file which includes the original illustrations4 ,see #dbgfd-;h4htm or #dbgfd-;h4zip3 7https3_/_/www4gutenberg4org_/cache_/epu b_/#dbgfd_/pg#dbgfd-;images4html7 or 7https3_/_/www4gutenberg4org_/files_/#db gfd_/dbgfd-;h4zip7 ,images of the original pages are available through ,internet ,archive_/,canadian ,libraries4 ,see http3_/_/archive4org_/details_/theethics ofmedic#jjomaluoft ,transcriber's note3 ,text enclosed by underscores is in italics 7italics74 ,small capital text has been replaced with all capitals4 ,the text 7page #bcd7 contains one chemical formula in which the numbers enclosed in curly braces are subscripted 7,c#ag;,h#ba,,no#d74 ,,the ,,ethics ,,of ,,medical ,,homicide ,,and ,,mutilation by ,,austin ,o',,malley1 ,m4,d41 ,,ph4,d41 ,,ll4,d4 ,illustration3 printer logo ,new ,york ,the ,devin-,adair ,company #aibb ,nihil obstat ,arthur ,j4 ,scanlan1 ,s4,t4,d4 ,censor ,librorum ,imprimatur see ,transcriber's note below ,,john ,,cardinal ,,farley ,archbishop of ,new ,york ,copyright1 #aiai1 by ,the ,devin-,adair ,company ,all ,rights ,reserved by ,the ,devin-,adair ,company ,third ,printing ,printed in ,u4,s4,a4 ,,contents ,,chapter ,i ,,general ,,principles ,,concerning ,,suicide ,,and ,,homicide ,,page ,there is a ,supreme ,being who alone is master of life4 ,the ,natural ,law4 ,the nature and determinants of morality4 ,probabilism4 ,permissive suicide4 ,suicide is illicit4 ,conscience4 ,homicide1 direct and indirect4 ,self-defence4 ,formal and material aggressors4 ,legalized homicide4 ,bibliography #a-bb ,,chapter ,,ii ,,general ,,principles ,,concerning ,,mutilation ,mutilation4 ,canonical irregularity4 ,self-mutilation4 ,the double effect in morality4 ,direct and indirect mutilation4 ,the ,state and mutilation4 ,the dominion of the ,state #bc-cb ,,chapter ,,iii ,,when ,,does ,,human ,,life ,,begin8 ,ancient and modern opinions4 ,the fetus is animated at the moment of conception4 ,the single cell as the primal life-organ4 ,cell growth and division4 ,germ cells4 ,the development of the embryo4 ,fetal viability4 ,theories of development4 ,the ,aristotelian and ,thomistic opinions4 ,the formal principle4 ,a soul exists4 ,the primordial cell is a sufficient organ for the soul4 ,metabolism in the cell4 ,cell motion4 ,animal heat and energy4 ,life in separated tissues4 ,the soul in monsters #cc-hb ,,chapter ,,iv ,,when ,,does ,,human ,,life ,,end8 ,the heart and life4 ,resuscitation after apparent death4 ,the last sacraments in apparent death4 ,suspended animation4 ,the living fetus in the womb of a dying or dead mother4 ,methods of resuscitation4 ,signs of death #hc-ia ,,chapter ,v ,,abortion ,abortion and miscarriage4 ,causes of abortion1 fetal1 maternal and paternal4 ,surgical operations and abortion4 ,the debitum in pregnancy4 ,premature labor4 ,threatened1 inevitable1 and incomplete abortions4 ,treatment4 ,the use of the tampon4 ,precautions against abortion4 ,therapeutic abortion4 ,methods of inducing abortion4 ,artificial abortion of an inviable fetus is never licit4 ,decrees of the church concerning abortion4 ,the civil law on abortion #ib-abc ,,chapter ,,vi ,,ectopic ,,gestation ,ectopic gestation or extrauterine pregnancy4 ,anatomy of the uterus and its adnexa4 ,place of fecundation4 ,the abnormal uterus4 ,tubal rupture and tubal abortion4 ,diagnosis4 ,decrees of the church on ectopic gestation4 ,removal of an inviable ectopic fetus except in present peril of life is illicit #abd-acb ,,chapter ,,vii ,,cesarean ,,delivery ,indications for cesarean delivery4 ,abnormal pelves4 ,symphyseotomy4 ,varieties of cesarean delivery4 ,morality4 ,amputation of the uterus after cesarean delivery4 ,precautionary sterilization of a cesarean case is illicit #acc-adb ,,chapter ,,viii ,,placenta ,,praevia ,,and ,,abruptio ,,placentae ,nature and effects of placenta praevia4 ,treatment4 ,morality and methods of treatment4 ,abruptio placentae4 ,morality of fetal removal #adc-adf ,,chapter ,,ix ,,abdominal ,,tumors ,,in ,,pregnancy ,tumors blocking parturition4 ,fibroids or myomata4 ,ovarian tumors4 ,cancer4 ,effects and morality of operation #adg-aeb ,,chapter ,x ,,appendicitis ,,in ,,pregnancy ,occurrence4 ,time of operation4 ,diagnosis #aec-aed ,,chapter ,,xi ,,puerperal ,,insanity ,,and ,,sterilization ,causes4 ,varieties4 ,prognosis4 ,precautionary sterilization of puerperal psychopaths is illicit #aee-aeg ,,chapter ,,xii ,,nephritis ,,in ,,pregnancy ,frequency4 ,effects4 ,abortion as a treatment4 ,varieties of nephritis4 ,pyelitis4 ,catalepsy #aeh-afa ,,chapter ,,xiii ,,eclampsia ,,parturientium ,definition4 ,symptoms4 ,prognosis4 ,causes4 ,precautions against eclampsia4 ,forced delivery4 ,the expectant treatment4 ,relative mortality and morality of the methods4 ,cesarean delivery as a treatment4 ,the expectant treatment is apparently the best #afb-afi ,,chapter ,,xiv ,,heart ,,diseases ,,in ,,pregnancy ,factors in abnormal gestation4 ,the use of pituitrin4 ,weak pains and the diseased heart4 ,the diseased heart in actual parturition4 ,operative risk in cardiopaths4 ,heart block and mitral regurgitation in labor4 ,prognosis #agj-agf ,,chapter ,,xv ,,hyperemesis ,,gravidarum ,pernicious vomiting4 ,occurrence4 ,symptoms4 ,stages4 ,effects4 ,causes4 ,therapeutic abortion in pernicious vomiting4 ,treatment #agg-aha ,,chapter ,,xvi ,,chorea ,,gravidarum ,,and ,,hysteria ,varieties of chorea4 ,differentiation4 ,prognosis4 ,hysteria4 ,causes4 ,epidemics of hysteria4 ,symptoms4 ,prognosis #ahb-ahf ,,chapter ,,xvii ,,acute ,,yellow ,,atrophy ,,of ,,the ,,liver ,,in ,,pregnancy ,icterus gravis4 ,causes4 ,symptoms4 ,prognosis #ahg-ahh ,,chapter ,,xviii ,,infectious ,,diseases ,,in ,,pregnancy ,effects on mother and fetus4 ,abortions in infectious diseases4 ,placental permeability4 ,typhoid4 ,smallpox4 ,pneumonia4 ,influenza4 ,scarlatina4 ,measles4 ,cholera4 ,tuberculosis4 ,artificial abortion in tuberculosis #ahi-bjj ,,chapter ,,xix ,,syphilis ,,in ,,pregnancy ,,and ,,marriage ,prognosis4 ,abortion4 ,infection of mother and fetus4 ,colles' ,law4 ,erroneous notions on the curability of syphilis4 ,once a syphilitic probably always a syphilitic4 ,the professional secret in syphilis4 ,nature of secrets4 ,the physician may warn an innocent person #bja-baa ,,chapter ,,xx ,,gonorrhoea ,,in ,,marriage ,the cause of gonorrhoea4 ,tests of cure4 ,effects on a woman4 ,chronicity4 ,prevalence4 ,surgical treatment in women4 ,morality of the surgical treatment4 ,conservative surgery4 ,salpingotomy4 ,ovariotomy4 ,evil effects of ovariotomy4 ,internal secretion of the ovary4 ,results of various operations4 ,pregnancy after operation4 ,morality of infection4 ,general effects of gonorrhoea4 ,ophthalmia neonatorum and gonorrhoea #bab-bbi ,,chapter ,,xxi ,,diabetes ,,in ,,pregnancy ,fatality of diabetes in pregnancy4 ,diagnosis4 ,sterility of diabetics4 ,prognosis4 ,heredity in diabetes4 ,therapeutic abortion in diabetes #bcj-bca ,,chapter ,,xxii ,,childbirth ,,in ,,twilight ,,sleep ,twilight sleep to avert pain in parturition4 ,stages of labor4 ,drugs used4 ,scopolamine and morphine4 ,danger in the use of these drugs in labor4 ,contradictory report of physicians on twilight sleep4 ,eminent authorities opposed to the methods4 ,baer's report on the evil effects4 ,the methods are morally illicit and useless #bcb-bdd ,,chapter ,,xxiii ,,vasectomy1 ,,or ,,sterilization1 ,,by ,,state ,,law ,the ,states that have this law4 ,reasons for the law4 ,hereditary transmission of certain diseases4 ,the operation4 ,its effects4 ,restoration of the function of the interrupted vas deferens4 ,vasectomy and impotence4 ,onanism4 ,vasectomy effects impotence from the moral point of view4 ,other conditions in the male that effect moral impotence4 ,immorality of artificial impregnation4 ,vasectomy a grave mutilation4 ,vasectomy as ordinarily practised is illicit4 ,the ,state and vasectomy4 ,the limitations of the ,state's dominion4 ,the ,state surgeon and vasectomy4 ,bibliography #bde-bfh ,,chapter ,,xxiv ,,the ,,ethics ,,of ,,birth ,,control #bfi ,index #bha ,,preface ,in this book is discussed the morality involved in the ordinary cases of medical homicide and mutilation4 ,craniotomy has been omitted because this operation on the living child is never morally licit1 and when done on the dead fetus it has no moral quality that requires explanation4 ,the articles may seem to be intended for ,catholic physicians and spiritual directors alone1 but the desire in writing them was to reach all practitioners1 to the end that the ,natural ,law which binds every man may be observed4 ,morality is not made such in its fundamental principles by any religious creed1 but by the requirements of ,divine ,order1 which finally prevails no matter what the opposition4 ,killing and maiming without sufficient extenuation did not become unlawful solely by the establishment of ,christianity4 ,practically1 however1 physicians who have no religion1 or a religion which is so illogical as to pay no attention to dogma1 or even to rail at it as obtrusive1 necessarily gravitates to the emotional in morality1 and the principles of this book will not even interest them4 ,dogmas are abstract propositions1 and all human society rests on abstract propositions4 ,the most vital facts in morality1 the basic distinction between crime and all that is virtuous or indifferent morally1 is in abstract principle alone1 but physicians and pastors who are not trained in philosophy and rational religion cannot appreciate an abstract principle--they are influenced only by the concrete4 ,obstetrical text-books1 unfortunately1 are written by such emotional men2 by men who lack all training in ethics other than that inculcated in childhood out of the mental vagaries of the women in the household2 and these authors prescribe therapeutic homicide as if it were a drug in the ,american ,pharmacopia4 ,the reader is told that if the patient is a ,catholic he is to respect her religious prejudices2 if she is not a ,catholic one need not bother about moral scruples when it is necessary to take a life to stop fits4 ,since the civil law does not prosecute a physician for therapeutic abortion on an inviable child1 most physicians deem such an act not only permissible but scientific1 and they hold that if a man's conscience will not let him kill a fetus to alleviate maternal distress he is guilty of malpractice4 ,decrees of the ,catholic ,church are cited in these pages1 not because morality is an asset of the ,catholic ,church alone1 but because it alone pronounces officially on these medical subjects after careful consideration by competent specialists4 ,this ,church has made decisions in comparatively few medico-moral cases1 and the questions still undecided authoritatively are very numerous4 ,they are quite difficult1 too1 because judgment supposes a knowledge of both medicine and ethics1 a combination seldom found in one person4 ,as physicians do not know ethics1 and moralists do not know medicine1 there is often trouble in getting at even a statement of the questions at issue between them4 ,in the preface to ,essays in ,pastoral ,medicine1 in #aijf1 ,i mentioned a noted case of this kind1 and in #aiaa a similar incident occurred in a discussion of the morality involved in the sterilization of criminals and the defective by the state4 ,this dispute was taken up by the leading canonists and moral theologians in the ,united ,states1 ,belgium1 ,holland1 ,austria1 ,spain1 ,italy and ,france1 and for nearly two years these men wrote article after article based upon utterly erroneous physical data4 ,the books we have on medico-moral subjects are either obsolete at present1 or insufficient2 or1 more commonly1 they are the work of amateurs in medicine4 ,these last are worthless when they are not harmful4 ,if1 however1 ,i may judge from the questions sent to me for answer by clergymen and physicians from all parts of the country1 our theological seminaries and medical schools are in grave need of courses on the morality of medical practice4 ,in this book1 to the preparation of which ,i have given years of anxious thought because of the extreme responsibility involved in its decisions1 the data for the most important parts of such courses are presented4 ,,austin ,o',,malley4 ,,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 recurs1 and the opinions of those in favor of putting the patient out of his misery are expressions of mere sentimentality1 as in ,maeterlinck's essay1 ,our ,eternity4 ,they think either that the passing of a law by a legislature removes all moral difficulty1 or that morality is a trifle which should never stand in the way of expediency4 ,those who oppose this method of euthanasia base their argument1 first1 on the fact that many patients supposed by even clever diagnosticians to be incurable recover health2 and1 secondly1 on the fact that the giving power of life and death to physicians is liable to grave abuse4 ,this side misses the central truth and argues from accidental and secondary premises4 ,whether it is expedient1 humane1 or impolitic to kill incurable patients are almost irrelevant considerations3 the fundamental question to be answered here is1 ,is there a ,supreme ,being who alone is master of life1 to give it or to take it8 ,by its very definition such a ,being is necessary 7as opposed to contingent71 self-existent2 its essence always has been and always will be actualized into existence1 and that from itself alone2 it is an individual substance of an intelligent nature1 and therefore a person4 ,a contingent being is one that happens to be 7contingere72 it is of necessity neither existent nor non-existent2 it has no logical aversion to existence1 but in itself it has no more than a possibility of actuality4 ,a necessary ,being1 on the contrary1 essentially must be2 it cannot not be2 it is absolutely and essentially its own existence4 ,there must be such a ,necessary ,being4 ,if there were not1 all things would be contingent1 which is an absurdity4 ,the absurdity arises from the fact that if all things were contingent nothing would be actual1 nothing could ever come into existence1 because there would be nothing to bring the primitive potentiality of the contingent beings into actual existence4 ,the sufficient reason for the existence of contingent beings is either in themselves or in something outside themselves4 ,it cannot be in themselves1 because as they do not yet exist they are nothing2 therefore it is in a ,being which is not contingent1 but whatever is not contingent is necessary4 ,therefore the existence of contingent beings absolutely requires the existence of a ,necessary ,being1 which always was in existence4 ,the ordinary name for this ,necessary ,being is ,god4 ,contingent beings are all creatures1 all organic and inorganic beings without exception4 ,there is1 then1 a ,god1 the first cause or creator of all contingent beings1 among whom is man2 and since ,god created man wholly1 this creature is wholly subservient to ,god1 under the dominion of ,god1 and his life is owned solely by ,god2 ,god alone is the master of life and death1 and he alone can delegate such mastery4 ,from the relation between the ,creator and the creatures arises the natural law4 ,violation of this law is the source of all moral evil in the world1 and of much of the physical evil4 ,reason shows us this law1 and the method of observing it2 and reason and unreason1 observance or disregard1 of the order fixed by the natural law are the foundation of happiness and unhappiness4 ,whatever a human being is or does1 he must seek happiness2 that is an essential quality of his being4 ,happiness is the satisfying of our desires2 but as our desires are limitless1 only infinite good can satisfy them4 ,the sole sufficient good that sates all human longing is the infinite ,necessary ,being1 and to be happy we must be united with that ,being4 ,obviously the only possible method of possessing this infinite ,god is through mental union1 by undisturbable contemplation of his infinite truth1 goodness1 being1 beauty1 and his other attributes4 ,if perfect1 everlasting happiness is not in that1 in what can it be8 ,is it in human fame1 honor1 riches1 science1 art1 man1 woman1 or child8 ,none of these can give lasting happiness1 and no other happiness is real happiness4 ,now1 the only means we have to obtain union with infinite good is to follow out the condition inexorably placed by ,god1 which is to act in life in keeping with right reason1 to obey the law4 ,man's supreme honor is in freedom from the tyranny of unreason1 and in a full obedience to external and immovable order1 with the belief that his chief duty is to apprehend and to conform thereto4 ,this is morality4 ,from the beginning men have held that certain acts are wrong and to be avoided1 and that others are to be done4 ,what is wrong1 moreover1 is such of its own nature1 not from our will3 we deem the fulfillment of duty1 obedience to law1 the first1 highest1 and last necessity of life4 ,if we deny this truth we let in chaos4 ,what is right or wrong is one or the other on its own merits1 prescinding from its pleasurableness or pain4 ,we must seek good whether we will or not4 ,good is the sole object upon which the will operates1 it is the raw material of the will's business4 ,the ultimate standard of this good is ,god himself as its exemplary cause1 but proximately the standard of moral good is our rational nature4 ,through our reason we judge whether a thing is good or bad2 that is1 whether it perfects or injures us2 and as it is good or bad for us our will's tendency toward it is good or bad4 ,many acts are indifferent in themselves1 but take on a good or bad quality from our intention2 others are good or bad in themselves apart from our volition3 charity is good1 lying is bad1 whether they are willed by us or not4 ,the morality of any action is determined 7#a7 by the object of the action2 7#b7 by the circumstances that accompany the action2 7#c7 by the end the agent had in view4 #a4 ,the term object has various meanings1 but here it means the deed performed in the action1 the thing which the will chooses4 ,that deed by its very nature may be good1 or it may be bad1 or it may be indifferent morally4 ,to help the afflicted is in itself a good action1 to blaspheme is a bad action1 to walk is an indifferent action4 ,some bad actions are absolutely bad2 they never can become good or indifferent--blasphemy or adultery1 for example2 others1 as stealing1 are evil because of a lack of right in the agent3 these may become indifferent or good by acquiring the missing right4 ,others are evil because of the danger necessarily connected with their performance1--the danger of sin connected with them1 or the unnecessary peril to life4 ,an action1 to have a moral quality1 must be voluntary1 deliberate2 and mere repugnance in doing an act does not in itself make the act involuntary4 #b4 ,circumstances sometimes1 though not always1 may add a new element of good or evil to an action4 ,the circumstances of an action are the ,agent1 the ,object1 the ,place in which the action is done1 the ,means used1 the ,end in view1 the ,method observed in using the means1 and the ,time in which the deed is done4 ,if a judge in his official capacity tells a sheriff to hang a criminal1 and a private citizen gives the same command1 the actions are very different morally because of the circumstance of the agent giving the command4 ,the object--it changes the morality of the deed whether one steals a cent or a thousand dollars4 ,the place--what might be an offensive action in a residence might be a sacrilege in a church4 ,the means--to support a family by labor or thievery4 ,the end in view--to give alms in obedience to divine command or to give them to buy votes4 ,the method used in employing the means--kindly1 say1 or cruelly4 ,the time--to do manual labor on ,sunday or on ,monday4 ,some circumstances aggravate the evil in a deed1 others excuse or attenuate it4 ,others may so color the deed that they specify it1 make it some special virtue or vice4 ,the circumstance that a murderer is the son of the man he kills specifies the deed as parricide4 #c4 ,the end also determines the morality of an action4 ,since the end is the first thing in the intention of the agent1 he passes from the object wished for in the end to choosing the means for obtaining it4 ,without the end the means cannot exist as such4 ,there are occasions when an end is only a circumstance3 for example1 if it is a concomitant or extrinsic end4 ,when this extrinsic end is in keeping with right reason or when it is discordant thereto1 it may become a determinant of morality4 ,in every voluntary1 or human1 act there is an interior and exterior act of the will1 and each of these acts has its own object4 ,the end is the proper object of the interior act of the will2 the exterior object acted upon is the object of the exterior act of the will2 both specify the morality1 but the interior object or end specifies more importantly1 as a rule1 than the exterior object does4 ,the will uses the body as an instrument on the external object1 and the action of the body is connected with morality only through the will4 ,we judge the morality of a blow not by the physical stroke1 but from the intention of the striker4 ,the exterior object of the will is1 in a way1 the matter of the morality1 and the interior object of the will1 or the end1 is the form4 ,aristotle said3 ,he that steals to be able to commit adultery is more of an adulterer than a thief4#a ,the thievery is a means to the principal end1 and this principal end chiefly specifies or informs the action4 #a ,ethics1 v1 c4 #b4 ,the means used to obtain an end are very important in a consideration of the morality of an act4 ,there are four classes of means--the good1 bad1 indifferent1 and excusable4 ,good means may be absolutely good1 but commonly they are liable to become vitiated by circumstances1--almsgiving is an example4 ,some means are bad always and inexcusable--lying1 for instance4 ,the excusable means are those which are bad1 but justifiable through circumstances4 ,to save a man's life by cutting off his leg is an excusable means4 ,the end sometimes may vitiate or hallow indifferent means1 but it does not in itself justify all means4 ,means1 like other circumstances1 are accidents of an action1 but they are in the action just as much as color is in a man4 ,color is not of a man's essence1 but we cannot have a man without color4 ,the effect of an action1 the result or product of an effective cause or agency1 may in itself be an end or an object or a circumstance1 and it has influence in the determination of morality4 ,sometimes an act has two immediate effects1 one good and the other bad4 ,for example1 ligating the blood-vessels going to the uterus to stop a hemorrhage and so save a woman's life1 a good effect1 has also in ectopic gestation while the fetus is living another immediate effect1 namely1 to shut off the blood supply from the fetus and so kill it1 a bad effect4 ,to make such a double-effect action licit there are four conditions which are explained in the chapter on ,mutilation4 ,the doctrine of ,probabilism is very important in morality4 ,any law must be promulgated before it really becomes a law1 and promulgation in a rational conscience is sufficient4 ,sometimes there is rational doubt of the existence1 the interpretation1 or the application of a law in a given case4 ,here probability is the only rule we can follow4 ,a law which is doubtful after honest and capable investigation has not been sufficiently promulgated1 and therefore it cannot impose a certain obligation because it lacks an essential element of a law4 ,when we have used such moral diligence as the gravity of the matter calls for1 but still the applicability of the law is doubtful in the action in view1 the law does not bind2 and what a law does not forbid it leaves open4 ,probabilism is not permissible where there is question of the worth of an action as compared with another1 or of issues like the physical consequences of an act4 ,if a physician knows a remedy for a disease that is certainly efficacious and another that is doubtfully efficacious1 he may not choose this probable cure4 ,probabilism has to do only with the existence1 interpretation1 or applicability of a law1 not with the differentiation of actions4 ,the term probable means provable1 not guessed at1 not jumped at without reason4 ,the doubt must be positive1 founded on reason1 not a matter of mere ignorance1 suspicion1 emotional bias4 ,the opinion against a law to permit probabilism must be solid4 ,it must rest upon an intrinsic reason from the nature of the case1 or an extrinsic reason from authority1 always supposing the authority is really an authority4 ,the probability is to be comparative also4 ,what seems to be a very good reason when standing alone may be weak when compared with reasons on the other side4 ,when we have weighed the arguments on both sides1 and we still have a good reason for holding our opinion in a doubtful case1 our opinion is probable4 ,the probability is1 moreover1 to be practical4 ,it must have considered all the circumstances of the case4 ,there is1 then1 a ,supreme ,being whom we must obey1 who created and owns human life primarily2 there is also a moral law4 ,on these facts rests the argument relating to the destruction of human life4 ,how far1 then1 has a human being dominion over his own life1 and1 secondly1 over the life of any one else8 ,st4 ,thomas1#b ,lessius1#c and others offer as one argument to prove suicide is not licit1 that it is an injury to society or the state of which the suicide is part1 and to which the use and profit of his service rightly belong4 ,lessius1 while developing this proof1 acknowledges its weakness4 #b ,summa ,theologica1 #a1 #b1 q4 #fd1 a4 #e4 #c ,de ,justitia et ,jure1 lib4 #b1 cap4 #i4 ,if there were only one man in the world1 and no society or state1 suicide would still be illicit1 because its basic deordination lies deeper than society or the state4 ,if suicide were a moral evil solely because it deprives the state of the suicide's life1 then for the same reason no one might become a citizen of another state1 emigrate1 nor might man abandon society and live as a recluse4 ,moreover1 if a man were detrimental to the state rather than beneficial1 in this point of view that fact alone would justify suicide1 and the state would then be justified in permitting or even commanding suicide2 and we shall show later that the state has not this power4 ,it is true that the injury done the state or society by loss of use and profit1 by scandal and similar evils1 is a solid argument against suicide1 as such injury aggravates the deordination of suicide1 but in itself the injury done to the state and society is not the fundamental reason against suicide4 ,st4 ,thomas#d argues against suicide because it is contrary to the charity a human being should have for himself4 ,this is true ordinarily1 and suicide takes on part of its guilt just because it is an offence against the rational regard a person should have for himself2 yet this argument is not basic4 ,we are told that if one sins against charity in killing his neighbor1 a fortiori he sins in killing himself4 ,yet suppose just what the advocates of euthanasia suggest1 viz41 that a neighbor is in great agony and incurable3 then the act of killing him takes on a quality of charity rather than of uncharity4 ,and so for the suicide3 if the patient is willing to be killed1 there would be no uncharity2 if he were unwilling1 then homicide in any form would be uncharitable and unjust4 ,the argument from charity1 therefore1 is too narrow to fit the whole case2 and its very weakness is a source of error for the advocates of euthanasia4 #d ,ibid4 ,still another argument is often advanced against suicide1 viz41 that a man is obliged to love his own life1 since it is the foundation1 or the necessary condition1 to him1 of all good and every virtue1 and this circumstance makes the destruction of that life unlawful4 ,that argument has solid truth1 but if it held absolutely it would prevent us from desiring death in any case1 and no one denies that there are conditions in which a desire for death is fully legitimate4 ,no desire for death1 however1 can give the slightest justification for the destruction of life4 ,again1 the argument that suicide is cowardice is not broad enough4 ,fortitude is a mean between fear and rashness1 and this argument maintains that the suicide sins against fortitude by rashness4 ,if we have good reason it is not rash to expose ourselves to death2 the soldier may do so1 the person struggling to save a neighbor's life1 and so on2 it may be the highest form of fortitude thus to expose oneself to death4 ,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 act1 and at least be above cowardice4 ,this argument is one that can be turned at times so as to cut the fingers of the man that uses it4 ,the fundamental reason that suicide is not lawful is that man cannot be master of his own life1 and therefore he may not dispose of it as he pleases4 ,suicide is the direct killing of oneself on one's own authority4 ,a killing is direct when death is intended as an end1 or chosen as a means to an end4 ,direct killing is positive by commission1 or negative by omission4 ,in such cases the will directly rests in the death as a voluntary and free act4 ,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 end1 but concomitantly1 or as a consequence1 results in death4 ,in such case death is an accidental effect1 and comes indirectly from the activity of the will--it is not necessarily voluntary4 ,if one has a right to do that other deed1 or if it is his duty to do it1 and there is a proportion between it and his life1 he may do the deed and permit the consequent death4 ,a direct homicide may be done on one's own authority1 or on that of another person4 ,it is done on one's own authority if the agent assumes a natural individual dominion over life1 and by virtue of such dominion directly kills himself or another2 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 law1 and in the name and on the authority of a positive divine or human legislator4 ,it is evident that ,god1 as ,creator1 has supreme dominion over human life1 and therefore by his positive authority he may command a man directly to kill himself4 ,god1 however1 does not by the natural law confer on man the right thus to kill4 ,the question here is of the natural duty or right which comes from the natural law alone4 ,direct suicide on one's own authority may happen in two ways3 positively1 that is1 by doing an act which is directly homicidal2 or negatively1 by omitting an act necessary for the preservation of life4 ,that a negative homicide be direct1 death must be intended as an end or means4 ,if1 however1 one voluntarily intends an end or a means1 but for the sake of antecedent good or evil omits some act necessary to preserve life1 his suicide is indirect1 per accidens1 and not always illicit unless there is a precept against just such an omission4 ,man has no dominion over his own life1 he has only the use of it2 and the natural law obliges us while using a thing which is under the dominion of another not to omit ordinary means for its preservation4 ,we are not1 however1 held to extraordinary means4 ,his own death is criminally imputable to him who negatively and indirectly kills himself by omitting the ordinary means for preserving his life1 because the precept he is under to preserve his own life makes his act voluntary4 ,if he omits extraordinary means1 the death is not criminally imputable to him because there is no precept obliging such means4 ,certain circumstances may by accident oblige one to use extraordinary means to preserve one's own life--a dependent family1 a public office in perilous times1 or the like4 ,the proposition1 then1 is3 ,the natural law does not give a man absolute dominion over his own life4 ,i4 ,the natural law gives no rights except such as are finally founded in human nature itself2 but human nature cannot give a title to dominion over one's own life2 therefore the natural law does not give man such a right4 ,every natural right is either congenital or acquired4 ,the title to a congenital right is human nature itself2 the title to an acquired right is some act consequent to the exercise of human activity4 ,the right to such exercise is1 in turn1 congenital and founded in human nature4 ,if nature established the title to dominion over one's own life it would thereby establish the power of destroying that life1 and thus of removing the fundamental title to all rights2 but nature exists as the foundation for rights1 not for the subversion of rights2 therefore human nature cannot give a final title to dominion over our own life4 ,again1 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 destruction1 but the direct contrary is the fact4 ,,ii4 ,the natural law cannot grant a right to man which is not a means to the common end of human life2 but absolute dominion over one's own life is not such a means1 therefore the natural law cannot give one dominion over his own life4 ,the natural law is only an ordination of man to that common end of human life and to the means toward that end4 ,as regards the minor of this second argument1 an absolute dominion over his own life would give man power to stop all his human activity1 yet the common end of human life is attainable only by man's activity4 ,the stopping1 or the power of stopping1 all activity cannot be a means to that end4 ,,iii4 ,the natural law cannot give man a power which is opposed to the essential needs of human nature itself2 but that a man should have absolute dominion over his own life is opposed to an essential need of human nature itself1 therefore the natural law cannot give such a power4 ,dominion over his own life implies the power in man of rebelling against the subjection which he owes to ,god2 but human nature essentially demands that man be in subjection to ,god1 since dominion over one's own life and subjection to ,god are contradictory4 ,again1 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 law4 ,a law1 however1 cannot give a power which nullifies itself4 ,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 act1 is irrelevant4 ,the injury in suicide is not to man at all1 but to ,god4 ,there is also nothing in the objection that a gratuitous gift may be renounced4 ,life is not a gratuitous gift2 it is an onerous gift with obligations inseparably affixed thereto which forbid the destruction of the gift4 ,,iv4 ,destruction is an act proper to a master alone4 ,man cannot be master of his own life2 he can have dominion of things that are outside himself1 distinguishable from himself1 but not of the very existence of himself1 which is not really distinguishable from himself4 ,the definition of dominion supposes relation4 ,the offices of master1 father1 magistrate1 are relative conditions which suppose superiority over another person1 not over oneself4 ,even ,god is not a superior over himself1 although he has all perfection4 ,for this reason a man cannot sell himself2 he can sell only his labor4 ,god1 who should have absolute dominion over all creatures1 and who has1 wills to confine these creatures to certain lines of action in keeping with the creature's nature4 ,this is the law underlying even the moral law when it touches humanity2 it is the eternal law coeternal with ,god's decree of creation1 but not necessary as ,god is4 ,when this law exists in the mind of ,god it is the eternal law2 when it exists in the minds of creatures it is the natural law1 governing the free acts of intellectual creatures4 ,when the natural law becomes a motive to the human will1 obliging but not forcing it1 a law through knowledge within the consciousness of a man regulating his behavior1 it is called the law of conscience4 ,conscience is an act1 a practical judgment on one's own action in some particular case4 ,it testifies1 accuses1 excuses1 restrains1 urges4 ,it is a rational faculty1 not an emotional1 sentimental power4 ,emotion blinds its judgments4 ,yet mere emotion1 and that foolish deordination of emotion called sentimentality1 are promptings which the ignorant mistake for conscience and obey4 ,conscience is the enlightened eye of the heart1 not the vagary of any appetite that blunders into action4 ,it must be educated2 left to itself1 it is guilty of all the perversions of the streets4 ,the natural law is immutable1 not subject to recall by every rascal under the goad of the flesh4 ,in morality what was1 is2 what was once right because reasonable1 always will be right and reasonable4 ,since opposition to the natural law as applied to man is repugnant to human nature1 no power can make opposition to that law licit4 ,for the same reason this law is not subject to evolution4 ,truth in morality is eternal4 ,what is ugly now was ugly a millennium ago2 what was immoral yesterday was immoral in the sixth century4 ,if our ancestors thought permissible what we know to be illicit1 our ancestors were ignorant2 the fact has not changed4 ,it was as immoral to steal1 lie1 or murder in the day of ,abraham as it is to-day4 ,the ultimate tendency of man is toward happiness1 and1 of course1 happiness1 or any other perfection1 is impossible without existence2 hence the instinctive recoil from the destruction of our life1 which is the requisite condition for happiness4 ,even those that abnormally destroy their own life do so with horror for the destruction itself1 and act thus unreasonably to escape evil1 not to escape life2 or they seek what they think will be a better life4 ,we can do no other injury to a man so great as the depriving him of his life1 for that deprivation destroys every right and possession he has4 ,he can recover from all other evil1 or hold his soul above every other evil1 but death is the absolute conqueror4 ,no matter how debased or how diseased a man's body may be1 no one may dissociate that body from its soul1 except in defence of individual or social life under peculiarly abnormal conditions2 but even such defence is permissible only while the defender respects other human life and the social life1 while he is innocent1 has done no harm to society commensurate with the loss of his own life4 ,the weariest and most loathed worldly life ,that age1 ache1 penury1 and imprisonment ,can lay on nature is a paradise ,to what we fear of death4 ,existence1 no matter how sordid1 is immeasurably better than non-existence1 for non-existence is nothing2 and when we consider eternal life after separation from the body1 even as a probability1 that raises existence to infinite possibilities above the void of non-existence4 ,a human life1 even in an ,australian ,bushman1 in a tuberculous pauper1 in the vilest criminal1 is in itself so stupendously noble a thing that the whole universe exists for its upholding toward betterment4 ,the raising of human life toward a higher condition has been the sole tendency of all the magnificent charity1 sacrifice1 patriotism1 and heroism the best men and women of the world since time began have striven in4 ,the necessary first cause itself is life1 and life is by far the most sacred thing possible for the first cause to effect4 ,eternal life is the greatest reward of the just4 ,it is not permissible under any possible circumstance directly to kill an innocent human being4 ,by killing directly is meant either 7#a7 as an end desirable in itself1 as when a man is killed for revenge2 or 7#b7 as a means to an end4 ,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 life4 ,to kill a human being is to destroy human nature1 by separating the vital principle from the body2 to destroy anything is to subordinate and sacrifice that thing absolutely to the purposes of the slayer2 but 7#a7 no one has a right so to subordinate another human being1 because man and his life are solely under the dominion of ,god4 ,if a man may not kill himself1 as we proved above1 because he is not master of his own life1 he surely may not kill another to whom he is no more closely related as master than he is to himself4 7#b7 ,no man has a right to subordinate another human being as is done in slaying him1 because this other human being is a person1 an intelligent nature1 and consequently free1 independent1 referring its operations solely to itself as to their centre4 ,this very freedom differentiates man from brutes and inanimate things4 ,these are not independent2 they are rightly possessed by man2 but man may be possessed by no one except ,god4 ,even extrinsic human slavery is abhorrent to us as a corollary of the intrinsic freedom of man1 which is absolute4 ,this intrinsic freedom is such that we may not under any circumstances lawfully resign it to another's possession4 ,this is one of the chief moral objections to oath-bound secret societies which exact blind obedience4 ,all morality depends on that freedom1 all peace in life1 all civilization1 and society itself4 ,the end of our struggles1 toil1 fortitude1 temperance1 thrift1 is freedom1--freedom to do and to hold1 freedom from the thraldom of vice and barbarity4 ,the rational endeavor of every civilized nation is that it be free2 and this means solely that every citizen thereof1 from the highest to the lowest1 is made secure in his rights as a human being4 ,it intends that justice should prevail4 ,nearly all the unhappiness1 crime1 moral misery1 and much of the physical misery in the world are due to a disregard for liberty1 for the safeguarding of men in their inalienable rights4 ,give every man his bare rights as a man and all troubles of capital and labor1 all race problems would cease1 the prisons would be empty1 war would be unknown4 ,our struggle toward justice1 toward the protection of the rights of man1 toward liberty1 must go on1 or anarchy and social destruction will ensue4 ,now1 as there is nothing greater and nobler than liberty1 the freedom of the sons of ,god to do what they have a right to do1 and as every human being has a right to that liberty1 so there is nothing baser than its contrary1 the destruction of that liberty2 and no destruction is so final as that of killing the man1 no usurpation so abhorrent to human nature and all liberty4 ,abhorrence for such a destruction is the primal instinct of all human beings2 even the irrational reflexes of our bodies react quickest in protecting us from that destruction4 ,justice and order must prevail2 that is a fundamental natural law to which all other laws are subordinate4 ,justice1 moreover1 is a moral equation1 and whenever one right transcends another it must be superior to the right it holds in abeyance4 ,the right an innocent human being has to his life1 however1 is so great that no other human right can be superior to it while he remains innocent4 ,subversion of this right by creatures is intrinsically evil1 as blasphemy and perjury are evil1 although not in exactly the same degree4 ,there are occasions upon which it is permissible to kill1 indirectly1 innocent persons4 ,an effect is brought about indirectly when it is neither intended as an end for its own sake1 nor chosen as means toward an end1 but is attached as a circumstance to the end or the means4 ,means help to an end1 circumstances often do not1 although they may affect the morality of an act4 ,suppose two swimmers1 ,peter and ,paul1 are trying to save ,thomas1 who dies in the water2 as he dies ,thomas grips ,peter and ,paul so tightly that they cannot shake the corpse off4 ,peter is weak1 and he will soon sink and drown1 owing to his weakness and the weight of the corpse2 ,paul also will go down later1 owing to the weight of ,peter and ,thomas4 ,peter1 however1 cuts his own clothing loose from the grip of the corpse and is saved2 but ,paul immediately is drowned1 owing to the fact that the full weight of the corpse comes upon him4 ,is ,peter justified in cutting himself loose8 ,certainly he is4 ,this is an example of indirect killing1 a case of double effect1 one good1 the saving of ,peter's life1 the other evil1 the loss of ,paul's life1 both proceeding immediately and equally from the causal act1 the cutting loose of the clothing4 ,the good effect is intended1 the bad effect is reluctantly permitted4 ,again1 let us set the same condition for ,peter1 ,paul1 and ,thomas2 but ,peter is not able to cut himself loose4 ,john1 a fourth person1 can cut ,peter loose and save him1 but can do no more2 he must let ,paul go down with the corpse of ,thomas4 ,may ,john cut ,peter loose8 ,certainly he may1 on the principle quod liceat per se licet per alium4 ,this is another case of double effect1 with the extenuating circumstances as above4 ,suppose1 however1 ,peter represents a living infant in the womb of ,ann1 and that she is in labor2 further1 this infant cannot be delivered owing to the contraction of ,ann's pelvis4 ,may ,john1 a physician1 cut away ,peter by craniotomy and so save ,ann's life8 ,certainly he may not4 ,john here directly brains ,peter to save ,ann1 although ,peter is not an unjust aggressor2 he does a murder to get a good effect1 and the end does not justify the means4 ,there are two effects1 but the good effect follows from the bad one1 and not immediately from the causal act4 ,take another example3 ,peter is a swimmer disabled by cramps and about to drown2 ,paul1 going to save ,peter1 is seized by ,peter1 and both are now in danger of drowning2 ,john goes to help ,peter and ,paul4 ,he cannot get ,peter's grip loose by ordinary means1 and he sees he can save only one man1 either ,peter or ,paul4 ,may ,john knock ,peter senseless to loosen his grip from ,paul1 bring in ,paul1 and thus leave ,peter to drown8 ,certainly he may4 ,you have the double effect here also4 ,moreover1 ,peter is a materially unjust aggressor2 he is like a maniac trying to kill ,paul4 ,in the craniotomy case the child is not a materially or formally unjust aggressor1 it is not doing anything at all4 ,it is where the mother put it1 and it has a full right to its position and its life4 ,john most probably might also knock ,paul senseless and save ,peter1 if through affection or similar motive he preferred this course4 ,he would then be justified by the double-effect principle alone1 although ,paul is in no sense an aggressor4 ,the intention of the blow would have to be solely to loosen ,paul's hold4 ,in a just war a commander may shell an enemy's works and indirectly thereby kill non-combatants4 ,the gunners that cause the death of the non-combatants do not intend this death2 they permit it as the evil effect which comes immediately with the good effect 7the capture of the works7 from the causal act of firing the guns4 ,if we keep within the bounds of a just defence we may protect ourselves against an unjust aggressor to the effusion of his blood1 or even1 if need be1 to killing him4 ,an aggressor is any one who does injury to us contrary to our rights and the ordination of right4 ,a formally unjust aggressor is a sane intelligent person who intentionally attacks us2 a materially unjust aggressor is one who is not intelligent1 not responsible1 as an insane person1 a child1 or a sane person who is injuring us unintentionally4 ,this question is important in medicine because the fetus in utero is often erroneously called an unjust aggressor4 ,it is a primary law of nature that every human being should and will strive to resist injury and destruction4 ,justice requires a moral equation1 and if one right prevails over another it must be superior to the right it supersedes4 ,at the outset both the aggressor and the intended victim have equal rights to life1 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 victim4 ,the moral power of the aggressor here is equal to his inborn right to life1 less the unrighteous use he makes of it2 while the moral power of the intended victim remains in its integrity1 and has therefore a higher juridic value4 ,the right of self-defence is not annulled by the fact that the aggressor is irresponsible4 ,the absence of knowledge saves him from moral guilt1 but it does not alter the character of the act considered objectively2 it is yet an unjust aggression1 and in the conflict the life assailed has still a superior juridic value4 ,in any case the right of wounding or of killing in self-defence is not based on the ill will of the aggressor1 but on the illegitimate character of the aggression4 ,the condition's of a blameless defence 7moderamen inculpatae tutelae7 are3 7#a7 that the aggressor really threatens the defender's life1 and there is no means of offsetting that violence except like violence2 7#b7 that no more violence is used than is adequately required3 if the aggression can be stopped by wounding the aggressor the defender is not to kill him2 7#c7 that the violence in the defence is used with the intention of defence1 not in revenge1 hatred1 anger1 or the like motives4 ,we may do an act good in itself from which a double effect immediately follows1 one good1 to which the agent has a right1 and the other bad1 which the agent is not obliged to omit if permitted by him and not intended2 but in the case of a necessary defence of life against an unjust aggressor1 made even with the death of the aggressor1 the defence is such an act1 provided the moderation of a blameless defence is observed4 ,the evil effect here is not a means to the good effect1 nor does it more immediately follow from the act done4 ,the evil effect is an effect per accidens1 and thus not directly voluntary1 either in itself1 because it is not intended1 or in its cause4 ,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 follows4 ,the act in the case is good in itself2 it is an application of physical force in defence of a proper right1 and any right supposes a compulsive power4 ,the two effects of this double-effect act are3 7a7 the preservation of the defender's life1 and 7b7 the death of the aggressor4 ,the first effect is good because the defender has a right to his own life2 the other effect is evil1 not only physically for the one who dies1 but morally inasmuch as the death conflicts with the dominion of ,god4 ,this death1 however1 is an accidental effect of the act1 because in general the defensive act is not directed by its nature to that death but to the preservation of the defender's life2 nor does the death follow more immediately than the preservation4 ,thus it is not a means of the defence4 ,finally1 the defensive act is not prohibited precisely lest that death follow3 not in justice1 for there is no justice in any right of the aggressor which requires from the defender an omission of defence unto the loss of life2 there is no obligation in charity1 since charity does not oblige us to love another more than ourselves1 or to exalt the good of another above our own4 ,in an aggression which is merely material--say1 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 defence4 ,the right of the aggressor yields to the superior right of the defender1 not through the fault of the aggressor but through his misfortune4 ,there is a collision where both rights cannot be exercised at the same time1 and there is no reason obliging the defendant to forego his own right4 ,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 right4 ,if the aggressor is our own father1 mother1 son1 or daughter1 or in general any one to whom charity obliges us more than to the person attacked1 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 blood4 ,ordinarily we are not obliged in justice or charity to defend another at the risk of our own life4 ,we may kill an unjust aggressor1 servatis servandis1 in defence of good equivalent in value to life3 for example1 to prevent life imprisonment1 the loss of reason1 a mutilation which would render us useless1 the loss of a woman's chastity4 ,there are cases of accidental homicide1 in medicine and elsewhere1 which have an element of guilt in them4 ,if a death follows accidentally upon an act which in itself is licit1 and the agent uses all proper precautions1 he is not morally guilty in case of an accidental death following his act4 ,this is true even if the agent foresaw a probable death but did not intend it4 ,if1 however1 the agent's primary act is illicit in itself1 and an accidental death follows from this act1 the agent may be guilty of homicide1 provided the first act in itself is naturally likely to cause homicide4 ,should the first act be always dangerous1 such that death commonly follows from it1 like rocking a row-boat1 aiming a supposedly unloaded gun at a person and pulling the trigger1 striking a pregnant woman1 drinking whiskey and then overlying an infant in the bed1 throwing building material from a roof to a street1 racing an automobile through a crowded thoroughfare1 sending a crew out in a rotten ship1 and so on1 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 death4 ,suppose1 secondly1 the original act of the agent is illicit but such that accidental death rarely follows from it2 then if he takes due precaution he is not ordinarily guilty of homicide4 ,he has1 say1 stolen an automobile1 and is going along the street leisurely1 when a careless child runs off the sidewalk under the machine and is killed4 #a4 ,no person1 then1 may hasten his own death or permit any one else to hasten it4 #b4 ,no physician may in any possible condition kill a patient merely to effect euthanasia4 #c4 ,the state has no more right than the physician to permit the killing of patients to bring about euthanasia4 ,were such permission given to physicians it would immediately be abused by men with even the best intentions4 ,in all countries and in the largest cities the medical profession is swarming with quacks4 ,what is done in crass ignorance by licensed physicians and specialists every day in the name of medicine is appalling4 ,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 physicians1 #ag per cent4 showed no disease at all1 and should not have been removed4 ,in this country the percentage of normal appendices removed because of vague abdominal pains is much larger4 ,the ,journal of the ,american ,medical ,association 7,june #g1 #aiac7 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 ratios3 ,diagnosis ,diagnosis correct4 incorrect4 ,per cent4 ,per cent4 ,diabetes ,mellitus #ie #e ,typhoid ,fever #ib #h ,aortic ,regurgitation #hd #af ,cancer of ,colon #gd #bf ,lobar ,pneumonia #gd #bf ,chronic ,glomerular ,nephritis #gd #bf ,cerebral ,tumor #gb4h #bg4b ,tuberculous ,meningitis #gb #bh ,gastric ,cancer #gb #bh ,mitral ,stenosis #fi #ca ,brain ,hemorrhage #fg #cc ,septic ,meningitis #fd #cf ,aortic ,stenosis #fa #ci ,phthisis1 ,active #ei #da ,miliary ,tuberculosis #eb #dh ,chronic ,interstitial ,nephritis #ej #ej ,thoracic ,aneurism #ej #ej ,hepatic ,cirrhosis #ci #fa ,acute ,endocarditis #ci #fa ,peptic ,ulcer #cf #fd ,suppurative ,nephritis #ce #fe ,renal ,tuberculosis #cc4c #ff4g ,bronchopneumonia #cc #ff ,vertebral ,tuberculosis #bc #gg ,chronic ,myocarditis #bb #gh ,hepatic ,abscess #bj #hj ,acute ,pericarditis #bj #hj ,acute ,nephritis #af #hd ,pneumonia is a very common disease1 extremely dangerous1 and by skilful treatment it is very often cured1 yet of these #ajj cases #ff were not diagnosed4 ,i recently saw a severe case of double pneumonia which a physician was treating as indigestion1 and he was giving pepsin tablets for the supposed indigestion4 ,there is such a thing as extraordinary scientific precision in medical work1 but it is rare2 the ordinary physician treats symptoms without knowing the cause of the symptoms2 that is1 the symptom-treater is a quack1 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 hands4 ,osteopaths and chiropractors are masseurs1 and they know very little of massage1 but they are licensed by legislatures to practise medicine1 and some of them even try obstetrical malpractice4 ,they1 too1 would be licensed to inflict euthanasia4 ,pure homeopathy is little more than a name at present2 it is faith-healing without prayer4 ,it attenuates its drugs #ajj per cent4 for thirty repetitions1 to a degree expressible by one with sixty ciphers4 ,consequently it gives sugar of milk or alcohol in minute quantities plus a label1 and one cannot make much of an impression on any disease with a label4 ,such practitioners also would come under the euthanasia act4 ,,bibliography ,cardinal ,john de ,lugo4 ,disputationes ,scholasticae et ,morales1 vol4 vi2 ,de ,justitia et ,jure1 disputatio x4 ,st4 ,augustine4 ,i ,contra ,petilianum1 cap4 #bd2 ,ad ,marcellianum ,comitem1 cap4 #ba2 ,de ,civitate ,dei1 cap4 #ag to #bh4 ,aristotle4 ,,iii ,ethicorum1 cap4 #g1 and lib4 v1 cap4 ii4 ,plato4 ,phaedo4 ,cicero4 ,quaestiones ,tusculanae4 ,i1 lib4 v2 ,de ,somno ,scipionis4 ,lessius4 ,de ,justitia et ,jure1 lib4 ii1 c4 #i1 dub4 #f1 #g4 ,molina4 ,de ,justitia et ,jure1 vol4 i1 tr4 #b1 disp4 #aai2 vol4 iv1 tr4 #c1 disp4 #a and #i4 ,st4 ,thomas ,aquinas4 ,summa ,theologica1 #b1 #b1 q4 #fd1 a4 #e1 #g4 ,st4 ,alphonsus ,liguori4 ,theologia ,moralis1 vol4 iv1 tr4 #d4 ,see this book for opposed opinions and a bibliography4 ,costa-,rossetti4 ,philosophia ,moralis1 thesis #abj4 ,ferretti4 ,philosophia ,moralis1 theses xci1 xciv4 ,macksey4 ,de ,ethica ,naturali1 theses xxxiv et seq4 ,,chapter ,,ii ,,general ,,principles ,,concerning ,,mutilation ,the members of the human body may be injured 7#a7 by a blow1 which without bloodshed causes pain or a bruise2 7#b7 by a wound1 which breaks the continuity of the tissues2 7#c7 by mutilation1 which1 without killing1 removes some member requisite for the integrity of the body4 ,the term ,mutilation as applied to the human body has various meanings4 ,in the civil law mutilation of a person is called ,mayhem1 an old form of the word ,maim1 and is defined by ,blackstone#e as such hurt of any part of a man's body as renders him less able in fighting to defend himself or annoy his adversary4 ,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 disable4 ,mutilation in the civil law now implies the taking away of some part of a legal instrument1 as a will1 contract1 or the like1 by any one who has no right to make this alteration4 #e ,commentary1 bk4 iv1 p4 #bje4 ,in canon law mutilation is like malicious or accidental mayhem in the civil law1 and it has also a technical phase in relation to irregularity as affecting the reception of ecclesiastical orders4 ,the mutilation requisite to irregularity as affecting the reception of ,holy ,orders may differ from mutilation in its purely moral and accidental aspects4 ,broadly1 an irregularity is a canonical and permanent impediment to the reception and exercise of ecclesiastical orders4 ,it does not exist unless it is actually promulgated in some canon1 and it is not necessarily grounded on corporal deformity4 ,defects of the body that cause canonical irregularity are such as would render the public ministration of a clergyman either impossible or indecent4 ,molina1 treating of mutilation1 says#f it does not exist unless there is an amputation or shortening 7detruncatio7 of a member4 ,when a foot or hand is so weakened without amputation that it cannot exercise its function the person is said to be maimed or lame1 not mutilated4 ,he holds that a finger1 and a fortiori a phalanx of a finger1 are not properly members4 ,in defining mutilation as a cause of canonical irregularity#g he contends that the weakening of a member so that it cannot perform its function is not a true mutilation canonically4 ,he does not agree#h with ,cajetan1 de ,soto1 and others who hold that an important part of a whole member is equivalent to a member so far as technical canonical mutilation is concerned4 ,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 distinct1 complete function of its own1 not be a mere part conducing to the function4 ,ballerini#i agrees with ,molina1 but he draws attention to a decretal of ,innocent ,i4 which makes an amputation by oneself of even a part of one's own finger a full canonical irregularity1 because of the unnatural quality of the act4 #f ,de ,justitia et ,jure1 disp4 #ai1 tr4 #c4 #g ,ibid41 disp4 #fh1 tr4 #c4 #h ,ibid41 n4 #fi4 #i ,theol4 ,moral4 vol4 vii4 ,suarez defines mutilation thus3 ,mutilare significat proprie membrum aliquod abscindere#aj--to mutilate means1 strictly speaking1 to cut off any member4 ,he holds with ,cajetan that an important part of a member is in itself equivalent to a member4 ,a reason he offers for his opinion is that a eunuch is enumerated among those who are canonically mutilated1 but the eunuch1 he tells us1 does not lack any member which in itself has a function in the body independent of all other organs4 ,this is not true4 ,the testicles1 which the eunuch lacks1 have two distinct functions1 independent of other organs--they make the spermatozoa and an important internal glandular secretion4 ,these facts were not known in ,suarez's time 7#aedh-afag74 ,suarez adds this remark3 ,there can be a grave sin in a marring diminutio of any chief member1 although there may be no grave mutilation2 as1 for example1 to cut off a part of a finger is undoubtedly a mortal sin1 yet1 in the opinion of all moralists1 it is not enough to cause irregularity4 #aj ,de ,censuris1 etc41 disp4 #dd1 sec4 #b1 #b4 ,st4 ,alphonsus ,liguori defines mutilation thus3 ,mutilation here signifies that some principal member be separated from the body2 that is1 a part of the body that has in itself a distinct function1 as a foot1 hand1 eye1 ear1 etc4#aa ,he says#ab canonical irregularity as a punishment is not incurred by a person who cuts off another man's finger1 thumb1 lips1 nose1 auricle1 or who knocks out teeth1 because these are supposed by canonists not to be properly members of the body1 but parts of members4 ,to blind a man in one eye is not enough to cause canonical irregularity2 the eye must be taken out4#ac ,all these injuries are of course mutilations in the moral sense of the term4 ,to blind a man without removing the eye1 to cut out his spleen in the treatment of ,banti's disease1 to remove a woman's ovary or uterus1 to cut off part of the point of a finger1 to crop the top of an auricle1 to knock out a tooth1 and any other permanent marring of the body1 even to cause an unsightly scar across the face1 are all mutilations in the moral sense of the term4 ,a physician1 midwife1 nurse1 or parent who neglects an infant's eyes1 and so permits ophthalmia neonatorum to blind the child1 is guilty of grave mutilation4 ,in the year #aiad1 in the ,chicago schools1 #de1agf children were found suffering from various defects1 and #ce1dbe were advised by the examining physicians to seek treatment2 in each of these cases the parents were informed of the nature of the disease and the necessity for treatment1 but only #dj per cent4 of the parents paid any attention to the notices4 ,of #eged cases of diseased tonsils1 which are likely to affect the heart permanently1 only #d per cent4 were treated2 of #abed cases of discharging ears only #aj per cent4 were treated1 although such a condition may go on to deafness if not attended to4 ,these parents were criminally guilty of grave neglect in permitting the mutilation of the heart and ears4 #aa ,theol4 ,moral41 lib4 #g1 cap4 #e1 disp4 #d1 n4 #cfe4 #ab ,ibid41 n4 #cgh4 #ac ,ibid41 n4 #chb4 ,any notable mutilation inflicted upon oneself is akin to the malice of suicide1 and when perpetrated on another it is related to homicide4 ,the dominion over the members of the body1 as over the whole body1 belongs to ,god alone4 ,man is constituted by his parts1 members1 taken together1 and if he were master of his members he would be master of himself4 ,again1 each member of the body is naturally united to that body and ordained for determined organic functions2 so it is wrong to render these members unfit for their natural function or to separate them from the body1 unless such actions are necessary for the preservation of life itself4 ,although man is not master of himself1 he is the administrator of himself2 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 whole4 ,a direct mutilation is one intended as an end1 or as a means to an end2 it is a voluntary and free act4 ,an indirect mutilation is one in which the mutilation is the natural effect of the act1 but the intention of the agent is directed toward another end4 ,the mutilation follows indirectly from the activity of the will1 but there is a satisfying proportion between the accidental effect 7the mutilation7 and the end intended4 ,in such an act there are two effects which follow the causal act aeque immediate1 or directly 7not indirectly1 that is1 not all from the other effect1 but each immediately from this cause73 one effect is good 7to save life1 avoid unbearable pain1 or the like71 and the other evil 7the mutilation71 but the good effect is the end intended1 the evil effect is reluctantly permitted4 ,such an act is licit provided the usual conditions of the double effect are present1 that is3 #a4 ,the action that is the cause of the good and bad effects must be itself good or indifferent morally4 #b4 ,the good and the bad effects must each be an immediate result of the causal act2 the good effect may be not so subordinated to the evil effect as to be obtainable only through the evil effect4 #c4 ,the bad effect must not be intended1 either immediately or remotely2 it may at most be tolerated as unavoidable4 #d4 ,there must be a sufficiently grave reason for the act4 ,indirect mutilation may be licit when the evil to be avoided is proportional to the mutilation4 ,direct mutilation1 where there is one direct effect of1 say1 the surgical operation1 namely1 to remove the somatic organ1 is not licit1 except for the good of the whole body2 and that good to the whole body must be juridically equivalent to the damage done the body by the mutilation4 ,there is to be a direct effect in such mutilation1 which is the good of the whole body4 ,it is not permitted to kill directly to save the life of another1 but it is permissible to mutilate directly to save the whole body4 ,direct mutilation1 however1 is never unavoidable because the agent can always correctly order his intention before the operation4 ,all direct mutilation1 unless for the good of the whole body1 implies deordination3 it offends against the supreme dominion of ,god1 who reserves to himself1 as ,creator1 ownership of human life and its organs4 ,as we may not destroy life1 which belongs to ,god1 we may not amputate a member to suppress any vital function4 ,the exception which permits us to mutilate a member or organ is1 as has been said1 the adequate good of the whole body4 ,the reason for this is that man is the administrator of his members1 to the good of the whole person4 ,each member is not for itself but for the whole body4 ,the good of the body is the sole cause that renders direct mutilation licit4 ,the members of the body by their nature are not immediately subordinate to anything except the conservation of the total natural good1 or that of the body4 ,therefore direct mutilation is not permissible to effect immediately spiritual good1 or the good of the soul4 ,we may not castrate a man1 or do vasectomy on him1 to preserve his continence1 because there is no immediate subordination and connection between the members of the body and the salvation of the soul4 ,moreover1 as ,st4 ,thomas says1#ad ,spiritual health can always be preserved by means other than amputation of bodily members1 that is1 through moderating by the will the use of these members4 ,if a mutilation that immediately conduces to the good of the whole body1 happens also to do good to the soul1 this second effect is then legitimate4 7,the various mutilations of the body by surgical operations will be considered separately hereafter47 #ad #b1 #b1 q4 lxv1 a4 #a1 ad #c4 ,may the state1 then1 sterilize criminals1 and persons afflicted with dangerous hereditary diseases1 to prevent the propagation of moral and physical defectives8 ,this question is considered specially in another chapter4 ,there is an error gradually infecting all nations of late which is that the state1 as such1 is above morality2 that what the civil authority permits or orders is by that fact alone made licit or obligatory4 ,hence the interference with individual liberty1 with the rights of man1 shown by laws for the mutilation of the physically degenerate1 laws conferring privileges on one part of the community to the detriment of another1 meddling in parental rights1 and so on4 ,political error has come to such a pass that the men on the street think any majority is justified1 solely because it is a majority1 in recalling a judge or a law1 in overriding authority for the satisfaction of appetite4 ,the sovereign people tries to be subject and sovereign at the same time1 and it deems its rulers mere hired men who may be discharged at will like cooks4 ,a law is a rule and standard of action2 a just1 permanent1 and rational ordination for the good of the community1 promulgated by one who has charge of that community4 ,dominion is the power of claiming a thing as one's own1 the right of ownership2 and if this possessor has created the object1 his dominion may be absolute4 ,a governor1 lawgiver1 judge1 has power or jurisdiction for the good of the governed4 ,the business of government1 of the state1 is to protect each citizen in the pursuit of temporal happiness1 to develop his natural faculties1 establish and preserve social order1 wherein each citizen is secured in his natural and legal rights1 and is held up to the fulfilment of his own duties so far as they bear on the good of the community as such2 and also to put within the reach of all citizens1 as far as possible1 a fair allowance of means to acquire temporal happiness1 or external peace and prosperity4 ,this is the whole business of the state4 ,the state is for the people1 and it may not transgress an inch beyond its proper limits1 which are as hard and fast as those that bind the individual citizen4 ,the citizen is not to be treated solely as an industrial or military unit2 nor are material progress and military power1 or even sheer intellectual civilization1 to be the sole aim of the state4 ,the state should develop a man's entire nature1 physical1 mental1 and moral4 ,we must obey civil authority1 but we are not slaves or chattels of that authority4 ,the state's authority over us is not dominative2 it is only a power for our good and utility4 ,the civil authority has no more right to invade the rights of its meanest citizen than it has to lie or to blaspheme4 ,god gives civil authority to the established community1 and the community entrusts this to its ruler2 authority is a divine institution1 rulers are directly a human institution and only indirectly divine4 ,when the ruler has once been set up1 has had authority entrusted to him1 obedience must be given to him while he acts in keeping with his contract4 ,kant and his followers erroneously separate the juridic from the moral order2 they deny that beyond the state there are any rights preeminent to the state's rights1 yet they say there is an innate liberty which belongs to every human being equally and inalienably4 ,the moral order comprehends all factors that are necessary to make the free activity of man in every respect well disposed1 and among these factors is the juridic order itself4 ,man is naturally social1 and whatever means are necessary to preserve human society are also naturally befitting man4 ,such means are to preserve for each man what are his1 and to abstain from injuring other men4 ,now1 so to act1 that is1 to abstain from murder1 theft1 and the like1 to fulfil contracts1 are strictly juridic duties1 and at the same time moral duties4 ,therefore the moral order comprehends the juridic order4 ,the end of the state1 then1 is not the public good considered as an end in itself4 ,the individual citizen is not his own end in life1 and so no mere multitude of men ever can become their own end4 ,if the end of the state is the public good1 then private good is subordinate to this1 and the public good becomes man's final end1 which is subversive of human dignity and is despotism4 ,a clear definition of the power of the state to interfere with the rights to life and limb of the individual citizen is very important1 because1 as has been said1 of late there is an alarming tendency on the part of the civil authority to override the rights of private citizens1 even in the most democratic forms of government4 ,encroachment on the liberty of the individual is characteristic of unchristian political societies1 and all states are now receding from ,christianity4 ,a striking example of this tyranny is the laws recently passed in ten ,american states for the mutilation of degenerates4 ,this definition is more readily made by considering concrete examples of public conduct4 ,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 inhabitants4 ,may the city cut off that member for the safety of the whole body politic1 as a person may cut off his own hand to save his life8 ,the state has not dominion over the life of a citizen1 nevertheless it may kill a citizen in punishment of crime1 because the punishment is useful to the whole people1 is for the common good1 is preservative of the social life4 ,why1 however1 should the state be permitted to kill a criminal rather than an innocent man1 since it has no dominion over the life of either1 and we suppose the death of each is necessary for the public good8 ,if you answer by saying a man may cut off a diseased member but not a sound one to save his body1 and the state in like manner may cut off a criminal1 unsound member1 but not an innocent one1 this answer does not remove the difficulty3 we may cut off even a sound member to save the body4 ,suppose1 for example1 a man caught by the arm and in danger of death from a flood2 he might sever a sound arm to escape death if no other means presented4 ,in like manner the state might cut off an innocent1 sound member to save its life from the enemy1 as described above4 ,this reasoning1 however1 is open to objection4 ,the state has no dominion over the life of its members1 and there is a vast difference between the members of the human body and those of a body politic4 ,a member of a human body has no right in itself against the other members2 nor is it capable of natural injury1 since it is not separable from the whole suppositum1 or person4 ,the suppositum1 or person1 has a right to the use of the members2 it alone is injured when a member is amputated2 and the members are solely for the utility of the suppositum4 ,therefore we may licitly destroy a member to save the suppositum for which this member exists4 ,the state1 however1 is not a suppositum in this sense2 it may not wrest the life of its members to its own utility1 because the citizens are not for the state2 on the contrary1 the state is for them and their utility4 ,that a rational being should be for the utility of another person or a society makes him a slave and supposes dominion in the user4 ,a slave is differentiated from a subject by the fact that the subject is only politically governed--that is1 governed for his own utility and good2 the slave is governed despotically--that is1 for the utility and good of his master4 ,the state may not1 as a master1 use the life of a subject for its own utility alone4 ,although the suppositum does not own its members1 yet since the members are not separable from the man1 are not self-centred as are the citizens in a state1 the man may use them for his own utility4 ,they are as slaves under a master1 not as subjects in a body politic2 therefore they may be sacrificed for the good of the suppositum4 ,this is the argument used by ,de ,lugo2 ,molina follows the same line of thought2 but both authorities finally reach the conclusion1 in the case of the enemy and the citizen whose life is required1 that the state may at least drive this citizen out of the city to save its own existence4 ,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 body2 this identification1 if pushed far enough1 becomes an analogical quibble4 ,some hold that a judge or the civil authority in general may kill or maim a criminal by gubernatorial power alone1 prescinding from dominative power1 and this not to the utility of the criminal but for the utility of society4 ,the killing of a criminal1 these objectors say1 is not for the good of the criminal2 it is a deterrent1 a protective act1 for the good of society4 ,this is not true4 ,the penal law which the criminal breaks was not made solely for society2 it was intended also for the utility of the person who becomes a criminal4 ,the law was made and the punishment established that all subjects indiscriminately should be helped to live honestly and blamelessly1 and to this end it was necessary to decree and inflict punishment as affecting all offenders4 ,the obligation to receive punishment is in a manner essential to man4 ,as he naturally requires direction and government unto virtue in his political and social life1 he has a connatural obligation to endure punishment when he violates the law made for his advantage--one condition cannot exist without the other4 ,hence punishment really is to the utility of the criminal4 ,,chapter ,,iii ,,when ,,does ,,human ,,life ,,begin8 ,by the embryologists from the moment the spermatozon joins the nucleus of the ovum until the end of the second week of gestation the product of conception is called the ,ovum2 from the end of the second week to the end of the fourth week it is the ,embryo2 from the end of the fourth week to birth it is the ,fetus4 ,at what moment during these three stages does the human soul1 the substantial form of a man in the full comprehension of the term1 enter the product of conception8 ,when does the thing become a human being8 ,the question is evidently one of the greatest importance4 ,if the rational soul does not enter until the ovum has developed into an embryo1 or only after the embryo has passed on into the fetal condition1 the destruction of this ovum1 by artificial abortion or otherwise1 would be a very different act morally from such destruction after the soul had turned the new growth into a living man4 ,if the product of conception has first only a vegetative vital principle1 and this is later replaced by a vital principle that is merely sensitive1 and this again is finally superseded by a rational vital principle1 the destruction by abortion or otherwise of the vegetative or sensitive life would not be a destruction of a rational life4 ,in this hypothesis the killing of the embryo would be a great crime1 because the embryo would be in potency for the reception of human life1 but the act would not be murder4 ,the discussion concerning the moment the human soul enters the body is older than ,christianity1 and it was taken up by many of the early ,greek and ,latin ,fathers of the ,church1 and revived again and again down to the present day4 ,plato thought the soul enters at birth2 ,asclepias1 ,heraclites1 and the ,stoics held it is not infused until the time of puberty2 ,aristotle#ae said the soul is infused in the male fetus about the fortieth day after conception1 and into the female fetus about the eightieth day4 #ae ,,ix1 ,de ,animalibus4 ,tertullian1#af ,apollinaris1 and a few others advocated ,traducianism1#ag or a transmission of the spiritual soul by the parents4 ,he said souls are carried over by conception and by the parents1 so that the soul of the father is the soul of the son1 and from one man comes the whole overflow of souls4 ,st4 ,augustine used the metaphor1 one soul lit from another as flame from flame1 without decay in either4 ,augustine was in doubt as to the origin of the soul1 and inclined to traducianism1 because it seemed to him better to explain the doctrine of the transmission of original sin4 ,tell me1 he wrote to ,st4 ,jerome in #dae1ah if souls are created singly for each person born to-day1 when do infants sin so that they need remission in the sacrament of ,christ1 sin in ,adam from whom the flesh of sin is propagated8444 ,since we cannot say that ,god makes of souls sinners1 or punishes the innocent1 nor may we hold that souls even of infants which without baptism leave the body are saved1 ,i ask you how that opinion can be defended which thinks that all souls are not made from the single soul of the first man1 yet as that soul was one to one man1 these are particular to particular individuals4 #af ,de ,anima1 cap4 #bg4 #ag ,from tradux1 a planted vine-shoot made to take root4 #ah ,migne1 vol4 xxxiii1 col4 #gbj4 ,again1 ,st4 ,augustine said3#ai ,i do not know how the soul came into my body2 he knows who gave it1 whether he drew it traxerit from my father1 or created it new as in the first man4 ,in the ,book of ,retractions1#bj speaking of the articles he had written against the ,academicians before he was a bishop1 he says3 ,as to the origin of the soul1 how it is set in the body--whether it is from that one man who first was created 444 or1 as in his case1 is made particularly for each particular individual1 ,i did not then know1 and ,i do not know now4 ,st4 ,gregory the ,great also said he could not tell whether the human soul descends from ,adam or is given particularly to each man4 #ai ,de ,anima et ejus ,origine1 i1 xv4 #bj ,i1 cap4 i1 n4 #c4 ,st4 ,gregory of ,nyssa1 however1 who died about #che1 thirty years before ,st4 ,augustine wrote the letter to ,st4 ,jerome1 held that the soul is infused into the body at the moment of conception1 and he argues with absolute precision for his opinion4#ba ,st4 ,maximus the ,theologian1 who was martyred in #ffb1 inveighs#bb against the notion that the soul is vegetative at first1 then sensitive1 and finally intellectual1 and he thinks the assertion of ,aristotle that the fetus is not animated before the fortieth day is altogether untrue4 #ba ,migne1 ,patrologia ,graeca1 vols4 xliv and xlvi4 #bb ,migne1 ,ibid41 vol4 xci1 col4 #acce4 ,st4 ,anselm1 who died in #aaji1 very dogmatically denied that the fetus is animated at conception1#bc and after his time the doctrine of ,aristotle1 which is commonly called the ,thomistic opinion1 became almost general4 ,vincent of ,beauvais1 however1 a contemporary of ,st4 ,thomas1 opposed the ,thomistic doctrine4 ,albertus ,magnus#bd had the same opinion as ,st4 ,thomas1 and probably taught it to ,st4 ,thomas4 ,in the middle ages all held that each soul is directly created by ,god1 and is infused into the embryo1 not at the instant of conception1 but when the embryo is sufficiently formed to receive it1 which1 as ,aristotle said1 happens at about the fortieth day in males and the eightieth day in females4 ,the ,thomists maintained the succession of the three souls2 many others opposed this particular opinion4 #bc ,de ,conceptione ,virginis1 cap4 xii4 #bd ,summa1 ,de ,homine1 q4 xvi1 art4 #c4 ,thomas ,fienus1 a physician and a professor in the ,university of ,louvain1 in #afbj published a book#be in which he held that the soul is infused about the third day after conception1 and his argument for the early advent of the soul is very sound4 ,as a result of ,fienus's revolutionary argument1 ,florentinus in #afeh brought out a book at ,lyons1 called ,de ,hominibus ,dubiis ,baptizandis1 in which he held that no matter what the age of the aborted fetus1 if it could be differentiated from a mole it should be baptized4 ,this book was brought before the ,congregation of the ,index4 ,the congregation did not condemn the book1 but the author was forbidden to teach that his doctrine holds sub gravi4 ,the book went through many editions and was approved by the faculties of the principal universities and the theologians of the leading religious orders4 #be ,de ,vi ,formatrice ,foetus ,liber4 ,zacchias1 chief physician to ,innocent ,x41 in #affa published his ,questiones ,medico-,legales1 and in this he maintained that the human fetus has not at any time any kind of soul other than a rational1 and this is created by ,god at the first moment of conception1 and is then infused4#bf ,by #agde the opinion of ,zacchias as to the moment life begins was virtually general among physicians1 and has since remained the doctrine of physicists4 ,modern discoveries by biologists have confirmed the fact that human life exists in the impregnated ovum exactly as it does in all stages of life1 and no scientist holds any other opinion4 ,there are1 however1 a few moralists at the present day who incline to the old ,thomistic doctrine or to modifications of it4 #bf ,tom4 ii1 lib4 ix1 tr4 #a4 ,st4 ,alphonsus ,liguori#bg was a follower of the ,thomistic opinion4 ,he affirmed3 ,they are wrong that say the fetus is animated at the instant of conception1 because the fetus certainly is not animated before it is formed1 as is proved from ,exod4 xxi3 #bb1 where in the ,septuagint version we find3 ',he that strikes a gravid woman and causes abortion1 will give life for life if the child was formed2 if it was not formed1 he will be fined4' ,this argument by ,st4 ,alphonsus is invalid apart from any facts that may bear upon either the ,thomistic or the modern opinion concerning the quickening of the fetus4 ,the text from the ,septuagint ,exodus is 7#a7 too doubtful in itself to be the basis of any argument2 but 7#b7 even if it were authentic just as it stands1 the conclusion ,st4 ,alphonsus draws from it is not warranted by the premises4 ,the ,septuagint text differs from the ,vulgate and the ,hebrew texts4 ,the ,vulgate has it thus3 ,si rixati fuerint viri et percusserit quis mulierem praegnantem1 et abortum quidem fercerit1 sed ipsa vixerit1 subjacebit damno quantum maritus mulieris expetierit et arbitri judicaverint2 sin autem mors fuerit subsecuta1 reddit animam pro anima1 oculum pro oculo1 dentem pro dente1 manum pro manu1 pedem pro pede1 adustionem pro adustione1 vulnus pro vulnere1 livorem pro livore4#bh ,this version has nothing whatever to say about the foetus formatus or non formatus2 it is merely an application of the ,semitic ,lex ,talionis1 and the form of the law is clearly corrupt and inaccurate4 #bg ,theologia ,moralis1 lib4 iv1 tr4 #d1 n4 #eid4 #bh ,if men quarrel1 and one strike a woman with child1 and she miscarry indeed1 but live herself1 he shall be answerable for so much damage as the woman's husband shall require and as arbiters shall award4 ,but if her death ensue thereupon1 he shall render life for life1 eye for eye1 tooth for tooth1 hand for hand1 foot for foot1 burning for burning1 wound for wound1 stripe for stripe4 ,the passage quoted by ,st4 ,alphonsus as that of the ,septuagint is not exact even as the ,septuagint has it4 ,the full text is3 ,if two men fight1 and one strike a woman that hath a child in the womb1 and her babe come forth not yet fully formed1#bi in a fine he shall be mulcted2 whatsoever the husband layeth upon him he shall give according to decision i4e41 of the judges4 ,but if it the babe be fully formed he will give life for life1 eye for eye1 tooth for tooth1 hand for hand1 foot for foot1 burning for burning1 wound for wound1 stripe for stripe4 #bi --not moulded out into form2 1 to mould out into form3 1 an icon1 image1 likeness4 ,this is 7#a7 evidently nothing but an application of the ,lex ,talionis1 with no thought whatever of the biological animation1 as such1 of the fetus4 ,it means that if a fully formed fetus be aborted1 either no real damage is done1 as such a child is viable2 or the formed child may be maimed1 and then the ,lex ,talionis is to be applied4 ,if the fetus is not fully formed it is not a fit subject of the ,lex ,talionis since it cannot lose an eye1 a tooth1 and so on1 because it lacks these organs and therefore the law of retaliation is not to be enforced4 7#b7 ,suppose1 however1 the writer of the text as the ,septuagint has it did think with ,st4 ,alphonsus that the formed fetus is animated1 and the unformed is not animated1 even then the conclusion drawn by ,st4 ,alphonsus is not warranted by the text4 ,the laws of ,exodus do not teach embryology1 physiology1 or any other part of physical science2 and no authority worth a hearing holds that the ,scriptures were intended to be infallible treatises on obstetrics or astronomy4 ,like the other parts of the ,bible1 the laws of ,exodus presuppose the unscientific biological1 astronomical1 and other physical notions of the time in which they were written--the moral truth is the matter the ,scripture is dealing with2 there no inaccuracy is to be found4 ,st4 ,john 7#a3ac7 speaks of those who believe in ,christ's name1 ,qui non ex sanguinibus1 neque ex voluntate carnis1 neque ex voluntate viri1 sed ex ,deo nati sunt4 ,here he expresses the contemporary notion1 which is also the ,thomistic opinion1 that men are generated from the specialized blood of their parents4 ,he was interested solely in conveying the truth that those who received ,christ were regenerated by him1 not through heredity2 and he does so1 although the biology is inexact4 ,if ,st4 ,alphonsus's conclusion is valid as from the text of ,exodus1 then men are generated ex sanguinibus1 and so on indefinitely4 ,the ,massoretic text of this passage seems to be the best preserved3 ,if men fight1 and one hurt a woman who is with child1 and her child come forth1 yet there is no mischief1 he who struck her shall be mulcted in a fine2 whatsoever the husband of the woman layeth upon him he shall pay according to the judges4 ,but if there be mischief1 then he shall give life for life1 eye for eye1 tooth for tooth1 hand for hand1 foot for foot1 burning for burning1 wound for wound1 stripe for stripe4 ,here the ,hebrew text follows the ,lex ,talionis exactly4 ,if1 in a brawl1 a man's pregnant wife is struck and abortion results1 the offender pays the penalty4 ,if the abortion does not kill or maim the child1 the culprit is fined by the ,sanhedrim2 if the child is killed or maimed1 then the penalty is according to the ,lex ,talionis4 ,in the ,hebrew text also there is no mention of a distinction between a foetus formatus and non formatus4 ,whether the fetus is animated at conception or some time later1 there is no foundation whatever for the notion that the female is quickened later than the male4 ,as was said before1 ,aristotle held that the human male fetus is animated at the fortieth day1 the female at the ninetieth day1 and the old moralists accepted his statement4 ,at the fortieth day1 however1 no one can differentiate sex unless the microscope is used1 and this particular use of the microscope is altogether modern--the knowledge requisite for such use was not in existence sixty years ago4 ,at the twentieth day1 with the microscope and a stained specimen1 a biologist can recognize whether the primordial ova are present or absent and thus determine sex4 ,only at the eighty-fourth day can sex now be differentiated without the aid of the microscope1 but then the embryo must be dissected3 nothing can be told from its external appearance4 ,sex can first be distinguished by the external appearance only at about the one hundred and twelfth day1 the end of the fourth month of gestation4 ,therefore when ,aristotle said the male fetus is animated at the fortieth day1 and the female at the eightieth or ninetieth day1 he was romancing4 ,the question1 then1 narrows to this3 ,is any human fetus animated immediately at conception1 or from forty to eighty days after conception8 ,the reason given by the followers of ,aristotle for deferring animation is that the vital principle requires organs in the receptive material1 but the embryo in the early stages1 they say1 lacks these organs4 ,this notion1 however1 as to the lack of organs is altogether erroneous1 and the rational soul enters the embryo in the oval stage1 immediately after the pronuclei unite3 there is organization in that stage of human life sufficient to receive the substantial form or soul4 ,we do not know how long after insemination the pronuclei unite1 but the proposition here is that as soon as they unite the human soul enters4 ,fecundation usually occurs after a menstruation1 but not necessarily so2 the spermatozon may live in the tube for seventeen days awaiting the ovum4 ,the human body is made up of billions of microscopic living cells1 all of which are derived by fission and differentiation from the two original single germ-cells1 the ovum and the spermatozon4 ,some nerve-cells have long processes running along the white fibres through the entire length of the body1 but they cannot be differentiated except by the microscope4 ,in the body are also various liquids which are not cellular1 as water1 saliva1 tears1 urine1 blood and lymph plasma1 and the gastric1 intestinal1 and glandular juices1 and these are secreted or excreted by the somatic cells4 ,the cells assimilate nutritive material carried to them by the blood1 excrete refuse substances1 secrete glandular products1 and are the media for all human operations below certain acts of the intellect4 ,a typical animal cell is commonly spherical in shape1 but it may take a great variety of forms through compression4 ,it has a cell-body or protoplasm1 which is called also cytoplasm1 especially when contrasted with the nuclear karyoplasm1 and a nucleus4 ,a few cells1 like fat-cells and the human ovum1 have an external covering membrane1 or cell-wall4 ,there is a part called the ,centrosome observable in many cells1 and this is made up of one or two minute dots surrounded by a radiating aster called the ,attraction-,sphere4 ,the centrosome is concerned in the process of cell-division and in the fertilization of the ovum2 it is an important organ in the production of cell from cell1 though its full nature and function are not yet known4 ,the ,plastid1 or ,protoplast1 is another less important part found in certain cells2 and in this by enlargement and differentiation are formed starch1 pigment1 and in some cases chlorophyl4 ,vacuoles are seen in cells2 and there is an opinion that these may be a special kind of plastid3 some vacuoles pulsate4 ,the ,nucleus is the most important part of a cell1 the centre of its activity4 ,the specific qualities of organism in origin and development are based upon nuclei1 so far as the material element of the living cells is concerned4 ,vital stimuli pass through the nucleus into the surrounding protoplasm1 and these stimuli control metabolism4 ,the nutritive cytoplasm assimilates1 but the vital principle energizes this assimilation through the nucleus1 for a part of a cell deprived of the nucleus may live for a time1 but it cannot repair itself4 ,constructive metabolism ceases when the nucleus is lost4 ,a toxic disease like diphtheria kills by disintegrating cellular nuclei4 ,in the nucleus are several elements1 the chief among which is ,chromatin4 ,chromatin takes various forms1 but commonly it is an irregular network4 ,from the chromatin are derived the ,chromosomes in the prophases of indirect cell-division which is the process of cell-division in the human body1 except in lymph-cells and white blood-corpuscles1 which split directly1 or by ,amitosis4 ,indirect cell-division is called ,mitosis or ,karyokinesis4 ,in the male and female chromosomes1 according to a common opinion of biologists1 all the elements of parental and phyletic physical heredity are transmitted to the embryo4 ,illustration3 ,fig4 ,i ,a ,,cell4 ,throughout the ,cytoplasm is a mesh containing numerous minute granules called ,microsomes4 ,the production of cell from cell is accomplished either by direct splitting of the nucleus and cytoplasm into two new cells1 or by indirect division through a series of stages4 ,in a typical direct1 or amitotic1 division the nucleus is constricted in the middle and divides into two daughter-nuclei4 ,these by amoeboid movements withdraw to the poles of the cell2 the cell finally divides between them1 and thus two cells are formed4 ,these1 again1 split into four1 the four into eight1 and so on4 ,an amoeba by direct division can separate into two distinct new animals in ten minutes4 ,heredity here is simple4 ,in unicellular organisms1 such as ,rhizopoda and ,infusoria1 each individual grows to a certain stage1 and then divides into two parts1 which are exactly alike in size and structure1 so that it is not possible to decide whether one is older or younger than the other4 ,these organisms reduce the size of their overgrown bodies by division4 ,each individual of any such unicellular species is a part split off serially from an organism which started into life ages ago4 ,some of them have come down in uninterrupted life from geological epochs that passed away eons before the first man was created4 ,many of these unicellular plants and animals have immeasurably the most ancient form of life on earth4 ,heredity with them depends upon the fact that each offspring is merely half of its parent4 ,in some cases the division has a sexual quality3 two cells in ,paramecium1 and1 like ,infusoria fuse and then divide if they come into contact2 they can1 however1 split without this sexual process4 ,multicellular plants and animals do not reproduce by simple division1 and the half of the parental body does not pass over into the progeny4 ,sexual reproduction is the chief means of multiplication in multicellular organisms1 and in no case is it completely wanting2 in most it is the only method of reproduction4 ,in multicellular animals the power of reproduction is in the germ-cells1 which differ from the somatic cells4 ,germ-cells do not maintain individual life as the body-cells do1 but the germ-cells alone preserve the species4 ,from two of these germ-cells under certain conditions is developed a complete bodily organism of the same species as the parents4 ,these two cells are in a sense the undying cells2 the somatic cells die4 ,multicellular animals--,man1 for example--grow embryologically by ,mitosis or ,indirect ,division4 ,as in ,direct ,division1 typically1 the nucleus in mitosis splits first and the cytoplasm secondly2 but before the nucleus divides its content undergoes a series of changes4 ,the chromatin loses its reticular arrangement and gives rise to a definite number of separate bodies1 usually rod-shaped1 known as ,chromosomes4 ,in this process the chromatin becomes a convoluted thread1 called the ,skein or ,spireme4 ,the thread thickens and opens out somewhat1 and finally breaks transversely to form the chromosomes1 which may be rods1 straight1 curved1 ovoid1 and sometimes annular4 ,commonly the nuclear material fades away and leaves the chromosomes in the cell-plasm4 7,fig4 ,,ii1 #b and #c47 ,illustration3 ,fig4 ,,ii ,,diagram ,,of ,,mitosis4 #a4 ,cell with resting ,nucleus4 #b4 ,prophase3 ,chromatin in thickened convoluted threads1 beginning of ,spindle4 #c4 ,prophase3 ,chromosomes4 #d4 ,prophase3 ,spindle in long axis of the ,nucleus1 ,chromosomes dividing4 #e4 ,anaphase3 ,chromosomes moving toward the ,centrosomes4 #f4 ,chromosomes at the poles forming the ,diaster1 beginning splitting of the ,cell-body4 #g4 ,telophase1 ,daughter-,nuclei returning to resting state4 #h4 ,daughter-,nuclei showing ,monaster below4 #i4 ,the two new ,cells4 ,it is almost an established fact that each species of animal and plant has a fixed and characteristic number of chromosomes1 which regularly recurs in the division of all its cells4 ,in forms arising by sexual production the number is even4 ,the number of chromosomes in the human cell is said to be forty-eight4 ,there are1 according to some observers1 forty-seven chromosomes in man and forty-eight in woman4 ,there seem to be twice as many chromosomes in white men as in negroes4 ,wilson gives the number#cj of specific chromosomes for seventy-four animals and plants4 ,germ-cells as differentiated from the somatic cells have in the perfected cell always half the number of chromosomes found in a somatic cell4 #cj ,the ,cell in ,development and ,inheritance1 p4 #bjg4 ,while these changes are going on in the chromatin the ,amphiaster forms4 ,this consists of a fibrous spindle-shaped body1 the ,spindle1 at either pole of which is an ,aster made up of rays4 ,in the centre of each aster is a ,centrosome1 and this may have a ,centrosphere about it4 ,as the amphiaster grows the centrosomes are grouped in a plane at the equator of the spindle1 forming the ,equatorial ,plate4 7,fig4 ,,ii1 ,no4 #d47 ,the process so far makes up the ,prophases of the ,mitosis4 ,in the ,metaphases of the ,karyokinesis begins the actual division of the cell4 ,each chromosome splits lengthwise into exactly similar halves1 and these1 in the ,anaphases of the mitosis1 drift out to the opposite poles of the spindle to form the daughter-nuclei of the new cells4 ,the daughter-nuclei receive precisely equivalent portions of chromatin from the mother-nucleus1 and this is an important fact in mitosis4 ,as the chromosomes go toward the poles the cell-body begins to constrict at the equator4 ,in the final phases1 the ,telophases1 the cell divides in a plane passing through the equator of the spindle1 and each daughter-cell receives half the chromosomes1 half the spindle1 and one of the asters with its centrosome4 ,a daughter-nucleus is reconstructed in each cell from the chromosomes4 ,the aster commonly disappears and the centrosome persists1 usually outside the new nucleus1 but sometimes within it4 ,every phase of mitosis is subject to variation in different kinds of cells1 but the outline of the division given here is the fundamental method4 ,the germ-cells differ from the body-cells in general by containing half the number of chromosomes characteristic of a given animal or plant4 ,if the body-cell has1 say1 twenty-four chromosomes1 the spermatozon of the animal or plant from which the cells are taken will have twelve chromosomes and the ovum will have twelve4 ,when the nuclei of these two cells unite in fertilization the resulting primordial cell will have the twenty-four chromosomes restored1 the specific number for this plant or animal4 ,in ogenesis and spermatogenesis the phases of ,reduction1 wherein the ovum and spermatozon get rid of half the chromosomes during the stages of maturation of these germ-cells1 are somewhat similar for both sexes4 ,the process is very complicated1 but it is of importance in the theories of inheritance4 ,all the physical characteristics in a human being that come to him from his parents and remoter ancestors are supposed1 by the biologists1 to reach him through the chromosomes in the nuclei of the single parental germ-cells4 ,the maternal physical heredity is handed on through the chromosomes in the ovum4 ,the fetus in the womb is a parasite1 autocentric1 feeding at the start from the deutoplasm1 or yolk1 in the ovum1 and later from the supplies brought to it by the maternal blood4 ,the physical material it gets directly from the mother is very probably all in the chromosomes of the fecundated ovum4 ,some weeks elapse1 and the embryo is quite advanced before it begins to draw food from the mother at all4 ,so far as the father is concerned1 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 spermatozon4 ,certain physical characteristics are passed on for centuries in a family--the ,norseman's body in northeastern ,ireland1 the skin-pigment in the ,american negro1 and so on indefinitely--and these qualities cannot come down except through the chromosomes4 ,the germ-plasm has come to us from the first man1 and it will be passed on to the last person of the race--we are all literally uterine brothers4 ,in the reduction of the germ-cells1 if the primordial cell that finally produces the ovum has1 say1 four chromosomes1 these four chromosomes first split longitudinally and reduce into two tetrads1 or two groups of four chromosomes4 ,outside the nucleus is a spindle toward which the two tetrads move2 they pass out of the nucleus and become the equatorial plane of the spindle2 each tetrad divides into dyads 7pairs of chromosomes71 and one pair of these dyads remains in the ovum1 while the other pair leaves the ovum entirely and becomes the nucleus of an abortive cell1 called the ,first ,polar ,body4 ,later a second polar body forms and carries another dyad 7two chromosomes7 out of the ovum1 leaving only one dyad1 or two chromosomes1 in the germ-cells2 that is1 half the number of chromosomes that were in the primordial cell4 ,the reduction-division in spermatozoa is similar1 but the end process leaves four active spermatozoa1 whereas in the ovum the final result is one ovum and three practically inert and cast-off polar bodies4 ,the reduction-division in both ovum and spermatozon is in reality far more complicated than the broad summary given here4 ,in parthenogenetic insects and animals a polar body takes the place of the spermatozon1 and fuses with the egg-nucleus to start mitosis4 ,in general1 the new nuclei in the cells formed by division are not made de novo1 but arise from the splitting of the nucleus in the mother-cell4 ,the new nucleus assimilates material1 grows to maturity1 and divides again into two daughter-nuclei4 ,whatever be the number of chromosomes that enter a new nucleus as it forms1 the same number issues from it in mitosis4 ,boveri said1#ca ,we may identify every chromatic element arising from a resting nucleus with a definite element that enters into the formation of that nucleus1 from which the remarkable conclusion follows that in all cells derived in the regular course of division from the fertilized egg1 one half of the chromosomes are of strictly paternal origin1 the other half of maternal4 ,it is not strictly true to say that the germ-nuclei fuse3 they send in two sets of chromosomes that lie side by side1 as has been frequently demonstrated since #ahibcb in many of the lower forms of life1 and this law almost certainly extends also to man4 #ca ,jenaische ,zeitschrift1 #ahia1 p4 #daj4 #cb ,see ,wilson1 op4 cit41 p4 #bii4 ,the primordial germ-cells appear in the human fetus about the twentieth day and finally mature at puberty4 ,then an ovum at menstruation breaks out through the surface of the ovary1 and is taken by the fimbriae of the ,fallopian tube into the lumen of this tube4 ,fecundation happens near the outer or ovarian end of the ,fallopian tube1 and the fecundated ovum finally is passed on to fasten on the wall of the uterus4 ,the spermatozon is a ciliated cell with the power of locomotion1 through the movement of the tail of the cell4 ,it can move #j4je to #j4jf mm41 or its own length1 in a second4 ,it thus passes up through the uterus and out through the ,fallopian tube1 against the cilary motion of the tubal cells1 until it meets the ovum4 ,a human ovum is a typical cell1 but it has a covering membrane1 and a minute quantity of deutoplasm or yolk1 which is not alive1 and is food for the growing embryo before the embryo begins to draw sustenance through the placenta4 ,the eggs of birds have a large quantity of food stored in the yolk1 since their embryos live in the ovum and draw food therefrom during the entire period which corresponds to the time of gestation in mammals4 ,the white and the calcareous shell of a hen's egg are adventitious parts1 added in the oviduct after the egg leaves the ovary4 ,the spermatozon is a complicated organism4 ,the head is partly covered with a thin protoplasmic cap1 and it contains the nucleus with the chromatin4 ,in the neck are two centrosomes4 ,the tail is in three parts with an axial filament throughout1 which is a bundle of extremely minute fibrils4 ,in the middle part the axial filament is surrounded by an inner sheath2 outside this sheath is a spiral filament lying in a clear substance2 and outside the spiral filament is a finely granular layer of protoplasm1 called the ,mitochondria4 ,this organism is a living animal cell1 and it can live in an incubator1 or in the ,fallopian tube for two or three weeks1 altogether removed from the living male body that produced it4 ,sir ,john ,lubbock#cc says he kept a queen ant alive for thirteen years4 ,this ant1 which died in #ahhh1 had been fertilized in #ahgd1 and never afterward4 ,she laid fertile eggs for thirteen years2 that is1 the spermatozoa in her oviduct retained their vitality for thirteen years4 #cc ,journal of the ,linnean ,society1 vol4 xx1 p4 #acc4 ,the human spermatozon is a living cell3 it has 7#a7 the requisite structure2 7#b7 the chemical composition of an organic being2 7#c7 a figure in keeping with its species2 7#d7 an origin from a living progenitor2 7#e7 the explicatio naturae2 7#f7 the power of assimilation2 7#g7 the duratio viventium2 7#h7 the power of reproduction2 7#i7 motion and locomotion4 ,as soon as the ovum breaks through the surface of the ovary it has all the qualities of the spermatozon except locomotion4 ,these two cells are animal cells1 not vegetable2 just as single-celled protozoa1 like ,actinophrys1 ,actinosphaerium1 ,closterium1 ,stentor1 and the ,amoebas are animals1 not plants4 ,it is not possible in our present knowledge sharply to differentiate ultimate forms of plants from animals4 ,to say that animals have the qualities of plants plus a sentient vital principle is not enough4 ,it is very doubtful that even the so-called sensitive plants feel1 and it is practically certain that many low forms of animal life do not feel--they have no sentient mechanism4 ,plants have the qualities enumerated above plus the power of drawing nutriment directly from inorganic material1 while animals can draw nutriment directly only from organic material2 yet some fungi1 bacteria for example1 will grow and thrive only on organic material1 and animals will take up mineral drugs4 ,it is questionable1 however1 that minerals which thus find a way into animal cells are really assimilated4 ,they excite or irritate these cells into intenser action1 and thus cause growth1 rather than affect development by direction4 ,the so-called mineral tonics used in medicine act by irritation4 ,this irritation or stimulation by drugs can in certain very low forms of animal life start mitosis in the unfertilized ovum1 and thus build up part1 at the least1 of a specific embryo parthenogenetically3 here probably a polar body takes the place of the spermatozon4 ,loeb1 by treating the unfertilized egg of ,arbacia 7a sea-urchin7 with magnesium chloride1 started mitosis that resulted1 it is said1 in a perfect ,pluteus larva4#cd #cd ,american ,journal of ,physiology1 #ahii1 iii1 #c4 ,the human ovum is about half the size of a period in the type of this page1 and two hundred and fifty spermatozoa will fit side by side along the horizontal diameter of the lowercase letter o here4 ,the nuclei of these cells are extremely minute3 they must be stained and be observed with a high-power objective on the microscope before they become visible4 ,this small nucleus of the spermatozon penetrates the covering membrane of the ovum1 enlarges1 and becomes the male pronucleus4 ,the pronucleus unites permanently with the pronucleus of the ovum1 and together they form the ,cleavage or ,segmentation ,nucleus of the fertilized ovum4 ,this new nucleus gives rise by division to the innumerable myriads of nuclei in the growing body4 ,hence every nucleus of the child apparently contains nuclear material derived from both parents1 as has been said4 ,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 cells4 ,when these nuclei unite in the ovum an intense activity at once is set up4 ,biologists offer very many theories to explain this awakening force4 ,herbert ,spencer1 ,herting1 and others held that protoplasm when perfected tends to pass into a state of stable equilibrium and consequent lessened activity1 but fertilization restores it to a labile state4 ,this and similar theories are verbose amplifications of the obvious fact that the cells start to divide and the biologists do not know the cause4 ,the soul1 of course1 cannot have anything to do with the matter1 because you cannot smell a soul4 ,senescence and rejuvenescence is another sonorous explanation that does not explain1 used by ,minot1 ,engelmann1 and ,hansen4 ,weismann rejects these theories for his own ,fertilization as a ,source of ,variation4 ,anyhow1 the fertilized cell starts to divide regardless of the biologists4 ,adult cells may be stimulated to divide by chemical irritation1 by mechanical pressure as in the formation of calluses1 traumatism1 by any agency that brings about an abnormal condition of the body1 but this fact does not explain the normal fission of the fecundated ovum4 ,in about fifteen days from the date of fertilization the ovum passes through the following stages3 #a4 ,the ovum1 with a full series of mitotic changes of the ordinary somatic type described above1 divides1 subdivides1 and grows within the cell-wall until a rounded mass of cells is formed1 which is called the ,morula or ,blastula--the original cell-wall1 of course1 stretches to hold these new cells4 ,they are of unequal size1 and they divide at unequal rates4 #b4 ,an albuminous fluid collects within the morula1 and thus the ,vesicle or ,blastocyst is formed4 ,the blastocyst is called more commonly the ,cleavage ,cavity or the ,segmentation ,cavity4 ,as this cavity widens the cells are seen to be arranged in two groups--7a7 an enveloping layer1 the epiblast1 from the outermost plate of which develops later the ,trophoblast1 or the nourishing and protecting covering of the embryo2 7b7 an ,inner ,cell ,mass1 made up of granular cells1 attached to the epiblastic layer at the ,embryonic ,pole of the ,vesicle4 ,these two stages probably take place in the ,fallopian tube1 and thereafter the embryo is in the cavity of the uterus4 #c4 ,in the third stage the ,inner ,cell-,mass separates into two layers derived from the inner cell-plate of the blastula4 ,the mass flattens and spreads peripherally1 until finally it is divided into two layers4 ,the outer is the ,ectoderm and the inner is the ,endoderm or ,hypoblast4 ,the three steps just described have not yet been seen in the human species by any one1 but they are inferred very confidently from what is well known of the development in mammals most closely resembling man in physical formation4 #d4 ,by the conversion of the one-layered blastula into two layers of cells1 the ,gastrula stage of the embryo is attained4 ,the ,gastrula consists of two layers of cells surrounding a central cavity1 which is the ,archenteron1 or the body-cavity that will hold the intestines4 ,during the past twelve years many specimens of human gastrulas have been observed4 ,the earliest form was that seen in #aijh by ,teacher and ,boyce4#ce ,this embryo was #a4ie mm4 in length by #j4ie mm4 in width1 about twice the size of a pin-head4 ,it showed on section the endoderm1 the ectoderm1 and the beginning mesoderm1 enclosed in a spherical mass of trophoblastic cells4 ,the mesoderm is a plate of cells lying between the endodermic and ectodermic plates4 ,when the mesoderm develops into two plates1 a cavity1 called the ,primitive ,coelom1 appears between the plates4 ,the ,coelom becomes the space between the viscera and the body-walls in later development4 #ce ,contributions to the ,study of the ,early ,development and ,embedding of the ,human ,embryo4 ,glasgow1 #aiaa4 ,from the primary embryonic layers of cells1 the ectoderm1 the endoderm1 and mesoderm1 all the parts of the body are built up4 ,from the ectoderm are produced the skin1 nails1 hair1 the epithelium of the sebaceous1 sweat1 and mammary glands1 the epithelium of the mouth and salivary glands1 the teeth-enamel1 the epithelium of the nasal tract1 of the ear1 of the front of the eye1 and the whole spinal cord and the brain1 with their outgrowths4 ,from the endoderm come the epithelium of the respiratory tract1 of most of the digestive tract with the liver and pancreas1 the epithelium of the thyroid body1 the bladder1 and other minor parts4 ,from the mesoderm are developed bone1 dentine1 cartilage1 lymph1 blood1 fibrous and alveolar tissues1 muscles1 all endothelial cells1 as of joint-cavities1 blood-vessels1 the pleura and peritoneum1 the spleen1 kidneys and ureters1 and the reproductive bodies4 ,the epiblast now with its mesoblastic lining begins to form the ,chorion1 an embryonic intrauterine appendage2 and the endoderm encloses the ,archenteron or primitive gut4 ,before the end of the second week of gestation the heart is indicated as two tubes in the mesoderm1 and the blood-vessels begin to be produced in the yolk-sac4 ,about the twelfth day the mouth-pit shows1 and the gut-tract is partly separated from the yolk-sac4 ,the medullary plate of the nervous system is laid down about the fourteenth day1 and the nasal area is observable4 ,the maternal blood escapes into spaces about the embryo enclosed by masses of embryonic cells1 which have not separated from one another1 but which are known collectively as ,syncytium4 #e4 ,with the third week the stage of the embryo1 technically so called1 begins4 ,during this week the body of the embryo is indicated4 ,there are three layers of cells1 already mentioned1 the ectoderm1 mesoderm1 and endoderm1 and these lie on the floor of the enveloping ,amnion4 ,the amnion is a loose fluid-filled sac 7the caul7 enveloping the fetus to protect it from jarring4 ,the fluid in it is the waters that escape in parturition when the infant breaks through the caul4 ,the archenteron in the third week shows the beginning of a division into two parts3 the part that will go to the body proper of the embryo1 and the part outside the body of the embryo which will form the yolk-sac1 or umbilical vesicle1 from which the embryo will draw sustenance until the placental vessels have been formed4 ,the part of the archenteron that remains within the embryo proper begins in this third week to be moulded into the head-cavity4 ,the forepart of the archenteron will later make the alimentary tract from the mouth to the middle of the duodenum1 or small intestine beyond the stomach4 ,the other part of the archenteron wall make the ,allantois1 the hind gut and the bladder4 ,the allantois becomes a part of the fetal umbilical cord after the formation of the placenta4 ,during this third week the dorsal outline of the embryo is concave2 the heart has a single cavity1 which will begin to divide during the fourth week2 the vitelline blood circulation begins1 and the blood-vessels of the visceral arch are laid down4 ,the digestive system is advanced to a gut-tract1 which is a straight tube connected with the yolk-sac4 ,the liver evagination is present and the oral pit is a five-sided fossa4 ,the respiratory system is represented by the anlage of the lungs1 a longitudinal protrusion of the ventral wall of the esophagus4 ,the genito-urinary system begins as the ,wolffian bodies4 ,the mesoderm starts to segment to form the skin1 and the neural canal 7from which develop the spinal cord and brain7 for the nervous system forms4 ,the fourth ventricle of the brain is indicated1 and the vesicles of the fore brain1 mid brain1 and hind brain are recognizable4 ,the ears1 nose1 and eyes1 muscular system1 skeleton1 and limbs are also beginning to be recognizable4 ,at about the sixteenth or eighteenth day of gestation the various parts of the embryo rapidly differentiate4 ,in the fourth week all these parts advance4 ,the atrium cavity of the heart begins to divide2 the alimentary tract shows the pharynx and esophagus1 stomach1 and gut2 the pancreas starts1 the liver diverticulum divides1 and the bile-ducts appear4 ,the lung anlage bifurcates and the primitive trachea is seen4 ,the ventral roots of the spinal nerves appear1 the interior ear is indicated1 and the eye is deeper4 ,the buds of the legs and arms appear about the twenty-first day--by the thirty-second day even the fingers are present4 ,the four heart-cavities are formed1 the intestinal canal is nearly closed1 the first indications of the liver and kidneys appear4 ,the child now has reached the fetal stage1 and its living body is made up of myriads of cells all derived from the original fertilized ovum4 ,the fetus is then one centimetre1 or two-fifths of an inch1 in length--about the length of the word fetus here4 ,at the end of the second month the fetus is two and a half centimetres long4 ,the ears appear1 and the tail-like process at the lower end of the spine disappears4 ,the arms show the three parts1 arm1 forearm1 and hand2 and a little later the thigh1 leg1 and foot are differentiated4 ,the navel begins to close1 the liver develops1 the abdomen is yet partly open4 ,at the end of the third lunar month the fetus is seven to nine centimetres long4 ,the intestinal canal is formed and contains bile4 ,the body resembles that of a human being1 but the head is proportionately very large4 ,bony tissue begins to appear4 ,illustration3 ,,fig4 ,,iii4 ,the ,development of the ,fetus4 ,at the end of the fourth lunar month the fetus is ten to seventeen centimetres long4 ,some muscles are movable4 ,the heart-beat is strong4 ,sex is distinguishable externally4 ,the skin is bright red1 and so transparent that the blood-vessels are visible through it4 ,toward the close of the fifth lunar month the head is about the size of a hen's egg4 ,the skin is somewhat less transparent4 ,there are indications of hair and nails4 ,the eyelids are closed4 ,parts of the brain and spinal cord are formed4 ,such a fetus may live for five or ten minutes if removed from the womb1 and it may make attempts at respiration4 ,at the end of the sixth lunar month the fetus1 if born1 may live for several hours under favorable circumstances4 ,its respiratory1 digestive1 and related organs are not developed1 and no artificial feeding will keep such a child alive4 ,the brain cortex1 the organ of consciousness1 begins to laminate into three strata of nerve-cells at the beginning of the sixth month4 ,here the time of fetal viability outside the womb may be considered4 ,langstein1 of the ,augusta ,victoria ,hospital in ,berlin1 reported#cf a study of the growth and nutrition of #bej prematurely born infants1 and he found that a weight of #ajjj grammes 7#b-a_/e pounds7 and a full body length of #cd centimetres 7#ac-c_/e inches7 are the lowest limits for viability under proper circumstances4 ,a fetus #ajjj grammes in weight and #cd centimetres in length has completed the sixth solar month1 or the sixth and a half lunar month2 that is1 it is viable at the beginning of its seventh month1 servatis servandis4 #cf ,berliner klinische ,wochenschrift1 ,june #ad1 #aiae4 ,the child at term1 as a rough average1 is from #dh to #eb centimetres 7#ai to #bj-a_/b inches7 in length1 and it weighs from about #f-c_/e to #g-a_/b pounds4 ,it is impossible1 however1 to obtain the sizes and weights of infants in utero with scientific accuracy1 because the date of conception cannot be determined with absolute certainty1 and individual fetuses vary as do infants after birth4 ,a full-term infant sometimes may weigh only #c-a_/b pounds when the mother is diseased1 and again an eight-month fetus will weigh as much as #h pounds4 ,large muscular and fat women have large babies2 women of the well-to-do classes have larger babies than do the poor2 women who work during gestation bear smaller babies than do those women that rest4 ,mothers who work in tobacco1 lead1 or phosphorus have puny babies2 white children are larger at birth than negro children2 boys at term are #c to #e ounces heavier than girls4 ,langstein says that prematurely born infants weighing from #ijj grammes 7#ca-a_/b ounces7 to #aejj grammes 7#c-a_/b pounds7--that is1 all born before the seventh solar month--must be kept in hot-water incubators in a room with ordinary ventilation4 ,babies weighing #bjjj grammes 7#d-a_/b pounds7 or more get along in an ordinary crib if they are kept surrounded with hot-water bags4 ,such children are to be fed with human milk through a catheter passed into the mouth or they die of inanition4 ,only a few of them are strong enough to suck from a bottle1 and these give up the effort after a few days and die4 ,they cannot utilize fat1 even from milk2 and all artificial food is dangerous4 ,most of the prematurely born become rachitic1 and even human milk is not preventive of this condition4 ,rachitis is a constitutional disease1 characterized by impaired nutrition of the bones and changes in their shape4 ,in the third or fourth month craniotabes is frequent--that is1 an atrophy of the skull bones with the formation of small conical pits4 ,these infants show also a morbid tendency to convulsions--spasmophilia4 ,such diseases are caused by a lack of mineral salts1 which normally are carried to the fetus by the placental blood during the last two months of gestation4 ,because of this lack premature infants require the administration of lime salts in their food2 they also need iron because they are anemic4 ,a fetus1 then1 of six calendar1 or solar1 months 7not lunar7 is viable if treated in a hospital by competent physicians4 ,otherwise it is not viable1 except in a strictly technical sense2 it will not live more than a few days or weeks4 ,reports of infants younger than six months as having been successfully reared are not credible--it is easy to make an error in the reckoning4 ,a full seven-months infant may be reared with proper feeding and skilled care2 a six-months infant may be reared 7with difficulty7 in a hospital with skilled care4 ,if it is certain that the removal of a six-months fetus will here and now save the life of a mother 7a very difficult matter to judge by the best diagnosticians71 this removal may be done1 provided the infant is delivered in circumstances where skilled care1 incubator1 and proper food are obtainable2 otherwise the removal is not justifiable4 ,that the ordinary physician says it is necessary to empty the uterus is not a sufficient reason1 as he is likely to act from ill-digested information set forth by professorial pagans1 who place no value whatever on human life in an infant4 ,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 fetus1 and the fetus therefore is really not a six-months child in development4 ,such an undeveloped fetus is not viable4 ,eclamptic women1 and those who have nephritis1 are most likely to have undeveloped fetuses4 ,in cases of this kind the seventh month should be completed before interference4 ,how is this human body in all its complexity developed from the microscopic germ-cells8 ,there has been a vast deal of ink spilled in striving to solve this mystery1 but we come out empty by the same door wherein we went4 ,the early ,preformationists guessed that the ovum contains an embryo fully formed in miniature1 and development is a mere unfolding of what had already existed4 ,the biologists of to-day mention the ,preformationists with superior scorn1 and then present ,preformationism under other names4 ,weismann's theory is the most fashionable at present4 ,in a paper read at the ,darwinian ,memorial ,congress in #aiji1 ,weismann said3 ,with others ,i regard the minimal amount of substance which is contained within the nucleus of the germ-cells in the form of rods1 bands1 or granules1 as the germ-substance1 or germ-plasm1 and ,i call the individual granules#cg ids4 ,there is always a multiplicity of such ids present in the nucleus1 either occurring individually or united in the forms of rods and bands 7chromosomes74 ,each id contains the primary constituents of the whole individual1 so that several ids are concerned in the development of a new individual4 ,actually there are such things as chromosomes1 and when these are stained and are under the highest power of the microscope they appear to be granular4 ,these granules ,weismann calls ids4 ,beyond the fact that there are such granules1 all else is sheer guessing4 #cg ,id is a word derived from ,ngeli's term idioplasm1 which means the chromosome granule4 ,he says further3 ,in every complex structure thousands of primary constituents must go to make up a single id2 these ,i call determinants1 and ,i mean by this name very small individual particles1 far beyond the limit of microscopic visibility1 vital units1 which feed1 grow1 and multiply by division4 ,these determinants control the parts of the developing embryo1--in what manner need not here concern us4 ,there is some truth here4 ,the id is made up of molecules and atoms1 ions and electrons1 and in some manner1 of course1 these have to do with the development of the embryo2 but as to the manner we have not the slightest knowledge1 and just this knowledge is what we need to make the theory anything more dignified than a child's game at guessing4 ,there is a structural differentiation in the unsegmented ovum1 with all the embryonal axes foreshadowed in it1 but this tells us nothing more than that the egg contains the man in germ4 ,he goes on3 ,the determinants differ among themselves2 those of a muscle are differently constituted from those of a nerve-cell or a glandular cell1 etc41 and each determinant is in its turn made up of minute vital units1 which ,i call biophors1 or the bearers of life4 ,that these so-called determinants differ among themselves may be true1 if they exist at all1 which is just the point to be proved4 ,giving ,greek names to inventions does not turn invention into fact4 ,these supposed determinants1 he says1 may vary quantitatively if the elements of which they are composed vary2 they 444 and their variations may give rise to corresponding variations of the organ1 cell1 or cell-group which they determine4 ,professor ,dwight said3#ch ,this is what is palmed off on us for science6 ,weismann assures us we must admit this farrago of clumsy fiction1 otherwise we should be forced to assume the help of a principle of design4#ci ,in the name of common sense1 then1 admit a principle of design1 and be done with it6 #ch ,thoughts of a ,catholic ,anatomist1 p4 #dh4 #ci ,contemporary ,review1 ,september1 #ahic4 ,darwin's ,gemmule ,theory is the same guessing2 and ,weismann rejects it because he did not think of it first4 ,as a theory the gemmule plot is just as good and just as bad scientifically as ,weismann's4 ,the chief objection to such imagining is that after its authors have put it into print a few times they lose all sense of humor1 and mistake phantasms for facts4 ,up to the present time we have discovered no living organism lower in grade than the cell4 ,if life ever originated from inorganic matter1 it appeared in an organized cell4 ,the ,weismann ids1 biophors1 and the rest1 supposing they existed outside his own imagination1 are not more capable of independent life than is a chromatin granule4 ,in any event1 these biophors could not have originated spontaneously in the first living being2 and if they could not so have come into existence1 life could never have begun4 ,however primitive any organism is1 it must be able to nourish itself and to develop into a higher specific form2 but such a variety of functions supposes differentiated structure1 composed of unstable chemical substances1 a correlation of parts1 a purposeful anticipation of ends4 ,inorganic substances1 crystals1 and the like are characteristically stable1 not unstable2 and these could not have been brought into the organic state on an earth burnt to a cinder and devoid of chlorophyl1 which itself presupposes organic cells4 ,whence came also the absolutely essential form of energy1 directive of vegetative life8 ,the only possible explanation is that life was created1 not evolved by a stranger miracle from a lump of lava4 ,we know the successive steps in the growth of the embryo from the time of fertilization to the end of gestation1 but how this vital process is effected is not so evident4 ,what we are certain of is that there is a vital principle of some kind from the beginning1 and this is the matter of real importance in the present discussion4 ,the old moralists held that this principle in the human being is at first vegetative2 after a while that vegetative vital principle is expelled by a sensitive principle2 and finally this sensitive soul is expelled by the rational vital principle1 or human soul4 ,st4 ,thomas#dj says3 ,some tell us the vital acts that appear in the embyro are not from its soul1 but from the soul of the mother1 or from the primitive force in the semen4 ,both these statements are false4 ,vital operations1 as sensation1 nutrition1 growth1 cannot come from an extrinsic principle2 therefore it must be admitted that a soul prexisted in the embryo1 nutritive at first1 then sensitive1 and finally intellectual4 ,after showing that an intellectual soul cannot be evolved from lower forms1 he concludes3 ,therefore we say that since the generation of one thing is always the corruption of another1 in man as in other animals1 when a more perfect form comes in this supposes the corruption of any precedent form2 so1 however1 that the sequent form has all perfection that was in the destroyed forms1 and something in addition3 and thus through many generations and corruptions the final substantial form is attained in man and other animals4 ,this is apparent to the senses in animals generated from putrefaction4 ,therefore the intellectual soul is created by ,god at the end of human generation1 and this soul is both sensitive and nutritive1 all precedent forms having been destroyed4 #dj ,i1 q4 #aah1 a4 #b1 ad #b4 ,there is no such thing as the generation of any animal or other living being from putrefaction2 but that is irrelevant4 ,st4 ,thomas's argument proves conclusively that if man has first a merely vegetative soul1 and secondly a merely sensitive soul1 which includes the power of the vegetative soul1 and thirdly an intellectual soul1 which does the work of all three1 that this final intellectual soul is not an evolution of the first two1 but a new form that replaces these after they have served their purpose and have been annihilated4 ,it does not even attempt to prove that man really has first a merely vegetative soul1 and secondly a sensitive1 and lastly an intellectual soul2 it supposes all this4 ,it starts out with the erroneous ,aristotelian theory and takes it for granted4 ,the reason for this statement is that the rational substantial form requires disposed matter to work upon1 and the ,thomists suppose 7again erroneously7 that in the human embryo during the period immediately after conception there is not enough matter to be a receptacle for the rational soul4 ,the soul according to the ,thomists1 who use the ,aristotelian definition1 is the first entelechy of a natural organic body that has life in potency4#da ,it is the determination that gives the body its specific and substantial being2 the primal actuation of a body or matter1 since only in matter is there a distinction between potency for substantial being and substantial actuality4 ,an entelechy is a realization1 actuality1 full perfection2 sight1 for example1 is the entelechy of the eye4 ,this body is natural1 not merely instrumental2 it is energized by an immanent principle1 not moved by an external force like a tool4 ,the body is also organic2 it must have organs1 faculties1 parts destined to perform definite functions4 ,to say the entelechy has life in potency means that since life1 or the operation of the soul1 is an immanent act1 there must be a receptacle within which it can be immanent1 and the soul is the primal actualization of that organic body1 which is in potency to produce those immanent actions in which life consists4 ,a body might be in potency while it still has no principle of operation1 or1 secondly1 while it has such a principle but is not using it4 ,in the second condition the human body is in potency for life at the moment of actualization4 #da 7,de ,anima1 ii1 #a74 ,a form fixes a thing in its proper species1 and the rational soul is such a form for the human body4 ,this substantial form is the completion1 perfection1 in operability and existence1 of the matter that receives it4 ,it is the formal cause of man1 not the efficient cause1 although it is the efficient cause of subsequent vital operations4 ,an efficient cause makes something numerically different from itself by its own real and physical action2 a formal cause and a material cause do not make anything different from themselves numerically1 but they intrinsically constitute the effect--they are intrinsic causes4 ,the human soul as the substantial form virtually contains vegetative and sensory faculties1 and through these lower organic capacities it informs and animates the body4 ,that form1 together with the matter1 the body1 does the vital acts of the composite human nature4 ,the rational soul enters the body at the beginning1 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 soul4 ,later1 some time after the birth of the child1 when the body is sufficiently formed1 the intellectual faculty comes into use4 ,the nature of a vital principle is that in which it normally issues4 ,if it issues as a rational substantial form1 as in man1 it was rational from the beginning4 ,if it was not rational from the beginning1 a rational principle replaced a sensory vital principle1 and that sensory vital principle replaced a vegetative vital principle4 ,the only reason for these replacements would be that the early human embryo1 as has been said1 lacks organization sufficient to sustain a form higher than a vegetative principle4 ,if this were sufficient reason for deferring the advent of the rational soul1 then a baby six months after birth would have no rational soul because it certainly lacks the supposedly requisite organs4 ,however1 as the rational soul is whole in each part of the adult body in the totality of its essence and perfection1 but not in the totality of its virtue1 because certain organs are lacking in particular parts of the body1 it is in the embryo whole in the totality of its essence and perfection1 but not in its virtue because certain organs are not yet formed1 and it is thus from the moment of conception4 ,as to the soul itself1 ,kant held that the soul is not a real1 but only a logical substance4 ,the ,pantheists1 ,transcendentalists1 and ,neo-,hegelians try to identify the soul with the divine consciousness4 ,the ,associationists 7,hume1 ,davis1 ,hffding1 ,sully7 say that the soul is a mere group of sensations4 ,the ,agnostics and ,positivists 7,locke1 ,herbert ,spencer1 ,james1 ,comte7 write volume after volume on the soul to prove that they know nothing about it4 ,then the ,materialists assert that there is no soul of any kind2 that we secrete thought as a mule secretes sweat4 ,yet the vital operations of man are inexplicable as resultants of the physical and chemical properties of matter4 ,there is an intrinsic energy that unifies the actions of man1 directs processes1 controls the tendency of organic matter to pass into the fixity of the inorganic1 and effects metabolism4 ,this intrinsic energy is the entelechy1 substantial form1 or what is popularly called the soul4 ,in any organic body there is a formal principle4 ,we know that there are activities that proceed from organic bodies1 and a formal principle of such activity is a substantial entity whence the organism derives basically its own kind of action1 which determines and orders the activity4 ,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 image1 not only as something objectively existing but as good or hurtful to the perceiving animal4 ,the innate and elicited appetites by which the animal tends toward or away from the object are recognized1 as are the spontaneous motions which are directed by that knowledge4 ,there must be a principle whence these actions proceed1 and this is either an accident of matter or something substantial4 ,it is not an accident of matter1 because action can never arise from an accident2 it must proceed from a substance4 ,if you say this principle whence these actions arise is not an accident of matter1 but matter itself1 you would have an extended1 composite1 inert mass acting2 but even if such thing could act1 it could never effect a simple immanent image of an object or group of objects external to itself4 ,no mere machine can build up itself1 can make any remote approach to metabolism as an organized body can2 and the principle of this immanent action is not matter itself1 because it uses1 makes1 subordinates matter to itself4 ,that principle is positively one1 not one by continuity as matter is4 ,matter as in a crystal grows by mere aggregation1 an organism grows by assimilation2 a crystal loses force in formation and growth1 an organism accumulates force4 ,the theory that denies the existence of this formal principle does not explain the phenomena of life in organic beings4 ,uniformity of tendency toward an end is not a characteristic of mere matter2 neither is a harmonious interaction of parts1 nor the dependence of parts on the unit1 nor motion1 nor the reproduction of the species4 ,moreover1 most of the greatest physical scientists strongly maintain that there must be a formal substantial principle in all living things4 ,among these are ,wallace1 ,ngeli1 ,askenasy1 ,preyer1 ,fechner1 ,agassiz1 von ,baer1 ,e4 de ,beaumont1 ,blanchard1 ,a4 ,braun1 ,brongniart1 ,bronn1 ,burmeister1 ,delff1 ,milne-,edwardes1 ,flourens1 ,goeppert1 ,griesbach1 ,heer1 ,koelliker1 ,mivart1 ,quatrefages1 ,quenstedt1 ,spiers1 ,volger1 ,r4 ,wagner1 ,liebig1 and ,joseph ,hyrtl4 ,the formal principle which coexists with matter in the organic body is really though not perfectly distinguished from matter4 ,a formal principle which is necessary for sensation should be either perfectly simple1 or at the least so one that its parts together make up one essence3 matter1 however1 cannot have such unity1 and as a consequence the formal principle must be distinct from matter4 ,anything is like its operation1 and the parts of any sensitive activity always result in an activity that is essentially one4 ,if we touch a table1 by that single touch we at once know that the object is one1 wooden1 hard1 angular1 smooth1 extended1 and so on1 and we also know that one subject perceives all these varied qualities4 ,one eye can convey knowledge at once of a thousand objects miles apart1 and these objects can be brought into one perception only by a simple subject4 ,an extended complex subject like matter would get one impression 7if it could perceive any impression7 on one side1 one on another1 and so on1 but it could not unite these4 ,the formal principle which is in organic bodies is a true substantial form1 actuating the body both as to its nature and substance4 ,together with the body1 this principle makes a being one in itself1 such that the matter and the form separably are incomplete as regards operation and being4 ,now1 a form is that principle through which anything is established in its own species2 light1 for example1 is the form of a luminous body1 heat of a hot substance4 ,a body1 however1 is established in the human species by receiving a rational soul1 and this soul1 then1 is its form4 ,it is also a substantial form because the soul itself is a substance1 not an accident dependent upon another subject4 ,moreover1 from its union with the body another substance--man--arises1 and not a thing added to a substance4 ,man's body is alive1 therefore it is a living substance2 but life in its secondary actuality is an operation2 in its primary actuality it is an essence4 ,the body is made a living substance1 not from itself1 but from the soul which is added to it4 ,when the soul departs the body is no longer alive4 ,now1 a principle which by a communication of itself determines the body in its essence and differentiates it as a living substance from everything else1 is a substantial form4 ,a substantial form1 then1 or a soul1 exists4 ,the soul1 however1 must have disposed matter for most of its operations2 it cannot exist as a substantial form bombinans in vacuo2 but it does not need a human organism complete in all its parts as a necessary condition for its indwelling4 ,there is organized matter enough in the first cell that comes into existence after the fusion of the germ-nuclei to hold this rational form1 or soul1 as perfectly as it needs to be held in this first stage of human life4 ,to inform the embryo any principle1 whether it is the rational soul or a force derived from the parental organism1 must have organs2 and if organs are present1 then the embryo is fit to receive the human soul1 as the only objection to its presence is a supposed lack of organs4 ,to use other principles when the human soul itself could be present would be a multiplicatio entium sine necessitate1 which is a condition repugnant to the universal method of the ,creator4 ,it has been said that the vital activity in the fertilized ovum does not proceed from the rational soul because1 in the first place1 it results from the fusion of two vital activities1 neither of which is rational2 secondly1 it results in the formation1 by fission1 and differentiation1 of two distinct and separate living cells1 each containing within itself a principle of vital activity4 ,now this principle of vital activity cannot be a rational soul1 for each cell has its own principle of activity1 and in man there is but one soul4 ,in the first place1 that vital activity does not result from the fusion of two vital activities neither of which is rational4 ,it results after the nuclei come together1 by particular creation1 and replaces their activity--the generation of the last vital force is the corruption of the first that existed in the separate nuclei1 not a derivative of that first force4 ,again1 when the embryo is in the two1 four1 eight cell stage1 and so on1 there are not two1 four1 eight vital principles present1 but one4 ,substantial unity is essential to life of any kind1 no matter how low its grade2 and if each cell had an independent vital principle1 any form of resultant life in the mass would be impossible4 ,an aggregation has no unity of substance2 there would be as many substances or natures as there are individual beings in the aggregate1 no matter whether ordered or in a mob1 consequently no life at all as a life4 ,the embryo in the two-cell stage is not made up of two independent organisms1 any more than the right and left halves of an adult man are two independent organisms4 ,the cells in the two-cell stage of the embryo are the right and left halves of the body1 not two individuals1 as has been proved repeatedly by biologists4 ,roux#db punctured with a hot needle one of the cells in the two-cell stage of a frog embryo without killing the embryo1 and it grew into a half-frog larva4 ,analogous results were obtained by operating in the four-cell stage4 ,later1 ,pflger1 ,schultze1 ,enders1 and ,morgan corroborated the work of ,roux4 ,newport#dc discovered this fact sixty years ago4 #db ,virchow's ,archiv 7#ahhh71 #aad4 #dc ,phil4 ,trans41 #ahed4 ,in analyzing the structure and functions of the individual cell we regard it as an independent elementary organic unit1 but this view is solely a matter of convenience1 almost a convention4 ,all the billions of cell's in an adult man are inseparable parts of the single living person4 ,no cell exists as an independent organism in multicellular animals1 except the germ-cells1 and these only after separation from the gland of origin4 ,indeed1 the biological theory of heredity1 already mentioned here1 wherein the germ-cell is supposed to carry forward the entire heredity1 is now changing toward the view which makes all the somatic cells influence the germ-cells2 that is1 the body-mass of cells sends on heredity through the germ-cell as the instrument4 ,adult organisms do not make cells de novo4 ,new cells are formed by division from prexisting cells1 but some biologists think the body-cells so affect the new germ-cells as to influence heredity4 ,the cells are organs1 nodal points1 of a single formative power which pervades the mass of cells as a whole4 ,the protoplasm of each cell is not only in direct apposition with its neighbors1 but nearly all biologists are now inclining to the opinion1 which ,heitzmann proposed in #ahgc1 that division of cell from cell is incomplete in nearly all forms of tissue2 and that even where cell-walls are present 7an exceptional condition in mammals7 they are traversed by strands of protoplasm1 by means of which the cells are in organic continuity4 ,the whole body1 he contended1 is thus a syncytium 7a mass of continuous protoplasm stippled with nuclei71 with the cells as mere nodal points in an almost homogeneous protoplasmic mass4 ,there are cell-bridges between the sieve-tubes of plants4 ,in #ahgi ,tangl discovered such connection between the endosperm cells of plants1 and later ,gardiner1 ,kienitz-,gerloff1 ,a4 ,meyer1 and many others demonstrated that in nearly all plant tissues the cell-walls are connected by intracellular bridges4 ,ranvier1 ,bizzozero1 ,retzius1 ,fleming1 ,pfitzner1 and many other observers have found these protoplasmic bridges in animal epithelium4 ,in the skin of a larval salamander they are quite conspicuous4 ,they are known to occur also in smooth muscle-fibre1 in cartilage cells1 in connective-tissue cells1 and in some nerve-cells4 ,harrison found1 in #aijh1 that in frogs the nerve-fibres develop out of these intracellular bridges4 ,dendy in #ahhh1 ,retzius in #ahhi1 and ,palladino in #ahij have shown that the follicle cells of the ovary are connected by protoplasmic bridges1 not only with one another1 but also with the ovum2 and similar connection between somatic cells and germ-cells has been found in a number of plants4 ,thus even the germ-cell is not independent until it has actually broken away from the gland4 ,a4 ,meyer holds that both the plant and animal individual are continuous masses of protoplasm1 in which the cytoplasmic substance forms a morphological unit1 no matter what the cell is4 ,that opinion is not finally settled as regards the animal after the fetal stage1 but it is much stronger as regards embryos4 ,in the early stages of many arthropods it is certain that the whole embryo is at first an unmistakable syncytium4 ,this is almost established also for ,amphioxus1 the ,echinoderm ,volvox1 and other animals4 ,adam ,sedgwick holds that it is true for vertebrates up to a late embryonic stage4 ,mitosis1 then1 is a form of growth of a mass1 not a generation of new individuals4 ,whether chromatin or any other element in the germ-cell be the idioplasm in which heredity inheres1 differentiation is a progressive transformation1 through physical and chemical changes1 of the substance of the ovum1 and this transformation occurs in a definite order and a definite distribution in the ovum4 ,the changes result in a cleavage of the egg into cells1 the boundaries of which sharply mark the areas of differentiation4 ,these cells take on specific characters4 ,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 system1 but only one of them1 the left-hand posterior cell1 gives rise to the nervous system of the trunk and to the muscles1 connective tissues1 and germ-cells4 ,the relation between the four original cells1 or blastomeres1 and the adult parts arising from them1 is not fixed1 because in some eggs these relations may be artificially changed4 ,a portion of the egg which normally would develop into a fragment of the body will1 if split off from the others1 give rise to an entire body of a diminished size4 ,conklin says#dd that in the ascidian ,styela there are four or five substances in the egg which differ in color1 so that their distribution to different regions of the egg and to different cleavage cells may be easily followed1 and even photographed1 while in the living condition4 ,the peripheral layer of protoplasm is yellow and it gathers at the lower pole of the egg1 where the sperm enters1 forming a yellow cap4 ,this yellow substance then moves1 following the sperm nucleus1 up to the equator of the egg on the posterior side1 and there forms a yellow crescent extending around the posterior side of the egg4 ,on the anterior side of the egg a gray crescent is formed in a somewhat similar manner1 and at the lower pole between these two crescents is a slate-blue substance1 while at the upper pole is an area of colorless protoplasm4 ,the yellow crescent goes into cleavage cells which become muscle and mesoderm1 the gray crescent into cells which become nervous system and notochord1 the slate-blue substance into endoderm cells1 and the colorless substance into ectoderm cells4 ,thus within a few minutes after the fertilization of the egg1 and before or immediately after the first cleavage1 the anterior and posterior1 dorsal and ventral1 right and left poles are clearly distinguishable1 and the substances which will give rise to ectoderm1 endoderm1 mesoderm1 muscles1 notochord1 and nervous system are plainly visible in their characteristic positions4 ,conklin followed these cells in every division until the embryo was developed1 making a complete genealogy up to the ovum proper4 #dd ,heredity and ,environment1 p4 #abc1 ,oxford ,press4 ,de ,vries#de assumed that the character of each cell is determined by ,pangens that migrate from the nucleus into the protoplasm4 ,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-mass1 an outcome of the action upon it by the whole system of cells of which it is a part4 ,hertwig said3#df ,each of the first two blastomeres contains the formative and differentiating forces not simply for the production of a half-body1 but for the entire organism2 the left blastomere develops into the left half of the body only because it is placed in relation to a right blastomere4 ,wilson#dg and ,driesch#dh came to the same conclusion about the time ,hertwig wrote4 ,driesch said3#di ,the relative position of a blastomere in the whole determines in general what develops from it2 if its position be changed it gives rise to something different2 in other words1 its prospective value is a function of its position4 #de ,intracellulre ,pangenesis4 ,jena1 #ahhi4 #df ,jenaische ,zeitschrift1 #ahib1 #a4 #dg ,journal of ,morphology1 #ahic1 #ahid4 #dh ,studien1 iv1 p4 #be4 #di ,ibid41 p4 #ci4 ,a discussion of this matter will be found in ,wilson1#ej but the many experiments made in the study of this subject show conclusively that the cells1 singly1 grouped1 and in mass1 are a morphological unit1 not an aggregation of distinct individuals4 ,they are not1 of course1 absolutely homogeneous1 because such a body could not have organs4 ,the substantial form1 therefore1 is not confined to the first cell4 #ej ,the ,cell in ,development and ,inheritance1 pp4 #dac et seq4 ,new ,york1 #aijf4 ,the cell-mass1 then1 has a unity sufficient to be the receptacle of a human vital principle2 again1 the basic vital operation of the human body at any age is metabolism1 and this is actually carried on in the first somatic cell of the embryo as in the cells of the adult man4 ,in the development of the human body in the embryonal stage the energy of cell-division is most intense in the early cleavage stage1 and this diminishes as the limit of growth approaches because further division is not needed4 ,when that limit is attained a more or less definite equilibrium is established4 ,some of the cells in the fully formed body cease to divide1 the nerve-cells1 for example2 others divide under special conditions1 as the blood-cells1 the connective-tissue cells1 gland-cells1 epithelial and muscle cells2 others continue to divide throughout life and thus replace worn-out cells of the same tissue1 as the ,malpighian layer of the skin4 ,cells grow1 divide1 function1 reproduce themselves1 and so on1 all through their vital activity1 sustained by the material brought to them by the blood4 ,weismann#ea and other biologists think that the vital processes of the higher animals are accompanied by a renewal of the morphological elements in most tissues4 ,the material is carried to the fetus in the womb by various agents1 but mostly by the maternal blood after the embryo uses up the yolk2 and when the fetal circulation has been established the nutritive material is taken from the maternal blood into the fetal circulation through the placenta1 and then carried to the cells by the fetal circulation itself4 ,after the child has been born the stomach and intestines take in the food4 ,the stomach does very little with it except in a preparatory manner2 the intestines further prepare it1 pass it into the body1 where it is again modified by other organs1 and finally it is carried by the blood to the cells4 ,the cells really use it2 the other organs are the farmers1 grocers1 railways1 and the like2 the cells are the consumers4 ,so far as the essential processes are concerned1 the embryological cells act as do the adult cells4 #ea ,the ,duration of ,life4 ,the first cell has contractility1 protoplasmic motion2 it can absorb perfectly all food-stuffs necessary for it from the deutoplasm of the ovum1 and the water that passes in from without to the ovum4 ,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 does1 and are exercising their function of building up and sustaining whatever part of the body they are destined for2 and this with all the complicated metabolism of the adult cell4 ,cell metabolism is the fundamental1 chief1 organic act of any human body at any age4 ,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 power4 ,the fundamental organ that conserves the body in its very existence under the government of the soul is the apparatus which effects metabolism4 ,incessant chemico-vital change is a characteristic of all living substances1 from the single cell up to the adult man2 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 operations4 ,the totality of the chemical changes1 or exchanges1 in living cells1 the transformation of unorganized food materials so that these may be assimilated1 and the chemical processes in the tissues themselves1 all are metabolism4 ,growth and repair 7anabolism7 occur side by side with the destruction of elementary tissue substance 7katabolism71 and the duration of life rests on these processes2 and all are mere cell activities4 ,food-stuffs 7water1 inorganic salts1 proteids1 albuminoids1 carbohydrates1 and fats7 undergo more or less combustion or oxidation4 ,oxygen unites with carbon to form carbon dioxide1 and with hydrogen to form water2 the nitrogen of the highly complex proteid substances reappears in combination with carbon1 hydrogen1 and oxygen as urea1 uric acid1 and other compounds2 and other ingesta are thus transformed through oxidation4 ,all maintain the temperature of the body1 replace outworn parts1 and accomplish the body's work4 ,oxidation occurs to a slight extent in the blood1 but the specific reactions are intracellular4 ,even when nothing exists but the cells and the blood1 as in the beginning embryo1 the cells really do the work1 and they do the work as they do in the adult4 ,the cells also from the very beginning are the organs that make the animal heat necessary for life4 ,rubner#eb proved that the source of at least #ij per cent4 of the animal heat in the body is a result of the chemical changes--oxidation--in the food ingested3 the other #aj per cent4 is caused by muscular contractions1 the flow of blood1 the friction of joints1 and like motions4 ,this oxidation is more active in young animals than in adults1 and in each it is1 of course1 a cellular process4 #eb ,zeitschrift f4 ,biologie1 #ahic1 bd4 #cj1 p4 #gc4 ,living matter contains hydrogen1 oxygen1 sulphur1 chlorine1 iodine1 fluorine1 nitrogen1 phosphorus1 carbon1 silicon1 potassium1 sodium1 calcium1 magnesium1 and iron4 ,the removal of one of these elements causes the death of the body4 ,they must be arranged in a definite1 prescribed order to constitute cellular protoplasm1 and any disarrangement of this order causes intoxication1 disease1 or death4 ,hydrogen is a constant product in the putrefaction of animal matter1 of animal food1 and is present in the intestinal tract4 ,oxygen is found dissolved in water and loosely combined in blood as oxyhemoglobin4 ,all the elements1 except fluorine1 combine with oxygen1 forming oxides1 and the process is called oxidation4 ,the production of heat and all vital motion depend on oxidation1 decomposition of matter4 ,in the nuclei of cells there is a so-called oxygen-carrier1 a nucleo-proteid1 which contains iron1 and this appears to be the chief oxidizing agent in the body4 ,chlorine1 which in hydrochloric acid is essential to digestion1 is ingested as chloride1 and leaves the body chiefly through the urine and sweat4 ,iodine is a necessary part of the thyroid gland1 an indispensable vital organ4 ,fluorine is found in all cells4 ,nitrogen goes into the body combined in proteids2 and phosphorus1 combined in the alkalies and alkaline earths of the foods4 ,carbon occurs in all cells and leaves them through the lungs as carbon dioxide4 ,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 elements1 and the liberated energy set free in the body appears as heat1 work1 and nervous impulse4 ,in a plant the chlorophyl and the sun's rays combine water and the carbon dioxide of the air into sugar and free oxygen4 ,this sugar is changed in a plant into starch1 cellulose1 and fat1 and also1 when combined with some nitrogen1 into proteid4 ,an animal eats this plant1 which contains starch1 cellulose1 fat1 and proteid1 and it either adds these ingredients to its own substance or oxidizes them so as to prevent the destruction of its own substance4 ,these are the ends of all food4 ,broadly speaking1 plants synthesize elements2 animals analyze them1 reduce them into simpler bodies4 ,such processes1 and those of the other elements of the body1 which have to do with the changing constituents of the human organism1 are all cellular processes--metabolism4 ,hence the chief organic act of the body is metabolic2 the basic organ of man is the cell4 ,arms1 legs1 heart1 brain1 stomach1 and similar organs are secondary1 though some of the latter are essential for certain operations4 ,now1 one cell is an organ amply sufficient for metabolism1 for the chief organic act of the body2 hence it is a fitting receptacle for a substantial form1 a soul4 ,therefore there is no reason why the soul may not be present in the one-cell stage of the embryo2 and since there is no reason why it should not be present1 but many why it should1 it is present4 ,conklin says3#ec ,the fertilized egg of a star-fish1 or frog1 or man is not a different individual from the adult form into which it develops1 rather it is a star-fish1 a frog1 or a human being in the one-celled stage4 ,this fertilized egg fuses with no other cells1 it takes into itself no living substance1 but manufactures its own protoplasm from food substances2 it receives food and oxygen from without and it gives out carbonic acid and other waste products2 it is sensitive to certain alterations in the environment1 such as thermal1 chemical1 and electrical changes--it is1 in short1 a distinct living thing1 an individuality4 ,under proper environmental conditions this fertilized egg-cell develops1 step by step1 without the addition of anything from the outside except food1 water1 oxygen1 and such other raw materials as are necessary to the life of any adult animal1 into the immensely complex body of a star-fish1 a frog1 or a man4 ,at the same time1 from the relatively simple reactions and activities of the fertilized egg there develop1 step by step1 without the addition of anything from without except raw materials and environmental stimuli1 the multifarious activities1 reactions1 instincts1 habits1 and intelligence of the mature animal4 #ec ,heredity and ,environment4 ,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 host1 or after the death of the host2 and1 secondly1 that in other separated tissues life is undoubtedly made evident under proper conditions4 ,some parts of the human body can be grafted upon another human body1 and human sarcomatous cells have been made to grow in vitro4 ,hair often lengthens after the death of a person1 if no embalming fluid has been injected4 ,dr4 ,alexis ,carrel#ed substituted a piece of a popliteal artery1 taken from an amputated human leg and kept in cold storage for twenty-four days1 for a part of the aorta of a small bitch1 and the dog lived for four years afterward and died in parturition4 ,magitot of ,paris1 in #aiaa1 took a piece of the cornea from an extirpated human eye1 and with it replaced a part of an opaque cornea on another man1 and this second man could see through the new cornea4 ,surgeons now remove skin1 bone1 and other tissues from still-born infants and accident cases1 preserve these1 for weeks if necessary1 in petrolate and ,ringer's solution in cold storage1 and then graft them on patients to repair lesions in skin1 bone1 cartilage1 or other parts of the body4 #ed ,journal of the ,american ,medical ,association1 vol4 lix1 n4 #g1 p4 #ebc4 ,if these separated tissues are alive1 what is the origin and nature of the life8 ,again1 if there is a low form of life in these separated tissues1 remaining after the departure of the human soul1 why could not such a low form of life precede in the embryo the advent of the human soul8 ,what is the nature of the life in the parasitic sarcomatous tissue which has been seen to proliferate for a short time in vitro8 ,we do not know1 nor is it relevant to the question4 ,that there is life of any kind in the cold-storage graft of bone and skin is certainly not evident2 rather every evidence points to the absence of all life4 ,when taken out of cold storage1 and the ordinary forces which corrupt a dead body are permitted to work1 these grafts corrupt exactly as any part of a corpse does4 ,that there is life of any kind in these grafts is a gratuitous assumption4 ,in cold storage they are kept ready for assimilation into the body as food may be kept4 ,bone and skin grafting is merely a peculiar form of assimilation4 ,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 tissues2 the graft is ready for assimilation without this preparation because it is already bone or skin4 ,the vital principle in a man1 or in anything else1 is at the end1 when it normally issues1 of the same nature as it was in the beginning4 ,if it is at perfection a substantial primary form1 it always was such--a substantial form cannot issue from an accidental form4 ,if the substantial form is the form of the cells in the completed organism1 it was such before that organism was perfected1 unless it replaced a lower substantial form2 but there is1 we repeat1 absolutely no need for such a secondary form at the beginning4 ,if the cells of the embryo 7not the infused germ-cells1 which are not the embryo7 had a forma corporeitatis1 or cellularis1 or whatever you wish to call it1 the human soul when it did come would not confer primal existence1 would not be a forma substantialis1 but an accidental form4 ,in proof of which1 says ,st4 ,thomas1#ee we must consider that a substantial form differs from an accidental form in this1 that an accidental form does not give being simply1 but such or such being2 as heat does not give being simply1 but heated being4 ,so when an accidental form comes in1 a thing is not said to come into existence or to be generated1 simply1 but to become such or such an object1 or to find itself in such or such a condition4 ,so1 also1 when an accidental form disappears1 a thing is not said to be destroyed simply1 but only to a certain degree4 ,a substantial form1 however1 gives being simply2 and therefore by its advent a thing is said to be generated simply1 and by its recession to be destroyed simply4 ,if1 therefore1 it happened that any substantial form other than the intellectual soul prexisted in matter1 by which the subject of that soul would come into actual being1 it would follow that the soul would not confer being simply1 and therefore would not be a substantial form2 also that the coming of the soul would not be a generation simply1 but only secundum quid--all of which is evidently false4 ,again1 ,st4 ,thomas says3#ef ,some tell us the vital acts that appear in the embryo are not from the soul1 but from the soul of the mother1 or from the primitive force in the semen4 ,both these statements are false4 #ee ,i1 q4 #gf1 corp4 #ef ,ia1 q4 #aah1 a4 #b1 ad #b4 ,an application of the opinion offered here--that is1 that the human soul is infused at the instant of conception--to multiple and monstrous embryos offers no real difficulty4 ,there are two kinds of human twins--those from two distinct ova and those from one ovum4 ,two ova may come from one or different ovaries1 or even from one ,graafian follicle1 be fertilized at the same time and develop synchronously4 ,if the ova are placed at some distance apart in the uterus1 two placentas appear2 if the ova are near each other the placentas may fuse1 but their circulations do not4 ,each child will have its own fetal envelope4 ,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 embryo4 ,when the twins come from one ovum the condition is not so simple4 ,the oval nucleus is the essential part that goes from the maternal side1 and human ova at times contain two nuclei1 as occasionally hens' eggs do2 a double-yoked hen's egg has two nuclei1 and two nuclei have been found in a single yolk4 ,klliker1 ,stckel1 and von ,franque have observed double germinal vesicles in single human ova4 ,in such a condition two spermatozoa could fecundate the two nuclei and the development go on as in the case of twins from distinct ova4 ,there is a theory which holds that homologous twins 7uni-oval7 can develop from a single germinal vesicle which splits into two primitive streaks and two gastrulas4 ,according to this opinion1 if the germinal vesicle divide entirely1 two fetuses develop which are always of the same sex1 and which resemble each other so closely in appearance that it is very difficult to differentiate them4 ,this theory holds also that should the germinal vesicle not split fully1 the lack of fission causes the various kinds of double monsters4 ,the germinal vesicle that supposedly splits into two is not fecundated by two spermatozoa1 they say1 because where there is only one nucleus in the beginning1 the entrance of a second spermatozon commonly kills the ovum4 ,this last assertion has been disproved of late4 ,some followers of the splitting theory hold that double monsters arise from the union of two originally separate primitive traces 7,verwachsungstheorie74 ,others say that a single primitive trace of blastoderm cleaves more or less thoroughly and makes the double monster 7,spaltungstheorie74 ,the earliest human double monster 7,ahlfeld's case7 was in the fourth week of gestation2 therefore whatever is held in these theories as regards human monsters is only through analogy with lower animals4 ,gerlach#eg saw bifurcation at the cephalic end of a chicken embryo sixteen hours old4 ,in this case the first change was a broadening of the anterior end of the primitive streak2 next a forked divergence appeared1 and by the twenty-sixth hour the bifurcation was half as long as the undivided posterior part4 ,whether this was a case of two nuclei or not is not known4 #eg ,u4 d4 ,entstchungsweise der vordern ,verdoppelung4 ,deutsch4 ,archiv4 f4 klin4 ,med41 #ahhg4 ,what seems to make for the fission theory is that in non-parasitic double terata1 no matter how unequally nourished or how variable in extent1 the union between the halves of double monsters is symmetric1 and the same part of each twin is joined4 ,this fact is used as a reason to exclude a fortuitous growing together of dissimilar areas of cell-masses1 at least in non-parasitic cases4 ,born1#eh in a study of fish ova1 found that eggs which produce double monsters begin with a segmentation like that of the simple normal ovum4 ,composite spermatozoa have been observed with two and three heads and one body and tail-piece1 but the significance of these abnormal cells is not known4 #eh;a ,u4 d4 ,furchung des ,eies bei ,doppelbildungen4 ,breslauer ,aertzliche ,zeitschrift1 #ahhg4 ,embryos of sea-urchins in the two-cell and four-cell stages can be separated by shaking into isolated blastomeres1 and the segments will grow into full though dwarfed larvae4 ,the same division with the growth of dwarfed larvae has been made in ,amphioxus1 in the teleost ,fundulus1 in ,triton1 in a number of ,hydromedusae and several other low forms of life4 ,when the division is not made completely double monsters result4 ,up to a certain stage of development the blastomeres of the ,medusa embryo are totipotent1 or capable of developing into any part of the body4 ,the limitation of development in a particular case lies in the cytoplasm rather than in the nuclei of the cells4 ,if frogs' eggs are fastened in abnormal positions1 inverted or on the side1 a rearrangement of the egg material results1 wherein the nucleus and cytoplasm rise and the deutoplasm sinks4 ,this change of axis shifts the embryo4 ,if an egg is turned upside down in the two-cell stage1 a whole embryo1 or half a double embryo1 may arise from each of the two blastomeres1 instead of a normal half-embryo4 ,a half-embryo or a whole dwarf may arise according to the artificial position of the blastomere4 ,each of the two blastomeres contains all the materials potentially for the formation of the whole body1 and these materials build up a whole body or a half body according to the grouping they take on4 ,primarily the egg cytoplasm1 in low forms of animal life1 is totipotent2 it has no fixed relation with the parts to which it gives rise1 and may be artificially modified or differentiated4 ,these effects1 from position and traumatic dislocation1 suggest explanations for teratic forms in higher animals4 ,human terata are now commonly classified in four groups3 7#a7 ,hemiteratic2 7#b7 ,heterotaxic2 7#c7 ,hermaphroditic2 and 7#d7 ,monstrous4 ,hemiterata are giants1 dwarfs1 persons showing anomalies in shape1 color1 closure of embryonal clefts1 in absence or excess of digits1 or like defects4 ,the ,heterotaxic group are persons whose left or right organs are reversed in position4 ,a true ,hermaphrodite would have the complete reproductive organs of both sexes1 but such an individual has not been observed4 ,there is never any question of double personality in hermaphrodites4 ,terata more properly so called may be single1 double1 or triple2 and single monsters may be autositic or independent of another fetus1 or they may be omphalositic1 dependent upon another which is commonly well developed and which supplies blood for both through the umbilical vessels4 ,there are four genera of autositic single monsters1 with eight species and thirty-four varieties4 ,of the monstra per defectum the commonest are caused by a failure of closure in the embryonal medullary canal1 which leaves part of the brain and spinal cord or their bony covering lacking4 ,some terata1 as the ,acephalia1 have no brain or spinal cord1 but they die in the fetal stage4 ,the ,anencephalia may have a spinal cord1 a medulla oblongata1 and parts of the basal ganglia1 but the cerebral hemispheres are wanting4 ,such monsters are sometimes born at term and live for several days3 they cry1 suckle1 show some reflexes and a sense of pain1 and move the arms and legs4 ,i described the various kinds of terata in ,essays in ,pastoral medicine1#eh;b and of these the most important in the matter under discussion here are the double and triple monsters4 ,many of the double monsters evidently were two persons4 ,there is only one well authenticated case of a triple human monster1 and this happened in ,italy in #ahca4 ,it had a single broad body with three distinct heads and two necks1 and was killed in delivery4 ,there is no proof as to whether it was one or more persons4 ,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 consciousnesses4 ,a monster double from the navel or breast downward 7terata anadidyma7 is1 ,i think1 one person4 ,there was an example of a monster in this group which was divided from the foreheads downward2 or better1 the distinct twins were united by their foreheads only2 but such a form is very exceptional4 ,in my article on ,human ,terata and the ,sacraments1 in ,essays in ,pastoral ,medicine1 in #aijf1 ,i expressed the opinion that a monster which is single to the navel and double below is composed of two persons1 but ,i now am of the opinion that such a monster is only one person1 because there is apparently only one consciousness4 ,there are about eight cases of two-headed monsters known which were evidently two persons in each case1 and several terata kata-anadidyma1 divided above and below but joined at the sternum1 abdomen or sacrum4 ,several ischiopagic twins1 joined at the pelvis with the heads at the opposite ends of the double body1 are grouped with either the katadidyma or kata-anadidyma4 ,it is commonly not difficult to recognize individuality or duality of personality in monsters1 but it is not easy to explain the origin of life1 to point out the moment the second soul enters these fused or undivided twins4 #eh;b ,chap4 vi1 p4 #fi4 ,new ,york1 #aijf4 ,we can artificially obtain double embryos of frogs by inverting the blastomeres in the two-cell stage4#eh;c ,we thus get united twins with heads turned in opposite directions1 twins united back to back like the ,blazek ,sisters1 twins united by their ventral sides1 and double-headed tadpoles1 but we have no knowledge of how similar doubling in human monsters takes place2 we must guess vaguely from analogy4 ,there was one soul1 at least1 present from the one-cell stage of the human monster2 when the second soul is created and infused we do not know1 but the moment of the creation of this second soul has no practical significance in this discussion4 #eh;c ,see ,wilson1 op cit441 p4 #dba4 ,the presence of certain kinds of monsters in the uterus can be diagnosed before labor1 but double monsters are mistaken for ordinary twins4 ,a woman who has given birth to a monster is likely to have subsequent monstrous fetuses4 ,where the intrauterine existence of a single monster is suspected the ,x-ray will at times clear up the diagnosis4 ,women gravid with monsters commonly abort early in pregnancy1 but even united twins may go on to term4 ,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 navel2 those joined at the middle are easier of delivery4 ,monsters that are joined at the pelves are commonly in a straight line1 and may not be difficult to deliver4 ,most double monsters cannot be delivered alive except by cesarean section1 and the fact that the content of the uterus is monstrous is1 as a rule1 not diagnosed until it is impossible to attempt cesarean section without killing the mother through infection4 ,in such a condition the double monster would1 in the ordinary medical practice1 be delivered by craniotomy1 exenteration1 cleidotomy1 or the like operation4 ,the ,rituale ,romanum ,pauli ,v#ei gives the following directions for the baptizing of human terata3 #ah4 ,in monstris vero baptizandis1 si casus eveniat1 magna cautio1 adhibenda est1 de quo si opus fuerit1 ordinarius loci1 vel alii periti consulantur1 nisi mortis periculum immineat4 #ai4 ,monstrum1 quod humanam speciem non praeseferat baptizari non debet2 de quo si dubium fuerit1 baptizatur sub hac conditione2 ,si tu es homo ego te baptizo1 etc4 #bj4 ,illud vero1 de quo dubium est1 una ne1 aut plures sint personae non baptizetur1 donee id discernatur3 discerni autem potest si habeat unum vel plura capita1 unum vel plura pectora2 tune enim totidem erunt corda et animae1 hominesque distincti1 et eo casu singuli seorsim sunt baptizandi1 unicuique dicendo3 ,ego te baptizo1 etc4 ,si vero periculum mortis immineat1 tempusque non suppetat1 ut singuli separatim baptizentur1 poterit minister singulorum capitibus aquam infundens omnes simul baptizari1 dicendo3 ,ego vos baptizo in nomine ,patris1 et ,filii1 et ,spiritus ,sancti4 ,quam tamen formam in iis solum1 et in aliis similibus mortis periculis1 ad plures simul baptizandos1 et ubi tempus non patitur1 ut singuli separatim baptizentur1 aliis nunquam1 licet adhibere4 #ba4 ,quando vero non est certum in monstro duas esse personas1 ut quia duo capita et duo pectora non habet distincta2 tune debet primus unus absolute baptizari1 et postea alter sub conditione1 hoc modo3 ,si non es baptizatus1 ego te baptizo in nomine ,patris1 et ,filii1 et ,spiritus ,sancti4 #ei ,tit4 ii1 cap4 #a1 nn4 #ah1 #ai1 #bj1 #ba4 ,any kind of monster coming from the human womb1 if it is only a head and lacks a body 7,acardiacus ,acormus71 or is a body and lacks a head and heart 7,acardiacus ,acephalus71 or is a ,foetus ,anideus1 which is a shapeless mass of flesh covered with skin1 should be baptized1 provided it shows signs of life4 ,number #ai in the ,ritual would be liable to an interpretation which is too narrow if it were not that very monstrous fetuses1 which appear to a lay observer to be not human1 are as a rule delivered dead4 ,here it may be worth while to mention that a hybrid between a human being and a lower animal is impossible4 ,as to number #bj1 the rule for differentiating unity or duality of personality is not the number of heads1 but the number of evident consciousnesses1 and this differentiation commonly cannot be made at birth4 ,there have been examples of two-headed monsters delivered alive1 which were single as to soul because the consciousness evidently was one4 ,,chapter ,,iv ,,when ,,does ,,human ,,life ,,end8 ,the moment human life begins in the human fetus is a subject of dispute1 but the moment human life ends is a mystery--we have no method of determining exactly just when the soul leaves the body4 ,daily throughout the world the priest reaches a patient who has just died4 ,conditional absolution1 extreme unction1 baptism might have been administered if there were signs of life1 but the heart and lungs are still1 the patient is dead1 and the priest leaves without doing anything4 ,yet it is always probable that the patient does not die at once even in a case of decapitation4 ,bichat1 at the beginning of the last century1 called the brain1 lungs1 and heart the tripod of life1 and from time immemorial we have based our judgment of the presence of somatic death on the lack of consciousness1 respiration1 and circulation in the patient4 ,the heart1 however1 beats after consciousness and respiration cease 7and sometimes respiration continues after the pulse cannot be felt71 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 quit1 when no heart-sounds can be heard by the stethoscope and muscular relaxation indicates death4 ,the stimulus of the heart-beat probably starts at the juncture of the superior vena cava with the right auricle of the heart4 ,some biologists think that in this spot life takes its last stand before the final retreat1 but that fact is disputed of late4 ,in the hospital of the ,rockefeller ,institute for ,medical ,research in ,new ,york1 ,dr4 ,g4 ,canby ,robinson#fj made records from about eight patients before and during the actual stopping of the heart1 using the electrocardiograph1 which can be employed without disturbing the patient4 ,he thus found--only in one case1 however--that the heart may beat for a half hour after all vascular and circulatory sounds have ceased to be audible4 ,in a letter to me ,dr4 ,robinson said3 ,undoubtedly the heart continues to show activity sufficient to be recorded by the string galvanometer very frequently after respiration has ceased1 both in man and the lower animals2 but this does not necessarily mean that it continues to be an efficient pump1 maintaining the circulation4 ,undoubtedly also in other instances the cardiac activity ceases before the respiration1 but ,i have never obtained electrocardiographic records of such cases4 #fj ,a ,study with the ,electrocardiograph of the ,mode of ,death of the ,human ,heart4 ,journal of ,experimental ,medicine1 #aiab1 xvi1 #bia4 ,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 minutes4 ,the cessation of the blood circulation causes degenerations in the nerve cells and fibres1 and these lesions may last even if the animal has been resuscitated4 ,crile thinks the human respiratory centre may survive anemia from thirty to fifty minutes2 the vasomotor and cardiac centres1 about twenty to thirty minutes2 the spinal cord1 eight to ten minutes2 the motor cortex1 eight to ten minutes2 the portion of the brain used in conscious activity as such1 six to seven minutes4 ,the higher neurons have been stimulated into reflex activity twenty-five minutes after complete clinical cardiac cessation of activity4 ,in any attempt to resuscitate a person apparently dead the maintenance of the blood circulation is the chief end4 ,if1 however1 the blood is not oxygenated the circulation will not go on automatically4 ,artificial respiration is used1 and the active principle of the adrenal gland is injected to stimulate the heart4 ,if the heart has stopped in diastole1--that is1 when distended with blood1--this distention must be relieved by cardiac massage1 commonly through an opening in the thoracic wall4 ,intratracheal insufflation of oxygen is also to be employed1 as a rule4 ,in ,essays in ,pastoral ,medicine#fa ,i mentioned several cases of resuscitation after what had appeared to be certain death4 ,two of these had been dead for forty-five minutes before they were revived temporarily4 ,wayne ,babcock#fb reported a number of new cases of his own4 ,one was a resuscitation which lasted for forty-three hours1 and which was begun twenty-five minutes after respiration had ceased4 ,the patient was a very fat negress who had collapsed after the use of scopolamine4 ,a man whose arm had been torn off died from shock in the operating-room4 ,after fifteen minutes of artificial respiration the circulation started again1 and he was kept alive for six hours in this manner1 but he died as soon as the artificial respiration was discontinued4 ,an exactly similar case was kept alive for seven hours by artificial respiration4 ,one of ,babcock's cases was a woman of eighty-seven years of age1 who apparently died on the table during an operation for strangulated hernia4 ,after ten minutes of cardiac and respiratory cessation she was revived4 ,she died four days later of peritonitis4 ,a man fifty-six years of age undergoing the same operation ceased breathing and his heart stopped4 ,he was completely revived and cured4 #fa ,new ,york1 #aijf1 p4 #afd4 #fb ,proceedings of the ,american ,therapeutic ,society1 #aiab4 ,father ,juan ,ferreres#fc holds that aborted and newly born children should be baptized1 although they give no sign of life1 if they show no clear evidence of putrefaction4 ,this opinion is mine also1 but the word maceration should be substituted as more exact4 ,eschbach#fd says3 ,infantes recenter natos et in vitae discrimine positos1 aut foetus abortivos plane formatos1 cum vel levissimus in eis motus apprehenditur1 absolute baptizari oportet3 cum autem sine motu et sensu iidem videantur neque tamen adhuc corrupti aut putrefacti sint1 sine mora baptizentur conditionate3 ,si vivis1 ego te baptizo1 etc4 ,these quotations give the common opinion of moralists at present1 and this opinion is fully safe4 ,eschbach1 however1 would have the fetus plane formatus1 which is erroneous and an echo of the old ,aristotelian notion4 ,if the fetus is visible at all1 open the membranes and baptize it conditionally1 even if it is not as big as a pea4 #fc ,la ,muerte ,real y ,apparente1 #dth ed41 p4 #ba4 ,madrid1 #aiaa4 #fd ,quaestiones ,physiologicae-,theologicae1 disp4 #c1 p4 #b1 c4 #c1 a4 #c4 ,an infant born apparently dead may be resuscitated after a delay very much longer than would be possible in an older person1 provided always the infant has not begun to breathe4 ,ferreres mistakes cases of catalepsy which have recovered consciousness for cases of apparent somatic death4 ,in these cataleptic conditions the blood circulation does not completely cease--if it did the nervous centres would be disintegrated4 ,the case he reports on p4 #bf1fe of the woman resuscitated by ,rigaudeaux in #agdh1 was one of catalepsy1 if it ever happened4 ,the same is true of the case from ,gaspar de los ,reyes1#ff which probably had some foundation in a condition of catalepsy1 but which more probably is a sheer invention by ,reyes4 ,it looks like an anecdote from a medieval ,florentine novella4 #fe ,p4 #cj in the ,english translation4 #ff ,p4 #ce2 p4 #ci1 ,english translation4 ,old writers speak of cessation of the pulse for long periods4 ,ballonius#fg mentions a person in whom there was no pulse for fourteen days before death2 ,ramazzini#fh describes a cessation of the pulse for four days before dissolution2 ,schenck#fi tells of a disappearance of the pulse for three days1 with recovery4 ,these all were apparently cataleptic cases1 where the circulation was very feeble and the radial pulse was not palpable4 ,cheyne gives an account of a ,colonel ,townsend who had the power of apparently dying at will4 ,he could so suspend the heart action that no pulse could be felt1 and after a short while the circulation would become normal again4 ,the longest period in which he remained in this condition was about thirty minutes4 ,st4 ,augustine mentions a priest named ,rutilutus who had a power like that of ,colonel ,townsend1 and ,caill#gj reported a similar case4 #fg ,opera ,medica ,omnia4 ,geneva1 #agfb4 #fh ,epistolae1 #afib4 #fi ,observationum ,medicarum1 etc4 ,frankfort1 #afjj4 #gj ,new ,orleans ,medical and ,surgical ,journal1 xvi4 ,the fakirs of ,india carry this power to great lengths4 ,braid1#ga on the authority of a ,sir ,claude ,wade1 says a fakir was buried unconscious at ,lahore in #ahcg1 and the grave was guarded day and night by sentinels from an ,english regiment4 ,six weeks after the burial the man was dug up and he presented all the appearance of a corpse4 ,the legs and arms were shrunken and stiff1 and the head reclined on the shoulder1 as happens in corpses4 ,there was no perceptible circulation anywhere1 yet he revived4 #ga ,treatise on ,human ,hibernation1 #ahej4 ,honigberger1 a ,german physician in the service of ,runjeet ,singh1 described#gb a fakir of the ,punjaub who was put into a sealed vault for forty days1 and the seal of ,runjeet ,singh was on the coffin4 ,grain was sown above the vault and it was well above the ground when the man was taken out of the vault and resuscitated4 ,sir ,henry ,lawrence testified to the truth of this story4 ,the fakir's chin was shaved1 ,honigberger says1 before the burial1 and the beard did not grow while he was in the vault4 #gb ,medical ,times and ,gazette1 vol4 i4 ,london1 #ahgj4 ,in keeping with these stories are many curious accounts of recovery after hanging4 ,these are frequent in writings of the sixteenth and seventeenth centuries1 when hanging was almost an every-day occurrence4 ,these narratives are much more authentic than the anecdotes told of recovery after premature burial1 which are as old as literature4 ,paul ,zacchias#gc tells of a young man who died of the plague and was set out with the corpses for burial4 ,he revived and was taken back to the pest-house4 ,he died again and was again prepared for the grave1 but he came to a second time4 ,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 her4 #gc ,quaestiones ,medico-,legales1 #agja4 ,the important fact1 however1 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 present1 and where there is question of giving the sacraments the person apparently dead should have the benefit of the doubt4 ,he is to receive conditional baptism1 absolution1 or extreme unction 7preferably by the short method71 in case these sacraments are required4 ,for a whole hour after apparent death the probability that the soul has not departed is so strong that1 in my opinion1 a priest who does not give the necessary sacraments is virtually as guilty as if he neglected to administer them to a person evidently alive4 ,crile1 one of the best medical authorities on this matter of somatic death1 holds that the human respiratory system may survive anemia for from thirty to fifty minutes4 ,how long after the hour a priest may administer the sacraments is not known1 but a second hour1 or even a third1 are not unreasonable periods of time during which the sacraments may be administered conditionally4 ,the sacraments are for man1 and there is no irreverence if they are administered conditionally and the priest explains to the bystanders the reason he has for his action4 ,if a pregnant woman dies slowly1 the fetus in her womb is likely to die owing to lack of oxygen2 if she dies suddenly1 the child may live for variable periods in various cases4 ,brotherton reported a case where a living child was taken from a woman twenty-three minutes after the death of the mother4 ,tarnier1 the noted ,french obstetrician1 told of a remarkable incident which happened in ,paris during the rioting by the ,commune after the war of #ahgj4 ,the rioters fired on a maternity hospital1 and a pregnant woman sitting on a bed in a ward was instantly killed by a bullet through her head4 ,after a while she was discovered dead1 and ,tarnier was sent for to save the fetus1 as its heart-sounds could be heard through the abdominal wall4 ,when he began the operation the hospital was fired upon again1 and it was necessary to carry the corpse to the cellar of the building4 ,there ,tarnier1 an hour and three quarters at least after the death of the women1 extracted a living child from the corpse4 ,hirst#gd 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 ,brazil4 ,a woman near term was killed instantly by a piece of shell4 ,as soon as she fell to the ground a ,brazilian surgeon1 who was standing near by1 cut open her abdomen with a penknife and drew out the child1 but it was already dead4 #gd ,a ,textbook of ,obstetrics1 #gth ed41 p4 #fdc4 ,philadelphia1 #aiab4 ,mack#ge was called to a pregnant woman1 and he found she had died suddenly about five minutes before he arrived4 ,he at once opened the uterus with a small lancet and extracted a child which was beyond the livid stage and had no heart-sound4 ,he worked on the child for forty minutes1 using the ordinary methods for reviving asphyxiated children1 but got no sign of life4 ,then he injected a hypodermic syringeful of a #a3ajjj epinephrin solution through the umbilical cord into the abdomen and continued the reviving motions4 ,in ten minutes the child was crying vigorously1 and it was a healthy baby afterward4 #ge ,journal of the ,american ,medical ,association1 ,august #bh1 #aiae4 ,gunn and ,martin1#gf in experiments on rabbits poisoned by chloroform and apparently dead1 found they could resuscitate about #gj per cent4 of the animals if treatment was begun within ten minutes after the heart ceased beating4 ,they started artificial respiration through a tube in the trachea1 then injected epinephrin into the pericardium1 and afterward massaged the heart through an opening in the abdomen4 ,the rate of compression of the heart in this massage must be somewhat less than half that of the normal beat1 and at short intervals the massage is to be stopped to allow the spontaneous beats to develop4 ,compression should be gradual and the relaxation abrupt4 ,the massage is applied by one of these four methods1 and they are arranged here in the order of their efficiency3 7#a7 by direct compression of the heart through an opening in the thorax2 7#b7 by compression above the diaphragm through an opening in the belly-wall2 7#c7 by simple compression of the abdomen2 7#d7 by simple compression of the thorax4 ,epinephrin1 or pituitary extract1 is used as an adjuvant intravenously to increase the cardiac movement after it has been started4 ,the same methods will probably be effective in man1 and have been used successfully4 #gf ,journal of ,pharmacology and ,experimental ,therapeutics4 ,baltimore1 ,july1 #aiae4 99 99 99 99 99 ,when a woman is in articulo mortis with a living fetus in her womb1 one should not wait for her death4 ,if one waits1 he will nearly always lose the child4 ,the cervix should be dilated forcibly1 the child turned and delivered4 ,even if this forcible delivery should happen to hasten somewhat the mother's death1 the action would be morally licit4 ,it would be a double-effect action2 the two effects would proceed immediately and equally from the act1 which is indifferent morally2 one effect1 the good one1 is to save the child for baptism at least1 and possibly permanently2 the second1 evil but reluctantly permitted1 is the possible hastening of the maternal death4 ,i should be willing even to slit the cervix1 if necessary1 provided the diagnosis were certain1 with the possibility of tearing the uterus1 in a case where the dilatation of the cervix would be too slow a method2 but this supposition is scarcely practical4 ,zsako#gg gives a method for determining the interval since death by muscular phenomena4 ,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 death4 ,the contraction may be elicited in the same manner on the living1 but it is more evident on a cadaver owing to the absence of antagonistic tonus in the muscles4 ,some muscles may move for four hours after death4 ,tapping along the radius from the elbow downward1 he says1 a point is found where the stroke causes extension of the hand2 tapping along the radius above the wrist makes the thumb bend2 tapping on the spaces between the bones of the hand closes up the corresponding fingers2 tapping on the back of the foot extends the toes1 on the leg adducts the foot1 on the tibia along the middle third extends the leg4 ,when the lower third of the thigh is tapped across the muscles move1 and if the back is struck between the scapula and the spine the shoulder blades move toward each other4 ,if there is no response the person must be dead from two to four hours4 ,i have had no experience with this method4 #gg ,mnchener medizinische ,wochenschrift1 ,january #ah1 #aiaf4 ,satre#gh reported that many soldiers brought into the dressing-stations apparently dead from shock1 head or spinal wounds1 or gas asphyxiation1 were revived after artificial respiration had been applied1 sometimes for even six hours before results were obtained4 ,two tests were used to find out whether the patient was alive or not4 ,in such cases ten c4c4 of a #bj per cent4 alkaline solution of fluorescine is injected subcutaneously1 and if there is any circulation this dye will be carried to the eye and turn the conjunctiva green4 ,the second test is to push a fine puncture-needle into the spleen or liver and thus remove a particle of the pulp4 ,this pulp is put on blue litmus-paper and drawn free from blood4 ,if the litmus-paper turns red the man is dead2 if it remains blue he is alive4 ,the reaction of the living pulp is alkaline1 blue2 this becomes acid1 red1 a half-hour after death2 an hour after death the acid reaction is quite marked4 #gh ,presse ,mdicale1 ,paris1 xxiv1 #ff4 ,,chapter ,v ,,abortion ,abortion1 as the term is used by physicians1 in its widest sense is the ejection or extraction of a fetus from the womb at any time before term4 ,the word is popularly contrasted with miscarriage1 where the fetus is ejected through disease or accident2 abortion in the lay sense supposes artificial1 and commonly criminal1 extraction of the fetus4 ,abortion 7from aboriri1 to perish7 etymologically has an association with destruction of life1 but the name is given by physicians to a removal of any premature fetus1 even if it is viable4 ,strictly1 however1 abortion is an interruption of pregnancy before the fetus is viable1 and premature labor is such an interruption after the fetus is viable4 ,throughout this chapter the words are used in this sense4 ,abortion as a medical and moral consideration may be considered from several points of view4 ,first1 involuntary pathologic and accidental interruptions of pregnancy are to be averted1 if it is possible to do so1 to save the life of the child2 and when the abortion is inevitable the treatment has moral qualities which involve the physician and the mother4 ,secondly1 voluntary and therapeutic abortion has peculiar moral and medical qualities arising 7a7 from the period of gestation or the viability of the child2 7b7 from the truth or error in the diagnosis as regards the necessity for interference1 and the advantage or damage resulting from the interference4 ,thirdly1 the technical skill or ignorance of the physician1 and the methods he employs may in themselves in any case avert or cause the death of the mother or grave injury to her1 and in the forced delivery of premature infants may save1 kill1 or maim the child4 ,fourthly1 voluntary criminal abortion has a special malice of its own1 which makes it somewhat more criminal than the therapeutic removal of an inviable infant4 ,fifthly1 there are positive canonical and civil penalties against abortion as it affects the inviable infant4 ,pathologic abortions1 and those arising from accident or carelessness1 are extremely common4 ,hegar estimated that there is one of these abortions to every eight normal parturitions1 and specialists in obstetrics find as many as one abortion to four deliveries at term4 ,these abortions are most frequent from the eighth to the twelfth week of gestation1 because the ovum is then not firmly attached to the uterus1 and it readily succumbs to external influence4 ,moreover1 the woman is not certain she is pregnant and neglects precautions4 ,many women1 again1 are under the error that there is no moral evil in getting rid of the ovum before quickening1 and they think quickening occurs only when they feel the fetal movements4 ,others1 erroneously again1 fancy that abortion in the early months is not dangerous or injurious to themselves4 ,the causes of pathologic and accidental abortion are very numerous and often interactive4 ,they may arise from the fetus1 the mother1 the father1 or from violence4 ,the death of the fetus1 or diseases of the fetus itself or of its appendages1 cause abortion4 ,weakness of the fetus from alcoholism in the parents1 anemia1 carbon monoxide and lead poisoning1 tobacco poisoning in women who are cigar-makers1 and similar conditions in one or both parents1 will bring on abortion4 ,monsters rarely go on to term4 ,acute or chronic affections in the mother1 as typhoid1 malaria1 smallpox1 cholera1 scarlatina1 measles1 tuberculosis1 and the like1 and syphilis in the mother or father1 effect abortion4 ,other abnormal states that bring on abortion are low blood-pressure in maternal anemia1 shock1 syncope2 hemorrhages into the placenta in maternal nephritis2 hemorrhages between the placenta and uterus from diseases of the placenta and decidua1 or from traumatism1 which detach the placenta2 sun or heat stroke2 sudden high temperature in fever2 toxemias1 as in some forms of hyperemesis gravidarum1 eclampsia1 chorea1 hepatic autolysis1 and impetigo herpetiformis4 ,chronic endometritis1 or inflammation of the lining membrane of the uterine cavity1 is the commonest maternal cause of abortion1 especially of habitual abortion4 ,in this condition hemorrhages in the decidua1 or uterine fold that holds the fetus1 kill the fetus1 or force the ovum off the uterine wall1 or excite expulsive uterine contractions4 ,without hemorrhage endometritis prevents a firm fixation of the ovum1 or it may bring about a malposition of the placenta1 called placenta praevia4 ,endometritis at the decidua may cause hydrorrhoea gravidarum1 and the accumulated serous secretions from this source are likely to start uterine contraction4 ,chronic metritis1 or inflammation of the deeper tissues of the uterus1 is commonly found with endometritis1 and it prevents the expansion of the uterine muscle4 ,this condition is more likely to cause abortion than endometritis alone4 ,acute gonorrhea1 inflammations of the ,fallopian tubes1 and appendicitis sometimes interrupt pregnancy4 ,other causes are malformations and diseases of the uterus1 infantilism1 fibroids1 polyps1 uterine horns1 lacerations and amputation of the cervix1 and retroversions and retroflexions of the uterus4 ,at times a replacement of the uterus will avert an abortion4 ,when the mother has an infectious disease like typhoid1 smallpox1 cholera1 or typhus1 the infection may reach the fetus and kill it1 or may cause an endometritis with a hemorrhagic tendency4 ,maternal sepsis may kill the fetus directly or secondarily1 and this is true also of maternal syphilis4 ,a sudden rise in temperature may excite expulsive uterine contraction4 ,in pneumonia the excess of carbon dioxide in the blood may bring on abortion4 ,like pneumonia1 anesthesia may kill the fetus if kept up for a long time1 or if marked by cyanosis4 ,prolonged nitrous-oxide anesthesia is especially dangerous to a fetus1 but a brief nitrous-oxide anesthesia for the extraction of a tooth may not bring on abortion4 ,the worst tooth stump can be extracted painlessly after local injection of novocain1 with no danger to the fetus4 ,the gums remain somewhat sore for a day or two after novocain infiltration1 but this inconvenience is a much less evil than total anesthesia1 even when there is no pregnancy4 ,it is probable that total anesthesia is morally unjustifiable for the extraction of a single tooth if the tooth is not wedged in4 ,violence1 accidental or intentional1 is a frequent primary or secondary cause of abortion4 ,sometimes a slight jar1 a misstep on a stairway1 a nervous shock1 a jump from a carriage-step1 lifting weights1 running sewing-machines1 sea-bathing1 a rough automobile ride1 will bring on an abortion where there is a predisposition4 ,often in healthy women1 on the other hand1 extreme violence does not interrupt pregnancy4 ,surgical operations are classed here with violence4 ,in a neurotic woman a slight operation on an organ not directly connected with the uterus will start expulsive contractions4 ,again1 #ff per cent4 of operations on ovarian tumors during pregnancy have left the uterus undisturbed4 ,de ,lee says he has removed fibroids from the pregnant uterus1 once even exposing the chorion1 and has amputated the cervix of a gravid uterus1 without interrupting pregnancy4 ,several cases have occurred where both ovaries have been removed during pregnancy without abortion4 ,the breast has been amputated and a kidney removed from a pregnant woman#gi without disturbing the pregnancy4 ,wiener#hj did eleven operations for ovarian tumors during pregnancy with only two abortions4 ,von ,holst#ha removed a myoma weighing two and a half pounds from the uterus at the seventh month of gestation without abortion4 ,davis of ,birmingham1 ,alabama1 reported#hb that a woman three and a half months pregnant was shot in the abdomen4 ,the rifle bullet made twenty-five perforations in her intestines4 ,she was taken eighty-five miles1 and then ,davis cut out five feet of the intestine4 ,she recovered and gave birth to a living child at term4 #gi ,cronk1 ,oklahoma ,state ,med4 ,assoc4 ,jour41 ,july1 #ahaf4 #hj ,amer4 ,jour4 ,obstet41 ,august1 #aiae4 #ha ,upsala ,lkareforenings ,frhandlingar1 xxi1 #h4 #hb ,journal ,amer4 ,med4 ,assoc41 ,october #bh1 #aiaf4 ,double ovariotomy brings on abortion in the early months of pregnancy oftener than in the later1 probably from the loss of the corpus luteum1 which1 it appears1 is necessary for the growth of the uterus4 ,appendicitis and appendectomy are especially likely to interrupt gestation1 apparently as a result of infection and because pregnant women are prone to defer operation4 ,the traumatism of criminal abortion1 punctures and lacerations from bougies and curettes1 and the exhibition of drugs like ergot and cantharides1 are sources and results of abortion4 ,drugs will not empty the uterus unless they are given in poisonous doses which endanger the woman's life4 ,in the father1 syphilis1 tuberculosis1 general paresis1 general debility from alcoholism1 unchastity1 and senility1 and septic conditions of the generative tract1 may cause abortion4 ,many men who work with lead1 phosphorus1 mercury1 or ,x-rays are sterile1 and before they become totally sterile their condition appears to cause debility in the fetus which leads to abortion4 ,in paternal lead poisoning there is a reduction of about #bj per cent4 in the weight of the infants at birth1 and a general weakness and retardation of the child4 ,the children of lead-poisoned fathers are frequently permanently under weight4 ,coition during gestation is a cause of abortion1 and the fault here1 as a rule1 lies with the husband4 ,st4 ,thomas#hc said3 ,st4 ,jerome protests against the sexual approach of the husband to his gravid wife1 not that in this condition such an act is always a mortal sin1 unless there is probable danger of abortion4 ,st4 ,alphonsus#hd says if there is danger of abortion the use of the debitum is a grave sin4 ,in n4 #ibd 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 is1 in such circumstances1 lost1 yet he thinks that in pregnancy there is little danger of abortion from this cause1 especially near term4 #hc ,in4 #d1 dist4 #ha4 #hd ,theologia ,moralis1 n4 #idc4 ,sabetti-,barrett#he says the wife is excused from the debitum conjugale if the husband is drunk1 or if there is a rational dread of grave injury1 or grave danger to health4 ,genicot#hf thinks that in pregnancy it can scarcely be shown that there is a notable danger of abortion4 ,lehmkuhl#hg holds that a married person is not obliged to grant the debitum if there is great danger of abortion2 but1 he adds1 ,even then1 if there is a grave danger of incontinence ,i do not think it certain that there is an absolute obligation to abstain4 #he ,theologia ,moralis1 n4 #icf4 #hf ,theologiae ,moralis ,institutiones1 vol4 ii1 n4 #edd4 #hg ,compendium ,theologiae ,moralis1 n4 #aaad4 ,unlike ,lehmkuhl1 moralists agree that if there is real danger of abortion from marital congress1 such an act is illicit1 but they are inclined to think that there is little or no danger of abortion1 especially at the end of gestation4 ,authorities on obstetrics1 on the contrary1 say that one of the causes of abortion in the early months of pregnancy is marital congress2 and one of the sources of sepsis in women1 which may result in the death of both mother and child1 is certainly congress at the end of gestation4 ,this causation of abortion is found especially in neurotic irritable women1 in such as have diseases of the generative tract1 or a tendency to habitual abortion4 ,whenever a woman shows any tendency to bleeding during gestation the use of the debitum is undoubtedly contraindicated1 because of the proximate danger of both abortion and septic infection4 ,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 parturition4 ,the staphylococcus pyogenes albus1 a dangerous septic microrganism1 exists as a saprophyte in #ej per cent4 of male urethras1 and the bacillus coli communis is another source of infection from the father during pregnancy4 ,de ,lee saw two cases of sepsis that killed both mother and child from such an infection shortly before term4 ,if a physician now examines a woman before delivery without using all the precautions known to prevent sepsis1 such as wearing a sterile rubber glove1 he is guilty of malpractice2 yet certain moralists are inclined to let a husband do what he likes4 ,moralists talk about the fetus as protected in the membranes4 ,that is nonsense1 because it has no relevancy to the question4 ,it can have the slight relevancy of untruth when the woman is rendered septic1 because then the membranes are no protection at all4 ,the mortality statistics of the ,united ,states ,census ,bureau show that a little more than #db per cent4 of the infants who died in the registration area in #aiaa did not last throughout the first month of extrauterine life1 and of these babies almost seven-tenths died of prenatal and delivery abnormalities4 ,in #aiab1 in the registration area1 which then took in #fc4b per cent4 of our population1 the total death-rate of infants under a year old was #ijce1 and of these #cije died of puerperal infection4 ,in the entire country a very conservative estimate of the annual number of deaths of infants from puerperal sepsis is #ejjj2 and about #ae1jjj women die here yearly from this etiology alone4 ,of course most of these deaths are caused by unclean midwives and quacks1 but a large number of them are brought about by incontinent husbands4 ,invalidism from puerperal sepsis happens many times #ae1jjj4 ,moreover1 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 husbands1 although not necessarily by coitus during gestation4 ,coition during pregnancy is unnatural because it necessarily fails of the end of coition1 which is procreation4 ,curiously1 too1 all the lower animals instinctively appear to avoid this act during pregnancy4 ,men should be told that marriage has restraints as well as celibacy4 ,women are reminded of the law of the debitum1 but not of the occasions when they are even obliged to deny it4 ,if a man cannot keep continent in the presence of his pregnant wife1 let him live in another part of the house4 ,regard for the woman is lacking in many ways4 ,young girls often marry without having the faintest notion of sexual life1 and they are panic-stricken when assaulted4 ,i have known two who were frightened into insanity4 ,priests should tell young married men that they are human beings1 not animals2 that they should act like rational beings when they are first married2 and that after the wife has become pregnant the husband should not be the cause of abortion in the first three months1 nor of puerperal sepsis in the last three months4 ,priestley1#hh in #bcbe pregnancies1 found one abortion in every four pregnancies2 ,guillemot and ,devilliers in ,france1 ,hirst in ,philadelphia1 and others report the same proportion4 ,these are natural1 not criminal1 abortions4 ,if1 then1 in normal pregnancies about one child in five is lost before birth1 husbands should be taught a continence which would to some degree avert this calamity4 ,superfetation has occurred by coition during pregnancy1 and this results commonly in abortion and the death of both fetuses4 #hh ,pathology of ,intrauterine ,death4 ,london1 #ahhg4 ,premature labor in cases where the child is viable is produced by the same agencies that interrupt gestation in the early months4 ,obstetricians think that syphilis is the commonest cause of premature labor1 and they estimate that from #ej to #hj per cent4 of these premature births are due to syphilis4 ,in a series of #gje fetal deaths in ,johns ,hopkins ,hospital1 #bf4d per cent4 were due to syphilis4 ,after syphilis the cause of premature labor next in frequency is nephritis with placental hemorrhages and infarcts4 ,twins are not seldom delivered prematurely because of lack of room in the uterus4 ,for the same reason any tumor of the uterus or abdomen may cause an abortion4 ,when successive pregnancies are interrupted prematurely the abortion is said to be habitual1 and again the commonest cause is syphilis4 ,in this disease1 as the virulence of the infection decreases1 the gestation is prolonged until a child is born infected with congenital syphilis4 ,this child commonly dies1 and later a child strong enough to live appears4 ,correct treatment of the parents will avert this slaughter of the innocents4 ,sometimes the syphilis is latent so far as clinical symptoms are concerned1 but we may find a positive ,wassermann reaction4 ,hubert reported#hi that #h4h per cent4 of #hfeb patients in a clinic at ,munich where all were subjected to the ,wassermann test had latent syphilis1 and in #eb per cent4 of these cases in men1 and #ge per cent4 in women1 the infection was altogether unknown to the patients4 #hi ,mnchener medizinische ,wochenschrift1 lxii1 #ci4 ,chronic endometritis1 where there is no syphilis1 will permit habitual abortion1 and each abortion makes the condition worse4 ,nephritis1 diabetes1 and other constitutional diseases cause habitual abortion4 ,in the first two months of gestation the decidual fold which holds the ovum against the uterine wall is thick1 vascular1 and friable4 ,the contracting uterus in abortion expels the decidua with considerable difficulty1 but the ovum containing the fetus may slip out easily and be lost4 ,a fetus two months old is about three-fourths of an inch in length4 ,if a physician1 nurse1 or other person finds the ovum1 no matter how small it is1 they should open it at once with a scalpel or scissors and baptize the fetus conditionally1 even if no sign of life is perceptible4 ,if the fetus is unmistakably dead--a diagnosis not easily made--there is no use in attempting baptism2 but always give the fetus the benefit of the doubt4 ,in the first six or eight weeks the whole ovum is usually born developed in decidual tissue2 sometimes the ovum will slip out of the decidua and be covered only with shaggy villi1 suggestive of a chestnut burr4 ,during the third and fourth months there may be 7#a7 an abortion of the whole ovum2 or 7#b7 the membranes may rupture1 the fetus be expelled1 and the secundines remain in the uterus1 and these may have to be removed by instrument or finger2 or 7#c7 the decidua reflexa and the chorion may split and let out the fetus into the amniotic sac3 here again the remaining secundines1 if they do not come away spontaneously1 must be removed4 ,abortion after the fifth month is like a regular labor at term1 but not so energetic4 ,an abortion may be threatened1 inevitable1 or incomplete4 ,in each of these conditions there is uterine pain and hemorrhage4 ,in inevitable and incomplete abortions we find softening and dilatation of the cervix1 and a presentation or expulsion of part or all of the ovum4 ,in pregnancy uterine hemorrhage and uterine pain are symptoms of a threatened abortion1 but not certain symptoms4 ,fromme found that #ag4i per cent4 of #aeg women who had these signs in the early months went on to term4 ,if the fact of pregnancy is not known it is not always easy to differentiate a threatened abortion from other uterine conditions1 like chronic metritis1 ectopic gestation1 a fibroid or other tumor1 hemorrhage from cervical erosions or varices1 or malposition of the uterus4 ,if the abortion is inevitable the diagnosis is made more readily4 ,the cervix is then more or less dilated and the ovum is palpable4 ,there is rather profuse hemorrhage1 flooding1 and painful uterine contractions are evident4 ,the rupture of the bag of waters may be simulated by the escape of secretions in hydrorrhoea gravidarum1 or the escape of waters may be a primary symptom of graviditas exochorialis4 ,hydrorrhoea gravidarum is an intermittent discharge of clear or bloody fluid from a catarrhal endometritis under the decidua4 ,it occurs in anemic1 weak women1 especially multiparae4 ,in graviditas exochorialis the fetus is left within the womb but outside the ruptured chorion1 and it may remain there for some time4 ,when an abortion is incomplete it is absolutely necessary to learn whether the entire ovum and decidual tissue have been expelled or not4 ,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 invalidism4 ,sepsis may result1 a placental polyp may form1 and even syncytioma malignum may start--this fatal tumor1 however1 is not so common after incomplete abortion as after hydatid mole formation4 ,the prognosis as regards health is worse after abortion than after normal pregnancy4 ,the involution of the uterus is slower than in full-term cases1 and if infection has occurred there is great likelihood of a chronic endometritis and metritis4 ,the woman may be rendered sterile1 or she may become a chronic invalid to be cured only by capital operations4 ,in threatened abortion examination is to be avoided unless it is absolutely necessary for diagnosis1 and then great gentleness is required so as not to excite uterine contractions4 ,the woman is to rest in bed1 not so much as raising her head to take a drink of water 7which is given to her through a tube71 and she is morally obliged to submit to this inconvenience4 ,if she refuses she is accountable for the death of the fetus4 ,if there is bleeding the foot of the bed should be elevated as in hemorrhage in typhoid fever4 ,the routine practice is to quiet the woman and the uterine irritability with morphine and other opium derivatives4 ,children are readily overwhelmed by opium because their circulation is not sufficient to neutralize the deoxidizing effects of the drug up to safety4 ,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 opium4 ,the danger to the child in such cases begins from the opium remaining in its circulation after the child has been separated from the mother4 ,often1 however1 fetuses in cases where scopolamine and morphine have been used on the mother during labor are born badly1 and even fatally narcotized1 despite the connection with the maternal circulation4 ,nevertheless1 even if there is some real danger to the fetus from the use of morphine in a threatened abortion1 the cautious use of this drug would be morally justifiable4 ,should the threatened abortion go on to actual abortion1 the fetus will certainly be killed1 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 life4 ,the immediate double effect from the morally indifferent act of giving a dose of morphine is1 on the good side1 the saving of the fetal life1 and on the other1 the evil side1 the danger of fetal narcosis1 which is not at all certain to follow4 ,evidently1 the good intended effect far overbalances the evil and somewhat hypothetical effect4 ,after about five days1 if the bleeding ceases1 the woman may be permitted to go back to her ordinary routine of life1 but with extreme caution1 and she must return to bed at the slightest show of blood4 ,morphine is used at the beginning to quiet the patient and the irritable uterus4 ,if the cervix is eroded1 applications of a #aj per cent4 nitrate of silver solution are made4 ,the bowels are kept locked for three days and a softening enema of olive-oil is used before emptying the bowel4 ,if the bleeding starts again every time the woman goes about her duties1 the abortion may be inevitable4 ,when the cervix is shortened and dilated so that the ovum is palpable and pieces of the decidua or ovum are expelled1 the hemorrhage is more or less profuse1 and especially if the bag of waters has ruptured and uterine contractions show1 the abortion is deemed inevitable4 ,in such a case the fetus may be alive1 or it may be dead2 and1 again1 conditions which show all the classic symptoms of inevitable abortion sometimes1 though rarely1 do not go on to abortion4 ,it is extremely difficult1 and often impossible1 to tell whether an early fetus is dead or alive4 ,a high1 lasting fever sometimes kills the child2 so do low blood-pressure1 profuse hemorrhages1 deoxidation of the blood in pneumonia1 separation of the placenta1 fatty degeneration of the placenta1 and the severe infections--in such cases there is always strong probability that the child is dead when the abortion shows its symptoms4 ,if the fetal tissues that appear indicate maceration1 or if the discharge is fetid or purulent1 the fetus is dead4 ,should the fetus be alive1 tamponing the vagina to check the hemorrhage often separates the fetus from the uterus by the dissecting force of the blood dammed back1 or in any case tamponing is almost certain to excite uterine contractions2 thus there is an indirect killing of the fetus4 ,the treatment of inevitable abortion after the fifth month differs very much from the methods used in the early months4 ,the prime principle is1 never interfere until forced to do so4 ,when the hemorrhage is dangerously profuse1 so that the woman's life is endangered 7an exceptional condition71 the uterine cervix and the vagina must be tamponed with sterile gauze and cotton to check the bleeding1 but this is a last resort4 ,if the fetus is alive1 or probably alive1 nothing short of a necessity to save the woman's life by this means justifies the use of the tampon4 ,de ,lee advises the routine use of the tampon in threatened abortion1 but this doctrine is erroneous medically and altogether false morally4 ,if the physician knows the fetus is dead1 he should1 of course1 tampon at once to get rid of the fetus4 ,the tampon excites uterine contractions and causes destruction of a living fetus by dissecting it loose from the uterine wall through the dammed blood4 ,elevation of the foot of the bed and the use of morphine will1 as a rule1 check the bleeding4 ,when the woman is bleeding to the risk of her life1 the tampon is put in to check the bleeding and so save her life4 ,the double effect immediately following this indifferent act is on one side good1 the saving of her life2 on the other side evil1 the killing of the fetus4 ,the good effect is intended1 the evil effect is reluctantly permitted4 ,such a procedure is morally licit4 ,where a tampon must be put in1 it is left in from sixteen to twenty-four hours1 even if the temperature goes up4 ,during this time there are painful contractions of the uterus1 as a rule1 and these are expulsive4 ,no drug is to be given to allay these pains if the intention is to have a dead or viable fetus expelled4 ,if the pains cease suddenly1 this is usually a sign that the fetus has been expelled above the tampon4 ,when the tampon is removed and the entire ovum is found1 it is best for the ordinary physician not to meddle with the uterus in any manner4 ,some advise that the physician should go over the uterine lining with a half-sharp curette to make certain that nothing has been left behind1 but this is dangerous advice to any one who is not an expert obstetrician4 ,should the temperature remain above #ajj degrees1 the uterus must be cleaned out1 and flushing with uterine catheters is not enough3 if the gloved finger cannot remove the secundines1 the curette is needed4 ,if1 when the tampon has been removed1 no ovum is found and the cervix is still closed1 another tampon is to be put in for another twenty-four hours1 supposing the removal of the ovum is licit4 ,forcible dilatation of the cervix is always a dangerous operation1 and should never be employed when avoidable4 ,steel dilators have ruptured the uterus and killed the patients again and again even when used by experts4 ,laminaria tents are not to be recommended2 the tamponade is enough4 ,when the retained ovum cannot be removed by the finger or squeezed out1 the free portion of the ovum is to be grasped by an ovum forceps and gently drawn out4 ,the operator should be sure he has a part of the ovum in the forceps and not a part of the uterine wall4 ,if he bites into the uterine wall 7a common catastrophe71 he may pull a hole in that wall1 and then the woman will probably die unless the rent can be closed immediately after opening the belly4 ,when the abdominal cavity has been opened in such an event1 the uterus is also to be opened1 cleansed1 and sutured4 ,this method is safer than curetting where there is a rent4 ,if one is certain the gut has not been injured--and it is extremely difficult to be certain--vaginal anterior hysterotomy may be substituted4 ,sometimes perforations1 when the uterus is not septic and the instruments are clean1 are not dangerous4 ,rest in bed1 ice-bags1 ergot1 and opium cure without operation4 ,physicians who are called into an abortion case should always be certain that no one has attempted to pass sounds1 curettes1 or similar instruments1 because a perforation may have been made by the meddler which will be charged to the second man himself4 ,if a uterus is flexed it is easy to poke a curette or like instrument through it at the bend1 especially if the uterus is thin or friable from sepsis4 ,again1 the placental site is raised1 it feels rough1 and the furrows in it lead one to think part of the placenta is still adherent1 whereas all has been removed4 ,repeated scraping1 due to this error1 may dig a hole through the uterine wall4 ,perforation in a septic case is practically always fatal to the woman4 ,the use of the curette supposes a special technic1 and no physician should presume to try its use unless he has been carefully and practically instructed4 ,in inevitable abortion after the third month it may be very difficult to get the embryo out4 ,the cervix1 in primiparae especially1 may be long1 thick1 and hard4 ,if the fetus is dead1 it may then be removed by morcellement--i4 e41 by cutting and breaking it into pieces1 and then taking out these pieces with an ovum or stone forceps4 ,sometimes1 though rarely1 the operator may find it impossible to get the entire fetus away4 ,then the uterus is packed with weak iodine gauze1 and after twenty-four hours the fetal remains are expelled4 ,in every abortion the presence or absence of extrauterine pregnancy is to be made out4 ,if there is an extrauterine pregnancy1 curettage will cause rupture of the sac4 ,when the interior of the aborting uterus has become septic the old treatment was to empty the uterus at once1 but now the treatment is expectant1 because the traumatism of the curetting makes the sepsis worse4 ,the commonest and worst infections are of the streptococcus putridus1 a pus staphylococcus1 and the bacterium coli communis4 ,curettage lets these microrganisms enter the circulation4 ,the cause of this condition is often unskilful attempts at artificial abortion4 ,when the womb contains decomposing material bleeding usually obliges tamponing1 and thus often the uterine contents come away in twenty-four hours with the gauze4 ,if there is no hemorrhage there should be no tamponing3 it is then better to get dilatation by packing and drain the uterus with gauze4 ,the curette should not be used at all4 ,where there is habitual abortion the cause must be found4 ,during gestation syphilis and displacements of the uterus1 as causes1 may be treated4 ,endometritis can be cured only when the uterus is empty4 ,rest in bed at the time when these abortions usually occur1 and at the time when menstruation customarily appears1 is required4 ,treatment of the husband is often necessary1 as he is virtually always the source of luetic infection4 ,attention or inattention to the mother's own hygiene during pregnancy has great effect on the fetus1 and care of hygiene may avert abortion4 ,the woman's dress should be simple and warm enough to prevent congestion from changes in temperature4 ,congestions are likely to affect the kidneys1 and care of the renal function is always one of the most important facts connected with pregnancy4 ,no circular constrictions of the trunk by lacing or stiff corsets should be attempted4 ,the corset forces the uterus and child downward into the pelvis and against the lower abdominal wall1 causing congestion of the pelvic veins and strain on the abdominal muscles4 ,tight corsets1 preventing the expansion of the uterus and the growth of the fetus1 may cause mutilations like club-foot and wry-neck1 or even kill the child4 ,the woman who would preserve her figure by corsets1 to the mutilation1 weakening1 or killing of her unborn infant1 and this is an every-day evil1 is either a criminal fool or an unmitigated scoundrel4 ,tight lacing to conceal pregnancy is a method of murder4 ,high-heeled shoes are somewhat injurious because of the constrained position into which they throw the woman4 ,x-ray photographing of pregnant women is very likely to cause abortion4 ,the woman's diet should be simple4 ,she must abstain from all alcoholic liquors even if she has been accustomed to their use at meals4 ,she should not overeat on the supposition that she has to feed two persons4 ,some popular books advise a special diet to reduce the bone-salts and thus get a smaller baby and one more easily delivered4 ,such advice is criminal4 ,the constipation of pregnancy is not to be treated by strong cathartics like ,epsom salt4 ,the kidneys are to be watched2 therefore the urine should be examined every three weeks up to the seventh month1 then oftener4 ,if there is any suspicion of toxemia or nephritis1 the urine should be examined daily4 ,obstetricians who have any regard for their own conscience and reputation will have nothing to do with a woman who refuses to take this precaution4 ,physical exercise should be gentle--say1 walking1 up to two miles in the daytime4 ,the vast majority of women are too lazy to take physical exercise as a hygienic duty at any time1 and during pregnancy their aversion to all effort to overcome indolence is so great they make even themselves believe they cannot4 ,just as most professional men think they think1 most women think they work4 ,there are thousands of women who have servants1 yet make not only their families and friends but themselves believe they are worked to death1 and their work is the spreading of four or five beds1 and the ordering of groceries over the telephone4 ,when these women are pregnant they quit even the bed-making4 ,cold and hot baths1 ,turkish and ,russian baths1 hot sitz-baths and ocean bathing are not permissible during gestation4 ,tepid baths and spongings are to be substituted4 ,near term the bath-tub is not safe because of danger of uterine infection from unclean water4 ,then shower-baths are better1 but these are dangerous if the woman must step over an enameled bath-tub side to take them1 because she may slip and fall4 ,vaginal douches are not to be used in pregnancy except in certain diseased conditions1 under the direction of a competent physician4 ,therapeutic abortion and therapeutic induction of premature labor are employed in five chief groups of conditions3 7#a7 contracted pelvis2 7#b7 diseases caused by pregnancy2 7#c7 diseases coincident with pregnancy2 7#d7 habitual death of the child after viability but before term2 7#e7 prolonged pregnancy4 ,there is no such act as therapeutic abortion of an inviable child2 all abortions of inviable children1 when direct1 are criminal1 and nothing criminal is therapeutic4 ,the consideration of narrow pelvis1 and the diseases caused by pregnancy and coincident therewith1 will be treated in detail4 ,when the child dies after viability but before term the cause is most commonly syphilis4 ,in such cases a ,wassermann reaction should be made from both parents2 and even if it is negative1 and no other definite cause for the fetal death can be found1 syphilitic treatment should be tried on the father and mother4 ,bright's disease1 even when scarcely diagnosable1 anemia1 diabetes1 adiposity1 and hypothyroidism are other lethal causes of habitually still-born infants4 ,not seldom the cause is in the husband4 ,if he is an alcoholic 7and two or three drinks of whiskey a day make any man an alcoholic71 if he is especially susceptible to the toxin of tobacco 7and tobacco alone may render some men not only sterile but impotent71 if he is a worker in poisonous metals1 an ,x-ray operator1 a user of narcotics1 exhausted with overwork and worry1 affected with weakening systemic disease1 his germ-cells are unfit for their function4 ,such men are not technically sterile1 but they are practically sterile4 ,some women carry the child beyond term1 with the effect that the baby is overgrown for normal delivery4 ,the head is harder and more angular than it should be1 the long bones stiffer and less pliable1 the muscles tenser4 ,all these changes make the delivery so difficult that the overgrown child may be fatally injured at birth4 ,physicians must be cautious in believing histories of enormous children at previous births at which they were not present4 ,mothers and nurses are likely to exaggerate the size of infants4 ,in cases where the children die at a particular time before term1 premature labor should be induced to save the child1 and when the child has been carried over term it may be necessary to induce labor4 ,in the first condition labor is not to be induced a week earlier than is necessary4 ,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 survival4 ,from #cj to #fj per cent4 of all prematurely delivered infants die4 ,the maternal passages do not dilate normally and the child is unformed2 its bones fracture readily2 it cannot sustain pressures and strains4 ,all induced labors are dangerous to the mother by shock and possible infection1 and only very grave necessity justifies any such procedure4 ,in inducing necessary premature labor the technical method may take on a moral quality4 ,there are over a score of methods1 and many of these1 although used1 are dangerous and should be obsolete4 ,a very common method1 begun in #ahee1 is to insert one or two elastic solid bougies into the uterus between the membranes and the uterine wall4 ,this is a dangerous method and should be obsolete4 ,other dangerous and obsolete methods are the puncture of the membranes with a trocar high up in the uterus2 intrauterine injections of hot or cold water1 glycerine1 milk1 and other liquids2 vaginal tamponade alone2 irrigation of the vagina with carbon-dioxide water2 a stream of hot water directed against the cervix1 electricity1 ,x-ray1 dilatation of the vagina with a rubber bag1 irritation of the nipples1 the use of drugs like quinine1 cimicifuga1 ergot1 or cantharides4 ,if haste is not necessary1 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 methods4 ,where rapid delivery is required1 cesarean section must be employed4 ,in cases of somewhat less urgency the membranes are first punctured and balloon dilators are used4 ,in any case puncture of the membranes is the most certain method to start labor1 but it has many bad disadvantages4 ,a dry labor in a primipara with an undilated cervix is a grave condition4 ,if the fetal head is not engaged in the pelvis1 puncture must not be attempted4 ,when the head is not engaged in the pelvis like a ball-valve1 the cord will prolapse1 be pinched1 and thus the blood supply will be cut off from the child and the loss will kill it4 ,for the same reason1 the waters must not be run off too quickly4 ,many operators insert a bag1 dilate1 and so start the labor1 without puncturing the membranes1 where there is no reason for haste4 ,therapeutic abortion1 as has been said1 is never permissible1 under any circumstances1 if the child is not viable4 ,in certain conditions1 say1 when a uterine tumor clearly threatens the life of the pregnant woman1 or if in extrauterine gestation there is a rupture of the tube1 an operation may be permissible1 or even obligatory1 which has for its direct end the removal of the tumor or the stopping of the hemorrhage4 ,if such a removal or ligation1 under these conditions1 indirectly causes the abortion of the inviable fetus1 or its death from a lack of blood1 these indirect effects may be reluctantly permitted4 ,they are cases of an equally immediate double effect1 one good and one evil1 where all the requirements are fulfilled4 ,a direct abortion of an inviable fetus1 however1 is never licit even to save the mother's life1 and in abortion the killing is direct because it is used as a means to an end4 ,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 now2 the secondary effect is the permitted death of the fetus from the shutting off of the blood supply4 ,in the abortion of a premature fetus the primary effect of the operation is to separate the placenta from the uterus1 to cut off the child's blood supply1 and as a direct consequence of this act1 which is essentially evil1 the woman's life is saved4 ,the original act in this abortion is evil1 and evil may not be done even if good follows4 ,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 aggressor4 ,in a killing in self-defence there are two distinct effects2 in abortion there is only one effect1 and the killing is a means to this one effect4 ,that you may kill an irresponsible insane man who is attacking your life1 or the life of one entrusted to your care1 is no reason that you may attack a fetus in the womb4 ,there is no parity4 ,the insane man is a materially unjust aggressor2 the fetus is not an aggressor at all4 ,the mother placed it where it is2 and if any one is an aggressor1 she is4 ,in the abortion you directly kill the fetus and indirectly save the woman's life1 and this indirection uses the death of the fetus as a means to the end of saving the woman's life4 ,in killing the insane aggressor you directly save the life of yourself or your ward1 and reluctantly permit the death of the aggressor4 ,the proofs of the essential immorality of direct homicide have already been established in the general chapter on ,homicide4 ,the assertion that an undeveloped fetus in the womb is not as valuable as the mother of a family is beside the question1 and in certain vital distinctions it is untrue4 ,any human life1 as such1 whether in a fetus or an adult1 is as valuable as another1 inasmuch as no one but ,god has any authority to destroy it1 except when it has lost its right to existence through culpable action4 ,secondly1 the quality of motherhood is an accidental addition to a mother's life1 not substantial as is the life itself4 ,this quality of motherhood does not create any juridic imbalance of values which justifies the destruction of the rights inherent in the fetus4 ,that the fetus may not be able to enjoy these rights if the mother dies is1 again1 an irrelevant consideration4 ,there is no question of a comparison of values4 ,a life is a life1 whether in mother or fetus1 and the destruction of an innocent life by any one except its creator1 ,god1 is essentially an evil thing1 like blasphemy4 ,an innocent fetus an hour old may not be directly killed to save the lives of all the mothers in the world4 ,insisting on such comparisons supposes ignorance and sentimental opposition to truth4 ,it is a good deed to save a mother's life2 but such saving by killing an innocent human being ceases to be good and becomes indescribably evil1 an enormous subversion of the order of the natural law1 as it is a usurpation of the dominion over life possessed by ,god alone4 ,if ,i owe a man a vast sum of money and the payment of this debt will ruin me and my children1 it would be a good thing for me and them to have this creditor put out of the way by death1 but that fact is no justification whatever for me to kill the man4 ,the fetus in the womb in a case where there is question of therapeutic abortion is like this creditor3 it would be well for the mother to have this fetus out of the way1 but that is no justification whatever for her to kill the fetus1 or to let it be killed by a physician4 ,the physician who kills such a fetus is exactly like a hired bravo who assassinates a troublesome creditor for a fee1 except that the physician does the nasty job for less money4 ,to hasten even an inevitable death is homicide1 and that quality of merely hastening adds nothing for extenuation3 every murder is merely a hastening of inevitable death4 ,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 health2 to ease pain is not commensurate with the horrible deordination of taking a human life4 ,this subversion of the moral law in the interest of mawkish sentimentality is one of the gravest evils of modern social ignorance4 ,physicians are constantly mistaking inclination1 or the mental vagaries of the nurses who influenced their childhood1 for rules of moral conduct4 ,a physician is not a public executioner1 nor a judge with the power of life and death3 his business is solely to save human life1 never to destroy it4 ,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 family1 where would such false logic stop8 ,if it held for the taking of life in an unpleasant condition1 it would hold a fortiori in every other less unpleasant condition where a life would not be at stake4 ,when a note that you had given falls due and it would bankrupt you to pay it1 does this inconvenience let you out of the difficulty in honor1 in the moral law1 or in the civil law8 ,it certainly does not2 but it should if the doctrine of the sentimentalists on abortion were true4 ,an eclamptic woman1 or one with hyperemesis gravidarum1 conceived the child1 got into the difficulty1 and she and her physician have no right to tear up the note they have given to the ,creator1 especially when such tearing implies murder4 ,suppose1 again1 a woman has done a deed for which she has in due process of just law been condemned to death2 suppose1 also1 there is only one man available to put her to death1 and if this man were killed she could escape4 ,would her physician be permitted to shoot that executioner to let her out of the difficulty8 ,certainly not4 ,that1 however1 is just what the physician does who empties an eclamptic uterus of an unviable fetus4 ,you may not do essential evil that anything under the sun1 good1 bad1 or indifferent1 may come of it4 ,if ,i may kill a so-called useless fetus to save a useful mother1 do gross evil to effect great good1 why should ,i stop there8 ,why1 then1 may ,i not rob a church to make my children rich1 murder a useless miser to employ his money in founding orphanages1 shoot any oppressor of the poor1 kick out of doors my senile and bothersome father1 reject all my most sacred promises whenever their observance makes me suffer8 ,where will the sentimental moralist draw the line8 ,that the civil law permits therapeutic abortion is no excuse at all2 it is merely a disgrace of the civil law4 ,the ,american civil law permits many things that are contrary to morality and the law of ,god3 it absolves bankrupts even if they afterward become solvent2 it permits the marriage of divorced persons2 it levies unjust school taxes2 it gives unjust privileges2 it squanders the money of the citizens2 and so on4 ,if a woman marries in good faith a man she deemed a gentleman1 but who turns out to be a syphilitic sot who disgraces her and makes her life a perpetual misery1 immeasurably worse than the condition of any eclamptic woman1 no greater blessing could come to her and her children than his death4 ,would she therefore be justified before any tribunal of ,god or man in murdering him to get rid of her trouble8 ,no2 she must bear with her evil for the sake of social order and of eternal right4 ,so must the eclamptic woman4 ,if it is murder to kill a child outside the womb1 and mere therapeutics to kill it inside the womb1 then it is murder to shoot a man on the street1 and mere good marksmanship to shoot him to death inside his house1 especially if he is an undesirable citizen4 ,all reputable physicians deem a fetus in a normal pregnancy so good that they will not dream of destroying this fetus4 ,they absolutely refuse to effect an abortion to get rid of a fetus which may disgrace an unmarried woman and her family1 and they are perfectly right in this refusal4 ,they talk and write with genuine indignation of race suicide4 ,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 life4 ,they observe the natural human instinctive repugnance to murder in this special speech and writing1 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 kidneys4 ,they show here the fine intellectual acumen and reasoning ability of a chronic lunatic4 ,the first fact in the social order is that justice1 law1 order1 should prevail1 no matter what the cost4 ,it might be better that the fetus should die than that the mother should die1 though that is not always true4 ,it is not better that an unbaptized fetus should die than that a mother in the state of grace should die4 ,but these are irrelevant considerations4 ,it is never better that the fetus should be killed than that the mother should die4 ,that is a very different matter4 ,the ,mignonette case in #ahhd1 tried in ,england by ,lord ,coleridge1 is a good example of evaluation of lives as in therapeutic abortion1 which came to grief4 ,a ship called the ,mignonette foundered #afjj miles from the ,cape of ,good ,hope1 and three of its crew1 with a boy1 were for a long time at sea in an open boat without provisions4 ,when they were almost starved the boy lay on the bottom of the boat1 asleep or half conscious from weakness4 ,two of the men plotted to kill the boy for therapeutic purposes2 they needed his flesh to save their own lives4 ,they killed the poor lad just as the therapeutic abortionist kills a fetus4 ,they got his uncooked flesh for four days4 ,later ,lord ,coleridge got them and he sentenced both of them to death4 ,another ,lord will get the therapeutic abortionists4 ,what1 then1 is the physician to do who meets a case that imperatively calls for therapeutic abortion according to the common medical practice8 ,he can do nothing4 ,the law may seem hard in certain circumstances to those who cannot see beyond the physical2 yet that fact does not abrogate the law1 which is one of essential morality4 ,may the physician call in a physician who1 he knows1 will not scruple to perform the therapeutic abortion on an unviable fetus8 ,if he does1 he is as much a murderer as if he did the deed himself4 ,he may not so much as suggest the name of some one who will do the deed4 ,he simply tells the family he can do nothing4 ,if they insist on the abortion he withdraws from the case4 ,in this connection it is necessary to mention again the question of viability4 ,langstein reported#ij a study of the growth and nutrition of #bej prematurely born infants1 and he found a confirmation of what was already known1 that a weight of #ajjj grammes 7#b-a_/e pounds7 and a full body length of #cd centimetres 7#ac-c_/e inches7 are the lowest limits for viability under proper circumstances4 ,a fetus #ajjj grammes in weight and #cd centimetres in length has completed the sixth solar or calendar month1 or the sixth and a half lunar month--it is beginning its seventh month1 not ending it1 yet it is viable under proper conditions4 #ij ,berliner klinische ,wochenschrift1 ,june #ad1 #aiae4 ,the child at term1 on a rough average1 is from #dh to #eb centimetres 7#ai to #bj-a_/b inches7 in length1 and it weighs from about #f-c_/e to #g-a_/b pounds4 ,it is impossible1 however1 to obtain the sizes and weights of infants in utero with scientific accuracy1 because the date of conception cannot be determined with absolute certainty1 and infants in utero vary as they do after birth4 ,a full-term infant sometimes may weigh only #c-a_/b pounds when the mother is diseased1 and at times an eight-months fetus will weigh as much as #h pounds4 ,as was said in ,chapter ,,iii1 a fetus of six completed calendar or solar months 7not lunar--the duration of gestation is often reckoned in lunar months by obstetricians7 is viable provided it is cared for by competent physicians in a hospital4 ,otherwise it is not viable1 except in a strictly technical sense2 it will not live more than a few days or weeks4 ,a full seven-months infant may be reared with proper feeding and skilled care2 a six-months infant may be reared 7with difficulty7 in a hospital with skilled care4 ,if it is certain that the removal of a six-months fetus will here and now save the life of a mother 7a very difficult matter to judge by the best diagnosticians71 this removal may be done1 provided the infant is delivered in circumstances where skilled care1 incubator1 and proper food are obtainable2 otherwise the removal is not justifiable4 ,the ,council of ,lerida1 in ,catalonia1 in the year #ebd1 decreed that abortionists of any kind must do penance all their lives1 and if they are clerics they are to be suspended perpetually from all ecclesiastical ministration4 ,the ,council of ,worms1 under ,hadrian ,,ii41 in the year #hfh1ia also judged women who procure abortion as certainly guilty of murder4 #ia ,cap4 #ce4 ,in the ,corpus ,juris1#ib among the decretals of ,gregory1 there is the following law3 ,if any one1 through lust or hatred1 does anything to a man or woman1 or gives them any drug1 so that they cannot either generate or conceive1 or bear children1 he is to be treated as a murderer4 #ib ,lib4 v1 tit4 xii1 c4 #e4 ,sixtus ,v41 in the ,constitution ,effraenatam1 ,october #bi1 #aehh1 mentions a decree of the ,sixth ,synod of ,constantinople1 in session in #fhj and #fha1 which subjects those who perform abortion1 or kill a fetus1 to the punishment inflicted on murderers4 ,sixtus then decreed that any one who effects the abortion1 directly or indirectly1 of an immature fetus1 whether the fetus is animated1 formed1 or not1 either by blows1 poison1 drugs1 or potions1 or tasks of hard labor imposed on pregnant women1 or any other method1 however subtle or obscure it be1 is guilty of murder1 and is to be punished accordingly4 ,he recalls all ecclesiastical privileges from clerics who cause abortion1 and says that they are to be reckoned as murderers according to the decree of the ,council of ,trent1#ic and he makes a law that abortionists may never be promoted to orders4 #ic ,session xiv1 ,de ,reformatione1 cap4 #g4 ,in the fifth paragraph he says3 ,moreover1 we decree that the same penalties are incurred 7#a7 by those who give potions and poisons to women to induce sterility or prevent conception1 or who cause these drugs to be administered1 and 7#b7 by the women themselves who freely and consciously take these drinks4 ,in paragraph seventh he decrees that any one1 man or woman1 cleric or lay1 who procures abortion by counsel1 favor1 drinks1 letters of advice1 signs1 or in any way whatever1 are ipso facto excommunicated1 and the excommunication is reserved to the ,pope himself4 ,gregory ,,xiv41 in the constitution ,sedes ,apostolica1 ,may #ca1 #aeia1 gave to priests who have special faculties for the purpose from the bishop1 permission to absolve from this excommunication1 but only in foro conscientiae4 ,sixtus ,v4 and ,gregory ,,xiv4 used the term foetus animatus1 in keeping with the old ,aristotelian notion of animation4 ,pius ,,ix41 in the constitution ,apostolicae ,sedis ,moderationi1 deleted the epithet animatus1 and extended the excommunication to all abortions1 no matter at what time of the gestation they occur4 ,he ordered that only the actual physical abortionist is to be excommunicated1 not those who counsel the crime4 ,some moralists hold that those who order abortion are direct abortionists and fall under this excommunication2 other moralists oppose this opinion4 ,pius ,,ix4#id excommunicates procurators of abortion if actual abortion is effected1 and this excommunication is reserved to the bishops1 not to the ,pope4 #id ,sect1 iii1 cap4 ii4 ,in this decree occur the words ,procurantes abortum1 effectu secuto1 and there has been considerable discussion of the question who are the procurantes1 the agents who fall under the excommunication8 ,again1 are craniotomy1 cephalotrypsis1 decapitation1 embryotomy1 and exenteration1 when performed on the living child1 abortions in the sense of the decree1 and thus matter of the excommunication8 ,those who do abortion are the principal agents who physically1 immediately1 of themselves1 in their own name1 or who morally1 through others1 perform an abortion4 ,the common opinion of moralists is that all those who of themselves or through others bring on an abortion are excommunicated1 but that assistants1 although guilty of crime1 are not excommunicated4 ,many eminent moralists are of the opinion that the mother herself who seeks an abortion does not fall under the excommunication because ,sixtus ,v4 does not explicitly mention her in this penal law1 and a penal law is to be interpreted literally4 ,if a pregnant woman goes to an abortionist and persuades him by speech and pay to do an abortion1 she is the direct moral cause of that abortion4 ,if it were not for her1 the abortion would not take place4 ,virtually all abortions done on married women are effected morally by the woman herself4 ,in my opinion1 and the new canon law states this explicitly1 the woman who procures an abortion on herself or on another woman is excommunicated4 ,sabetti-,barrett#ie holds that craniotomy on a living child and the removal of an inviable extrauterine fetus are not abortion in the scope of this excommunication1 because as a penal law these operations are not specifically mentioned4 ,all mutilating operations1 like craniotomy and the others enumerated above1 first kill the fetus1 then extract its body from the womb2 abortion first extracts the fetus and then lets its die4 ,the result is the same1 but the operations differ technically1 and a penal law is ad literam4 ,a cleric who procures abortion of an inviable fetus at any time of gestation falls under the excommunication and suspension a sacris perpetually1 although he probably is not technically irregular canonically if he procures the abortion before the ,aristotelian date of animation4 ,the bull ,effraenatam makes the canonical irregularity at the ,aristotelian date obsolete practically4 #ie ,compendium ,theologiae ,moralis1 #aiae1 n4 #ajji4 ,in the church the ,holy ,office 7that is1 the ,inquisitors-,general in matters of faith and morals7 is the official authority which interprets1 under the approval of the ,pope1 the morality of acts like abortion and related operations4 ,in #ahie the following difficulty was proposed to the ,holy ,office for solution3 ,a physician is treating a woman with a disease which will certainly be fatal to her unless cured medically1 and the disease is due to the presence of a fetus in her womb4 ,to save her it is necessary to empty the uterus1 but the fetus is not yet viable4 ,the question is1 ,may the physician perform therapeutic abortion in such circumstances8 ,on ,july #bd1 #ahie1 the ,holy ,office answered3 ,the ,inquisitors-,general in matters of faith and morals1 with the vote of their ,consultors1 decree3 ,negatively1 in accord with the other decrees of ,may #bh1 #ahhd1 and ,august #ai1 #ahhh4 ,in ,may1 #ahih1 the following questions were proposed to the ,holy ,office3 ,i4 ,is the induction of premature labor licit when a contracted maternal pelvis prevents the birth of a child at term8 ,,ii4 ,if the maternal pelvis is so narrow that premature delivery is impossible1 is it licit to perform abortion1 or to effect cesarean delivery at the proper time8 ,,iii4 ,is laparotomy in extrauterine gestation licit8 ,may #d1 #ahih1 the ,holy ,office answered1 with the assent of ,leo ,,xiii3 ,i4 ,premature labor in itself is not illicit1 provided it is done for sufficient reason1 and at the time and by such methods as will under ordinary circumstances preserve the life of the mother and the fetus4 ,,ii4 ,as to the first part1 the answer is negative1 according to the decree of ,july #bd1 #ahie1 on the unlawfulness of abortion4 ,as to the second part1 there is no objection to the cesarean delivery at the proper time4 ,,iii4 ,in a case of necessity1 a laparotomy to remove an ectopic fetus from the mother is licit1 provided the lives of both mother and fetus are1 so far as is possible1 carefully and opportunely preserved4#if #if ,dummodo et foetus et matris vitae serio et opportune provideatur4 ,march #e1 #aijb1 this question was asked the ,holy ,office3 ,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 conception8 ,the answer was3 ,negatively1 in accord with the decree of ,may #d1 #ahih1 by which the lives of the fetus and mother1 as far as possible1 are carefully and opportunely preserved4 ,as to the time1 the questioner is reminded by the same decree that no premature delivery is licit unless effected at the time and by the methods which1 under ordinary circumstances1 will preserve the lives of mother and fetus4 ,the ,english civil law concerning abortion#ig is3 ,whoever shall unlawfully supply or procure any poison or other noxious thing1 or any instrument or thing whatsoever1 knowing that the same is intended to be unlawfully used or employed with intent to procure the miscarriage of any woman1 whether she be or be not with child1 shall be guilty of a misdemeanor1 and being convicted thereof shall be liable1 at the discretion of the court1 to be kept in penal servitude for the term of three years1 or to be imprisoned for any term not exceeding two years1 with or without hard labor4 #ig ,statutes #bd and #be1 ,victoria1 cap4 #ajj1 sec4 #ei4 ,alfred ,susaine ,taylor1#ih commenting on this law1 said3 ,strictly speaking1 there is no such thing as justifiable abortion2 the law recognizes no such possibility4 ,a medical man must always remember this when he contemplates emptying a pregnant uterus4 #ih ,principles and ,practice of ,medical ,jurisprudence4 ,london1 #aije4 ,it is obvious that the only reasons that can be thought of by an honorable man as justifying the induction of labor are 7#a7 to save the life of the mother2 7#b7 to save the life of the child4 7,some religions will not contemplate the first reason1 but that we are not now concerned with47 ,it cannot be done for the sake of family honor nor for any similar ethical reason4444 ,the golden rule is never to empty a uterus without first having a second professional opinion as to its necessity2 if this opinion be adverse1 do not do it2 if it be favorable1 it is well to get it in writing1 and it is well also to get the written or attested consent of the woman and her husband1 and then proceed to do it with all the skill and care possible4 ,the death of the fetus is at any time the most certain means of causing the womb to empty itself1 but after the sixth month the operation is performed necessarily with a view to preserving this life1 and steps must be taken accordingly4 ,coke1 about #afae1 judged that to kill a child in the womb is not murder1 but if it is expelled by violence and dies after it leaves the womb1 that is murder4 ,the law in ,pennsylvania#ii is3 ,if any person1 with intent to procure the miscarriage of any woman1 shall unlawfully administer to her any poison1 drug1 or substance whatsoever1 or shall unlawfully use any instrument1 or other means whatsoever1 with the like intent1 such person shall be guilty of felony1 and being thereof convicted1 shall be sentenced to pay a fine not exceeding five hundred dollars1 and undergo an imprisonment1 by separate or solitary confinement at labor1 not exceeding three years4 ,it makes no difference in ,pennsylvania law whether the child is quickened or not4 #ii ,laws of ,pennsylvania1 ,act of ,march #ca1 #ahfj1 sec4 #hh4 p4 #djd4 ,the ,new ,jersey1 ,massachusetts1 and ,wisconsin laws are like the ,pennsylvania law4 ,the law in ,iowa#ajj is3 ,if any person1 with intent to procure the miscarriage of any pregnant woman1 wilfully administer to her any drug or substance whatever1 or1 with such intent1 use any instrument or other means whatever1 unless such miscarriage shall be necessary to save her life1 he shall be imprisoned in the penitentiary for a term not exceeding five years1 and be fined in a sum not exceeding one thousand dollars4 ,to the same effect are the laws in ,connecticut1 ,maine1 ,new ,york1 ,ohio1 ,michigan1 ,minnesota1 ,colorado1 ,texas1 and ,maryland4 #ajj ,laws of #ahig1 ,iowa ,code1 #dgei4 ,frank ,winthrop ,draper1 professor of legal medicine in ,harvard ,university1#aja commenting on the ,massachusetts law of ,october1 #aijc1 cap4 #bab1 secs4 #ae1 #af1 says3 ,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 labor4 ,the statute is general in its application4 ,it is1 of course1 obvious that the best sentiment of the medical profession and of obstetric teachers is favorable to interference of pregnancy1 7#a7 whenever there is such anatomical deviation or mechanical obstruction in the mother's pelvis that the birth of a child is impossible2 or 7#b7 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 gestation4 ,under such conditions the physician is not only warranted in inducing premature labor1 but is required to do so by a sense of duty to his patient1 with a view thereby to save one life at least1 and1 if possible1 the lives of both mother and offspring4 #aja ,legal ,medicine1 #aije4 ,nevertheless1 as the law now stands1 a prudent practitioner will not expose himself to any risk1 if a few precautions will save him4 ,in the event of the death of the mother and child in such an emergency1 the attending physician might find himself in jeopardy1 with the imputation of gross carelessness and criminal neglect hanging over him1 an imputation which requires years to remove4 ,so the attending physician should never undertake to do an instrumental operation without these precautions3 #a4 ,the consent of the patient1 with that of her husband or family4 #b4 ,especially1 a consultation with some other physician or physicians in whom there is full confidence4 ,attention to these simple and sensible safeguards1 by making the conduct appear by its candor and openness in the strongest possible contrast with the secret methods of the abortionist1 may save great embarrassment4 ,the ethics of this doctrine is1 of course1 absurd1 as has been shown1 and it is cited here only to show how the civil law considers abortion4 ,wharton and ,stille#ajb give the same information in a more technical manner4 ,it is a general rule1 they say1 independent of statute1 that the act of a physician in aiding a miscarriage is not unlawful1 where the miscarriage was the inevitable result of other causes4 ,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 mother4 ,and the statutes of many of the ,states penalize the causing1 or attempting to cause1 an abortion1 unless necessary to preserve the life of the woman1 or unless advised by a designated number of physicians to be necessary for such purpose1 the absence of both the necessity and the advice being an essential ingredient in the crime4 ,the physician by whom the deed is done1 however1 cannot act as his own adviser in the matter4 ,and an indictment under the statute must not only allege that the act was not necessary to preserve the woman's life1 but must also negative the advice of physicians2 and such averments cannot be inserted as an amendment after demurrer4 #ajb ,medical ,jurisprudence1 vol4 iii1 sec4 #ebf4 ,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 question2 and the absence of necessity may be determined from circumstantial evidence4 ,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 general1 and would rest with the accused2 though it may be proved by a preponderance of the evidence and need not be established beyond a reasonable doubt4 ,but either that the act was necessary to preserve the life of another1 or that it was advised by physicians to be necessary for that purpose1 is of equally good defence2 and the destruction of the child need not have been both necessary and advised by physicians4 ,and statutes of this class apply only in cases in which the death of the mother could reasonably be expected to result from natural cause1 unless the child was destroyed1 and do not apply to a case in which the mother threatened suicide unless she was relieved from her trouble4 ,,chapter ,,vi ,,ectopic ,,gestation ,ectopic ,gestation1 called also extrauterine pregnancy1 is gestation outside the uterus in the adnexa or the peritoneal cavity4 ,pregnancy in the horn of an abnormal or rudimentary uterus is classed with ectopic gestation because the effects are similar1 although pregnancy at times in a rudimentary uterus goes on to term normally4 ,the uterus is in the pelvic cavity1 between the bladder and the rectum1 and above the vagina1 into which it opens4 ,it is a hollow1 pear-shaped1 muscular organ1 somewhat flattened1 and about three inches long1 two inches broad1 and an inch thick4 ,the fundus or base is upward1 and the neck is downward4 ,passing horizontally out from the corners or horns of the uterus1 which are at the fundus1 are the two ,fallopian tubes1 one on either side4 ,these are about five inches in length and somewhat convoluted4 ,they are true tubes1 opening into the uterus1 and they are about one-sixteenth of an inch in diameter throughout the greater part of their extent4 ,the ends farthest from the uterus are fringed and funnel-shaped2 and this funnel end1 called the ,infundibulum or ,fimbriated ,extremity1 opens into the abdominal or peritoneal cavity4 ,near the ,fimbriated ,extremity of each tube is an ,ovary1 an oval body about one and a half inches long by three-quarters of an inch in width4 ,for convenience in description1 each tube is divided into four parts3 7#a7 the ,uterine ,portion1 which is that part included in the wall of the uterus itself3 it extends from the outer end of the horn into the upper angle of the uterine cavity1 and its lumen is so small that it will admit only a very fine probe2 7#b7 the ,isthmus1 or the narrow part of the tube which lies nearest the uterus3 it gradually widens into the broader part called 7#c7 the ,ampulla2 7#d7 the ,infundibulum1 or the funnel-shaped end of the ,ampulla4 ,one of the fimbriae1 the ,fimbria ,ovarica1 is longer than the others1 and it forms a shallow gutter which extends to the ovary4 ,the uterus1 tubes1 and ovaries lie in a septum which reaches across the pelvis from hip to hip4 ,this septum is called the ,broad ,ligament4 ,if a man's soft hat1 of the style called ,fedora1 is inverted1 the fold along the crown coming up into the cavity of the hat is like the broad ligament4 ,as the crown is held downward the uterus would be in the middle1 its fundus upward1 and outside the hat1 representing the pelvic cavity1 but in the crown fold4 ,the tubes and ovaries would also be in the crown fold1 or broad ligament1 and the fimbriated extremities would open into the interior of the pelvic cavity through holes4 ,the ovum breaks through the surface of the ovary into the pelvic cavity1 passes1 probably on a capillary layer of fluid1 into the fimbria ovarica and thence into the infundibulum1 whence it moves along slowly into the uterus4 ,ovulation and menstruation occur about the same time ordinarily1 and if the ovum produced is not fecundated it gradually shrivels and passes off through the uterus and vagina4 ,fecundation of the ovum rarely occurs in the uterus1 but ordinarily in the ,fallopian tube4 ,after fecundation the ovum is pushed on through the ,fallopian tube into the uterus in from five to seven days1 where it fastens to the wall and develops normally4 ,hyrtl described an ovum which appeared to reach the uterus in three days4 ,if from some abnormal condition of the ,fallopian tube the fecundated ovum is blocked and held in the tube1 the embryo grows where the ovum stopped1 and we have a case of ,ectopic ,gestation4 ,in normal pregnancy in the uterus1 the uterus grows with the embryo1 but a tube does not4 ,in the latter condition1 when the ovum is big enough it bursts the tube or slips out through the ampulla1 causing hemorrhage or other pathological symptoms4 ,there are certain rare abnormalities of the uterus through imperfect embryological development1 and pregnancy in such a uterus may result in symptoms like those of ectopic gestation4 ,normally the uterus and vagina are formed by the fusion of the two ,mllerian ducts4 ,when these ducts do not fuse perfectly1 or when one develops partly1 the various kinds of abnormal wombs and vaginas are the results4 ,there may be a double uterus with a single or double vagina1 a uterus with a complete or partial septum down the middle1 a uterus with one horn1 a uterus with a developed horn and a rudimentary horn1 and the rudimentary horn may be open or shut1 and so on4 ,in many of these conditions the ovum becomes blocked and rupture follows as in ectopic gestation4 ,when the ectopic ovum begins to develop in the ,fallopian tube the placental villi erode the tubal wall and the blood-vessels4 ,at length the ovum slips out of the ampulla--the common result--or the tube bursts4 ,the break may be traumatic in origin1 from jarring or a like accident1 or it may be spontaneous4 ,if the rupture is through the tube there is hemorrhage into the pelvic cavity2 if the ovum slips out of the ampulla the tubal abortion causes hemorrhage as in uterine abortion4 ,in either case the blood with peritoneal fibrin forms a hematocele1 and this1 with the ovum1 may be finally absorbed2 or the woman may bleed to death unless the hemorrhage is checked surgically2 or the child may live for varying periods up to term4 ,the tube rarely ruptures into the fold of the broad ligament4 ,the fetus usually dies after rupture or tubal abortion1 and if it has not advanced beyond the eighth week it is absorbed4 ,sometimes it lives4 ,when the rupture or abortion does not tear the placental site the fetus may develop in the abdominal cavity4 ,between #ahhi and #ahif ,haines#ajc found #dj operations for ectopic gestation done after the seventh month of pregnancy with #aj maternal deaths4 ,of the children1 #bg survived the operation from a few moments to fifteen years4 ,sittner1 in #aijc1 compiled from the medical reports #adb cases of viable ectopic fetuses1 and ,essen found #be additional cases4 ,since ,essen's article more have been reported1 about #agc to my knowledge1 but the number is considerably larger4 #ajc ,kelly's ,operative ,gynaecology4 ,new ,york1 #ahih4 ,hirst says an experienced obstetrical specialist sees from #ab to #bd cases of ectopic pregnancy annually4 ,kstner himself operated on #aje cases in five years4 ,about #gh per cent4 of all ectopic gestations result in tubal abortion and #bb per cent4 in rupture4 ,many specialists now are of the opinion that the diagnosis of ectopic gestation ordinarily is not difficult1 but most physicians find it very difficult4 ,before rupture of the tube or a hemorrhage diagnosis is hardly ever made by any one1 and no pelvic condition gives rise to more diagnostic errors4 ,when there is rupture or tubal abortion the symptoms may lead the physician to mistake the condition for uterine abortion4 ,in uterine abortion the onset of the symptoms is quiet1 with gradually intensifying and regular pains1 resembling labor1 in the lower abdomen4 ,in ectopic pregnancy the symptoms of a rupture or tubal abortion arise quickly1 with irregular and colicky or very violent pains1 localized on one side4 ,in uterine abortion the external hemorrhage is more or less profuse1 with clots2 in ectopic gestation the external hemorrhage is slight or absent2 the shock in the latter case is out of proportion to the visible blood loss4 ,parts of the ovum1 or the presence of the whole ovum1 as uterine1 are found in ordinary abortion1 but in the ectopic condition the ovum proper does not appear4 ,an intrauterine angular pregnancy1 or pregnancy in a uterine horn1 causing the upper corner of the womb to bulge sidewise1 may be mistaken for ectopic gestation4 ,pregnancy in a retroflexed uterus1 tumors of the adnexa1 the twisted pedicle of an ovarian tumor1 a burst pyosalpinx1 an appendicitis in pregnancy1 or a combined intrauterine and ectopic gestation1 also may confuse the diagnosis4 ,when there is a dangerous hemorrhage from rupture or tubal abortion the diagnosis is usually made without difficulty from the collapse and other signs4 ,the diagnosis as to whether the fetus in the pelvis is dead or alive may be made 7#a7 from the absence or presence of symptoms of tubal rupture during the second and third months1 or of mild symptoms indicating only slight bleeding2 7#b7 from the continuation and progress of the evidences of pregnancy1 as nausea1 mammary changes1 fetal movements1 or audibility of the fetal heart2 7#c7 from the presence of a loud uterine blood souffle2 7#d7 from the absence of toxemia or suppuration2 7#e7 from a growth of the uterus and a softening of the cervix2 7#f7 from a gradual increase in the size of the suspected ectopic fetal tumor4 ,in making the diagnosis great caution must be observed1 as roughness in manipulation may start hemorrhage or rupture a thinned tube4 ,the diagnosis may be made3 7#a7 that ectopic gestation exists without symptoms of maternal hemorrhage1 and the fetus is not viable2 7#b7 that the same maternal condition may be present1 but the fetus is viable2 7#c7 that there may be symptoms of slight bleeding1 and the fetus is inviable2 7#d7 that there may be symptoms of grave maternal hemorrhage at any stage of the gestation4 ,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 removed4 ,if the fetus is alive and inviable this procedure will1 of course1 kill it4 ,only a few obstetricians of authority advise an expectant treatment4 ,schauta found #ge recoveries and #aff maternal deaths in #bda cases treated expectantly--a mortality of #fi per cent4 ,if there are no symptoms of maternal hemorrhage but the fetus is evidently dead1 the fetus is to be removed4 ,if it is evidently alive1 or doubtfully alive1 the treatment must be expectant4 ,the woman is to be removed to a hospital and kept under constant watch1 day and night1 with everything prepared for immediate operation4 ,any woman while bearing an ectopic fetus is in constant grave danger of death1 but the moralists hold that her danger is not so imminent before actual rupture as to justify the death of the fetus by precautionary removal4 ,in #ahhf the ,archbishop of ,cambrai proposed the following list of questions to the ,holy ,office for decision3 #a4 ,may a pregnant woman in danger of death from eclampsia or hemorrhage be prematurely delivered of a viable child8 #b4 ,may a woman in the same condition be delivered in urgency by means which will kill the infant8 #c4 ,may a woman in articulo mortis be delivered of a viable child if the delivery will somewhat hasten her death8 #d4 ,may the woman in question #a be delivered of an inviable fetus8 #e4 ,may the woman in question #c be delivered of an inviable fetus8 #f4 ,may a woman who is about to become blind1 paralytic1 or insane from her pregnancy be prematurely delivered of a viable child8 #g4 ,may the woman in question #f be delivered by means which will kill the fetus8 #h4 ,may the woman in question #f be delivered of an inviable child8 #i4 ,may the woman in question #f be delivered of an inviable child1 supposing the child to be in articulo mortis8 #aj4 ,may an ectopic fetus be killed by operation1 electricity1 or poison1 to avert possible danger of death from the mother8 #aa4 ,may a surgeon who has opened the abdomen for some condition not uterine incidentally remove a viable ectopic fetus8 #ab4 ,with conditions like those in question #aa1 except that the fetus is not viable1 may the surgeon remove the inviable ectopic fetus8 ,three years later1 ,august #ai1 #ahhi1 the ,holy ,office answered these questions comprehensively3 ,in ,catholic schools it may not be safely taught that craniotomy is licit1 as was decided ,may #bh1 #ahhd1 or any other surgical operation which directly kills the fetus or the pregnant mother4 ,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 morally4 ,the ,holy ,office1 ,may #d1 #ahih1 again decreed3 ,necessitate cogente1 licitam esse laparotomiam ad extrahendos e sinu matris ectopicos conceptus1 dummodo et foetus et matris vitae1 quantum fieri potest1 serio et opportune provideatur4#ajd ,this decision was not clearly understood1 and on ,march #e1 #aijb1 the same congregation reported the following question3 ,is it ever licit to remove from the maternal pelvis an ectopic fetus which is still immature2 that is1 which has not yet completed the sixth month after conception8 ,the answer was1 ,no2 according to the decree of ,may #d1 #ahih1 which prescribes that the life of the fetus and the mother must as far as possible be carefully safeguarded4 ,as to the time1 according to the same decree1 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 fetus4#aje #ajd ,in a case of necessity1 it is licit to do a laparotomy for the removal of an ectopic gestation sac from the maternal pelvis1 provided the life of both fetus and mother be carefully safeguarded4 #aje ,negative1 juxta decretum #d ,maii1 #ahih1 vi cujus1 foetus et matris vitae1 quantum fieri potest serio et opportune providendum est3 quod vero tempus1 juxta idem decretum1 orator meminerit1 nullam partus accelerationem licitam esse1 nisi perficiatur tempore et modis1 quibus ex ordinarie contingentibus1 matris ac foetus vitae consulatur4 ,if the fetus is removed and so killed to avert a threatened danger to the maternal life1 but not an actually operative destruction of her life1 this removal or homicide is an evil means used to avert the danger4 ,there is no question of a double effect1 that is1 of two effects1 one good and the other evil1 coming with equal directness from the cause1 which is the removal or killing of the fetus2 but of a good effect1 the averting of the danger to the mother1 issuing from an evil cause1 the removal and death of the fetus4 ,a good effect does not justify the use of evil means2 it is not permitted morally directly to kill the fetus1 as in this case1 to save the mother from a threatened grave danger4 ,the case is not like that of the woman who has an operable cervical cancer while she is bearing an inviable fetus4 ,if the cancerous uterus is not removed the woman will surely die2 if it is removed she has a reasonable chance of cure2 but if the inviable ectopic fetus is not removed it is by no means certain that the woman will die4 ,in the cancer the uterus is directly removed1 the fetus is indirectly killed2 in the ectopic case the fetus is directly killed1 and the danger to the woman's life is removed as a direct effect of the killing4 ,again1 the killing of the inviable ectopic fetus cannot be justified by maintaining that the fetus is an unjust aggressor against the life of the mother4 ,an aggressor against life may be such formally or materially4 ,a formally unjust aggressor consciously and voluntarily attacks the life of the victim unjustly4 ,this perversion1 or evil1 in the aggressor's consciously actuated will sets his own right to life in juridic inferiority to that of the victim's right to life1 and the victim may defend his own life1 even unto the indirect death of the aggressor in necessity4 ,the materially unjust aggressor attacks the victim's life unjustly1 but whether the aggressor is sane or insane1 the attack is not voluntary4 ,when an insane aggressor appears to use his will1 such use lacks all moral quality because of the absence of intellect and reason2 he wills improperly1 as a brute is said to will4 ,in either case1 nevertheless1 there is active aggression directed against the victim's life1 which also sets the aggressor in juridic inferiority to the victim1 and permits the victim to defend his own life to extremes4 ,as great an authority as ,de ,lugo holds that in such defence1 whether the aggressor is formally or only materially such1 the victim may directly kill1 but direct killing is never necessary1 as it is all a matter of intention4 ,the ectopic fetus cannot1 of course1 be a formal aggressor because it cannot exercise either intelligence or will4 ,it is not a materially unjust aggressor1 because the only action it is capable of is to increase in size in obedience to the natural law of growth4 ,it is not trying in any manner to tear the maternal blood-vessels4 ,it has a right to its own life and a right to grow4 ,its growth may finally bring about a maternal hemorrhage1 but just now it is not causing that hemorrhage4 ,an aggressor is such only while there is an actual attack going on here and now1 directed against the victim's life4 ,the fetus is necessarily passive always1 never aggressive in any sense of the term1 until the actual rupture occurs4 ,if it may be deemed materially aggressive when the actual rupture is taking place1 the question becomes irrelevant1 because at that time the fetus may be removed for other reasons altogether4 ,if an insane man is in a room with a loaded revolver which he may not use against me1 but which he probably will1 ,i may not kill him in self-defence until he actually begins the aggression4 ,the opinion expressed here is the contrary of the opinion ,i expressed1 in #aijf1 in ,essays in ,pastoral ,medicine4 ,the second condition proposed is that the ectopic gestation exists without symptoms of maternal hemorrhage1 but the child is viable4 ,in such a case it is probably better to remove the fetus at once1 but only a skilled abdominal surgeon should attempt the operation because it is likely to be difficult from adhesions4 ,a viable ectopic fetus is usually deformed4 ,winckel found #ej per cent4 of them deformed--the head in #ge per cent41 the pelvic end in #ej per cent41 the arms in #dj per cent4 ,compression1 infraction1 hydrocephalus1 and meningocele are common4 ,the longer the fetus is left in1 the worse for the mother so far as peritoneal adhesions and danger and difficulty in removing the fetus are concerned4 ,the third case supposed that the fetus is not viable but the symptoms of maternal hemorrhage are slight4 ,the danger to the mother in waiting is greater here than in case one1 and the decision must be made in keeping with evidences in the particular case4 ,the surgeon who assumes responsibility is obliged to remain ready for instant operation4 ,where there are symptoms of grave hemorrhage in the mother at any stage of ectopic gestation the surgeon must operate at once1 and ligate the bleeding vessels to save the woman's life4 ,the ligation will shut off the blood supply to the fetus1 and thus indirectly1 permissively1 the fetus must be unavoidably allowed to die4 ,this is a clear case of double effect immediately issuing from the same cause1 and the operation is morally licit4 ,no matter how young the fetus is1 the surgeon or an assistant is to baptize it2 if it is very young it may be necessary to split the envelopes to get at the fetus4 ,,chapter ,,vii ,,cesarean ,,delivery ,in the cesarean delivery 7partus cesareus1 celiohysterotomy7 the infant is brought out through an opening made in the abdominal and uterine walls4 ,the chief indications for this operation may be a contracted maternal pelvis1 an abnormally large fetal head or body1 death of the pregnant mother before delivery1 certain forms of rigidity of the cervix uteri1 some cases of stenosis of the vagina1 relative vaginal narrowness1 blocking tumors1 or a ventrofixed uterus4 ,sometimes abruptio placentae1 eclampsia1 placenta praevia1 and other accidents of pregnancy are taken as indications for cesarean delivery4 ,an abnormal bony pelvic girdle is the most frequent obstruction to delivery of the fetus4 ,the lower part of the pelvis1 called the pelvis minor or true pelvis1 supports the muscles of the pelvic floor1 and gives shape and trend to the parturient canal4 ,the inlet and outlet of the true pelvis are narrower than its middle portion and are called the superior and inferior straits4 ,the inlet is somewhat cordate in outline1 and normally from front to back1 at its so-called conjugata vera1 it averages #aa centimetres 7#d-e_/af inches7 in depth2 from side to side it measures #ac centimetres 7#e-a_/h inches72 obliquely from the right posteriorly to the left anteriorly it is #ab-a_/b centimetres 7nearly #e inches71 and the other oblique conjugate is #ab centimetres 7#d-c_/d inches7 long4 ,the transverse diameter of the outlet1 from right to left1 is #aa centimetres2 the diameter from front to back1 because the coccyx can be pushed back in labor1 is from #i-a_/b 7#c-c_/d inches7 to #ab cm4 ,normal fetal head measurements average from side to side at the widest part1 #i-a_/b cm4 7#c-c_/d inches72 from the root of the nose to the occiput1 #aa cm42 from the chin to the occiput1 #ac cm42 from the vertex to the neck behind1 #i-a_/b cm4 ,the size of the fetal head is the most important factor in delivery1 so far as the child is concerned1 because1 as a rule1 when the head is delivered the compressible trunk follows readily4 ,normally the child presents in delivery with the vertex of the head first2 other presentations are transitional1 abnormal or pathologic4 ,in #dh1dii cases ,karl ,braun found vertex presentations in #ie4i per cent41 and ,schroeder in #bej1jjj cases found an average of #ie per cent4 ,the child's head is engaged when its largest diameter has passed the plane of the inlet4 ,an abnormal pelvis may be generally contracted1 dwarfed1 in all its diameters2 it may be flat or narrow from front to back2 it may be contracted from side to side2 it may be generally contracted and flat at the same time2 it may be obliquely contracted 7,ngeli's pelvis72 or it may be crowded together irregularly4 ,rachitis1 osteomalacia1 curvature of the spine1 habit scoliosis1 hip dislocation1 and similar pathologic states cause these distortions and contractions4 ,contraction of the pelvis affects the mother and child in parturition in proportion to the degree of the narrowing4 ,besides this1 the prognosis depends on the size of the child1 its presentation1 position1 and attitude1 the strength of the pains1 the skill and surgical cleanliness of the operator1 and the presence or absence of complications4 ,obstruction may bring about rupture of the uterus1 septicemia1 exhaustion and shock1 pressure narcosis1 or tears of the cervix or vagina4 ,if the child's head becomes impacted the vagina and vulva may become even gangrenous4 ,pressure may cause areas of necrosis resulting in fistulas into the bladder1 rectum1 or between the uterus and the vagina4 ,when the contracture is sufficient to let the fetus just engage1 pressure may interfere with the placental circulation and kill the child4 ,compression of the vagus nerve may slow the child's pulse and asphyxiate it through lack of oxygen in the blood4 ,the cord may prolapse4 ,the pressure on the child's head may cause fatal intracranial hemorrhage1 or effect permanent injury to the brain4 ,often it is extremely difficult to find out the best plan for delivering a woman who has a contracted pelvis4 ,where the conjugata vera is #i4e cm4 7#c-e_/h inches7 or above1 ,ludwig and ,savor found that #ge per cent4 were delivered without instrumental help4 ,at #i cm4 7#c-a_/b inches71 #eh per cent4 so end2 at #h cm4 7#c-c_/af inches71 #be per cent4 ,should the conjugata vera be less than #e-a_/b cm4 7#b-c_/af inches7 in a flat pelvis1 or #f cm4 7#b-c_/h inches7 in a generally contracted pelvis1 this is an absolutely contracted pelvis according to the old standard1 and the delivery must be by cesarean section1 whether the child is living or dead4 ,the minimal requirements have been gradually extended4 ,in #aija ,williams of ,johns ,hopkins ,university advocated that the absolute indication for cesarean section be changed to #g cm4 in the generally contracted pelvis1 and to #g4e cm4 in the simple flat pelvis4 ,his opinion was accepted by ,webster1 ,jewett1 ,edgar1 and others4 ,now some obstetricians of authority extend the measurements to #h cm4 ,if the woman is seen before labor1 or early in labor1 cesarean delivery alone is done4 ,when the uterus is infected it is usually necessary to remove it after taking away the child1 because an infected uterus left in place causes death by sepsis1 as a rule4 ,text-books on obstetrics have a series of rules1 based on pelvic measurements1 concerning the indications for cesarean or other methods of delivery in cases of contracted pelvis1 but the problems are not so simple and uniform as to be always accurately solved by the data derived from measurements4 ,one woman with a contracted pelvis may require cesarean delivery2 another woman with the same measurements may have a normal parturition because the child happens to be small or its skull compressible4 ,the best pelvic measurement is made with the fetal head4 ,a difficult decision as to whether a cesarean delivery is necessary or not comes up in the majority of cases in primiparae2 in multiparae the physician has the experience from former births to guide him4 ,in over #ij per cent4 of primiparae the fetal head normally is found engaged in the pelvis in the last week of gestation1 and can be felt by a vaginal examination4 ,in multiparae the head usually is not engaged until labor begins4 ,if the fetal head does not engage in a primipara1 this fact at once suggests an absolutely or relatively narrow pelvis4 ,when labor has begun1 if the fetal head cannot be pushed into the true pelvis of a primipara1 especially after anesthesia1 the necessity for cesarean delivery may be clearly evident4 ,in the cases where there is doubt that the child can get through the pelvis1 but good reason to think that it can1 many obstetrical experts try the effect of labor for two hours or a little more1 and if there is no real progress they deliver through laparotomy4 ,there is considerable objection now to version or the application of high forceps1 but many skilful men prefer these methods at times4 ,when version has been done and it fails there is no chance to save the child's life4 ,in the trial of labor1 the expectant treatment1 extraordinary watchfulness is required and a full knowledge of the special procedure that may be necessary4 ,in minor degrees of pelvic contraction the obstetrical practice is either to induce premature labor at the thirty-second week1 or to deliver by a cesarean operation1 or to delay and try labor4 ,in the last event there may be one of the following issues3 spontaneous delivery1 version and delivery1 extraction by high forceps1 cesarean delivery1 symphyseotomy1 hebosteotomy1 or craniotomy4 ,craniotomy on a living child is never to be considered under any circumstances4 ,symphyseotomy is a cutting of the maternal pelvic girdle through the symphysis pubis1 the rigid joint at the front middle part of the pelvis1 and thus letting the bony girdle dilate4 ,hebosteotomy or pubiotomy is a sawing through the pelvis near that joint to get the dilatation4 ,symphyseotomy has been replaced by hebosteotomy because the maternal mortality and morbidity are somewhat lessened by the latter method4 ,schlfli in #aijh reported #gjj hebosteotomies with a maternal mortality of #d4if per cent4 and a fetal of #i4ah per cent4 ,other operators have a better average2 still others a worse4 ,this operation is done very seldom of late except in a case where the fetal head is caught low in the pelvis1 or there is a chin-posterior or brow or face presentation1 and the cesarean operation would not deliver the child4 ,the varieties of the cesarean delivery as practised at present are the classic cesarean1 called also celiohysterotomy1 the ,porro cesarean1 or celiohysterectomy1 where the uterus is removed after the extraction of the child1 and the two sections in the cervical end of the uterus1 viz41 the extraperitoneal cesarean and the transperitoneal cervical cesarean4 ,before the days of antiseptic surgery cesarean delivery was practically always fatal to the mother4 ,tarnier could not find one successful outcome for the mother in ,paris during the nineteenth century up to his own time1 and ,spaeth said the same for ,vienna up to #ahgg4 ,in #ahgg ,porro of ,pavia advised the supravaginal amputation of the uterus after the child was delivered to avoid hemorrhage and peritoneal infection4 ,this operation replaced the classic cesarean until #ahhb1 when ,snger invented a suture which would keep the uterine incision shut1 and applied antisepsis4 ,snger's operation has been improved so much that cesarean delivery1 when performed by skilled obstetricians1 has an extremely low mortality in cases which have not been infected4 ,routh1 in #aiaj1 collected the statistics of ,great ,britain1 comprising #abhb cases1 which may be taken as a standard for all civilized countries1 and he found a steady decrease in the mortality until now it is near #b per cent4 in uninfected cases4 ,the dangers in the operation increase with every hour the woman is in labor1 but even then the general mortality is now down to about #h4a per cent4 ,this1 it must be remembered1 is the rate when competent men operate4 ,when the ordinary practitioner in small cities1 towns1 and country places operates the mortality is very high4 ,newell#ajf said that in four cities of from #be1jjj to #dj1jjj inhabitants within forty miles of ,boston he collected the following data3 in ,a no patient on whom cesarean section had been done is known to have recovered--a mortality of #ajj per cent4 ,in ,b the mortality is from #fj to #gj per cent4 ,in ,c the operation is invariably fatal when done by the local surgeons4 ,in ,d the fatality is from #aj to #bj per cent4 in average cases1 but since cesarean section has become popular as a method of treatment for eclampsia the mortality is over #ej per cent4 #ajf ,jour4 ,amer4 ,med4 ,assoc41 ,february #bd1 #aiag4 ,in spite of perfect technic by the best obstetricians1 the operation has a high morbidity3 fever1 peritonitis1 pneumonia1 dilatation of the stomach1 and other bad results are common4 ,before antiseptic surgery began1 opening the abdominal cavity was almost always fatal1 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 peritoneum4 ,the uterus was incised near its cervical end4 ,this method1 called extraperitoneal cesarean delivery1 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 womb4 ,the technic is more difficult than in the classic cesarean1 and the operation was not kindly received1 but of late some men are having so much success with it that it is reviving1 and rightly so4 ,baisch#ajg says that the first eleven women he delivered by extraperitoneal cesarean section recovered more readily than they would from an ordinary laparotomy4 ,in nineteen cases of transperitoneal but cervical section he had no trouble1 and six of these were infected cases4 ,the technic of this low incision protects the peritoneal cavity better than the classic incision1 apparently4 ,two of the nineteen women were in slight fever and the uterine fluids were fetid4 ,two primiparae forty years of age had been in labor seventy hours4 ,eight of the women were able to leave the clinic on the tenth day4 ,only one child was lost1 and that was a delayed case4 ,hofmeier#ajh compiled #aid cases of transperitoneal cervical cesarean section with three deaths4 ,kstner did #aaj extraperitoneal cesarean sections with no mortality4 ,this makes #cjd cases of cesarean cervical section1 not the classic operation1 with only three deaths1 less than #a per cent4 mortality2 and fully #ej per cent4 of these cases were not surgically clean4 ,from these statistics it is evident that the cervical operation in the hands of competent surgeons should be the operation of choice4 #ajg ,zentralblatt f4 ,gynkologie4 ,leipsic1 ,october #cj1 #aiae4 #ajh ,mnchener medizinische ,wochenschrift1 ,january #d1 #aiaf4 ,the ordinary practitioner1 however1 is utterly unfitted to do a cesarean section of any kind4 ,in large cities it is easy to find a trained surgeon to do the operation1 but in small towns and in country places there is seldom any one available4 ,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 day1 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 him4 ,this is as things should be2 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 city4 ,the physician in any case should be able at least to make the diagnosis in time1 before labor sets in1 and have the woman sent to the nearest city1 if possible4 ,dr4 ,bull#aji reported that he had traveled seventy-five miles to see a woman who was having severe hemorrhages at term4 ,he found her in a log cabin1 with a centrally implanted placenta 7i4e41 right across the opening of the cervix uteri71 and she had had three hemorrhages before his arrival4 ,he narcotized her1 took her in a train to a hospital1 delivered her by cesarean section1 and saved her and the child4 ,if he had delivered her by version in the log cabin1 he would almost certainly have lost both the mother and the child4 #aji ,jour4 ,amer4 ,med4 ,assoc41 ,september #cj1 #aiaf4 ,the question of removing the uterus comes up when the uterus is infected1 or as a method of sterilizing the woman to avoid the danger of a subsequent gestation4 ,whenever a uterus is gravely infected and a cesarean delivery is finally necessary1 the infection is commonly due to ignorance or carelessness1 and the physician or midwife is guilty4 ,there should be no such business as that of the midwife who actually delivers the patient4 ,the state should provide physicians for the poor4 ,even the midwife who calls herself a practical nurse1 but who is not a licensed trained nurse1 is commonly a public danger1 although some so-called practical nurses are better than the ordinary trained nurses4 ,suppose1 however1 that the uterus is infected unavoidably4 ,if this infection has been done by a competent obstetrician working in a hospital with sterile instruments1 it may be safe to deliver the woman by an extraperitoneal or cervical trans-peritoneal cesarean section4 ,if the practitioner has tried to deliver the woman at her home with forceps and has failed1 especially if repeated attempts have been made by the physician and an assistant or consultant1 the uterus should be amputated4 ,it will not do to deliver by a low cesarean and await developments1 because if the infection is serious no subsequent removal of the uterus will save the woman's life4 ,the grave mutilation of removing the uterus is1 of course1 licit1 as it is the only means of saving the woman's life4 ,some moralists hold that a woman from whom the uterus has been removed is impotent1 but this question has never been decided authoritatively1 as we shall show in the chapter on ,vasectomy2 and until it has been so decided the woman must be given the benefit of the doubt4 ,the question of removing the uterus solely to prevent the danger of subsequent deliveries differs from the condition just considered4 ,if the woman has had a cesarean delivery for an absolutely narrow pelvis1 her subsequent deliveries must be by the same method4 ,after a cesarean section there is more or less danger of rupture at the scar in other labors4 ,some think the danger is greater if the placenta becomes implanted on the scar2 others think this implantation does not weaken a good scar4 ,if the convalescence after the cesarean section already done has been abnormal1 the prognosis for rupture is not good4 ,where there has been an abnormal convalescence1 each new pregnancy must be watched closely1 and often an early subsequent cesarean is indicated to prevent rupture4 ,no matter how well the section has been done1 latent gonorrhea may prevent perfect healing of the wound4 ,twins1 hydramnios1 and overtime gestation are other causes of rupture4 ,the tendency with obstetricians in the future will probably be to do the section toward the cervical end of the uterus2 and as the uterus is thinnest there1 it might be thought that it will be more likely to break1 but ,spalding#aaj found the contrary true--the rupturing was usually in the thick part of the uterus4 ,version1 high forceps1 uterine tampons1 hydrostatic bags1 and pituitary extract should be avoided where an old cesarean scar exists1 but ,vogt and ,kroback have done version a few times without rupture4 ,vogt had one patient with a true conjugate of #f-c_/d cm4 7#b-h_/af inches7 to #g cm4 7#b-c_/d inches74 ,she was delivered in the first three labors by craniotomy2 in the fourth by version2 in the fifth and sixth by cesarean section2 in the seventh she had twins one of which was born spontaneously2 in the eighth by version and perforation of the after-coming head2 in the ninth she refused operation and was delivered spontaneously4 ,skilful operators have the fewest ruptures after cesarean delivery4 ,olshausen had one in #abj cases1 ,leopold none in #bcb cases1 ,schauta none in #agg cases1 ,kstner none in #ajj cases4 ,olshausen1 in a series of #bi cases1 operated on two patients twice and upon three patients three times4 ,as early as #ahge1 ,nancrede of ,philadelphia had operated the sixth time on the same woman4 ,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 cavity4 ,in #aej cases of repeated section collected by ,polak in #aiji the mortality was only #e per cent4 #aaj ,jour4 ,amer4 ,med4 ,assoc41 ,december #a1 #aiag4 ,a woman may not be sterilized by having the uterus removed1 by fallectomy1 or otherwise1 solely to obviate danger or morbidity from subsequent pregnancies and cesarean deliveries4 ,such a sterilization would be a grave mutilation without a present excusing danger1 and it would render the primary end of marriage always impossible4 ,such sterilization of a woman is in contravention to the decretal of ,gregory#aaa as given in the chapter on ,vasectomy4 ,it is also against the bull ,effraenatam of ,sixtus ,v41 who extended all penalties prescribed for abortionists to those who give women drugs which cause sterility1 and to those who purposely prevent the development of the fetus or in any manner abet the deed2 and the penalties are to be applied to the women themselves who willingly use these means4 ,these penalties are enumerated in the chapter on ,abortion4 ,the ,congregation of the ,holy ,office1 ,may #bb1 #ahie1 answered negatively the following question3 ,si sia lecita la practica sia attiva sia passiva di un procedimento il quale si propone intenzionalmente come fine espresso la sterilizatione della donne8#aab #aaa ,corpus ,juris1 lib4 v1 tit4 xii1 c4 #e4 #aab ,is any active or passive procedure licit which is undertaken with the express end of sterilizing a woman8 ,the reason for these laws is that any act which deprives one of the power to generate1 and which prevents conception and makes the semen fail of its end1 is against the chief intrinsic end of marriage and any benefit that arises therefrom1 which is the good of offspring4 ,the act is also against the intrinsic end of the semen1 which is to generate2 and since the semen cannot possibly effect its end1 the conjugal act degenerates into an equivalent of onanism4 ,this act of sterilization1 done not to save the whole body from immediate danger1 is intrinsically evil1 and therefore unjustifiable4 ,to say that marriage is also a licit remedy of concupiscence is no excuse4 ,marriage is such only in a secondary sense1 and this secondary end is necessarily subordinate to the primary end1 and coexistent with that primary end1 which is the generation of children4 ,even when a surgeon is doing a ,porro operation1 his main intention may not be to sterilize the woman4 ,he must directly intend to save her life by removing the infected uterus1 and reluctantly permit the sterilization as an evil part of the double effect coming from the causal amputation4 ,,chapter ,,viii ,,placenta ,,praevia ,,and ,,abruptio ,,placentae ,cesarean delivery is used frequently of late in placenta praevia4 ,it may be necessary also in abruptio placentae1 gunshot wounds of the abdomen during pregnancy1 sometimes in appendicitis complicating gestation1 rarely in prolapse of the cord to save the child1 and when twins become interlocked in delivery4 ,placenta praevia is a development of the placenta in that part of the uterus which dilates at the end of gestation or during delivery4 ,this dilatation1 with the mechanical pressure of the child1 detaches the placenta enough to cause a hemorrhage which may be fatal to the woman if not checked4 ,the hemorrhages begin sometimes as early as the sixth month of gestation1 but most frequently in the eighth month4 ,premature labor is a common effect4 ,the position of the placenta may cause malposition of the fetus1 prolapse of the cord1 weak pains1 air embolism into the blood1 rupture of the uterus1 sepsis1 profound anemia1 and other evils4 ,the child may be premature1 puny1 have collapsed lungs1 hemorrhages1 and it is very likely to be killed in delivery4 ,the mortality of the women varies1 but it averages about #g per cent2 that of the children averages #fa per cent4 ,the tendency with obstetricians is to deliver the child as soon as the diagnosis has been made4 ,when the bleeding is slight1 and the child is viable1 one may delay delivery provided the woman will remain in bed in a good maternity hospital without moving4 ,at home the woman may flood and bleed to death before a physician can reach her4 ,if the woman refuses to go to a hospital1 and to permit the induction of labor1 any physician who has regard for his own reputation will drop the case and leave the woman to her own devices4 ,there are various methods of treatment1 and much depends on the position of the abnormally placed placenta4 ,the treatments all consist in stopping the hemorrhage for the instant1 emptying the uterus1 insuring permanent hemostasis1 and meeting the anemia4 ,the ,braxton-,hicks version is one method4 ,the child is quickly turned so that the head is upward in the uterus1 and a leg is pulled down to plug the cervix uteri until there is enough dilatation to extract the child4 ,very many children are lost by this method4 ,when the placenta praevia is marginal to the cervix or lateral in the uterus the child has a better chance when a colpeurynter1 or inflatable rubber bag1 is inserted in the cervix as a plug4 ,much skill and discrimination is required in the management of this bag until the child is delivered4 ,the obstetrician may be obliged to sit by the bed and hold on to the bag for from three to twelve hours4 ,hasty extraction through a poorly dilated cervix is a very dangerous process1 as a tear cannot be repaired quickly enough1 as a rule1 to check the hemorrhage1 which will be fatal4 ,when version has been done haste may compress the head in the tight cervix and asphyxiate the child4 ,when the child is viable a cesarean section is by far the best method for the child1 as it lowers the fetal mortality from #fa to about #e per cent4 ,the mother1 too1 has a better chance by the cesarean section1 provided it is done by a competent man1 early in labor before infection has set in1 and in a hospital4 ,if the child is not viable the hemorrhage must be stopped to save the woman's life4 ,as a rule1 the hemorrhages are not dangerous before the seventh month4 ,in the #abh deaths of ,mller's statistics there was not one before the seventh month of gestation4 ,hirst1 however1 says he has been obliged to empty the uterus at the fifth month for placenta praevia4 ,the woman must be kept in bed1 the foot of the bed elevated1 sedatives used1 and so on1 as in threatened abortion1 and the vagina tamponed securely with cotton4 ,if it is evident that the fetus is dead1 it must be extracted as in the case of a viable fetus4 ,if it is probable that the fetus is alive1 it is to be treated as in a case of inevitable abortion as described in the chapter on ,abortion4 ,the tamponing of the vagina to stop the hemorrhage will cause the abortion of the fetus indirectly4 ,this is another double-effect case1 and the tamponing is morally permissible provided the intention is correct4 ,abruptio placentae is a tearing loose of a placenta which is situated in the normal position1 not abnormally as in placenta praevia4 ,the cause may be a disease of the placenta or decidua2 for example1 syphilis1 chronic metritis1 traumatism from a blow or fall1 jumping from a carriage-step1 and so on4 ,nephritis is often found where there is abruptio placentae4 ,in labor the placenta may be torn loose by a version1 by the delivery of the first of a pair of twins1 or because the cord is too short4 ,there is always profuse hemorrhage1 which is usually concealed at first1 but finally external4 ,it is possible at times for a woman to bleed to death into her own uterus1 when it is distensible4 ,the mortality is about #ej per cent4 for the women1 and where there is concealed hemorrhage about #ie per cent4 of the children are lost4 ,a differential diagnosis is to be made to exclude placenta praevia1 rupture of the uterus1 extrauterine pregnancy1 rupture of an appendical abscess1 gall-stone colic1 or intrabdominal injury4 ,if the child is viable it must be delivered as quickly as possible4 ,if it is dead and the head is developed1 craniotomy should be done to hasten extraction4 ,when the abruptio takes place before the seventh month of gestation the fetus will die in about ten minutes1 whether in the uterus or outside it2 no matter what method might be adopted to empty the uterus1 the child would be dead before delivery4 ,the diagnosis would have to be made and instruments prepared1 and this would take up more than the ten minutes of life left to the fetus4 ,it is necessary to get the fetus out to stop the bleeding of the open sinuses by contraction of the uterus4 ,the removal of the fetus here is not like an artificial abortion4 ,in abortion the abortionist separates the placenta from the uterine sinuses and so kills the fetus2 the removal from the uterus is secondary to that separation which kills4 ,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 cause4 ,in a removal of the fetus after an abruptio placentae the death of the fetus is not caused by the physician at all1 but by the force that effected the abruptio4 ,as the child will be dead before sufficient dilatation of the cervix to deliver it can be attained1 there is no objection to beginning the delivery as soon as the diagnosis is clear4 ,,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 life4 ,the commonest tumors complicating pregnancy are fibroids1 cancers1 and ovarian tumors1 especially cysts and dermoids1 but tumors of other kinds are not frequently met4 ,schauta1 in #aaa1aab pregnant women1 found fibroids in #hf1 one in #abib cases2 ,pinard1 in #ac1iae1 found #hd1 one in #afe cases2 ,pozzi1 in #ab1jej1 had #hc1 one in #acc cases2 in ,st4 ,petersburg1 in #ac1jgf deliveries1 there were only #d1 one in #cbfi cases2 and in the ,charit in ,berlin1 #f in #ai1jeb births1 one in #cage cases4 ,the ovarian cyst in pregnancy is rarer than the fibroid--#e in #ag1hcb births1 one in #ceff cases1 in the ,berlin ,frauenklinik4 ,cancer of the cervix also seldom appears--once in about #bjjj cases4 ,other very rare conditions1 related to these1 are polyps of the cervix1 enlarged and prolapsed kidneys1 extrauterine pregnancy combined with intrauterine1 echinococcus cysts1 parametric abscesses1 cancers of the rectum1 rectal strictures1 tumors of the bladder1 stones in the bladder1 tumors of the pelvic bones or cartilages1 and tumors of the vagina or vulva4 ,fibroids1 called also fibromyomata1 fibromata1 and myomata1 in the uterine muscle or adnexa commonly enlarge during pregnancy1 and if they are big enough and low in the pelvis may block the parturient canal4 ,these tumors may suppurate1 grow gangrenous1 or take on red degeneration2 they may cause abortion1 peritoneal adhesions1 pain1 or hemorrhage2 simulate threatened abortion2 bring on retroflexion of the uterus1 placenta praevia1 abnormal presentations1 sometimes weak pains or pains so strong as to rupture the uterus1 and they may check contraction after delivery so as to start hemorrhage4 ,they may so kink the uterus as to incarcerate the placenta and cause sepsis4 ,the percentage of degeneration in fibroids taken generally is #bb1 according to ,william ,mayo4#aac #aac ,jour4 ,amer4 ,med4 ,assoc41 ,march #bd1 #aiag4 ,myomata often obscure the diagnosis in pregnancy4 ,the tumor may be mistaken for a twin child1 or vice versa4 ,a large symmetrical interstitial myoma may be mistaken for pregnancy1 or vice versa4 ,sometimes1 even after the belly has been opened1 it is difficult to be sure whether the condition is pregnancy or a tumor4 ,as eminent a surgeon as ,deaver says this diagnosis cannot always be made by any one no matter what his experience4 ,we cannot give a general mortality average for myomata in pregnancy because only bad cases are reported1 but in bad cases the mortality is very high--#ej per cent4 for the mother and about #fj per cent4 for the children1 with almost #cj per cent4 of abortions4 ,the majority of women who have myomata go on to delivery without trouble4 ,in some there is much pain or hemorrhage1 and these conditions may finally oblige the obstetrician to operate1 but the operation should be deferred as long as possible4 ,where there are signs of necrosis of the tumor1 operation is necessary at once to prevent sepsis4 ,removal of a myoma during pregnancy does not always cause abortion4 ,the statistics are that about #hc per cent4 of those operated upon are removed without abortion4 ,in the ,mayo ,clinic#aad fourteen cases of degenerating fibroids in pregnant wombs were removed and the majority went on to term4 ,the removal is always a very bloody operation1 and it requires great surgical skill4 ,where enucleation of the tumor alone was intended it may finally become necessary to amputate the uterus to stop hemorrhage4 #aad ,ibid4 ,when the case has gone on to labor at term the diagnosis as to position and size of the tumor is to be made1 and what the effects will be as to blocking the canal or crushing the tumor so as to bring on sloughing4 ,if a tumor blocking the canal cannot be pushed up out of the way of the child1 a cesarean section should be done immediately4 ,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 opportunity4 ,it may be necessary to do cesarean section to liberate an incarcerated placenta4 ,sometimes the fetus is so involved with a gangrenous myoma that enucleation of the tumor will kill or hasten the death of the fetus4 ,when1 in such a complication1 it is evident that the life of the woman depends on the immediate removal of the tumor1 yet a second but evil effect follows from the operation1 namely1 the unavoidable death of the fetus1 the removal is morally licit provided the operator has the proper intention4 ,the death of the child as an effect in this case is only indirectly voluntary from the physical point of view1 and only permissively voluntary from the moral aspect4#aae #aae ,cf4 ,ferreres1 ,nouvelle ,revue ,thologique1 ,september and ,october1 #aiab1 and the appendix of his book ,de ,vasectomia ,duplici1 ,madrid1 #aiac4 ,ovarian tumors in pregnancy are1 as has been said1 rarer than myomata4 ,such tumors are mostly cysts and dermoids4 ,in #hfb cases collected by ,mac,kerron1 #fh per cent4 were cysts1 #bc per cent4 dermoids1 #e per cent4 malignant tumors1 and a few were myomata4 ,cysts and dermoids do not1 like the myomata1 grow bigger during pregnancy1 but they may hinder delivery or grow gangrenous and septic4 ,when treated early the mortality in pregnancy is from #b4a to #e4i per cent for the women1 but delay gives a maternal mortality of from #ca to #ci per cent4 ,the fetal mortality in ,heiberg's statistics of #bga cases was #ff per cent4 ,most obstetricians advise the removal of an ovarian tumor in pregnancy as soon as diagnosed1 provided it is of a size to cause difficulty in parturition1 but such a removal causes abortion in over #bj per cent4 of the cases4 ,the expectant treatment causes abortion in about #ag per cent4 ,if the child is viable1 ,fehling1 ,martin1 ,norris1 and ,de ,lee are in favor of the expectant treatment4 ,late operators leave weak scars at labor4 ,when there are symptoms of torsion of the pedicle of the tumor1 infection1 incarceration in the pelvis1 involvement of the uterine broad ligament1 or overdistention of the belly1 the tumor must be removed immediately4 ,whether vaginal puncture or laparotomy is the better method is to be decided particularly4 ,dermoid cysts are likely to bring on sepsis if they are broken in enucleation1 and the diagnosis and operation must be carefully made4 ,when it is necessary to save the life of the woman to remove an ovarian tumor1 the risk of abortion may be taken permissively4 ,cancers of the cervix uteri are always malignant and cause death if they are not removed before they have gone on to metastasis4 ,as this tumor commonly appears after the child-bearing age1 it is rare in pregnancy2 the ordinary ratio is one in #bjjj deliveries1 but ,de ,lee saw only one in ,chicago in #af1jjj consecutive labors4 ,abortion occurs in from #cj to #dj per cent4 of the cases4 ,spontaneous rupture of the uterus may happen1 and placenta praevia is frequent relatively4 ,pregnancy hastens the growth and spread of cancer very much4 ,eight per cent4 of the women die undelivered1 and #dc per cent4 die during labor or immediately afterward4 ,of all uterine cancers1 #hj per cent4 are cervical4 ,the diagnosis should be as certain as possible4 ,rarely nodules which are not cancerous appear in the cervix during pregnancy1 and these are to be examined microscopically4 ,snipping out of a piece of the nodule for examination does not cause abortion4 ,vaughan of ,michigan ,university1 who is a skilful and careful observer1 said#aaf that in an investigation of #bjj cases of cancer1 upon which more than #cj1jjj differential blood-counts were made1 he discovered a method of diagnosing the operability of a cancer as follows3 ,he makes a blood-count and then injects intraperitoneally one c4c4 of placental residue4 ,the next day he begins a series of blood-counts1 and if the number of polymorphonuclear cells decreases the case is operable1 no metastasis has occurred2 if there is no change in the number of the polymorphonuclears1 or an increase with a corresponding decrease of the large mononuclears1 the case is inoperable1 metastasis has begun4 #aaf ,jour4 ,amer4 ,med4 ,assoc41 ,december #h1 #aiag4 ,in cancer of the cervix operability does not mean curability always4 ,inoperability signifies that the woman has no chance at all for life and that it is useless to do anything2 operability means that she has one chance in four and that it is worth while taking the chance4 ,the following conditions may be met3 #a4 ,the case may be operable and the child inviable4 #b4 ,the case may be operable and the child viable4 #c4 ,the case may be inoperable and the child inviable4 #d4 ,the case may be inoperable and the child viable4 ,in the first case the supposition is that the case is operable but the child inviable4 ,to save the woman the uterus1 with its adnexa1 must be removed1 and this1 of course1 kills the fetus4 ,the case differs from the enucleation of a gangrenous myoma which involves the death of an inviable fetus4 ,in the myoma case the woman has practically every chance for her life through operation2 in this cancer case the woman has only one chance in four1 as #ge per cent4 of such operations fail through recurrence of the cancer4 ,the child has about one chance in two of going on to viability1 owing to the tendency to abortion1 if no operation is done2 but the mother loses her chance for life if the operation is not done at once1 as the cancer will spread beyond cure4 ,zweifel has seen such a growth extend a finger's breadth in one week4 ,the one chance in four in immediate operation gives the mother a solid ground for hope1 and the probability is sufficient1 in my opinion1 to permit the operation with a permissive loss of the fetus4 ,in the second case the cancer is operable and the child is viable4 ,the child should at once be delivered by cesarean section1 and the uterus with its adnexa removed4 ,the third case is that of an inoperable cancer and an inviable child4 ,there the operation should be deferred1 if possible1 until the child becomes viable4 ,the fourth case supposes the cancer is inoperable but the child viable4 ,in the interest of the child1 immediate cesarean section is the best thing to do2 it is much better than waiting until term4 ,at term this operation will have to be done anyhow1 and the earlier it is done1 the better the woman can stand the strain4 ,there is a risk that she will die from the first operation done to deliver the viable child1 but she may licitly take this risk1 as she might licitly run into a burning house to save a child1 even if not her own4 ,she may also licitly refuse the first operation4 ,,chapter ,x ,,appendicitis ,,in ,,pregnancy ,primary appendicitis in pregnancy is very rare2 recurrent appendicitis is not so rare4 ,when appendicitis goes on to suppuration and perforative peritonitis the condition is worse in pregnant women than in the non-pregnant4 ,in pregnancy protective adhesions1 walling off1 are less likely to occur2 the inflammation is more intense owing to increased vascularity2 thrombosis and phlebitis are more frequent2 drainage may be obstructed and the burrowing of pus widespread2 tympany1 too1 causes dyspnoea earlier4 ,about #ge per cent4 of the cases occur after the third month1 and the earlier the appendicitis appears1 the better the prognosis4 ,during labor the contracting uterus sometimes tears open an adhesive appendix1 or ruptures a pus sac and starts a general peritonitis4 ,this condition may be mistaken for a general sepsis which is puerperal4 ,acute appendicitis is likely to be confused with an inflammation of a ,fallopian tube4 ,when the appendicitis is perforative abortion1 infection of the uterine contents and death of the child happen in most cases4 ,labor is very painful when appendicitis is present1 and the uterine contractions are often weak4 ,after delivery many forms of infection of the uterus and its adnexa are possible4 ,operation is much less difficult in the first half of gestation than in the latter months4 ,at the beginning of gestation the operation does not1 as a rule1 cause abortion4 ,late in pregnancy appendicitis rapidly goes on to suppuration and perforation1 with a high mortality4 ,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 infection4 ,john ,deaver says1 ,always cut down on the sore spot and do not handle the uterus4 ,an infected uterus after cesarean section complicated with appendicitis has to be amputated4 ,the diagnosis between appendicitis1 ectopic gestation1 twisted ovarian tumors1 ureteritis1 and ureteral stone is to be made4 ,in a discussion of a paper by ,finley on ,appendicitis in ,pregnancy1#aag ,dr4 ,john ,murphy of ,chicago1 a great authority1 advised operation as soon as the diagnosis is made1 and he was of the opinion that this diagnosis is not difficult to make in pregnancy4 ,deaver said a diagnosis of catarrhal appendicitis is not seldom very difficult to make4 ,this form is very rare in pregnancy4 ,deaver is not of the same opinion as ,murphy as to operating as soon as the diagnosis is made in all cases4 ,where there is a general peritonitis1 operation commonly only makes matters worse by spreading infection4 ,the mortality of cases of appendicitis in pregnancy left without operation is as high as #gg per cent42 where the cases are operated upon within forty-eight hours after diagnosis the mortality is #f4g per cent4 and it would be better if the operation were done within twenty-four hours4 ,finley says that in the fifteen cases reviewed in his paper the operation did not cause abortion4 ,deaver tells us the muscular rigidity in the right groin characteristic of appendicitis is often missing in pregnancy1 and that sometimes the pain is on the left side of the belly4 #aag ,jour4 ,amer4 ,med4 ,assoc41 ,december #bd1 #aiab4 ,,chapter ,,xi ,,puerperal ,,insanity ,,and ,,sterilization ,from #h to #aj per cent4 of all insanity in women develops during the puerperium--the incidence is about one case to #djj births4 ,puerperal insanity in nearly #gj per cent4 of the cases begins within the first two weeks after parturition4 ,next in frequency of occurrence is the period of lactation1 especially in multiparae4 ,insanity during pregnancy itself is relatively rare1 and it begins usually after the fourth month4 ,as in other forms of insanity1 hereditary predisposition is found in from #be to #cj per cent4 of the cases4 ,alcoholism1 sepsis1 and neuroses like hysteria1 chorea1 and epilepsy1 are the predisposing elements4 ,the most common immediate exciting cause during pregnancy is toxemia from faulty metabolism and excretion4 ,other frequent direct excitants are mental worry from poverty1 desertion1 seduction1 and the like troubles4 ,prolongation of the lactation period beyond the usual time for weaning1 from the ninth to the twelfth month1 is common among ignorant and lazy women4 ,some women prolong lactation in the erroneous notion that it prevents renewed impregnation4 ,such lactation is injurious to the child1 as a rule4 ,ploss says hyperlactation is frequent in ,spain1 and that some ,japanese1 ,chinese1 and ,armenian women may nurse their children for years1 but this practice is undoubtedly injurious1 especially among ,european races4 ,the women get tabes lactea with emaciation1 asthenia1 anemia1 backache1 pain in the breasts1 neurasthenia1 cramps1 and blindness4 ,the uterus atrophies in some cases and may be permanently injured4 ,insanity is not unusual4 ,the forms of mental disturbance commonest in puerperal insanity are mania with or without delirium1 melancholia1 and dementia4 ,dementia is the final stage in the cases that become chronic4 ,mania is the prevailing type in insanity after labor1 and melancholia in insanity during gestation4 ,the melancholy of insanity during gestation is often suicidal1 and must always be watched4 ,religious and erotic symptoms are also observed4 ,the onset may be very sudden during labor4 ,an outbreak after labor may be suicidal or homicidal4 ,maniacal puerperal women are dangerous4 ,they have delusions and hallucinations1 with very rapid and incessant changes that range from obscenity to prayer4 ,melancholy in the puerperium is likely to be suicidal4 ,about #ge per cent4 of puerperal insanity cases recover within five or six months4 ,from #b to #aj per cent4 die from sepsis1 exhaustion1 or intercurrent diseases2 the remainder become permanently insane4 ,the nearer the delivery the insanity appears1 the better the prognosis4 ,menzies found that of cases which began during gestation #ef4g per cent4 remained insane2 of those that began during the puerperium #be per cent4 did not recover2 of those that began during lactation #dc4e per cent4 remained insane4 ,melancholia is more favorable than mania in pregnancy1 but after labor mania gives the better prognosis4 ,the maniacal patient is more likely to die1 but the melancholic is more likely to remain insane4 ,the older the woman1 the greater the number of her pregnancies1 the more the depression1 and the higher the temperature1 the worse the prognosis4 ,alcoholism is an added risk always4 ,all puerperal insanities should be treated in sanatoria or asylums and not at home4 ,when a woman with puerperal insanity is allowed to remain at home she cannot get proper treatment1 and is a constant menace to her own life and the lives of her family4 ,a woman who has had puerperal insanity and has recovered her mental health is likely to have a recurrence of her malady at subsequent pregnancies4 ,the question has been asked me a few times1 ,would it not be justifiable to sterilize such a woman to prevent this recurrence1 with its dangers and terrors8 ,it would not be justifiable3 #a4 ,because it is not licit to inflict a grave mutilation to avert a possible or probable future evil4 #b4 ,there are other means to escape the danger3 a woman with this tendency is justified in denying the debitum4 #c4 ,once crazy1 always crazy1 is an aphorism with much truth in it1 and it is doubtful that sterilization in itself will prevent ultimate insanity4 #d4 ,the conjugal relation of a sterilized woman would be no better than onanistic4 #e4 ,the sterilization would fall under the decrees and penalties described at the end of the chapter on ,cesarean ,section4 ,,chapter ,,xii ,,nephritis ,,in ,,pregnancy ,in pregnancy the kidneys always give evidence of a constant congestion1 and the chief symptom of this is the great quantity of renal epithelium shed with the urine4 ,this engorgement has given rise to the term kidney of pregnancy4 ,there has been much discussion of this condition1 especially as to the possibility of differentiating it from beginning nephritis4 ,in #bbg consecutive cases of pregnancy in which the urine was examined at short intervals by myself throughout the entire gestation1 there was always an enormous quantity of epithelium1 and this presence of epithelium is so constant that its absence is a proof that pregnancy does not exist4 ,it is as physiological as any other somatic change in the puerperium4 ,von ,leyden and other ,german observers look upon the degenerative alteration in the epithelium of the renal tubules as pathological1 but apparently more definite symptoms are necessary to make a diagnosis of significant nephritis4 ,williams#aah says that in the examination of #ajjj pregnant women at ,johns ,hopkins ,hospital in ,baltimore traces of albumin were found in #ej per cent4 without subsequent serious disturbance1 but where considerable albumin with casts other than hyaline was seen there were symptoms of toxemia later1 and several of these went on into eclampsia4 ,fisher#aai held that red blood-corpuscles in these cases indicate acute nephritis2 and granular and epithelial casts1 chronic nephritis4 ,like the ,johns ,hopkins cases1 he found albumin in #ej per cent4 of his patients4 ,albumin in slight quantities is found to be extremely common toward the end of pregnancy4 ,meyer1#abj in an extensive study of the kidney in pregnancy1 made at ,copenhagen1 found albumin in #e4d per cent4 of the women4 ,during the last month of gestation #ga per cent4 of the women showed albumin4 ,premature births occurred in #h per cent4 of the patients who had had albuminuria1 but in #ba4e per cent4 of the women who had had casts4 ,delicate tests for albumin are used by men who find these high averages1 as a few leucocytes from leucorrhoea will give the reaction4 ,most of these cases have no clinical significance4 #aah ,obstetrics1 p4 #def4 #aai ,praeger medizinische ,wochenschrift1 #ahib n4 #ag4 #abj ,zeitschrift fr ,geburtshlfe1 bd4 #af1 n4 #b4 ,it is usually impossible to differentiate in pregnancy a lighting up of an old nephritis from a toxemia4 ,where there is a history of nephritis before the pregnancy1 this often clears up the diagnosis4 ,nephritis is likely to manifest itself in pregnancy earlier than toxemia2 albuminuric retinitis is commoner in nephritis1 but these facts are no real help in differentiation4 ,the position of the uterus may be a cause of nephritis1 according to the ,american ,text-,book of ,obstetrics2 but ,de ,lee and others hold that the growing womb cannot possibly be a cause4 ,many other origins have been suggested1 but without sufficient proof4 ,the treatment of the nephritides of pregnancy is that described in chap4 xiii for eclamptic symptoms4 ,when albuminuric retinitis occurs1 the medical tendency is to empty the uterus4 ,all text-books counsel this procedure1 but they give no convincing reasons for the advice4 ,if the child is viable the therapeutic abortion might be done when necessary2 if the child is not viable the operation is1 of course1 not licit4 ,in the nephritis of pregnancy it is not certain that emptying the uterus artificially1 with the entailed shock1 is the best method of treatment2 but1 as a rule1 nephritis is made worse by pregnancy1 and the irritation lessens with the termination of gestation in some cases1 but not in true chronic nephritis4 ,eclampsia is more toxic than nephritis1 and the treatment may differ in important details3 it certainly is doubtful that artificial abortion in eclampsia is the method of choice at present4 ,i saw a case of albuminuric retinitis ten years ago1 which could not have been worse4 ,the woman was in the seventh month of gestation2 she was nearly blind and half comatose4 ,the albumin in her urine always was so great that it would not fully precipitate in a centrifuge tube1 and every field under the microscope was covered with large casts in such enormous quantities that they were felted together4 ,yet the woman was carried on to term by ,dr4 ,joseph ,o',malley and delivered of a fully developed child4 ,she since has had two other children at term who are perfectly healthy1 and she herself could pass a life insurance examination4 ,this is1 of course1 only one case1 and it is exceptional2 but it is impossible to say what will happen in any particular case--whether it will go on to death or recovery4 ,both subacute and chronic parenchymatous nephritis show clinically much albumin1 many casts1 marked edema 7except in very emaciated cases71 absence of high blood-pressure1 and the heart is not enlarged4 ,this condition is caused commonly by chronic tuberculosis1 syphilis1 sepsis1 and malignant tumors4 ,with these clinical symptoms and the history1 we may differentiate the nephritis of pregnancy from ,bright's disease4 ,again1 acute intestinal nephritis or glomerulonephritis has urinary findings like the nephritides just described1 and there may be edema4 ,the heart and the blood-vessels are normal4 ,the cause is usually a pus microrganism1 and there may be anemia from the sepsis4 ,in subacute glomerulonephritis1 or intestinal nephritis1 the urinary findings are marked 7much albumin and many casts71 anemia is rather constant1 the blood-pressure gradually goes up to #ahj or #bjj1 edema may be marked or absent4 ,the cause is usually a pus microrganism4 ,chronic glomerulonephritis shows much epithelium and many casts 7sometimes in showers71 the blood-pressure is high1 the heart is usually somewhat enlarged1 there is polyuria and some blood1 edema is common 7but there are dry cases71 albuminuric retinitis is rare1 and anemia is marked and secondary4 ,it may be difficult to find the cause of this chronic glomerulonephritis1 but there is1 as a rule1 a history of tonsillitis1 septic rheumatism1 endocarditis1 a true influenza1 or the like infection4 ,primary arteriosclerotic contracted kidney shows hypertension and secondary circulatory disturbance4 ,the urinary findings are comparatively slight and transient1 and there is little or no anemia4 ,the development is insidious1 and the etiology is not known4 ,there is evidence of late to find a septic cause for most of the nephritides1 such as infectious fevers1 pyorrhea of the teeth1 and like bacterial intoxications2 in pregnancy the nephritis may be toxemic from sources that are not bacterial4 ,it is extremely difficult1 and not seldom impossible1 to make any differentiation1 as has been said4 ,when the child is viable1 whether the uterus should be emptied or not must be decided for the individual case2 no general rule can be set down to cover all conditions4 ,one of the kidneys may be dislocated during pregnancy--usually the right kidney4 ,if a floating kidney becomes twisted on its pedicle1 abortion may be a consequence4 ,the torsion may compress the renal blood-vessels and bring on acute hydronephrosis with high fever1 great abdominal tenderness1 and a peritonic facial expression4 ,pyelitis of the renal pelvis is not seldom met in pregnancy4 ,the gonococcus1 colon bacillus1 or some other pyogenic bacterium gets a nidus after pressure and lowered power of resistance4 ,this condition is sometimes mistaken for appendicitis4 ,catalepsy is a rare complication of pregnancy1 in which the woman lies in an unconscious condition4 ,the disease is a neurosis1 but it might be mistaken for a toxic or uremic condition by a superficial observer4 ,the infants of such women may be cataleptic1 and may die as a consequence of the condition4 ,,chapter ,,xiii ,,eclampsia ,,parturientium ,the term ,eclampsia was first used to describe the sudden exaltation1 flashing forth 7eklampsis71 of the vital faculties at puberty2 later it was applied to convulsions1 but now it is restricted to convulsions in pregnancy which sometimes begin suddenly1 as in a flash4 ,the disease is characterized by a series of violent convulsive movements1 loss of consciousness1 and coma1 and is one of the most dangerous complications of gestation4 ,all convulsions and comas in pregnancy1 not due to hysteria1 epilepsy1 cervical tuberculosis1 apoplexy1 pneumonia1 phosphorus1 strychnia and like poisons1 uremia1 and meningitis1 are commonly classed as eclamptic4 ,when the symptoms of eclampsia are present with the exception of the convulsions1 a rare condition1 this state also is said to be eclampsia4 ,reineke#aba reported a case like this4 ,after death the heart1 kidneys1 and liver showed all the signs of eclampsia4 #aba ,mnchener medizinische ,wochenschrift1 ,july #cj1 #aijg4 ,the eclamptic attack may occur without warning1 but almost always there are premonitory symptoms for from a few hours to some weeks4 ,the preclamptic symptoms are headache 7commonly frontal71 nausea and vomiting1 vertigo1 nervous excitement or somnolence1 muscle twitching1 occasional delirium1 cramps in the calves1 disturbances of sight1 tinnitus1 and pain in the epigastrium4 ,epigastric pain1 headache1 and disturbances of the optic tract are important symptoms4 ,if these last signs are present in a woman who has some edema and nephritis1 the eclampsia will certainly occur1 if proper means to relieve the condition are not promptly taken4 ,when the prodromata appear there is nephritis1 as a rule1 but exceptions are observed4 ,when the attack comes1 if the patient is standing she falls unconscious4 ,the pupils dilate1 the eyes and head are turned to the side4 ,she opens her mouth1 and the jaw is pulled laterally4 ,the woman stiffens1 her face is distorted1 her arms bent1 and the whole body curves sidewise in a tonic spasm4 ,after a few seconds her jaws chop1 and if her tongue is between the teeth it is lacerated2 twitching runs down from the face and ends in a violent convulsion of the whole body1 which may toss the patient from the bed1 and she may even fracture her skull or long bones in the fall4 ,the breathing stops1 the bloodshot eyes stick out1 the face swells and darkens1 the lips become purple4 ,gradually the convulsions wane1 and the woman appears to be dying2 but after deep sighing she begins to breathe stertorously2 then she sinks into a coma1 or1 in favorable cases1 revives4 ,after a few minutes to an hour or more another convulsion may befall her1 or she may have no more than one4 ,in very grave cases consciousness may never return after the first fit4 ,the convulsions may run up into extraordinary numbers--a hundred or more4 ,there is a pseudoeclampsia where the convulsions have been as many as two hundred4 ,if there are many attacks in the first twenty-four hours with no clear evidence of subsidence1 the woman nearly always dies4 ,fever begins in such cases1 and goes up to #ajc or even #ajg degrees4 ,in an untreated case ,black found a temperature of #aaj degrees before death4 ,the average number of attacks in these cases is from five to fifteen1 and the convulsions are from a half minute to two or three minutes apart4 ,olshausen had six patients who recovered after having had from twenty-two to thirty-six convulsions1 but those who have above fifteen commonly die4 ,if the convulsions are severe the woman as a rule aborts1 and often rapidly4 ,after the child is delivered the eclamptic symptoms may subside1 or they may come on again1 even a week after labor4 ,often the fetus dies during the attack2 rarely it survives and is carried to term2 again1 it may die and the eclampsia may subside1 but the fetus remains in the uterus for some time4 ,if the woman is to die the eclamptic attacks usually increase in frequency and violence2 the temperature runs up very high1 or it sinks2 the pulse becomes weak and running1 edema of the lungs comes on1 with rattling and cyanosis1 and the urine ceases to flow4 ,the woman may die in a convulsion from apoplexy or heart paralysis4 ,at times the child is delivered1 but the coma deepens and the woman dies4 ,in other cases there are coma and death without convulsions4 ,rarely there is a condition akin to acute yellow atrophy of the liver1 with delirium1 twitchings1 coma1 and death4 ,women who have chronic nephritis seldom have convulsions in pregnancy unless there happens to be cerebral hemorrhage as an effect1 but they suffer the other results of chronic ,bright's disease--dropsy1 uremia1 edema of the lungs1 paralysis of the heart1 and albuminuric retinitis2 they also are inclined to premature labor1 and to hemorrhages that loosen the placenta4 ,when acute nephritis happens in pregnancy convulsions are quite common1 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 eclampsia4 ,the real cause of eclampsia is unknown1 but the most plausible explanation of this disease of theories1 as ,zweifel of ,leipsic called it1 is that it is a toxemia which attacks the liver1 and directly or indirectly the kidneys1 and brings on convulsions by toxic action on the anterior cerebral cortex4 ,the great difficulty is to explain how these toxins originate4 ,one authority suggests that the poison comes from the liver2 another1 from the fetus2 a third1 from the placenta1 the intestines1 the general metabolism1 disturbed glandular balance1 bacteria1 and so on1 but nothing is certain as to the etiology except that it is an intoxication4 ,on an average1 #bj per cent4 of the women who have eclampsia die1--but statistics vary from #e4ca per cent4 to #de4g for the mother and from #cj to #db per cent4 for the child4 ,eclampsia occurring ante-partum has the worst mortality2 intra-partum1 less2 post-partum1 least4 ,about half the children die from prematurity1 toxemia1 asphyxiation1 narcotics administered to the mother1 or injuries at birth4 ,if the patient's pulse remains full and hard and below #abj1 there is no immediate danger of death2 but if faster1 weaker1 and running1 the prognosis is bad4 ,high fever is not necessarily fatal to the mother1 but it is very dangerous to the fetus4 ,edema of the lungs is a very grave symptom1 but recovery is possible4 ,when the convulsions have gone beyond twenty the prognosis is bad1 but there have been recoveries4 ,deep cyanosis1 marked restlessness1 anuria1 and intense albuminuria are all bad symptoms4 ,apoplexy is nearly always fatal4 ,after delivery the recovery of the woman is by no means certain4 ,she may get pneumonia1 sepsis1 or another eclamptic attack4 ,hirst finds that if the diastolic pressure does not rise above a ratio of #a to #c times the pulse pressure 7i4 e41 the difference between the systolic and diastolic pressures71 the prognosis is good4 ,every pregnant woman should be watched to prevent eclampsia1 if possible1 because all are liable to this outcome4 ,the hygienic methods mentioned in the chapter on ,abortion are most important here4 ,the family history is of weight--if the women of the patient's family have been eclamptic1 if her parents were alcoholic or insane1 these facts increase her liability to the disease4 ,if she has had eclampsia before1 if her kidneys are acutely diseased1--especially if injured by infections1--if she is inclined to digestive disturbance1 she is disposed to eclampsia4 ,albuminuria1 diminishing amounts in the daily excretion of urine1 and decrease in the total solids of the urine1 casts or blood in the urine1 are serious symptoms4 ,if albumin increases and urea decreases1 this is a grave sign4 ,the blood should be examined for the various anemias4 ,if the thyroid gland is deficient or altered in activity1 thyroid extract may be indicated--this acts also as a diuretic4 ,uterine malpositions should be corrected4 ,treatment should be given where there is any evidence of toxemia1 as headache1 altered secretion and excretion1 neuralgia1 mental eccentricity1 increased vasomotor stimulation1 high tension1 disturbance in the sensory apparatus1 obstinate constipation and jaundice4 ,toxemia is not necessarily renal in origin4 ,in any of these conditions the proteids should be kept low in the diet1 so that the kidneys may not be overtaxed4 ,to throw off toxins1 the emunctories should be stimulated by laxatives1 water for diuresis1 tepid bathing4 ,if the symptoms grow threatening1 and the kidneys are involved1 the woman should be put to bed1 on water alone4 ,after three days an absolute milk diet should be begun4 ,as she improves1 starches are added1 then the vegetables containing proteid1 vegetable oils1 and butter4 ,as the improvement goes on1 the diet may be vegetables1 fruit easy of digestion1 and one egg a day4 ,later fish and chicken are used1 but never a full meat diet4 ,beef1 mutton1 veal1 and similar heavy meats are not to be eaten4 ,the drink is to be water1 buttermilk1 or koumiss4 ,when the eclampsia is inevitable the question of inducing labor arises4 ,if the child is not viable1 abortion is out of the question1 as has been proved in the chapter on ,abortion and the general chapter on ,homicide4 ,if the child is viable1 there are three opinions3 one1 that the premature delivery should be effected as soon as possible2 a second1 that this delivery should be delayed as long as possible2 and a third1 that it should not be attempted at all4 ,those who hold that the uterus should be emptied as soon as possible1 induce labor at the first convulsion1 rapidly and under deep narcosis4 ,chloroform is dangerous to the heart in such cases for full anesthesia2 ether is better4 ,braun first observed that the convulsions cease or are lessened after delivery4 ,dhrssen found these results in #ic4gb per cent41 ,olshausen in #he per cent41 ,zweifel in #ff per cent4 ,peterson said that in #fae cases of early delivery--as soon as possible after the first convulsion--the maternal mortality was #ae4i per cent41 but #bh4i per cent4 in the same maternities under the expectant method4 ,olshausen was not in favor of forced delivery4 ,charpentier#abb held that forced delivery is dangerous and should be absolutely proscribed4 ,his statistics of mortality are3 after spontaneous labor1 #ah4if2 after artificial labor1 #cj4jd2 after forced delivery1 #dj4gd4 #abb ,nouvelle ,archives d',obsttrique et de ,gyncologie1 #ahic4 ,lichtenstein#abc reported1 from ,zweifel's clinic in ,leipsic1 the results of #djj cases of eclampsia1 and he found that the eclamptic convulsions cease in only one-third of the cases after any form of delivery4 ,he says the mortality of induced labor is no better than that after forced delivery1 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 intervention4 ,the difference in the mortality between eclampsia without delivery or with delivery seems to depend on the relative loss of blood4 ,in #dj per cent4 of eclamptic cases operated upon1 the loss of blood was #ejj c4c4 above the loss in cases of spontaneous delivery4 ,the loss of blood tends to produce collapse when the blood comes from the uterus1 although it may be beneficial if removed by venesection before delivery4 ,five hundred c4c4 of blood is one-eighth to one-ninth of the entire blood supply of the body in a woman of average size4 ,if #ejj c4c4 of blood is withdrawn before the shock of forced delivery and replaced by an equal quantity of normal salt solution1 the toxin is thus reduced by one-fourth or one-third and then diluted by the normal salt solution1 so that it has less poisonous effect4 #abc ,archiv fr ,gynkologie1 #aiaa1 xcv1 #a4 ,lichtenstein#abd describes the expectant treatment by phlebotomy and narcotics to replace operative interference1 and this method has revolutionized the mortality of the treatment of eclampsia4 ,in ninety-four cases of eclampsia his mortality was only #e4c per cent41 and none of the deaths could be ascribed to the treatment4 ,the infant mortality was #cg4c per cent41 as against his #ch4h per cent4 in active operative interference during preceding years4 ,werner1 in the ,second ,gynecological ,clinic in the ,university of ,vienna1#abe by this new method in thirty-eight cases of eclampsia had a maternal mortality of #e4b1 as ,lichtenstein had1 but his infant mortality was only #ad4fe per cent41 an enormous advance for the better4 ,formerly the mortality in the ,viennese clinic was #ae4h for the women and #dd4c for the children1 in a series of #abj cases of eclampsia4 ,a mortality of #ej per cent4 in the children is common in the old method4 ,in ,lichtenstein's cases there were mental disturbances in #b4a per cent4 of the women1 as against #f4ge per cent4 in the old method4 ,eclamptics may go insane and kill the child after delivery4 ,lichtenstein treated #gd consecutive cases without a single death4 ,in #ed per cent4 of his cases the convulsions ceased after one venesection1 and #db per cent4 of the women with ante-partum attacks recovered before labor came on4 ,engelmann#abf reported a case where a woman who had had #ahh convulsions recovered after the third venesection4 #abd ,monatsschrift fr ,geburtshlfe und ,gynkologie1 xxxviii1 #b4 ,berlin4 #abe ,mnchener medizinische ,wochenschrift1 ,november #bc1 #aiae4 #abf ,centralbl4 f4 ,gynk4 xxxi1 #aa4 ,in this method the woman is put in a dark1 quiet room2 #djj to #fjj c4c4 of blood are withdrawn by venesection1 and #j4jjb gm4 morphine is injected2 two hours later #c gm4 chloral is given in an enema4 ,if the fetus presents in a position for prompt delivery it is removed with forceps1 or by expression to spare the mother2 but expression is a dangerous process always4 ,zinke#abg of ,cincinnati has a method which reduces the maternal mortality1 but it has an enormous infantile mortality4 ,he depresses the maternal pulse by veratrum viride1 and this depression is probably the cause of the infantile mortality through asphyxia4 ,veit introduced the use of morphine in eclampsia1 and ,winckel the use of chloral4 ,it has been found that narcotics check the action of toxins on the nuclei of cells1 and in eclampsia the action of narcotics may be of this nature4 ,baker of ,alabama in #ahei first gave veratrum viride in eclampsia4 ,the drug lowers arterial tension by depressing the vasomotor centres and the heart itself4 ,in eclampsia it diverts blood from the brain and depresses the motor neurons of the spinal cord4 ,aconite has the same effect in acute cerebral congestion without depressing the vasomotor centres or irritating the stomach as veratrum viride does4 #abg ,new ,york ,state ,journal of ,medicine1 xiii1 #h4 ,cesarean delivery is used frequently of late in eclampsia4 ,the mortality of the children is lowered somewhat by a cesarean section1 but the mortality of the mothers is much worse than in the expectant method described by ,lichtenstein4 ,eclamptic women usually have badly affected kidneys1 and the anesthetic used in the section may be a cause of the raised mortality4 ,peterson reviewed #ejj cases of cesarean section for eclampsia#abh done by #bei operators in various countries4 ,up to #aijh the maternal mortality was #dg4ig per cent4 in #aih cases2 from #aijh to #aiac it was #be4gi per cent4 in #bhc cases4 ,convulsions ceased in only #ed4ib per cent4 of the women after cesarean delivery1 and in those cases in which the convulsions continued the mortality was #ca4ec per cent4 ,in #adf cases where the convulsions ceased the mortality was still #ai4h per cent4 for the mothers4 ,the fetal mortality was #aj4fi per cent41 counting all children who died within three days after delivery by section4 ,the maternal mortality after cesarean section increases with the age of the patient4 ,the cesarean delivery1 then1 has a maternal mortality of late of #be4gi1 with a tendency to increase as unskilled men attempt it2 the expectant method has a maternal mortality of only #e4c per cent4 ,the cesarean delivery has a fetal mortality of #aj4fi per cent42 the expectant1 #ad4fe per cent4 ,the expectant method is preferable4 #abh ,amer4 ,jour4 ,obstetrics and ,diseases of ,women and ,children1 lxix1 #f4 ,,chapter ,,xiv ,,heart ,,diseases ,,in ,,pregnancy ,over #bj1jjj women die in childbirth each year in the ,united ,states1 and about #ajj1jjj infants1 and more or less permanent injury from parturition is almost general in mothers4 ,the mortality in the trenches during the present great war is #b per cent42 the mortality of infants during the first year is #ad per cent4 ,very much of this mortality and invalidism is attributable to lack of skill in the licensed unfit4 ,we commonly deem parturition merely a physiological process1 and for that reason the state permits ignorant midwives and quacks to take upon themselves with impunity the responsibility and the risks of delivery4 ,it is difficult to draw the line between normal and abnormal parturition1 but every labor1 as women now are in civilized countries1 should be regarded as a grave surgical operation1 and the indications that must be met in a surgical operation are likely to occur in almost any parturition4 ,the strength of the patient1 the condition of the heart1 lungs1 kidneys1 and blood1 sepsis and antisepsis1 the nature and technic of the various operations that may be required1 and the complications that may arise1 are all to be understood and met conscientiously4 ,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 delivery4 ,if the mother or child dies because of the bungling or surgical uncleanness of the physician or midwife1--and unfortunately such deaths occur almost hourly1--this physician or midwife is guilty of murder4 ,there may be an abnormality of the uterine or abdominal muscles used in parturition1 a disproportion between the parturient canal and the child1 or various accidents of labor2 and these conditions are so frequent in occurrence and so grave that their removal requires great medical skill1 fine discernment1 quick and exact judgment1 and often decidedly courageous purpose4 ,new methods of treatment frequently appear1 and the quack is likely to be among the first by which the new is tried4 ,the use and abuse of pituitrin is an example of such a method4 ,about #aiji1 pituitary extract as a uterine stimulant was first described and it was immediately taken up by competent men and more frequently1 perhaps1 by the quack4 ,the extract is from the posterior lobe of the pituitary gland1 and when injected subcutaneously or into a muscle it is a very powerful oxytocic4 ,in a few minutes the injection markedly increases the intensity and duration of the pains4 ,the effect lasts for an hour or an hour and a half4 ,whitridge ,williams#abi 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 cases1 but its ignorant use places the life of the mother and child in jeopardy4 ,mundell#acj found twelve cases of rupture of the uterus1 thirty-four cases of fetal death1 and forty-one cases of fetal asphyxia pallida in which resuscitation was effected only after prolonged and vigorous efforts1 sometimes for over an hour4 #abi ,obstetrics1 #dth ed4 ,new ,york1 #aiag4 #acj ,jour4 ,amer4 ,med4 ,assoc41 ,june #b1 #aiag4 ,if there is any serious obstacle at all to delivery in the parturient canal or in the fetal position1 or the like1 pituitrin is likely to cause rupture of the uterus and asphyxiation of the child4 ,it should never be used when there is the slightest danger of rupture of the uterus2 or when the child is suffering2 or in a shoulder and most pelvic presentations2 or in elderly primiparae with rigid muscles2 or when the cervix is not fully dilated1 lest the undilated cervix be torn off2 or where there is inertia after prolonged effort to overcome an obstacle to delivery4 ,it is never to be used in a normal delivery merely to hasten the birth4 ,obstetrical cases are tedious1 and an impatient physician with an atonic conscience is likely to use pituitrin so that he can get back to his bed4 ,comparisons between the fetal mortality after the use of pituitrin or the forceps are erroneous4 ,quigley#aca contrasted the fetal mortality in these conditions4 ,in #adg pituitrin cases it was #b4g per cent41 in about five or six times the number of forceps cases it varied from #e4g to #ae4fc per cent42 but wherever there is any real need at all for the forceps1 pituitrin at once is contraindicated except in easy low forceps deliveries1 where in the hands of a skilled man pituitrin may safely replace the forceps to avoid possible instrumental infection of the uterus4 ,there are contractions of the uterus toward the end of gestation1 before labor proper sets in1 which cause what are called ,false ,pains1 and these must not be mistaken for the beginning of labor1 as unnecessary examinations and meddlesome interference may bring on great harm4 ,uterine atony1 or weak pains1 may affect the patient in the first stage of labor1 in which the cervix of the uterus should be dilated2 or the second stage1 in which the child is delivered2 or the third stage1 the post-partum period1 when the placenta is thrown off4 ,contractions of the uterine muscle cause pain1 and these contractions themselves are called the ,pains4 ,in the first stage weak pains may prolong the dilatation of the cervix for days and expose the mother to sepsis or exhaustion1 and the child to consequent danger4 #aca ,jour4 ,amer4 ,med4 ,assoc41 ,april #aj1 #aiae4 ,in the second stage the abdominal muscles1 which push the child out of the uterus1 fail to work if the pains are weak4 ,causes of unsuccessful pains in the second stage are3 an infantile uterus1 fibroids or other tumors in or near the uterus1 peritoneal adhesions1 a full rectum or bladder1 abnormal position of the uterus1 a pendulous abdomen1 diseases of the uterine wall1 scars from past operations1 chronic metritis or endometritis1 primiparity in relatively advanced age1 twins1 distention of the bag of waters1 gas in the uterus1 abnormal position of the child1 contracted pelvis1 adhesions of the membranes about the os uteri1 fatigue of the woman1 and tetany or stricture of the uterus4 ,the obstetrician must be able to diagnose the special cause and treat the indications4 ,one of the causes of weak pains is a diseased heart4 ,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 importance4 ,if there is a genuine cardiac lesion with good compensation1 the labor is usually successful and without notable damage to the woman1 although obstetricians like ,de ,lee think that such patients appear to develop decompensation sooner than do women who are not pregnant4 ,if the heart disease is advanced and the heart is in unstable equilibrium1 especially if there is myocarditis or fatty degeneration1 the heart is likely to break down in pregnancy or labor4 ,in chronic cardiac lesions1 pregnancy1 through venous congestion1 tends to renal and hepatic disturbance1 or to dyspnoea and carbonic acid narcosis4 ,the uplifting of the diaphragm by the enlarged uterus increases the respiratory difficulty4 ,there may be edema of the lungs1 hypostatic pneumonia1 dropsy1 insomnia1 albuminuria1 and other serious symptoms4 ,during labor a diseased heart may fail and cause sudden death1 especially if the second stage is prolonged4 ,at times there is collapse and death shortly after delivery4 ,the mortality of heart disease in pregnancy varies in the reports on various series from #d to #he per cent4 ,babcock#acb says that the mortality in mitral disease in pregnancy is #ej per cent42 that in disease of the aortic valve is #bc per cent4 ,these figures are far above those given by later obstetricians of skill4 ,fellner and ,demelin1 in ninety-four and forty-one cases respectively1 had a mortality of only #f4c and #e per cent4 ,hirst says he never lost a case4 ,jaschke#acc found a mortality of only #d per cent4 in #aedh cases of pregnant cardiopaths4 ,a great danger is in treating heart conditions by general rules1 and in giving digitalis and other drugs without discrimination4 ,in uncompensated heart conditions many of the children die from prematurity1 abruptio placentae1 diseases of the placenta1 or asphyxiation4 #acb ,diseases of the ,heart4 ,new ,york1 #aije4 #acc ,medizin4 ,klinik1 ,february #be1 #aiab4 ,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 insufficiency4 ,expectancy is the rule4 ,lusk advises abortion as soon as mitral stenosis is discovered4 ,surgeons of the ,mayo ,clinic1 in a report#acd on ,operative ,risk in ,cardiac ,disease1 hold that a valvular lesion is not a rational basis for judging a cardiopath so far as prognosis in a surgical operation is concerned1 but this statement is not true for an obstetrical case4 ,if we except angina pectoris and related diseases1 the four disorders of the heart's mechanism that surgeons deem the worst risks in operation are auricular fibrillation1 auricular flutter1 impaired auriculoventricular conduction1 and impaired intraventricular conduction4 ,these conditions are usually accompanied by extensive lesions of the heart muscle4 #acd ,jour4 ,amer4 ,med4 ,assoc41 lxix1 #bd4 ,in auricular fibrillation there are rapid incordinate contractions1 twitchings in individual muscle bundles of the auricular wall4 ,the auricle loses its power to pump the blood and dilates4 ,the pulse is commonly arhythmic and rapid4 ,a permanent fibrillation is worse than a paroxysmal state4 ,the condition is found especially in advanced cases of exophthalmic goitre4 ,in the ,mayo ,clinic the operative mortality in seventy cases of exophthalmic goitre with auricular fibrillation was only #b4h per cent4 ,in auricular flutter1 or heart block1 there are foci of irritation in the auricular wall which cause rapid cordinate contractions4 ,the auricle may contract twice as often as the ventricle1 and the pulse may be regular or markedly irregular4 ,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 ventricle4 ,this bridge may be so affected that the stimulus is delayed1 or prevented at times from crossing over1 or completely blocked4 ,one patient with complete heart block was operated upon at the ,mayo ,clinic three times in eleven years for appendicitis1 cancer of the breast1 and the excision of recurring skin nodules1 and is still alive and reasonably well4 ,in intraventricular block the risk of operation is worth taking1 according to the opinion at the ,mayo ,clinic1 where there is exophthalmic goitre or tonsillitis4 ,in general1 where there is question of surgical operation on a cardiopath1 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 health4 ,extremely severe cardiac disease can be relieved or even completely cured by the surgical removal of infectious1 mechanical1 or toxic sources of heart degeneration1 especially goitre4 ,when the myocardial insufficiency is so marked that no medical treatment restablishes a reasonable compensation1 no surgical operation is permissible4 ,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 operation4 ,life depends on ventricular action1 not on auricular1 and the ventricular reserve is the standard for judgment in these cases4 ,fibrillation and heart block are grave conditions when found in pregnancy1 but disease of the mitral valve because of frequency is more important1 and when compensation is unstable mitral lesions are dangerous4 ,in mitral stenosis the enlarged uterus in the last months of gestation1 by crowding the intestines and diaphragm1 embarrasses the heart4 ,as the diaphragm cannot descend well1 the flow of blood out of the right ventricle is not aided by respiration as in normal conditions4 ,pressure on the abdominal veins increases the blood tension and throws greater work on the left ventricle4 ,in the expulsive stage of labor there is danger of the right ventricle giving way under the added strain4 ,in mitral regurgitation the left ventricle is dilated1 and in pregnancy the regurgitation is increased by the peripheral resistance or obstruction4 ,if the dilated ventricle is also hypertrophied it stands the strain much better4 ,in the second stage of labor the danger is the same as in mitral stenosis4 ,in disease of the aortic valve the strain of child-bearing is on the left ventricle1 but patients in this condition undergo labor more successfully than do those with mitral disease4 ,labor in any cardiac disease requires close watching even when the compensation is good4 ,there is always a possibility of collapse in the third stage or during the puerperium4 ,the obstetrician must stay by the bedside1 and he is to have everything ready for a sudden emergency1 which is likely to result in death if not instantly met4 ,all the instruments for operative delivery are to be kept sterilized and ready for immediate use4 ,when symptoms of imminent collapse appear1 delivery is to be done at once4 ,if a cardiopath collapses in the early stages of gestation1 before the child is viable1 the rule explained in the chapter on ,abortion holds--the child may not be killed by removal to save the woman's life4 ,jaschke1#ace in his consideration of #aedh pregnant cardiopaths1 found that seven-eighths went to term1 and that the women were prematurely delivered in only about #i per cent4 of the total number of cases4 ,therapeutic interruption of pregnancy was necessary in only about #a per cent4 ,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 lacking1 as a rule1 in specialists who are not internists4 #ace ,loc4 cit4 ,a combined mitral and aortic disease with great enlargement of the heart1 heaving of the chest wall1 and some protrusion makes pregnancy very dangerous4 ,osler thinks mitral insufficiency in itself not very dangerous4 ,he had one patient with such a condition1 a loud apex systolic murmur1 and some enlargement1 who bore nine children and lived to past sixty years of age4 ,mitral stenosis is not so favorable1 but even in extreme stenosis some women bear several children without collapse4 ,,chapter ,,xv ,,hyperemesis ,,gravidarum ,hyperemesis ,gravidarum1 the ,pernicious ,vomiting of ,pregnancy1 is commonly classified among the toxemias2 but as the etiology is not known definitely1 this classification is one of convenience more than exactness4 ,nausea and vomiting occur so frequently in the early months of gestation that they are deemed almost physiological1 but when these symptoms become very grave and persistent they are undoubtedly pathologic1 and are said to be pernicious1 as they may lead to abortion1 or to the death of the woman4 ,in #ahac1 ,simmond first successfully employed artificial abortion to save the woman in this condition1 and thus added a possible moral quality to the disease4 ,therapeutic abortion was used in #afjh1 and ,soranus of ,ephesus1 in the second century1 mentions it4 ,the pernicious nausea commonly begins in the second month of pregnancy1 less frequently in the fourth month1 but it may be delayed until the sixth month2 if it occurs after the sixth month it is1 almost as a rule1 an evidence of nephritis4 ,it may last from about a month and a half to three months1 but in toxemic cases it may result in death in two weeks4 ,sometimes remissions occur4 ,in #aheb1 ,paul ,dubois described the disease1 and his division into three stages is still used in articles on pernicious vomiting1 although these stages are not clearly marked clinically4 ,in the early months of gestation the stomach may become unable to retain food1 and there is notable loss of appetite2 the condition is then grave4 ,there may be retching at the sight of food1 at any change of position1 or at the entrance of a person into the room4 ,the emesis may recur so often at night as to cause exhaustion from insomnia4 ,hiccough1 thirst1 pain in the stomach1 and soreness of the thoracic muscles are frequent and troublesome symptoms4 ,in some cases there is salivation4 ,the vomitus is food1 mucus1 and some bile at first2 later mucus and bile2 finally it contains blood4 ,the blood may come from the mouth1 pharynx1 or stomach1 and it is serious if it is gastric4 ,the urine is scanty1 and shows nephritic irritation4 ,at times it contains blood1 bile1 acetone1 diacetic acid1 indican1 and rarely sugar4 ,in the second stage of the disease all symptoms are aggravated1 and the stomach will not retain anything4 ,there is extreme thirst2 the patient faints often1 and loses weight rapidly4 ,in chronic cases there is much emaciation4 ,the mouth is like that in a case of typhoid4 ,sometimes there is a low fever2 again1 the temperature is subnormal1 with a rise before death4 ,the pulse is rapid and weak1 and the post-mortem heart shows fatty degeneration as in a fatal sepsis4 ,in the third stage the mind is affected1 there is delirium1 stupor1 and coma2 the vomiting ceases1 the pulse grows more rapid and feebler1 and the weakness becomes more and more overwhelming until the patient dies4 ,this third stage is commonly short4 ,in these conditions it is too late to empty the uterus1 and any attempt to do so then only hastens death4 ,in some cases the fetus is apparently not affected2 in toxic cases it is affected1 and then there may be miscarriage4 ,if the fetus dies the vomiting ceases1 as a rule4 ,the liver enlarges in the first stage and later diminishes4 ,there may be a general hemorrhagic hepatitis and acute yellow atrophy1 or partial fatty degeneration around the central lobular veins4 ,necrosis also occurs4 ,acute parenchymatous nephritis and hemorrhages into the kidneys are often observed4 ,neurotic and hysteric women are more liable to this disease than the nervously stable4 ,there is a direct communication by the sympathetic and vagus nerves between the stomach and the uterus and its adnexa1 and thus reflex irritations readily pass to the stomach4 ,through this path vomiting is caused by any unusual distention of the uterus1 as when the fetus grows too rapidly2 or when the size of the ovum is larger than normal1 as in twin pregnancies2 or in irritations like hydramnios1 displacement of the uterus1 acute anteversions1 retroversions1 or flexions which pinch and stretch the nerves4 ,inflammations1 as metritis1 endrometritis1 and cervicitis2 tumors of the uterus2 diseases of the adnexa or of the pelvic connective tissue or peritoneum are other sources of reflex vomiting4 ,the proof that such are causes is that the vomit ceases when the conditions mentioned are cured4 ,such conditions exist1 however1 in women who are not pregnant without causing vomit2 there is therefore some special disposition in the pregnant4 ,diseases which in themselves have vomiting as a symptom will in pregnancy make the vomit pernicious4 ,such are chronic gastritis1 gastric ulcer1 enteritis1 cancer1 helminthiasis1 large fecal concretions1 enteroptosis1 tubercular peritonitis1 and gall-stones4 ,what is apparently pernicious vomiting in pregnancy may be the beginning of acute miliary tuberculosis4 ,diseases of the air passages--hypertrophied turbinates1 septal spurs1 laryngeal and apical tuberculosis--seem to cause the vomiting or to dispose to it4 ,when vomit is associated with uremia1 this occurs1 as a rule1 in the last months of pregnancy4 ,the cause1 again1 may be in the nervous system1 from either a demonstrable lesion or a functional imbalance--paresis1 locomotor ataxia1 tumors or tubercle of the brain1 meningitis1 polyneuritis4 ,even when the nervous system is not directly the cause of the emesis1 the remote irritant may work through the nervous system4 ,a bad neurotic inheritance1 as from alcoholic1 insane1 or weak parents1 disposes to neurotic hyperemesis4 ,toxins from the fetal syncytium appear to be another cause of the vomit4 ,the syncytium is a mass of protoplasm without cell demarkation but with nuclei scattered throughout the substance4 ,sometimes this embryological cellular material starts to grow after the manner of a cancer1 and then it is very malignant 7syncytioma malignum71 but its connection with the pernicious vomit of pregnancy is more theoretical than established4 ,in physiological conditions the toxins in the blood are neutralized by the secretions of the ductless glands of the body1 and in pregnancy probably these same glands by intensified activity effect the same result4 ,injection of blood serum taken from healthy pregnant women has cured cases of toxemic pernicious vomit1 and this makes the theory much more probable4 ,to diagnose the etiology of pernicious vomiting is not always easy4 ,we must decide first whether the emesis is really pernicious or not2 secondly1 we have to determine whether or not it is due to the presence of the fetus2 thirdly1 we are to differentiate the primary and adjuvant causes for intelligent treatment4 ,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 necessary1 in medical opinion1 to do so4 ,trousseau emptied the uterus of a woman to stop her pernicious vomit1 but she died1 and at the autopsy he found a cancer of the stomach4 ,caseaux discovered tubercular peritonitis in a woman who had died after a diagnosis of hyperemesis gravidarum2 ,beau1 tubercular meningitis in a like case4 ,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 abortion4 ,there is no settled mortality percentage in hyperemesis gravidarum because so much depends on diagnosis and treatment4 ,braun1 in #aej1jjj obstetrical cases1 never had a death from pernicious vomit2 others have a mortality of #dj per cent4 ,the treatment is technical1 and is given in detail in books like ,de ,lee's ,principles and ,practice of ,obstetrics4#acf ,suggestion and the environment are important elements in the treatment4 ,local anesthetics1 mechanical drugs like cerium oxalate and bismuth1 depressomotors1 external applications1 and gastric lavage are indicated in the early stages of the disease1 but are rather harmful than useful in later stages4 ,adrenalin1 ten drops of a #a3ajjj solution by mouth1 or three drops hypodermically as doses1 often cures4 ,sergent and ,lian reported six such cases in one paper in #aiac4 ,hypodermic injection of the extract of corpus luteum in #a c4c4 doses has been effective in some cases4 ,so has the injection of defibrinated serum from a healthy pregnant woman4 ,curtis describes the technic in the ,journal of the ,american ,medical ,association1 ,february #bh1 #aiad4 ,the gynecologist must adjust uterine displacements and heal cervical erosions4 ,the oculist1 laryngologist1 and otologist are to remedy refractive errors and remove irritants in the air passages and the ear4 #acf ,philadelphia1 #aiac4 ,the treatment of last resort is to empty the uterus4 ,this will cure all cases of neurotic and reflex origin if done early enough4 ,in these cases1 if the therapeutic abortion is deferred until very late1 the patient will die of exhaustion4 ,toxemic cases do not react well after therapeutic abortion because of the damage previously done by the circulating poison1 especially in the liver4 ,a positive diagnosis of toxemia cannot always be made1 and many patients in whom the diagnosis has been made correctly recover without abortion4 ,apart from moral considerations1 it is very difficult to determine the proper time to empty the uterus4 ,a test is made of the glycolytic power of the liver by giving two ounces of levulose internally2 and if sugar shows in the urine1 this means that the liver is unable to act normally1 that it has been attacked and disabled by the toxin1 and therefore the therapeutic abortion should be done4 ,again1 a marked concentration of the blood1 shown by erythrocytosis and leucocytosis1 indicates starvation4 ,some obstetricians perform abortion when the pulse remains above #ajj1 at the appearance of fever1 blood from the stomach1 jaundice1 albuminuria1 mellituria1 acetonuria1 indicanuria1 or marked loss of weight4 ,polyneuritis1 with icterus and bile in the urine1 is another indication for abortion2 a patient may die from polyneuritis alone after the hyperemesis has ceased4 ,not one but all these facts must be considered1 together with one's own clinical experience4 ,in hyperemesis gravidarum1 as elsewhere1 therapeutic abortion is never permissible1 under any circumstances1 if the child is not viable4 ,if the mother cannot be saved without emptying the uterus1 the mother must die2 there is no way out of the difficulty4 ,the proof that this doctrine is correct has been given in the introductory chapter on ,homicide and when considering abortion in general4 ,,chapter ,,xvi ,,chorea ,,gravidarum ,,and ,,hysteria ,recurring1 permanent1 localized spasms of facial or other groups of muscles1 which are often called chorea1 are tics1--convulsive tic1 painful tic1 accessorius spasm1 and so on4 ,chorea is also characterized by various recurrent spasmodic movements1 but the origin of the disease is commonly an infectious endocarditis1 rheumatism1 tonsillitis1 or the like disease4 ,this is ,chorea ,minor1 ,st4 ,vitus's ,dance1 or ,infectious ,chorea4 ,there is also a common chorea1 which is not from an infection but from some nervous irritation1 usually eye-strain1 and disappears with the removal of the irritation4 ,the chorea of pregnancy is often an infectious chorea1 and then it is an extremely dangerous condition3 the mortality in some collections of toxic cases is as high as #bb per cent4 ,we meet1 too1 in pregnancy hysterical chorea1 and a form which is partly hysterical and partly infectious in origin4 ,primigravidae are more susceptible to infectious chorea in pregnancy than multigravidae4 ,if a woman has not had true rheumatism she very rarely gets chorea after the first gestation4 ,rheumatism in the patient or in her immediate ancestors1 epilepsy1 fright and other emotions1 and anemia are predisposing causes4 ,the patients are all very neurotic2 and if they had chorea in childhood1 the condition is likely to recur in pregnancy4 ,mild cases may be cured without damage to the woman or fetus1 but many cases go on to abortion and death in coma and fever4 ,some severe cases result in a mania which may last for months2 again1 there is paralysis and delirium4 ,the earlier in pregnancy the attack1 the greater the danger to the fetus4 ,it is very important to differentiate infectious chorea from hysterical chorea--the latter may or may not be dangerous2 chorea always is dangerous4 ,in hysterical chorea the movements are sudden1 isolated1 and sometimes rhythmical1 especially in the fingers2 there are zones of anesthesia1 and the perversity of the hysteric soon manifests itself4 ,the movements in hysteria are never so intense as to exhaust the patient4 ,in true chorea the movements are irregular1 spasmodic1 and increased by motion and voluntary effort1 especially if the effort is sustained2 they exhaust the patient4 ,maniacal chorea differs from the mania of the puerperium from other causes3 in maniacal chorea the woman is not so sullen1 and is more garrulous than the patient with puerperal mania4 ,the prognosis is better in maniacal chorea as to recovery of reason4 ,sometimes1 however1 the mania of puerperal chorea persists for months1 or it may become even permanent4 ,if the fetus is viable and the choreic woman1 with a clear toxic chorea1 shows signs of exhaustion from the spasms and insomnia1 or if her mania is becoming fixed and her delusions are dangerous 7such women are likely to kill the infant71 or if she has endocarditis1 the uterus should be emptied1 as a rule4 ,if1 however1 the symptoms show a recession on treatment1 the uterus should not be emptied4 ,albrecht#acg reported a case of chorea cured by an injection of serum from a normal pregnant woman4 ,each case must be judged by its own characteristics4 ,the last sacraments should be given as soon as the symptoms grow grave4 #acg ,zeitschr4 f4 ,geburtshlfe u4 ,gynk41 lxxvi1 #c1 p4 #fgg4 ,stuttgart4 ,hysteria in a woman1 even when mild1 may grow serious in pregnancy when it takes the form of melancholia2 but it is dangerous when it passes into maniacal excitement4 ,in mania there may be exhaustion from a refusal to take food1 and in labor maniacal hysteria may wreak grave injury on both mother and child4 ,hysterical women should be treated before pregnancy2 indeed1 the process of avoiding hysteria should have begun in the patient's grandparents4 ,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 hysteria4 ,it is now etymologically meaningless--men also grow hysterical4 ,briquet found #aa male to #bjd female hysterics1 and later statistics increase the number of males4 ,the disease is not readily definable4 ,the patient is usually a young emotional woman1 oftenest between fifteen and twenty years of age4 ,she commonly has anesthetic spots on her body1 concentric limitations of the fields of vision and reversals in the color fields1 hysterogenetic zones1 or tender points1 which when pressed appear to inhibit the hysterical fit4 ,the symptoms enumerated here are not1 however1 found in every case of hysteria1 and it is difficult at times to diagnose the case4 ,there is a popular notion that hysteria is a disease of malingerers1 but it is as real as typhoid fever or a broken leg1 and a much greater affliction than either of these conditions4 ,malingering is only a symptom of the disease4 ,the conditions that bring about hysteria are hysteria in a parent1 or insanity1 alcoholism1 or some similar neurotic taint in an ancestor4 ,immediate causes are acute depressive emotions1 shocks from danger1 sudden grief1 severe revulsions of feeling1 as from disappointment in love or abandonment by a husband2 and1 secondly1 cumulative emotional disturbance1 as from worry1 poverty1 ill treatment1 unhappy marriage1 or religious revivals4 ,certain diseased conditions1 as anemia1 chronic intoxications1 pelvic trouble1 start it into activity when it is latent4 ,it is also communicated by imitation and it may become epidemic4 ,after the great plague1 the ,black ,death1 in the fourteenth century1 there were very remarkable epidemics of imitative hysteria in ,germany and elsewhere4 ,in #acgd1 at ,aix-la-,chapelle1 crowds of men and women danced together in the streets until they fell exhausted in a cataleptic state4 ,these dances spread over ,holland and ,belgium and extended to ,cologne and ,metz4 ,the ,dancing ,plague broke out again1 in #adah1 at ,strasburg and in ,belgium and along the lower ,rhine4 ,in #abcg there was a similar outbreak among children at ,erfurt and many died from exhaustion4 ,the tarantism in ,italy from the fifteenth to the eighteenth century is another example of epidemic hysteria4 ,there were epidemics of hysteria in ,tennessee1 ,kentucky1 and a part of ,virginia1 which began in #ahjj and recurred for a number of years4 ,these outbreaks started in revivals and camp meetings4 ,the majority of the cases were in youths from fifteen to twenty-five years of age1 but the hysteria was observed in persons from six to sixty years old4 ,the muscles affected were those of the neck1 trunk1 and arms1 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 bank4 ,convulsions1 tremors1 paralyses of various forms and degrees are common in hysteria4 ,in major hysteria the patient falls into a convulsion gently4 ,there is checked breathing1 up to apparent danger of suffocation4 ,then follows a furious convulsion1 even with a bloody froth at the mouth1 but there is a trace of wilfulness or purpose in the movements4 ,next may come a stage of opisthotonos1 in which the body is bent back in a rigid arch until the patient rests on her head and heels only1 like a wrestler2 and this is followed by relaxation and a recurrence of the contortions4 ,an ecstatic phase succeeds this at times1 the so-called crucifix position1 with outbursts of various emotions1 and a final regaining of the normal state4 ,any of these stages1 however1 may constitute the entire fit4 ,some major hysterics can simulate demoniacal possession with extraordinary ingenuity4 ,in minor hysteria there is commonly a sensation of a rising ball in the throat--the globus hystericus4 ,there may be uncontrollable laughter or weeping1 and muscular rigidity is frequent4 ,the patient1 especially if she is a child1 may mimic dogs and other animals4 ,the snarling1 biting1 and barking of false rabies are hysterical2 such symptoms do not occur at all in real hydrophobia4 ,there are innumerable physical symptoms of the disease1 but the mental phases have most to do with the treatment4 ,the hysterical person is characterized by an overmastering desire to be an object of sympathy1 interest1 admiration1 rather than by a tendency to baser instincts4 ,the will is weak1 the emotions explosive1 the patient is impulsive and lacking in self-control4 ,she readily goes from absurd laughter into floods of tears4 ,she simulates pains and other symptoms of disease1 and she is always a liar1 no matter what her state in life1 from nurse-girl to nun4 ,acquired hysteria may be cured1 but the congenital form is virtually hopeless2 yet even with this latter kind much can be done by patient training4 ,such a girl or boy must be reared carefully and with a firm hand4 ,a marked congenital hysteric should not marry4 ,marriage makes them worse1 and they beget other hysterics4 ,when a hysterical girl gets one of her fits the chief obstacle to cure is sympathetic visits from relatives and friends4 ,if a patient in the vapors is taken from school and wept over1 she will never come down to earth again4 ,the girl who faints at the communion-rail regularly is always a hysteric1 and the cure for her is a bucket of cold water in the sacristy1 or a threat to turn her over to the police4 ,you will find these fainters with a perfect pulse despite the faint4 ,but there are other cases in which rough treatment is harmful1 and the only method is patient tact4 ,such persons are objects of great pity and should be dealt with as one would deal with any deficient mind4 ,,chapter ,,xvii ,,acute ,,yellow ,,atrophy ,,of ,,the ,,liver ,,in ,,pregnancy ,acute yellow atrophy of the liver in pregnancy was formerly called ,icterus ,gravis4 ,the disease is not necessarily connected with pregnancy1 but half the cases are in pregnant women1 and with them it may appear at any time in gestation or shortly after delivery4 ,pernicious vomiting1 eclampsia1 sepsis1 chloroform poisoning1 typhoid1 osteomyelitis1 diphtheria1 erysipelas1 alcoholism1 or phosphorus poisoning in pregnant women may end in this acute yellow atrophy4 ,bendig#ach reported two cases1 both fatal1 which were caused by syphilis4 #ach ,mnchener medizinische ,wochenschrift1 ,august1 #aiae4 ,the liver lessens in size1 is friable1 yellow-streaked1 mottled with red2 the heart degenerates1 and all tissues are stained with bile1 icteric4 ,if the hepatic atrophy is a consequence of the diseases enumerated above1 the symptoms of these diseases precede those of the atrophy4 ,in chloroform poisoning the attack may end fatally within six hours1 or it may last for five or six days before death4 ,if a pregnant woman has had gastric catarrh with weakness and headache1 and then suddenly becomes delirious1 begins to toss about the bed with rolling of the head from side to side1 is jaundiced1 shows epigastric tenderness1 and a diminution of the liver dullness1 the diagnosis is almost certain4 ,the reflexes are exaggerated1 there are minute petechiae on the trunk1 arms1 and legs1 the tongue is dry and brown1 the breath is foul1 the pulse is fast and weak1 the temperature is usually high 7#ajb-ajd degrees71 and the urine shows nephritis4 ,the prognosis is always bad4 ,the fetus nearly always dies4 ,if the fetus is viable the uterus should be emptied at once even if the woman is so near death that the procedure appears useless3 it may at least give a chance to baptize the infant4 ,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 death1 yet the fetal heart-sounds can be heard through her abdominal wall4 ,in that case ,i should be in favor of performing the abortion to baptize the infant1 reluctantly permitting the chance of hastening the mother's death4 ,but this hastening is by no means certain4 ,when a diagnosis of acute yellow atrophy has been made the patient should receive the last sacraments as soon as possible4 ,,chapter ,,xviii ,,infectious ,,diseases ,,in ,,pregnancy ,any of the acute infections1 as typhoid1 typhus1 smallpox1 measles1 scarlatina1 and the others1 attacks a pregnant woman as readily as one who is not pregnant4 ,pregnancy1 as a rule1 lessens the resistance to the infection1 and the infection is likely to cause abortion4 ,the toxin of the infection is added to the physiological toxins of pregnancy1 the kidneys often are overwhelmed1 and there is a tendency to hemorrhage4 ,after the exhaustion from the disease1 delivery1 whether premature or at term1 is liable to end in collapse1 especially if the heart or lungs have been injured4 ,puerperal sepsis1 either general or local1 is a common effect of these bacterial diseases4 ,in smallpox there is infection from the pustules and the virus itself2 in typhoid the typhoid bacillus and the streptococci in ,peyer's patches get into the blood2 in influenza1 pneumonia1 erysipelas1 and diphtheria the bacteria directly cause sepsis1 and in scarlatina the pus organisms from the throat are found in the septic foci4 ,in these infections the fetus may be killed by the high temperature2 it may die from asphyxia brought on by feeble maternal blood-pressure and consequent stagnation of the circulation in the uterine sinuses2 it may be overwhelmed by maternal hemorrhage2 by deoxidation of the maternal blood1 as in pneumonia2 by a hemorrhage in the placenta1 and a consequent separation of the placenta itself from the uterine wall2 by fatty degeneration of the fetal villi1 which renders respiration of gases impossible4 ,again1 the child may be infected by the disease of the mother1 or it may be killed by the toxins in the maternal circulation4 ,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 blood4 ,the communication between mother and fetus is by osmosis1 but certain toxins1 drugs1 and bacteria may also pass from the maternal to the fetal circulation through the placenta4 ,strychnia injected directly into the embryos of animals by ,savory and ,gussarow killed the mother after passing to her through the placenta4 ,there is no direct communication 7except by osmosis7 between the fetal chorionic villi and the maternal intervillous blood spaces4 ,in the first half of pregnancy fetal and maternal blood are separated by the syncytium1 ,langhan's layer of cells1 the stroma of the villi1 and the walls of the fetal capillaries2 in the second half of gestation ,langhan's layer gradually disappears4 ,in the fetal blood-vessels are found many nucleated red corpuscles1 but these are lacking in the maternal intervillous spaces4 ,snger also discovered that in pernicious leucemia the leucocytes of the mother are not present in the fetal circulation4 ,that gaseous substances pass through the fetal barrier of tissues was proved by ,zweifel1 ,cohnstein1 and ,zuntz4 ,zweifel showed that chloroform administered to the mother rapidly reaches the fetus4 ,as early as #ahag1 ,mayer proved the passage of cyanide of potassium4 ,since then we have been made certain of the transmission of iodide and ferrocyanide of potassium1 salicylic acid1 bichloride of mercury1 methylene blue1 and many other substances4 ,krnig and ,futh1 in #aija1 determined that the maternal and the fetal blood freeze at the same temperature1 which indicates that they possess equal osmotic power1 and that osmosis may occur in either direction4 ,some bacteria do not get through to the fetus1 but a few do get in4 ,tubercle bacilli were found in the fetus by ,birch-,hirschfeld#aci in #ahia1 and ,schmorl#adj demonstrated them in #ej per cent4 of the placentas in one series of examinations4 ,bar and ,renon#ada found them in the blood of the umbilical cord in two of five cases4 ,actual congenital tuberculosis is possible1 though very exceptional3 the bacteria either pass through the wall between mother and fetus1 or destroy this wall and then get in4 ,smallpox1 measles1 and scarlatina1 the causes of which have not yet been demonstrated2 typhoid1 cholera ,asiatica1 pneumonia1 bubonic plague1 erysipelas1 pus infection1 anthrax1 syphilis1 febris recurrens1 and malaria have already been demonstrated in the fetus4 ,lynch of ,johns ,hopkins collected sixteen cases of typhoid in the fetus4 ,i found the typhoid bacillus in the liver and kidneys of a still-born fetus whose mother was ill with typhoid fever2 this case was not among those collected by ,lynch4 #aci ,arbeiten d4 pathologisch4 ,instit4 zu ,leipsig4 ,jena1 #ahia4 #adj ,mnchener medizinische ,wochenschrift1 #aijd1 vol4 li1 p4 #afgf4 #ada ,l',obsttrique1 vol4 i1 p4 #fi4 ,the majority of writers give unfavorable prognoses for typhoid in pregnancy4 ,abortion or premature labor is extremely common1 with great danger to the mother's life4 ,when labor begins in these cases the last sacraments should be administered early4 ,therapeutic abortion in typhoid is very likely to cause death1 yet a number of women recover after abortion4 ,as regards the woman's life1 cases of premature labor have a worse prognosis than early abortion4 ,the greatest danger is while the fever is high1 and abortion is commoner in the first week of fever than in the second or third4 ,in protracted typhoid abortion is likely to occur in the fourth week or later4 ,after defervescence the prognosis is better1 but there is always danger4 ,different physicians have markedly varying results4 ,there is no medical condition where skill in the physician counts more than in typhoid2 it is the supreme test of the therapeutist4 ,sacquin#adb collected from various sources the statistics of #bcc cases of pregnancy during typhoid1 and abortion or premature labor occurred in #aej of these1 with death in #af per cent4 ,many skilful men have a mortality as low as #c per cent4 in typhoid not complicated with pregnancy4 #adb ,thse4 ,nancy1 #ahhe4 ,the subject of typhoid is too vast for complete treatment here3 the article on ,typhoid in the ,american edition of ,nothnagel's ,encyclopedia of ,practical ,medicine covers #dgb large octavo pages4 ,a very important point is not to mistake typhoid for a septicemia in its early stage4 ,a ,widal reaction should be made in apparently septic cases to exclude typhoid4 ,sometimes1 however1 a streptococcic infection will give a positive ,widal1 and there may be a mixed typhoid and streptococcic infection4 ,smallpox in pregnancy causes abortion or premature labor in the majority of cases1 and the child usually dies4 ,the child may be born in the eruptive stage1 or pockmarked4 ,franklin reported a case where a vaccinated woman was delivered of a child while her husband was in the house ill with smallpox4 ,the mother did not take the infection1 but the child was born dead of smallpox3 the contagion had passed to the child through the unaffected mother4 ,vaccinated women at times bear children which are after birth immune to vaccinia and smallpox--vaccinia1 in the commonly held opinion at present1 is an attenuated smallpox4 ,pregnant women should be vaccinated1 when there is smallpox in their neighborhood1 to protect themselves and their children1 unless they have been successfully vaccinated within four or five years4 ,vaccination prevents smallpox in more than #ij per cent4 of the exposures to the disease4 ,the death-rate was #eh per cent4 in the unvaccinated cases and #af per cent4 in the vaccinated in a group of #ejjj cases of smallpox studied by ,welch in #ahid4 ,during the eighteenth century1 according to ,bernouilli's calculation1 one-twelfth of all the children born succumbed to this disease4 ,in #agjg1 in ,iceland1 #ah1jjj of the entire population of #ej1jjj died of smallpox4 ,as late as #ahhe1 #cafd persons died of the disease in ,montreal in one epidemic brought on at a time when vaccination had been neglected4 ,in ,prussia1 from #ahea to #ahfj1 without compulsory vaccination for civilians1 there were #cf1egg deaths from smallpox2 in the ,prussian army during the same time1 with compulsory vaccination1 there were only fourteen deaths4 ,during the war of #ahgj the ,french armies1 without vaccination1 lost #bc1dfi men from smallpox2 the ,german armies lost only #dei men and there was a great epidemic of the disease in ,germany at the time4 ,the efficiency and necessity of vaccination against smallpox1 which is as virulent now as it ever was1 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 smallpox4 ,revaccination is necessary every eighth year if smallpox reappears4 ,agitation against vaccination is not mere ignorance3 it is a dangerous crime1 exactly like loosing a mad dog2 and it is combined with the insolence of ignorance4 ,persons who have seen smallpox are very much afraid of it1 because it is one of the most dreadful afflictions humanity is exposed to2 those who have not seen it1 yet say they are not afraid of it1 are mere fools4 ,a pregnant woman who is infected with smallpox should receive the last sacraments as soon as possible4 ,if she aborts she may die very quickly in collapse4 ,if she is evidently in articulo mortis and the fetal heart can be heard1 her cervix should be forcibly dilated1 the child turned1 and delivered for baptism4 ,if the physician waits for death1 the child will be dead also1 and sectional delivery will be too late for any good4 ,pneumonia in pregnancy is a rare but very dangerous disease4 ,in one series of #ac1faa pregnancies there were #abj cases of pneumonia--eight-tenths of one per cent42 in another series of #ahdb pregnancies two and three-tenths had pneumonia4 ,wallich1#adc in a study of the mortality of this condition1 found that pneumonia causes abortion in one-third of the cases that occur during the first six months of gestation1 and in two-thirds of the cases that happen between the sixth month and term4 ,on the third day of the pneumonia the abortions are most likely to occur4 ,the maternal mortality varies between #ej and #ajj per cent4 in the groups studied1 and the fetal mortality is #hj per cent4 in general1 but about #dj per cent4 for viable fetuses4 ,the large size of the uterus in the last months of pregnancy interferes with the descent of the diaphragm in respiration1 and the heart is likely to fail4 ,the more advanced the pregnancy1 the greater the danger to both mother and child from pneumonia4 ,among the dangers to the child is the imperfect oxygenation of its blood1 and in a few cases the pneumococci reach the fetus4 #adc ,annales de ,gyncologie4 ,june1 #ahhi ,randall1 in a study of #aij pregnant women who had pneumonia1 found a somewhat lower mortality than that observed by ,wallich4 ,in ,randall's series #gj died 7#cf4g per cent472 of #aah who did not abort1 only #ab died 7#aj4g per cent474 ,in a second group of #ceb cases abortion happened in #eh4h per cent4 ,of #add patients in the first six months of gestation1 #bb4jh per cent4 died1 but of those that aborted #eb4jh per cent4 died4 ,again1 of #afd cases in the last three months1 #cj4di per cent4 died1 but #gj4ab per cent4 died of those that aborted during these three months4 ,of #hb that aborted1 #hg4h per cent4 died4 ,the mortality in women under #be years of age was #ac4cc per cent42 in women from #be to #ce years1 #bc4b per cent42 over #ce1 #bb per cent4 ,pneumonia in pregnancy is made worse by the mechanical interference with respiration brought about by the enlargement of the uterus1 and the heart1 which is overburdened in ordinary pneumonia1 is still more exhausted by the additional strain of pregnancy in the pneumonia of gestation2 moreover1 the lungs1 which are obliged to do enhanced labor in pregnancy in eliminating1 are clogged by the pneumonia2 it would seem1 then1 that1 if the fetus is viable1 the womb should be emptied to give the mother a better chance for recovery4 ,statistics1 however1 are against therapeutic abortion4 ,the evacuation of the uterus determines blood to the inflamed lungs1 which are already overburdened4 ,the exhaustion of labor weakens the patient1 and makes her liable to general septic infection4 ,matton#add found that in eighteen cases where pregnancy was artificially interrupted1 nine women died 7#ej per cent472 while in twenty cases where no interference was attempted1 only one woman died4 ,this comparison is not exact1 perhaps1 because we do not know the gravity of the infection in each group1 but in any consideration the difference is remarkable4 ,in a group studied by ,chatelain#ade the results in natural and artificial delivery were virtually the same4 ,inasmuch as therapeutic abortion at the best is no better than non-interference1 there is no justification for therapeutic abortion1 unless in unusual circumstances4 #add ,jour4 de ,md4 de ,bruxelles1 #ahgb1 p4 #dab4 #ade ,ibid41 #ahgj1 vol4 l1 pp4 #dcj1 #eaf1 and vol4 li1 p4 #aa4 ,pneumonia is an infectious disease1 and a pregnant woman should1 for her own sake and the sake of the fetus1 avoid exposure to infection4 ,when the disease is present the last sacraments should not be deferred1 as it may be impossible to make a confession when near death4 ,influenza in pregnancy is more severe than it is in the non-gravid state4 ,by the laity1 and sometimes even by physicians1 influenza is confused with la grippe1 but there is an influenza vera and an influenza nostras1 or la grippe1 and this latter is not nearly so serious a disease4 ,the real influenza is caused by a specific bacillus2 it appears in epidemics which have a tendency to become pandemic1 and then the disease disappears for a generation4 ,la grippe is a bronchitis or coryza with some fever and muscle-soreness4 ,true influenza 7the name is ,italian1 influenza di freddo7 is very infectious4 ,the pandemic of #ahhi-ij started in ,turkestan in ,june1 #ahhi1 and by ,october1 #ahij1 influenza had gone westward and encircled the earth along the trade routes4 ,the preceding pandemic occurred in #ahdg-dh4 ,there is no clear proof that pregnant women are especially liable to infection by influenza1 but there is always a notable fall in the birth-rate after marked epidemics of the disease4 ,this has been observed in ,france1 ,germany1 and ,switzerland4 ,when it does occur in pregnancy it is likely to cause abortion4 ,pasquier1 as early as #adaj1 noticed this fact4 ,the disease is likely to cause hemorrhage from the uterus in non-gravid women1 especially in those who are past the climacteric1 and menorrhagia in younger women who are not pregnant4 ,moeller#adf found abortion or premature labor in #bh4c per cent4 of twenty-one severe cases4 ,in severe influenza where there is diffuse capillary bronchitis1 pleuropneumonia1 or spasmodic cough1 abortion is most likely to occur1 and such abortion is always dangerous4 ,the hemorrhages in abortions from influenza are often alarmingly profuse4 #adf ,deutsch4 med4 ,wochensch41 #aijj1 ,no4 #bh4 ,in threatened respiratory or cardiac failure in influenza complicating pregnancy there may be question of therapeutic abortion1 but in such an event great care must be taken to avoid exhaustion and shock4 ,the child should be extracted2 the woman should not be made to labor4 ,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 infection1 because of the danger to the child's life and the risk of its loss without baptism1 and also because of the danger to her own life4 ,scarlatina 7,italian scarlattina1 ,low ,latin febris scarlatina71 or ,scarlet ,fever1 is very rare in pregnancy4 ,popularly1 scarlatina is used for a light form of scarlet fever1 as varioloid is used for a light attack of smallpox2 but physicians do not make this distinction between scarlatina and scarlet fever3 they use the terms synonymously4 ,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 state1 but the received opinion now is that real scarlet fever is very rare in pregnancy4 ,those who report large numbers of scarlet fever cases in pregnancy err in diagnosis4 ,the mortality in the scarlatina of pregnancy may be very high--#eb per cent4 in some epidemics2 and if the infection happens immediately after delivery1 the mortality is still higher4 ,a septic rash is sometimes mistaken for scarlatina1 but where the genuine disease is present the pregnant woman is gravely obliged to avoid exposure to it1 both for her own sake and for that of the fetus4 ,in the early months of gestation scarlatina commonly causes abortion4 ,measles in pregnancy is also very rare1 but when it does occur it is a serious disease4 ,gestation is interrupted in #ee per cent4 of the cases1 and the mortality is #ae per cent4 for the women4 ,the same moral and related conditions that obtain in scarlatina are found in measles4 ,there is a marked tendency to hemorrhage and pneumonia4 ,of eleven cases reported by ,klotz1#adg nine aborted4 #adg ,archiv4 f4 ,gyn41 vol4 xxix1 p4 #ddh4 ,in epidemics of ,asiatic cholera the mortality among pregnant women is extremely high4 ,in the ,hamburg epidemic of #ahig1 fifty-seven per cent4 of the pregnant women affected died4 ,abortion is very frequent because of the hemorrhagic endometritis4 ,the mortality for all patients in ,asiatic cholera is very great--almost #ej per cent4 at the beginning of the epidemic4 ,typhus fever is the ship or famine fever of #ahdg4 ,it is very rare now4 ,when it does occur it is about three times as fatal as typhoid4 ,it is a disease of poverty and war1 and is spread largely by the body-louse1 as happened in ,serbia in #aiae4 ,skilled hygiene1 however1 soon gains control of the epidemic4 ,erysipelas in pregnancy is rare1 but not infrequent after delivery4 ,in the puerperium it appears commonly as a septic infection in abrasions about the parturient canal4 ,when it starts on the face1 scalp1 or breast the prognosis is relatively favorable1 but even then it causes death2 when it starts on the genitalia it has a mortality of #dc per cent4 ,erysipelas causes abortion4 ,as it begins from pus bacteria1 it is not seen so frequently now as formerly1 owing to greater attention to asepsis4 ,in the puerperium it is often an infection brought on by dirty midwives or physicians4 ,malaria1 if severe1 may interrupt gestation through fever or cachexia4 ,during labor in such cases the uterine action is feeble1 and hemorrhages are common after delivery4 ,by proper treatment during pregnancy these evils can be averted4 ,the infection is spread from one malaria patient to another by a mosquito 7,anopheles71 as yellow fever is spread by another mosquito 7,stegomyia fasciata74 ,pulmonary tuberculosis in pregnancy is somewhat frequent2 the estimate is that about #cb1jjj tubercular women become pregnant annually in the ,united ,states2 and obstetricians incline to the opinion that pregnancy commonly1 though not always1 makes the tuberculosis worse4 ,nearly all agree that the combined effect of pregnancy1 the puerperium1 and lactation is a grave burden on the consumptive and lowers the power of resistance4 ,trembley of the ,saranac ,lake ,sanitarium reported that #fc per cent4 of #bdj tubercular married women under his observation gave a history which showed that the disease was first recognized during pregnancy or the puerperium4 ,schauta's clinic found such origins in #bi per cent4 ,fisberg1 ,funk1 ,jacob1 ,panwitz1 and other observers1 in a series of #aajj cases1 said #ci per cent4 of these women thought the disease began during pregnancy or the puerperium4 ,some tubercular women during pregnancy give no clinical evidence of an aggravation of the pulmonary disease1 but these cases are exceptional4 ,tubercular women who apparently improve during pregnancy are likely to have a subsequent detrimental reaction4 ,as tubercular cases1 however1 are prone to show exacerbations even if not pregnant1 it is not possible to say that pregnancy is the sole cause of the progressive lesions in particular instances4 ,where there are no wide or deep areas of infection1 there may be no recognizable damage from pregnancy1 but advanced and active tuberculosis1 with fever or cavity formation1 does badly1 especially if the throat is involved4 ,the pressure of the enlarged uterus causes dyspnoea2 the cough and fever may bring on miscarriage4 ,miscarriage1 however1 is rare in tuberculosis2 it is more common in cardiac and renal diseases4 ,bernheim1 in a series of #cae tubercular pregnancies1 found that abortion occurred in #bc per cent4 ,the later in gestation the tuberculosis becomes florid1 the more likely it is that abortion will happen4 ,conception may take place at any stage of the tuberculosis1 although women in the final stage are commonly sterile4 ,sometimes a woman will give birth to a sound child and die herself of tuberculosis a few days after the parturition4 ,pregnancy in consumptive women is not necessarily detrimental to each particular patient1 nor is it1 as a rule1 a justification for emptying the uterus of even the viable fetus4 ,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 deterioration4 ,if the woman conceives in the final stage of pulmonary tuberculosis she will die1 whether she goes on to term or not4 ,bonney#adh describes three cases of advanced pulmonary tuberculosis which were cured during pregnancy1 by the bodily changes peculiar to that condition1 but such results are altogether exceptional4 #adh ,pulmonary ,tuberculosis1 p4 #eej4 ,philadelphia1 #aijh4 ,artificially induced premature labor sometimes causes more damage than normal parturition at term4 ,much depends upon the methods used for the induction of the abortion4 ,the insertion of bougies1 catheters1 or sounds is always contraindicated in advanced tuberculosis4 ,hirst of the ,university of ,pennsylvania#adi thinks the notion that tubercular women improve in pregnancy is a superstition1 and that such women should neither marry nor have children4 ,de ,lee#aej holds that tubercular women should not marry because the woman is likely to infect her husband and children4 ,he thinks the disease grows worse in pregnancy1 and that hemorrhage is frequent except in chronic ulcerative tuberculosis4 ,in this last condition pregnancy does not ordinarily aggravate the condition4 ,in tubercular laryngitis complicating pregnancy1 ,kttner found the mortality to be #ij per cent4 ,such laryngitis is usually fatal1 whether pregnancy is present or not4 ,when there is a miscarriage in tuberculosis1 the infection often becomes florid and resembles pneumonia4 ,advanced cases have a tedious and dangerous labor1 with dyspnoea and occasionally hemorrhage or cardiac exhaustion4 ,edema of the lungs is not infrequent4 #adi ,a ,text-book of ,obstetrics1 p4 #dbg4 ,philadelphia1 #aiab4 #aej ,the ,principles and ,practice of ,obstetrics1 p4 #dhj4 ,philadelphia1 #aiac4 ,williams of ,johns ,hopkins ,university1 in the #aijc edition of his ,obstetrics1 tells of a woman who died of tuberculous peritonitis a short time after parturition4 ,the uterus was studded with tubercles and its interior was covered with tuberculous ulcers4 ,the tubercle bacillus had been found in cultures taken from the interior of the uterus during life4 ,her child was born perfectly healthy and remained so4 ,williams says in the same place that the induction of premature labor because of tuberculosis is justifiable only in the interests of the child1 and this only in those rare cases in which the woman is so ill that she probably will die before term4 ,norris#aea of ,philadelphia agrees with ,williams that induction of premature labor is useless1 and he says all authorities unite in this opinion4 #aea ,pennsylvania ,medical ,journal1 ,february1 #aiaf4 ,a tubercular woman should not nurse her infant because she will infect it and exhaust herself4 ,infants are very susceptible to tuberculosis4 ,birch-,hirschfeld1 in #ahia1 first demonstrated tuberculosis in the fetus1 and ,schmorl found it in the placenta in #ej per cent4 of a series of cases that he examined4 ,infection of the child in utero1 however1 is extremely rare even by the placental way4 ,there is a high death-rate from tuberculosis among infants1 but the infection is postnatal4 ,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 year4 ,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 gestation4 ,,chapter ,,xix ,,syphilis ,,in ,,pregnancy ,,and ,,marriage ,syphilis in pregnancy at times assumes peculiar malignancy4 ,the virulence depends on the patient's power of resistance1 and whether or not there are septic microrganisms mixed with the syphilitic spirochetes4 ,there are1 moreover1 varying strains of spirochetes which differ in virulence1 or there are familial idiosyncrasies4 ,tropical syphilis is worse than northern infections1 and syphilis of the nervous system is often incurable4 ,fournier was of the opinion that a syphilitic woman who becomes pregnant is more likely to abort than a pregnant woman who becomes syphilitic4 ,the percentage of fetal deaths is also greater in the first class than in the second4 ,the longer a woman has been syphilitic1 provided she has not been treated for the disease1 the worse the prognosis for the duration of the pregnancy and the life of the fetus4 ,the earlier in pregnancy the syphilis appears1 the worse the prognosis for gestation4 ,general fetal mortality in syphilis under the best circumstances is #ge per cent4 ,syphilis should be looked for in every case where the cause of an abortion is not evident4 ,ruge holds that in #hc per cent4 of repeated abortions syphilis is at fault2 late abortions are characteristic of this disease4 ,inoculation with syphilis before conception almost always results in abortion4 ,in #acj women studied by ,le ,pileur there were #c4h per cent4 still-births before infection by syphilis1 but #gh per cent4 after infection4 ,in premature labor the child is1 as a rule1 born dead2 less frequently it is born syphilitic2 still less frequently it is born apparently sound1 but the syphilis appears later2 in a few cases1 when the maternal syphilis is old1 the child may be born normal4 ,interruption of gestation is the commonest symptom in syphilis complicating pregnancy4 ,the labor itself is affected3 the pains are weak and tardy4 ,abnormal presentations occur frequently when the fetus is dead4 ,chancres on the cervix may cause obstruction1 and there may be indurations so dense as to necessitate cesarean delivery4 ,the perineum may become so friable as to tear1 as ,de ,lee says1 like wet paper4 ,when the mother is infected at the time of conception the child is always syphilitic4 ,if the mother is infected early in pregnancy the child is almost always infected4 ,if she is infected late in pregnancy the child may escape infection4 ,men with tertiary syphilis have begotten children without1 to all clinical appearance1 inoculating the wife4 ,in such a case the mother may nurse the child with safety to herself1 but the child will infect a wet nurse other than its own mother1 and in very rare instances mothers in this condition have been floridly infected4 ,the condition here described is called ,colles's ,law4#aeb ,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 infected4 ,the term now used is ,syphilis by ,conception4#aec ,the virus passes through the fetal placenta to the mother1 although immunizing substances are held back by the placenta4 ,a fetus cannot make immunizing bodies before its eighth month1 and on that account the earlier the fetus is infected1 the more likely it is to die4 ,recently1 however1 some scanty testimony has been collected which sustains ,colles's ,law in a few cases4 ,ledermann reported three cases1 and ,nonne others1 in which the wives of men with tabes or paralysis bore syphilitic children and yet never responded positively themselves to the ,wassermann test1 or showed any symptoms suggesting syphilis4 ,to this list ,kroon#aed adds a case corresponding fully to the requirements of ,colles's ,law4 ,a woman of twenty-eight years who had had eight abortions was delivered of a child with undoubted congenital syphilis4 ,the child's father had been infected with syphilis twelve years before4 ,the woman showed no signs of syphilis1 two ,wassermann tests were negative1 and she nursed the child without injury to herself4 #aeb ,from ,abraham ,colles1 ,dublin1 #ahcg4 #aec ,wolff1 #ahgi4 #aed ,nederlandisch ,tijdschrift voor ,geneeskunde1 i1 #i4 ,should the husband have florid primary or secondary syphilis1 and infect his wife at impregnation1 abortion is the rule4 ,the commonest cases are those where the husband has been treated for syphilis more or less thoroughly before marriage4 ,even if at the time of impregnation the husband has no apparent infective lesion1 the child is usually syphilitic1 or it may show signs of the disease later in life4 ,ibsen's ,ghosts is founded on a case like this4 ,if the syphilis is recent1 or uncured1 the child dies1 macerates1 and is expelled4 ,these conditions recur in pregnancy after pregnancy1 until the virus is removed by time or drugs4 ,as the nucleus of the spermatozon is too small to carry the spirochete of syphilis1 the infection is through the semen in a manner not yet clear to us4 ,wolff#aee studied a group of nine syphilitic women and their children4 ,there were sixty-six pregnancies1 but only thirty-three viable children were born4 ,of these last fourteen died in childhood1 three committed suicide at twelve1 twenty1 and twenty-eight years of age2 and of the thirteen still living only two were normal4 ,the others are all feeble-minded1 epileptic1 hysteric1 or otherwise neurotic4 ,post#aef tabulated the mortality in thirty syphilitic families in which there were #afh pregnancies4 ,of these fifty-three ended in still-birth or miscarriage and there were forty-four early deaths--a total loss of #eg per cent4 ,of the children that were born alive #ch per cent4 are now dead1 and of the seventy-one that are alive only thirty-nine are apparently healthy4 ,there are very many cases of diseased children and adults with serious lesions of obscure etiology1 and in a great number of instances of anemia1 malnutrition1 extreme nervousness1 aortitis1 bone diseases1 vague pain1 and similar conditions1 the origin is congenital syphilis4 ,stoll1#aeg in sixty-eight such cases1 found a positive luetin syphilitic reaction1 and a positive ,wassermann in #ag per cent4 #aee ,zeitschr4 f4 klinisch4 ,med41 vol4 lxxvi4 ,berlin4 #aef ,boston ,med4 and ,surg4 ,jour41 vol4 clvii1 n4 #d4 #aeg ,jour4 ,amer4 ,med4 ,assoc41 ,october #ca1 #aiad4 ,gottheil1#aeh professor of dermatology and syphilography in ,fordham ,university1 holds that if a man has gone through a modern treatment for syphilis1 given by a competent physician and extended over three years1 and if during the fourth year1 without treatment1 he repeatedly shows a negative ,wassermann reaction1 he may marry4 ,that is the common opinion of physicians1 but it is decidedly erroneous4 #aeh ,forchheimer's ,therapeusis of ,internal ,diseases1 vol4 ii1 p4 #dba4 ,new ,york1 #aiac4 ,in one series of #efb cases of hereditary syphilis observed by the great syphilographer ,fournier1 sixty children1 or over #aj per cent41 were infected more than six years after the primary parental inoculation4 ,he tells of one woman who had nineteen consecutive still-births from syphilis4 ,gowers#aei says3 ,there is no evidence that the disease ever is or ever has been cured1 the word 'disease' being here used to designate that which causes the various manifestations of the malady4 ,this statement is too sweeping1 but it is very near the truth4 #aei ,syphilis and the ,nervous ,system1 #ahib4 ,bruhns recently reported the outcome of the ,wassermann test repeated about yearly from #aijh to #aiae in one hundred private cases infected with syphilis ten or more years before the time of the report4 ,in forty-two the test was constantly negative2 in thirty-two1 positive at first but negative later2 in seven1 constantly positive notwithstanding repeated courses of treatment2 in three1 positive at first1 then long negative1 but finally changing to positive again2 in eight1 negative at first1 then positive1 and finally negative2 and in eight1 negative at first but finally positive4 ,the last three groups are particularly significant4 ,in some the long negative reaction1 for five or six years1 indicated cure1 and physicians would pronounce such cases positively cured2 but suddenly they changed to a positive reaction without any clinical manifestations showing at the time4 ,after renewed courses of treatment in the following two years the reaction became negative4 ,among the cases with constant negative reaction there were some who developed brain syphilis1 or tabes1 proving that they were not cured despite the absence of clinical manifestations of the disease and the negative ,wassermann reactions4 ,professor ,blaschko of ,berlin1 at the seventeenth ,international ,medical ,congress in #aiac1 in the presence of ,ehrlich1 ,wassermann and ,hata1 said no one could even talk of a cure of syphilis until an interval of ten years without symptoms had occurred4 ,where a blood ,wassermann is negative a spinal fluid reaction may be positive4 ,in from #fj to #ge per cent4 of all cases of tabes or paresis members of the family other than the patient have shown infection4 ,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 extremes4 ,tabes is also called locomotor ataxia4 ,it is a degeneration of a part of the spinal cord1 with unsteadiness and incordination of motion1 lightning pains1 disorders of vision1 and other symptoms4 ,paresis is softening of the brain1 with insanity and death4 ,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 does4 ,no one has cured either tabes or paresis4 ,raven reported in #aiad an investigation of ninety families in each of which a case of metalues had developed4 ,the interval between the date of infection and the marriage was known in about half of these1 and it was four years in two families1 five years in one1 and from six to twenty-one years in ten6 ,fournier1 in #ddjj cases of syphilis1 saw three cases where the tertiary symptoms appeared fifty years after infection1 and in one case fifty-five years after infection4 ,bonnet#afj reported such a case which came to him for treatment fifty-four years after infection4 ,the man had no children4 #afj ,lyon ,med41 ,november #g1 #aijg4 ,syphilis that affects the nervous system as in tabes and paresis is an incurable syphilis1 and there is no means whereby any physician1 no matter how skilful he may be1 can tell whether or not a given patient has such an infection4 ,the physician1 then1 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 rashness4 ,once a syphilitic1 not necessarily always a syphilitic2 but once a syphilitic1 possibly and probably always a syphilitic1 and that no matter what the treatment or the lack of clinical symptoms4 ,damaged goods of this kind are to be looked upon as damaged goods forever4 ,any man or woman1 then1 who has ever had a clear case of syphilis 7and the diagnosis is easy1 as a rule7 is likely to be for the remainder of life a source of syphilitic infection4 ,there is even question of late of spirochete-carriers1 as there are typhoid-carriers and diphtheria-carriers1 who may infect others while not suffering themselves4 ,if one who has been a syphilitic marries without informing the other party to the contract of the condition1 the injustice is1 without doubt1 very grave4 ,i should call such concealment a mortal sin1 and a condition exposing the sacrament to sacrilege4 ,suppose the second party is informed of the old infection and is then foolish enough to risk the marriage4 ,no one but an experienced physician has any notion of the indescribable horror that may come of taking this risk1 and no one has the right to expose his own body to infection by syphilis for the advantage of marriage4 ,there is no approach to a juridic equilibrium between these two conditions4 ,if in such a marriage children are begotten and infected1 7#a7 embryos will die without baptism2 7#b7 later possible children will be born who will die of congenital syphilis2 7#c7 possible children who will escape syphilis2 7#d7 children who may have to pass through tabes or paresis to death1 after begetting other degenerates4 ,a syphilitic embryo which dies without baptism is better than no child at all4 ,it will live in a state of natural happiness after abortion4 ,a baptized child which has congenital syphilis is immeasurably better off than a sound child that lacks baptism4 ,eugenics as a prudent investigation of conditions before marriage is a good thing2 eugenics as the drivel of agitators1 who cannot tell the difference between a gentleman and a corn-fed hog1 is quite another thing4 ,the marriage1 therefore1 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 imminent4 ,it is difficult to estimate the morality of the act as it refers to the children infected congenitally1 and to society4 ,the natural order1 charity1 justice1 and related principles give every child the right to be born with bodily health1 if such an event is possible4 ,if it is not possible in particular circumstances1 then melius esse quam non esse1 and the decision in each case depends on its own qualities4 ,if a physician knows that a person who has been infected with syphilis is about to marry1 should the physician warn the innocent party8 ,there are several conditions3 7#a7 the infected person about to marry may be actively infectious2 7#b7 the person may be probably infective1 as any one is who has once had syphilis2 7#c7 the physician may know the fact of the infection officially or unofficially2 7#d7 the infective person may have gone to the physician for treatment for a condition not connected with the syphilis--say1 for a bronchitis or a broken bone--and the physician in the examination discovers syphilis4 ,again1 there are various kinds of secrets4 ,st4 ,alphonsus ,liguori#afa classifies secrets in three groups3 7#a7 natural2 7#b7 promised2 7#c7 entrusted secrets4 ,a natural secret is one which obliges us in justice to observe it if divulging it will gravely injure any one in reputation or possessions4 ,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 gravely4 ,a promised secret obliges to silence either gravely or lightly1 according to the intention of the promiser4 ,where reasonable doubt exists as to grave obligation1 such obligation does not exist4 ,a promise to secrecy made even under oath is not binding if one is obliged in justice to reveal the secret2 therefore we must testify to the crime of another when a judge legitimately demands our testimony1 even if we have promised not to tell anything4 ,if a secret is entrusted to one1 and divulging would cause grave damage1 but justice1 or similar circumstances1 do not oblige us to reveal it1 we are bound to observe it even when questioned by legitimate authority4 ,then we may answer we know nothing about it1 at least for revelation4 ,st4 ,alphonsus's text is3 ,potes respondere te nihil scire1 scilicet ad revelandum4 ,his meaning seems to be3 ,you may say you know nothing about the matter inquired into4 ,any other signification would be futile4 ,to say literally1 ,i do not know anything ,i may tell1 would only expose one to punishment for contempt4 ,he seems to make the answer a conventional denial1 like the not guilty of a criminal4 ,a judge may not abrogate the natural right by which an entrusted secret is protected1 unless the secret is already known in some other way1 or there is a just cause for revealing it4#afb #afa ,theologia ,moralis1 iv1 n4 #igj et seq4 #afb ,cf4 ,de ,lugo1 ,de ,justitia et ,jure1 disp4 #ad1 n4 #ada4 ,when an entrusted secret1 however1 which is also called a strict or absolutely natural secret1 is imparted expressly or tacitly1 say1 to physicians1 lawyers1 or priests1 and becomes a professional secret1 it obliges more strictly than any other4 ,there are four conditions under which such an entrusted secret may be revealed1 at least without mortal sin 7except by a confessor73 7#a7 ,if we have the presumed consent of the principal4 7#b7 ,if the material of the secret is trivial1 or if it is known from another source1 or is already public4 ,is it a mortal sin to divulge a grave entrusted secret to a responsible person who is under the same bond8 ,st4 ,alphonsus1 ,de ,lugo1 and others say probably it is not1 provided the secret is not divulged to the particular person from whom the principal wished it to be concealed4 ,the term probably here is technical and refers more to the absolute truth of an assertion than to its practical application4 7#c7 ,one might reveal such a secret without mortal sin1 through inadvertence or thoughtlessness1 or under the supposition that it is not a grave secret4 ,some moralists hold1 however1 that to excuse from mortal sin1 the revealer must be certain that the matter of the secret is not grave4 7#d7 ,such a secret may be revealed if keeping it would cause public injury1 or injury to an innocent person1 or injury to the person to whom the secret has been entrusted2 then the law of charity demands that it be revealed4 ,therefore1 even if one has bound himself under oath1 he may reveal the secret--always excepting a priest or confessor4 ,this is the common doctrine of moral theologians4 ,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 conceal4 ,to let an infective syphilitic1 for example1 spread his contagion merely because an entrusted secret should be kept is a much greater damage to the public than a good4 ,barrett#afc says a physician may not divulge the diseases of a family to an insurance company unless the family assents2 he may not tell the man before marriage that the woman had been operated upon1 say1 for ovariotomy1 unless the woman gives permission2 nor may he let the woman know1 before marriage1 of those diseases of the man which are not contagious4 ,ho says further that if a man has had syphilis and is now completely cured1 the physician may not reveal this previous condition to the woman4 #afc ,sabetti-,barrett1 ,compend4 ,theol4 ,moral41 n4 #efe4 ,new ,york1 #aiae4 ,that doctrine about ovariotomy1 if it includes double ovariotomy1 is disputed by physicians because1 they say1 such a woman is sterile and she knowingly is going to deprive the man of his chances of having children2 secondly1 a woman upon whom double ovariotomy has been performed is almost always a neurasthenic invalid with a marked tendency to insanity1 and it is a grave injustice to any man to saddle such a degenerate upon him for life by treachery4 ,the prospective injury to the man is so great that the physician should first try to induce the woman to divulge her condition1 and if she does not1 the physician at least may divulge it4 ,secondly1 ,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 infection4 ,the facts ,i have cited in this chapter prove conclusively that once a syphilitic always probably a syphilitic1 and the risk is always so great that the physician is obliged first to insist that the man does not marry1 and if the man persists the physician may let the woman know4 ,if preparations for the marriage have been made publicly1 the physician will1 as a rule1 for his pains from the woman and her family get only a rebuff and the woman will later get her syphilis more or less certainly4 ,if the man is actively infective the physician is bound to let the woman know1 through her confessor if no other way presents1 provided the man cannot be frightened out of his scoundrelism4 ,if nothing else avails1 the physician would be justified in reporting such a man to the ,board of ,health or the sanitary police4 ,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 patients4 ,it never does have such an effect1 although physicians constantly expose such cases in the interests of humanity4 ,because a man who is apparently cured of syphilis may or may not infect the woman1 this doubt probably excuses the physician from the strict obligation of divulging the condition1 although he may tell her if he wishes to do so1 salvo meliore consilio1 as far as the release from strict obligation to divulge is concerned4 ,if a patient with syphilis goes to a physician for the treatment of some other physical disability1 and the physician discovers the syphilis in the course of the examination1 this knowledge of the syphilis would be a tacitly entrusted secret4 ,whether1 however1 a secret that a man is actively infective or very probably infective is entrusted either tacitly or directly1 it is not a privileged secret owing to the danger or certainty of extraordinary calamity to the innocent second party4 ,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 condition2 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 woman1 and is to be treated accordingly4 ,if a woman may kill an unjust aggressor in defence of her chastity1 and if quod liceat per se licet per alium1 her natural protectors1 kin1 physician1 and so on1 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 rape4 ,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 death1 or which they leave unguarded in their offices1 are likely to be read by some third party who has no right to the secrets they contain4 ,case histories which the patients would not have divulged should be kept in cipher so far as proper names and addresses are concerned4 ,,chapter ,,xx ,,gonorrhea ,,in ,,marriage ,gonorrhea is caused by the gonococcus discovered by ,neisser in #ahgi4 ,the name was given to the disease in the second century by ,galen1 who supposed that the condition is a spermatorrhea4 ,the infection begins as a surface inflammation and gradually penetrates more or less deeply into the underlying tissues4 ,in the male1 gonorrhea may affect any part of the body2 and when the disease is chronic it is a source of infection for years4 ,if a man who has had gonorrhea wishes to marry after careful treatment1 most physicians will permit him to do so if he passes the customary tests which indicate cure1 but he is always dangerous4 ,the tests are3 7#a7 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 months2 7#b7 the microscopic and cultural examinations of urethral spontaneous and artificial discharges must be negative in the same manner2 7#c7 the microscopic and cultural findings of the secretion expressed from the prostate and seminal vesicles must be negative in the same manner2 7#d7 urethroscopic examinations of the anterior and posterior urethra must show no unhealed lesions2 7#e7 the complement fixation test is to be repeatedly negative4 ,the complement fixation test is like a ,wassermann reaction1 but the antigen should be polyvalent4 ,this test does not give a positive reaction where no gonorrhea is present1 but it is often negative where the gonococcus is present4 ,hence a positive result has value1 but a negative result has little or no value4 ,all these tests are to be tried repeatedly1 and if negative for months1 the physician may say the man is probably cured1 but no physician can guarantee the cure so as to take the responsibility of the decision4 ,not one physician in five hundred can make these tests himself1 because physicians in general lack the special training and the means to make them4 ,as the effects of gonorrheic infection in a woman are so appalling1 any woman who wittingly marries a man who has had gonorrhea is very rash1 and the man who takes the risk of infecting such a woman is a rascal4 ,a physician is obliged to let a woman who innocently is about to marry a cured gonorrheic know of the man's condition1 as in a case of supposedly cured syphilis4 ,taber ,johnson1 ,noble1 and other authorities1 say no one can tell when a gonorrheic is absolutely cured4 ,in women infection of the cervix uteri occurs in about #hj per cent4 of the cases of acute gonorrhea1 and in #ie per cent4 of all chronic cases4 ,the infection may extend up into the uterus at the menstrual period or just after parturition4 ,in the cervix1 owing to the histologic formation1 the disease tends to chronicity1 but the inflammation within the uterus is much more likely to subside naturally4 ,chronic gonorrhea of the endometrium is usually accompanied by tubular infection4 ,the infection of the uterus may be superficial or it may extend down into the underlying myometrium4 ,the inflammation extends from the endometrium to the ,fallopian tubes and beyond1 causing salpingitis1 pyosalpinx1 hydrosalpinx1 tubovarian abscess1 tubovarian cysts1 and pelvic peritonitis4 ,the most frequent form of tubal gonorrhea is pyosalpinx1 or pus tube4 ,in the acute stage of tubal infection the tubes become elongated and swollen1 and the mucous surfaces within are covered with a seropurulent exudate4 ,this condition is called salpinx or salpingitis4 ,when the condition advances so far that the external abdominal ostium of the tube is closed1 a pyosalpinx forms4 ,the pyosalpinx may be quite large4 ,a hydrosalpinx is like a pyosalpinx1 with both tubal ends sealed1 except that its content is a serous or watery fluid4 ,when infected material escapes through the distal end of the tube1 periophoritis develops1 and the ovary becomes adherent to the tube and other adnexa4 ,more commonly only the surface of the ovary is affected1 but frequently the infection gets into the body of the ovary and causes ophoritis4 ,the ovary then swells and there is a tendency to the formation of retention and other cysts1 or an abscess of the ovary4 ,a tubovarian cyst is a hydrosalpinx in communication with an ovarian retention cyst1 and a tubovarian abscess is a like formation4 ,gonorrhea1 especially in women1 is likely to be very chronic4 ,emil ,noeggerath1 who in #ahgb published a book#afd which changed the medical doctrine on the disease1 said of women1 ,once infected1 always infected4 ,norris#afe reports a case where the gonococcus was latent in a man for twenty years1 and he then infected his wife and wished to divorce her until he found that he himself was at fault4 ,sax#aff reported an infection after fourteen years2 ,mac,munn1#afg one after fifteen years4 ,these are exceptional durations in the male for virulence1 though not for continuance of the diplococcus4 #afd ,die latente ,gonorrhoea in weib4 ,geschlect4 ,bonn4 #afe ,gonorrhea in ,women1 p4 #abc4 ,philadelphia1 #aiac4 #aff ,trans4 ,amer4 ,urological ,assoc41 vol4 iii4 #afg ,lancet1 ,november #bd1 #aijf4 ,neisser1 who discovered the cause of gonorrhea1 holds that1 with the exception of measles1 gonorrhea is the most widespread of all maladies4 ,by sterilizing men and women and by abortion it holds down the birth-rate more than any other disease4 ,the number of deaths from the consequences of gonorrhea 7pelvic abscess1 peritonitis1 septicemia1 endocarditis1 and so on7 is enormous4 ,norris thinks that #ab1jjj prostitutes die annually from the effects of gonorrhea alone4 ,woodruff#afh holds that #fj1jjj is nearer the truth4 ,the estimate1 too1 is that #ej per cent4 of all pelvic inflammatory diseases in women is gonorrheic2 and ,neisser1 ,bumm1 and ,frbinger hold that from #bj to #ej per cent4 of childless marriages are due to gonorrhea4 ,probably more than #bj per cent4 of all the blindness in the world is from the same cause4 ,the ,committee of ,seven1#afi in #aija1 after examining most of the hospital records in ,new ,york and hearing from #dgej physicians1 estimated that there were more than #bbj1jjj venereal patients in ,new ,york ,city4 ,bierhoff#agj reckoned that in #aiaj there were about #hjj1jjj gonorrheics in that city4 ,in #aijf1 in ,baltimore1 there were #ccaj cases of the infectious diseases like measles1 diphtheria1 scarlet fever1 and tuberculosis combined1 but #idej cases of venereal diseases4 ,in ,new ,york ,city1 in round numbers1 there are annually about #da1jjj cases of infectious diseases1 excluding the venereal group1 but #bdc1jjj cases of venereal diseases--over five times more cases of venereal diseases than of all the other infectious diseases together4 ,of #ab1jjj1jjj persons insured in ,germany1 #gej1jjj annually are infected with venereal diseases4 ,in the ,united ,states navy between #aijd and #aijh1 with an average of #dc1afe men in the navy and marine corps1 there were #cb1heb admissions to the hospitals for venereal diseases1 and of these #aa1ebf were cases of gonorrhea4 ,this report is far below the actual numbers1 as only men incapacitated for work are included in the list4 ,in the ,english navy in #aijf the daily number of men rendered inefficient by venereal diseases was #hfg4 ,in the total relative number of venereal diseases the ,american army and navy1 before the present war1 were the worst in the world1 the ,japanese navy next1 the ,english army and navy next4 #afh ,expansion of ,races4 ,new ,york1 #aiji4 #afi ,medical ,news1 ,december #ba1 #aiji4 #agj ,new ,york ,med4 ,jour41 ,november #ab1 #aiaj4 ,sullivan and ,spaulding#aga reported on the prevalence and effects of gonorrhea in #ebb women and girls in a ,massachusetts reformatory for women4 ,of these women #ge4g per cent4 had gonorrhea by positive diagnosis4 ,the average length of time the infection had existed when diagnosed was four years and five months1 but one woman had had the disease for twenty-six years1 and seven had had it for over twenty years4 ,in #hb4g per cent4 there had been no cessation of the clinical symptoms from the time of infection to the time of diagnosis4 ,of the total number #fh per cent4 had pelvic inflammation on one side1 and #bg per cent4 had it on both sides4 ,there were #da per cent4 of the cases which had had surgical operations or which required such treatment4 #aga ,jour4 ,amer4 ,med4 ,assoc41 ,january #h1 #aiaf4 ,of #fc women committed for alcoholism #eb4d per cent4 had gonorrhea1 #db4h per cent4 had syphilis1 and #i4f per cent4 had doubtful syphilis2 but of #djj women who had been at some time prostitutes #ih4b per cent4 had gonorrhea1 #fe4e per cent4 had syphilis1 and #i4e per cent4 had doubtful syphilis4 ,of #aai mental defectives among these women1 #ij4h per cent4 had gonorrhea1 #fa4c per cent4 had syphilis1 and #f4g per cent4 had doubtful syphilis4 ,dr4 ,thomas ,haines#agb reported on #cfe cases of boys and girls under eighteen years of age committed to an ,ohio reformatory1 and of these #bj4h per cent4 had syphilis1 and it was mostly acquired syphilis1 not congenital--over one-fourth of the boys were so affected4 ,mc,neil#agc examined #abjj adult negroes in ,galveston1 ,texas1 for syphilis and found the disease in #cj per cent4 of the #abjj4 #agb ,jour4 ,amer4 ,med4 ,assoc41 ,january #h1 #aiaf4 #agc ,jour4 ,amer4 ,med4 ,assoc41 ,september #cj1 #aiaf4 ,howard ,kelly#agd estimated that venereal diseases cost the ,united ,states three billion dollars annually1 and ,norris thinks this estimate too low4 ,the ravages of the disease are so frightful1 physically and morally1 that any one who spreads it by infection1 especially of an innocent woman1 is guilty of the gravest moral injustice4 ,morrow#age thinks that #bej1jjj married women in the ,united ,states are suffering from gonorrhea4 ,as most of these unfortunate women are infected by immoral husbands1 and as the invalidism and suffering they undergo are indescribable and cure is often impossible1 the physician who permits a gonorrheic to marry without a protest is responsible for the evil as an accomplice2 and1 as has been said1 once a gonorrheic1 probably always a gonorrheic4 #agd ,jour4 ,amer4 ,med4 ,assoc41 ,october #f1 #aiab4 #age ,social ,diseases and ,marriage1 #aijd4 ,pelvic inflammatory disease includes in the uterus and its adnexa alone metritis1 salpingitis1 ophoritis1 pelvic peritonitis1 cellulitis1 lymphangitis1 and perimetritis4 ,pus may rupture into the pelvic cavity and set up local or general peritonitis or septicemia4 ,it may burrow through from behind the uterus into the vagina1 rectum1 or other parts of the intestines1 or into the bladder1 and leave fistulas4 ,pus has been known to get through the abdominal wall itself4 ,when the disease advances beyond the tubes there is1 as a rule1 invalidism until after the menopause1 although the woman may be cured by surgery4 ,even skilled surgery does not always cure1 because it is practically impossible to get rid of the gonococcus once it has been fixed in the tissues4 ,in cases where the gonorrheic or other bacterial infection has been chronic in the uterine adnexa1 palliative treatment will in a certain percentage of cases make surgical intervention unnecessary1 and when such treatment does not avail we must decide between the total removal of organs and the partial removal4 ,partial removal is called conservative surgery1 and the term conservative is used as a synonym of preservative4 ,prochownick#agf reported #dbj cases where pus in the tubes or ovaries was let out extraperitoneally1 and no organs were removed4 ,of these cases1 one hundred and sixty1 or #ch per cent41 were permanently cured4 ,fourteen of the one hundred and sixty who had received only one treatment subsequently gave birth to children1 and three aborted4 ,after a second treatment twenty-seven remained well and three became pregnant1 of whom one aborted4 ,olshausen1#agg a great authority in gynecology1 used the palliative treatment1 and he commonly waited for nine months after the infection and until the temperature was normal4 ,goth#agh reported excellent results in seven hundred cases of pelvic disease treated by the palliative method4 ,the chief objections to this method are the time required to get the result1 and the difficulty of controlling the patients and their chronically diseased husbands1 who reinfect them despite the medical prohibition of marital intercourse4 #agf ,monatschrift f4 ,geburt4 u4 ,gyn41 #aiji1 n4 #bj4 #agg ,zeitschr4 f4 ,geb4 u4 ,gyn41 #aijg1 vol4 lix1 n4 #a4 #agh ,archiv4 f4 ,gyn41 vol4 xcii1 n4 #b4 ,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 part4 ,the text-books decide the question without any heed whatever to the notion of the morality of mutilation as such4 ,they take into account the age of the patient1 whether she has children or is desirous of maternity1 whether or not she supports herself by manual labor1 her temperament and character1 and the results attained by men who have tried various methods of operating4 ,the conservative surgery of the uterus and its adnexa in gonococcal pelvic peritonitis was for many years looked upon with disfavor by surgeons4 ,these conservative operations often failed or later required secondary intervention4 ,preliminary palliative treatment as now used greatly lessened the number of failures4 ,operations in peritonic conditions are dangerous because they may let loose encysted bacteria and start up a general septic peritonitis1 which may be fatal4 ,by delay and palliative treatment the virulence of the bacteria subsides1 except where the woman is reinfected by her husband4 ,in any case the blood-count should have been normal for at least a month and a half before any surgical interference is attempted4 ,olshausen waited nine months to let nature disinfect the pus4 ,the removal of a part of a tube is called salpingotomy2 the taking out of the whole tube is salpingectomy2 the opening up of a shut tube is salpingostomy4 ,the presence of pus in a tube is absolute indication for removal according to the gynecologists at present4 ,howard ,kelly and others have succeeded at times in such cases with conservative surgery1 yet such treatment is now deemed obsolete--the dangers and failures seem to overbalance the little good effected4 ,the end of conservative surgery is to try to restore function without pain1 to preserve menstruation and ovulation1 to put the organs in a condition to make pregnancy possible1 and to preserve the internal secretion of the ovaries4 ,the ovaries1 so far as the woman's health is concerned1 are the most important of her generative organs4 ,if a woman is at the end of her child-bearing age there is no reason to preserve the tubes when they are affected1 and conservation is likely to fail2 but the ovaries should always be preserved1 wholly or in part1 when possible4 ,if one tube is infected from the uterus many gynecologists are inclined to remove both tubes4 ,when a single tube is affected the cause is seldom the gonococcus1 but some other bacteria which are not persistent4 ,when both tubes are affected the cause is commonly the gonococcus1 and attempts at preservation then fail1 as a rule4 ,norris1 who is a reliable authority1 holds that the only cases in which a salpingostomy is justifiable is on old1 non-active hydrosalpinges1 and in those cases of tubal occlusion or phimosis resulting from extratubal inflammation1 such as sometimes result from appendicitis or ectopic pregnancies4#agi ,when a tube is shut1 if it can be opened the opening tends to close again4 ,a few cases of subsequent pregnancy have occurred after salpingostomy1 but such a result is exceptional1 because the origin is usually the gonococcus1 which destroys tissue and is very persistent4 #agi ,gonorrhea in ,women1 p4 #bhe4 ,philadelphia1 #aiac4 ,the ovary corresponds to the testicle1 and the ,fallopian tube to the vas deferens4 ,removal of the ovaries1 or removal or closure of the ,fallopian tubes1 renders the woman sterile1 but removal of the ovaries has other profound effects beside sterility4 ,loss of the ovaries brings on suppression of ovulation1 menstruation1 pregnancy1 and ovarian internal secretion1 various neuroses1 and a tendency to insanity in certain cases4 ,the testicles and prostate gland produce an internal secretion containing spermin1 and the ovaries a similar nitrogenous base called ovarin1 which acts like spermin4 ,the suprarenal glands secrete epinephrin2 the thyroid gland and the pituitary body also make internal secretions1 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 elimination4 ,if there is a hypersecretion from one or more of these glands1 the excess causes congestion of the cerebrum and cerebellum and of the nerve centres there1 and one effect may then be a sexual erethism that leads to masturbation and similar deordination4 ,castration in the male or ovariotomy in the female stops all production of spermin and ovarin4 ,in man the prostate gland also ceases its function after castration1 and vasectomy lessens the production of spermin4 ,in castration or spaying1 again1 when we remove the power of producing spermin or ovarin1 that function of the testes and ovaries whereby the body is immunized against poisoning by its own effete material is also inhibited1 and evil effects arise from this waste material4 ,these toxins act just as would an excess of spermin or ovarin--they congest the cranial nerve centres1 excite fever1 neuroses1 or temporary sexual erethism4 ,this excitement may gradually subside as equilibrium is restored and neutralization effected1 through a compensatory overproduction of the internal secretions by the other glands remaining in the body4 ,cimoroni#ahj found after ovariotomy an increase in size of the pituitary body with dilatation of the blood-vessels4 ,goldstein#aha reported a case of gigantism from overactivity of the pituitary gland after castration4 ,acromegaly in cases where there was no castration has been accompanied by atrophy of testicles and ovaries4 ,cecca#ahb found like effects in the thyroid1 and several have observed these effects in the adrenals4 ,all these results have also been produced experimentally on animals4 #ahj ,policlinico1 #aijg1 p4 #af4 #aha ,mnchener medizinische ,wochenschrift1 ,april #h1 #aiac4 #ahb ,soc4 ,med4-,chir4 de ,bologne1 #aijd4 ,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 function4 ,ovariotomy in younger women produces this menopause artificially and suddenly2 and women from whom both ovaries have been removed1 as a rule1 become neurotic invalids with a tendency to insanity if they are unstable in character or have a bad inheritance4 ,if the whole thyroid gland is removed1 death results from intoxication4 ,extreme obesity is an effect of undersecretion by the glands and a consequent lack of oxidation4 ,fat children have deficient glands1 as a rule1 and eunuchs grow fat as capons do4 ,removal of the ovaries before puberty arrests or prevents the development of the uterus2 removal after puberty stops menstruation1 the breasts atrophy1 and there is an arrest of general physical growth4 ,gordon#ahc reported on #aab cases of ophorectomy4 ,of these thirty-four had had before operation various symptoms of neurasthenia1 hysteria1 or psychasthenia1 and vague abdominal disturbances4 ,surgeons in each of these thirty-four cases blamed the ovaries for the symptoms2 and although these organs were not diseased in any degree1 the surgeons removed them4 ,in twenty-five of these cases there was no improvement whatever2 in the remaining nine there was improvement for a few weeks1 but complete relapse later1 and finally their symptoms grew worse4 ,the obsessions became permanent and expanded4 ,those women in the group who had hysterical paroxysms began to have stronger and more frequent attacks4 ,several psychasthenics had to be confined in asylums for the insane4 ,three of the women who had complained merely of vague nervous symptoms1 as pain in the abdomen1 head1 or back1 or of constipation or diarrhea1 after ophorectomy grew irritable1 highly nervous1 quarrelsome1 fickle1 restless1 showed a tendency to travel about1 to complain of others2 finally there was insomnia1 and loss of appetite or voracity4 ,in the remaining seventy-five cases one or both the ovaries were diseased1 but both ovaries were completely removed4 ,all these women developed symptoms like those described above1 but several grew much worse in their mental condition than the psychasthenics among the first thirty-four women4 ,the generally observed symptoms are3 restlessness with a tendency to move from place to place2 loss of self-control2 dissatisfaction with all persons and things2 want of interest in work2 indolence2 pessimism4 ,sometimes there are outbursts of anger1 with a tendency to attack4 ,the mental conditions do not1 as a rule1 become clearly developed melancholias or manias1 although a few do grow definitely insane4 ,the morbid symptoms1 however1 persist obstinately4 ,after ten years' observation ,gordon found no improvement in some of these psychasthenics4 #ahc ,jour4 ,amer4 ,med4 ,assoc41 ,october #ag1 #aiad4 ,when the ovaries must be removed for diseases like cystic degeneration or abscess1 the surgeon leaves1 if possible1 part of an ovary1 or he engrafts part of an ovary in the abdominal wound1 under the skin1 or elsewhere4 ,this grafting is beneficial in many cases1 but it has little or no effect in many others4 ,the graft is absorbed and it disappears in a year or two1 but before it is absorbed it makes the onset of the surgical menopause gradual and thus prevents much suffering4 ,in thirty-two cases reported by ,chalfant#ahd the graft gave evidence of functioning in five of seventeen women from whom the uterus and ovaries had been removed2 in others it acted for months and then failed2 in others it lessened the unfavorable symptoms2 in others it had no effect at all4 ,stocker#ahe reported two successful implantations of ovarian grafts and one testicular graft4 #ahd ,surgery1 ,gynecology1 and ,obstetrics1 ,november1 #aiae4 ,chicago4 #ahe ,correspondenz-,blatt f4 ,schweizer ,aerzte1 ,february #ab1 #aiaf4 ,giles#ahf says that in his series of #aeg cases of double ophorectomy severe mental depression occurred in various groups in from #aj to #cc per cent41 and two women became insane4 ,sex instinct was abolished in #af per cent4 ,dickinson#ahg found1 in #bjj cases where one or both ovaries had been removed1 that not more than #bj per cent4 fell into the surgical menopause even when the uterus had been taken out2 but ,giles1 in #ej removals of one ovary1 found irregularity1 diminution1 or cessation of the menses in #af per cent4 ,carmichael1 ,valtorta1 and ,mc,ilroy#ahh discovered in animals a compensatory hypertrophy of the remaining ovary after one ovary had been removed4 ,the internal function and nutrition seem to depend upon the ovarian secretion1 as atrophy occurs after bilateral ophorectomy4 ,in all operations upon or near the ovaries there is likelihood of interference with the blood supply of the ovary1 either by including ovarian arteries in the ligatures1 or by tension of these vessels1 which occludes them1 or by malposition and prolapse of the ovary1 which kinks them3 these accidents result in degeneration or retention cysts4 ,in most cases of pelvic peritonitis the uterus is retrodisplaced1 and this position prevents cure until it is corrected4 #ahf ,jour4 ,obstet4 and ,gynecol4 of ,brit4 ,empire1 ,march and ,april1 #aiaj4 #ahg ,trans4 ,amer4 ,gyn4 ,soc41 vol4 xxxvi1 p4 #cbd4 #ahh ,norris1 ,gonorrhea in ,women1 p4 #bhi4 ,when there is pus in the ovary1 resection1 in the opinion of gynecologists at present1 is not an advisable operation2 the ovary should be removed4 ,watkins1#ahi however1 says he resects small ovarian abscesses in young women with good results4 ,in resection the blood supply is1 as has been said1 usually disturbed1 and the cause for the operation is1 as a rule1 the gonococcus1 and both these circumstances make the prognosis bad4 ,the stitches necessarily used in resection operations are an additional source of irritation4 ,turetta#aij speaks in favor of resection in certain cases4 ,a single retention cyst may be resected1 especially when pedunculated4 ,boldt#aia had only one bad result in forty-five resections where a part of the ovary was saved4 ,if the blood supply after the resection is evidently to be poor1 resection is useless4 ,skill in surgical technic has much to do with success in all these cases4 ,when the uterus is removed because of tumors1 even near the time of the menopause1 if one or both ovaries can be left in1 this should be done4 ,in such conservative operations ,dickinson found #hj per cent4 of the patients free from nervous disturbance at the time of the menopause4 #ahi ,jour4 ,amer4 ,med4 ,assoc41 ,january1 #aiac4 #aij ,il ,policlinico1 ,january #c1 #aiai4 #aia ,trans4 ,amer4 ,gynecol4 ,soc41 vol4 xxxiv1 p4 #cbg4 ,philadelphia1 #aiji4 ,polak#aib describes an operation for the preservation of the menstrual function in double suppurative disease of the tubes and chronic metritis4 ,he maintains that even if only one tube is infected1 both should be removed because this apparently sound second tube will later1 almost as a rule1 show infection--probably by extension from the fundus of the uterus inside4 ,ordinarily inflammation of the tubes happens to be bilateral4 ,owing to the persistence of the gonococcus in the uterine muscle1 surgeons are inclined to the removal of the whole uterus and both tubes4 ,after such an operation menstruation ceases1 and in the removal of the uterus the blood supply to the ovary is interfered with so that the ovaries degenerate4 ,the consequent artificial menopause has a decidedly injurious effect on the woman's general physical and mental health4 ,the parts of the uterus permanently infected by chronic gonorrhea are the cervical region1 the fundus and the partes interstitiales of the ,fallopian tubes4 ,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 tubes1 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 tubes4 ,this leaves the body of the uterus and does not injure the circulation to the ovaries4 ,in the last seventeen cases thus operated upon by him he had success4 #aib ,jour4 ,amer4 ,med4 ,assoc41 ,december #h1 #aiag4 ,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 also1 because in such cases the uterus and vagina atrophy and this condition later causes trouble4 ,giles came upon such trouble in #aa per cent4 of sixty-two cases4 ,as the uterus is useless after the removal of the ovaries and tubes1 there is no reason why it should not be removed4 ,the danger of atrophy is sufficient reason for the mutilation4 ,in operations for pelvic peritonitis it is well to remove also the appendix1 because it is nearly always diseased1 or it will give trouble from adhesions later and cause a secondary operation4 ,it has no function we know of at present4 ,in conservative surgery of the uterus and adnexa for pelvic inflammatory diseases1 the results attained by four skilled surgeons are3 ,giles cured #ij per cent4 of #acb cases2 ,polak cured #ce per cent4 of #cjj cases2 ,robins cured #ajj per cent4 of #bj cases2 ,norris cured #gc per cent4 of #aia cases4 ,polak's patients became pregnant after operation much oftener than those of the other operators4 ,seventeen per cent4 of his patients1 from whom he removed one ovary and resected the other1 became pregnant4 ,giles found that of his married patients under fifty years of age at the time of the operation #be per cent4 became pregnant and went to term4 ,they bore twenty-five children4 ,five of these also miscarried4 ,in sixty-eight of ,morris's cases seventeen were delivered of living children after the operation2 three had two children each1 one had three children1 and there were seven miscarriages4 ,in one of his cases where he removed one ovary and both tubes1 the woman bore a healthy full-term child two years after the operation4 ,dudley#aic found that about #aj per cent4 of #bafh cases of resection became pregnant after operation4 ,ectopic gestation is likely to occur in a few cases after conservative operations4 ,giles had seven such cases in his series of #acb operations1 ,polak one1 and ,norris two4 #aic ,jour4 ,amer4 ,med4 ,assoc41 vol4 xli1 n4 #bd4 ,when it is necessary to remove the uterus1 the choice between supravaginal hysterectomy1 where the cervix is left in after the destruction of its mucosa1 and panhysterectomy1 where the cervix and the body of the uterus are removed1 offers no moral problem except the necessity of deciding upon what will be best for the woman4 ,rupture of a pus tube is a very dangerous accident--all the patients suffering from such a rupture die if not operated upon1 and fifty per cent4 die even after operation4 ,a physician may do this damage by ignorant or careless examination1 and he may be morally responsible for the death4 ,the accident happens not unfrequently from marital congress1 and if the husband has been warned by a physician but does not heed this warning1 he is guilty of murder if the woman dies after rupture of the pus tube4 ,pregnant women are more liable to infection by the gonococcus than non-gravid women1 because of the increased blood supply to the generative organs in gestation1 and the softening of these organs4 ,for the same reason1 latent gonorrhea is likely to become active and to spread during pregnancy4 ,a like activity and extension of latent gonorrhea often occurs during menstruation4 ,women with gonorrhea are commonly sterile--this is the chief reason why prostitutes are usually sterile4 ,in married women gonorrhea may cause dyspareunia2 it may bring on abortion through endometritis2 it may shut the tubes and prevent conception2 it may destroy the ovaries4 ,the disease is extremely frequent during pregnancy4 ,gurd#aid isolated the gonococcus in #eb of #aac pregnant women who came to his dispensary service because of pelvic pain4 ,leopold1 ,stephenson1 ,fruhinholtz1 and many others estimated that about #bj per cent4 of all pregnant women have gonorrhea1 but more recent observers think that from #e to #aj per cent4 is nearer the truth4 #aid ,montreal ,med4 ,jour41 vol4 xxxvii4 ,when a pregnant woman has gonorrhea great care must be taken in treatment to prevent abortion4 ,powerful antiseptics in the cervix1 or dilatation of the cervix1 are not permissible1 and operative interference is to be delayed as long as possible--in each instance to avoid abortion4 ,the vaginal douche as a routine treatment is not used now by obstetricians in these cases4 ,when the gonorrhea is in the uterus douches of hot bichloride solution1 #a to #aj1jjj1 are used twice daily during the last few weeks of gestation1 with the intention of saving the infant's eyes from infection during delivery4 ,after delivery the cavity of the uterus should not be entered with instruments lest infection be carried in1 unless absolute necessity requires this instrumental procedure4 ,post-partum gonorrheal sepsis is differentiated from other septic conditions chiefly by the history of gonorrhea in the husband1 by bacteriological examinations1 and by the technical differentiation of symptoms4 ,the moral guilt of a person who infects another with gonorrhea is affected by the extent of the physical injury done4 ,gonorrhea causes1 besides the effects already described3 7#a7 chronic cystitis1 with all the suffering1 loss of work1 and danger of renal infection in such a condition2 7#b7 lymphadenitis of the inguinal canal1 and rarely of other places2 7#c7 proctitis1 or inflammation of the rectum1 especially in women and young children2 7#d7 ophthalmia1 vaginitis1 and proctitis in infants and children1 and metastatic conjunctivitis2 7#e7 stomatitis or inflammation of the mouth in adults and children2 7#f7 nasal gonorrhea 7a doubtful condition72 7#g7 gonorrheal septicemia1 bacteremia1 or toxemia1 which may affect any organ in the entire body2 7#h7 bone and joint lesions3 7a7 gonorrheal arthritis in any joint in the body 7this condition may be fatal1 or it may leave permanent disability1 or it may disappear72 7b7 tenosynovitis1 or pain1 swelling1 and edema along affected tendon sheaths2 7c7 gonorrheal periostitis1 where the bone and periosteum near a joint are affected2 7d7 perichondritis and chondritis1 a rare condition1 where cartilage is attacked2 7#i7 endocarditis1 or inflammation of the lining membrane of the heart 7one of the most frequent secondary lesions of gonorrhea72 7#aj7 pericarditis1 or inflammation of the sac which contains the heart2 7#aa7 myocarditis1 an inflammation of the heart muscle itself1 usually as an extension of endocarditis2 7#ab7 aortitis1 or inflammation of the aorta--a rare condition2 7#ac7 phlebitis1 an inflammation of the veins--a very rare condition2 7#ad7 thrombosis1 or blocking of a blood-vessel by exudate 7this may be fatal72 7#ae7 skin lesions1 as erythema1 erythema nodosum1 bullous and hemorrhagic eruptions1 hyperceratosis1 and ulcers2 7#af7 gonorrhea of the lungs in septicemia2 7#ag7 gonorrheal pleurisy in septicemia2 7#ah7 gonorrheal nephritis1 which is frequent in gonorrheal septicemia--the condition is often fatal2 7#ai7 perinephritis1 a very rare condition2 7#bj7 gonorrhea of the nervous system1 as neuritis or neuralgia1 or neuroses1 which vary from slight melancholia to severe mental disturbances2 7#ba7 parotiditis1 a very rare condition2 7#bb7 otitis1 or inflammation of the middle ear1 a very rare condition2 7#bc7 suppuration in muscles1 or under the skin2 7#bd7 wound septicemia2 7#be7 venereal warts2 and 7#bf7 epididymitis1 which often causes not only sterility but impotence4 ,campbell#aie reported a gonorrheal infection of a compound fracture at the ankle--it required four months to get the wound free of the infection4 ,gonorrheal obliterating epididymitis is quite common4 ,delbet and ,chevassu#aif found #aad cases of male sterility in #aca cases of epididymitis4 ,more than half of such cases are left permanently sterile1 and if the function of the testicle cannot be restored by the surgeon the patient is impotent1 and any marriage he would make1 444 is rendered void4 ,these two surgeons have restored function in six such cases by uniting the vas with the epididymis by ,martin's operation4 ,it is much easier to restore function after vasectomy than after obliterating epididymitis4 #aie ,new ,york ,medical ,journal1 ,february #bb1 #aijh4 #aif ,canadian ,presse ,mdic41 ,july1 #aijh4 ,there are frequent cases of arthritic rheumatism in which the source of the infection is a chronic gonorrhea of the seminal vesicles4 ,fuller#aig has done #aja vesiculotomies for this condition1 and of these twenty-three were gonorrheal4 ,in these twenty-three the excision of the infected vesicles cured the rheumatism4 ,in vesiculotomy great care must be taken not to cut the vas deferens4 ,if it is cut the man is impotent until the vas is restored1 and it would be a very difficult operation to reunite the vas if cut near the vesicles4 #aig ,new ,york ,medical ,journal1 ,may #cj1 #aijh4 ,of all the gonorrheal affections of the body the most dangerous and important are the cardiac inflammations and ophthalmia neonatorum4 ,this ophthalmia is a purulent infection of the external parts of the eye in infants4 ,it may be caused by many kinds of toxic bacteria1 but the worst cases are from the diphtheria bacillus 7a very rare condition7 and the gonococcus 7a very frequent condition74 ,before #ahha1 when ,cred introduced prophylactic treatment for ophthalmia neonatorum1 every maternity hospital had a department isolated for the care of babies suffering with this disease4 ,at the present day1 however1 despite the precautions taken1 this disease is quite common4 ,pennsylvania and ,new ,york alone spent #bdb1jjj annually for the support of asylums for the blind1 and about #dj per cent4 of the children in these institutions were blinded by gonorrheal ophthalmia4 ,the ,united ,states spends #a1hjj1jjj yearly on victims of ophthalmia neonatorum4 ,stephenson#aih tells us that in the practice of forty-one oculists who reported to him the gonococcus was found in #fg4ad per cent4 of their #afeh cases of ophthalmia4 ,mayou found the gonococcus in #fc4e per cent4 of #adhc cases4 #aih ,ophthalmia ,neonatorum4 ,london4 #aijg4 ,there is an infection of the child's eyes by gonococci possible even while the child is in the womb1 but this is very exceptional2 the infection happens in the vagina during delivery1 as a rule4 ,when the child's head is born its lids and eyelashes should be cleansed with vaseline1 or #a to #ejjj bichloride1 or carbolized oil1 before the eyes are opened to put in the silver nitrate solution4 ,this solution should be made from a pure drug or it will injure the eyes4 ,a one per cent4 solution is strong enough for routine work1 but if the gonococcus is suspected1 or if it is known that the mother has gonorrhea1 then the lids of the infant must be everted and touched everywhere with a five per cent4 solution of silver nitrate4 ,this is neutralized with a salt solution and washed out before the lids are turned back4 ,it is rash to trust any of the albuminoid preparations of silver1 like argyrol1 silvol1 or protargol1 in gonorrhea or suspected gonorrhea of the eyes4 ,if the child develops ophthalmia the treatment should be turned over to an oculist when possible4 ,when a child can have a day and a night nurse1 this method should be adopted1 but ordinarily there is no nurse except some woman about the house or the mother4 ,in such cases one eye1 commonly the right1 does better than the other because the first eye treated is opened readily1 but after the infant has been irritated it shuts the eyes so strongly that it is difficult to open them at all4 ,the first eye treated is habitually the same4 ,the nurse should begin to treat the eyes alternately on this account1 or wait to treat the second eye until after the baby has quieted down4 ,iced compresses should be used1 but not so long as to chill the eye very much--five to ten minutes at a time is enough4 ,if the physician himself makes the applications of silver nitrate1 the nurse should use some silver salt like argyrol4 ,three to eight grains of zinc sulphate to eight ounces of boric solution is a good regular eye-wash in these cases4 ,atropine must also be instilled to protect the iris4 ,if only one eye is affected1 the other eye should be protected under a watch glass sealed over it4 ,all persons who have gonorrhea1 or who treat gonorrhea1 must be warned of the danger they are in of infecting their own eyes4 ,a new treatment of gonorrhea is described by ,weiss4#aii ,the gonococci are killed by a temperature of #ajg4f degrees ,fahrenheit1 and in eleven cases ,weiss subjected men to a hot bath for forty to fifty-five minutes1 with the temperature of the water gradually increased from #ajd to #aaj degrees ,fahrenheit4 ,in one instance the body temperature was raised to #ajh4e degrees ,f4 in a forty-minute bath and the gonococci disappeared at once4 ,in the other cases the body temperature did not go up so high1 but the vitality of the gonococcus was evidently reduced1 and under a few local injections they all disappeared4 #aii ,mnchener medizinische ,wochenschrift1 ,november #b1 #aiae4 ,,chapter ,,xxi ,,diabetes ,,in ,,pregnancy ,diabetes ,mellitus is rare in pregnancy1 but when it does occur the disease is fatal in three-fourths of the children1 and it hastens the death of the woman1 according to the common opinion of obstetricians1 but this opinion is disputed4 ,in making the diagnosis we must exclude lactosuria and other pseudodiabetic conditions4 ,a sugar reaction which is often mistaken for the glycosuria of true diabetes is from lactose in excessive milk secretion4 ,this lactosuria is harmless4 ,again1 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 cherry4 ,the phloridzin so acts on the epithelium of the kidneys that it lets the blood-sugar escape into the urine4 ,medical writers who report diabetes in large numbers of pregnant women mistake these reactions for the reaction of true glycosuria4 ,in the genuine diabetes of pregnancy there is a high mortality4 ,offergeld1#bjj in sixty cases1 found that the women died within two and a half years1 and that #gf per cent4 of the children were lost4 ,diabetics commonly are sterile from atrophy of the uterus and ovaries3 in a series of #aad diabetic married women1 ,lacorch found only seven pregnancies4 ,in a third of such as do become pregnant abortion or premature labor occurs4 ,coma happens in #cj per cent4 of these pregnancies1 and it is almost always fatal4 ,delivery frequently causes collapse1 coma1 or sudden death4 ,the liver in any gestation has more work than it has in the unimpregnated state1 but a diabetic liver is unfit for almost any normal function4 ,if albuminuria is found the prognosis becomes very bad4 ,diabetic women have poor resistance against a tubercular infection4 ,half their children are still-born1 and #aj per cent4 more die within a few days after birth 7many of these children are diabetic74 #bjj ,archiv4 f4 ,gyn41 bd4 #hf1 n4 #a4 ,there is some evidence of heredity in diabetes--it is likely to run in a family4 ,heiberg#bja reported one family in which five of thirteen children had diabetes2 in another1 four of eight children1 the mother1 two of the mother's brothers1 and the maternal grandfather had diabetes4 ,in another1 two brothers1 the father1 and grandfather died of it4 ,i know of a case where the only two sons and the father in a family died of it4 ,heiberg did not find any essential difference in the histology between the hereditary cases and those which were not hereditary4 #bja ,deutsche medizinische ,wochenschrift1 xlii1 #i4 ,joslin#bjb reported seven cases of diabetes associated with pregnancy4 ,four of the seven are now dead1 one by suicide1 one from uremia1 one from coma1 one from tuberculosis4 ,of the three living one is in good condition1 one is not well and she has lost two of three children1 and one is very ill with diabetes4 ,in persons beyond middle age diabetes with proper treatment may go on for from ten to fifteen years before it is fatal1 but it quickly kills young patients4 ,a young woman at the marriageable age who has diabetes will die anyhow in two or three years1 and if she marries and becomes pregnant she will die very probably in her first pregnancy4 #bjb ,boston ,medical and ,surgical ,journal1 ,november #be1 #aiae4 ,when the child is viable1 and the diabetic mother shows albuminuria1 progressive weakness1 or diacetic acid in marked quantity1 it may be necessary to perform therapeutic abortion2 but if this is done no anesthetic may be used1 and great precautions should be taken to avert physical and mental shock4 ,even ergot acts badly with these cases4 ,the last sacraments should be given in good time1 especially if coma threatens4 ,when labor begins in a diabetic and everything appears to be normal the sacraments should be given1 because there is always danger of sudden collapse and death4 ,,chapter ,,xxii ,,childbirth ,,in ,,twilight ,,sleep ,a method of effecting painless childbirth through the use of scopolamine and morphine was first used in #aijb by ,steinbuechel1 and in #aijf ,gauss1 of the ,university of ,freiburg in ,baden1 reported a series of five hundred obstetrical cases in which scopolamine and morphine had been used4 ,the woman's condition was called in ,freiburg a ,dmmerschlaf1 a ,twilight ,sleep1 because she is somnolent and forgetful of pain4 ,in #aijc the chief obstetricians in several of the leading ,american and ,german universities tried the drugs1 but they quickly abandoned the method because they found it dangerous and unscientific4 ,the process was exploited here by ,mc,clure's ,magazine1#bjc ,the ,ladies' ,home ,journal1 and other lay periodicals4 ,the articles in these magazines were written by persons who are not physicians1 and their erroneous statements are misleading4 ,the ,ladies' ,home ,journal1 however1 while favoring the method1 published letters from several leading obstetricians in the ,united ,states1 all of whom are opposed to the use of these drugs during parturition because they had tried them and found them unscientific4 ,the method is illicit morally1 and it is unscientific4 #bjc ,june1 #aiaa4 ,obstetricians divide a parturition into three stages4 ,in most primiparae and many multiparae there is a prodromal stage1 in which false labor pains 7dolores praesagientes7 are the most evident symptom4 ,when the real labor sets in there are rhythmic uterine contractions about every fifteen minutes1 which cause pain to the woman by the pressure of the fetus on the uterine nerves--dolores praeparantes4 ,from the time the pains become rhythmic1 and are effective in dilating the neck and mouth of the womb1 until the mouth of the womb is completely stretched and flush with the vaginal wall1 thus completing the continuous parturient canal1 is the first stage of labor4 ,the fetal enveloping membranes 7the bag of waters7 usually rupture at the end of this stage1 but sometimes the bag bursts before the end1 or as late as the second stage of labor4 ,the first period is the stage of dilatation4 ,the second stage extends from the end of the dilatation until the expulsion of the child is completed4 ,this is the stage of expulsion4 ,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 afterbirth4 ,normal parturition is always painful to the woman4 ,as the labor progresses the pains gradually grow more intense1 and the interval between them shorter4 ,after a few hours the pain is strong enough to cause the woman to cry out1 but there is a great variety in the endurance of these pains1 as the women's characters differ4 ,neurotic women begin to scream and act hysterically even in the early part of the first stage4 ,when the pains are fully developed each lasts about half a minute4 ,in most cases the infant comes out head first1 but almost any part of its body may present4 ,before the advancing child part of the liquor amnii within the fetal enveloping membranes is forced down into the neck of the womb1 and causes dilatation4 ,in primiparae especially the bag of waters may rupture prematurely and thus cause what is called a dry labor1 which is commonly tedious and painful4 ,often operative interference is required in dry labors4 ,in the second stage the pains are stronger1 recur every two or three minutes1 and are expulsive4 ,the woman then strives to expel the child4 ,she strains violently with the abdominal muscles--literally labors2 her pulse is high1 the veins of her neck stand out1 her face is turgid1 and her body is covered with sweat4 ,when at last the head of the child is driven out the woman feels as if she were being torn asunder in the dolores conquassantes4 ,the pain is so great that the woman may faint from it1 but that is not the rule4 ,after a pause the shoulders are forced out1 and then the trunk in one long convulsive effort4 ,the umbilical cord is tied and cut1 and the child is born4 ,after from five to twenty minutes the womb begins to contract again1 but the pains 7dolores ad secundum partum7 are not nearly so intense as they were during labor4 ,then in from fifteen minutes to about three hours the placenta is expelled4 ,the pains of labor are so evident that the expulsive contractions of the uterus1 of which the pains are symptoms1 are themselves called the pains4 ,these pains in all scientific exactness of statement are1 as has been said1 agonizing4 ,in dolore paries filios is a very literal text4 ,the scopolamine-morphine method was devised with the intention of mitigating them1 or mercifully rendering the woman unconscious of them during at least a part of the labor4 ,if she is unconscious of pain she is thus saved also from shock and depression1 which render her susceptible to infection4 ,such results certainly are immeasurably valuable if attainable without taint of moral evil1 but as the method stands just now1 they are not free from that taint4 ,scopolamine hydrobromide1 one of the drugs used in this method1 is an alkaloid obtained from the roots of ,scopolia 7or ,scopola7 carniolica1 and it cannot be differentiated chemically from hyoscine hydrobromide1 which is made from henbane and other plants of the ,solanaceae group4 ,rusby was of the opinion that scopolamine is really a mixture of hyoscine1 hyoscyamine1 and atropine3 one-tenth hyoscine and nine-tenths hyoscyamine and atropine4 ,cushny and others find different proportions of these alkaloids4 ,as the leaves of ,scopolia are used to adulterate the belladonna leaves from which atropine is derived1 hyoscine and scopolamine are substituted for each other--if1 indeed1 there is an any real difference between them4 ,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 asker4 ,even in a pure state hyoscine and scopolamine have the same chemical formula 7,c#ag;,h#ba,,no#d71 and their physiological action is the same4 ,each can exist in three isomeric forms1 and in one of these forms they turn polarized light to the left1 in another to the right1 while in a third form they do not affect the light at all4 ,the higher the rotatory power of the drugs1 the more active they are physiologically4 ,the levorotatory scopolamine has1 according to ,cushny1 ,peebles1 and ,hug1 double the action of the inactive scopolamine on the cardiac inhibitory fibres of the vagus1 but the levoactive and the inactive scopolamine produce the same effect on the central nervous system4 ,the drug on the market is usually composed of a mixture of the levoactive and the inactive forms1 and as one or the other predominates the results differ3 the rotatory power of a given specimen should be known4 ,old solutions of scopolamine decompose and give rise to toxic substances4 ,gauss attributed post-partum hemorrhages in the women and asphyxia in infants to these decomposition products1 but he avoided these untoward effects somewhat by cutting down the morphine dose4 ,he had five infant deaths before he cut down the morphine1 and #be per cent4 of the children were intoxicated4 ,the chief action of scopolamine or hyoscine is upon the cerebral cortex1 producing sleep1 which is accompanied often by a low delirium4 ,they depress the centre of respiration1 and have a depressant effect also on that part of the spinal cord which governs the motions of the body4 ,they intensify the action of morphine and other narcotics4 ,morphine1 which is used to prevent pain1 is the chief drug in the twilight sleep method1 and it is greatly intensified in action by the presence of scopolamine4 ,when1 however1 morphine and scopolamine are given to a pregnant woman hypodermically1 these drugs are at once carried by the blood to the fetus4 ,children for years after birth all withstand the action of morphine badly1 and a fetus in utero may be overwhelmed by it4 ,just in this fact lies the chief moral crux in the use of the twilight sleep method of obstetrical delivery4 ,the woman may go on to the end more or less safely in competent hands1 but if constant watch is not kept at the bedside by a skilled observer the infant is liable to be killed1 and the danger comes to it not solely from the drug directly--it may be drowned in the amniotic fluid1 its condition may be masked by the restlessness of the mother1 which prevents proper observation3 when a woman is plunging all over the bed1 as is extremely common in twilight sleep1 the pulse-rate of the baby cannot be properly watched4 ,if the mother happens to be particularly susceptible to scopolamine or morphine1 the first will cause delirium and the second coma2 or the respirations may become arhythmic and be reduced to only five or six a minute4 ,the kidneys may be affected by the morphine so as to bring on total suppression of urine4 ,labor is prolonged1 and it may be very much prolonged4 ,in some women uterine atony is induced by the morphine1 with very dangerous consequent post-partum hemorrhage4 ,morphine relaxes all musculature1 and it relaxes the muscle of the arterial walls and so disposes to hemorrhage4 ,there is little or no premonitory symptom of these idiosyncrasies 7except in the case of an injured kidney7 to inform the physician that he should avoid the scopolamine-morphine treatment4 ,dr4 ,polak1 professor of obstetrics at the ,long ,island ,college ,hospital1 reported#bjd on #aee cases of the twilight sleep method1 and he is in favor of it under several restrictions4 ,he uses the drugs from ampules which contain one two-hundredth of a grain of scopolamine and half a grain of narcophin1 which is a proprietary drug said to be composed of the meconate of morphine with the meconate of narcotin in molecular proportion4 ,morphine itself is a tribasic meconate1 and narcotin1 of course1 another opium derivative4 ,the ,american ,council on ,pharmacy and ,chemistry was unable to accept the claims made for narcophin4#bje ,polak says he finds no difference between morphine and narcophin4 #bjd ,long ,island ,medical ,journal1 ,december1 #aiad1 and ,american ,journal of ,obstetrics1 ,may1 #aiae4 #bje ,jour4 ,amer4 ,med4 ,assoc41 ,november #ba1 #aiad4 ,in the twilight sleep treatment the patient1 especially if she is a primipara1 should be definitely in labor before any injection is given4 ,she should have pains occurring at regular intervals1 preferably every four or five minutes1 before the first injection of scopolamine and morphine is administered2 that is1 the first stage of labor should be well advanced4 ,gauss gives one-sixth of a grain of morphine at the first injection1 and ,polak nearly three-fourths of a grain of narcophin1 with one two-hundredth of a grain of scopolamine4 ,if the woman is a multipara1 ,polak begins the treatment at the very beginning of the pains4 ,the patient is kept in bed1 in a darkened room1 removed from all noise and excitement4 ,some stop the ears and blindfold the patient1 and1 according to ,baer of ,chicago1 the women are put into restraining sheets as a routine practice in certain clinics to keep them from infecting themselves4 ,the ordinary practice is to give a half dose of scopolamine an hour after the first dose and about every two hours thereafter1 according to the indications4 ,the morphine may be discontinued1 or used approximately every six hours in a long labor4 ,smaller doses are required if the first is given early in the labor1 and larger if the pains have been well developed4 ,in these latter cases the danger to the child is1 of course1 greater4 ,the condition of the patient's pulse1 respiration1 pupillary reaction1 and the frequency and character of the uterine contractions are constantly watched1 to guard against poisoning4 ,fonyo#bjf reported two fatal poisonings by the scopolamine-morphine method as used in surgery4 ,both were operations for the delivery of women by laparotomy1 and in each case the centre of respiration was overwhelmed4 ,in each of these operations only one-hundredth of a grain of scopolamine and one-third of a grain of morphine had been used1 but chloroform was administered later4 ,robinson recently reported the fatal poisoning of a negress by scopolamine1 and ,chandler of ,philadelphia two more where one thirty-third of a grain of scopolamine had been used4 ,one-ninetieth of a grain given hypodermically has caused severe toxic disturbance which lasted for twenty-eight hours1 and ,root#bjg reported a case where one three-hundredth of a grain given by mouth poisoned violently4 #bjf ,zentralblatt f4 ,gynkologie1 ,september #ai1 #aiad4 ,leipsic4 #bjg ,therapeutic ,gazette1 vol4 ii4 ,in ,freiburg1 ,gauss tests the consciousness of the women about every half hour by showing them some object1 and if they remember having seen this object he gives an additional dose of scopolamine4 ,polak says this memory test is not necessary3 even if the patient gives outward evidence of pain by cries and motion1 she is apparently but very dimly conscious in his opinion4 ,the progress of the delivery must be constantly watched by repeated extrabdominal or rectal examinations1 following the fetal shoulder as it rotates--and not by vaginal examinations--to avoid sepsis4 ,the fetal heart must be auscultated every half hour at most1 between and during the pains4 ,if the child's pulse grows arhythmic or slow between pains1 these are bad prognostic signs4 ,all use of the drugs is to be discontinued1 and the child is to be delivered at once to save its life1 by the most suitable method and route4 ,polak holds that the solutions of the drugs must be absolutely pure1 and that hyoscine cannot be substituted for scopolamine1 but that narcophin is no better than morphine3 the ,american preparations have produced delirium4 ,as ,i have shown1 no one can possibly tell the difference between hyoscine and scopolamine1 even by chemical analysis4 ,all we can do is to take the druggist's word that the drug at hand was made from ,scopolia and not from ,hyoscyamus niger4 ,it does not make any difference which is the source of the supply4 ,polak says the morphine shortens the first stage of labor by softening the cervix1 but that the treatment lengthens the second stage4 ,other observers have not found that it shortens the first period4 ,he tells us that if this second stage--that is1 the time from the full dilatation of the os until the delivery of the child--lasts over an hour in multiparae1 or over two hours in primiparae1 delivery must be effected by the ,kristeller expression or by low forceps4 ,in the ,kristeller expression the child is pushed out of the canal by the hands of the physician applied to the fundus uteri4 ,it should be a method of last resort1 because there is danger of rupturing the uterus1 of tearing the placenta loose1 or of crushing an ovary4 ,in his report ,polak says he has had no failures2 the patients had no recollection of the labor2 in the first series of fifty-one the children showed no sign of asphyxiation or even cyanosis except in two cases4 ,in this first series one patient had a long second stage and the child had to be resuscitated4 ,there were1 he said1 no post-partum hemorrhages2 no low forceps2 the placentas were delivered without difficulty2 none of the women showed signs of tire or exhaustion the next day2 in fact1 they were better off than the women who have normal labor4 ,this report is different from that made by other men just as competent1 and in exactly the same circumstances2 even ,gauss confesses many failures4 ,the lay journals say ,gauss had no failures1 but he himself should know4 ,in ,april1 #aiae1 ,i was told in ,new ,york ,city that there had been no failures there1 yet in ,may1 ,dr4 ,broadhead1 professor of obstetrics at the ,postgraduate ,school of ,medicine in that city1 after observing seventy-two cases confessed#bjh several failures where the child was concerned4 ,one ,catholic woman1 a member of the executive committee in a ,twilight ,sleep ,league of married and unmarried women1 was killed in ,brooklyn by the method in the summer of #aiae4 #bjh ,the ,postgraduate1 ,may1 #aiae4 ,dr4 ,charles ,m4 ,green1 professor of obstetrics in ,harvard ,university1 tells us3#bji ,my own observations1 published in #aijc1 led me at the time to favor this therapeutic means of producing the ',twilight ,sleep1' and removing the consciousness of pain1 or at least preventing all remembrance of it4 ,i have long since abandoned this agent1 however1 for two reasons3 ,first1 because it has apparently been the cause1 occasionally1 of fetal asphyxia4 ,second1 because the effect of the drug on the mother is often uncertain1 and unless used with great care may cause unfavorable or dangerous results4 ,moreover1 we have other and safer measures for the relief of pain in labor4 ,so ,i have given up teaching the use of scopolamine in my lectures4 #bji ,ladies' ,home ,journal4 ,dr4 ,williams1 professor of obstetrics in ,johns ,hopkins ,university1 and the author of a book on obstetrics which is very valuable1 says3#baj ,we have used the scopolamine treatment of childbirth in two separate series of cases at the ,johns ,hopkins ,hospital1 but in neither series were the results satisfactory1 nor did they in any way approach the claims made for the treatment4 ,we expect to do more with it next year4 ,in the fourth edition of his ,obstetrics1 published in #aiag1 he thinks that the twilight sleep method will fall into disuse1 or at least that its use will be restricted to a small group of neurotic patients4 ,from his experience1 he says1 the method is not adapted for private practice4 #baj ,ibid4 ,dr4 ,hirst1 professor of obstetrics in the ,university of ,pennsylvania1 tried the scopolamine treatment in the maternity hospital of the university in about #cjj cases at three different times4 ,he tried it first in #aijc1 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 child4 ,at a meeting of the ,obstetrical ,society of ,philadelphia#baa ,hirst1 commenting on a paper by ,polak1 said3 ,i am sorry to say ,i cannot agree with my friend ,dr4 ,polak in his conclusions 444 ,i had to discontinue morphia and scopolamine because there were too many cases of post-partum hemorrhage1 too many cases in which forceps had to be used1 too many asphyxiated babies4 ,so ,i am not an enthusiast for 'twilight sleep4' #baa ,proceedings printed in ,american ,journal of ,obstetrics1 ,may1 #aiae4 ,dr4 ,joseph ,b4 ,de ,lee1 professor of obstetrics in the ,northwestern ,university ,medical ,school1 ,chicago1 and the author of a book on obstetrics which is now one of the best we have in ,english1 tells us#bab that the impressions he received from studying ten cases of childbirth in ,professor ,krnig's clinic at ,freiburg were decidedly unfavorable to the method of ',twilight ,sleep4' ,in all the ten cases1 he testifies1 the birth pains were weakened1 and labor prolonged--in two instances for forty-eight hours4 ,in three cases pituitrin1 which is in itself a dangerous drug to use before the uterus has been almost emptied1 had to be given to save the child from imminent asphyxia4 ,in five of the cases forceps had to be used owing to the paralyzing effects of the drug1 and all these forceps cases were extensively lacerated4 ,several of the women became so delirious and violent that ether had to be used to quiet them1 with the result that the infants were born narcotized and asphyxiated to a degree4 ,one child had convulsions for several days4 #bab ,ladies' ,home ,journal4 ,the complete failure in these ten cases is so obvious as to be a scandal1 although ,de ,lee does not say so4 ,he abandoned the use of the method twelve years ago1 and in #aiac he visited the maternities at ,berlin1 ,vienna1 ,munich1 and ,heidelberg1 and found that all had tried the method and had rejected it4 ,several so-called detoxicated substitutes for morphine1 like tocanalgine and analgine1 have been tried2 but these turned out to be morphine1 and to be equal in strength to morphine as we ordinarily have it4 ,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 ,freiburg4 ,they are morphine treacherously disguised1 and the assertions in the ,cosmopolitan were never retracted when attention was called to the untruth by the ,journal of the ,american ,medical ,association4 ,in the ,american ,journal of ,obstetrics for ,may1 #aiae1 is a full description of these drugs 7page #ggb74 ,dr4 ,joseph ,baer reported#bac sixty cases of the morphine-scopolamine treatment at the ,michael ,reese ,maternity ,hospital in ,chicago1 and his results were diametrically opposed to those ,dr4 ,polak himself obtains4 ,the rooms used were large1 and had cork-lined sound-proof walls and doors2 obstetricians and specially trained nurses were present day and night4 ,the circumstances1 then1 were the best that could be had4 #bac ,jour4 ,amer4 ,med4 ,assoc41 ,may #bb1 #aiae1 lxiv1 #ba1 p4 #agbc4 ,he used ,merck's scopolamine at first1 and later a solution made up after the formula of ,straub of ,freiburg1 which is more stable4 ,his doses of morphine were from one-eighth to one-fourth of a grain2 ,gauss uses one-eighth to one-sixth of a grain2 ,polak1 as much as three-fourths of a grain of narcophin for his first dose4 ,baer's series ended on ,february #e1 #aiae1 and of his sixty cases only five were successful4 ,three of the successful cases received one-fiftieth of a grain of scopolamine in all1 and some of the unsuccessful cases got as high as one-sixteenth of a grain1 with only wild delirium as a result4 ,the labor was lengthened by about seven hours over untreated cases4 ,as to the amnesia1 in twenty-six cases the memory was not dulled at all1 although they received more scopolamine than thirty-nine cases in which the memory was cloudy4 ,thirty-two women had unbearable thirst throughout the labor1 and nothing would slake this thirst4 ,their incessant cries for water were very distressing to the attendants4 ,headache was present in twenty-seven cases and vertigo in thirty-one1 and the headache1 which was very intense in some women1 lasted for several days after delivery4 ,pain was diminished in thirty-nine cases1 absent in one1 as severe as in the average untreated woman in nineteen1 and increased in one4 ,that is1 only one woman in sixty did not suffer the pain for which the treatment was devised4 ,the reason evidently is that his dose of morphine was too small1 yet if he went above this dose he ran the risk of post-partum hemorrhage and of narcotizing the baby4 ,as it was1 he had seven post-partum hemorrhages1 but in a series of sixty unselected normal delivery cases he had only one hemorrhage4 ,restlessness was present in eighteen cases1 and delirium in nine2 six of these women had to be wrapped in restraining sheets1 and one had to be shackled for four days after she had overpowered a nurse in an effort to jump out of a window4 ,it took three attendants to get her into the strait-jacket4 ,chandler of ,philadelphia saw a woman in a like delirium who was shackled only after six attendants together had tackled her4 ,two physicians in the ,chicago maternity were severely beaten by women in a twilight sleep delirium4 ,baer says the serious risk of self-infection during labor through the uncontrollable motion of these women is a source of constant anxiety4 ,they sit cross-legged1 and the heel infects them with coli communis from the expressed feces4 ,the dazed women constantly try to get at the vague pain with their hands1 and on this account1 according to ,baer1 some clinics that practise the twilight sleep method keep all the women in strait-jackets1 but they omit to publish this fact4 ,one of ,baer's patients died from a ruptured uterus1 and her dead baby was taken from her belly-cavity4 ,the drug will mask symptoms in a case like this4 ,sudden cessation of puerperal pain as a symptom of rupture1 and the peculiar pain of a premature loosening of the placenta1 are both covered from observation by the drugs1 the darkening of the room1 and the tossing of the patient1 which prevent proper examinations4 ,one patient had a mitral insufficiency and myocarditis4 ,this should be an ideal case for the treatment1 according to the twilight sleep men4 ,the woman1 however1 after three doses of the scopolamine developed pulmonary edema4 ,her child was delivered in asphyxia pallida and resuscitated with difficulty4 ,thirteen of the children did not breathe at delivery1 six were asphyctic1 and two cases relapsed into asphyxia4 ,one child was killed1 as we said1 when the mother's uterus ruptured4 ,avarffy#bad had one fatal case in fifty1 and ,chrobak one in one hundred and seven4 #bad ,gynkol4 ,rundschau1 #aiji1 iii4 ,eight of the women had blurred vision after delivery1 which lasted for over twenty-four hours2 two had marked delirium for from two to four days after childbirth4 ,as to exhaustion after labor1 ,baer says he found no difference between the twilight sleep women and the normal cases4 ,some advocates of the twilight sleep method say that there is less use of the forceps in this method than in normal delivery4 ,at ,freiburg1 for example1 operative delivery has been reduced to six or seven per cent4 ,six per cent41 as a matter of truth1 is two per cent4 above the normal average for forceps delivery in eighteen ,german maternities4 ,in #ie1jbe deliveries in these hospitals the average forceps delivery was #d4e per cent41 and some were small teaching hospitals where the forceps were used on any provocation for class demonstration4 ,the twilight sleep method has a much higher operative delivery1 and this varies1 of course1 according to the skill and judgment of the operators4 ,holmes1 one of the first in ,chicago to try the newly revived method1 says#bae that in ,july1 #aiad1 before the great war broke out1 there were twenty-five malpractice suits pending in one ,german city as a result of the morphine-scopolamine fad4 ,he quotes a noted obstetrician on this subject3 ,if you will use the method1 have the patient in the best hospital possible1 with all the appurtenances requisite for the revival of the child2 if you do not know1 learn at once the differences between asphyxia1 oligoapneia1 and narcotic poisoning1 and the methods of treating them2 get the best and the most reliable product called scopolamine2 and then be sure you are in a position to be adequately defended by a lawyer versed in malpractice suits4 #bae ,american ,journal of ,obstetrics1 ,may1 #aiae4 ,this is the state of the question4 ,two or three men in the best circumstances say they get one hundred perfect results2 other men1 equally or far more skilled and in equally favorable circumstances1 get one hundred results which are anything but successful1 often a disgrace to science1 and undoubtedly immoral4 ,they are immoral because they risk human life in an attempt to ease a physiological pain1 and this is not a sufficient reason2 moreover1 these attempts fail oftener than they succeed4 ,the second group of practitioners have no motive except honesty to induce them to make their unfavorable reports of failure4 ,the reports of the two groups are directly contradictory1 and the judgment is thus a matter of motives4 ,testimony from women who have gone through the process is not to be taken into account4 ,they were dazed1 and in any case they are not competent to judge a matter which is wholly technical4 ,we know the limitation of morphine and scopolamine and we cannot improve their use4 ,if enough is given to still pain1 we take a criminal risk2 if we do not give enough to remove the sense of pain1 why not use the safer nitrous oxide1 ether1 and chloroform8 ,if enough morphine and scopolamine are administered early in labor to a multipara1 the labor is commonly stopped2 if this dosage is given after the pains are developed1 the baby is born1 as a rule1 before they take effect4 ,,chapter ,,xxiii ,,vasectomy1 ,,or ,,sterilization1 ,,by ,,state ,,law ,the ,state of ,indiana in #aijg enacted a vasectomy law which obliges the superintendents of some prisons and asylums to appoint two surgeons whose office is to sterilize sexually criminals1 idiots1 imbeciles1 and similar persons1 if these surgeons1 in consultation with the chief physician of the institution1 deem the propagation of children by such so-called degenerates detrimental to society4 ,the same law has been incorporated in the statutes by ,new ,york1 ,new ,jersey1 ,washington1 ,iowa1 ,nevada1 ,wisconsin1 ,connecticut1 ,california1 ,utah1 ,kansas1 ,oregon1 and ,minnesota4 ,the law has been proposed several times in the ,legislature of ,pennsylvania1 but it was vetoed twice and held up once in the ,assembly4 ,in ,new ,jersey there was question of sterilizing an epileptic girl1 and the ,supreme ,court of that ,state#baf decided in #aiac that the law is contrary to the ,state and ,federal constitutions4 ,in #aiaf ,probate ,judge ,lapeer of ,michigan declared the law as passed in his ,state in #aiac unconstitutional1 but the ,state appealed against this decision4 ,the ,supreme ,court of ,washington#bag 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 punishment4 ,the constitutionality of the ,iowa law is on appeal to the ,united ,states ,supreme ,court after a ,federal judge had declared it unconstitutional4 ,the law in ,indiana was put into effect in hundreds of cases1 but ,governor ,marshall set the law in abeyance4 ,two ,federal judges in ,kansas said the law is unconstitutional and granted an injunction against its application in a particular case4 ,in #ahjh the superintendent of a ,kansan institution for the feeble-minded castrated forty-eight boys4 ,up to ,april1 #aiaf1 about twenty-five feeble-minded boys in the ,wisconsin institution at ,chippewa ,falls were sterilized1 and the authorities then said they intended to sterilize the girls4 ,the law has been advocated by alienists in ,switzerland1 and ,french and ,english physicians have advocated it4 #baf ,smith vs4 ,board of ,examiners of the ,feeble-minded1 #hh alt4 ,r4 #ifc4 #bag ,state vs4 ,feilen1 #abf ,pac4 ,r4 #ge4 ,the reason given by the advocates of this law is the alarming prevalence of feeble-mindedness with its tendency to criminality2 and as1 they say1 heredity accounts for #fe per cent4 of feeble-mindedness1 the feeble-minded should be prevented from propagating their kind4 ,sweden1 with #e1ejj1jjj inhabitants1 has #ah1jjj insane1 #ad1jjj idiots1 #bj1jjj imbeciles1 and #g1jjj epileptics4 ,much of this degeneracy is due to the notorious alcoholism of the ,swedes1 which only lately has been brought under some control4 ,pennsylvania had about #ag1jjj feeble-minded in #aiac4 ,in a single county almshouse in that ,state were #aje women who had given birth to #aja defective children4 ,one feeble-minded couple in the same ,state had #ai defective children2 two other families had #i imbeciles and #g idiots4 ,in ,new ,jersey the history of #dhj individuals of the famous ,kallikak family 7a pseudonym71 descended from a feeble-minded woman who lived at the time of the ,revolutionary ,war1 has been traced out1 and of these descendants only #dj were normal4 ,new ,york ,state has #cb1jjj known feeble-minded persons4 ,one ,state school for the feeble-minded in ,indiana in #aijh had #ajed inmates4 ,there are #fjjj mentally defective children in the schools of ,chicago4 ,an investigation made in ,illinois about #aijg brought out the conclusion that all the defectives and delinquents in that ,state at the time could be traced to #aej families4 ,poehlmann of ,bonn traced the descendants of one female drunkard through six generations in #hjj individuals1 and of these #ajg were illegitimate1 #ajb were beggars1 #aha were prostitutes1 #gf were criminals in a grave degree1 #g were murderers1 and they had cost the ,state #a1bjf1jjj4 ,the ,jukes sisters1 two illegitimate prostitutes in ,new ,york ,state1 in five generations bred #gji criminals4 ,fifty-two per cent4 of the women were prostitutes1 whereas the ordinary ratio of prostitutes to other women is #a4ff per cent4 ,alcoholics engender degenerates4 ,in three generations of #bae ,french alcoholic families1 ,legrand found that #fj per cent4 of the children were degenerates4 ,bourneville found that #fb per cent4 of #ajjj idiotic1 epileptic1 and feeble-minded children in ,paris had alcoholic parents4 ,hereditary transmission is certainly a cause also of many diseases of the nervous system4 ,friedrich's ataxia is hereditary4 ,it is an incurable progressive incordination of the limbs1 tongue1 larynx1 and eyes1 which attacks commonly between the tenth and the twentieth year1 and the patient dies from some intercurrent disease1 usually an infection4 ,progressive muscular dystrophy is also hereditary and incurable4 ,the legs and trunk atrophy1 and death comes from an intercurrent disease4 ,related to this malady are hereditary progressive neurotic muscular atrophy1 progressive spinal muscular atrophy in infants1 and progressive spinal amyotrophy in adults4 ,amaurotic 7amaurosis1 blindness7 family idiocy is hereditary1 and the child dies at about two years of age4 ,huntington's chorea appears in every generation of an affected family4 ,its symptoms show between the ages of thirty and forty years1 and it progresses from choreic and ataxic signs to dementia and death4 ,the death is often by suicide4 ,in eastern ,long ,island1 southwestern ,connecticut1 and eastern ,massachusetts #ifb cases were all traced back to six persons1 three of whom were probably brothers1 who came to ,america in the seventeenth century4 ,in the #cjjj relatives of these choreics were #ci cases of epilepsy1 #ea cases of cerebral inflammation1 #da cases of hydrocephaly1 #gc feeble-minded children1 and other evidences of neuroses4 ,the heredity in this disease is apparently ,mendelian4 ,besides the diseases enumerated here1 there are several pathologic conditions of the eyes which are hereditary--presenile cataract1 stationary night blindness1 and retinitis pigmentosa4 ,if the persons who have these diseases are sexually sterile1 evidently the heredity so far as they are concerned will be cut across2 hence the advocates of legal sterilization wish to have these patients sterilized to protect society4 ,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 testicles4 ,this interruption may be a severing of each vas1 a cutting out of a part of each vas1 or a ligation of the vasa4 ,the term vasectomy is now used loosely to cover all these methods4 ,the vas deferens1 or seminal duct1 passes from the testicle up along the groin on each side1 in through the belly-wall by the inguinal canal1 down along the pelvis and under the bladder1 where it opens into the bottom of the urethra a short distance in front of the bladder exit4 ,each vas is about two feet in length1 and it has a diameter of one-tenth of an inch throughout the greater part of its length1 but its lumen is extremely narrow4 ,there are two essential parts in the semen1 the spermatozoa and the carrying liquid4 ,the spermatozoa1 which fructify the ovum1 are formed in the testicle2 the liquid1 which is the essential vehicle of the spermatozoa1 and without which the spermatozoa are inert and sterile1 is secreted1 except a few drops from the testicles1 at the distal end of the vasa deferentia under the base of the bladder1 in the seminal vesicles1 the prostate gland1 and ,cowper's and ,littr's glands4 ,the semen is made up of #ij per cent4 water and #aj per cent4 solids1 and in these solids is the nitrogenous base called spermin1 which is produced by the interstitial cells of the testicles and the prostate gland4 ,ovarin1 secreted from the ovaries1 corresponds in the woman to spermin in the man4 ,the ductless glands1 and some that have ducts1 produce secretions which sustain the tone of the blood-vessels and neutralize the toxins from waste substances while these are in the body before excretion4 ,an excess of spermin or ovarin causes congestion of the cerebrum and cerebellum and the nerve centres there1 with consequent sexual erethism4 ,when there is a pathologic sexual erethism from an excess of spermin or ovarin1 vasectomy1 castration1 spaying1 or the menopause cuts off this excess and the erethism disappears4 ,sometimes the waste product toxins excite the patient when the spermin or ovarin has been eliminated1 just as the excess of spermin or ovarin excites1 and the neurotic disturbance or sexual erethism continues until compensation by other glands neutralizes the irritating substance4 ,the testicles in man are by no means the sole organ of generation4 ,there are at least seventeen distinct organs in the male generative system4 ,the seminal vesicles with the prostate gland are as necessary in generation as the testicles1 as their removal sterilizes the spermatozoa and prevents the formation of the liquid vehicle4 ,castration effects an atrophy of several parts of the generative tract1 and an irremediable degeneration2 vasectomy cuts off the spermatozoa but causes no atrophy or degeneration1 and the condition is remediable4 ,dr4 ,edward ,martin of ,philadelphia found active living spermatozoa in a testicle that had been ligated off for twenty years4 ,running along the vasa deferentia1 within the sheath of the two spermatic cords1 are the spermatic arteries1 the pampiniform plexus of veins1 and the deferential arteries4 ,these vessels1 with the vas deferens and the sheath enveloping the bundle1 make up the spermatic cord4 ,in vasectomy1 under local anesthesia1 a slit is made through the skin of the scrotum behind1 the sheath of the spermatic cord is opened1 and the vas is isolated and tied or cut4 ,the skin wound is left to heal4 ,this operation is repeated on the second vas4 ,if the blood-vessels in the cord are ligated or cut with the vas1 the testicle will atrophy2 if the vas alone is operated upon1 the testicle is not injured4 ,the person upon whom vasectomy has been done is conscious of no change4 ,the semen is discharged as before the operation1 but in a slightly less quantity1 and it is1 of course1 sterile from the lack of spermatozoa4 ,dr4 ,carrington of ,virginia reported1 in #aiaj1bah twelve cases of vasectomy on convicts4 ,he said ten of this dozen had been confirmed masturbators1 and all were cured by vasectomy4 ,one masturbating epileptic was cured of both conditions4 ,two dangerous homicides were rendered harmless and peaceable4 ,one of these two homicides was a negro under a long sentence for murder4 ,he grew insane in prison1 and while insane killed a second person4 ,a confirmed masturbator and sodomist1 and a dangerous savage1 he became lucid and relapsed into insanity several times4 ,a year after vasectomy he was a sleek1 fat1 docile1 intelligent fellow1 a trusty about the yard4 #bah ,virginia ,medical ,semi-monthly1 vols4 xiv1 xv4 ,dr4 ,sharp of ,indianapolis1 after ten years' experience with the operation1 during which time he did #def vasectomies1 says3#bai ,there is no atrophy of the testicle1 no cystic degeneration1 no disturbed mental or nervous condition following4 ,he says1 further1 that #agf men in the ,indiana ,reformatory asked him to perform the operation on them4 ,vasectomy tends to check masturbation1 and the minds of the masturbators frequently improve after the operation4 #bai ,jour4 ,amer4 ,med4 ,assoc41 ,december #d1 #aiji4 ,if a man has been sterilized by vasectomy1 restoration of function and removal of the sterility seems practically always possible4 ,if a ligature has been used1 releasing the ligature restores function4 ,dr4 ,william ,t4 ,belfield of ,chicago#bbj restored function fully by removing the ligature eight weeks after it had been applied4 ,in a letter to me1 ,dr4 ,belfield said3 ,my observation accords with the general experimental and clinical experience that the restoration of the lumen after vasectomy or ligation1 or both1 is more certain than the lasting occlusion of the vasa by these measures4 ,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 restoration4 ,in one case ,i tied a waxed 7to avoid cutting through7 silk ligature tightly around the sheath of each vas2 a specimen examined a month later was devoid of sperms2 one six months later contained plenty of them4 ,i cut down upon the ligatures1 found them in place and neatly encysted1 and removed them4 ,evidently the pressure from behind had squeezed a passage on at least one side4 ,the gynecologists have learned that ligatures around the ,fallopian tubes are apt to cut through1 whereupon the tubal lumen is restored1 though pressure must be less than in the vas4 ,even when a piece of the vas has been excised cases of spontaneous restoration have been observed in men and dogs4#bba #bbj ,jour4 ,amer4 ,med4 ,assoc41 ,october #ai1 #aiab4 #bba ,belfield1 loc4 cit4 ,when the ends of a cut vas are released from cicatricial tissue1 these ends may be sutured together2 but as the lumen of the vas is extremely small1 there is sometimes obliteration by occlusion at the juncture4 ,christian and ,sanderson#bbb described a method of preventing this obliteration4 ,a piece of ,no4 #j twenty-day catgut is inserted three-eighths of an inch into each end of the vas1 and these ends are brought together by two catgut sutures1 leaving the inserted catgut in the canal4 ,the ends heal together and the catgut in the canal is absorbed4 ,this method has been used successfully to join the cut end of a ,fallopian tube4 #bbb ,jour4 ,amer4 ,med4 ,assoc41 ,december #ac1 #aiac4 ,gemelli#bbc did vasectomy on eleven dogs and seven cats2 about six months later he reunited the cut ends1 and on dissection found restoration perfect1 anatomically and functionally1 in the eighteen animals4 ,the vas deferens in these animals is smaller than in man2 and therefore offers greater difficulty in the suturing4 ,he used no inserted catgut1 but told me he employed the method ,carrel applies in joining cut arteries4 ,in one case1 where the dissection was broad1 he successfully inserted a piece of a vas taken from another animal4 ,whether there is occlusion or not after end-to-end suturing depends largely on the skill of the surgeon4 #bbc ,la ,scuola ,cattolica1 ,november1 #aiaa4 ,dr4 ,edward ,martin of the ,pennsylvania ,university#bbd and ,delbet#bbe have removed sterility by effecting a patulous anastomosis between the vas and the epididymis1 and this method is applicable after vasectomy by cutting1 but it is not successful1 as a rule4 ,it has been done effectively where the vas had no stricture4 ,mc,kenna1#bbf in five attempts on men1 succeeded once4 ,frbringer#bbg said that in his experience with a thousand cases of double epididymis1 the condition is incurable in #hj per cent4 of the gonorrheal infections4 #bbd ,university of ,pennsylvania ,medical ,bulletin1 #aijb1 p4 #chh2 #aijc1 xv1 #b2 ,therapeutic ,gazette1 ,december #ae1 #aiji4 #bbe ,revue de ,thrapeutique ,mdico-chirurgicale1 ,january #ae1 #aiab4 #bbf ,journal ,amer4 ,med4 ,assoc41 ,january #bf1 #aiae4 #bbg ,deutsche med4 ,wochenschrift1 xxxix1 #bi4 ,apart from the so-called vasectomy law1 gynecologists quite frequently sterilize women who have chronic heart disease1 tuberculosis1 nephritis1 diabetes1 or hereditary mental taints4 ,some men1 like ,spinelli1 ,cramer1 ,polak1 and others1 would sterilize also in chronic anemia1 persistent albuminuria1 epilepsy1 syphilis1 contracted pelvis1 diseases of metabolism1 infections1 and cirrhosis of the liver4 ,there are several methods of sterilizing women--removal of the ovaries1 ligation of the ,fallopian tubes1 resection of portions of the tubes1 resection of the whole tube on each side1 cutting the tubes and burying the cut end in the tissues by various methods1 and destruction of the lining of the uterus by vaporization or the thermocautery4 ,de ,tarnowsky#bbh describes the various methods4 ,some ligations and short resections have failed to sterilize4 ,when the ovaries or uterus are removed1 or the major part of the tubes are resected1 or the lining of the uterus has been destroyed1 the sterilization is permanent4 ,almost certainly function could be restored where the resection of the tubes is not too destructive4 ,apart from the matter of mutilation1 the effects of double ophorectomy are very grave1#bbi and removal of the uterus or the ovaries merely for sterilization is not only immoral1 but altogether unjustifiable scientifically4 #bbh ,jour4 ,amer4 ,med4 ,assoc41 ,april #ai1 #aiac4 #bbi ,see the chapter on ,gonorrhea4 ,a phase of this subject which is important and has occasioned much discussion is whether vasectomy causes sexual impotence or not4 ,from a medical point of view1 there is no question of impotence2 physicians would say it causes sterility only4 ,most canonists1 however1 hold that the condition after vasectomy is technically impotence in the canonical sense4 ,ferreres of ,tortosa1 a leading ,spanish canonist1 in several articles in the ,ecclesiastical ,review1 in ,razon y ,fe 7xxviii1 #cgf2 xxxi1 #dif71 and in his book ,de ,vasectomia ,duplici 7,madrid1 #aiac71 opposed my opinion published in #aiab and #aiac1 which then was that vasectomy does not cause canonical impotence4 ,de ,smet of ,bruges#bcj holds that it causes impotence4 ,so do ,ojetti1#bca ,ren ,michaud1#bcb ,wouters1#bcc ,eschbach1#bcd ,capello1#bce ,stucchi1#bcf ,de ,becker1 ,vermeersch1 ,de ,villers1 and ,salsmans of the ,university of ,louvain1 and others4 ,gemelli of ,milan#bcg agreed with me4 ,the weight of authority is certainly in favor of the notion of impotence1 but the arguments are by no means convincing1 as virtually every canonist who has discussed the question has made gross misstatements of the physical facts in the case4 #bcj ,ecclesiastical ,review1 ,september1 #aiab4 #bca ,synopsis ,rerum ,moralium et ,juris ,pontificii1 #cast ed41 n4 #bdbe4 #bcb ,nouvelle ,revue ,thologique4 #bcc ,nederlandische ,katholische ,stemmen1 ,january #ae1 #aiaa4 #bcd ,analecta ,ecclesiastica1 ,september1 #aiaa1 and ,la ,scuola ,cattolica1 ,february1 #aiab4 #bce ,la ,scuola ,cattolica1 ,february1 #aiab4 #bcf ,ibid41 ,november1 #aiaa4 #bcg ,ibid41 ,november1 #aiaa4 ,if a man or woman is impotent1 the disability is an impedimentum juris naturalis1 and as such it would nullify any marriage1 no matter what the dispensation4 ,there are two opinions among moralists as to the essence of canonical impotence4 ,i4 ,some hold that any permanent obstruction to fecundation1 no matter in what stage of the physiological process or in what part of the genital tract it occurs1 constitutes impotence4 ,they maintain that a woman whose ovaries or uterus have been removed is impotent4 ,roman ,congregations have promulgated several decrees in peculiar cases permitting the marriage of spayed women2 but1 these moralists say1 it is not clear that in those special cases the entire ovary on each side of the whole uterus was taken out2 they hold there is doubt as to the fact4 ,and1 since there is disagreement of moralists1 the ,holy ,office or other congregations would give the same decision because of the dubium juris4 ,april #b1 #aiji1 the ,congregation on the ,discipline of the ,sacraments decreed that the marriage of a ,spanish woman1 from whom1 according to the physician in charge of the case1 the uterus and both ovaries had certainly been removed1 should not be prevented4 ,february #c1 #ahhg1 the ,holy ,office made the same decree in the case of a woman from whom the uterus and both ovaries had been removed4 ,july #bc1 #ahij1 the ,holy ,office made the like decree under the same conditions4 ,july #ca1 #ahie1 the ,holy ,office permitted the marriage of a woman from whom both ovaries had been removed4 ,another case1 in #aijb1 in which the physician was not certain that the whole ovary on each side had been removed1 was decided in the same manner4 ,there have been1 then1 four decisions so far permitting the marriage of women who lacked both ovaries1 and three of these women lacked the uterus also4 ,the ,congregation of the ,council has made four decisions in recent time forbidding the marriage of women because of impotence2 ,march #ba1 #ahfc1 a case in which there was neither vagina nor uterus2 ,january #bd1 #ahga1 a case in which the vagina was only two inches in depth2 ,september #g1 #ahie1 a case in which the vagina was obliterated in greater part2 ,december #af1 #ahii1 a case in which the vagina was only five centimetres in depth4 ,that a woman who certainly lacks both ovaries is canonically impotent is the opinion of ,antonelli1#bch ,lehmkuhl1#bci ,rosset1#bdj ,alberti1#bda ,bucceroni1#bdb and others4 ,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 removed1 although as a matter of fact the physician in one case testified explicitly that both ovaries and the whole uterus were undoubtedly removed4 ,that a woman lacking both ovaries is not impotent is the opinion of ,gasparri1 ,d',annibale1 ,gnicot1 ,berardi1 ,aertnys1 ,tanquerey1 ,ojetti1 ,de ,smet1 and others4#bdc #bch ,medicina ,pastoralis1 vol4 ii1 n4 #dc4 #bci ,theologia ,moralis1 #hth ed41 ii1 n4 #gdd4 #bdj ,de ,matrimonio4 #bda ,theologia ,pastoralis1 p4 iv1 n4 #hh4 #bdb ,theologia ,moralis1 ii1 n4 #iid4 #bdc ,see ,ferreres1 ,de ,vasectomia ,duplici necnon de ,matrimonio ,mulieris ,excisae1 p4 #aaj4 ,madrid1 #aiac4 ,,ii4 ,the second opinion on impotence is that this condition is caused exclusively by those permanent disabilities which exist in the copula itself4 ,if the sexual act contains in itself all that is essential to generation1 if the copula is de se apta ad generationem1 prescinding from all antecedent and subsequent1 temporary or permanent1 obstructions to generation1 there is no impotence4 ,in this opinion the woman without ovaries is not impotent1 but the vasectomized man is2 in the first opinion both the mulier excisa and the vasectomized man are impotent4 ,the second group says the vasectomized man is incapable of performing an act de se apta ad generationem because his semen lacks the essential spermatozoa4 ,if one objects that the spayed woman1 who is not impotent according to some moralists that so interpret the decisions of the congregations1 lacks the essential ovum1 so that she cannot perform an act de se apta ad generationem because she has nothing to generate with1 they answer that her copula is per se apta1 that there happens in it everything which takes place in a copula from which generation actually follows4 ,the vasectomized man cannot go through the form of the act with all the elements which1 so far as the act is concerned1 are required and sufficient for generation because he lacks the spermatozoa1 but the mulier excisa can4 ,his inability is intrinsic to the act1 it vitiates the very substance of the act2 her inability to present ova is not intrinsic to the act1 they say4 ,all that is necessary in her case is that she be capable of receiving the semen4 ,marriage was instituted to beget children2 that is the proper end of the contract1 its basic justification4 ,whenever the debitum is used it must be with the intention of generating children4 ,even the use of marriage as a remedy of concupiscence is so secondary an end that it alone is not enough to legitimize marriage4 ,because a woman does not always have ova present in the tubes1--and there is no means of knowing just when the ova are present1--it is justifiable to repeat the conjugal act until the woman is impregnated2 secondarily and dependently1 the repetition may be a remedy of concupiscence4 ,the sexual act does not form either the spermatozoa or the ova2 these pre-exist4 ,the spermatozoa are always released in a normal sexual act2 the ova are not always present when the spermatozoa are released4 ,a copula which is perfectly de se apta ad generationem supposes not at the time the presence of both sperm and ovum1 but it does suppose the possibility of the ovum1 otherwise generation is utterly impossible2 and every copula becomes justifiable solely because there is a hope that it may be present4 ,it is a mere quibble to say that an act is de se apta ad generationem if by no possibility generation ever can take place2 nevertheless the congregations in four cases have apparently judged to the contrary4 ,in these special decisions1 however1 ,rosset1 ,antonelli1 ,bucceroni1 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 uterus4 ,bucceroni expressly states#bdd that the ,cardinal ,secretary of the ,holy ,office told him personally the members of the congregation supposed in the particular cases that generation could follow4 ,therefore these decisions do not say that the mulier excisa in general is not impotent or potent2 they merely gave the women of these cases the benefit of the doubt4 ,tho question is entirely open so far as these decisions are concerned4 #bdd ,theologia ,moralis1 #eth ed41 vol4 ii1 p4 #cia1 n4 #iid4 ,those who hold that vasectomy causes canonical impotence say also the constitution of ,sixtus ,v4 forbidding the marriage of eunuchs is applicable necessarily to the vasectomized man1 because the semen from the vasectomized man1 inasmuch as it lacks spermatozoa1 is not genuine semen1 and ,sixtus ,v4 said eunuchs cannot produce true semen4 ,the relevant passage in the constitution is3 ,cum frequenter in istis regionibus eunuchi et spadones1 qui utroque teste carent1 et ideo certum ac manifestum est eos verum semen emittere non posse2 quia impura carnis tentigine atque immundis complexibus cum mulieribus se comiscent1 et humorem forsan quemdam similem semini1 licet ad generationem et ad matrimonii causam minime aptam1 effundunt1 matrimonium 444 contrahere praesumant 444 mandamus ut conjugia per dictos et alios quoscumque eunuchos 444 contrahi prohibeas4 ,sixtus ,v4 says here3 7#a7 that eunuchs who lack both testicles certainly and evidently cannot emit true semen2 7#b7 that although eunuchs may perhaps produce a kind of liquid resembling semen1 this is by no means fit for generation or marriage2 7#c7 therefore eunuchs are forbidden to marry4 ,the effects of castration in the eunuch are3 7a7 that all spermatozoa are absent2 7b7 that1 as a consequence of the absence of the testicles1 the power of penetration is lost2 7c7 that1 as another consequence1 the liquor seminis1 which normally is formed in the seminal vesicles1 the prostate and other glands1 is no longer secreted4 ,the eunuch1 then1 is completely impotent1 in the full sense of the term4 ,ferreres is of the opinion1 erroneously1 that eunuchs1 as a rule1 have the power of penetration and of emitting a humor semini similis1 and that amputation of the penis is requisite to cause impotence in eunuchs4 ,there are only five authentic cases of temporary apparent potence in eunuchs in modern medical records1 and these are explicable as cases of erethism from waste-product intoxication4 ,the canonists who hold that the vasectomized man is impotent interpret the words of ,sixtus ,v4 to fit their opinion1 although the vasectomized man has all the sexual potency of the normal man except that his spermatozoa are occluded4 ,the potestas coeundi is not lost in any degree2 neither he nor the woman is conscious of any change whatever4 ,only the microscope can tell that the spermatozoa are absent if the fact that he has been vasectomized is not told4 ,moreover1 if vasectomy has been done by mere cutting without considerable resection1 and especially if the vasa have been shut by ligation alone1 no one can be certain that the occlusion is either certain or permanent4 ,there is always doubt that the spermatozoa are present if the microscope is not used1 and these canonists all disclaim the use of the microscope in such circumstances4 ,the argument ,ferreres uses1 to the effect that the absence of spermatozoa is seriously injurious to the woman1 is a supposition of his own arising from an erroneous notion of potency in the vasectomized4 ,this absence is not injurious to her1 but it is probably injurious to the vasectomized man because of the partial ejaculation4 ,onanism1 which is different1 is decidedly injurious to both the man and the woman4 ,onanism1 coitus interruptus1 or withdrawal before ejaculation1 which takes place extra vas1 is intended to prevent impregnation4 ,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 cerebrum4 ,cowper's and ,littr's glands secret an alkaline fluid which neutralizes the acid urine in the urethra and thus prevents killing of the spermatozoa4 ,muscular peristaltic action presses out the spermatozoa and the secretions of the seminal vesicles and the prostate4 ,when the act is normal there is a complete emptying of the tract of semen and of the blood engorgement2 in coitus interruptus there is incomplete ejaculation and only partial deplethorization4 ,the seminal vesicles remain distended1 and this distention1 with the congestion of the prostate1 causes continual excitation of the sexual centres without relief4 ,there is irritability and exhaustion of the centres1 and this state brings on premature ejaculation and final impotentia coeundi4 ,other common effects are tenesmus of the urinary bladder1 incontinence of urine1 nocturnal pollutions1 sexual neurasthenia1 pain in the legs1 over the eyes1 and in almost any part of the body1 general weakness1 headache1 vertigo1 cardiac palpitation1 neurotic dyspepsia1 and a train of psychic symptoms which not seldom end in suicide4 ,in the woman there is the like blood engorgement and a pouring out of the secretions of ,bartholin's and the other glands1 but deplethorization takes place later in the woman than in the man1 and for this reason the woman suffers more from coitus interruptus than the man does4 ,in onanism1 as in masturbation1 after the diseased conditions have been established it is extremely difficult to induce the patient to resist the almost overwhelming irritation4 ,the canonists have interpreted the text of ,sixtus ,v4 to the effect that the eunuch is impotent precisely and solely because he cannot produce semen elaboratum in testibus4 ,no man produces semen elaboratum in testibus--more than #ic per cent4 of the semen is produced entirely outside the testicle2 nothing but the spermatozoa and two or three drops of a lubricating fluid are produced in the testicles4 ,the eunuch really is impotent because the removal of the testicles and their nervous system so breaks the genital circuit1 which consists of at least seventeen distinct parts1 that erection is prevented1 the formation of spermatozoa is impossible1 the secretion of the essential vehicle of the sperm and of the fluids which render it fertile is cut off4 ,the eunuch cannot penetrate and he cannot form any semen2 he is impotent2 the vasectomized man can penetrate1 and he forms a semen which is sterile4 ,i think now the vasectomized man is really impotent for the reason that ,i think the mulier excisa is impotent1 but he is not impotent because of the constitution of ,sixtus ,v41 which is not relevant at all to his case4 ,if the vasectomized man is impotent1 the following cases are also impotent3 #a4 ,a man whose germ-cells have been destroyed by the action of the ,x-ray4 #b4 ,a man with double permanent occluding epididymitis4 #c4 ,a man whose vasa deferentia open into the ureters and not into the urethra4 #d4 ,a man whose vasa are shut by surgical operations for stone1 or cysts of the prostate1 or seminal vesicles4 #e4 ,a man whose seminal vesicles are shut by concretions1 cysts1 or tumors4 #f4 ,a man with bilateral cryptorchidism4 #g4 ,a man with a tuberculous condition of the testicles4 #h4 ,a man with absolute neurotic aspermia4 #i4 ,a man with congenital lack of development of the testicles or vasa4 ,sterility in the male would exist only in advanced diabetes1 general tuberculosis1 senility1 or in cases of absent or diseased prostate gland or seminal vesicles4 ,here it is worth noting that since the copula must be natural1 fit for generation in the natural manner1 artificial impregnation by the use of instruments is immoral1 and forbidden by a decree of the ,holy ,office1 promulgated ,march #bd1 #ahig4 ,artificial impregnation does not effect a copula which is by its nature proper to generation1 but is an act contrary to nature1 one from which generation does not follow in a natural manner1 secundum communem speciem actus4 ,it supposes deliberate pollution and semination outside the vagina1 both of which actions are intrinsically evil4 ,in discussing the morality of vasectomy the following points must be considered3 #a4 ,in what degree of mutilation is vasectomy8 #b4 ,vasectomy may be done either at the request or by the permission of the vasectomized person2 or by order of the ,state4 7a7 ,if done by the request or permission of the vasectomized person1 it may be either 7#a7 as a means to use the debitum without the inconvenience of having children2 or 7#b7 as a therapeutic measure to cure some malady4 7b7 ,if done by order of the ,state1 it may be 7#a7 a punishment2 or 7#b7 a prophylactic measure to avert physical or moral evil in society4 ,if vasectomy causes canonical impotence1 that fact adds a special moral quality4 ,the weight of authority is on the side that it does cause canonical impotence1 as has already been mentioned4 ,a slight mutilation1 in the sense of the term as commonly used1 can be any permanent effect of a wound1 bruise1 or similar cause1 from a mere scar to an amputation or other injury whereby any member of the body is rendered unfit for normal action4 ,that the causal wound or injury is trivial in itself1 apart from its effect1 as in vasectomy1 has little or no direct bearing on the morality of the mutilation4 ,it is possible to have a very gross mutilation without extensive wounding4 ,we can blind a man permanently by putting the point of a fine cambric needle one-twentieth of an inch within the pupil4 ,vasectomy is a grave mutilation because 7#a7 it removes from the man the power of generation2 7#b7 it inhibits the function of the testicle1 which is an important organ of the body4 ,although they are not the entire organ of generation1 the testicles are together a complete organ in themselves1 the function of which is to produce the spermatozoa essential to the procreation of the human species4 ,if by a wound one inhibits the function of the testicles1 he gravely mutilates the human body1 for a grave mutilation is nothing but an inhibition of the function of a distinct organ through a wound4 ,a mutilation of this kind1 since it frustrates the production and action of the human generative semen and prevents generation1 is what is technically called a mortal sin against nature1 unless there is sufficient cause to necessitate the frustration1 such as to save life1 to restore as a sole means the health of the whole body1 to protect society1 or a similar reason4 ,what is said here of vasectomy is true for fallectomy or other methods of sterilizing the woman4 ,fallectomy1 however1 is in itself a dangerous operation1 and ophorectomy is never justifiable as a mere method of sterilization because of its very injurious effects on the whole body and mind of the woman4 ,among the decretals of ,gregory in ,corpus ,juris 7lib4 v1 tit4 xii1 c4 #e7 is the following canon3 ,if any one1 for the sake of indulging lust1 or through revenge1 does anything to a man or woman1 or gives them anything to drink1 whereby they cannot generate1 or conceive1 or bear children1 he is to be treated as a homicide4 ,any one who sterilizes a man by vasectomy or a woman by fallectomy or ophorectomy1 for an improper motive1 ipso facto falls under this decree1 and is before the canon law classed in the same category as a murderer2 that is1 the agent is deemed guilty of a grave crime against nature4 ,if a man has vasectomy done upon himself1 his intention may be 7#a7 to use the debitum without the inconvenience of having children2 or 7#b7 to avert from a wife with a narrow pelvis the dangers of the cesarean section or other obstetrical operation to herself and the child2 or 7#c7 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 chapter2 or 7#d7 to cure himself of some malady4 #a4 ,if vasectomy is done merely to be able to use the debitum without the inconvenience of having children1 it is evidently illicit4 ,it is in that condition the same as onanism2 it is contrary to the basic justification of marriage2 it is a frustration of nature2 and so on4 #b4 ,if it is done to safeguard a wife with a narrow pelvis it is a means1 evil in itself1 used directly to effect a good end2 and a good end1 or any end or effect1 never justifies a direct evil means or cause4 ,there is in reality no such thing as a good effect from an evil means or cause2 the evil means or cause essentially and substantially vitiates the effect4 ,there is no question here of a double effect1 one good and one evil1 wherein the good effect is intended and the evil permitted1 both coming with equal directness from the single causal act4 ,on the contrary1 from the vasectomy here there is the single direct effect that the man is sterilized1 and then directly from this sterility comes the desired effect1 the protection of the wife4 ,for exactly the same reason1 vasectomy done to prevent the transmission of a hereditary disease is illicit2 it is an evil means used directly to effect an end intended4 ,in artificial abortion when the fetus is inviable the act done is to empty the uterus1 and this act itself kills the fetus1 which is not an unjust aggressor1 and is murder4 ,this murder may save the mother's life1 but the end does not justify the means4 ,the vasectomy to protect the mother's life or to avert an evil heredity is a parallel case4#bde #bde ,see the chapter on ,general ,principles concerning ,mutilation for an explanation of the act with a double effect4 ,the fourth case supposes that the vasectomy was done to cure the man of some malady4 ,if there were a malady that endangered the patient's life1 or destroyed the health of the body and it could be cured by vasectomy1 the operation would of course be licit for the reasons given in the chapter on ,general ,principles concerning ,mutilation4 ,dr4 ,carrington tells us#bdf that he did vasectomy on an epileptic convict and cured him4 ,such a cure is doubtful as to permanence4 ,he describes two dangerous insane negro homicides who were rendered harmless by vasectomy4 ,in cases like those of the homicides any one responsible for them would probably be justified in having the operation done1 although these two cases are the only direct ones on record4 ,epileptics sometimes show a homicidal tendency1 but it is doubtful that vasectomy would help them4 ,the operation of vasectomy as a cure for bodily ill has a very limited field4 ,there are very many conditions in women where it is necessary to remove the ovaries or the tubes to save life1 or to cure chronic invalidism of an unbearable nature4 ,these conditions are discussed in the chapter on ,gonorrhea4 ,there is no objection to the removal of a tube or an ovary when such removal is absolutely necessary1 but the necessity must be clearly evident4 ,there is a tendency in some surgeons to mutilate women in this manner without sufficient reason or to follow out a therapeutic theory4 #bdf ,virginia ,medical ,semi-monthly1 vols1 xiv1 xv4 ,men1 like ,sharp1 who have done hundreds of vasectomies1 say the operation commonly removes the inclination to masturbation4 ,masturbation is1 as a rule1 a moral condition1 but it can1 like alcoholism1 come to have a large physical element4 ,idiots almost unexceptionally have this vice1 and in them there is no morality possible4 ,if by vasectomy they can be cured of this vice1 which injures their health and is a social indecency and a source of sin in observers1 the operation would be licit in their case4 ,when the patient is morally responsible vasectomy would not be licit1 as there is no adequation between a physical evil like sterilization and a moral vice4 ,there are cases of pathological sexual erethism which are so violent that the patients must be put into strait-jackets to prevent constant masturbation4 ,the semen of such patients is usually devoid of spermatozoa4 ,if the patient is confined in a strait-jacket he will die1 and vasectomy1 according to ,sharp1 will quiet such a man4 ,vasectomy would be permissible in these circumstances4 ,the question has arisen in the case of a sane masturbator who is neurotic1 weak-willed1 and a confirmed addict to his vice1 whether or not his vasa might be tied off by ligatures1 temporarily1 with the intention of removing the ligature later and restoring function4 ,i think not4 ,even temporary sterilization is sterilization1 a grave mutilation1 while it lasts1 and the condition is really moral fundamentally1 and therefore not a fitting object for physical remedies4 ,when vasectomy is done by the ,state1 it is done either as a penal or as a prophylactic measure4 ,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 order2 but even then any punishment1 to be justifiable1 must be effective and necessary1 and it has to be either reformative1 exemplary1 or reparative in regard to the crime for which it is inflicted4 ,capital punishment and mutilation are effective usually1 and are necessary for the preservation of society4 ,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 necessary3 since the natural law requires the existence of civil society1 it must allow what is necessary for the preservation of that society4 ,there is no question here of a good end justifying evil means2 the means which otherwise would be evil in these conditions become good4 ,homicide and mutilation are not mere killing or mere maiming1 but unjust killing or unjust maiming4 ,killing or maiming is not intrinsically wrong under all circumstances1 as lying1 blasphemy1 and some other crimes are2 nevertheless1 as a punishment by maiming1 vasectomy is ordinarily wrong1 and therefore a law making it an ordinary mode of punishment for certain whole classes of criminals1 or all criminals1 is unjust4 ,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 punishment4 ,in ,dr4 ,sharp's list of vasectomies done in ,indiana prisons1 #agf operations were done on men who voluntarily asked for vasectomy4 ,there is no pain1 no inconvenience caused by the operation1 no sexual change perceptible1 but a fitting of the criminal to indulge his lust without the various inconveniences of impregnation4 ,instead of being reformatory1 it is conducive to crime4 ,i find only one man who objected to vasectomy4#bdg ,in this man vasectomy was added to life imprisonment as a punishment for rape4 #bdg ,state of ,washington vs4 ,feilen1 #abf ,pac4 ,r4 #ge4 ,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 condition1 a physical disease1 and not a matter of volition4 ,this ,lombrosan absurdity is now held by no physical scientist1 and from an ethical point of view it is nonsense4 ,moreover1 if the ,state vasectomized all the criminals in the jails1 this method would not appreciably affect the supply of criminals1 nor reach an appreciable minority of the criminal class1 as the most dangerous criminals are not in jails4 ,the operation is not a punishment to the men upon whom it is done1 but it is an unnecessary deprivation of an essential right of these men1 an excessive1 ill-ordered attack on a primary right of man1 and an act of violence against human nature and its ,author without adequate reason4 ,the law is against the natural order because it directly deprives a man1 and that against his will1 of functions which are at times a moral necessity to him1 and puts him into the occasion of sin4 ,vasectomy does not remove his venereal desires1 but gives opportunity to lust2 it turns the conjugal relation into mere onanism and degrades marriage into a crime4 ,other conditions1 like military service1 in which necessity obliges the ,state to place its citizens and thus prevent the conjugal relation1 cause an indirect temporary prevention1 reluctantly permitted1 not directly intended4 ,vasectomy is an evil directly intended4 ,it is to the interest of the ,state to prevent the transmission of hereditary disease1 and in doing so it may to a certain degree curtail the natural liberty of its citizens4 ,when the peril is great1 as in a plague1 the ,state may isolate infected individuals1 and thus indirectly1 but temporarily1 prevent a natural right--namely1 the conjugal relation4 ,it may even perpetually isolate1 as in leprosy4 ,vasectomy1 however1 is a direct prevention without reason1 and it is done as a direct evil means to effect a so-called end which it never attains4 ,a man with ,huntington's chorea1 if married and if he has children1 will surely transmit the disease to some of these children1 and they to their children4 ,vasectomy on him will prevent a propagation of his kind but will cure no disease4 ,moreover1 he is not a criminal and not amenable to punishment4 ,the bad effect1 sterilization1 must be perpetual in his case or it is foolish1 but the sterilization is not a punishment1 nor a means of saving the health of the patient4 ,whatever good comes of the act comes out of an evil cause4 ,if such a man persists in marrying1 his marriage might be prevented1 but that is different from mutilating him4 ,the ,state has no direct dominion over the lives or members of its citizens1 nor are citizens naturally mere instruments for the good of the government2 on the contrary1 the government exists solely for the good and utility of the citizen4 ,the ,state may not take the life of an innocent person1 nor mutilate him1 unless these acts are necessary either 7#a7 to protect the life or rights of individuals2 or 7#b7 to preserve the social life of the commonwealth4 ,now1 neither of these two requisites is present when there is question of vasectomizing a man4 ,the right or life of no individual is at stake4 ,the rights of the possible children1 yet unborn1 are not injured1 because1 as these children are not in existence1 they have no rights4 ,should they come into being1 it is always better to be1 even though diseased1 than not to be4 ,the methods of cattle-breeders in dealing with human beings is not a virtue in the ,state1 but an outrage and a degradation of human nature4 ,the rights of the wife are not injured1 because she personally receives no injury2 and if her possible children have chorea1 for example1 she either voluntarily took that risk when she married1 or if she did not1 through ignorance1 there are other means to avoid the trouble than the evil of sterilization1 which in itself would render the use of marriage onanistic4 ,if the husband has syphilis1 gonorrhea1 leprosy1 tuberculosis1 or any other infectious disease1 vasectomy is no protection for the wife4 ,may a physician employed by the ,state in a prison1 an institution for the feeble-minded1 or a like place1 do vasectomy at the command of the law8 ,certainly he may not1 except in those rare cases where vasectomy is permissible as described above4 ,the advocates of freakish legislation harp on the assertion that insanity and imbecility are increasing alarmingly1 and as a consequence the entire nation is degenerating4 ,to cure this evil we are to mutilate certain criminals and the mentally defective4 ,it is not true that insanity and mental imbecility are increasing in a very marked degree in the ,united ,states4 ,the number of inhabitants in this country is increasing rapidly1 and as there are more people here than there were a few years ago1 the number of the insane and the mentally defective has increased pari passu1 but the percentage does not increase to any degree that calls for immoral and ineffective legislation4 ,only of late years have the ,state governments begun to classify1 diagnose1 and gather up the insane and the imbecile1 whom we always have had with us1 and these processes have brought the defectives into the light4 ,our late immigrants are not equal in race1 in mental and moral strength1 to the old northern ,european immigrants4 ,in ,philadelphia the foreign-born population is #bd4g per cent4 of the whole1 but that foreign-born population gives us #dd per cent4 of the indigent insane4 ,in ,new ,york ,state #bg per cent4 of the registered insane are not ,american citizens4 ,what we need here is not sterilization1 but a better control of the immigrant1 a keeping out of the unfit4 ,again1 our insanity percentage is increased avoidably by the undoubted increase of insanity among negroes4 ,we are accountable for this because we do not care for our helpless negroes4 ,these people are prevented by trades-unions from learning and working at elevating trades1 and they are thus forced unjustly into a poverty and degradation which lead to vice and mental deterioration4 ,the cure is not a jail surgeon's scalpel1 evidently4 ,a system of education that ignores the will1 upon which morality and virtue are based1 and substitutes a sham intellectuality as elaborated by ignorant boards of education and administered by emotional1 half-educated women1 together with a lack of genuine religion1 is a prolific source of mental and moral deterioration and consequent degeneracy in the physical and moral orders4 ,our ,american public-school system is such1 and its deity is the unwashed and crassly depraved god ,demos1 whose bible is the evening newspaper4 ,if we could civilize our schools1 we should have no mention of legislation by vagary4 ,,bibliography ,ecclesiastical ,review1 vols1 xlii1 xliii1 xliv1 xlvi1 xlvii1 xlviii1 passim4 ,philadelphia4 ,gemelli4 ,la ,scuola ,cattolica1 ,november1 #aiaa4 ,milan4 ,stucchi4 ,ibid4 ,eschbach4 ,ibid41 ,february1 #aiab2 ,analecta ,ecclesiastica1 ,september and ,october1 #aiaa4 ,capello4 ,la ,scuola ,cattolica1 ,february1 #aiab4 ,michaud4 ,nouvelle ,revue ,thologique4 ,paris1 #aiad4 ,schmidt4 ,zeitschrift fr katholische ,theologie1 nn4 #a and #d1 #aiaa4 ,ferreres4 ,de ,vasectomia ,duplici necnon de ,matrimonio ,mulieris ,excisae4 ,madrid1 #aiac4 ,de ,smet4 ,collationes ,brugenses1 ,december1 #aiaj4 ,wouters4 ,nederlandische kathol4 ,stemmen1 ,january #ae1 #aiaa4 ,waffelaert4 ,de ,virtutibus ,cardinalibus1 vol4 ii4 ,bruges1 #ahhi4 ,sharp4 ,journal of the ,american ,medical ,association1 ,december #d1 #aiji4 ,this is the article which started the entire vasectomy controversy4 ,barker4 ,maryland ,medical ,journal1 ,april1 #aiaj4 ,bell4 ,hereditary ,criminality4 ,medico-,legal ,journal1 vol4 xvii4 ,new ,york4 ,desfosses4 ,presse ,md41 vol4 xviii4 ,rentoul4 ,st4 ,thomas ,hospital ,gazette1 vol4 xx4 ,london4 ,swift4 ,maine ,medical ,association ,journal1 ,december1 #aiad4 ,lydston4 ,medical ,record1 ,november #h1 #aiac4 ,new ,york4 ,,chapter ,,xxiv ,,the ,,ethics ,,of ,,birth ,,control ,a corollary of the doctrine which treats of the destruction in medical practice of existent human life1 is a consideration of what is called ,birth ,control1 or the criminal prevention of possible human life by onanistic contraceptive methods4 ,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 conception4 ,the laws which the agitators wish to have abrogated declare that contraceptive information is indecent and should be classed with the circulation of obscene literature1 pornographic pictures1 and instruction in abortion4 ,the birth control advocates pay no attention to accusations like those expressed in the laws1 or to those made by persons who have accurate notions of morality and common decency1 but assert that the spread of contraceptive information tends to benefit the individual and human society4 ,birth control as advocated by its perpetrators is intrinsically contrary to the natural law1 and therefore immoral2 it mentally and physically debases those that are guilty of the practice2 it does not benefit the poor as its advocates claim it does2 the arguments urged by its supporters are foolish and frequently deliberate untruths2 and it is destructive of society and the state4 ,broadly speaking the natural law rests on the principle that order1 reason1 justice1 what is congruous with the nature of a being or faculty and tends to its perfection in being or action1 should prevail1 and that disorder1 unreason1 injustice1 the unnatural1 must be avoided4 ,the right order of nature as established by the ,supreme ,creator of nature is the standard of action2 what is contrary to that order is evil1 wrong1 destructive1 criminal1 injurious1 or the like1 in different circumstances1 but altogether these deordinate conditions must be removed1 not accepted4 ,morality also depends on these facts4 ,morality is merely the observance of the natural law1 and immorality is revolt against that law4 ,since the natural law evidently prescribes that man must live in society and that the human race which constitutes this society1 is to be preserved by the generation of new human beings who will replace those that die1 or are made useless by disease or other accident1 whatever tends to this sustention of humanity according to the natural law1 and in the proper conditions1 is good1 and whatever tends to the destruction of humanity is evil and to be avoided4 ,the generation of new replacing human beings must take place only in the state of marriage1 because thus solely the wife and the child are protected1 the children are educated physically1 mentally and morally1 and the degradation and bestiality of promiscuous sexual relationship are averted4 ,the first and principal end of marriage is the procreation of children4 ,that end of marriage must be the end on which is founded primarily the natural necessity for this contract1 but the natural necessity for the contract is the propagation of the human kind through lawful generation and education4 ,marriage1 too1 in its very nature is fitted for that chief end1 and for that end it was instituted by the ,author of nature--a stable1 perpetual association of the sexes for the attainment of what is requisite for the propagation of mankind4 ,there are secondary ends of marriage1 such as a reciprocal love and help of the husband and wife1 and also that aspect of marriage which makes it a restraint upon promiscuous lust4 ,these last1 however1 are not enough to justify marriage in themselves without the first or chief end1 which is the procreation of children4 ,whatever is subversive of the end of marriage1 and that is the propagation of mankind1 is subversive of the very foundation of human society1 is contrary to the nature of man1 frustrates the primal function of nature1 and is therefore essentially and always evil1 as bestiality1 sodomy1 or incest are evil4 ,such is birth control as ordinarily practised4 ,birth control if it is effective through a reciprocal consent of a wedded couple1 for grave reason1 and solely by mutual abstention from the debitum may be in certain conditions an indifferent act morally4 ,if1 however1 birth control is effected by contraceptive drugs1 or like methods1 it is a crime against nature1 and always a crime which no circumstance can excuse1 no more than no circumstance can excuse bestiality1 sodomy1 or incest4 ,secondly1 marriage1 which was instituted primarily to perpetuate the creative act of ,god1 when such practices prevail degenerates to mere concubinage1 a gratification of lust protected from the police4 ,such practices1 moreover1 lower man and woman below the brutes1 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 pigs4 ,onan is the patron of ,birth ,control advocates4 ,the ,book of ,genesis said ,onan1 the son of ,judah1 did a detestable thing1 therefore the ,lord slew him4 ,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 law4 ,furthermore1 there is always another way out of the difficulties1 mostly imaginary1 the birth control advocates conjure up4 ,granting that all the difficulties from multiple births are real1 no end justifies essentially evil means1 and a subversion of the natural law is always essentially evil4 ,war1 homicide1 and like acts are not always evil2 under certain circumstances both war and homicide may be holy deeds2 but to act contrary to nature is never justifiable in any condition4 ,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 removed1 but that good end does not justify murder2 no more does any condition of poverty justify a contraceptive act against nature1 especially when such an act is never the sole means of evasion4 ,we must protect the married state1 but in ,america we are destroying it4 ,human society had its origin in marriage1 and it depends on marriage for its preservation1 but our ,american divorce laws have made marriage a travesty4 ,in ,new ,york alone in #aiaf there were #gd1hic women divorced1 nearly twenty-eight times as many as were divorced in ,england and ,wales in that year1 and over forty-nine per cent4 of these women were childless1 very significantly4 ,probably ninety-five per cent4 of the childless women had used contraceptive methods1 yet there are few forces better able to hold the marriage knot tied as it should be tied than a child's fingers4 ,in ,england and ,wales1 too1 in #aiaf1 forty per cent4 of the divorced couples were also birth controllers1 at least they had no children4 ,pennsylvania is much more shameless than ,new ,york in granting divorces for no reason at all4 ,among the arguments used by those in favor of spreading contraceptive information is that large families keep the laboring classes down to low living standards1 and it would be better for those families and the state that these children were not born4 ,large families as such do not keep the laboring classes down to low standards of living2 bad legislation which allows profiteering1 which criminally permits extortion in the prices of food1 clothing1 in taxes1 rents1 the cost of coal1 and the like1 which does not force employers to give laborers an honest price for labor1 or check the extortions of monopolists1 and a hundred similar economic deeds of injustice1 together with a parental shiftlessness1 unthrift1 alcoholism1 lack of education through neglect1 and so on indefinitely1 are the causes4 ,big families have more wages than small families1 and as a rule they do better than the small families when the children are old enough to work4 ,society is at fault1 not the size of the family2 the active and the passive selfish are at fault1 not the babies2 the liars1 hypocrites1 and the buttoned pockets are at fault1 not the holy innocents2 the professional meddlers in the business of better folk are the nuisance1 not the blessed children1 who are the brightest things in this darkened world until we spoil them1 and make them like ourselves instead of better4 ,one decent mother is worth a hundred shirkers who raise nothing but lap dogs4 ,the children of large families1 the birth controllers say1 are more afflicted by infectious diseases than those of small families4 ,i was for years in charge of the infectious diseases ,bureau of the ,washington ,health ,department1 and ,i have had ample opportunity here and in ,europe to study this matter4 ,large families in proper economic positions are not different from small families as regards the infectious diseases4 ,these diseases spread among the poor because the houses of the poor are commonly owned by land sharks and politicians who laugh at health regulations2 our health departments can not get enough money away from the political ringleaders in power to employ capable sanitary experts2 our laws for the regulation of medical practice and education are a disgrace to our civilization1 and every town is swarming with quacks who can not recognize even smallpox when they see it4 ,the fault here is in ourselves not in the large families4 ,control the professional politicians and quacks and there will be no occasion for foolish talk about birth control4 ,again1 the children of poor but large families1 we are told1 have slight or no chance to rise in the social order4 ,benjamin ,franklin1 however1 one of the greatest men ,america has produced1 was the youngest of seventeen children in a poor family2 ,lyman ,beecher1 a poor man1 had eleven children1 and every man and woman among them became famous2 ,theodore ,schwann1 the father of the cell doctrine and of all modern biology1 was one of thirteen poor children2 ,john ,mueller1 one of the greatest of modern scientists1 and the ,father of ,german medicine1 was one of five children of a very poor family2 ,emerson was one of five sons1 so was ,farragut2 ,john ,wesley the founder of ,methodism1 was the eighteenth child of his parents2 ,ignatius ,loyola was the eighth2 ,saint ,catherine of ,sienna1 among the greatest women intellectually and morally that ,europe ever produced1 was the twenty-fourth child of her parents4 ,this list can be extended indefinitely from the biographical dictionaries4 ,every enormous fortune made in ,america was built up originally by a man who arose from the depths--,rockefeller1 ,carnegie1 ,vanderbilt1 ,astor1 ,ryan1 ,havemeyer1 ,schwab1 ,ford1 ,gould1 and so on4 ,poverty is a necessary foundation for a great fortune4 ,the great soldiers of the world almost without exception rose from the ranks of poverty--,napoleon1 ,washington1 ,sheridan1 ,grant1 ,sherman1 ,pershing1 ,de ,lacy in ,russia1 ,prim in ,spain1 ,o',higgins in ,chili1 ,stonewall ,jackson1 and others4 ,the powerful ,dukes of ,tetuan in ,spain came from an ,irish adventurer1 the fifth of eight sons of a poor man4 ,big families make for strength of character in the struggle for existence2 the solitary child in a family is pampered1 spoiled4 ,advocates of birth control say that ,holland has had a ,neomalthusian ,league openly operative since #ahha1 with fifty-two clinics where contraceptive information is publicly given4 ,as a direct consequence1 and solely from the work of this ,league1 ,holland has a dropping death rate and an increase in population1 and even the stature of the ,dutch has increased four inches since #ahha4 ,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 causes4 ,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 methods4 ,the assertion about the fifty-two clinics in ,holland was investigated4 ,an army officer sent out by the committee searched fourteen days before he could find even one secret birth control propaganda station4 ,the present prime minister of ,holland1 de ,beerenbrouk1 is an earnest ,catholic man1 and if anyone talks birth control in ,holland during his administration he guarantees them a long term in jail4 ,there was really a ,neomalthusian ,league with #f1gjd members1 now greatly decreased in number1 in the northern ,protestant provinces of ,holland4 ,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 true4 ,as to the increase of four inches in stature--since this is a physical impossibility the spinner of the original yarn was an ignorant romancer1 lacking plausibility in his untruth4 ,where there is birth control there are no children to increase or maintain the population1 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 control4 ,the birth control movement assumes that the world suffers from overpopulation4 ,it does not2 it suffers from incorrect distribution of populations1 and no doctrine of birth control will ever affect this fact4 ,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 stationary1 not to talk of overcrowding4 ,two children reaching maturity replace their parents1 and because of the high mortality in infancy1 and the large number of the unmarried and the birth controllers and abortionists1 four children are needed to a family to make a new generation as large as the old4 ,an average of one1 two1 or even three children to a family means a loss in population1 unless the loss is supplied1 as in the ,united ,states1 by immigration4 ,an average of five or six children means an increase in the population4 ,having none or two children to a family and relying on immigration to preserve the nations means political annihilation1 as can be readily shown4 ,in ,new ,york ,state in #aiai instead of the required four children to keep the population stationary1 as far as the native ,americans are concerned1 there was one child to every ten families4 ,the ,american nation was founded and built up wholly by ,nordic races1 immigrants from ,great ,britain and ,ireland1 ,germany1 and a few from ,france1 ,holland and ,sweden4 ,all our national traditions are from these ,nordic immigrants1 our notions of self government1 our peculiar democracy1 our constitution1 our language and literature4 ,these ,nordic peoples are dying out here in appalling numbers for two chief reasons1 one of which is birth control and the other is the ,american climate4 ,the civilization which affects us has always existed along a geographical belt reaching from the ,british ,isles to above ,rome1 and covering ,great ,britain1 ,ireland1 ,france1 ,spain1 middle and western ,germany1 and ,italy to below ,florence4 ,the ,grecian civilization was not indigenous1 but the result of a ,nordic occupation1 and it ceased centuries before ,christ4 ,huntington of ,yale and several others have shown1 by studying the production of thousands of piece workers and students over a long time1 that man does his best work physically and mentally under four climatic conditions3 a mean temperature of about sixty-two degrees ,fahrenheit for physical work and about forty degrees for mental work2 secondly1 there must be a humidity of about seventy-five per cent42 thirdly1 the climate must be variable1 be that of the belt of cyclonic storms2 fourthly1 there must be a quantity of sunlight such as that found in the ,european racial habitat of the person considered4 ,these conditions are found curiously in exactly these degrees in the civilized parts of ,europe and not elsewhere4 ,above and below that area they are lacking and there has never been any civilization where they are wanting4 ,the reason physical and mental productivity lessen annually with us in ,december1 ,january1 and ,february is because these climatic conditions are absent during these three months4 ,again1 men are differentiated into races1 thrive1 develop1 and reach and maintain mental and physical perfection within well defined climatic areas4 ,nature preserves the race that has acquired through countless ages acclimatization in a given environment1 and kills off very quickly immigrants coming from far north or south of the given latitudes4 ,the natural geographical position for the black man is from the equator to the thirtieth parallel of north or south latitude4 ,the thirtieth parallel in ,america runs through upper ,florida1 southern ,louisiana1 and the lowest third of ,texas4 ,from the thirtieth to the thirty-fifth parallel is the zone of the brown man1 like the ,malay4 ,the thirty-fifth parallel runs along the southern border of ,north ,carolina and ,tennessee1 through the middle of ,arkansas1 ,new ,mexico1 ,arizona1 and the lowest third of ,california4 ,from the thirty-fifth to the forty-fifth parallel is the zone of the brune ,mediterranean races4 ,the forty-fifth parallel passes near ,halifax1 ,bangor in ,maine1 ,ogdensburg1 ,ottawa1 and ,st4 ,paul4 ,in ,europe it runs near ,bordeaux1 ,turin1 ,bosnia1 and the ,crimea4 ,new ,york is as far south as ,naples1 ,philadelphia is sixty miles south of ,naples1 and has the sun of southern ,italy4 ,the ,nordic races that we are interested in as our origins all live above the ,united ,states1 and the summer temperatures they have been accustomed to are above the ,united ,states4 ,an immigrant coming from northern ,ireland to ,philadelphia moves southward a thousand miles2 a ,norwegian going to ,texas moves southward two thousand miles1 and his family disappears as a rule in two generations4 ,in historic times there have been sudden movements southward of ,european races for about seven hundred miles and all ended disastrously4 ,the ,lombards went south from upper ,prussia to middle ,italy at the level of ,boston and disappeared in two hundred years4 ,the ,teutonic ,goths went from the ,baltic to ,italy and ,spain4 ,they lasted sixty-two years in ,italy4 ,eighty thousand ,vandals with their families went down from ,brandenburg to ,north ,africa at the level of ,virginia4 ,they were annihilated by the climate in one hundred and eight years4 ,the ,burgundians disappeared in sixty years from ,greece1 as the ,celts who had carried the ,homeric sagas to ,greece also disappeared4 ,rome was great while the ,nordic ,cisalpine ,celt ruled it1 and died forever with the ,celt4 ,italian art ended at ,florence1 the southern boundary of ,cisalpine ,gaul4 ,the ,slav disappeared the same way from southeastern ,europe and left only language traces to the ,turanian and ,semite there4 ,no ,european race of pure blood has ever had grandchildren in the tropics4 ,the northern races of ,europe die out with amazing rapidity in the northern ,united ,states4 ,the ,irish death rate at the level of ,new ,york is double the death rate in ,ireland under much worse economic conditions2 the death rate of the southern ,italian and the southern ,russian is much better in ,new ,york than it is in their ,european racial habitats4 ,in #aiaj our ,english immigration was only six per cent4 of the whole1 and the ,irish immigration is now negligible because there are no more people in ,ireland to leave it1 but we have seven million ,slavs who came in during the ten years before the war4 ,we have three million southern ,italians1 three million ,poles1 and hundreds of thousands of nondescript folk from all the back alleys of the old world4 ,at an army camp in ,massachusetts during the late war there were thirty languages other than ,english spoken1 and seven thousand men there never had heard the term ,anglo-,saxon4 ,the extreme southern1 eastern1 and southeastern ,european hordes are overwhelming us1 and these hordes never knew a single political principle that even remotely resembles what we understand as ,american principles4 ,they come of races who were ruled1 if they had any rule at all1 by despots1 but we shall make ,anglo-,saxons1 ,americans1 or whatever you like to call the final metamorphosis we effect1 out of these barbarians4 ,never6 ,even in a millenium4 ,centuries from today the ,slav here will be a ,slav1 the ,sicilian a ,sicilian1 the ,russian a ,russian1 all with a veneer of ,american slang on the tongue of an eternal racial character4 ,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 yet4 ,the ,nordic peoples die out here4 ,only the dark-skinned southern ,germans last with us2 the sun kills out the red and blond in two or three generations4 ,i recently went over fifty ,irish families which ,i knew perfectly1 and they have degenerated eighty-six per cent4 numerically and otherwise in my own lifetime3 killed off by the climate which keeps our southern states empty of white men4 ,by two ,american censuses and one ,english we know that fifty per cent4 of ,washington's army was born in ,ireland1 but there are no ,irish in the revolutionary societies because the ,revolutionary ,irish have disappeared4 ,if there is any chance at all for our civilization1 flimsy as it is1 this world must be ruled by the ,nordic ,european races1 not by the southern1 eastern and southeastern ,european barbarian ,semite4 ,we must rule for our own sake and for their sake2 they can not rule anything4 ,if we do not rule them1 then welcome the final curtain as soon as possible4 ,how can we rule ,america1 not to think of the rest of the world1 unless we have ,nordic children to take our place1 and how can we have such children if we let sex-brained misfits run about spreading contraceptive drivel8 ,the rascal that preaches such doctrine is a traitor to ,america1 the worst enemy our country ever has had1 more treacherous than any spy that sneaked in among us during the war just past4 ,the ,french have had their lesson in birth control1 and we should learn from their misfortune4 ,in the first six months of #aiad when ,europe was still at peace the total number of births in ,france was #cha1cih2 a decrease of #d1jjj on the year #aiac4 ,at the same time the deaths increased #bj1hde4 ,thus the population of ,france during the first six months of #aiad decreased #bd1haf4 ,for the past thirty years the birth rate of that country has steadily decreased by contraceptive methods1 while the death rate has increased proportionately to the number of inhabitants4 ,january1 #aiaf1 found ,france with about seven hundred thousand less people than she had in ,january1 #aiad1 and then came the horrible carnage of the great war4 ,no matter what change of heart war may bring to ,france no increase in her population can be expected for many years yet to come4 ,she is daily crying out to the world for treaties to protect her from ,germany1 despite the prostration of ,germany1 because she knows ,germany had a birth rate of two males for her one1 and for twenty years to come ,germany probably can put twice as many men into the field as ,france can4 ,if ,france will give over her unclean birth control she will not need to whine for protection4 ,the advocates of birth control assert that it lessens venereal diseases4 ,it does not2 it increases the spread of venereal disease4 ,the more reasonable among the birth control propagandists are anxious lest their public talks suggest temptation to the young4 ,there is at present for youth the deterrent of the natural consequences of lust2 with birth control knowledge spread broadcast that check is removed and promiscuity will become more general1 because safer socially4 ,venereal diseases will spread also as incontinence spreads4 ,nowhere in the world has the crime of birth control been practised as in ,france nor for a longer time1 and in that country together with the lowest birth rate in the world there is the highest death rate from venereal diseases according to ,dr4 ,dublin the statistician of the ,new ,york ,metropolitan ,life ,insurance ,company4 ,not long ago one of the leading medical writers of ,france1 ,doyen1 said in the ,academy of ,medicine in ,paris that syphilis is the chief cause of death in ,france4 ,france now asserts she has given over birth control1 but that is a hard disease to cure after it has been established4 ,unchastity is its own punishment1 and if ,france goes the way of those nations that have died along the pathway of civilization1 and great would be the pity1 she has nothing to blame for it but this abominable moral leprosy1 birth control4 ,she is as striking an example of the insanity of birth control as ,russia is of the insanity of communism4 ,,index ,abnormal pelves1 #acc1 #acd1 #ace ,abortion1 #ia after fifth month1 #ajb agents of1 #aag ,american law on1 #aai causes of1 #ib civil law on1 #aba ,council of ,lerida on1 #aae ,council of ,worms on1 #aae decretal of ,gregory on1 #aae direct1 #aji excommunication for1 #aaf1 #aag ,gregory ,,xiv on1 #aaf habitual1 #ih ,holy ,office decrees on1 #aah homicide in1 #aaj incomplete1 #aja inevitable1 #aja irregularity and1 #aag morality of1 #aji-aad morphine in1 #aja paternal causes of1 #ie ,pius ,,ix on1 #aaf precautions against1 #aje1 #ajf prognosis after1 #ajj sepsis after1 #aje ,sixtus ,v on1 #aae statistics of1 #ig1 #ih symptoms of1 #ii syphilis and1 #ajg tampon1 use of1 #ajc therapeutic1 #ajg1 #aji threatened1 #ii treatment of1 #ajb violence and1 #id ,abruptio placentae1 #add causes of1 #add effects of1 #add ,acute yellow atrophy of the liver1 #ahf ,aggressor1 #ag1 #ai ,amnion1 #eb ,amphiaster1 #dd ,anaesthesia and the fetus1 #ic ,analgine1 #bdj ,animal heat1 #ga ,animal life1 #dh ,animation1 #cc1 #ci ,aristotle on1 #ci biologists on1 #di ,conklin on1 #gc ,fienus on1 #ce ,greek fathers on1 #cc ,greek philosophers on1 #cc ,st4 ,alphonsus on1 #ci ,st4 ,anselm on1 #ce ,st4 ,augustine on1 #cd ,st4 ,gregory of ,nyssa on1 #ce ,st4 ,thomas on1 #ce ,zacchias on1 #cf ,aortic stenosis in pregnancy1 #age ,apparent death1 #hb ,appendicitis in pregnancy1 #aeb ,archenteron1 #ej ,artificial impregnation1 #beh ,attraction sphere1 #dj ,baer on twilight sleep1 #bdj ,baptism of monsters1 #hj ,beginning of life1 #cc ,blameless defence1 #ah ,blastocyst1 #ej ,blastulas1 #ej ,braxton-,hicks version1 #adc ,bright's disease in pregnancy1 #aeg ,broad ligament1 #abd ,cancers in pregnancy1 #adi morality of operation1 #aej ,canonical irregularity1 #bc1 #bd1 #be ,capital punishment1 #ca ,carrington's vasectomies1 #bdh ,catalepsy1 #he in pregnancy1 #afj ,cell1 #dj bridges1 #fj differentiation1 #fg1 #fh division1 #da1 #db heredity1 #de life1 #dh motion1 #gj reduction1 #de union1 #fe1 #ff ,centrosome1 #dj ,cesarean delivery1 #acb amputation of the uterus after1 #ach indications for1 #acb morality of1 #acf1 #acg repeated sections1 #adj sterilizations and1 #aci1 #adj1 #ada ,chemico-vital changes1 #gj1 #ga ,cholera in pregnancy1 #aie ,chorea gravidarum1 #aha ,chorion1 #ea ,chromosome1 #db numbers of1 #dc ,chromatin1 #da ,circumstances1 #c ,citizen as member of the ,state1 #ca ,coelom1 #ea ,coition in gestation1 #ie1 #if1 #ig ,congenital tuberculosis1 #ahi ,conscience1 #ab ,constitution ,effraenatam1 #aae ,contingent being1 #a ,contracted pelves1 #acc ,craniotomy and excommunication1 #aag ,dmmerschlaf1 #bca ,death1 signs of1 #hi1 #ij ,de ,lugo on the ,state1 #ca ,development of the body1 #ef ,diagnosis1 percentage of correct1 #ba ,diabetes in pregnancy1 #bbi ,differentiation by position1 #fh1 #fi ,division1 direct and indirect1 #db ,double effects1 #ah1 #bf ,double monsters1 #gh1 #gi ,dry labor1 #aji ,eclampsia parturientium1 #afa abortion in1 #afe expectant treatment of1 #aff forced delivery in1 #afe mortality1 #afc1 #afh ,lichtenstein's method in1 #aff precautions against1 #afd symptoms of1 #afa veratrum viride in1 #afg ,ectoderm1 #ej derivatives of1 #ea ,ectopic gestation1 #abc decrees of the ,holy ,office on1 #abh1 #abi diagnosis of1 #abf1 #abg morality of operations1 #abi1 #acj ,effects of an action1 #f ,egg shell1 #dg ,embryo1 #cc growth of1 #ej stages of1 #eb ,end of an action1 #d ,end of life1 #hb ,endoderm1 #ej ,endometritis1 #ic ,entelechy1 #fj ,erysipelas in pregnancy1 #aif ,eunuchs1 #bee1 #bef ,euthanasia1 #a ,fallopian tubes1 #abc ,fecundation1 #abd ,fetus1 #cc and the dead mother1 #hg at term1 #ed months1 #ec1 #ed1 #ee stages1 #ec ,fibrillation1 #agd ,fibroids1 #adf ,fission theory1 #gg ,form1 #fj ,gemmule theory1 #eh ,germ cells1 #dd ,god's existence1 #b ,gonorrhoea in marriage1 #baa abortion and1 #bbd blindness and1 #bbf conservative surgery for1 #bag effects1 #bab1 #bac1 #bae1 #baf1 #bbe1 #bbf operations for1 #baf professional secret and1 #bab tests of cure1 #baa treatment by heat1 #bbh ,good1 #c ,grippe1 #aid ,happiness1 #b ,hastening of death1 #aaa ,hebosteotomy1 #ace ,heart beat1 #hc ,heart block1 #agc ,heart diseases in labor1 #agb1 #agd ,heart diseases in pregnancy1 #afi ,mayo clinic on1 #agc ,heart1 origin of1 #eb ,homicide1 #ac accidental1 #ai arguments against1 #ad1 #ae1 #af1 #ag bibliography of1 #bb direct and indirect1 #ac self-defence and1 #ag1 #ah1 #ai ,human terata1 #gh ,hyperemesis gravidarum1 #agf ,hysteria1 imitative1 #ahc major and minor1 #ahd marriage and1 #ahe in pregnancy1 #aha1 #ahb1 #ahc ,icterus gravis1 #ahf ,impotence1 #beh opinions on1 #beb ,infectious diseases in pregnancy1 #ahh ,influenza in pregnancy1 #aid ,insanity1 puerperal1 #aed spread of1 #bff ,kant on morality1 #bi ,karyokinesis1 #da ,la grippe in pregnancy1 #aid ,law1 definition of1 #bh ,life in separated tissues1 #gc1 #gd ,malaria in pregnancy1 #aif ,male generative system1 #bdh ,male pronucleus1 #di ,maniacal chorea1 #ahb ,marriage1 end of1 #bed ,mayhem1 #bc ,means of an action1 #e ,measles in pregnancy1 #aie ,mesoderm1 #ej ,metabolism of the cell1 #fi1 #gj1 #gb ,metaphases of mitosis1 #dd ,midwives1 #ach ,mignonette case1 #aac ,mitosis1 #da ,miscarriage1 #ia ,mitral regurgitation in pregnancy1 #agd ,monsters1 #ge by displacement1 #gh multiple1 #gf ,morality1 #c determinants of1 #c ,morphine1 effects on fetus1 #bcd effects in labor1 #bcd1 #bce ,morula1 #ej ,mutilation1 #bc argument against1 #bf1 #bg argument for1 #bg civil law on1 #bc direct and indirect1 #bf ,molina on1 #bd ,st4 ,alphonsus on1 #be ,state and1 #bh1 #bi1 #cj1 #ca1 #cb self-mutilation1 #bf ,suarez on1 #bd ,myomata in pregnancy1 #adf effects of1 #adg fetus and1 #adh mortality of1 #adg ,natural law1 #b1 #ab ,necessary being1 #a ,nephritis in pregnancy1 #aeg treatment of1 #aeh varieties of1 #aeh ,nervous system1 #ea ,nucleus1 #dj1 #df ,object of an action1 #c ,onanism1 #bef ,operations during pregnancy1 #id ,operative risk in cardiopaths1 #agc ,ophthalmia neonatorum1 #bbf1 #bbg1 #bbh ,organs1 origin of1 #ea of the body1 #fd ,ovaries1 removal of1 #bah1 #bbc resection of1 #bba ,ovarian tumors in pregnancy1 #adh ,ovarian1 #bdg ,ovariotomy1 decrees of the ,holy ,office on1 #beb1 #bec effects of1 #bai impotence and1 #beb1 #bed1 #bee psychoses after1 #bai1 #bbj1 #bba ,ovum1 #cc1 #dg ,oxidation1 #gb ,pangens1 #fh ,paresis1 #bjd ,parturition1 #afi1 #bca1 #bcb1 #bcc ,partus cesareus1 #acb ,pathogenesis1 #dh1 #di ,pelvic diameters1 #acb ,penal law1 #ca ,pernicious vomit of pregnancy1 #agf abortion for1 #ahj causes and symptoms1 #agg diagnosis of1 #agi treatment1 #agi ,pituitrin1 #agj ,placental infection1 #ahh ,placental osmosis1 #ahi ,placenta praevia1 #adb ,plastid1 #dj ,pneumonia in pregnancy1 #aib1 #aic ,polak's operation on the tubes1 #bbb ,polar body1 #df ,porro's operation1 #acf ,preformationists1 #ef ,premature infants1 #ee ,premature labor1 #ih1 #ajh ,probabilism1 #f ,prophases of mitosis1 #dd ,protoplasmic bridges1 #fg ,puerperal insanity1 #aed prognosis1 #aee sterilization and1 #aed ,pyelitis in pregnancy1 #afj ,quacks1 #bb ,resuscitation1 #hc1 #hd methods of1 #hh ,right and wrong1 #c ,rupture of ,fallopian tube1 #abe ,sacraments in apparent death1 #hb ,salpingectomy1 #bag ,salpingostomy1 #bag ,salpingotomy1 #bag ,scarlatina in pregnancy1 #aie ,scopolamine1 #bcc ,secrets1 #bjf1 #bjg ,segmentation cavity1 #ej ,segmentation nucleus1 #di ,self-defence1 #ag1 #ah ,semen1 #bdg ,sixtus ,v1 bull of1 #bee ,smallpox in pregnancy1 #aia ,soul1 #fj ,spaltungstheorie1 #gf ,spermatozon1 #df1 #dg1 #dh ,spermin1 #bdg ,spindle1 #dd ,spireme1 #dc ,state1 citizen and1 #cj dominion of1 #bh1 #bi end of1 #bi ,sterilization of women1 #bea ,substantial form1 #fj1 #fb1 #ge ,suicide1 #g arguments against1 #g-ab ,suspended animation1 #he ,syncytium1 #eb1 #ff ,symphyseotomy1 #ace ,syphilis1 abortion in1 #bjj curability of1 #bjc fetal1 #bja incurability of1 #bjd marriage and1 #bje nervous system affections1 #bjd pregnancy in1 #bjj1 #bjb professional secret in1 #bjf ,tabes1 #bjd ,telophases in mitosis1 #dd ,terata1 #ge ,tetrads1 #df ,tocanalgine1 #bdj ,tonics1 #dh ,traducianism1 #cd ,trophoblast1 #ej ,tubal abortion1 #abe ,tuberculosis in pregnancy1 #aif1 #aig1 #aih ,tumors in pregnancy1 #adf ,tumors and premature labor1 #aji ,twilight sleep1 #bca authorities opposed to1 #bch1 #bci effects of1 #bdj1 #bda1 #bdb1 #bdc methods used1 #bce1 #bcf1 #bcg ,twins1 #gf ,two-celled stage of the embryo1 #fe ,typhoid in the fetus1 #aij ,typhoid in pregnancy1 #aif ,typhus in pregnancy1 #aif ,unity of the soul1 #fe ,uterine adnexa1 #abc ,uterus1 abnormalities of1 #abd anatomy of1 #abc ,vaccination1 #aia ,vas deferens1 restoration of1 #bdi1 #bej ,vasectomy1 #bdd arguments against1 #bfj-bfe bibliography1 #bff1 #bfg bull of ,sixtus ,v and1 #bee1 #bef effects of1 #bdh1 #bdi grave mutilation1 #bei hereditary disease and1 #bfd impotence and1 #bea morality of1 #bei not a punishment1 #bfc1 #bfd operation for1 #bdg reasons for the operation1 #bde1 #bdf ,state and1 #bdd ,state surgeon and1 #bfe ,venereal diseases1 prevalence of1 #bac1 #bad1 #bae ,verwachsungstheorie1 #gf ,viability of the fetus1 #ed1 #aad ,vital principle1 #eh1 #fa ,vital processes1 #fi ,weak pains1 #aga ,weismann's theories1 #di1 #ef ,yellow atrophy of the liver1 #ahf ,yolk sac1 #eb 7,think7 ,thoughts are the ,masters and the ,thinkers are the ,doers4--,confucius4 ,one of the most successful of teachers is a ,montreal ,principal--successful because she insistently teaches undergraduates to ,,think4 ,force of thought is better than force of will4 ,a triphammer is all force1 but unless guided by a ,,thinker strikes a pile or a cream-puff with equal power4 ,then there is the nagger with a tongue-will of poiseless perpetual power but--thought-proof4 ,do you as host1 hostess or guest want a spur to cleverness of thought1 wit and repartee8 ,do you fail in clearness of thought and expression--especially in conversation8 ,do you teach1 preach--or lecture8 ,do you dictate at home787 at office--or both8 ,do you want to give straight-to-the-point advice to your children1 your friends1 your employees and ,,yourself8 ,if an employer you will commend ,,keystones ,,of ,,thought to your employees--surely to the stenographers4 ,if easily discouraged1 a victim of worry1 fear1 the blues1 ,keystones is your prescription4 ,is ,christianity a ,failure8 ,have you an active or passive grouch against the clergy 7a now fashionable disease usually confined to the middle aisle7 because of what they say and do and because of the way they live8 ,do you want something to crib for public dinners and other occasions8 ,the greatest after-dinner speaker in the world is a ,new ,yorker4 ,never lengthy1 always aphoristic1 he says more in five minutes than all the wax-works on the dais drone or spout in hours4 ,,then ,,read ,,keystones of ,,thought ,by ,,austin ,o',,malley1 ,m4,d41 ,ph4,d41 ,,ll4,d4 ,the only book of original and genuine aphorisms in ,english4 ,written by the ,world's master of aphoristic thought and expression4 ,the successful aphorist is about ten thousand times scarcer than the successful essayist1 or story teller1 or ,assyriologist4 ,humor without effort1 wit without bitterness1 philosophy without pretension6 ,dr4 ,o',malley has written a book that is worth possessing4--,from a review of the book written by the editor of the ,n4 ,y4 ,sun himself4 ,special gift book edition1 sude1 gold edges1 in box--a very useful ornament for ,den1 ,desk1 or ,drawing ,room1 #d4jj net1 ,postpaid4 ,cloth1 gold letters and design1 #b4jj net1 ,postpaid4 ,,note3 ,whether young or old1 ,sage or ,seer1 ,poet1 ,philosopher1 or what-not1 if you think ,,you can match ,,keystones ,,of ,,thought in aphoristic originality1 in depth1 deftness1 wit1 wisdom and humor--in tonic-cheer for all of life's worries1 troubles and adversities1 you are welcome to try4 ,if successful ,the ,devin-,adair ,company will send you a check for an acceptable but well-earned sum1 and your work will be promptly published4 ,,the ,,devin-,,adair ,,company1 ,publishers #dcg ,,fifth ,,avenue1 ,,new ,,york 99 99 99 99 99 ,transcriber's note3 ,variations in spelling1 punctuation and hyphenation have been retained except in obvious cases of typographical error4 ,the symbol of a ,maltese cross precedes ,,john ,,cardinal ,,farley4 ,page #aea3 #c4 ,the case may be inoperable and the child inviable4 ,the word be was added by the transcriber4 ,page #aid3 ,footnote #ade ,ibid41 #aigj1 vol4 l1 pp4 #dcj1 #eaf1 and vol4 li1 p4 #aa4 ,the transcriber has changed #aigj changed to #ahgj4 ,page #bae3 ,a missing anchor was added by the transcriber for ,footnote #agj ,new ,york ,med4 ,jour41 ,november #ab1 #aiaj4 ,page #bbb ,footnote #ahe ,correspondenz-,blatt f4 ,schweizer ,aertze ,the transcriber has changed ,aertze to ,aerzte4