 1903 the chief obstetricians
in several of the leading American and German universities tried
the drugs, but they quickly abandoned the method because they found
it dangerous and unscientific. The process was exploited here by
_McClure's Magazine_,[203] _The Ladies' Home Journal_, and other
lay periodicals. The articles in these magazines were written by
persons who are not physicians, and their erroneous statements are
misleading. _The Ladies' Home Journal_, however, while favoring
the method, published letters from several leading obstetricians
in the United States, all of whom are opposed to the use of these
drugs during parturition because they had tried them and found them
unscientific. The method is illicit morally, and it is unscientific.

  [203] June, 1911.

Obstetricians divide a parturition into three stages. In most
primiparae and many multiparae there is a prodromal stage, in which
false labor pains (_dolores praesagientes_) are the most evident
symptom. When the real labor sets in there are rhythmic uterine
contractions about every fifteen minutes, which cause pain to the
woman by the pressure of the fetus on the uterine nerves--_dolores
praeparantes_. From the time the pains become rhythmic, and are
effective in dilating the neck and mouth of the womb, until the
mouth of the womb is completely stretched and flush with the vaginal
wall, thus completing the continuous parturient canal, is the first
stage of labor. The fetal enveloping membranes (the "bag of waters")
usually rupture at the end of this stage, but sometimes the bag
bursts before the end, or as late as the second stage of labor. The
first period is the stage of dilatation.

The second stage extends from the end of the dilatation until the
expulsion of the child is completed. This is the stage of expulsion.

The third stage lasts from the delivery of the child until after the
expulsion of the placenta and membranes and the retraction of the
uterus has ended--the period of the afterbirth.

Normal parturition is always painful to the woman. As the labor
progresses the pains gradually grow more intense, and the interval
between them shorter. After a few hours the pain is strong enough
to cause the woman to cry out, but there is a great variety in the
endurance of these pains, as the women's characters differ. Neurotic
women begin to scream and act hysterically even in the early part of
the first stage. When the pains are fully developed each lasts about
half a minute.

In most cases the infant comes out head first, but almost any part of
its body may present. Before the advancing child part of the _liquor
amnii_ within the fetal enveloping membranes is forced down into the
neck of the womb, and causes dilatation. In primiparae especially the
bag of waters may rupture prematurely and thus cause what is called
a dry labor, which is commonly tedious and painful. Often operative
interference is required in dry labors.

In the second stage the pains are stronger, recur every two or three
minutes, and are expulsive. The woman then strives to expel the
child. She strains violently with the abdominal muscles--literally
labors; her pulse is high, the veins of her neck stand out, her face
is turgid, and her body is covered with sweat. When at last the head
of the child is driven out the woman feels as if she were being torn
asunder in the _dolores conquassantes_. The pain is so great that the
woman may faint from it, but that is not the rule. After a pause the
shoulders are forced out, and then the trunk in one long convulsive
effort. The umbilical cord is tied and cut, and the child is born.

After from five to twenty minutes the womb begins to contract again,
but the pains (_dolores ad secundum partum_) are not nearly so
intense as they were during labor. Then in from fifteen minutes to
about three hours the placenta is expelled.

The pains of labor are so evident that the expulsive contractions of
the uterus, of which the pains are symptoms, are themselves called
"the pains." These pains in all scientific exactness of statement
are, as has been said, agonizing. "In dolore paries filios" is a
very literal text. The scopolamine-morphine method was devised with
the intention of mitigating them, or mercifully rendering the woman
unconscious of them during at least a part of the labor. If she is
unconscious of pain she is thus saved also from shock and depression,
which render her susceptible to infection. Such results certainly are
immeasurably valuable if attainable without taint of moral evil, but
as the method stands just now, they are not free from that taint.

Scopolamine hydrobromide, one of the drugs used in this method, is
an alkaloid obtained from the roots of _Scopolia_ (or _Scopola_)
_carniolica_, and it cannot be differentiated chemically from
hyoscine hydrobromide, which is made from henbane and other plants of
the _Solanaceae_ group. Rusby was of the opinion that scopolamine is
really a mixture of hyoscine, hyoscyamine, and atropine: one-tenth
hyoscine and nine-tenths hyoscyamine and atropine. Cushny and others
find different proportions of these alkaloids. As the leaves of
_Scopolia_ are used to adulterate the belladonna leaves from which
atropine is derived, hyoscine and scopolamine are substituted for
each other--if, indeed, there is an any real difference between
them. Some of the largest drug-houses in Germany before the war
supplied hyoscine and scopolamine from the same stock bottle--the
name depended on the asker. Even in a pure state hyoscine and
scopolamine have the same chemical formula (C{17}H{21}NO{4}),
and their physiological action is the same. Each can exist in three
isomeric forms, and in one of these forms they turn polarized light
to the left, in another to the right, while in a third form they do
not affect the light at all. The higher the rotatory power of the
drugs, the more active they are physiologically. The levorotatory
scopolamine has, according to Cushny, Peebles, and Hug, double
the action of the inactive scopolamine on the cardiac inhibitory
fibres of the vagus, but the levoactive and the inactive scopolamine
produce the same effect on the central nervous system. The drug on
the market is usually composed of a mixture of the levoactive and
the inactive forms, and as one or the other predominates the results
differ: the rotatory power of a given specimen should be known. Old
solutions of scopolamine decompose and give rise to toxic substances.
Gauss attributed post-partum hemorrhages in the women and asphyxia
in infants to these decomposition products, but he avoided these
untoward effects somewhat by cutting down the morphine dose. He had
five infant deaths before he cut down the morphine, and 25 per cent.
of the children were intoxicated. The chief action of scopolamine
or hyoscine is upon the cerebral cortex, producing sleep, which is
accompanied often by a low delirium. They depress the centre of
respiration, and have a depressant effect also on that part of the
spinal cord which governs the motions of the body. They intensify the
action of morphine and other narcotics.

Morphine, which is used to prevent pain, is the chief drug in the
twilight sleep method, and it is greatly intensified in action by the
presence of scopolamine. When, however, morphine and scopolamine are
given to a pregnant woman hypodermically, these drugs are at once
carried by the blood to the fetus. Children for years after birth all
withstand the action of morphine badly, and a fetus _in utero_ may be
overwhelmed by it. Just in this fact lies the chief moral crux in the
use of the twilight sleep method of obstetrical delivery. The woman
may go on to the end more or less safely in competent hands, but if
constant watch is not kept at the bedside by a skilled observer the
infant is liable to be killed, and the danger comes to it not solely
from the drug directly--it may be drowned in the amniotic fluid, its
condition may be masked by the restlessness of the mother, which
prevents proper observation: when a woman is plunging all over the
bed, as is extremely common in twilight sleep, the pulse-rate of the
baby cannot be properly watched.

If the mother happens to be particularly susceptible to scopolamine
or morphine, the first will cause delirium and the second coma; or
the respirations may become arhythmic and be reduced to only five or
six a minute. The kidneys may be affected by the morphine so as to
bring on total suppression of urine. Labor is prolonged, and it may
be very much prolonged. In some women uterine atony is induced by
the morphine, with very dangerous consequent post-partum hemorrhage.
Morphine relaxes all musculature, and it relaxes the muscle of the
arterial walls and so disposes to hemorrhage. There is little or no
premonitory symptom of these idiosyncrasies (except in the case of
an injured kidney) to inform the physician that he should avoid the
scopolamine-morphine treatment.

Dr. Polak, professor of obstetrics at the Long Island College
Hospital, reported[204] on 155 cases of the twilight sleep method,
and he is in favor of it under several restrictions. He uses the
drugs from ampules which contain one two-hundredth of a grain of
scopolamine and half a grain of narcophin, which is a proprietary
drug said to be composed of the meconate of morphine with the
meconate of narcotin in molecular proportion. Morphine itself is a
tribasic meconate, and narcotin, of course, another opium derivative.
The American Council on Pharmacy and Chemistry was unable to accept
the claims made for narcophin.[205] Polak says he finds no difference
between morphine and narcophin.

  [204] _Long Island Medical Journal_, December, 1914, and
  _American Journal of Obstetrics_, May, 1915.

  [205] _Jour. Amer. Med. Assoc._, November 21, 1914.

In the twilight sleep treatment the patient, especially if she is
a primipara, should be definitely in labor before any injection
is given. She should have pains occurring at regular intervals,
preferably every four or five minutes, before the first injection of
scopolamine and morphine is administered; that is, the first stage of
labor should be well advanced. Gauss gives one-sixth of a grain of
morphine at the first injection, and Polak nearly three-fourths of a
grain of narcophin, with one two-hundredth of a grain of scopolamine.
If the woman is a multipara, Polak begins the treatment at the very
beginning of the pains. The patient is kept in bed, in a darkened
room, removed from all noise and excitement. Some stop the ears and
blindfold the patient, and, according to Baer of Chicago, the women
are put into restraining sheets as a routine practice in certain
clinics to keep them from infecting themselves. The ordinary practice
is to give a half dose of scopolamine an hour after the first dose
and about every two hours thereafter, according to the indications.
The morphine may be discontinued, or used approximately every six
hours in a long labor. Smaller doses are required if the first is
given early in the labor, and larger if the pains have been well
developed. In these latter cases the danger to the child is, of
course, greater.

The condition of the patient's pulse, respiration, pupillary
reaction, and the frequency and character of the uterine contractions
are constantly watched, to guard against poisoning. Fonyo[206]
reported two fatal poisonings by the scopolamine-morphine method
as used in surgery. Both were operations for the delivery of
women by laparotomy, and in each case the centre of respiration
was overwhelmed. In each of these operations only one-hundredth
of a grain of scopolamine and one-third of a grain of morphine
had been used, but chloroform was administered later. Robinson
recently reported the fatal poisoning of a negress by scopolamine,
and Chandler of Philadelphia two more where one thirty-third of a
grain of scopolamine had been used. One-ninetieth of a grain given
hypodermically has caused severe toxic disturbance which lasted
for twenty-eight hours, and Root[207] reported a case where one
three-hundredth of a grain given by mouth poisoned violently.

  [206] _Zentralblatt f. Gynäkologie_, September 19, 1914. Leipsic.

  [207] _Therapeutic Gazette_, vol. ii.

In Freiburg, Gauss tests the consciousness of the women about every
half hour by showing them some object, and if they remember having
seen this object he gives an additional dose of scopolamine. Polak
says this memory test is not necessary: even if the patient gives
outward evidence of pain by cries and motion, she is apparently but
very dimly conscious in his opinion.

The progress of the delivery must be constantly watched by repeated
extraäbdominal or rectal examinations, following the fetal shoulder
as it rotates--and not by vaginal examinations--to avoid sepsis. The
fetal heart must be auscultated every half hour at most, between
and during the pains. If the child's pulse grows arhythmic or slow
between pains, these are bad prognostic signs. All use of the drugs
is to be discontinued, and the child is to be delivered at once to
save its life, by the most suitable method and route.

Polak holds that the solutions of the drugs must be absolutely pure,
and that hyoscine cannot be substituted for scopolamine, but that
narcophin is no better than morphine: the American preparations
have produced delirium. As I have shown, no one can possibly tell
the difference between hyoscine and scopolamine, even by chemical
analysis. All we can do is to take the druggist's word that the drug
at hand was made from _Scopolia_ and not from _Hyoscyamus niger_. It
does not make any difference which is the source of the supply.

Polak says the morphine shortens the first stage of labor by
softening the cervix, but that the treatment lengthens the second
stage. Other observers have not found that it shortens the first
period. He tells us that if this second stage--that is, the time from
the full dilatation of the os until the delivery of the child--lasts
over an hour in multiparae, or over two hours in primiparae, delivery
must be effected by the Kristeller expression or by low forceps. In
the Kristeller expression the child is pushed out of the canal by
the hands of the physician applied to the fundus uteri. It should be
a method of last resort, because there is danger of rupturing the
uterus, of tearing the placenta loose, or of crushing an ovary.

In his report Polak says he has had no failures; the patients had
no recollection of the labor; in the first series of fifty-one the
children showed no sign of asphyxiation or even cyanosis except
in two cases. In this first series one patient had a long second
stage and the child had to be resuscitated. There were, he said,
no post-partum hemorrhages; no low forceps; the placentas were
delivered without difficulty; none of the women showed signs of
tire or exhaustion the next day; in fact, they were better off
than the women who have normal labor. This report is different from
that made by other men just as competent, and in exactly the same
circumstances; even Gauss confesses many failures. The lay journals
say Gauss had no failures, but he himself should know. In April,
1915, I was told in New York City that there had been no failures
there, yet in May, Dr. Broadhead, professor of obstetrics at the
Postgraduate School of Medicine in that city, after observing
seventy-two cases confessed[208] several failures where the child was
concerned. One Catholic woman, a member of the executive committee in
a Twilight Sleep League of married and unmarried women, was killed in
Brooklyn by the method in the summer of 1915.

  [208] _The Postgraduate_, May, 1915.

Dr. Charles M. Green, professor of obstetrics in Harvard University,
tells us:[209] "My own observations, published in 1903, led me at
the time to favor this therapeutic means of producing the 'Twilight
Sleep,' and removing the consciousness of pain, or at least
preventing all remembrance of it. I have long since abandoned this
agent, however, for two reasons: First, because it has apparently
been the cause, occasionally, of fetal asphyxia. Second, because the
effect of the drug on the mother is often uncertain, and unless used
with great care may cause unfavorable or dangerous results. Moreover,
we have other and safer measures for the relief of pain in labor. So
I have given up teaching the use of scopolamine in my lectures."

  [209] _Ladies' Home Journal._

Dr. Williams, professor of obstetrics in Johns Hopkins University,
and the author of a book on obstetrics which is very valuable,
says:[210] "We have used the scopolamine treatment of childbirth in
two separate series of cases at the Johns Hopkins Hospital, but in
neither series were the results satisfactory, nor did they in any way
approach the claims made for the treatment. We expect to do more with
it next year." In the fourth edition of his _Obstetrics_, published
in 1917, he thinks that the twilight sleep method will fall into
disuse, or at least that its use will be restricted to a small group
of neurotic patients. From his experience, he says, the method is
not adapted for private practice.

  [210] _Ibid._

Dr. Hirst, professor of obstetrics in the University of Pennsylvania,
tried the scopolamine treatment in the maternity hospital of the
university in about 300 cases at three different times. He tried it
first in 1903, but he found that if sufficient morphine is given
to abolish pain there is danger of hemorrhage in the mother and
of asphyxia in the child. At a meeting of the Obstetrical Society
of Philadelphia[211] Hirst, commenting on a paper by Polak, said:
"I am sorry to say I cannot agree with my friend Dr. Polak in his
conclusions ... I had to discontinue morphia and scopolamine because
there were too many cases of post-partum hemorrhage, too many cases
in which forceps had to be used, too many asphyxiated babies. So I am
not an enthusiast for 'twilight sleep.'"

  [211] Proceedings printed in _American Journal of Obstetrics_,
  May, 1915.

Dr. Joseph B. De Lee, professor of obstetrics in the Northwestern
University Medical School, Chicago, and the author of a book on
obstetrics which is now one of the best we have in English, tells
us[212] that the impressions he received from studying ten cases of
childbirth in Professor Krönig's clinic at Freiburg were "decidedly
unfavorable to the method of 'Twilight Sleep.'" In all the ten cases,
he testifies, the birth pains were weakened, and labor prolonged--in
two instances for forty-eight hours. In three cases pituitrin, which
is in itself a dangerous drug to use before the uterus has been
almost emptied, had to be given to save the child from imminent
asphyxia. In five of the cases forceps had to be used owing to the
paralyzing effects of the drug, and all these forceps cases were
extensively lacerated. Several of the women became so delirious and
violent that ether had to be used to quiet them, with the result that
the infants were born "narcotized and asphyxiated to a degree." One
child had convulsions for several days.

  [212] _Ladies' Home Journal._

The complete failure in these ten cases is so obvious as to be a
scandal, although De Lee does not say so. He abandoned the use of
the method twelve years ago, and in 1913 he visited the maternities
at Berlin, Vienna, Munich, and Heidelberg, and found that all had
tried the method and had rejected it.

Several so-called detoxicated substitutes for morphine, like
"tocanalgine" and "analgine," have been tried; but these turned
out to be morphine, and to be equal in strength to morphine as
we ordinarily have it. These were the drugs that were advocated
in the _Cosmopolitan Magazine_ as "having nothing to do with the
morphine-scopolamine treatment originating some years ago in
Freiburg." They are morphine treacherously disguised, and the
assertions in the _Cosmopolitan_ were never retracted when attention
was called to the untruth by the _Journal of the American Medical
Association_. In the _American Journal of Obstetrics_ for May, 1915,
is a full description of these drugs (page 772).

Dr. Joseph Baer reported[213] sixty cases of the morphine-scopolamine
treatment at the Michael Reese Maternity Hospital in Chicago, and
his results were diametrically opposed to those Dr. Polak himself
obtains. The rooms used were large, and had cork-lined sound-proof
walls and doors; obstetricians and specially trained nurses were
present day and night. The circumstances, then, were the best that
could be had.

  [213] _Jour. Amer. Med. Assoc._, May 22, 1915, lxiv, 21, p. 1723.

He used Merck's scopolamine at first, and later a solution made up
after the formula of Straub of Freiburg, which is more stable. His
doses of morphine were from one-eighth to one-fourth of a grain;
Gauss uses one-eighth to one-sixth of a grain; Polak, as much as
three-fourths of a grain of narcophin for his first dose.

Baer's series ended on February 5, 1915, and of his sixty cases
only five were successful. Three of the successful cases received
one-fiftieth of a grain of scopolamine in all, and some of the
unsuccessful cases got as high as one-sixteenth of a grain, with only
wild delirium as a result.

The labor was lengthened by about seven hours over untreated cases.
As to the amnesia, in twenty-six cases the memory was not dulled at
all, although they received more scopolamine than thirty-nine cases
in which the memory was cloudy.

Thirty-two women had unbearable thirst throughout the labor, and
nothing would slake this thirst. Their incessant cries for water
were very distressing to the attendants. Headache was present in
twenty-seven cases and vertigo in thirty-one, and the headache,
which was very intense in some women, lasted for several days after
delivery.

Pain was diminished in thirty-nine cases, absent in one, as severe
as in the average untreated woman in nineteen, and increased in one.
That is, only one woman in sixty did not suffer the pain for which
the treatment was devised. The reason evidently is that his dose of
morphine was too small, yet if he went above this dose he ran the
risk of post-partum hemorrhage and of narcotizing the baby. As it
was, he had seven post-partum hemorrhages, but in a series of sixty
unselected normal delivery cases he had only one hemorrhage.

Restlessness was present in eighteen cases, and delirium in nine; six
of these women had to be wrapped in restraining sheets, and one had
to be shackled for four days after she had overpowered a nurse in an
effort to jump out of a window. It took three attendants to get her
into the strait-jacket. Chandler of Philadelphia saw a woman in a
like delirium who was shackled only after six attendants together had
tackled her. Two physicians in the Chicago maternity were severely
beaten by women in a twilight sleep delirium.

Baer says the serious risk of self-infection during labor through the
uncontrollable motion of these women is a source of constant anxiety.
They sit cross-legged, and the heel infects them with coli communis
from the expressed feces. The dazed women constantly try to get at
the vague pain with their hands, and on this account, according to
Baer, some clinics that practise the twilight sleep method keep all
the women in strait-jackets, but they omit to publish this fact.

One of Baer's patients died from a ruptured uterus, and her dead
baby was taken from her belly-cavity. The drug will mask symptoms in
a case like this. Sudden cessation of puerperal pain as a symptom
of rupture, and the peculiar pain of a premature loosening of
the placenta, are both covered from observation by the drugs, the
darkening of the room, and the tossing of the patient, which prevent
proper examinations.

One patient had a mitral insufficiency and myocarditis. This should
be an ideal case for the treatment, according to the twilight sleep
men. The woman, however, after three doses of the scopolamine
developed pulmonary edema. Her child was delivered in asphyxia
pallida and resuscitated with difficulty.

Thirteen of the children did not breathe at delivery, six were
asphyctic, and two cases relapsed into asphyxia. One child was
killed, as we said, when the mother's uterus ruptured. Avarffy[214]
had one fatal case in fifty, and Chrobak one in one hundred and seven.

  [214] _Gynäkol. Rundschau_, 1909, iii.

Eight of the women had blurred vision after delivery, which lasted
for over twenty-four hours; two had marked delirium for from two
to four days after childbirth. As to exhaustion after labor, Baer
says he found no difference between the twilight sleep women and the
normal cases.

Some advocates of the twilight sleep method say that there is less
use of the forceps in this method than in normal delivery. At
Freiburg, for example, operative delivery has been "reduced" to six
or seven per cent. Six per cent., as a matter of truth, is two per
cent. above the normal average for forceps delivery in eighteen
German maternities. In 95,025 deliveries in these hospitals the
average forceps delivery was 4.5 per cent., and some were small
teaching hospitals where the forceps were used on any provocation
for class demonstration. The twilight sleep method has a much higher
operative delivery, and this varies, of course, according to the
skill and judgment of the operators.

Holmes, one of the first in Chicago to try the newly revived
method, says[215] that in July, 1914, before the great war broke
out, there were twenty-five malpractice suits pending in one German
city as a result of the morphine-scopolamine fad. He quotes a noted
obstetrician on this subject: "If you will use the method, have the
patient in the best hospital possible, with all the appurtenances
requisite for the revival of the child; if you do not know, learn
at once the differences between asphyxia, oligoapneia, and narcotic
poisoning, and the methods of treating them; get the best and the
most reliable product called scopolamine; and then be sure you
are in a position to be adequately defended by a lawyer versed in
malpractice suits."

  [215] _American Journal of Obstetrics_, May, 1915.

This is the state of the question. Two or three men in the best
circumstances say they get one hundred perfect results; other men,
equally or far more skilled and in equally favorable circumstances,
get one hundred results which are anything but successful, often
a disgrace to science, and undoubtedly immoral. They are immoral
because they risk human life in an attempt to ease a physiological
pain, and this is not a sufficient reason; moreover, these attempts
fail oftener than they succeed. The second group of practitioners
have no motive except honesty to induce them to make their
unfavorable reports of failure. The reports of the two groups are
directly contradictory, and the judgment is thus a matter of motives.
Testimony from women who have gone through the process is not to be
taken into account. They were dazed, and in any case they are not
competent to judge a matter which is wholly technical.

We know the limitation of morphine and scopolamine and we cannot
improve their use. If enough is given to still pain, we take a
criminal risk; if we do not give enough to remove the sense of pain,
why not use the safer nitrous oxide, ether, and chloroform? If
enough morphine and scopolamine are administered early in labor to
a multipara, the labor is commonly stopped; if this dosage is given
after the pains are developed, the baby is born, as a rule, before
they take effect.




CHAPTER XXIII

VASECTOMY, OR STERILIZATION, BY STATE LAW


The State of Indiana in 1907 enacted a vasectomy law which obliges
the superintendents of some prisons and asylums to appoint two
surgeons whose office is to sterilize sexually criminals, idiots,
imbeciles, and similar persons, if these surgeons, in consultation
with the chief physician of the institution, deem the propagation
of children by such so-called degenerates detrimental to society.
The same law has been incorporated in the statutes by New York, New
Jersey, Washington, Iowa, Nevada, Wisconsin, Connecticut, California,
Utah, Kansas, Oregon, and Minnesota. The law has been proposed
several times in the Legislature of Pennsylvania, but it was vetoed
twice and held up once in the Assembly.

In New Jersey there was question of sterilizing an epileptic girl,
and the Supreme Court of that State[216] decided in 1913 that the
law is contrary to the State and Federal constitutions. In 1916
Probate Judge Lapeer of Michigan declared the law as passed in his
State in 1913 unconstitutional, but the State appealed against this
decision. The Supreme Court of Washington[217] decided in favor
of the law in a case where a man convicted of rape was sentenced
by the trial judge to life imprisonment and to vasectomy as a
punishment. The constitutionality of the Iowa law is on appeal to the
United States Supreme Court after a Federal judge had declared it
unconstitutional. The law in Indiana was put into effect in hundreds
of cases, but Governor Marshall set the law in abeyance. Two Federal
judges in Kansas said the law is unconstitutional and granted an
injunction against its application in a particular case. In 1808
the superintendent of a Kansan institution for the feeble-minded
castrated forty-eight boys. Up to April, 1916, about twenty-five
feeble-minded boys in the Wisconsin institution at Chippewa Falls
were sterilized, and the authorities then said they intended to
sterilize the girls. The law has been advocated by alienists in
Switzerland, and French and English physicians have advocated it.

  [216] _Smith vs. Board of Examiners of the Feeble-minded, 88 alt.
  R. 963._

  [217] _State vs. Feilen, 126 Pac. R. 75._

The reason given by the advocates of this law is the alarming
prevalence of feeble-mindedness with its tendency to criminality; and
as, they say, heredity accounts for 65 per cent. of feeble-mindedness,
the feeble-minded should be prevented from propagating their kind.
Sweden, with 5,500,000 inhabitants, has 18,000 insane, 14,000 idiots,
20,000 imbeciles, and 7,000 epileptics. Much of this degeneracy is
due to the notorious alcoholism of the Swedes, which only lately
has been brought under some control. Pennsylvania had about 17,000
feeble-minded in 1913. In a single county almshouse in that State
were 105 women who had given birth to 101 defective children. One
feeble-minded couple in the same State had 19 defective children;
two other families had 9 imbeciles and 7 idiots. In New Jersey the
history of 480 individuals of the famous "Kallikak" family (a
pseudonym), descended from a feeble-minded woman who lived at the
time of the Revolutionary War, has been traced out, and of these
descendants only 40 were normal. New York State has 32,000 known
feeble-minded persons. One State school for the feeble-minded in
Indiana in 1908 had 1054 inmates. There are 6000 mentally defective
children in the schools of Chicago. An investigation made in Illinois
about 1907 brought out the conclusion that all the defectives and
delinquents in that State at the time could be traced to 150
families. Poehlmann of Bonn traced the descendants of one female
drunkard through six generations in 800 individuals, and of these
107 were illegitimate, 102 were beggars, 181 were prostitutes, 76
were criminals in a grave degree, 7 were murderers, and they had
cost the State $1,206,000. The Jukes sisters, two illegitimate
prostitutes in New York State, in five generations bred 709
criminals. Fifty-two per cent. of the women were prostitutes,
whereas the ordinary ratio of prostitutes to other women is 1.66
per cent. Alcoholics engender degenerates. In three generations
of 215 French alcoholic families, Legrand found that 60 per cent.
of the children were degenerates. Bourneville found that 62
per cent. of 1000 idiotic, epileptic, and feeble-minded children in
Paris had alcoholic parents.

Hereditary transmission is certainly a cause also of many diseases
of the nervous system. Friedrich's ataxia is hereditary. It is an
incurable progressive incoördination of the limbs, tongue, larynx,
and eyes, which attacks commonly between the tenth and the twentieth
year, and the patient dies from some intercurrent disease, usually
an infection. Progressive muscular dystrophy is also hereditary
and incurable. The legs and trunk atrophy, and death comes from
an intercurrent disease. Related to this malady are hereditary
progressive neurotic muscular atrophy, progressive spinal muscular
atrophy in infants, and progressive spinal amyotrophy in adults.
Amaurotic (_amaurosis_, blindness) family idiocy is hereditary,
and the child dies at about two years of age. Huntington's chorea
appears in every generation of an affected family. Its symptoms show
between the ages of thirty and forty years, and it progresses from
choreic and ataxic signs to dementia and death. The death is often
by suicide. In eastern Long Island, southwestern Connecticut, and
eastern Massachusetts 962 cases were all traced back to six persons,
three of whom were probably brothers, who came to America in the
seventeenth century. In the 3000 relatives of these choreics were
39 cases of epilepsy, 51 cases of cerebral inflammation, 41 cases
of hydrocephaly, 73 feeble-minded children, and other evidences of
neuroses. The heredity in this disease is apparently Mendelian.
Besides the diseases enumerated here, there are several pathologic
conditions of the eyes which are hereditary--presenile cataract,
stationary night blindness, and retinitis pigmentosa. If the persons
who have these diseases are sexually sterile, evidently the heredity
so far as they are concerned will be cut across; hence the advocates
of legal sterilization wish to have these patients sterilized to
protect society.

The surgical operation by which the man is sterilized according to
the State laws mentioned above is an interruption of the continuity
of the vasa deferentia near the testicles. This interruption may be
a severing of each vas, a cutting out of a part of each vas, or a
ligation of the vasa. The term vasectomy is now used loosely to cover
all these methods. The vas deferens, or seminal duct, passes from the
testicle up along the groin on each side, in through the belly-wall
by the inguinal canal, down along the pelvis and under the bladder,
where it opens into the bottom of the urethra a short distance in
front of the bladder exit. Each vas is about two feet in length, and
it has a diameter of one-tenth of an inch throughout the greater part
of its length, but its lumen is extremely narrow.

There are two essential parts in the semen, the spermatozoa and
the carrying liquid. The spermatozoa, which fructify the ovum, are
formed in the testicle; the liquid, which is the essential vehicle
of the spermatozoa, and without which the spermatozoa are inert and
sterile, is secreted, except a few drops from the testicles, at the
distal end of the vasa deferentia under the base of the bladder, in
the seminal vesicles, the prostate gland, and Cowper's and Littré's
glands. The semen is made up of 90 per cent. water and 10 per cent.
solids, and in these solids is the nitrogenous base called spermin,
which is produced by the interstitial cells of the testicles and the
prostate gland. Ovarin, secreted from the ovaries, corresponds in the
woman to spermin in the man. The ductless glands, and some that have
ducts, produce secretions which sustain the tone of the blood-vessels
and neutralize the toxins from waste substances while these are in
the body before excretion. An excess of spermin or ovarin causes
congestion of the cerebrum and cerebellum and the nerve centres
there, with consequent sexual erethism. When there is a pathologic
sexual erethism from an excess of spermin or ovarin, vasectomy,
castration, spaying, or the menopause cuts off this excess and the
erethism disappears. Sometimes the waste product toxins excite the
patient when the spermin or ovarin has been eliminated, just as the
excess of spermin or ovarin excites, and the neurotic disturbance
or sexual erethism continues until compensation by other glands
neutralizes the irritating substance.

The testicles in man are by no means the sole organ of generation.
There are at least seventeen distinct organs in the male generative
system. The seminal vesicles with the prostate gland are as necessary
in generation as the testicles, as their removal sterilizes the
spermatozoa and prevents the formation of the liquid vehicle.
Castration effects an atrophy of several parts of the generative
tract, and an irremediable degeneration; vasectomy cuts off the
spermatozoa but causes no atrophy or degeneration, and the condition
is remediable. Dr. Edward Martin of Philadelphia found active living
spermatozoa in a testicle that had been ligated off for twenty years.

Running along the vasa deferentia, within the sheath of the two
spermatic cords, are the spermatic arteries, the pampiniform plexus
of veins, and the deferential arteries. These vessels, with the vas
deferens and the sheath enveloping the bundle, make up the spermatic
cord. In vasectomy, under local anesthesia, a slit is made through
the skin of the scrotum behind, the sheath of the spermatic cord
is opened, and the vas is isolated and tied or cut. The skin wound
is left to heal. This operation is repeated on the second vas. If
the blood-vessels in the cord are ligated or cut with the vas,
the testicle will atrophy; if the vas alone is operated upon, the
testicle is not injured. The person upon whom vasectomy has been done
is conscious of no change. The semen is discharged as before the
operation, but in a slightly less quantity, and it is, of course,
sterile from the lack of spermatozoa.

Dr. Carrington of Virginia reported, in 1910,[218] twelve cases of
vasectomy on convicts. He said ten of this dozen had been confirmed
masturbators, and all were cured by vasectomy. One masturbating
epileptic was cured of both conditions. Two dangerous homicides were
rendered harmless and peaceable. One of these two homicides was a
negro under a long sentence for murder. He grew insane in prison,
and while insane killed a second person. A confirmed masturbator and
sodomist, and a dangerous savage, he became lucid and relapsed into
insanity several times. A year after vasectomy he was "a sleek, fat,
docile, intelligent fellow, a trusty about the yard."

  [218] _Virginia Medical Semi-monthly_, vols. xiv, xv.

Dr. Sharp of Indianapolis, after ten years' experience with the
operation, during which time he did 456 vasectomies, says:[219]
"There is no atrophy of the testicle, no cystic degeneration, no
disturbed mental or nervous condition following." He says, further,
that 176 men in the Indiana Reformatory asked him to perform the
operation on them. Vasectomy tends to check masturbation, and the
minds of the masturbators frequently improve after the operation.

  [219] _Jour. Amer. Med. Assoc._, December 4, 1909.

If a man has been sterilized by vasectomy, restoration of function
and removal of the sterility seems practically always possible. If
a ligature has been used, releasing the ligature restores function.
Dr. William T. Belfield of Chicago[220] restored function fully by
removing the ligature eight weeks after it had been applied. In a
letter to me, Dr. Belfield said: "My observation accords with the
general experimental and clinical experience that the restoration of
the lumen after vasectomy or ligation, or both, is more certain than
the lasting occlusion of the vasa by these measures. The perseverance
of natural forces in restoring the lumen of the vas--and the success
achieved over such obstacles as silk ligatures--is surprising until
one reflects upon the natural factors favoring such restoration. In
one case I tied a waxed (to avoid cutting through) silk ligature
_tightly_ around the sheath of each vas; a specimen examined a month
later was devoid of sperms; one six months later contained plenty of
them. I cut down upon the ligatures, found them in place and neatly
encysted, and removed them. Evidently the pressure from behind had
squeezed a passage on at least one side. The gynecologists have
learned that ligatures around the Fallopian tubes are apt to cut
through, whereupon the tubal lumen is restored, though pressure
must be less than in the vas. Even when a piece of the vas has been
excised cases of spontaneous restoration have been observed in men
and dogs."[221]

  [220] _Jour. Amer. Med. Assoc._, October 19, 1912.

  [221] _Belfield, loc. cit._

When the ends of a cut vas are released from cicatricial tissue,
these ends may be sutured together; but as the lumen of the vas is
extremely small, there is sometimes obliteration by occlusion at
the juncture. Christian and Sanderson[222] described a method of
preventing this obliteration. A piece of No. 0 twenty-day catgut is
inserted three-eighths of an inch into each end of the vas, and these
ends are brought together by two catgut sutures, leaving the inserted
catgut in the canal. The ends heal together and the catgut in the
canal is absorbed. This method has been used successfully to join the
cut end of a Fallopian tube.

  [222] _Jour. Amer. Med. Assoc._, December 13, 1913.

Gemelli[223] did vasectomy on eleven dogs and seven cats; about
six months later he reunited the cut ends, and on dissection found
restoration perfect, anatomically and functionally, in the eighteen
animals. The vas deferens in these animals is smaller than in man;
and therefore offers greater difficulty in the suturing. He used no
inserted catgut, but told me he employed the method Carrel applies in
joining cut arteries. In one case, where the dissection was broad,
he successfully inserted a piece of a vas taken from another animal.
Whether there is occlusion or not after end-to-end suturing depends
largely on the skill of the surgeon.

  [223] _La Scuola Cattolica_, November, 1911.

Dr. Edward Martin of the Pennsylvania University[224] and Delbet[225]
have removed sterility by effecting a patulous anastomosis between
the vas and the epididymis, and this method is applicable after
vasectomy by cutting, but it is not successful, as a rule. It has
been done effectively where the vas had no stricture. McKenna,[226]
in five attempts on men, succeeded once. Fürbringer[227] said that
in his experience with a thousand cases of double epididymis, the
condition is incurable in 80 per cent. of the gonorrheal infections.

  [224] _University of Pennsylvania Medical Bulletin_, 1902, p.
  388; 1903, xv, 2; _Therapeutic Gazette_, December 15, 1909.

  [225] _Revue de Thérapeutique Médico-chirurgicale_, January 15,
  1912.

  [226] _Journal Amer. Med. Assoc._, January 26, 1915.

  [227] _Deutsche med. Wochenschrift_, xxxix, 29.

Apart from the so-called vasectomy law, gynecologists quite
frequently sterilize women who have chronic heart disease,
tuberculosis, nephritis, diabetes, or hereditary mental taints.
Some men, like Spinelli, Cramer, Polak, and others, would sterilize
also in chronic anemia, persistent albuminuria, epilepsy, syphilis,
contracted pelvis, diseases of metabolism, infections, and
cirrhosis of the liver. There are several methods of sterilizing
women--removal of the ovaries, ligation of the Fallopian tubes,
resection of portions of the tubes, resection of the whole tube on
each side, cutting the tubes and burying the cut end in the tissues
by various methods, and destruction of the lining of the uterus by
vaporization or the thermocautery. De Tarnowsky[228] describes the
various methods. Some ligations and short resections have failed
to sterilize. When the ovaries or uterus are removed, or the major
part of the tubes are resected, or the lining of the uterus has
been destroyed, the sterilization is permanent. Almost certainly
function could be restored where the resection of the tubes is not
too destructive. Apart from the matter of mutilation, the effects of
double oöphorectomy are very grave,[229] and removal of the uterus
or the ovaries merely for sterilization is not only immoral, but
altogether unjustifiable scientifically.

  [228] _Jour. Amer. Med. Assoc._, April 19, 1913.

  [229] See the chapter on Gonorrhea.

A phase of this subject which is important and has occasioned much
discussion is whether vasectomy causes sexual impotence or not.
From a medical point of view, there is no question of impotence;
physicians would say it causes sterility only. Most canonists,
however, hold that the condition after vasectomy is technically
impotence in the canonical sense. Ferreres of Tortosa, a leading
Spanish canonist, in several articles in the _Ecclesiastical Review_,
in _Razon y Fe_ (xxviii, 376; xxxi, 496), and in his book _De
Vasectomia Duplici_ (Madrid, 1913), opposed my opinion published in
1912 and 1913, which then was that vasectomy does not cause canonical
impotence. De Smet of Bruges[230] holds that it causes impotence.
So do Ojetti,[231] René Michaud,[232] Wouters,[233] Eschbach,[234]
Capello,[235] Stucchi,[236] De Becker, Vermeersch, De Villers,
and Salsmans of the University of Louvain, and others. Gemelli of
Milan[237] agreed with me. The weight of authority is certainly
in favor of the notion of impotence, but the arguments are by no
means convincing, as virtually every canonist who has discussed the
question has made gross misstatements of the physical facts in the
case.

  [230] _Ecclesiastical Review_, September, 1912.

  [231] _Synopsis Rerum Moralium et Juris Pontificii_, 31st ed., n.
  2425.

  [232] _Nouvelle Revue Théologique._

  [233] _Nederlandische Katholische Stemmen_, January 15, 1911.

  [234] _Analecta Ecclesiastica_, September, 1911, and _La Scuola
  Cattolica_, February, 1912.

  [235] _La Scuola Cattolica_, February, 1912.

  [236] _Ibid._, November, 1911.

  [237] _Ibid._, November, 1911.

If a man or woman is impotent, the disability is an _impedimentum
juris naturalis_, and as such it would nullify any marriage, no
matter what the dispensation. There are two opinions among moralists
as to the essence of canonical impotence.

I. Some hold that any permanent obstruction to fecundation, no matter
in what stage of the physiological process or in what part of the
genital tract it occurs, constitutes impotence. They maintain that a
woman whose ovaries or uterus have been removed is impotent. Roman
Congregations have promulgated several decrees in peculiar cases
permitting the marriage of spayed women; but, these moralists say,
it is not clear that in those special cases the entire ovary on each
side of the whole uterus was taken out; they hold there is doubt as
to the fact. And, since there is disagreement of moralists, the Holy
Office or other congregations would give the same decision because of
the _dubium juris_.

April 2, 1909, the Congregation on the Discipline of the Sacraments
decreed that the marriage of a Spanish woman, from whom, according to
the physician in charge of the case, the uterus and both ovaries had
certainly been removed, should not be prevented.

February 3, 1887, the Holy Office made the same decree in the case of
a woman from whom the uterus and both ovaries had been removed.

July 23, 1890, the Holy Office made the like decree under the same
conditions.

July 31, 1895, the Holy Office permitted the marriage of a woman from
whom both ovaries had been removed.

Another case, in 1902, in which the physician was not certain that
the whole ovary on each side had been removed, was decided in the
same manner.

There have been, then, four decisions so far permitting the marriage
of women who lacked both ovaries, and three of these women lacked the
uterus also. The Congregation of the Council has made four decisions
in recent time forbidding the marriage of women because of impotence;
March 21, 1863, a case in which there was neither vagina nor uterus;
January 24, 1871, a case in which the vagina was only two inches in
depth; September 7, 1895, a case in which the vagina was obliterated
in greater part; December 16, 1899, a case in which the vagina was
only five centimetres in depth.

That a woman who certainly lacks both ovaries is canonically impotent
is the opinion of Antonelli,[238] Lehmkuhl,[239] Rosset,[240]
Alberti,[241] Bucceroni,[242] and others. These men meet the
decisions of the congregations concerning the spayed women by saying
it is not certain the whole ovarian tissue or the entire uterus
was removed, although as a matter of fact the physician in one
case testified explicitly that both ovaries and the whole uterus
were undoubtedly removed. That a woman lacking both ovaries is not
impotent is the opinion of Gasparri, D'Annibale, Génicot, Berardi,
Aertnys, Tanquerey, Ojetti, De Smet, and others.[243]

  [238] _Medicina Pastoralis_, vol. ii, n. 43.

  [239] _Theologia Moralis_, 8th ed., ii, n. 744.

  [240] _De Matrimonio._

  [241] _Theologia Pastoralis_, p. iv, n. 88.

  [242] _Theologia Moralis_, ii, n. 994.

  [243] See Ferreres, _De Vasectomia Duplici necnon de Matrimonio
  Mulieris Excisae_, p. 110. Madrid, 1913.

II. The second opinion on impotence is that this condition is caused
exclusively by those permanent disabilities which exist in the copula
itself. If the sexual act contains in itself all that is essential
to generation, if the copula is _de se apta ad generationem_,
prescinding from all antecedent and subsequent, temporary or
permanent, obstructions to generation, there is no impotence. In
this opinion the woman without ovaries is not impotent, but the
vasectomized man is; in the first opinion both the _mulier excisa_
and the vasectomized man are impotent. The second group says the
vasectomized man is incapable of performing an act _de se apta ad
generationem_ because his semen lacks the essential spermatozoa. If
one objects that the spayed woman, who is not impotent according to
some moralists that so interpret the decisions of the congregations,
lacks the essential ovum, so that she cannot perform an act _de se
apta ad generationem_ because she has nothing to generate with,
they answer that her copula is _per se apta_, that there happens in
it everything which takes place in a copula from which generation
actually follows. The vasectomized man cannot go through the form
of the act with all the elements which, _so far as the act is
concerned_, are required and sufficient for generation because he
lacks the spermatozoa, but the _mulier excisa_ can. His inability is
intrinsic to the act, it vitiates the very substance of the act; her
inability to present ova is not intrinsic to the act, they say. All
that is necessary in her case is that she be capable of receiving the
semen.

Marriage was instituted to beget children; that is the proper end of
the contract, its basic justification. Whenever the debitum is used
it must be with the intention of generating children. Even the use
of marriage as a remedy of concupiscence is so secondary an end that
it alone is not enough to legitimize marriage. Because a woman does
not always have ova present in the tubes,--and there is no means
of knowing just when the ova are present,--it is justifiable to
repeat the conjugal act until the woman is impregnated; secondarily
and dependently, the repetition may be a remedy of concupiscence.
The sexual act does not form either the spermatozoa or the ova;
these pre-exist. The spermatozoa are always released in a normal
sexual act; the ova are not always present when the spermatozoa are
released. A copula which is perfectly _de se apta ad generationem_
supposes not at the time the presence of both sperm and ovum, but
it does suppose the possibility of the ovum, otherwise generation
is utterly impossible; and every copula becomes justifiable solely
because there is a hope that it may be present. It is a mere
quibble to say that an act is _de se apta ad generationem_ if by
no possibility generation ever can take place; nevertheless the
congregations in four cases have apparently judged to the contrary.
In these special decisions, however, Rosset, Antonelli, Bucceroni,
and Palmieri hold there was a doubt in the minds of the members of
the congregation as to the complete removal of the ovaries or uterus.
Bucceroni expressly states[244] that the Cardinal Secretary of the
Holy Office told him personally the members of the congregation
supposed in the particular cases that generation could follow.
Therefore these decisions do not say that the _mulier excisa_ in
general is not impotent or potent; they merely gave the women of
these cases the benefit of the doubt. Tho question is entirely open
so far as these decisions are concerned.

  [244] _Theologia Moralis_, 5th ed., vol. ii, p. 391, n. 994.

Those who hold that vasectomy causes canonical impotence say also
the constitution of Sixtus V. forbidding the marriage of eunuchs is
applicable necessarily to the vasectomized man, because the semen
from the vasectomized man, inasmuch as it lacks spermatozoa, is not
genuine semen, and Sixtus V. said eunuchs cannot produce true semen.
The relevant passage in the constitution is: "Cum frequenter in istis
regionibus eunuchi et spadones, qui utroque teste carent, et ideo
certum ac manifestum est eos verum semen emittere non posse; quia
impura carnis tentigine atque immundis complexibus cum mulieribus
se comiscent, et humorem forsan quemdam similem semini, licet ad
generationem et ad matrimonii causam minime aptam, effundunt,
matrimonium ... contrahere praesumant ... mandamus ut conjugia per
dictos et alios quoscumque eunuchos ... contrahi prohibeas."

Sixtus V. says here: (1) that eunuchs "who lack both testicles
certainly and evidently cannot emit true semen"; (2) that "although
eunuchs may perhaps produce a kind of liquid resembling semen,
this is by no means fit for generation or marriage"; (3) therefore
eunuchs are forbidden to marry. The effects of castration in the
eunuch are: (_a_) that all spermatozoa are absent; (_b_) that, as a
consequence of the absence of the testicles, the power of penetration
is lost; (_c_) that, as another consequence, the _liquor seminis_,
which normally is formed in the seminal vesicles, the prostate and
other glands, is no longer secreted. The eunuch, then, is completely
impotent, in the full sense of the term. Ferreres is of the opinion,
erroneously, that eunuchs, as a rule, have the power of penetration
and of emitting a _humor semini similis_, and that amputation of the
penis is requisite to cause impotence in eunuchs. There are only five
authentic cases of temporary apparent potence in eunuchs in modern
medical records, and these are explicable as cases of erethism from
waste-product intoxication.

The canonists who hold that the vasectomized man is impotent
interpret the words of Sixtus V. to fit their opinion, although the
vasectomized man has all the sexual potency of the normal man except
that his spermatozoa are occluded. The _potestas coeundi_ is not
lost in any degree; neither he nor the woman is conscious of any
change whatever. Only the microscope can tell that the spermatozoa
are absent if the fact that he has been vasectomized is not told.
Moreover, if vasectomy has been done by mere cutting without
considerable resection, and especially if the vasa have been shut by
ligation alone, no one can be certain that the occlusion is either
certain or permanent. There is always doubt that the spermatozoa
are present if the microscope is not used, and these canonists
all disclaim the use of the microscope in such circumstances. The
argument Ferreres uses, to the effect that the absence of spermatozoa
is seriously injurious to the woman, is a supposition of his own
arising from an erroneous notion of potency in the vasectomized. This
absence is not injurious to her, but it is probably injurious to the
vasectomized man because of the partial ejaculation. Onanism, which
is different, is decidedly injurious to both the man and the woman.

Onanism, _coitus interruptus_, or withdrawal before ejaculation,
which takes place _extra vas_, is intended to prevent impregnation.
In the normal sexual act the male genital tract suddenly becomes
congested with blood through nervous action of centres in the
lumbar cord and the cerebrum. Cowper's and Littré's glands secret
an alkaline fluid which neutralizes the acid urine in the urethra
and thus prevents killing of the spermatozoa. Muscular peristaltic
action presses out the spermatozoa and the secretions of the seminal
vesicles and the prostate. When the act is normal there is a complete
emptying of the tract of semen and of the blood engorgement; in
_coitus interruptus_ there is incomplete ejaculation and only
partial deplethorization. The seminal vesicles remain distended,
and this distention, with the congestion of the prostate, causes
continual excitation of the sexual centres without relief. There is
irritability and exhaustion of the centres, and this state brings on
premature ejaculation and final _impotentia coeundi_. Other common
effects are tenesmus of the urinary bladder, incontinence of urine,
nocturnal pollutions, sexual neurasthenia, pain in the legs, over the
eyes, and in almost any part of the body, general weakness, headache,
vertigo, cardiac palpitation, neurotic dyspepsia, and a train of
psychic symptoms which not seldom end in suicide.

In the woman there is the like blood engorgement and a pouring
out of the secretions of Bartholin's and the other glands, but
deplethorization takes place later in the woman than in the man, and
for this reason the woman suffers more from _coitus interruptus_ than
the man does. In onanism, as in masturbation, after the diseased
conditions have been established it is extremely difficult to induce
the patient to resist the almost overwhelming irritation.

The canonists have interpreted the text of Sixtus V. to the effect
that the eunuch is impotent precisely and solely because he cannot
produce semen "_elaboratum in testibus_." No man produces semen
_elaboratum in testibus_--more than 93 per cent. of the semen is
produced entirely outside the testicle; nothing but the spermatozoa
and two or three drops of a lubricating fluid are produced in the
testicles. The eunuch really is impotent because the removal of the
testicles and their nervous system so breaks the genital circuit,
which consists of at least seventeen distinct parts, that erection is
prevented, the formation of spermatozoa is impossible, the secretion
of the essential vehicle of the sperm and of the fluids which render
it fertile is cut off. The eunuch cannot penetrate and he cannot form
any semen; he is impotent; the vasectomized man can penetrate, and he
forms a semen which is sterile.

I think now the vasectomized man is really impotent for the reason
that I think the _mulier excisa_ is impotent, but he is not impotent
because of the constitution of Sixtus V., which is not relevant at
all to his case.

If the vasectomized man is impotent, the following cases are also
impotent:

     1. A man whose germ-cells have been destroyed by the action of
     the X-ray.

     2. A man with double permanent occluding epididymitis.

     3. A man whose vasa deferentia open into the ureters and not
     into the urethra.

     4. A man whose vasa are shut by surgical operations for stone,
     or cysts of the prostate, or seminal vesicles.

     5. A man whose seminal vesicles are shut by concretions, cysts,
     or tumors.

     6. A man with bilateral cryptorchidism.

     7. A man with a tuberculous condition of the testicles.

     8. A man with absolute neurotic aspermia.

     9. A man with congenital lack of development of the testicles or
     vasa.

Sterility in the male would exist only in advanced diabetes, general
tuberculosis, senility, or in cases of absent or diseased prostate
gland or seminal vesicles.

Here it is worth noting that since the copula must be natural, fit
for generation in the natural manner, artificial impregnation by the
use of instruments is immoral, and forbidden by a decree of the Holy
Office, promulgated March 24, 1897. Artificial impregnation does not
effect a copula which is by its nature proper to generation, but is
an act contrary to nature, one from which generation does not follow
in a natural manner, _secundum communem speciem actus_. It supposes
deliberate pollution and semination outside the vagina, both of which
actions are intrinsically evil.

In discussing the morality of vasectomy the following points must be
considered:

1. In what degree of mutilation is vasectomy?

2. Vasectomy may be done either at the request or by the permission
of the vasectomized person; or by order of the State.

     (_a_) If done by the request or permission of the vasectomized
         person, it may be either (1) as a means to use the debitum
         without the inconvenience of having children; or (2) as a
         therapeutic measure to cure some malady.

     (_b_) If done by order of the State, it may be (1) a punishment;
         or (2) a prophylactic measure to avert physical or moral evil
         in society.

If vasectomy causes canonical impotence, that fact adds a special
moral quality. The weight of authority is on the side that it does
cause canonical impotence, as has already been mentioned.

A slight mutilation, in the sense of the term as commonly used, can
be any permanent effect of a wound, bruise, or similar cause, from a
mere scar to an amputation or other injury whereby any member of the
body is rendered unfit for normal action. That the causal wound or
injury is trivial in itself, apart from its effect, as in vasectomy,
has little or no direct bearing on the morality of the mutilation.
It is possible to have a very gross mutilation without extensive
wounding. We can blind a man permanently by putting the point of a
fine cambric needle one-twentieth of an inch within the pupil.

Vasectomy is a grave mutilation because (1) it removes from the
man the power of generation; (2) it inhibits the function of the
testicle, which is an important organ of the body. Although they
are not the entire organ of generation, the testicles are together
a complete organ in themselves, the function of which is to produce
the spermatozoa essential to the procreation of the human species.
If by a wound one inhibits the function of the testicles, he gravely
mutilates the human body, for a grave mutilation is nothing but an
inhibition of the function of a distinct organ through a wound.

A mutilation of this kind, since it frustrates the production and
action of the human generative semen and prevents generation, is
what is technically called a mortal sin against nature, unless
there is sufficient cause to necessitate the frustration, such as
to save life, to restore as a sole means the health of the whole
body, to protect society, or a similar reason. What is said here of
vasectomy is true for fallectomy or other methods of sterilizing the
woman. Fallectomy, however, is in itself a dangerous operation, and
oöphorectomy is never justifiable as a mere method of sterilization
because of its very injurious effects on the whole body and mind of
the woman.

Among the decretals of Gregory in _Corpus Juris_ (lib. v, tit.
xii, c. 5) is the following canon: "If any one, for the sake of
indulging lust, or through revenge, does anything to a man or woman,
or gives them anything to drink, whereby they cannot generate, or
conceive, or bear children, he is to be treated as a homicide." Any
one who sterilizes a man by vasectomy or a woman by fallectomy or
oöphorectomy, for an improper motive, _ipso facto_ falls under this
decree, and is before the canon law classed in the same category as
a murderer; that is, the agent is deemed guilty of a grave crime
against nature.

If a man has vasectomy done upon himself, his intention may be (1) to
use the debitum without the inconvenience of having children; or (2)
to avert from a wife with a narrow pelvis the dangers of the cesarean
section or other obstetrical operation to herself and the child; or
(3) to avoid the transmission to possible offspring of a hereditary
disease like Huntington's chorea or one of the others mentioned at
the beginning of this chapter; or (4) to cure himself of some malady.

1. If vasectomy is done merely to be able to use the debitum without
the inconvenience of having children, it is evidently illicit. It is
in that condition the same as onanism; it is contrary to the basic
justification of marriage; it is a frustration of nature; and so on.

2. If it is done to safeguard a wife with a narrow pelvis it is
a means, evil in itself, used directly to effect a good end; and
a good end, or any end or effect, never justifies a direct evil
means or cause. There is in reality no such thing as a good effect
from an evil means or cause; the evil means or cause essentially
and substantially vitiates the effect. There is no question here of
a double effect, one good and one evil, wherein the good effect is
intended and the evil permitted, both coming with equal directness
from the single causal act. On the contrary, from the vasectomy
here there is the single direct effect that the man is sterilized,
and then directly from this sterility comes the desired effect, the
protection of the wife. For exactly the same reason, vasectomy done
to prevent the transmission of a hereditary disease is illicit; it is
an evil means used directly to effect an end intended. In artificial
abortion when the fetus is inviable the act done is to empty the
uterus, and this act itself kills the fetus, which is not an unjust
aggressor, and is murder. This murder may save the mother's life,
but the end does not justify the means. The vasectomy to protect the
mother's life or to avert an evil heredity is a parallel case.[245]

  [245] See the chapter on General Principles concerning Mutilation
  for an explanation of the act with a double effect.

The fourth case supposes that the vasectomy was done to cure the man
of some malady. If there were a malady that endangered the patient's
life, or destroyed the health of the body and it could be cured by
vasectomy, the operation would of course be licit for the reasons
given in the chapter on General Principles concerning Mutilation.
Dr. Carrington tells us[246] that he did vasectomy on an epileptic
convict and cured him. Such a cure is doubtful as to permanence. He
describes two dangerous insane negro homicides who were rendered
harmless by vasectomy. In cases like those of the homicides any
one responsible for them would probably be justified in having the
operation done, although these two cases are the only direct ones on
record. Epileptics sometimes show a homicidal tendency, but it is
doubtful that vasectomy would help them. The operation of vasectomy
as a cure for bodily ill has a very limited field. There are very
many conditions in women where it is necessary to remove the ovaries
or the tubes to save life, or to cure chronic invalidism of an
unbearable nature. These conditions are discussed in the chapter on
Gonorrhea. There is no objection to the removal of a tube or an ovary
when such removal is absolutely necessary, but the necessity must be
clearly evident. There is a tendency in some surgeons to mutilate
women in this manner without sufficient reason or to follow out a
therapeutic theory.

  [246] _Virginia Medical Semi-monthly_, vols, xiv, xv.

Men, like Sharp, who have done hundreds of vasectomies, say the
operation commonly removes the inclination to masturbation.
Masturbation is, as a rule, a moral condition, but it can, like
alcoholism, come to have a large physical element. Idiots almost
unexceptionally have this vice, and in them there is no morality
possible. If by vasectomy they can be cured of this vice, which
injures their health and is a social indecency and a source of sin
in observers, the operation would be licit in their case. When the
patient is morally responsible vasectomy would not be licit, as there
is no adequation between a physical evil like sterilization and a
moral vice. There are cases of pathological sexual erethism which
are so violent that the patients must be put into strait-jackets to
prevent constant masturbation. The semen of such patients is usually
devoid of spermatozoa. If the patient is confined in a strait-jacket
he will die, and vasectomy, according to Sharp, will quiet such a
man. Vasectomy would be permissible in these circumstances.

The question has arisen in the case of a sane masturbator who is
neurotic, weak-willed, and a confirmed addict to his vice, whether
or not his vasa might be tied off by ligatures, temporarily, with
the intention of removing the ligature later and restoring function.
I think not. Even temporary sterilization is sterilization, a grave
mutilation, while it lasts, and the condition is really moral
fundamentally, and therefore not a fitting object for physical
remedies.

When vasectomy is done by the State, it is done either as a penal
or as a prophylactic measure. As a general statement we can say
the State in certain conditions has the right to kill or mutilate
a criminal in defence of the social order; but even then any
punishment, to be justifiable, must be effective and necessary,
and it has to be either reformative, exemplary, or reparative in
regard to the crime for which it is inflicted. Capital punishment
and mutilation are effective usually, and are necessary for the
preservation of society. The natural law permits the State to
preserve itself against the unjust encroachments of individuals by
curtailing their rights in so far as that curtailment is effective
and necessary: since the natural law requires the existence of civil
society, it must allow what is necessary for the preservation of that
society. There is no question here of a good end justifying evil
means; the means which otherwise would be evil in these conditions
become good. Homicide and mutilation are not mere killing or mere
maiming, but unjust killing or unjust maiming. Killing or maiming is
not intrinsically wrong under all circumstances, as lying, blasphemy,
and some other crimes are; nevertheless, as a punishment by maiming,
vasectomy is ordinarily wrong, and therefore a law making it an
ordinary mode of punishment for certain whole classes of criminals,
or all criminals, is unjust.

It is wrong because as a punishment it is neither effective nor
necessary nor reformatory nor exemplary nor reparative--it lacks
every quality of a justifiable punishment. In Dr. Sharp's list
of vasectomies done in Indiana prisons, 176 operations were done
on men who voluntarily asked for vasectomy. There is no pain, no
inconvenience caused by the operation, no sexual change perceptible,
but a fitting of the criminal to indulge his lust without the various
inconveniences of impregnation. Instead of being reformatory,
it is conducive to crime. I find only one man who objected to
vasectomy.[247] In this man vasectomy was added to life imprisonment
as a punishment for rape.

  [247] _State of Washington vs. Feilen, 126 Pac. R. 75._

The legislators in the States which have passed the vasectomy law
all seem to have been influenced by the pseudoscientific notion that
criminality is a hereditary condition, a physical disease, and not
a matter of volition. This Lombrosan absurdity is now held by no
physical scientist, and from an ethical point of view it is nonsense.
Moreover, if the State vasectomized all the criminals in the jails,
this method would not appreciably affect the supply of criminals, nor
reach an appreciable minority of the criminal class, as the most
dangerous criminals are not in jails.

The operation is not a punishment to the men upon whom it is done,
but it is an unnecessary deprivation of an essential right of these
men, an excessive, ill-ordered attack on a primary right of man,
and an act of violence against human nature and its Author without
adequate reason. The law is against the natural order because it
directly deprives a man, and that against his will, of functions
which are at times a moral necessity to him, and puts him into the
occasion of sin. Vasectomy does not remove his venereal desires, but
gives opportunity to lust; it turns the conjugal relation into mere
onanism and degrades marriage into a crime. Other conditions, like
military service, in which necessity obliges the State to place its
citizens and thus prevent the conjugal relation, cause an indirect
temporary prevention, reluctantly permitted, not directly intended.
Vasectomy is an evil directly intended.

It is to the interest of the State to prevent the transmission of
hereditary disease, and in doing so it may to a certain degree
curtail the natural liberty of its citizens. When the peril is great,
as in a plague, the State may isolate infected individuals, and thus
indirectly, but temporarily, prevent a natural right--namely, the
conjugal relation. It may even perpetually isolate, as in leprosy.
Vasectomy, however, is a direct prevention without reason, and it is
done as a direct evil means to effect a so-called end which it never
attains.

A man with Huntington's chorea, if married and if he has children,
will surely transmit the disease to some of these children, and they
to their children. Vasectomy on him will prevent a propagation of
his kind but will cure no disease. Moreover, he is not a criminal
and not amenable to punishment. The bad effect, sterilization, must
be perpetual in his case or it is foolish, but the sterilization is
not a punishment, nor a means of saving the health of the patient.
Whatever good comes of the act comes out of an evil cause. If such a
man persists in marrying, his marriage might be prevented, but that
is different from mutilating him.

The State has no _direct dominion_ over the lives or members of its
citizens, nor are citizens naturally mere instruments for the good of
the government; on the contrary, the government exists solely for the
good and utility of the citizen. The State may not take the life of
an innocent person, nor mutilate him, unless these acts are necessary
either (1) to protect the life or rights of individuals; or (2) to
preserve the social life of the commonwealth. Now, neither of these
two requisites is present when there is question of vasectomizing a
man.

The right or life of no individual is at stake. The rights of the
possible children, yet unborn, are not injured, because, as these
children are not in existence, they have no rights. Should they come
into being, it is always better to be, even though diseased, than not
to be. The methods of cattle-breeders in dealing with human beings is
not a virtue in the State, but an outrage and a degradation of human
nature.

The rights of the wife are not injured, because she personally
receives no injury; and if her possible children have chorea, for
example, she either voluntarily took that risk when she married, or
if she did not, through ignorance, there are other means to avoid
the trouble than the evil of sterilization, which in itself would
render the use of marriage onanistic. If the husband has syphilis,
gonorrhea, leprosy, tuberculosis, or any other infectious disease,
vasectomy is no protection for the wife.

May a physician employed by the State in a prison, an institution
for the feeble-minded, or a like place, do vasectomy at the command
of the law? Certainly he may not, except in those rare cases where
vasectomy is permissible as described above.

The advocates of freakish legislation harp on the assertion that
insanity and imbecility are increasing alarmingly, and as a
consequence the entire nation is degenerating. To cure this evil we
are to mutilate certain criminals and the mentally defective. It is
not true that insanity and mental imbecility are increasing in a very
marked degree in the United States. The number of inhabitants in this
country is increasing rapidly, and as there are more people here than
there were a few years ago, the number of the insane and the mentally
defective has increased _pari passu_, but the percentage does
not increase to any degree that calls for immoral and ineffective
legislation. Only of late years have the State governments begun to
classify, diagnose, and gather up the insane and the imbecile, whom
we always have had with us, and these processes have brought the
defectives into the light.

Our late immigrants are not equal in race, in mental and moral
strength, to the old northern European immigrants. In Philadelphia
the foreign-born population is 24.7 per cent. of the whole, but
that foreign-born population gives us 44 per cent. of the indigent
insane. In New York State 27 per cent. of the registered insane are
not American citizens. What we need here is not sterilization, but a
better control of the immigrant, a keeping out of the unfit. Again,
our insanity percentage is increased avoidably by the undoubted
increase of insanity among negroes. We are accountable for this
because we do not care for our helpless negroes. These people are
prevented by trades-unions from learning and working at elevating
trades, and they are thus forced unjustly into a poverty and
degradation which lead to vice and mental deterioration. The cure is
not a jail surgeon's scalpel, evidently.

A system of education that ignores the will, upon which morality
and virtue are based, and substitutes a sham intellectuality as
elaborated by ignorant boards of education and administered by
emotional, half-educated women, together with a lack of genuine
religion, is a prolific source of mental and moral deterioration and
consequent degeneracy in the physical and moral orders. Our American
public-school system is such, and its deity is the unwashed and
crassly depraved god Demos, whose bible is the evening newspaper.
If we could civilize our schools, we should have no mention of
legislation by vagary.


BIBLIOGRAPHY

     Ecclesiastical Review, vols, xlii, xliii, xliv, xlvi, xlvii,
     xlviii, _passim_. Philadelphia.

     Gemelli. La Scuola Cattolica, November, 1911. Milan.

     Stucchi. _Ibid._

     Eschbach. _Ibid._, February, 1912; Analecta Ecclesiastica,
     September and October, 1911.

     Capello. La Scuola Cattolica, February, 1912.

     Michaud. Nouvelle Revue Théologique. Paris, 1914.

     Schmidt. Zeitschrift für katholische Theologie, nn. 1 and 4,
     1911.

     Ferreres. De Vasectomia Duplici necnon de Matrimonio Mulieris
     Excisae. Madrid, 1913.

     De Smet. Collationes Brugenses, December, 1910.

     Wouters. Nederlandische kathol. Stemmen, January 15, 1911.

     Waffelaert. De Virtutibus Cardinalibus, vol. ii. Bruges, 1889.

     Sharp. Journal of the American Medical Association, December 4,
     1909. This is the article which started the entire vasectomy
     controversy.

     Barker. Maryland Medical Journal, April, 1910.

     Bell. Hereditary Criminality. Medico-Legal Journal, vol. xvii.
     New York.

     Desfosses. Presse Méd., vol. xviii.

     Rentoul. St. Thomas Hospital Gazette, vol. xx. London.

     Swift. Maine Medical Association Journal, December, 1914.

     Lydston. Medical Record, November 8, 1913. New York.




CHAPTER XXIV

THE ETHICS OF BIRTH CONTROL


A corollary of the doctrine which treats of the destruction in
medical practice of existent human life, is a consideration of what
is called Birth Control, or the criminal prevention of possible human
life by onanistic contraceptive methods. There has been an agitation
for several years past in western and northwestern Europe and in the
United States to bring about the repeal of laws which forbid the
spreading of information on the methods of preventing conception.
The laws which the agitators wish to have abrogated declare that
contraceptive information is indecent and should be classed with
the circulation of obscene literature, pornographic pictures, and
instruction in abortion. The birth control advocates pay no attention
to accusations like those expressed in the laws, or to those made by
persons who have accurate notions of morality and common decency, but
assert that the spread of contraceptive information tends to benefit
the individual and human society.

Birth control as advocated by its perpetrators is intrinsically
contrary to the natural law, and therefore immoral; it mentally and
physically debases those that are guilty of the practice; it does not
benefit the poor as its advocates claim it does; the arguments urged
by its supporters are foolish and frequently deliberate untruths;
and it is destructive of society and the state. Broadly speaking the
natural law rests on the principle that order, reason, justice, what
is congruous with the nature of a being or faculty and tends to its
perfection in being or action, should prevail, and that disorder,
unreason, injustice, the unnatural, must be avoided. The right
order of nature as established by the Supreme Creator of nature is
the standard of action; what is contrary to that order is evil,
wrong, destructive, criminal, injurious, or the like, in different
circumstances, but altogether these deordinate conditions must be
removed, not accepted. Morality also depends on these facts. Morality
is merely the observance of the natural law, and immorality is revolt
against that law.

Since the natural law evidently prescribes that man must live in
society and that the human race which constitutes this society,
is to be preserved by the generation of new human beings who will
replace those that die, or are made useless by disease or other
accident, whatever tends to this sustention of humanity according to
the natural law, and in the proper conditions, is good, and whatever
tends to the destruction of humanity is evil and to be avoided.

The generation of new replacing human beings must take place only in
the state of marriage, because thus solely the wife and the child
are protected, the children are educated physically, mentally and
morally, and the degradation and bestiality of promiscuous sexual
relationship are averted. The first and principal end of marriage is
the procreation of children. That end of marriage must be the end on
which is founded primarily the natural necessity for this contract,
but the natural necessity for the contract is the propagation of the
human kind through lawful generation and education. Marriage, too, in
its very nature is fitted for that chief end, and for that end it was
instituted by the Author of nature--a stable, perpetual association
of the sexes for the attainment of what is requisite for the
propagation of mankind. There are secondary ends of marriage, such
as a reciprocal love and help of the husband and wife, and also that
aspect of marriage which makes it a restraint upon promiscuous lust.
These last, however, are not enough to justify marriage in themselves
without the first or chief end, which is the procreation of children.

Whatever is subversive of the end of marriage, and that is the
propagation of mankind, is subversive of the very foundation of human
society, is contrary to the nature of man, frustrates the primal
function of nature, and is therefore essentially and always evil,
as bestiality, sodomy, or incest are evil. Such is birth control as
ordinarily practised. Birth control if it is effective through a
reciprocal consent of a wedded couple, for grave reason, and solely
by mutual abstention from the _debitum_ may be in certain conditions
an indifferent act morally. If, however, birth control is effected
by contraceptive drugs, or like methods, it is a crime against
nature, and always a crime which no circumstance can excuse, no
more than no circumstance can excuse bestiality, sodomy, or incest.
Secondly, marriage, which was instituted primarily to perpetuate the
creative act of God, when such practices prevail degenerates to mere
concubinage, a gratification of lust protected from the police. Such
practices, moreover, lower man and woman below the brutes, because
brutes do not frustrate the natural law except in the case of the
male rat and a few other low grade rodents and boar pigs. Onan is the
patron of Birth Control advocates. The Book of Genesis said Onan, the
son of Judah, "did a detestable thing, therefore the Lord slew him."

These are the fundamental reasons those of us recognize who do not
wish that the ignorant and vicious should be taught to act contrary
to the natural law. Furthermore, there is always another way out
of the difficulties, mostly imaginary, the birth control advocates
conjure up. Granting that all the difficulties from multiple births
are real, no end justifies essentially evil means, and a subversion
of the natural law is always essentially evil. War, homicide, and
like acts are not always evil; under certain circumstances both
war and homicide may be holy deeds; but to act contrary to nature
is never justifiable in any condition. If I owe a man a large sum
of money it may be to the advantage of myself or my children that
this man be removed, but that good end does not justify murder;
no more does any condition of poverty justify a contraceptive act
against nature, especially when such an act is never the sole means
of evasion. We must protect the married state, but in America we
are destroying it. Human society had its origin in marriage, and it
depends on marriage for its preservation, but our American divorce
laws have made marriage a travesty. In New York alone in 1916 there
were 74,893 women divorced, nearly twenty-eight times as many as
were divorced in England and Wales in that year, and over forty-nine
per cent. of these women were childless, very significantly. Probably
ninety-five per cent. of the childless women had used contraceptive
methods, yet there are few forces better able to hold the marriage
knot tied as it should be tied than a child's fingers. In England and
Wales, too, in 1916, forty per cent. of the divorced couples were
also birth controllers, at least they had no children. Pennsylvania
is much more shameless than New York in granting divorces for no
reason at all.

Among the arguments used by those in favor of spreading contraceptive
information is that large families keep the laboring classes down
to low living standards, and it would be better for those families
and the state that these children were not born. Large families
as such do not keep the laboring classes down to low standards of
living; bad legislation which allows profiteering, which criminally
permits extortion in the prices of food, clothing, in taxes, rents,
the cost of coal, and the like, which does not force employers to
give laborers an honest price for labor, or check the extortions
of monopolists, and a hundred similar economic deeds of injustice,
together with a parental shiftlessness, unthrift, alcoholism, lack of
education through neglect, and so on indefinitely, are the causes.
Big families have more wages than small families, and as a rule they
do better than the small families when the children are old enough
to work. Society is at fault, not the size of the family; the active
and the passive selfish are at fault, not the babies; the liars,
hypocrites, and the buttoned pockets are at fault, not the holy
innocents; the professional meddlers in the business of better folk
are the nuisance, not the blessed children, who are the brightest
things in this darkened world until we spoil them, and make them like
ourselves instead of better. One decent mother is worth a hundred
shirkers who raise nothing but lap dogs.

The children of large families, the birth controllers say, are more
afflicted by infectious diseases than those of small families. I
was for years in charge of the infectious diseases Bureau of the
Washington Health Department, and I have had ample opportunity
here and in Europe to study this matter. Large families in proper
economic positions are not different from small families as regards
the infectious diseases. These diseases spread among the poor
because the houses of the poor are commonly owned by land sharks and
politicians who laugh at health regulations; our health departments
can not get enough money away from the political ringleaders in power
to employ capable sanitary experts; our laws for the regulation of
medical practice and education are a disgrace to our civilization,
and every town is swarming with quacks who can not recognize even
smallpox when they see it. The fault here is in ourselves not in the
large families. Control the professional politicians and quacks and
there will be no occasion for foolish talk about birth control.

Again, the children of poor but large families, we are told, have
slight or no chance to rise in the social order. Benjamin Franklin,
however, one of the greatest men America has produced, was the
youngest of seventeen children in a poor family; Lyman Beecher, a
poor man, had eleven children, and every man and woman among them
became famous; Theodore Schwann, the father of the cell doctrine
and of all modern biology, was one of thirteen poor children; John
Mueller, one of the greatest of modern scientists, and the Father
of German medicine, was one of five children of a very poor family;
Emerson was one of five sons, so was Farragut; John Wesley the
founder of Methodism, was the eighteenth child of his parents;
Ignatius Loyola was the eighth; Saint Catherine of Sienna, among the
greatest women intellectually and morally that Europe ever produced,
was the twenty-fourth child of her parents. This list can be extended
indefinitely from the biographical dictionaries. Every enormous
fortune made in America was built up originally by a man who arose
from the depths--Rockefeller, Carnegie, Vanderbilt, Astor, Ryan,
Havemeyer, Schwab, Ford, Gould, and so on. Poverty is a necessary
foundation for a great fortune. The great soldiers of the world
almost without exception rose from the ranks of poverty--Napoleon,
Washington, Sheridan, Grant, Sherman, Pershing, De Lacy in Russia,
Prim in Spain, O'Higgins in Chili, Stonewall Jackson, and others. The
powerful Dukes of Tetuan in Spain came from an Irish adventurer, the
fifth of eight sons of a poor man. Big families make for strength
of character in the struggle for existence; the solitary child in a
family is pampered, spoiled.

Advocates of birth control say that Holland has had a Neomalthusian
League openly operative since 1881, with fifty-two clinics where
contraceptive information is publicly given. As a direct consequence,
and solely from the work of this League, Holland has a dropping death
rate and an increase in population, and even the stature of the Dutch
has increased four inches since 1881. The main objection to these
statements about Holland is that they are absolutely false in every
particular except that the population of Holland has increased--from
other causes. Before the great war every civilized nation had a
dropping death rate and an increase in population except France
where birth control worked against the increase made by the progress
of preventive medicine and a diffusion of sanitary methods. The
assertion about the fifty-two clinics in Holland was investigated. An
army officer sent out by the committee searched fourteen days before
he could find even one secret birth control propaganda station. The
present prime minister of Holland, de Beerenbrouk, is an earnest
Catholic man, and if anyone talks birth control in Holland during
his administration he guarantees them a long term in jail. There
was really a Neomalthusian League with 6,704 members, now greatly
decreased in number, in the northern Protestant provinces of Holland.
As a matter of fact just where this league exists the birth rate
decreased and the death rate increased and where it did not exist
the direct opposite is true. As to the increase of four inches in
stature--since this is a physical impossibility the spinner of the
original yarn was an ignorant romancer, lacking plausibility in
his untruth. Where there is birth control there are no children
to increase or maintain the population, but the New York birth
controller who invented the Dutch story says that in Holland where
there are no children born through birth control the population
increases through birth control.

The birth control movement assumes that the world suffers from
overpopulation. It does not; it suffers from incorrect distribution
of populations, and no doctrine of birth control will ever affect
this fact. All the authorities on the statistics of population tell
us it requires an average of four children to each family to keep
the population even stationary, not to talk of overcrowding. Two
children reaching maturity replace their parents, and because of the
high mortality in infancy, and the large number of the unmarried and
the birth controllers and abortionists, four children are needed to
a family to make a new generation as large as the old. An average
of one, two, or even three children to a family means a loss in
population, unless the loss is supplied, as in the United States, by
immigration. An average of five or six children means an increase in
the population. Having none or two children to a family and relying
on immigration to preserve the nations means political annihilation,
as can be readily shown. In New York State in 1919 instead of the
required four children to keep the population stationary, as far as
the native Americans are concerned, there was one child to every ten
families.

The American nation was founded and built up wholly by Nordic races,
immigrants from Great Britain and Ireland, Germany, and a few from
France, Holland and Sweden. All our national traditions are from
these Nordic immigrants, our notions of self government, our peculiar
democracy, our constitution, our language and literature. These
Nordic peoples are dying out here in appalling numbers for two chief
reasons, one of which is birth control and the other is the American
climate. The civilization which affects us has always existed along a
geographical belt reaching from the British Isles to above Rome, and
covering Great Britain, Ireland, France, Spain, middle and western
Germany, and Italy to below Florence. The Grecian civilization was
not indigenous, but the result of a Nordic occupation, and it ceased
centuries before Christ. Huntington of Yale and several others have
shown, by studying the production of thousands of piece workers and
students over a long time, that man does his best work physically
and mentally under four climatic conditions: a mean temperature
of about sixty-two degrees Fahrenheit for physical work and about
forty degrees for mental work; secondly, there must be a humidity
of about seventy-five per cent.; thirdly, the climate must be
variable, be that of the belt of cyclonic storms; fourthly, there
must be a quantity of sunlight such as that found in the European
racial habitat of the person considered. These conditions are found
curiously in exactly these degrees in the civilized parts of Europe
and not elsewhere. Above and below that area they are lacking and
there has never been any civilization where they are wanting. The
reason physical and mental productivity lessen annually with us in
December, January, and February is because these climatic conditions
are absent during these three months.

Again, men are differentiated into races, thrive, develop, and
reach and maintain mental and physical perfection within well
defined climatic areas. Nature preserves the race that has acquired
through countless ages acclimatization in a given environment, and
kills off very quickly immigrants coming from far north or south
of the given latitudes. The natural geographical position for the
black man is from the equator to the thirtieth parallel of north
or south latitude. The thirtieth parallel in America runs through
upper Florida, southern Louisiana, and the lowest third of Texas.
From the thirtieth to the thirty-fifth parallel is the zone of the
brown man, like the Malay. The thirty-fifth parallel runs along the
southern border of North Carolina and Tennessee, through the middle
of Arkansas, New Mexico, Arizona, and the lowest third of California.
From the thirty-fifth to the forty-fifth parallel is the zone of
the brune Mediterranean races. The forty-fifth parallel passes near
Halifax, Bangor in Maine, Ogdensburg, Ottawa, and St. Paul. In
Europe it runs near Bordeaux, Turin, Bosnia, and the Crimea. New
York is as far south as Naples, Philadelphia is sixty miles south of
Naples, and has the sun of southern Italy. The Nordic races that we
are interested in as our origins all live above the United States,
and the summer temperatures they have been accustomed to are above
the United States. An immigrant coming from northern Ireland to
Philadelphia moves southward a thousand miles; a Norwegian going to
Texas moves southward two thousand miles, and his family disappears
as a rule in two generations.

In historic times there have been sudden movements southward
of European races for about seven hundred miles and all ended
disastrously. The Lombards went south from upper Prussia to middle
Italy at the level of Boston and disappeared in two hundred years.
The Teutonic Goths went from the Baltic to Italy and Spain. They
lasted sixty-two years in Italy. Eighty thousand Vandals with their
families went down from Brandenburg to North Africa at the level
of Virginia. They were annihilated by the climate in one hundred
and eight years. The Burgundians disappeared in sixty years from
Greece, as the Celts who had carried the Homeric sagas to Greece also
disappeared. Rome was great while the Nordic Cisalpine Celt ruled it,
and died forever with the Celt. Italian art ended at Florence, the
southern boundary of Cisalpine Gaul. The Slav disappeared the same
way from southeastern Europe and left only language traces to the
Turanian and Semite there. No European race of pure blood has ever
had grandchildren in the tropics.

The northern races of Europe die out with amazing rapidity in the
northern United States. The Irish death rate at the level of New
York is double the death rate in Ireland under much worse economic
conditions; the death rate of the southern Italian and the southern
Russian is much better in New York than it is in their European
racial habitats.

In 1910 our English immigration was only six per cent. of the whole,
and the Irish immigration is now negligible because there are no more
people in Ireland to leave it, but we have seven million Slavs who
came in during the ten years before the war. We have three million
southern Italians, three million Poles, and hundreds of thousands
of nondescript folk from all the back alleys of the old world. At
an army camp in Massachusetts during the late war there were thirty
languages other than English spoken, and seven thousand men there
never had heard the term Anglo-Saxon. The extreme southern, eastern,
and southeastern European hordes are overwhelming us, and these
hordes never knew a single political principle that even remotely
resembles what we understand as American principles. They come of
races who were ruled, if they had any rule at all, by despots, but
we shall make "Anglo-Saxons," Americans, or whatever you like to
call the final metamorphosis we effect, out of these barbarians.
Never! Even in a millenium. Centuries from today the Slav here will
be a Slav, the Sicilian a Sicilian, the Russian a Russian, all
with a veneer of American slang on the tongue of an eternal racial
character. Whole counties of Pennsylvania are filled with Germans
who have been here since before the Revolution and they have not so
much as learned English yet. The Nordic peoples die out here. Only
the dark-skinned southern Germans last with us; the sun kills out the
red and blond in two or three generations. I recently went over fifty
Irish families which I knew perfectly, and they have degenerated
eighty-six per cent. numerically and otherwise in my own lifetime:
killed off by the climate which keeps our southern states empty of
white men. By two American censuses and one English we know that
fifty per cent. of Washington's army was born in Ireland, but there
are no Irish in the revolutionary societies because the Revolutionary
Irish have disappeared.

If there is any chance at all for our civilization, flimsy as it
is, this world must be ruled by the Nordic European races, not by
the southern, eastern and southeastern European barbarian Semite.
We must rule for our own sake and for their sake; they can not rule
anything. If we do not rule them, then welcome the final curtain
as soon as possible. How can we rule America, not to think of the
rest of the world, unless we have Nordic children to take our place,
and how can we have such children if we let sex-brained misfits
run about spreading contraceptive drivel? The rascal that preaches
such doctrine is a traitor to America, the worst enemy our country
ever has had, more treacherous than any spy that sneaked in among
us during the war just past. The French have had their lesson in
birth control, and we should learn from their misfortune. In the
first six months of 1914 when Europe was still at peace the total
number of births in France was 381,398; a decrease of 4,000 on the
year 1913. At the same time the deaths increased 20,845. Thus the
population of France during the first six months of 1914 decreased
24,816. For the past thirty years the birth rate of that country has
steadily decreased by contraceptive methods, while the death rate
has increased proportionately to the number of inhabitants. January,
1916, found France with about seven hundred thousand less people than
she had in January, 1914, and then came the horrible carnage of the
great war. No matter what change of heart war may bring to France
no increase in her population can be expected for many years yet to
come. She is daily crying out to the world for treaties to protect
her from Germany, despite the prostration of Germany, because she
knows Germany had a birth rate of two males for her one, and for
twenty years to come Germany probably can put twice as many men into
the field as France can. If France will give over her unclean birth
control she will not need to whine for protection.

The advocates of birth control assert that it lessens venereal
diseases. It does not; it increases the spread of venereal disease.
The more reasonable among the birth control propagandists are anxious
lest their public talks suggest temptation to the young. There is at
present for youth the deterrent of the natural consequences of lust;
with birth control knowledge spread broadcast that check is removed
and promiscuity will become more general, because safer socially.
Venereal diseases will spread also as incontinence spreads. Nowhere
in the world has the crime of birth control been practised as in
France nor for a longer time, and in that country together with the
lowest birth rate in the world there is the highest death rate from
venereal diseases according to Dr. Dublin the statistician of the
New York Metropolitan Life Insurance Company. Not long ago one of
the leading medical writers of France, Doyen, said in the Academy
of Medicine in Paris that syphilis is the chief cause of death in
France. France now asserts she has given over birth control, but that
is a hard disease to cure after it has been established. Unchastity
is its own punishment, and if France goes the way of those nations
that have died along the pathway of civilization, and great would be
the pity, she has nothing to blame for it but this abominable moral
leprosy, birth control. She is as striking an example of the insanity
of birth control as Russia is of the insanity of communism.




INDEX


  Abnormal pelves, 133, 134, 135

  Abortion, 91
    after fifth month, 102
    agents of, 117
    American law on, 119
    causes of, 92
    civil law on, 121
    Council of Lerida on, 115
    Council of Worms on, 115
    decretal of Gregory on, 115
    direct, 109
    excommunication for, 116, 117
    Gregory XIV on, 116
    habitual, 98
    Holy Office decrees on, 118
    homicide in, 110
    incomplete, 101
    inevitable, 101
    irregularity and, 117
    morality of, 109-114
    morphine in, 101
    paternal causes of, 95
    Pius IX on, 116
    precautions against, 105, 106
    prognosis after, 100
    sepsis after, 105
    Sixtus V on, 115
    statistics of, 97, 98
    symptoms of, 99
    syphilis and, 107
    tampon, use of, 103
    therapeutic, 107, 109
    threatened, 99
    treatment of, 102
    violence and, 94

  Abruptio placentae, 144
    causes of, 144
    effects of, 144

  Acute yellow atrophy of the liver, 186

  Aggressor, 17, 19

  Amnion, 52

  Amphiaster, 44

  Anaesthesia and the fetus, 93

  Analgine, 240

  Animal heat, 71

  Animal life, 48

  Animation, 33, 39
    Aristotle on, 39
    biologists on, 49
    Conklin on, 73
    Fienus on, 35
    Greek fathers on, 33
    Greek philosophers on, 33
    St. Alphonsus on, 39
    St. Anselm on, 35
    St. Augustine on, 34
    St. Gregory of Nyssa on, 35
    St. Thomas on, 35
    Zacchias on, 36

  Aortic stenosis in pregnancy, 175

  Apparent death, 82

  Appendicitis in pregnancy, 152

  Archenteron, 50

  Artificial impregnation, 258

  Attraction sphere, 40


  Baer on twilight sleep, 240

  Baptism of monsters, 80

  Beginning of life, 33

  Blameless defence, 18

  Blastocyst, 50

  Blastulas, 50

  Braxton-Hicks version, 143

  Bright's disease in pregnancy, 157

  Broad ligament, 124


  Cancers in pregnancy, 149
    morality of operation, 150

  Canonical irregularity, 23, 24, 25

  Capital punishment, 31

  Carrington's vasectomies, 248

  Catalepsy, 85
    in pregnancy, 160

  Cell, 40
    bridges, 60
    differentiation, 67, 68
    division, 41, 42
    heredity, 45
    life, 48
    motion, 70
    reduction, 45
    union, 65, 66

  Centrosome, 40

  Cesarean delivery, 132
    amputation of the uterus after, 138
    indications for, 132
    morality of, 136, 137
    repeated sections, 140
    sterilizations and, 139, 140, 141

  Chemico-vital changes, 70, 71

  Cholera in pregnancy, 195

  Chorea gravidarum, 181

  Chorion, 51

  Chromosome, 42
    numbers of, 43

  Chromatin, 41

  Circumstances, 3

  Citizen as member of the State, 31

  Coelom, 51

  Coition in gestation, 95, 96, 97

  Congenital tuberculosis, 189

  Conscience, 12

  Constitution _Effraenatam_, 115

  Contingent being, 1

  Contracted pelves, 133

  Craniotomy and excommunication, 117


  _Dämmerschlaf_, 231

  Death, signs of, 89, 90

  De Lugo on the State, 31

  Development of the body, 56

  Diagnosis, percentage of correct, 21

  Diabetes in pregnancy, 229

  Differentiation by position, 68, 69

  Division, direct and indirect, 42

  Double effects, 18, 26

  Double monsters, 78, 79

  Dry labor, 109


  Eclampsia parturientium, 161
    abortion in, 165
    expectant treatment of, 166
    forced delivery in, 165
    mortality, 163, 168
    Lichtenstein's method in, 166
    precautions against, 164
    symptoms of, 161
    veratrum viride in, 167

  Ectoderm, 50
    derivatives of, 51

  Ectopic gestation, 123
    decrees of the Holy Office on, 128, 129
    diagnosis of, 126, 127
    morality of operations, 129, 130

  Effects of an action, 6

  Egg shell, 47

  Embryo, 33
    growth of, 50
    stages of, 52

  End of an action, 4

  End of life, 82

  Endoderm, 50

  Endometritis, 93

  Entelechy, 60

  Erysipelas in pregnancy, 196

  Eunuchs, 255, 256

  Euthanasia, 1


  Fallopian tubes, 123

  Fecundation, 124

  Fetus, 33
    and the dead mother, 87
    at term, 54
    months, 53, 54, 55
    stages, 53

  Fibrillation, 174

  Fibroids, 146

  Fission theory, 77

  Form, 60


  Gemmule theory, 58

  Germ cells, 44

  God's existence, 2

  Gonorrhoea in marriage, 211
    abortion and, 224
    blindness and, 226
    conservative surgery for, 217
    effects, 212, 213, 215, 216, 225, 226
    operations for, 216
    professional secret and, 212
    tests of cure, 211
    treatment by heat, 228

  Good, 3

  Grippe, 194


  Happiness, 2

  Hastening of death, 111

  Hebosteotomy, 135

  Heart beat, 83

  Heart block, 173

  Heart diseases in labor, 172, 174

  Heart diseases in pregnancy, 169
    Mayo clinic on, 173

  Heart, origin of, 52

  Homicide, 13
    accidental, 19
    arguments against, 14, 15, 16, 17
    bibliography of, 22
    direct and indirect, 13
    self-defence and, 17, 18, 19

  Human terata, 78

  Hyperemesis gravidarum, 176

  Hysteria,
    imitative, 183
    major and minor, 184
    marriage and, 185
    in pregnancy, 181, 182, 183


  Icterus gravis, 186

  Impotence, 258
    opinions on, 252

  Infectious diseases in pregnancy, 188

  Influenza in pregnancy, 194

  Insanity,
    puerperal, 154
    spread of, 266


  Kant on morality, 29

  Karyokinesis, 41


  La grippe in pregnancy, 194

  Law, definition of, 28

  Life in separated tissues, 73, 74


  Malaria in pregnancy, 196

  Male generative system, 248

  Male pronucleus, 49

  Maniacal chorea, 182

  Marriage, end of, 254

  Mayhem, 23

  Means of an action, 5

  Measles in pregnancy, 195

  Mesoderm, 50

  Metabolism of the cell, 69, 70, 72

  Metaphases of mitosis, 44

  Midwives, 138

  Mignonette case, 113

  Mitosis, 41

  Miscarriage, 91

  Mitral regurgitation in pregnancy, 174

  Monsters, 75
    by displacement, 78
    multiple, 76

  Morality, 3
    determinants of, 3

  Morphine,
    effects on fetus, 234
    effects in labor, 234, 235

  Morula, 50

  Mutilation, 23
    argument against, 26, 27
    argument for, 27
    civil law on, 23
    direct and indirect, 26
    Molina on, 24
    St. Alphonsus on, 25
    State and, 28, 29, 30, 31, 32
    self-mutilation, 26
    Suarez on, 24

  Myomata in pregnancy, 146
    effects of, 147
    fetus and, 148
    mortality of, 147


  Natural law, 2, 12

  Necessary being, 1

  Nephritis in pregnancy, 157
    treatment of, 158
    varieties of, 158

  Nervous system, 51

  Nucleus, 40, 46


  Object of an action, 3

  Onanism, 256

  Operations during pregnancy, 94

  Operative risk in cardiopaths, 173

  Ophthalmia neonatorum, 226, 227, 228

  Organs, origin of, 51
    of the body, 64

  Ovaries,
    removal of, 218, 223
    resection of, 221

  Ovarian tumors in pregnancy, 148

  Ovarian, 247

  Ovariotomy,
    decrees of the Holy Office on, 252, 253
    effects of, 219
    impotence and, 252, 254, 255
    psychoses after, 219, 220, 221

  Ovum, 33, 47

  Oxidation, 72


  Pangens, 68

  Paresis, 204

  Parturition, 169, 231, 232, 233

  Partus cesareus, 132

  Pathogenesis, 48, 49

  Pelvic diameters, 132

  Penal law, 31

  Pernicious vomit of pregnancy, 176
    abortion for, 180
    causes and symptoms, 177
    diagnosis of, 179
    treatment, 179

  Pituitrin, 170

  Placental infection, 188

  Placental osmosis, 189

  Placenta praevia, 142

  Plastid, 40

  Pneumonia in pregnancy, 192, 193

  Polak's operation on the tubes, 222

  Polar body, 46

  Porro's operation, 136

  Preformationists, 56

  Premature infants, 55

  Premature labor, 98, 108

  Probabilism, 6

  Prophases of mitosis, 44

  Protoplasmic bridges, 67

  Puerperal insanity, 154
    prognosis, 155
    sterilization and, 154

  Pyelitis in pregnancy, 160


  Quacks, 22


  Resuscitation, 83, 84
    methods of, 88

  Right and wrong, 3

  Rupture of Fallopian tube, 125


  Sacraments in apparent death, 82

  Salpingectomy, 217

  Salpingostomy, 217

  Salpingotomy, 217

  Scarlatina in pregnancy, 195

  Scopolamine, 233

  Secrets, 206, 207

  Segmentation cavity, 50

  Segmentation nucleus, 49

  Self-defence, 17, 18

  Semen, 247

  Sixtus V, bull of, 255

  Smallpox in pregnancy, 191

  Soul, 60

  _Spaltungstheorie_, 76

  Spermatozoön, 46, 47, 48

  Spermin, 247

  Spindle, 44

  Spireme, 43

  State,
    citizen and, 30
    dominion of, 28, 29
    end of, 29

  Sterilization of women, 251

  Substantial form, 60, 62, 75

  Suicide, 7
    arguments against, 7-12

  Suspended animation, 85

  Syncytium, 52, 66

  Symphyseotomy, 135

  Syphilis,
    abortion in, 200
    curability of, 203
    fetal, 201
    incurability of, 204
    marriage and, 205
    nervous system affections, 204
    pregnancy in, 200, 202
    professional secret in, 206


  Tabes, 204

  Telophases in mitosis, 44

  Terata, 75

  Tetrads, 46

  Tocanalgine, 240

  Tonics, 48

  Traducianism, 34

  Trophoblast, 50

  Tubal abortion, 125

  Tuberculosis in pregnancy, 196, 197, 198

  Tumors in pregnancy, 146

  Tumors and premature labor, 109

  Twilight sleep, 231
    authorities opposed to, 238, 239
    effects of, 240, 241, 242, 243
    methods used, 235, 236, 237

  Twins, 76

  Two-celled stage of the embryo, 65

  Typhoid in the fetus, 190

  Typhoid in pregnancy, 196

  Typhus in pregnancy, 196


  Unity of the soul, 65

  Uterine adnexa, 123

  Uterus, abnormalities of, 124
    anatomy of, 123


  Vaccination, 191

  Vas deferens, restoration of, 249, 250

  Vasectomy, 244
    arguments against, 260-265
    bibliography, 266, 267
    bull of Sixtus V and, 255, 256
    effects of, 248, 249
    grave mutilation, 259
    hereditary disease and, 264
    impotence and, 251
    morality of, 259
    not a punishment, 263, 264
    operation for, 247
    reasons for the operation, 245, 246
    State and, 244
    State surgeon and, 265

  Venereal diseases,
    prevalence of, 213, 214, 215

  _Verwachsungstheorie_, 76

  Viability of the fetus, 54, 114

  Vital principle, 58, 61

  Vital processes, 69


  Weak pains, 171

  Weismann's theories, 49, 56


  Yellow atrophy of the liver, 186

  Yolk sac, 52




                        ("Think")

"_Thoughts are the Masters and the Thinkers are the
                  Doers._"--_Confucius._

One of the most successful of teachers is a Montreal
Principal--successful because she insistently teaches undergraduates
to THINK. Force of thought is better than force of will. A triphammer
is all force, but unless guided by a THINKER strikes a pile or
a cream-puff with equal power. Then there is the nagger with a
tongue-will of poiseless perpetual power but--thought-proof.

     Do you as host, hostess or guest want a spur to cleverness of
     thought, wit and repartee?

     Do you fail in clearness of thought and expression--especially
     in conversation?

     Do you teach, preach--or lecture?

     Do you dictate at home(?) at office--or both?

     Do you want to give straight-to-the-point advice to your
     children, your friends, your employees and YOURSELF?

     If an employer you will commend KEYSTONES OF THOUGHT to your
     employees--surely to the stenographers.

     If easily discouraged, a victim of worry, fear, the blues,
     "Keystones" is your prescription.

     Is Christianity a Failure? Have you an active or passive grouch
     against the clergy (a now fashionable disease usually confined
     to the middle aisle) because of "what they say and do and
     because of the way they live"?

Do you want something to "crib" for public dinners and other
occasions? The "greatest after-dinner speaker in the world" is a
New Yorker. Never lengthy, always aphoristic, he says more in five
minutes than all the "wax-works" on the dais drone or spout in hours.


                           THEN READ

                     KEYSTONES _of_ THOUGHT

               By AUSTIN O'MALLEY, M.D., Ph.D., LL.D.

The only book of original and genuine aphorisms in English. Written
   by "the World's master of aphoristic thought and expression."

     "_The successful aphorist is about ten thousand times scarcer
     than the successful essayist, or story teller, or Assyriologist.
     Humor without effort, wit without bitterness, philosophy without
     pretension! Dr. O'Malley has written a book that is worth
     possessing._"--_From a review of the book written by the editor
     of the N. Y. Sun himself._

               Special gift book edition, suède, gold
     edges, in box--a very useful ornament for Den, Desk, or Drawing
     Room, $4.00 net, Postpaid. Cloth, gold letters and design, $2.00
                            net, Postpaid.

NOTE: Whether young or old, Sage or Seer, Poet, Philosopher, or
what-not, if you think YOU can match KEYSTONES OF THOUGHT in
aphoristic originality, in depth, deftness, wit, wisdom and humor--in
tonic-cheer for all of life's worries, troubles and adversities, you
are welcome to try. If successful The Devin-Adair Company will send
you a check for an acceptable but well-earned sum, and your work will
be promptly published.


                THE DEVIN-ADAIR COMPANY, Publishers

                   437 FIFTH AVENUE, NEW YORK




       *       *       *       *       *




Transcriber's note:

Variations in spelling, punctuation and hyphenation have been
retained except in obvious cases of typographical error.

The symbol of a Maltese cross precedes "JOHN CARDINAL FARLEY".

Page 151: "3. The case may be inoperable and the child inviable."
The word "be" was added by the transcriber.

Page 194: Footnote 145 "_Ibid._, 1970, vol. l, pp. 430, 516,
and vol. li, p. 11." The transcriber has changed 1970 changed to 1870.

Page 215: A missing anchor was added by the transcriber for Footnote
170 "_New York Med. Jour._, November 12, 1910."

Page 222 Footnote 185 "_Correspondenz-Blatt f. Schweizer Aertze_"
The transcriber has changed "Aertze" to "Aerzte".