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diff --git a/42764-0.txt b/42764-0.txt index 3a60beb..116b62f 100644 --- a/42764-0.txt +++ b/42764-0.txt @@ -1,40 +1,4 @@ -The Project Gutenberg eBook, The Ethics of Medical Homicide and -Mutilation, by Austin O'Malley - - -This eBook is for the use of anyone anywhere at no cost and with -almost no restrictions whatsoever. 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You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - - - - -Title: The Ethics of Medical Homicide and Mutilation - - -Author: Austin O'Malley - - - -Release Date: May 22, 2013 [eBook #42764] - -Language: English - -Character set encoding: ISO-8859-1 - - -***START OF THE PROJECT GUTENBERG EBOOK THE ETHICS OF MEDICAL HOMICIDE AND -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_). - - Text enclosed by plus signs is transliteration of Greek - (example: +kai exelthê+). - - 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 Pharmacopoeia. 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 thewomb, 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] +kai exelthê paidion autês mê exeikonismenon+--not moulded - out into form; +exeikonizein+, to mould out into form: +eikôn+, - 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] +hê psychê estin entelecheia hê prôtê sômatos physikou - organikou dunamei zôhên echontos+ (_De Anima_, ii, 1). - -A form fixes a thing in its proper 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,[58a] 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. 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You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at <a -href="http://www.gutenberg.org">www.gutenberg.org</a></p> -<p>Title: The Ethics of Medical Homicide and Mutilation</p> -<p>Author: Austin O'Malley</p> -<p>Release Date: May 22, 2013 [eBook #42764]</p> -<p>Language: English</p> -<p>Character set encoding: UTF-8</p> -<p>***START OF THE PROJECT GUTENBERG EBOOK THE ETHICS OF MEDICAL HOMICIDE AND MUTILATION***</p> <p> </p> -<h4>E-text prepared by Dianna Adair, Julia Neufeld,<br /> - and the Online Distributed Proofreading Team<br /> - (<a href="http://www.pgdp.net">http://www.pgdp.net</a>)<br /> - from page images generously made available by<br /> - Internet Archive/Canadian Libraries<br /> - (<a href="http://archive.org/details/toronto">http://archive.org/details/toronto</a>)</h4> <p> </p> <table border="0" style="background-color: #ccccff;margin: 0 auto;" cellpadding="10"> <tr> @@ -13088,360 +13072,6 @@ for an explanation of the act with a double effect.</p></div> <p> </p> <p> </p> -<hr class="pg" /> -<p>***END OF THE PROJECT GUTENBERG EBOOK THE ETHICS OF MEDICAL HOMICIDE AND MUTILATION***</p> -<p>******* This file should be named 42764-h.txt or 42764-h.zip *******</p> -<p>This and all associated files of various formats will be found in:<br /> -<a href="http://www.gutenberg.org/dirs/4/2/7/6/42764">http://www.gutenberg.org/4/2/7/6/42764</a></p> -<p> -Updated editions will replace the previous one--the old editions -will be renamed.</p> - -<p> -Creating the works from public domain print editions means that no -one owns a United States copyright in these works, so the Foundation -(and you!) can copy and distribute it in the United States without -permission and without paying copyright royalties. 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You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - - - - -Title: The Ethics of Medical Homicide and Mutilation - - -Author: Austin O'Malley - - - -Release Date: May 22, 2013 [eBook #42764] - -Language: English - -Character set encoding: ISO-646-US (US-ASCII) - - -***START OF THE PROJECT GUTENBERG EBOOK THE ETHICS OF MEDICAL HOMICIDE AND -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_). - - Text enclosed by plus signs is transliteration of Greek - (example: +kai exelthe+). - - 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 Pharmacopoeia. 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 spermatozoon 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 thewomb, 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] +kai exelthe paidion autes me exeikonismenon+--not moulded - out into form; +exeikonizein+, to mould out into form: +eikon+, - 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 spermatozoon 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 spermatozoon. -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 -spermatozoon 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 oogenesis and -spermatogenesis the phases of "Reduction," wherein the ovum and -spermatozoon 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 spermatozoon. 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 spermatozoon 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 spermatozoon, 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 spermatozoon 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 spermatozoon 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 spermatozoon 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 -spermatozoon 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 spermatozoon. -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 spermatozoon 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 Naegeli'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 preexisted 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] +he psyche estin entelecheia he prote somatos physikou - organikou dunamei zohen echontos+ (_De Anima_, ii, 1). - -A form fixes a thing in its proper 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, Hoeffding, 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, Naegeli, 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, Pflueger, 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 preexisting 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] _Intracellulare 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 preexisted 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. -Koelliker, Stoeckel, 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 spermatozoon 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,[58a] 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 Caille[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] _Muenchener 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 Medicale_, 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 Laekareforenings Foerhandlingar_, 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 microorganism, 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] _Muenchener 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 microorganisms 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 Muellerian 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. Kuestner 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 (Naegeli'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. Schlaefli 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 Saenger invented a suture -which would keep the uterine incision shut, and applied antisepsis. -Saenger'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. -Kuestner 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. Gynaekologie._ Leipsic, October 30, 1915. - - [108] _Muenchener 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, Kuestner -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 Mueller'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 intraabdominal 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 Charite 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 Theologique_, 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 fuer Geburtshuelfe_, 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 microorganism, 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 microorganism. 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] _Muenchener 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 preeclamptic 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. Duehrssen 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'Obstetrique et de Gynecologie_, 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 fuer Gynaekologie_, 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 fuer Geburtshuelfe und Gynaekologie_, xxxviii, - 2. Berlin. - - [125] _Muenchener medizinische Wochenschrift_, November 23, 1915. - - [126] _Centralbl. f. Gynaek._ 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 incoordinate 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 coordinate 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 reestablishes 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. Geburtshuelfe u. Gynaek._, 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] _Muenchener 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. Saenger 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. Kroenig 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] _Muenchener medizinische Wochenschrift_, 1904, vol. li, p. - 1676. - - [141] _L'Obstetrique_, 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] _These._ 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 Gynecologie._ 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 Med. 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, Kuettner 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 microorganisms 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 -spermatozoon 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 -incoordination 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, -tuboovarian abscess, tuboovarian 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, perioophoritis 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 oophoritis. The ovary then swells and -there is a tendency to the formation of retention and other cysts, -or an abscess of the ovary. A tuboovarian cyst is a hydrosalpinx -in communication with an ovarian retention cyst, and a tuboovarian -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 Fuerbinger 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, oophoritis, 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. Gynae._, 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] _Muenchener 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 oophorectomy. 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 oophorectomy 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 -oophorectomy 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 -oophorectomy. 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 Medic._, 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 Crede 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] _Muenchener 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, Lacorche 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 _Daemmerschlaf_, 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. Gynaekologie_, 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 -extraabdominal 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 Kroenig'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] _Gynaekol. 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 incoordination 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 Littre'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. Fuerbringer[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 Therapeutique Medico-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 oophorectomy 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] Rene 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 Theologique._ - - [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, Genicot, 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 Littre'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 -oophorectomy 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 -oophorectomy, 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 Theologique. Paris, 1914. - - Schmidt. Zeitschrift fuer 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 Med., 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 - - - _Daemmerschlaf_, 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 - - Spermatozoon, 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, suede, 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. 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