The ethics of medical homicide and mutilation

THE ETHICS

OF

MEDICAL HOMICIDE

AND

MUTILATION

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

NEW YORK
THE DEVIN-ADAIR COMPANY

1922

tl obstat

ARTHUR J. SCANLAN, S.T.D.

Censor Librorum

imprimatur

JOHN CARDINAL FARLEY

Archbishop of New York

Copyright, 1919, by
THE DEVIN-ADAIR COMPANY

All Rights Reserved by
The Devin-Adair Company

Third Printing

PRINTED IN U. S. A.

CONTENTS

CHAPTER I

GENERAL PRINCIPLES CONCERNING SUICIDE AND HOMICIDE

PAGE

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

CHAPTER II

GENERAL PRINCIPLES CONCERNING MUTILATION1

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

CHAPTER III

WHEN DOES HUMAN LIFE BEGIN?

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

CHAPTER IV

WHEN DOES HUMAN LIFE END?

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

iv CONTENTS

ABORTION

PAGE

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

CHAPTER VI

ECTOPIC GESTATION

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

CHAPTER VII

CESAREAN DELIVERY

Indications for cesarean delivery. Abnormal pelves. Sym-
physeotomy. Varieties of cesarean delivery. Morality.
Amputation of the uterus after cesareau delivery. Pre
cautionary sterilization of a cesarean case is illicit .133-142

CHAPTER VIII

PLACENTA PRAEVIA AND ABRTJPTIO PLACENTAE

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

CHAPTER IX

ABDOMINAL TUMORS IN PREGNANCY

Tumors blocking parturition. Fibroids or myomata. Ovarian

tumors. Cancer. Effects and morality of operation .147-152

CONTENTS v

CHAPTER X

APPENDICITIS IN PREGNANCY

PAGE

Occurrence. Time of operation. Diagnosis . . 9 JL53-154

CHAPTEE XI

PUERPERAL INSANITY AND STERILIZATION

Causes. Varieties. Prognosis. Precautionary sterilization of

puerperal psychopaths is illicit 155-157

CHAPTER XII

NEPHRITIS IN PREGNANCY

Frequency. Effects. Abortion as a treatment. Varieties of

nephritis. Pyelitis. Catalepsy .... .158-161

CHAPTER XIII

ECLAMPSIA PARTURIENTIUM:

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

CHAPTER XIV

HEART DISEASES IN PREGNANCY

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

CHAPTER XV

HYPEREMESIS GRAVIDARUM

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

vi CONTENTS

CHAPTER XVI

CHOREA GRAVIDARUM AND HYSTERIA

PAGE

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

CHAPTER XVH

ACUTE YELLOW ATROPHY OF THE LIVER IN" PREGNANCY

Icterus gravis. Causes. Symptoms. Prognosis . . .187-188
CHAPTER XVIII

INFECTIOUS DISEASES IN PREGNANCY

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

CHAPTER XIX

SYPHILIS IN PREGNANCY AND MARRIAGE

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

CHAPTER XX

GONORRHOEA IN MARRIAGE

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

CONTENTS vii

CHAPTER XXI

DIABETES IN PREGNANCY

PAGE

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

CHAPTER XXII

CHILDBIRTH IN TWILIGHT SLEEP

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

CHAPTER XXIII

VASECTOMY, OR STERLIZATION, BY STATE LAW

The States that have this law. Reasons for the law. Hered
itary transmission of certain diseases. The operation.
Its effects. Restoration of the function of the inter
rupted vas deferens. Vasectomy and impotence. On-
anism. Vasectomy effects impotence from the moral
point of view. Other conditions in the male that effect
moral impotence. Immorality of artificial impregna
tion. Vasectomy a grave mutilation. Vasectomy as or
dinarily practised is illicit. The State and vasectomy.
The limitations of the State's dominion. The State sur
geon and vasectomy. Bibliography . . . .245-268

CHAPTER XXIV

THE ETHICS OF BIRTH CONTROL 269

Index 281

PREFACE

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

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

Obstetrical text-books, unfortunately, are written by such
emotional men; by men who lack all training in ethics other
than that inculcated in childhood out of the mental vagaries
of the women in the household; and these authors prescribe
therapeutic homicide as if it were a drug in the American
Pharmacopoeia. The reader is told that if the patient is a
Catholic he is to respect her religious "prejudices"; if she is
not a Catholic one need not bother about moral scruples when
it is necessary to take a life to stop fits. Since the civil law
does not prosecute a physician for therapeutic abortion on an

PREFACE

inviable child, most physicians deem such an act not only per
missible but scientific, and they hold that if a man's conscience
will not let him kill a fetus to alleviate maternal distress he
is guilty of malpractice.

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

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

AUSTIN O'M ALLEY.

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

By its very definition such a Being is necessary (as op
posed to contingent), self-existent; its essence always has
been and always will be actualized into existence, and that
from itself alone; it is an individual substance of an intel
ligent nature, and therefore a person. A contingent being
is one that happens to be (coniingere) ; it is of necessity
neither existent nor non-existent; it has no logical aversion
to existence, but in itself it has no more than a possibility

1

2 THE ETHICS OF MEDICAL HOMICIDE

of actuality. A necessary Being, on the contrary, essentially
must be ; it cannot not be ; it is absolutely and essentially its own
existence.

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

From the relation between the Creator and the creatures
arises the natural law. Violation of this law is the source
of all moral evil in the world, and of much of the physical
evil. Reason shows us this law, and the method of observing
it; and reason and unreason, observance or disregard, of the
order fixed by the natural law are the foundation of happi
ness and unhappiness. Whatever a human being is or does,
he must seek happiness; that is an essential quality of his
being. Happiness is the satisfying of our desires; but as
our desires are limitless, only infinite good can satisfy them.
The sole sufficient good that sates all human longing is the
infinite Necessary Being, and to be happy we must be united
with that Being. Obviously the only possible method of pos-

GENERAL PRINCIPLES CONCERNING HOMICIDE 3

sessing this infinite God is through mental union, by undis-
turbable contemplation of his infinite truth, goodness, being,
beauty, and his other attributes. If perfect, everlasting hap
piness is not in that, in what can it be ? Is it in human fame,
honor, riches, science, art, man, woman, or child? None of
these can give lasting happiness, and no other happiness is
real happiness.

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

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

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

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

1. The term object has various meanings, but here it

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

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

3. The end also determines the morality of an action.
Since the end is the first thing in the intention of the agent,

GENERAL PRINCIPLES CONCERNING HOMICIDE 5

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

The means used to obtain an end are very important in a
consideration of the morality of an act. There are four classes
of means — the good, bad, indifferent, and excusable. Good
means may be absolutely good, but commonly they are liable to
become vitiated by circumstances, — almsgiving is an example.
Some means are bad always and inexcusable — lying, for in
stance. The excusable means are those which are bad, but
justifiable through circumstances. To save a man's life by
cutting off his leg is an excusable means. The end some
times may vitiate or hallow indifferent means, but it does not
in itself justify all means. Means, like other circumstances,
are accidents of an action, but they are in the action just as
much as color is in a man. Color is not of a man's essence, but
we cannot have a man without color.
1 Ethics, v, c. 2.

6 THE ETHICS OF MEDICAL HOMICIDE

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

The doctrine of Probabilism is very important in morality.
Any law must be promulgated before it really becomes a law,
and promulgation in a rational conscience is sufficient. Some
times there is rational doubt of the existence, the interpreta
tion, or the application of a law in a given case. Here prob
ability is the only rule we can follow. A law which is doubtful
after honest and capable investigation has not been sufficiently
promulgated, and therefore it cannot impose a certain obliga
tion because it lacks aii essential element of a law. When we
have used such moral diligence as the gravity of the matter
calls for, but still the applicability of the law is doubtful in
the action in view, the law does not bind; and what a law
does not forbid it leaves open. Probabilism is not permissible
where there is question of the worth of an action as compared
with another, or of issues like the physical consequences of an
act. If a physician knows a remedy for a disease that is cer
tainly efficacious and another that is doubtfully efficacious, he
may not choose this probable cure. Probabilism has to do
only with the existence, interpretation, or applicability of a
law, not with the differentiation of actions. The term prob
able means provable, not guessed at, not jumped at without
reason. The doubt must be positive, founded on reason, not
a matter of mere ignorance, suspicion, emotional bias. The
opinion against a law to permit probabilism must be solid. It
must rest upon an intrinsic reason from the nature of the case,
or an extrinsic reason from authority, always supposing the
authority is really an authority. The probability is to be com-

parative also. What seems to be a very good reason when
standing alone may be weak when compared with reasons on
the other side. When we have weighed the arguments on both
sides, and we still have a good reason for holding our opinion
in a doubtful case, our opinion is probable. The probability is,
moreover, to be practical. It must have considered all the cir
cumstances of the case.

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

St. Thomas,2 Lessius,8 and others offer as one argument
to prove suicide is not licit, that it is an injury to society
or the state of which the suicide is part, and to which the use
and profit of his service rightly belong. Lessius, while de
veloping this proof, acknowledges its weakness.

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

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

St. Thomas 4 argues against suicide because it is contrary
to the charity a human being should have for himself. This

2 Summa Theologica, 1, 2, q. 64, a. 5.

3 De Justitia et Jure, lib. 2, cap. 9.
•/bid.

8 THE ETHICS OF MEDICAL HOMICIDE

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

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

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

Suicide is the direct killing of oneself on one's own author-

GENERAL PRINCIPLES CONCERNING HOMICIDE 9

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

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

Direct suicide on one's own authority may happen in two
ways: positively, that is, by doing an act which is directly
homicidal ; or negatively, by omitting an act necessary for the
preservation of life. That a negative homicide be direct,
death must be intended as an end or means. If, however, one
voluntarily intends an end or a means, but for the sake of
antecedent good or evil omits some act necessary to preserve
life, his suicide is indirect, per accidens, and not always illicit
unless there is a precept against just such an omission. Man
has no dominion over his own life, he has only the use of it;
and the natural law obliges us while using a thing which is
under the dominion of another not to omit ordinary means for
its preservation. "We are not, however, held to extraordinary

10 THE ETHICS OF MEDICAL HOMICIDE

means. His own death is criminally imputable to him who
negatively and indirectly kills himself by omitting the or
dinary means for preserving his life, because the precept he
is under to preserve his own life makes his act voluntary. If
he omits extraordinary means, the death is not criminally im
putable to him because there is no precept obliging such means.
Certain circumstances may by accident oblige one to use ex
traordinary means to preserve one's own life — a dependent
family, a public office in perilous times, or the like. The
proposition, then, is: The natural law does not give a man
absolute dominion over his own life.

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

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

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

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

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

The natural law is only an ordination of man to that com
mon end of human life and to the means toward that end. As
regards the minor of this second argument, an absolute domin-

GENERAL PRINCIPLES CONCERNING HOMICIDE 11

ion over his own life would give man power to stop all his
human activity, yet the common end of human life is attain
able only hy man's activity. The stopping, or the power of
stopping, all activity cannot he a means to that end.

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

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

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

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

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

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

God, who should have absolute dominion over all creatures,
and who has, wills to confine these creatures to certain lines of

12 THE ETHICS OF MEDICAL HOMICIDE

action in keeping with the creature's nature. This is the law
underlying even the moral law when it touches humanity; it
is the eternal law coeternal with God's decree of creation, but
not necessary as God is. When this law exists in the mind
of God it is the eternal law; when it exists in the minds of
creatures it is the natural law, governing the free acts of intel
lectual creatures. When the natural law becomes a motive to
the human will, obliging but not forcing it, a law through
knowledge within the consciousness of a man regulating his
behavior, it is called the law of conscience.

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

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

The ultimate tendency of man is toward happiness, and,
of course, happiness, or any other perfection, is impossible
without existence; hence the instinctive recoil from the de
struction of our life, which is the requisite condition for hap
piness. Even those that abnormally destroy their own life do

GENERAL PRINCIPLES CONCERNING HOMICIDE 13

so with horror for the destruction itself, and act thus unrea
sonably to escape evil, not to escape life; or they seek what
they think will be a better life. We can do no other injury
to a man so great as the depriving him of his life, for that
deprivation destroys every right and possession he has. He
can recover from all other evil, or hold his soul above every
other evil, but death is the absolute conqueror. No matter how
debased or how diseased a man's body may be, no one may
dissociate that body from its soul, except in defence of in
dividual or social life under peculiarly abnormal conditions;
but even such defence is permissible only while the defender
respects other human life and the social life, while he is in
nocent, has done no harm to society commensurate with the loss
of his own life.

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

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

It is not permissible under any possible circumstance
directly to kill an innocent human being. By killing directly
is meant either (1) as an end desirable in itself, as when a
man is killed for revenge; or (2) as a means to an end. By
an innocent human being is meant a person who has not by

14 THE ETHICS OF MEDICAL HOMICIDE

any voluntary act of his own done harm commensurate with
the loss of his own life.

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

The end of our struggles, toil, fortitude, temperance, thrift,
is freedom, — freedom to do and to hold, freedom from the
thraldom of vice and barbarity. The rational endeavor of
every civilized nation is that it be free; and this means solely
that every citizen thereof, from the highest to the lowest, is
made secure in his rights as a human being. It intends that
justice should prevail. Nearly all the unhappiness, crime,
moral misery, and much of the physical misery in the world
are due to a disregard for liberty, for the safeguarding of men
in their inalienable rights. Give every man his bare rights as
a man and all troubles of capital and labor, all race problems
would cease, the prisons would be empty, war would be un
known. Our struggle toward justice, toward the protection

GENEEAL PRINCIPLES CONCERNING HOMICIDE 15

of the rights of man, toward liberty, must go on, or anarchy
and social destruction will ensue. Now, as there is nothing
greater and nobler than liberty, the freedom of the sons of
God to do what they have a right to do, and as every human
being has a right to that liberty, so there is nothing baser than
its contrary, the destruction of that liberty; and no destruc
tion is so final as that of killing the man, no usurpation so
abhorrent to human nature and all liberty. Abhorrence for
such a destruction is the primal instinct of all human beings;
even the irrational reflexes of our bodies react quickest in pro
tecting us from that destruction.

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

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

Suppose two swimmers, Peter and Paul, are trying to save
Thomas, who dies in the water ; as he dies Thomas grips Peter
and Paul so tightly that they cannot shake the corpse off. Peter
is weak, and he will soon sink and drown, owing to his weak
ness and the weight of the corpse; Paul also will go down
later, owing to the weight of Peter and Thomas. Peter, how
ever, cuts his own clothing loose from the grip of the corpse
and is saved; but Paul immediately is drowned, owing to the
fact that the full weight of the corpse comes upon him. Js
Peter justified in cutting himself loose? Certainly he is.
This is an example of indirect killing, a case of double effect,

16 THE ETHICS OF MEDICAL HOMICIDE

one good, the saving of Peter's life, the other evil, the loss of
Paul's life, both proceeding immediately and equally from
the causal act, the cutting loose of the clothing. The good
effect is intended, the bad effect is reluctantly permitted.

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

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

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

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

intention of the blow would have to be solely to loosen Paul's
hold.

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

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

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

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

18 THE ETHICS OF MEDICAL HOMICIDE

defence is not based on the ill will of the aggressor, but on
the illegitimate character of the aggression.

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

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

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

The act in the case is good in itself; it is an application
of physical force in defence of a proper right, and any right
supposes a compulsive power. The two effects of this double-
effect act are: (a) the preservation of the defender's life, and
(6) the death of the aggressor. The first effect is good because
the defender has a right to his own life ; the other effect is evil,
not only physically for the one who dies, but morally inasmuch
as the death conflicts with the dominion of God. This death,
however, is an accidental effect of the act, because in general
the defensive act is not directed by its nature to that death
but to the preservation of the defender's life; nor does the
death follow more immediately than the preservation. Thus it

is not a means of the defence. Finally, the defensive act is
not prohibited precisely lest that death follow: not in justice,
for there is no justice in any right of the aggressor which re
quires from the defender an omission of defence unto the loss
of life; there is no obligation in charity, since charity does not
oblige us to love another more than ourselves, or to exalt the
good of another above our own.

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

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

We may kill an unjust aggressor, servatis servandis, in de
fence of good equivalent in value to life: for example, to pre
vent life imprisonment, the loss of reason, a mutilation which
would render us useless, the loss of a woman's chastity.

There are cases of accidental homicide, in medicine and
elsewhere, which have an element of guilt in them. If a death
follows accidentally upon an act which in itself is licit, and
the agent uses all proper precautions, he is not morally guilty
in case of an accidental death following, his act. This is true
even if the agent foresaw a probable death but did not intend
it. If, however, the agent's primary act is illicit in itself,
and an accidental death follows from this act, the agent may
be guilty of homicide, provided the first act in itself is natur-

20 THE ETHICS OF MEDICAL HOMICIDE

ally likely to cause homicide. Should the first act be always
dangerous, such that death commonly follows from it, like
rocking a row-boat, aiming a supposedly unloaded gun at a
person and pulling the trigger, striking a pregnant woman,
drinking whiskey and then overlying an infant in the bed,
throwing building material from a roof to a street, racing an
automobile through a crowded thoroughfare, sending a crew
out in a rotten ship, and so on, the accidental homicide
that follows is imputable to the agent no matter how much pre
caution he may say he has used to avert such a death.

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

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

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

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

Were such permission given to physicians it would imme
diately be abused by men with even the best intentions. In
all countries and in the largest cities the medical profession
is swarming with quacks. What is done in crass ignorance by
licensed physicians and specialists every day in the name of
medicine is appalling. Professor Orth of the Pathologic In
stitute 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 physi
cians, 17 per cent, showed no disease at all, and should not
have been removed. In this country the percentage of normal
appendices removed because of vague abdominal pains is much
larger.

The Journal of the American Medical Association (June
7, 1913) gave a list of post-mortem examinations where the

GENERAL PRINCIPLES CONCERNING HOMICIDE 21

diagnosis made by men with a reputation for fair work had
been correct in only the following ratios:

Diagnosis Diagnosis

correct. incorrect.

Per cent. Per cent.

Diabetes Mellitus 95 5

Typhoid Fever 92 8

Aortic Kegurgitation 84 16

Cancer of Colon 74 26

Lobar Pneumonia 74 26

Chronic Glomerular Nephritis 74 26

Cerebral Tumor 72.8 27.2

Tuberculous Meningitis 72 28

Gastric Cancer 72 28

Mitral Stenosis 69 31

Brain Hemorrhage 67 33

Septic Meningitis 64 36

Aortic Stenosis 61 39

Phthisis, Active 59 41

Miliary Tuberculosis 52 48

Chronic Interstitial Nephritis 50 50

Thoracic Aneurism 50 50

Hepatic Cirrhosis 39 61

Acute Endocarditis 39 61

Peptic Ulcer 36 64

Suppurative Nephritis , 35 65

Renal Tuberculosis 33.3 66.7

Bronchopneumonia 33 66

Vertebral Tuberculosis 23 77

Chronic Myocarditis 22 78

Hepatic Abscess 20 80

Acute Pericarditis 20 80

Acute Nephritis 16 84

Pneumonia is a very common disease, extremely danger
ous, and by skilful treatment it is very often cured, yet of
these 100 cases 66 were not diagnosed. I recently saw a
severe case of double pneumonia which a physician was treat
ing as "indigestion," and he was giving pepsin tablets for
the supposed indigestion. There is such a thing as extraor
dinary scientific precision in medical work, but it is rare;
the ordinary physician treats symptoms without knowing the
cause of the symptoms ; that is, the symptom-treater is a quack,
and if euthanasia were legalized thousands of such quacks
would be permitted to murder with an overdose of morphine
any querulous old man or woman who might fall into their

22 THE ETHICS OF MEDICAL HOMICIDE

hands. Osteopaths and chiropractors are masseurs, and they
know very little of massage, but they are licensed by legisla
tures to practise medicine, and some of them even try obstet
rical malpractice. They, too, would be licensed to inflict
euthanasia. Pure homeopathy is little more than a name at
present; it is faith-healing without prayer. It attenuates its
drugs 100 per cent, for thirty repetitions, to a degree expres
sible by one with sixty ciphers. Consequently it gives sugar
of milk or alcohol in minute quantities plus a label, and one
cannot make much of an impression on any disease with a
label. Such practitioners also would come under the euthan
asia act.

BIBLIOGEAPHY

Cardinal John de Lugo. Disputationes Scholasticae et

Morales, vol. vi; De Justitia et Jure, disputatio x.
St. Augustine. I Contra Petilianum, cap. 24; Ad Marcel-

lianum Comitem, cap. 21; De Civitate Dei, cap. 17 to

28.

Aristotle. IJI Ethicorum, cap. 7, and lib. v, cap. ii.
Plato. Phaedo.
Cicero. Quaestiones Tusculanae. I, lib. v; De Somno

Scipionis.

Lessius. De Justitia et Jure, lib. ii, c. 9, dub. 6, 7.
Molina. De Justitia et Jure, vol. i, tr. 2, disp. 119 ; vol. iv,

tr. 3, disp. 1 and 9.
St. Thomas Aquinas. Summa Theologica, 2, 2, q. 64, a.

5,7.
St. Alphonsus Liguori. Theologia Moralis, vol. iv, tr. 4.

See this book for opposed opinions and a bibliography.
Costa-Rossetti. Philosophia Moralis, thesis 120.
Ferretti. Philosophia Moralis, theses xci, xciv.
Macksey. De Ethica Naturali, theses xxxiv et seq.

CHAPTER II

GENERAL PRINCIPLES CONCERNING MUTILATION

THE members of the human body may be injured (1) by
a blow, which without bloodshed pauses pain or a bruise ;

(2) by a wound, which breaks the continuity of the tissues;

(3) by mutilation, which, without killing, removes some mem
ber requisite for the integrity of the body. The term Mutila
tion as applied to the human body has various meanings. In
the civil law mutilation of a person is called Mayhem, an old
form of the word Maim, and is defined by Blackstone * as
"such hurt of any part of a man's body as renders him less able
in fighting to defend himself or annoy his adversary." By
statute in the United States and Great Britain the scope of
the offence has been so extended as to include injuries to a
person which merely disfigure or disable. Mutilation in the
civil law now implies the taking away of some part of a legal
instrument, as a will, contract, or the like, by any one who has
no right to make this alteration.

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

1 Commentary, bk. iv, p. 205.

23

24 THE ETHICS OF MEDICAL HOMICIDE

Molina, treating of mutilation, says 2 it does not exist un
less there is an amputation or shortening (detruncatio} of a
member. When a foot or hand is so weakened without ampu
tation that it cannot exercise its function the person is said to
be maimed or lame, not mutilated. He holds that a finger,
and a fortiori a phalanx of a finger, are not properly members.
In defining mutilation as a cause of canonical irregularity 3
he contends that the weakening of a member so that it cannot
perform its function is not a true mutilation canonically. He
does not agree 4 with Cajetan, de Soto, and others who hold
that an important part of a whole member is equivalent to a
member so far as technical canonical mutilation is concerned.
Molina says that a part of the body as a member to fulfil the
requirements of the law on mutilation as a cause of irregu
larity must have a distinct, complete function of its own, not
be a mere part conducing to the function. Ballerini 5 agrees
with Molina, but he draws attention to a decretal of Jnnocent
I. which makes an amputation by oneself of even a part of
one's own finger a full canonical irregularity, because of the
unnatural quality of the act.

Suarez defines mutilation thus: "Mutilare significat
proprie membrum aliquod abscindere" 6 — to mutilate means,
strictly speaking, to cut off any member. He holds with Caje
tan that an important part of a member is in itself equivalent
to a member. A reason he offers for his opinion is that a
eunuch is enumerated among those who are canonically muti
lated, but the eunuch, he tells us, "does not lack any member
which in itself has a function in the body independent of all
other organs." This is not true. The testicles, which the
eunuch lacks, have two distinct functions, independent of
other organs — they make the spermatozoa and an important
internal glandular secretion. These facts were not known in
Suarez's time (1548-1617). Suarez adds this remark: "There
can be a grave sin in a marring [diminutio] of any chief mem-

1 De Justitia et Jure, disp. 19, tr. 3.

1 Ibid., disp. 68, tr. 3.

4 Ibid., n. 69.

" Theol. Moral, vol. vii.

* De Censuris, etc., disp. 44, sec. 2, 2.

PELNTCIPLES CONCEENING MUTILATION 25

her, although there may be no grave mutilation; as, for ex
ample, to cut off a part of a finger is undoubtedly a mortal
sin, yet, in the opinion of all moralists, it is not enough to
cause irregularity."

St. Alphonsus Liguori defines mutilation thus: "Muti
lation here signifies that some principal member be separated
from the body; that is, a part of the body that has in itself a
distinct function, as a foot, hand, eye, ear, etc." 7 He says 8
canonical irregularity as a punishment is not incurred by a
person who cuts off another man's finger, thumb, lips, nose,
auricle, or who knocks out teeth, because these are supposed
by canonists not to be properly members of the body, but parts
of members. To blind a man in one eye is not enough to cause
canonical irregularity; the eye must be taken out.9 All these
injuries are of course mutilations in the moral sense of the
term. To blind a man without removing the eye, to cut out
his spleen in the treatment of Banti's disease, to remove a
woman's ovary or uterus, to cut off part of the point of a
finger, to crop the top of an auricle, to knock out a tooth, and
any other permanent marring of the body, even to cause an
unsightly scar across the face, are all mutilations in the moral
sense of the term. A physician, midwife, nurse, or parent
who neglects an infant's eyes, and so permits ophthalmia
neonatorum to blind the child, is guilty of grave mutilation.
In the year 1914, in the Chicago schools, 45,176 children were
found suffering from various defects, and 35,425 were advised
by the examining physicians to seek treatment; in each of
these cases the parents were informed of the nature of the
disease and the necessity for treatment, but only 40 per cent,
of the parents paid any attention to the notices. Of 5754
cases of diseased tonsils, which are likely to affect the heart
permanently, only 4 per cent, were treated; of 1254 cases of
discharging ears only 10 per cent, were treated, although such
a condition may go on to deafness if not attended to. These

* Theol. Moral, lib. 7, cap. 5, disp. 4, n. 365.
8 Ibid., n. 378.
•Ibid., n. 382.

26 THE ETHICS OF MEDICAL HOMICIDE

parents were criminally guilty of grave neglect in permitting
the mutilation of the heart and ears.

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

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

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

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

PRINCIPLES CONCERNING MUTILATION 27

3. The had effect must not be intended, either imme
diately or remotely; it may at most be tolerated as unavoid
able.

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

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

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

The good of the body is the sole cause that renders direct
mutilation licit. The members of the body by their nature
are not immediately subordinate to anything except the con
servation of the total natural good, or that of the body. There
fore direct mutilation is not permissible to effect immediately
spiritual good, or the good of the soul. We may not castrate
a man, or do vasectomy on him, to preserve his continence,
because there is no immediate subordination and connection
between the members of the body and the salvation of the

28 THE ETHICS OF MEDICAL HOMICIDE

soul. Moreover, as St. Thomas says,10 "Spiritual health can
always be preserved by means other than amputation of bodily
members," that is, through moderating by the will the use
of these members. If a mutilation that immediately conduces
to the good of the whole body, happens also to do good to the
soul, this second effect is then legitimate. (The various muti
lations of the body by surgical operations will bo considered
separately hereafter. )

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

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

A law is a rule and standard of action; a just, perma
nent, and rational ordination for the good of the community,
promulgated by one who has charge of that community.
Dominion is the power of claiming a thing as one's own, the
right of ownership; and if this possessor has created the
object, his dominion may be absolute. A governor, lawgiver,
judge, has power or jurisdiction for the good of the governed.
The business of government, of the state, is to protect each
citizen in the pursuit of temporal happiness, to develop his
natural faculties, establish and preserve social order, wherein
each citizen is secured in his natural and legal rights, and is

10 2, 2, q. Ixv, a. 1, ad 3.

PRINCIPLES CONCERNING MUTILATION 29

held up to the fulfilment of his own duties so far as they bear
on the good of the community as such ; and also to put within
the reach of all citizens, as far as possible, a fair allowance
of means to acquire temporal happiness, or external peace and
prosperity. This is the whole business of the state. The
state is for the people, and it may not transgress an inch
beyond its proper limits, which are as hard and fast as those
that bind the individual citizen. The citizen is not to be
treated solely as an industrial or military unit; nor are ma
terial progress and military power, or even sheer intellectual
civilization, to be the sole aim of the state. The state should
develop a man's entire nature, physical, mental, and moral.

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

The end of the state, then, is not the public good consid-

30 THE ETHICS OF MEDICAL HOMICIDE

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

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

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

PRINCIPLES CONCERNING MUTILATION 31

off an innocent, sound member to save its life from the enemy,
as described above.

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

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

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

32 THE ETHICS OF MEDICAL HOMICIDE

identification, if pushed far enough, becomes an analogical
quibble.

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

CHAPTER III
WHEN DOES HUMAN LIFE BEGIN?

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

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

The discussion concerning the moment the human soul
enters the body is older than Christianity, and it was taken up
by many of the early Greek and Latin Fathers of the Church,
and revived again and again down to the present day. Plato
thought the soul enters at birth ; Asclepias, Heraclites, and the
Stoics held it is not infused until the time of puberty; Aris-

33

34 THE ETHICS OF MEDICAL HOMICIDE

totle * said the soul is infused in the male fetus about the for
tieth day after conception, and into the female fetus about the
eightieth day.

Tertullian,2 Apollinaris, and a few others advocated
Traducianism,3 or a transmission of the spiritual soul by the
parents. He said souls are carried over by conception and by
the parents, so that the soul of the father is the soul of the
son, and from one man conies the whole overflow of souls.
St. Augustine used the metaphor, one soul lit from another as
flame from flame, without decay in either. Augustine was in
doubt as to the origin of the soul, and inclined to traducianism,
because it seemed to him better to explain the doctrine of the
transmission of original sin. "Tell me," he wrote to St.
Jerome in 41 5, 4 "if souls are created singly for each person
born to-day, when do infants sin so that they need remission
in the sacrament of Christ, sin in Adam from whom the flesh
of sin is propagated? . . . Since we cannot say that God
makes of souls sinners, or punishes the innocent, nor may we
hold that souls even of infants which without baptism leave
the body are saved, ,1 ask you how that opinion can be de
fended which thinks that all souls are not made from the
single soul of the first man, yet as that soul was one to one
man, these are particular to particular individuals."

Again, St. Augustine said : 5 "I do not know how the soul
came into my body; he knows who gave it, whether he drew
it [traxerit] from my father, or created it new as in the first
man." In the Book of Retractions? speaking of the articles
he had written against the Academicians before he was a
bishop, he says : "As to the origin of the soul, how it is set in
the body — whether it is from that one man who first was
created . . . or, as in his case, is made particularly for each
particular individual, I did not then know, and I do not know
now." St. Gregory the Great also said he could not tell

*IX, De Animalibus.

* De Anima, cap. 27.

* From tradux, a planted vine-shoot made to take root.

* Migne, vol. xxxiii, col. 720.

* De Anima et ejus Origine, i, xv.
"I, cap. i, n. 3.

35

whether the human soul descends from Adam or is given par
ticularly to each man.

St. Gregory of Nyssa, however, who died about 385, thirty
years before St. Augustine wrote the letter to St. Jerome, held
that the soul is infused into the body at the moment of con
ception, and ho argues with absolute precision for his opinion.7
St. Maximus the Theologian, who was martyred in 662, in
veighs 8 against the notion that the soul is vegetative at first,
then sensitive, and finally intellectual, and he thinks the asser
tion of Aristotle that the fetus is not animated before the for
tieth day is altogether untrue.

St. Anselm, who died in 1109, very dogmatically denied
that the fetus is animated at conception,9 and after his time
the doctrine of Aristotle, which is commonly called the Thom-
istic opinion, became almost general. Vincent of Beauvais,
however, a contemporary of St. Thomas, opposed the Thomis-
tic doctrine. Albertus Magnus 10 had the same opinion as
St. Thomas, and probably taught it to St. Thomas. In the
middle ages all held that each soul is directly created by God,
and is infused into the embryo, not at the instant of concep
tion, but when the embryo is sufficiently formed to receive it,
which, as Aristotle said, happens at about the fortieth day in
males and the eightieth day in females. The Thomists main
tained the succession of the three souls; many others opposed
this particular opinion.

Thomas Fienus, a physician and a professor in the Univer
sity of Louvain, in 1620 published a book11 in which he held
that the soul is infused about the third day after conception,
and his argument for the early advent of the soul is very sound.
As a result of Fienus's revolutionary argument, Florentinus in
1658 brought out a book at Lyons, called De Hominibus Dubiis
Baptizandis, in which he held that no matter what the age
of the aborted fetus, if it could be differentiated from a mole
it should be baptized. This book was brought before the Con-

I Migne, Patrologia Graeca, vols. xliv and xlvi.

8 Migne, Ibid., vol. xci, col. 1335.

9 De Conceptione Virginia, cap. xii.

10 Summa, De Homine, q. xvi, art. 3.

II De Vi Formatrice Foetus Liber.

36

gregation of the Index. The congregation did not condemn
the book, but the author was forbidden to teach that his doc
trine holds sub gravi. The book went through many editions
and was approved by the faculties of the principal universities
and the theologians of the leading religious orders.

Zacchias, chief physician to Innocent X., in 1661 published
his Quest iones Medico-Legates, and in this he maintained that
"the human fetus has not at any time any kind of soul other
than a rational, and this is created by God at the first moment
of conception, and is then infused."12 By 1745 the opinion
of Zacchias as to the moment life begins was virtually general
among physicians, and has since remained the doctrine of
physicists. Modern discoveries by biologists have confirmed
the fact that human life exists in the impregnated ovum ex
actly as it does in all stages of life, and no scientist holds any
other opinion. There are, however, a few moralists at the
present day who incline to the old Thomistic doctrine or to
modifications of it.

St. Alphonsus Liguori * 3 was a follower of the Thomistic
opinion. He affirmed: "They are wrong that say the fetus is
animated at the instant of conception, because the fetus cer
tainly is not animated before it is formed, as is proved from
Exod. xxi : 22, where in the Septuagint version we find : 'He
that strikes a gravid woman and causes abortion, will give life
for life if the child was formed ; if it was not formed, he will
be fined.' ' This argument by St. Alphonsus is invalid apart
from any facts that may bear upon either the Thomistic or
the modern opinion concerning the quickening of the fetus.
The text from the Septuagint Exodus is (1) too doubtful in
itself to be the basis of any argument; but (2) even if it were
authentic just as it stands, the conclusion St. Alphonsus draws
from it is not warranted by the premises. The Septuagint text
differs from the Vulgate and the Hebrew texts. The Vulgate
has it thus: "Si rixati fuerint viri et percusserit quis mulierem
pracgnantem, et abortum quidem fercerit, sed ipsa vixerit,
subjacebit damno quantum maritus mulieris expetierit et

"Tom. ii, lib. ix, tr. 1.

11 Thcologia Moralis, lib. iv, tr. 4, n. 594.

WHEN DOES HUMAN LIFE BEGIN? 37

arbitri judicaverint ; sin autem mors fuerit subsecuta, reddit
animam pro anima, oculum pro oculo, dentem pro dente,
manum pro mami, pedem pro pede, adustionem pro adustione,
vulnus pro vulnere, livorem pro livore.14 This version has
nothing whatever to say about the foetus formatus or non for-
matus; it is merely an application of the Semitic Lex Talionis,
and the form of the law is clearly corrupt and inaccurate.

The passage quoted by St. Alphonsus as that of the Sep-
tuagint is not exact even as the Septuagint has it. The full
text is : "If two men fight, and one strike a woman that hath
[a child] in the womb, and her babe come forth not yet fully
formed,15 in a fine he shall be mulcted; whatsoever the hus
band layeth upon him he shall give according to decision [i.e.,
of the judges]. But if it [the babe] be fully formed he will
give life for life, eye for eye, tooth for tooth, hand for hand,
foot for foot, burning for burning, wound for wound, stripe
for stripe."

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

(2) Suppose, however, the writer of the text as the Sep
tuagint has it did think with St. Alphonsus that the formed
fetus is animated, and the unformed is not animated, even
then the conclusion drawn by St. Alphonsus is not warranted
by the text. The laws of Exodus do not teach embryology,
physiology, or any other part of physical science; and no

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

5 KCU e£e\0# Traidiov avrijs M1? e^iKOVurufvov — not moulded out into
form; l£tiKovi£ eiv,to mould out into fonn:euc«i', an icon, image, like
ness.

38

authority worth a hearing holds that the Scriptures were in
tended to be infallible treatises on obstetrics or astronomy.
Like the other parts of the Bible, the laws of Exodus pre
suppose the unscientific biological, astronomical, and other
physical notions of the time in which they were written — the
moral truth is the matter the Scripture is dealing with; there
no inaccuracy is to be found. St. John (1:13) speaks of those
who believe in Christ's name, "Qui non ex sanguinibus, neque
ex voluntate carnis, neque ex voluntate viri, sed ex Deo nati
sunt." Here he expresses the contemporary notion, which is
also the Thomistic opinion, that men are generated from the
specialized blood of their parents. He was interested solely in
conveying the truth that those who received Christ were re
generated by him, not through heredity; and he does so, al
though the biology is inexact. If St. Alphonsus's conclusion
is valid as from the text of Exodus, then men are generated
ex sanguinibus, and so on indefinitely.

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

Whether the fetus is animated at conception or some time
later, there is no foundation whatever for the notion that
the female is quickened later than the male. As was said
before, Aristotle held that the human male fetus is animated
at the fortieth day, the female at the ninetieth day, and tho

WHEN DOES HUMAN LIFE BEGIN? 39

old moralists accepted his statement. At tlie fortieth day,
however, no one can differentiate sex unless the microscope
is used, and this particular use of the microscope is alto
gether modern — the knowledge requisite for such use was not
in existence sixty years ago. At the twentieth day, with
the microscope and a stained specimen, a biologist can rec
ognize whether the primordial ova are present or absent
and thus determine sex. Only at the eighty-fourth day can
sex now be differentiated without the aid of the microscope,
but then the embryo must be dissected: nothing can be told
from its external appearance. Sex can first be distinguished
by the external appearance only at about the one hundred
and twelfth day, the end of the fourth month of gestation.
Therefore when Aristotle said the male fetus is animated
at the fortieth day, and the female at the eightieth or nine
tieth day, he was romancing.

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

The human body is made up of billions of microscopic liv
ing cells, all of which are derived by fission and differentia
tion from the two original single germ-cells, the ovum and the
spermatozoon. Some nerve-cells have long processes running
along the white fibres through the entire length of the body,
but they cannot be differentiated except by the microscope.

40 THE ETHICS OF MEDICAL HOMICIDE

In the body are also various liquids which are not cellular,
as water, saliva, tears, urine, blood and lymph plasma, and
the gastric, intestinal, and glandular juices, and these are
secreted or excreted by the somatic cells. The cells ' assimi
late nutritive material carried to them by the blood, excrete
refuse substances, secrete glandular products, and are the
media for all human operations below certain acts of the in
tellect.

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

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

In the nucleus are several elements, the chief among which

41

is Chromatin. Chromatin takes various forms, but commonly
it is an irregular network. From the chromatin are derived
the • Chromosomes in the prophases of indirect cell-division
which is the process of cell-division in the human body, ex
cept in lymph-cells and white blood-corpuscles, which split
directly, or by Amitosis. Indirect cell-division is called
Mitosis or Karyokinesis. In the male and female chromo
somes, according to a common opinion of biologists, all the

Fig. I

fWo Ceotro6<xnes in an attraction-sphere

Nueteolus or
PUsmosome

Chromatin

Linin
Karyosome

Vacuoto

si ve bodies t

suspended in the moh,
<X the Cytoplaanx

A CELL.

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

elements of parental and phyletic physical heredity are trans
mitted to the embryo.

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

42 THE ETHICS OF MEDICAL HOMICIDE

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

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

Multicellular animals — Man, for example — grow embryo-
logically by Mitosis or Indirect Division. As in Direct Divi
sion, typically, the nucleus in mitosis splits first and the cyto
plasm secondly; but before the nucleus divides its content un
dergoes a series of changes. The chromatin loses its reticular
arrangement and gives rise to a definite number of separate
bodies, usually rod-shaped, known as Chromosomes. In this
process the chromatin becomes a convoluted thread, called the

WHEN" DOES HTJMAH LIFE BEGIN?

Skein or Spireme. The thread thickens and opens out some
what, and finally breaks transversely to form the chromo
somes, which may be rods, straight, curved, ovoid, and some
times annular. Commonly the nuclear material fades away
and leaves the chromosomes in the cell-plasm. (Fig. II, 2

and 3.)

Fig. II

DIAGRAM OP MITOSIS.

1. Cell with resting Nucleus. 2. Prophase: Chromatin in thickened con
voluted threads, beginning of Spindle. 3. Prophase: Chromosomes. 4. Pro-
phase: Spindle in long axis of the Nucleus, Chromosomes dividing. 5. Ana-
phase: Chromosomes moving toward the Centrosomes. 6. Chromosomes at
the poles forming the Diaster, beginning splitting of the Cell-body. 7. Telo-
phase, Daughter-Nuclei returning to resting state. 8. Daughter- Nuclei show
ing Monaster below. 9. The two new Cells.

It is almost an established fact that each species of animal
and plant has a fixed and characteristic number of chromo
somes, which regularly recurs in the division of all its cells.
In forms arising by sexual production the number is even.
The number of chromosomes in the human cell is said to be

44 THE ETHICS OF MEDICAL HOMICIDE

forty-eight. There are, according to some observers, forty-
seven chromosomes in man and forty-eight in woman. There
seem to be twice as many chromosomes in white men as
in negroes. Wilson gives the number18 of specific chromo
somes for seventy-four animals and plants. Germ-cells as
differentiated from the somatic cells have in the perfected cell
always half the number of chromosomes found in a somatic
cell.

While these changes are going on in the chromatin the
Amphiaster forms. This consists of a fibrous spindle-shaped
body, the Spindle, at either pole of which is an Aster made
up of rays. In the centre of each aster is a Centrosome, and
this may have a Centrosphere about it. As the amphiaster
grows the centrosomes are grouped in a plane at the equator
of the spindle, forming the Equatorial Plate. (Fig. ,11, No.
4.) The process so far makes up the Prophases of the Mi
tosis.

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

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

The germ-cells differ from the body-cells in general by

18 The Cell in Development and Inheritance, p. 207.

WHEN DOES HUMAN LIFE BEGIN? 45

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

In the reduction of the germ-cells, if the primordial cell
that finally produces the ovum has, say, four chromosomes,

46 THE ETHICS OF MEDICAL HOMICIDE

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

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

In general, the new nuclei in the cells formed by division
are not made de novo, but arise from the splitting of the
nucleus in the mother-cell. The new nucleus assimilates ma
terial, grows to maturity, and divides again into two daughter-
nuclei. Whatever be the number of chromosomes that enter
a new nucleus as it forms, the same number issues from it in
mitosis. Boveri said,17 "We may identify every chromatic
element arising from a resting nucleus with a definite element
that enters into the formation of that nucleus, from which the
remarkable conclusion follows that in all cells derived in the
regular course of division from the fertilized egg, one half
of the chromosomes are of strictly paternal origin, the other
half of maternal." It is not strictly true to say that the
germ-nuclei fuse: they send in two sets of chromosomes that
lie side by side, as has been frequently demonstrated since
" Jenaische Zeitschrift, 1891, p. 410.

47

1892 18 in many of the lower forms of life, and this law al
most certainly extends also io man.

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

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

The spermatozoon is a complicated organism. The head
is partly covered with a thin protoplasmic cap, and it con
tains the nucleus with the chromatin. fn the neck are two
centrosomes. The tail is in three parts with an axial filament
throughout, which is a bundle of extremely minute fibrils. In
the middle part the axial filament is surrounded by an inner
sheath ; outside this sheath is a spiral filament lying in a clear
substance; and outside the spiral filament is a finely granular
layer of protoplasm, called the Mitochondria. This organ
ism is a living animal cell, and it can live in an incubator, or
in the Fallopian tube for two or three weeks, altogether re
moved from the living male body that produced it. Sir

u See Wilson, op. cit., p. 299.

48 THE ETHICS OF MEDICAL HOMICIDE

John Lubbock19 says be kept a queen ant alive for thirteen
years. This ant, which died in 1888, had been fertilized in
1874, and never afterward. She laid fertile eggs for thirteen
years; that is, the spermatozoa in her oviduct retained their
vitality for thirteen years.

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

This irritation or stimulation by drugs can in certain very

low forms of animal life start mitosis in the unfertilized ovum,

and thus build up part, at the least, of a specific embryo par-

thenogenetically : here probably a polar body takes the place

"Journal of the Linnean Society, vol. xx, p. 133.

WHEN DOES HUMAN LIFE BEGIN? 49

of the spermatozoon. Loeb, by treating the unfertilized egg
of Arbacia (a sea-urchin) with magnesum chloride, started
mitosis that resulted, it is said, in a perfect Pluteus larva.20
The human ovum is about half the size of a period in the
type of this page, and two hundred and fifty spermatozoa will
fit side by side along the horizontal diameter of the lower
case letter o here. The nuclei of these cells are extremely
minute: they must be stained and be observed with a high-
power objective on the microscope before they become visible.
This small nucleus of the spermatozoon penetrates the cover
ing membrane of the ovum, enlarges, and becomes the male
pronucleus. The pronucleus unites permanently with the
pronucleus of the ovum, and together they form the Cleavage
or Segmentation Nucleus of the fertilized ovum. This new
nucleus gives rise by division to the innumerable myriads of
nuclei in the growing body. Hence every nucleus of the child
apparently contains nuclear material derived from both par
ents, as has been said.

The two perfected germ-cells before fecundation are in a
state of nuclear rest after the numerous mitotic changes that
have taken place in the maturation of these cells. When
these nuclei unite in the ovum an intense activity at once is
set up. Biologists offer very many theories to explain this
awakening force. Herbert Spencer, Herting, and others held
that protoplasm when perfected tends to pass into a state of
stable equilibrium and consequent lessened activity, but fer
tilization restores it to a labile state. This and similar
theories are verbose amplifications of the obvious fact that the
cells start to divide and the biologists do not know the cause.
The soul, of course, cannot have anything to do with the
matter, because you cannot smell a soul. "Senescence and re
juvenescence" is another sonorous explanation that does not
explain, used by Minot, Engelmann, and Hansen. Weismann
rejects these theories for his own "Fertilization as a Source
of Variation." Anyhow, the fertilized cell starts to divide
regardless of the biologists. Adult cells may be stimulated
to divide by chemical irritation, by mechanical pressure as in
"American Journal cf Physiology, 1899, iii, 3.

50 THE ETHICS OF MEDICAL HOMICIDE

the formation of calluses, traumatism, by any agency that
brings about an abnormal condition of the body, but this fact
does not explain the normal fission of the fecundated ovum.

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

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

2. An albuminous fluid collects within the morula, and
thus the Vesicle or Blastocyst is formed. The blastocyst is
called more commonly the Cleavage Cavity or the Segmenta
tion Cavity. As this cavity widens the cells are seen to be
arranged in two groups — (a-) an enveloping layer, the epi-
blast, from the outermost plate of which develops later the
Trophoblast, or the nourishing and protecting covering of the
embryo; (5) an Inner Cell Mass, made up of granular cells,
attached to the epiblastic layer at the Embryonic Pole of the
Vesicle. These two stages probably take place in the Fallo
pian tube, and thereafter the embryo is in the cavity of the
uterus.

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

4. By the conversion of the one-layered blastula into two
layers of cells, the Gastrula stage of the embryo is attained.
The Gastrula consists of two layers of cells surrounding a
central cavity, which is the Archenteron, or the body-cavity
that will hold the intestines. During the past twelve years
many specimens of human gastrulas have been observed. The

WHEN DOES HUMAN LIFE BEGIN? 51

earliest form was that seen in 1908 by Teacher and Boyce.21
This embryo was 1.95 mm. in length by 0.95 mm. in width,
about twice the size of a pin-head. It showed on section the
endoderm, the ectoderm, and the beginning mesoderm, en
closed in a spherical mass of trophoblastic cells. The mes
oderm is a plate of cells lying between the endodermic and
ectodermic plates. When the mesoderm develops into two
plates, a cavity, called the Primitive Coelom, appears between
the plates. The Coelom becomes the space between the vis
cera and the body-walls in later development.

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

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

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

The epiblast now with its mesoblastic lining begins to form
the Chorion, an embryonic intrauterine appendage; and the
endoderm encloses the Archenteron or primitive gut. Before
the end of the second week of gestation the heart is indicated
as two tubes in the mesoderm, and the blood-vessels begin to
be produced in the yolk-sac. About the twelfth day the
mouth-pit shows, and the gut-tract is partly separated from
the yolk-sac. The medullary plate of the nervous system is
laid down about the fourteenth day, and the nasal area is

" Contributions to the Study of the Early Development and Em
bedding of the Human Embryo. Glasgow, 1911.

52 THE ETHICS OF MEDICAL HOMICIDE

observable. The maternal blood escapes into spaces about the
embryo enclosed by masses of embryonic cells, which have
not separated from one another, but which are known collec
tively as Syncytium.

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

During this third week the dorsal outline of the embryo is
concave; the heart has a single cavity, which will begin to
divide during the fourth week; the vitelline blood circula
tion begins, and the blood-vessels of the visceral arch are laid
down. The digestive system is advanced to a gut-tract, which
is a straight tube connected with the yolk-sac. The liver
evagination is present and the oral pit is a five-sided fossa.
The respiratory system is represented by the anlage of the
lungs, a longitudinal protrusion of the ventral wall of the esoph
agus. The genitourinary system begins as the Wolffian
bodies. The mesoderm starts to segment to form the skin,
and the neural canal (from which develop the spinal cord

WHEN DOES HUMAN LIFE BEGIN? 53

and brain) for the nervous system forms. The fourth ven
tricle of the brain is indicated, and the vesicles of the fore
brain, mid brain, and hind brain are recognizable. The ears,
nose, and eyes, muscular system, skeleton, and limbs are also
beginning to be recognizable. At about the sixteenth or eight
eenth day of gestation the various parts of the embryo rap
idly differentiate.

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

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

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

At the end of the fourth lunar month the fetus is ten to
seventeen centimetres long. Some muscles are movable.
The heart-beat is strong. Sex is distinguishable externally.

54

WHEN DOES HUMAN LIFE BEGIN? 55

The skin is bright red, and so transparent that the blood-vessels
are visible through it.

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

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

Here the time of fetal viability outside the womb may be
considered. Langstein, of the. Augusta Victoria Hospital in
Berlin, reported 22 a study of the growth and nutrition of 250
prematurely born infants, and he found that a weight of 1000
grammes (2£ pounds) and a full body length of 34 centi
metres (13f inches) are the lowest limits for viability under
proper circumstances. A fetus 1000 grammes in weight and
34 centimetres in length has completed the sixth solar month,
or the sixth and a half lunar month; that is, it is viable at the
beginning of its seventh month, servatis servandis.

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

M Berliner klinische Wochenschrift, June 14, 1915.

56 THE ETHICS OF MEDICAL HOMICIDE

phorus have puny babies; white children are larger at birth
than negro children; boys at term are 3 to 5 ounces heavier
than girls.

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

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

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

A full seven-months infant may be reared with proper
feeding and skilled care; a six-months infant may be reared
(with difficulty) in a hospital with skilled care. If it is cer
tain that the removal of a six-months fetus will here and now

WHEN DOES HUMAN LIFE BEGIN? 57

save the life of a mother (a very difficult matter to judge by
the best diagnosticians), this removal may be done, provided
the infant is delivered in circumstances where skilled care,
incubator, and proper food are obtainable; otherwise the re
moval is not justifiable. That the ordinary physician says
it is necessary to empty the uterus is not a sufficient reason,
as he is likely to act from ill-digested information set forth
by professorial pagans, who place no value whatever on human
life in an infant.

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

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

In a paper read at the Darwinian Memorial Congress in
1909, Weismann said: "With others I regard the minimal
amount of substance which is contained within the nucleus of
the germ-cells in the form of rods, bands, or granules, as the
germ-substance, or germ-plasm, and I call the individual gran
ules 23 ids. There is always a multiplicity of such ids pres
ent in the nucleus, either occurring individually or united in

* Id is a word derived from Nageli's term idioplasm, which meana
the chromosome granule.

58 THE ETHICS OF MEDICAL HOMICIDE

the forms of rods and bands (chromosomes). Each id con
tains the primary constituents of the whole individual, so that
several ids are concerned in the development of a new indi
vidual." Actually there are such things as chromosomes, and
when these are stained and are under the highest power of the
microscope they appear to be granular. These granules
Weismann calls ids. Beyond the fact that there are such
granules, all else is sheer guessing.

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

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

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

That these so-called determinants differ among themselves
may be true, if they exist at all, which is just the point to be
proved. Giving Greek names to inventions does not turn
invention into fact. These supposed determinants, he says,
"may vary quantitatively if the elements of which they are
composed vary; they . . . and their variations may give
rise to corresponding variations of the organ, cell, or cell-
group which they determine." Professor Dwight said:24
" Thoughts of a Catholic Anatomist, p. 48.

59

"This is what is palmed off on us for science!" Weismann
assures us we must admit this farrago of clumsy fiction, other
wise we should be forced "to assume the help of a principle
of design." 25 In the name of common sense, then, admit a
principle of design, and be done with it!

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

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

We know the successive steps in the growth of the embryo

from the time of fertilization to the end of gestation, but how

this vital process is effected is not so evident. What we are

certain of is that there is a vital principle of some kind from

* Contemporary Review, September, 1893.

60

the beginning, and this is the matter of real importance in
the present discussion. The old moralists held that this prin
ciple in the human being is at first vegetative; after a while
that vegetative vital principle is expelled by a sensitive prin
ciple ; and finally this sensitive soul is expelled by the rational
vital principle, or human soul. St. Thomas 2G says : "Some
tell us the vital acts that appear in the embyro are not from
its soul, but from the soul of the mother, or from the primi
tive force in the semen. Both these statements are false.
Vital operations, as sensation, nutrition, growth, cannot come
from an extrinsic principle; therefore it must be admitted
that a soul preexisted in the embryo, nutritive at first, then
sensitive, and finally intellectual." After showing that an
intellectual soul cannot be evolved from lower forms, he con
cludes: "Therefore we say that since the generation of one
thing is always the corruption of another, in man as in other
animals, when a more perfect form comes in this supposes the
corruption of any precedent form; so, however, that the se
quent form has all perfection that was in the destroyed forms,
and something in addition : and thus through many generations
and corruptions the final substantial form is attained in man
and other animals. This is apparent to the senses in animals
generated from putrefaction. Therefore the intellectual soul
is created by God at the end of human generation, and this
soul is both sensitive and nutritive, all precedent forms having
been destroyed."

There is no such thing as the generation of any animal
or other living being from putrefaction ; but that is irrelevant.
St. Thomas's argument proves conclusively that if man has
first a merely vegetative soul, and secondly a merely sensitive
soul, which includes the power of the vegetative soul, and
thirdly an intellectual soul, which does the work of all three,
that this final intellectual soul is not an evolution of the first
two, but a new form that replaces these after they have served
their purpose and have been annihilated. It does not even
attempt to prove that man really has first a merely vegetative
soul, and secondly a sensitive, and lastly an intellectual soul;
"I, q. 118, a. 2, ad 2.

WHEN DOES HUMAN LIFE BEGIN? 61

it supposes all this. It starts out with the erroneous Aristote
lian theory and takes it for granted. The reason for this
statement is that the rational substantial form requires dis
posed matter to work upon, and the Thomists suppose (again
erroneously) that in the human embryo during the period im
mediately after conception there is not enough matter to be a
receptacle for the rational soul.

The soul according to the Thomists, who use the Aristote
lian definition, is the first entelechy of a natural organic body
that has life in potency.27 It is the determination that gives
the body its specific and substantial being; the primal actua
tion of a body or matter, since only in matter is there a dis
tinction between potency for substantial being and substantial
actuality. An entelechy is a realization, actuality, full perfec
tion; sight, for example, is the entelechy of the eye. This
body is natural, not merely instrumental; it is energized by
an immanent principle, not moved by an external force like a
tool. The body is also organic ; it must have organs, faculties,
parts destined to perform definite functions. To say the en
telechy has life in potency means that since life, or the op
eration of the soul, is an immanent act, there must be a re
ceptacle within which it can be immanent, and the soul is the
primal actualization of that organic body, which is in potency
to produce those immanent actions in which life consists. A
body might be in potency while it still has no principle of
operation, or, secondly, while it has such a principle but is not
using it. In the second condition the human body is in po
tency for life at the moment of actualization.

A form fixes a thing in its proper species, and the ra
tional soul is such a form for the human body. This sub
stantial form is the completion, perfection, in operability and
existence, of the matter that receives it. It is the formal
cause of man, not the efficient cause, although it is the efficient
cause of subsequent vital operations. An efficient cause makes
something numerically different from itself by its own real
and physical action; a formal cause and a material cause do

27 ^ ^X1^ tffriv tvTtKkxtia. $ irp&Tij aco/iaros 4>vffiKov bpyavtKov
(De Anima, ii, 1).

62 THE ETHICS OF MEDICAL HOMICIDE

not make anything different from themselves numerically, but
they intrinsically constitute the effect — they are intrinsic
causes.

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

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

As to the soul itself, Kant held that the soul is not a real,
but only a logical substance. The Pantheists, Transcenden-
talists, and ISTeo-Hegelians try to identify the soul with the
divine consciousness. The Associationists (Hume, Davis,
Hoffding, Sully) say that the soul is a mere group of sensa
tions. The Agnostics and Positivists (Locke, Herbert Spen-

WHEN DOES HUMAN LIFE BEGIN? 63

cer, James, Comte) write volume after volume on the soul
to prove that they know nothing about it. Then the Material
ists assert that there is no soul of any kind; that we secrete
thought as a mule secretes sweat. Yet the vital operations of
man are inexplicable as resultants of the physical and chem
ical properties of matter. There is an intrinsic energy that
unifies the actions of man, directs processes, controls the tend
ency of organic matter to pass into the fixity of the inorganic,
and effects metabolism. This intrinsic energy is the entel-
echy, substantial form, or what is popularly called the soul.

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

No mere machine can build up itself, can make any re
mote approach to metabolism as an organized body can; and
the principle of this immanent action is not matter itself, be
cause it uses, makes, subordinates matter to (itself. That
principle is positively one, not one by continuity as matter
is. Matter as in a crystal grows by mere aggregation, an or-

64 THE ETHICS OF MEDICAL HOMICIDE

ganism grows by assimilation ; a crystal loses force in forma
tion and growth, an organism accumulates force.

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

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

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

The formal principle which is in organic bodies is a true
substantial form, actuating the body both as to its nature and
substance. Together with the body, this principle makes a
being one in itself, such that the matter and the form sep-

WHEN DOES HUMAN LIFE BEGIN? G5

arably are incomplete as regards operation and being.
Now, a form is that principle through which anything is es
tablished in its own species; light, for example, is the form
of a luminous body, heat of a hot substance. A body, how
ever, is established in the human species by receiving a ra
tional soul, and this soul, then, is its form. It is also a sub
stantial form because the soul itself is a substance, not an ac
cident dependent upon another subject. Moreover, from its
union with the body another substance — man — arises, and not
a thing added to a substance. Man's body is alive, therefore
it is a living substance; but life in its secondary actuality is
an operation; in its primary actuality it is an essence. The
body is made a living substance, not from itself, but from the
soul which is added to it. When the soul departs the body
is no longer alive. Now, a principle which by a communica
tion of itself determines the body in its essence and differen
tiates it as a living substance from everything else, is a sub
stantial form. A substantial form, then, or a soul, exists.

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

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

It has been said that the vital activity in the fertilized
ovum does not proceed from the rational soul because, "in the
first place, it results from the fusion of two vital activities,
neither of which is rational; secondly, it results in the for-

66 THE ETHICS OF MEDICAL HOMICIDE

mation, by fission, and differentiation, of two distinct and sep
arate living cells, each containing within itself a principle of
vital activity. Now this principle of vital activity cannot
be a rational soul, for each cell has its own principle of ac
tivity, and in man there is but one soul."

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

The embryo in the two-cell stage is not made up of two
independent organisms, any more than the right and left
halves of an adult man are two independent organisms. Ths
cells in the two-cell stage of the embryo are the right and left
halves of the body, not two individuals, as has been proved
repeatedly by biologists. Roux 28 punctured with a hot
needle one of the cells in the two-cell stage of a frog embryo
without killing the embryo, and it grew into a half-frog larva.
Analogous results were obtained by operating in the four-cell
stage. Later, Pfliiger, Schultze, Enders, and Morgan corrobo
rated the work of Roux. Newport 29 discovered this fact sixty
years ago.

In analyzing the structure and functions of the individ
ual cell we regard it as an independent elementary organic
unit, but this view is solely a matter of convenience, almost
a convention. All the billions of cell's in an adult man are

n Virchow's Archiv (1888), 114.
"Phil Trans., 1854.

WHEN DOES HUMAN LIFE BEGIN? 67

inseparable parts of the single living person. No cell exists
as an independent organism in multicellular animals, except the
germ-cells, and these only after separation from the gland of ori
gin. Indeed, the biological theory of heredity, already men
tioned here, wherein the germ-cell is supposed to carry forward
the entire heredity, is now changing toward the view which
makes all the somatic cells influence the germ-cells; that is, the
body-mass of cells sends on heredity through the germ-cell as
the instrument. Adult organisms do not make cells de novo.
New cells are formed by division from preexisting cells, but
some biologists think the body-cells so affect the new germ-cells
as to influence heredity.

The cells are organs, nodal points, of a single formative
power which pervades the mass of cells as a whole. The
protoplasm of each cell is not only in direct apposition with its
neighbors, but nearly all biologists are now inclining to the
opinion, which Heitzmann proposed in 1873, that division
of cell from cell is incomplete in nearly all forms of tissue;
and that even where cell-walls are present (an exceptional
condition in mammals) they are traversed by strands of proto
plasm, by means of which the cells are in organic continuity.
The whole body, he contended, is thus a syncytium (a mass of
continuous protoplasm Stippled with nuclei), with the cells
as mere nodal points in an almost homogeneous protoplasmic
mass. There are cell-bridges between the sieve-tubes of
plants. In 1879 Tangl discovered such connection between
the endosperm cells of plants, and later Gardiner, Kienitz-
Gerloff, A. Meyer, and many others demonstrated that in
nearly all plant tissues the cell-walls are connected by intra-
cellular bridges. Kanvier, Bizzozero, Eetzius, Fleming, Pfitz-
ner, and many other observers have found these protoplasmic
bridges in animal epithelium. In the skin of a larval sala
mander they are quite conspicuous. They are known to oc
cur also in smooth muscle-fibre, in cartilage cells, in connec
tive-tissue cells, and in some nerve-cells. Harrison found, in
1908, that in frogs the nerve-fibres develop out of these intra-
cellular bridges. Dendy in 1888, Ketzius in 1889, and Pal-
ladino in 1890 have shown that the follicle cells of the ovary

68 THE ETHICS OF MEDICAL HOMICIDE

are connected by protoplasmic bridges, not only with one an
other, but also with the ovum; and similar connection between
somatic cells and germ-cells has been found in a number of
plant's. Thus even the germ-cell is not independent until it
has actually broken away from the gland. A. Meyer holds
that both the plant and animal individual are continuous
masses of protoplasm, in which the cytoplasmic substance forms
a morphological unit, no matter what the cell is. That opinion
is not finally settled as regards the animal after the fetal stage,
but it is much stronger as regards embryos. In the early stages
of many arthropods it is certain that the whole embryo is at
first an unmistakable syncytium. This is almost established
also for Amphioxus, the Echinoderm Volvox, and other ani
mals. Adam Sedgwick holds that it is true for vertebrates up
to a late embryonic stage. Mitosis, then, is a form of growth
of a mass, not a generation of new individuals.

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

Conklin says 30 that in the ascidian Styela "there are four
or five substances in the egg which differ in color, so that their

" Heredity and Environment, p. 123, Oxford Press.

WHEN DOES HUMAN LIFE BEGIN? 69

distribution to different regions of the egg and to different
cleavage cells may be easily followed, and even photographed,
while in the living condition. The peripheral layer of proto
plasm is yellow and it gathers at the lower pole of the egg,
where the sperm enters, forming a yellow cap. This yellow
substance then moves, following the sperm nucleus, up to the
equator of the egg on the posterior side, and there forms a yel
low crescent extending around the posterior side of the egg.
On the anterior side of the egg a gray crescent is formed in
a somewhat similar manner, and at the lower pole between
these two crescents is a slate-blue substance, while at the up
per pole is an area of colorless protoplasm. The yellow cres
cent goes into cleavage cells which become muscle and meso-
derm, the gray crescent into cells which become nervous sys
tem and notochord, the slate-blue substance into endoderm
cells, and the colorless substance into ectoderm cells. Thus
within a few minutes after the fertilization of the egg, and be
fore or immediately after the first cleavage, the anterior and
posterior, dorsal and ventral, right and left poles are clearly
distinguishable, and the substances which will give rise to ec
toderm, endoderm, mesoderm, muscles, notochord, and nervous
system are plainly visible in their characteristic positions."
Conklin followed these cells in every division until the em
bryo was developed, making a complete genealogy up to the
ovum proper.

De Vries 31 assumed that the character of each cell is de
termined by "Pangens" that migrate from the nucleus into
the protoplasm. Driesch and Oscar Hertwig held that the
peculiar development of a given blastomere is a result of its
relation to the remainder of the cell-mass, an outcome of the
action upon it by the whole sytem of cells of which it is a
part. Hertwig said : 32 "Each of the first two blastomeres con
tains the formative and differentiating forces not simply for
the production of a half -body, but for the entire organism;
the left blastomere develops into the left half of the body
only because it is placed in relation to a right blastomere."

* Iniracelluldre Pangenesis. Jena, 1889.
"Jenaische Zeitschrift, 1892, 1.

70 THE ETHICS OF MEDICAL HOMICIDE

Wilson 33 and Driesch 34 came to the same conclusion about
the time Hertwig wrote. Driesch said : 85 "The relative po
sition of a blastomere in the whole determines in general what
develops from it; if its position be changed it gives rise to
something different; in other words, its prospective value is
a function of its position."

A discussion of this matter will be found in Wilson,86 but
the many experiments made in the study of this subject show
conclusively that the cells, singly, grouped, and in mass, are
a morphological unit, not an aggregation of distinct individ
uals. They are not, of course, absolutely homogeneous, be
cause such a body could not have organs. The substantial
form, therefore, is not confined to the first cell.

The cell-mass, then, has a unity sufficient to be the recep
tacle of a human vital principle ; again, the basic vital operation
of the human body at any age is metabolism, and this is ac
tually carried on in the first somatic cell of the embryo as in
the cells of the adult man. In the development of the human
body in the embryonal stage the energy of cell-division is
most intense in the early cleavage stage, and this diminishes as
the limit of growth approaches because further division is not
needed. When that limit is attained a more or less definite
equilibrium is established. Some of the cells in the fully
formed body cease to divide, the nerve-cells, for example;
others divide under special conditions, as the blood-cells, the
connective-tissue cells, gland-cells, epithelial and muscle cells;
others continue to divide throughout life and thus replace
worn-out cells of the same tissue, as the Malpighian layer of
the skin. Cells grow, divide, function, reproduce themselves,
and so on, all through their vital activity, sustained by the
material brought to them by the blood. Weismann 37 and
other biologists think that the vital processes of the higher
animals are accompanied by a renewal of the morphological

"Journal of Morphology, 1893, 1894.

* Studien, iv, p. 25.
KIUd., p. 39.

* The Cell in Development and Inheritance, pp. 413 et seq. New
York, 1906.

17 The Duration of Life.

WHEN DOES HUMAN LIFE BEGIN? 71

elements in most tissues. The material is carried to the fetus
in the womb by various agents, but mostly by the maternal
blood after the embryo uses up the yolk; and when the fetal
circulation has been established the nutritive material is taken
from the maternal blood into the fetal circulation through the
placenta, and then carried to the cells by the fetal circula
tion itself. After the child has been born the stomach and in
testines take in the food. The stomach does very little with it
except in a preparatory manner; the intestines further pre
pare it, pass it into the body, where it is again modified by
other organs, and finally it is carried by the blood to the cells.
The cells really use it; the other organs are the farmers, gro
cers, railways, and the like; the cells are the consumers. So
far as the essential processes are concerned, the embryological
cells act as do the adult cells.

The first cell has contractility, protoplasmic motion; it
can absorb perfectly all food-stuffs necessary for it from the
deutoplasm of the ovum, and the water that passes in from
without to the ovum. In a few days the embryonic cells have
used up the deutoplasm and are taking up food from the ma
ternal blood as perfectly as any adult cell does, and are exer
cising their function of building up and sustaining whatever
part of the body they are destined for; and this with all the
complicated metabolism of the adult cell. Cell metabolism
is the fundamental, chief, organic act of any human body at
any age. That the embryo does this impelled by the virtus
formativa transmitted from the parents is a mere gratuitous
assumption to fit the theory that the embryonic cell lacks or
ganic power. The fundamental organ that conserves the body
in its very existence under the government of the soul is the
apparatus which effects metabolism. Incessant chemico-vital
change is a characteristic of all living substances, from the
single cell up to the adult man; and in all cases this activity
has to do with a transformation of the complex molecules
which build up the protoplasm or are associated with its op
erations. The totality of the chemical changes, or exchanges,
in living cells, the transformation of unorganized food ma
terials so that these may be assimilated, and the chemical proc-

72

esses in the tissues themselves, all are metabolism. Growth
and repair (anabolism) occur side by side with the destruction
of elementary tissue substance (katabolism), and the dura
tion of life rests on these processes; and all are mere cell ac
tivities. Food-stuffs (water, inorganic salts, proteids, albumi
noids, carbohydrates, and fats) undergo more or less combus
tion or oxidation. Oxygen unites with carbon to form carbon
dioxide, and with hydrogen to form water; the nitrogen of
the highly complex proteid substances reappears in combina
tion with carbon, hydrogen, and oxygen as urea, uric acid, and
other compounds; and other ingesta are thus transformed
through oxidation. All maintain the temperature of the body,
replace outworn parts, and accomplish the body's work. Oxi
dation occurs to a slight extent in the blood, but the specific
reactions are intracellular. Even when nothing exists but the
cells and the blood, as in the beginning embryo, the cells really
do the work, and they do the work as they do in the adult.

The cells also from the very beginning are the organs
that make the animal heat necessary for life. Rubner 38 proved
that the source of at least 90 per cent, of the animal heat in
the body is a result of the chemical changes — oxidation — in
the food ingested: the other 10 per cent, is caused by muscular
contractions, the flow of blood, the friction of joints, and like
motions. This oxidation is more active in young animals
than in adults, and in each it is, of course, a cellular process.

Living matter contains hydrogen, oxygen, sulphur, chlo
rine, iodine, fluorine, nitrogen, phosphorus, carbon, silicon, po
tassium, sodium, calcium, magnesium, and iron. The removal
of one of these elements causes the death of the body. They
must be arranged in a definite, prescribed order to constitute
cellular protoplasm, and any disarrangement of this order
causes intoxication, disease, or death. Hydrogen is a constant
product in the putrefaction of animal matter, of animal food,
and is present in the intestinal tract. Oxygen is found dis
solved in water and loosely combined in blood as pxyhemoglobin.
All the elements, except fluorine, combine with oxygen, form
ing oxides, and the process is called oxidation. The produc-
" Zeitschrift f. Biologic, 1893, bd. 30, p. 73.

WHEN DOES HUMAN LIFE BEGIN? 73

tion of heat and all vital motion depend on oxidation, decom
position of matter. In the nuclei of cells there is a so-called
"oxygen-carrier," a micleo-proteid, which contains iron, and
this appears to be the chief oxidizing agent in the body.
Chlorine, which in hydrochloric acid is essential to digestion,
is ingested as chloride, and leaves the body chiefly through
the urine and sweat. Iodine is a necessary part of the thyroid
gland, an indispensable vital organ. Fluorine is found in all
cells. Nitrogen goes into the body combined in proteids; and
phosphorus, combined in the alkalies and alkaline earths of
the foods. Carbon occurs in all cells and leaves them through
the lungs as carbon dioxide.

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

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

74 THE ETHICS OF MEDICAL HOMICIDE

why it should not he present, hut many why it should, it is
present.

Conklin says : 39 "The fertilized egg of a star-fish, or frog,
or man is not a different individual from the adult form into
which it develops, rather it is a star-fish, a frog, or a human
being in the one-celled stage. This fertilized egg fuses with
no other cells, it takes into itself no living substance, but man
ufactures its own protoplasm from food substances; it receives
food and oxygen from without and it gives out carbonic acid
and other waste products; it is sensitive to certain alterations
in the environment, such as thermal, chemical, and electrical
changes — it is, in short, a distinct living thing, an individual
ity. Under proper environmental conditions this fertilized
egg-cell develops, step by step, without the addition of any
thing from the outside except food, water, oxygen, and such
other raw materials as are necessary to the life of any adult
animal, into the immensely complex body of a star-fish, a frog,
or a man. At the same time, from the relatively simple re
actions and activities of the fertilized egg there develop, step
by step, without the addition of anything from without except
raw materials and environmental stimuli, the multifarious ac
tivities, reactions, instincts, habits, and intelligence of the
mature animal."

An objection to the opinion that the soul is in the embryo
from the beginning is made from a consideration of the facts
that there appears to be an aptitude for life in certain animal
cells and tissues after removal from the original host, or after
the death of the host; and, secondly, that in other separated
tissues life is undoubtedly made evident under proper condi
tions. Some parts of the human body can be grafted upon
another human body, and human sarcomatous cells have been
made to grow in vitro. Hair often lengthens after the death
of a person, if no embalming fluid has been injected. Dr.
Alexis Carrel 40 substituted a piece of a popliteal artery, taken
from an amputated human leg and kept in cold storage for

"Heredity and Environment.

"Journal of the American Medical Association, vol. lix, n. 7,
p. 523.

WHEN DOES HUMAN LIFE BEGIN? 75

twenty-four days, for a part of the aorta of a small bitch, and
the dog lived for four years afterward and died in parturition.
Magitot of Paris, in 1911, took a piece of the cornea from an
extirpated human eye, and with it replaced a part of an opaque
cornea on another man, and this second man could see through
the new cornea. Surgeons now remove skin, bone, and other
tissues from still-born infants and accident cases, preserve
these, for weeks if necessary, in petrolate and Ringer's solu
tion in cold storage, and then graft them on patients to repair
lesions in skin, bone, cartilage, or other parts of the body.

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

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

The vital principle in a man, or in anything else, is at the
end, when it normally issues, of the same nature as it was in
the beginning. If it is at perfection a substantial primary
form, it always was such — a substantial form cannot issue
from an accidental form. If the substantial form is the form
of the cells in the completed organism, it was such before that

76 THE ETHICS OF MEDICAL HOMICIDE

organism was perfected, unless it replaced a lower substantial
form; but there is, we repeat, absolutely no need for such a
secondary form at the beginning. If the cells of the embryo
(not the infused germ-cells, which are not the embryo) had
a forma corporeitaiis, or cellular is, or whatever you wish to
call it, the human soul when it did come would not confer pri
mal existence, would not be a forma subsianiialis, but an
accidental form. "In proof of which," says St. Thomas,41
"we must consider that a substantial form differs from an ac
cidental form in this, that an accidental form does not give
being simply, but such or such being; as heat does not give
being simply, but heated being. So when an accidental form
comes in, a thing is not said to come into existence or to be
generated, simply, but to become such or such an object, or
to find itself in such or such a condition. So, also, when an ac
cidental form disappears, a thing is not said to be destroyed
simply, but only to a certain degree. A substantial form,
however, gives being simply; and therefore by its advent a
thing is said to be generated simply, and by its recession to be
destroyed simply. Jf, therefore, it happened that any sub
stantial form other than the intellectual soul preexisted in
matter, by which the subject of that soul would come into ac
tual being, it would follow that the soul would not confer be
ing simply, and therefore would not be a substantial form;
also that the coming of the soul would not be a generation
simply, but only secundum quid — all of which is evidently
false." Again, St. Thomas says:42 "Some tell us the vital
acts that appear in the embryo are not from the soul, but from
the soul of the mother, or from the primitive force in the
semen. Both these statements are false."

An application of the opinion offered here — that is, that
the human soul is infused at the instant of conception — to mul
tiple and monstrous embryos offers no real difficulty. There
are two kinds of human twins — those from two distinct ova
and those from one ovum. Two ova may come from one or
different ovaries, or even from one Graafian follicle, be ferti-

41 1, q. 76, corp.

tt la, q. 118, a. 2, ad 2.

WHEN DOES HUMAN LIFE BEGIN? 77

lized at the same time and develop synchronously. If the
ova are placed at some distance apart in the uterus, two pla
centas appear ; if the ova are near each other the placentas may
fuse, but their circulations do not. Each child will have its
own fetal envelope.

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

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

Some followers of the splitting theory hold that double
monsters arise from the union of two originally separate prim
itive traces (Verwachsungstheorie}. Others say that a single
primitive trace of blastoderm cleaves more or less thoroughly
and makes the double monster (Spaltungstheorie'). The earli
est human double monster (Ahlfeld's case) was in -the fourth
week of gestation; therefore whatever is held in these theories

78 THE ETHICS OF MEDICAL HOMICIDE

as regards human monsters is only through analogy with lower
animals.

Gerlach 43 saw bifurcation at the cephalic end of a chicken
embryo sixteen hours old. In this case the first change was a
broadening of the anterior end of the primitive streak; next a
forked divergence appeared, and by the twenty-sixth hour the
bifurcation was half as long as the undivided posterior part.
Whether this was a case of two nuclei or not is not known.

What seems to make for the fission theory is that in
non-parasitic double terata, no matter how unequally nour
ished or how variable in extent, the union between the halves of
double monsters is symmetric, and the same part of each twin
is joined. This fact is used as a reason to exclude a fortui
tous growing together of dissimilar areas of cell-masses, at
least in non-parasitic cases. Born,44 in a study of fish ova,
found that eggs which produce double monsters begin with a
segmentation like that of the simple normal ovum. Composite
spermatozoa have been observed with two and three heads and
one body and tail-piece, but the significance of these abnormal
cells is not known.

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

Up to a certain stage of development the blastomeres of
the Medusa embryo are totipotent, or capable of developing
into any part of the body. The limitation of development
in a particular case lies in the cytoplasm rather than in the
nuclei of the cells. If frogs' eggs are fastened in abnormal
positions, inverted or on the side, a rearrangement of the egg
material results, wherein the nucleus and cytoplasm rise and
the deutoplasm sinks. This change of axis shifts the embryo.

" U. d. Entstehungsweise der vordern Verdoppelung. Deutsch.
Archiv. f. Uin. Ned., 1887.

44 U. d. Furchung des Eies "bei Doppelbildungen. Breslauer Aertz-
liche Zeitschrift, 1887.

WHEN DOES HUMAN XIFE BEGIN? 79

If an egg is turned upside down in the two-cell stage, a whole
embryo, or half a double embryo, may arise from each of the
two blastomeres, instead of a normal half-embryo. A half-
embryo or a whole dwarf may arise according to the artificial
position of the blastomere. Each of the two blastomeres con
tains all the materials potentially for the formation of the
whole body, and these materials build up a whole body or a
half body according to the grouping they take on. Primarily
the egg cytoplasm, in low forms of animal life, is totipotent;
it has no fixed relation with the parts to which it gives rise,
and may be artificially modified or differentiated. These ef
fects, from position and traumatic dislocation, suggest expla
nations for teratic forms in higher animals.

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

Terata more properly so called may be single, double, or
triple; and single monsters may be autositic or independent
of another fetus, or they may be omphalositic, dependent upon
another which is commonly well developed and which supplies
blood for both through the umbilical vessels. There are four
genera of autositic single monsters, with eight species and
thirty-four varieties. Of the monstra per defectum the com
monest are caused by a failure of closure in the embryonal
medullary canal, which leaves part of the brain and spinal
<x>rd or their bony covering lacking. Some terata, as the Ace-
phalia, have no brain or spinal cord, but they die in the fetal
stage. The Anencephalia may have a spinal cord, a medulla
oblongata, and parts of the basal ganglia, but the cerebral hem
ispheres are wanting. Such monsters are sometimes born at

80 THE ETHICS OF MEDICAL HOMICIDE

term and live for several days : they cry, suckle, show some re
flexes and a sense of pain, and move the arms and legs.

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

We can artificially obtain double embryos of frogs by in
verting the blast omeres in the two-cell stage.46 We thus get

49 Chap, vi, p. 69. New York, 1906.
* See Wilson, op. cit., p. 421.

81

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

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

The Rituale Romanum Pauli V 47 gives the following di
rections for the baptizing of human terata:

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

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

4T Tit. ii, cap. 1, nn. 18, 19, 20, 21.

82 THE ETHICS OF MEDICAL HOMICIDE

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

"21. Quando vero non est certum in monstro duas esse
personas, ut quia duo capita et duo pectora non babet distinc-
ta; tune debet primus unus absolute baptizari, et postea alter
sub conditione, boc modo : Si non es baptizatus, ego te baptizo
in nomine Patris, et Filii, et Spiritus Sancti."

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

CHAPTER IV

WHEN DOES HUMAN LIFE END?

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

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

The stimulus of the heart-beat probably starts at the junc
ture of the superior vena cava with the right auricle of the
heart. Some biologists think that in this spot life takes its
last stand before the final retreat, but that fact is disputed of
late. In the hospital of the Rockefeller Institute for Medical
Research in New York, Dr. G. Canby Robinson l made records

1 A Study with the Electrocardiograph of the Mode of Death of
the Human Heart. Journal of Experimental Medicine, 1912, xvi,
291.

83

84: THE ETHICS OF MEDICAL HOMICIDE

from about eight patients before and during the actual stop
ping of the heart, using the electrocardiograph, which can be
employed without disturbing the patient. He thus found —
only in one case, however — that the heart may beat for a half
hour after all vascular and circulatory sounds have ceased to
be audible. In a letter to me Dr. Robinson said : "Undoubt
edly the heart continues to show activity sufficient to be re
corded by the string galvanometer very frequently after res
piration has ceased, both in man and the lower animals; but
this does not necessarily mean that it continues to be an effi
cient pump, maintaining the circulation. Undoubtedly also
in other instances the cardiac activity ceases before the respira
tion, but I have never obtained electrocardiographic records of
such cases."

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

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

WHEN DOES HUMAN LIFE END? 85

In Essays in Pastoral Medicine 2 I mentioned several cases
of resuscitation after what had appeared to be certain death.
Two of these had been "dead" for forty-five minutes before
they were revived temporarily. Wayne Babcock 3 reported
a number of new cases of his own. One was a resuscitation
which lasted for forty-three hours, and which was begun twenty-
five minutes after respiration had ceased. The patient was
a very fat negress who had collapsed after the use of scopo-
lamine. A man whose arm had been torn off died from shock
in the operating-room. After fifteen minutes of artificial res
piration the circulation started again, and he was kept alive
for six hours in this manner, but he died as soon as the artifi
cial respiration was discontinued. An exactly similar case
was kept alive for seven hours by artificial respiration. One
of Babcock's cases was a woman of eighty-seven years of age,
who apparently died on the table during an operation for
strangulated hernia. After ten minutes of cardiac and respir
atory cessation she was revived. She died four days later of
peritonitis. A man fifty-six years of age undergoing the same
operation ceased breathing and his heart stopped. He was
completely revived and cured.

Father Juan Ferreres 4 holds that aborted and newly born
children should be baptized, although they give no sign of life,
if they show no clear evidence of putrefaction. This opinion
is mine also, but the word maceration should be substituted as
more exact. Eschbach 5 says : "Infantes recenter natos et in
vitae discrimine positos, aut foetus abortivos plane formates,
cum vel levissimus in eis motus apprehenditur, absolute
baptizari oportet: cum autem sine motu et sensu iidem videan-
tur neque tamen adhuc corrupti aut putrefacti sint, sine mora
baptizentur conditionate : Si vivis, ego te baptizo, etc." These
quotations give the common opinion of moralists at present, and
this opinion is fully safe Eschbach, however, would have
the fetus "plane formatus," which is erroneous and an echo
of the old Aristotelian notion. If the fetus is visible at all,

1 New York, 1906, p. 164.

'Proceedings of the American Therapeutic Society, 1912.
'La Muerte Real y Apparente, 4th ed., p. 21. Madrid, 1911.
• Quaestiones Physiologicae-Theologicae, disp. 3, p. 2, c. 3, a. 3.

86 THE ETHICS OF MEDICAL HOMICIDE

open the membranes and baptize it conditionally, even if it is
not as big as a pea.

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

Ferreres mistakes cases of catalepsy which have recovered
consciousness for cases of apparent somatic death. In these
cataleptic conditions the blood circulation does not completely
cease — if it did the nervous centres would be disintegrated.
The case he reports on p. 2G,6 of the woman resuscitated by
Rigaudeaux in 1748, was one of catalepsy, if it ever happened.
The same is true of the case from Gaspar de los Reyes,7 which
probably had some foundation in a condition of catalepsy, but
which more probably is a sheer invention by Reyes. It looks
like an anecdote from a medieval Florentine novella.

Old writers speak of cessation of the pulse for long periods.
Ballonius 8 mentions a person in whom there was no pulse for
fourteen days before death ; Ramazzini 9 describes a cessation
of the pulse for four days before dissolution ; Schenck 10 tells
of a disappearance of the pulse for three days, with recovery.
These all were apparently cataleptic cases, where the circula
tion was very feeble and the radial pulse was not palpable.
Cheyne gives an account of a Colonel Townsend who had the
power of apparently dying at will. He could so suspend the
heart action that no pulse could be felt, and after a short while
the circulation would become normal again. The longest period
in which he remained in this condition was about thirty min
utes. St. Augustine mentions a priest named Rutilutus who
had a power like that of Colonel Townsend, and Caille n re
ported a similar case.

The fakirs of India carry this power to great lengths.
Braid,12 on the authority of a Sir Claude Wade, says a fakir
was buried unconscious at Lahore in 1837, and the grave was

* P. 30 in the English translation.
TP. 35; p. 39, English translation.

* Opera Medico, Omnia. Geneva, 1762.
8 Epistolae, 1692.

10 Observationum Medicarum, etc. Frankfort, 1600.
u New Orleans Medical and Surgical Journal, xvi.
" Treatise on Human Hibernation, 1850.

WHEN" DOES HUMAN LIFE END? 87

guarded day and night by sentinels from an English regiment.
Six weeks after the burial the man was dug up and he pre
sented all the appearance of a corpse. The legs and arms were
shrunken and stiff, and the head reclined on the shoulder, as
happens in corpses. There was no perceptible circulation any
where, yet he revived.

Honigberger, a German physician in the service of Run-
jeet Singh, described 13 a fakir of the Punjaub who was put
into a sealed vault for forty days, and the seal of Runjeet
Singh was on the coffin. Grain was sown above the vault and
it was well above the ground when the man was taken out of
the vault and resuscitated. Sir Henry Lawrence testified to
the truth of this story. The fakir's chin was shaved, Honig
berger says, before the burial, and the beard did not grow
while he was in the vault.

In keeping with these stories are many curious accounts
of recovery after hanging. These are frequent in writings of
the sixteenth and seventeenth centuries, when hanging was
almost an every-day occurrence. These narratives are much
more authentic than the anecdotes told of recovery after pre
mature burial, which are as old as literature. Paul Zacchias14
tells of a young man who died of the plague and was set out
with the corpses for burial. He revived and was taken back
to the pest-house. He "died" again and was again prepared
for the grave, but he came to a second time. The stock story
in these premature burial cases is that of the woman who is
revived by a thief who cuts her finger in an effort to steal the
rings buried with her.

The important fact, however, is that in any case of death
the exact moment in which the soul leaves the body is not know-
able by any means we have at present, and where there is
question of giving the sacraments the person apparently dead
should have the benefit of the doubt. He is to receive condi
tional baptism, absolution, or extreme unction (preferably by
the short method), in case these sacraments are required. For
a whole hour after apparent death the probability that the

a Medical Times and Gazette, vol. i. London, 1870.
" Quaestiones Medico-Legales, 1701.

88 THE ETHICS OF MEDICAL HOMICIDE

soul has not departed is so strong that, in my opinion, a priest
who does not give the necessary sacraments is virtually as
guilty as if he neglected to administer them to a person evi
dently alive. Crile, one of the best medical authorities on
this matter of somatic death, holds that the human respiratory
system may survive anemia for from thirty to fifty minutes.
How long after the hour a priest may administer the sacra
ments is not known, but a second hour, or even a third, are not
unreasonable periods of time during which the sacraments may
be administered conditionally. The sacraments are for man,
and there is no irreverence if they are administered condition
ally and the priest explains to the bystanders the reason he has
for his action.

If a pregnant woman dies slowly, the fetus in her womb
is likely to die owing to lack of oxygen; if she dies suddenly,
the child may live for variable periods in various cases.
Brotherton reported a case where a living child was taken from
a woman twenty-three minutes after the death of the mother.
Tarnier, the noted French obstetrician, told of a remarkable
incident which happened in Paris during the rioting by the
Commune after the war of 1870. The rioters fired on a ma
ternity hospital, and a pregnant woman sitting on a bed in a
ward was instantly killed by a bullet through her head. After
a while she was discovered dead, and Tarnier was sent for to
save the fetus, as its heart-sounds could be heard through the
abdominal wall. When he began the operation the hospital
was fired upon again, and it was necessary to carry the corpse
to the cellar of the building. There Tarnier, an hour and
three quarters at least after the death of the women, extracted
a living child from the corpse. Hirst15 tells of another case
which was narrated to him by an American naval surgeon who
saw it in the harbor of Rio Janeiro during the revolution at
the beginning of the present republic of Brazil. A woman
near term was killed instantly by a piece of shell. As soon
as she fell to the ground a Brazilian surgeon, who was standing
near by, cut open her abdomen with a penknife and drew out
the child, but it was already dead.

" A Textbook of Obstetrics, 7th ed., p. 643. Philadelphia, 1912.

WHEN DOES HUMAN LIFE END? 89

Mack18 was called to a pregnant woman, and he found
she had died suddenly about five minutes before he arrived.
He at once opened the uterus with a small lancet and extracted
a child which was beyond the livid stage and had no heart-
sound. He worked on the child for forty minutes, using the
ordinary methods for reviving asphyxiated children, but got no
sign of life. Then he injected a hypodermic syringeful of a
1 :1000 epinephrin solution through the umbilical cord into the
abdomen and continued the reviving motions. In ten min
utes the child was crying vigorously, and it was a healthy
baby afterward.

Gunn and Martin,17 in experiments on rabbits poisoned
by chloroform and apparently dead, found they could resusci
tate about 70 per cent of the animals if treatment was begun
within ten minutes after the heart ceased beating. They
started artificial respiration through a tube in the trachea,
then injected epinephrin into the pericardium, and afterward
massaged the heart through an opening in the abdomen. The
rate of compression of the heart in this massage must be some
what less than half that of the normal beat, and at short in
tervals the massage is to be stopped to allow the spontaneous
beats to develop. Compression should be gradual and the
relaxation abrupt. The massage is applied by one of these
four methods, and they are arranged here in the order of their
efficiency: (1) by direct compression of the heart through an
opening in the thorax; (2) by compression above the dia
phragm through an opening in the belly-wall; (3) by simple
compression of the abdomen; (4) by simple compression of the
thorax. Epinephrin, or pituitary extract, is used as an ad
juvant intravenously to increase the cardiac movement after it
has been started. The same methods will probably be effective
in man, and have been used successfully.

When a woman is in articulo mortis with a living fetus in
her womb, one should not wait for her death. If one waits, he

"Journal of the American Medical Association, August 28, 1915.
" Journal of Pharmacology and Experimental Therapeutics. Bal
timore, July, 1915.

90 THE ETHICS OF MEDICAL HOMICIDE

will nearly always lose the child. The cervix should be dilated
forcibly, the child turned and delivered. Even if this forcible
delivery should happen to hasten somewhat the mother's death,
the action would be morally licit. jit would be a double-effect
action; the two effects would proceed immediately and equally
from the act, which is indifferent morally; one effect, the
good one, is to save the child for baptism at least, and pos
sibly permanently; the second, evil but reluctantly permitted,
is the possible hastening of the maternal death. I should be
willing even to slit the cervix, if necessary, provided the diag
nosis were certain, with the possibility of tearing the uterus,
in a case where the dilatation of the cervix would be too slow
a method; but this supposition is scarcely practical.

Zsako * 8 gives a method for determining the interval since
death by muscular phenomena. Tapping with a percussion
hammer on certain muscles of the body excites a reflex contrac
tion up to from an hour and a half to two hours after death.
The contraction may be elicited in the same manner on the
living, but it is more evident on a cadaver owing to the ab
sence of antagonistic 'tonus in the muscles. Some muscles
may move for four hours after death. Tapping along the
radius from the elbow downward, he says, a point is found
where the stroke causes extension of the hand; tapping along
the radius above the wrist makes the thumb bend; tapping on
the spaces between the bones of the hand closes up the corre
sponding fingers; tapping on the back of the foot extends the
toes, on the leg adducts the foot, on the tibia along the middle
third extends the leg. "When the lower third of the thigh is
tapped across the muscles move, and if the back is struck be
tween the scapula and the spine the shoulder blades move to
ward each other. If there is no response the person must be
dead from two to four hours. I have had no experience with
this method.

Satre 19 reported that many soldiers brought into the dress
ing-stations apparently dead from shock, head or spinal
wounds, or gas asphyxiation, were revived after artificial res-

"Miinchener medizinische Wochcnschrift, January 18, 1916.
" Presse Medicale, Paris, xxiv, 66.

WHEN DOES HUMAN LIFE END? 91

piration had been applied, sometimes for even six hours before
results were obtained. Two tests were used to find out whether
the patient was alive or not. In such cases ten c.c. of a 20 per
cent, alkaline solution of fluorescine is injected subcutaneously,
and if there is any circulation this dye will be carried to the
eye and turn the conjunctiva green. The second test is to push
a fine puncture-needle into the spleen or liver and thus re
move a particle of the pulp. This pulp is put on blue litmus-
paper and drawn free from blood. If the litmus-paper turns
red the man is dead; if it remains blue he is alive. The re
action of the living pulp is alkaline, blue; this becomes acid,
red, a half -hour after death; an hour after death the acid
reaction is quite marked.

CHAPTER V
ABORTION

A3ORTIOX, as the term is used by physicians, in its
widest sense is the ejection or extraction of a fetus from
the womb at any time before term. The word is popularly
contrasted with miscarriage, where the fetus is ejected through
disease or accident; abortion in the lay sense supposes arti
ficial, and commonly criminal, extraction of the fetus. Abor
tion (from dboriri, to perish) etymologically has an associa
tion with destruction of life, but the name is given by physi
cians to a removal of any premature fetus, even if it is viable.
Strictly, however, abortion is an interruption of pregnancy
before the fetus is viable, and premature labor is such an in
terruption after the fetus is viable. Throughout this chapter
the words are used in this sense.

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

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

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

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

92

ABORTION" 93

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

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

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

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

94 THE ETHICS OF MEDICAL HOMICIDE

emesis gravidarum, eclampsia, chorea, hepatic autolysis, and
impetigo herpetiformis.

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

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

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

ABORTION 95

convenience is a much less evil than total anesthesia, even when
there is no pregnancy. It is probable that total anesthesia is
morally unjustifiable for the extraction of a single tooth if the
tooth is not wedged in.

Violence, accidental or intentional, is a frequent primary
or secondary cause of abortion. Sometimes a slight jar, a
misstep on a stairway, a nervous shock, a jump from a carriage-
step, lifting weights, running sewing-machines, sea-bathing, a
rough automobile ride, will bring on an abortion where there
is a predisposition. Often in healthy women, on the other
hand, extreme violence does not interrupt pregnancy. Sur
gical operations are classed here with violence. In a neurotic
woman a slight operation on an organ not directly connected
with the uterus will start expulsive contractions. Again, 66
per cent, of operations on ovarian tumors during pregnancy
have left the uterus undisturbed. De Lee says he has removed
fibroids from the pregnant uterus, once even exposing the
chorion, and has amputated the cervix of a gravid uterus, with
out interrupting pregnancy. Several cases have occurred
where both ovaries have been removed during pregnancy with
out abortion. The breast has been amputated and a kidney
removed from a pregnant woman * without disturbing the preg
nancy. Wiener 2 did eleven operations for ovarian tumors dur
ing pregnancy with only two abortions. Von Hoist 3 removed
a myoma weighing two and a half pounds from the uterus at
the seventh month of gestation without abortion. Davis of
Birmingham, Alabama, reported 4 that a woman three and a
half months pregnant was shot in the abdomen. The rifle
bullet made twenty-five perforations in her intestines. She
was taken eighty-five miles, and then Davis cut out five feet
of the intestine. She recovered and gave birth to a living
child at term.

Double ovariotomy brings on abortion in the early months
of pregnancy oftener than in the later, probably from the loss
of the corpus luteum, which, it appears, is necessary for the

1Cronk, Oklahoma State Med. Assoc. Jour., July, 1816.
1 Amer. Jour. Obstet., August, 1915.

3 Upsala Ldkareforenings Forhandlingar, xxi, 8.

4 Journal Amer. Med. Assoc., October 28, 1916.

96 THE ETHICS OF MEDICAL HOMICIDE

growth of the uterus. Appendicitis and appendectomy are
especially likely to interrupt gestation, apparently as a
result of infection and because pregnant women are prone
to defer operation. The traumatism of criminal abortion,
punctures and lacerations from bougies and curettes, and the
exhibition of drugs like ergot and cantharides, are sources and
results of abortion. Drugs will not empty the uterus unless
they are given in poisonous doses which endanger the woman's
life.

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

Coition during gestation is a cause of abortion, and the
fault here, as a rule, lies with the husband. St. Thomas 5
said: "St. Jerome protests against the sexual approach of the
husband to his gravid wife, not that in this condition such an
act is always a mortal sin, unless there is probable danger of
abortion." St. Alphonsus 6 says if there is danger of abor
tion the use of the debitum is a grave sin. In n. 924 he again
teaches that while it is true that if by the use of the debitum
the life or formation of the fetus is endangered or checked the
right to the use of the debitum is, in such circumstances, lost,
yet he thinks that in pregnancy there is little danger of abor
tion from this cause, especially near term.

Sabetti-Barrett 7 says the wife is excused from the debitum
conjugale if the husband is drunk, or if there is a rational
dread of grave injury, or grave danger to health. Genicot8

'In. 4, dist. 81.

* Theologia Moralis, n. 943.
f Theologia Moralis, n. 936.

* Theologiae Moralis Institutiones, vol. ii, n. 544.

ABORTION 97

thinks that in pregnancy it "can scarcely be shown that there
is a notable danger of abortion." Lehmkuhl 9 holds that a
married person is not obliged to grant the debitum if there is
great danger of abortion; but, he adds, "Even then, if there
is a grave danger of incontinence I do not think it certain that
there is an absolute obligation to abstain."

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

* Compendium Theologiae Moralis, n. 1114.

98 THE ETHICS OF MEDICAL HOMICIDE

is rendered septic, because then the membranes are no protec
tion at all.

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

Coition during pregnancy is unnatural because it neces
sarily fails of the end of coition, which is procreation. Cu
riously, too, all the lower animals instinctively appear to avoid
this act during pregnancy. Men should be told that marriage
has restraints as well as celibacy. Women are reminded of
the law of the debitum, but not of the occasions when they are
even obliged to deny it. If a man cannot keep continent in
the presence of his pregnant wife, let him live in another part
of the house. Regard for the woman is lacking in many ways.
Young girls often marry without having the faintest notion of
sexual life, and they are panic-stricken when assaulted. I
have known two who were frightened into insanity. Priests
should tell young married men that they are human beings,
not animals; that they should act like rational beings when
they are first married; and that after the wife has become
pregnant the husband should not be the cause of abortion in
the first three months, nor of puerperal sepsis in the last three

ABORTION" 99

months. Priestley, 10 in 2325 pregnancies, found one abortion
in every four pregnancies ; Guillemot and Devilliers in France,
Hirst in Philadelphia, and others report the same propor
tion. These are natural, not criminal, abortions. If, then, in
normal pregnancies about one child in five is lost before birth,
husbands should be taught a continence which would to some
degree avert this calamity. Superfetation has occurred by
coition during pregnancy, and this results commonly in abor
tion and the death of both fetuses.

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

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

Chronic endometritis, where there is no syphilis, will per-

10 Pathology of Intrauterine Death. London, 1887.
u Munchener medizinische Wochenschrift, Ixii, 39.

100 THE ETHICS OF MEDICAL HOMICIDE

mit habitual abortion, and each abortion makes the condition
worse. Nephritis, diabetes, and other constitutional diseases
cause habitual abortion.

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

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

An abortion may be threatened, inevitable, or incomplete.
In each of these conditions there is uterine pain and hem
orrhage. In inevitable and incomplete abortions we find soft
ening and dilatation of the cervix, and a presentation or ex
pulsion of part or all of the ovum.

In pregnancy uterine hemorrhage and uterine pain are
symptoms of a threatened abortion, but not certain symptoms.
Fromme found that 17.9 per cent, of 157 women who had these
signs in the early months went on to term. If the fact of
pregnancy is not known it is not always easy to differentiate

ABORTION 101

a threatened abortion from other uterine conditions, like chronic
metritis, ectopic gestation, a fibroid or other tumor, hemorrhage
from cervical erosions or varices, or malposition of the uterus.
If the abortion is inevitable the diagnosis is made more read
ily. The cervix is then more or less dilated and the ovum is
palpable. There is rather profuse hemorrhage, flooding, and
painful uterine contractions are evident. The rupture of the
bag of waters may be simulated by the escape of secretions in
hydrorrhoea gravidarum, or the escape of waters may be a
primary symptom of graviditas exochorialis. Hydrorrhoea
gravidarum is an intermittent discharge of clear or bloody
fluid from a catarrhal endometritis under the decidua. It
occurs in anemic, weak women, especially multiparae. In
graviditas exochorialis the fetus is left within the womb but
outside the ruptured chorion, and it may remain there for some
time.

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

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

In threatened abortion examination is to be avoided unless
it is absolutely necessary for diagnosis, and then great gentle
ness is required so as not to excite uterine contractions. The
woman is to rest in bed, not so much as raising her head to take
a drink of water (which is given to her through a tube), and
she is morally obliged to submit to this inconvenience. If she
refuses she is accountable for the death of the fetus. If there

102 THE ETHICS OF MEDICAL HOMICIDE

is bleeding the foot of the bed should be elevated as in hem
orrhage in typhoid fever. The routine practice is to quiet
the woman and the uterine irritability with morphine and other
opium derivatives. Children are readily overwhelmed by opium
because their circulation is not sufficient to neutralize the de
oxidizing effects of the drug up to safety. While the embryo
is connected with the maternal circulation through the placenta
the mother's circulation often safeguards the fetus from the
effects of the opium. The danger to the child in such cases
begins from the opium remaining in its circulation after the
child has been separated from the mother. Often, however,
fetuses in cases where scopolamine and morphine have been
used on the mother during labor are born badly, and even
fatally narcotized, despite the connection with the maternal
circulation. Nevertheless, even if there is some real danger
to the fetus from the use of morphine in a threatened abor
tion, the cautious use of this drug would be morally justifiable.
Should the threatened abortion go on to actual abortion, the
fetus will certainly be killed, but the use of morphine on the
woman is the best and virtually the only means we have to avert
a threatened abortion and so save the fetal life. The imme
diate double effect from the morally indifferent act of giving
a dose of morphine is, on the good side, the saving of the fetal
life, and on the other, the evil side, the danger of fetal nar
cosis, which is not at all certain to follow. Evidently, the good
intended effect far overbalances the evil and somewhat hypo
thetical effect.

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

If the bleeding starts again every time the woman goes
about her duties, the abortion may be inevitable. When the

ABORTION 103

cervix is shortened and dilated so that the ovum is palpable
and pieces of the decidua or ovum are expelled, the hemorrhage
is more or less profuse, and especially if the bag of waters has
ruptured and uterine contractions show, the abortion is deemed
inevitable. In such a case the fetus may be alive, or it may
be dead; and, again, conditions which show all the classic
symptoms of inevitable abortion sometimes, though rarely, do
not go on to abortion. It is extremely difficult, and often im
possible, to tell whether an early fetus is dead or alive. A high,
lasting fever sometimes kills the child; so do low blood-pres
sure, profuse hemorrhages, deoxidation of the blood in pneu
monia, separation of the placenta, fatty degeneration of the
placenta, and the severe infections — in such cases there is al
ways strong probability that the child is dead when the abor
tion shows its symptoms. If the fetal tissues that appear in
dicate maceration, or if the discharge is fetid or purulent, the
fetus is dead. Should the fetus be alive, tamponing the va
gina to check the hemorrhage often separates the fetus from
the uterus by the dissecting force of the blood dammed back,
or in any case tamponing is almost certain to excite uterine
contractions ; thus there is an indirect killing of the fetus.

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

ration of the foot of the bed and the use of morphine will, as
a rule, check the bleeding.

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

Where a tampon must be put in, it is left in from sixteen
to twenty-four hours, even if the temperature goes up. Dur
ing this time there are painful contractions of the uterus, as
a rule, and these are expulsive. Xo drug is to be given to allay
these pains if the intention is to have a dead or viable fetus
expelled. If the pains cease suddenly, this is usually a sign
that the fetus has been expelled above the tampon. When
the tampon is removed and the entire ovum is found, it is best
for the ordinary physician not to meddle with the uterus in
any manner. Some advise that the physician should go over
the uterine lining with a half-sharp curette to make certain
that nothing has been left behind, but this is dangerous advice
to any one who is not an expert obstetrician. Should the tem
perature remain above 100 degrees, the uterus must be cleaned
out, and flushing with uterine catheters is not enough: if the
gloved finger cannot remove the secundines, the curette is
needed.

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

When the retained ovum cannot be removed by the finger
or squeezed out, the free portion of the ovum is to be grasped
by an ovum forceps and gently drawn out. The operator

ABORTION 105

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

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

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

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

In every abortion the presence or absence of extrauterine

106 THE ETHICS OF MEDICAL HOMICIDE

pregnancy is to be made out If there is an extrauterine preg
nancy, curettage will cause rupture of the sac.

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

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

Attention or inattention to the mother's own hygiene dur
ing pregnancy has great effect on the fetus, and care of hy
giene may avert abortion. The woman's dress should be sim
ple and warm enough to prevent congestion from changes in
temperature. Congestions are likely to affect the kidneys, and
care of the renal function is always one of the most important
facts connected with pregnancy. No circular constrictions of
the trunk by lacing or stiff corsets should be attempted. The
corset forces the uterus and child downward into the pelvis
and against the lower abdominal wall, causing congestion of
the pelvic veins and strain on the abdominal muscles. Tight
corsets, preventing the expansion of the uterus and the growth
of the fetus, may cause mutilations like club-foot and wry
neck, or even kill the child. The woman who would "preserve

ABORTION 107

her figure" by corsets, to the mutilation, weakening, or killing
of her unborn infant, and this is an every-day evil, is either
a criminal fool or an unmitigated scoundrel. Tight lacing to
conceal pregnancy is a method of murder. High-heeled shoes
are somewhat injurious because of the constrained position into
which they throw the woman. X-ray photographing of preg
nant women is very likely to cause abortion.

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

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

Cold and hot baths, Turkish and Russian baths, hot sitz-
baths and ocean bathing are not permissible during gestation.
Tepid baths and spongings are to be substituted. Near term
the bath-tub is not safe because of danger of uterine infection
from unclean water. Then shower-baths are better, but these

108 THE ETHICS OF MEDICAL HOMICIDE

are dangerous if the woman must step over an enameled bath
tub side to take them, because she may slip and fall. Vaginal
douches are not to be used in pregnancy except in certain dis
eased conditions, under the direction of a competent physician.

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

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

Some women carry the child beyond term, with the effect
that the baby is overgrown for normal delivery. The head is
harder and more angular than it should be, the long bones
stiffer and less pliable, the muscles tenser. All these changes
make the delivery so difficult that the overgrown child may
be fatally injured at birth. Physicians must be cautious in
believing histories of enormous children at previous births at

ABORTION" 109

which they were not present. Mothers and nurses are likely
to exaggerate the size of infants.

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

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

If haste is not necessary, packing the cervical canal and the
lower uterine segment antiseptically with a strip of gauze three
to five yards long and three inches wide and leaving it in for
about twenty-four hours is one of the best methods. Where
rapid delivery is required, cesarcan section must be employed.
In cases of somewhat less urgency the membranes are first
punctured and balloon dilators are used. In any case puncture

110 THE ETHICS OF MEDICAL HOMICIDE

of the membranes is the most certain method to start labor,
but it has many bad disadvantages. A dry labor in a primi-
para with an undilated cervix is a grave condition. If the fe
tal head is not engaged in the pelvis, puncture must not be at
tempted. When the head is not engaged in the pelvis like a
ball-valve, the cord will prolapse, be pinched, and thus the
blood supply will be cut off from the child and the loss will
kill it. For the same reason, the waters must not be run off
too quickly. Many operators insert a bag, dilate, and so start
the labor, without puncturing the membranes, where there is
no reason for haste.

Therapeutic abortion, as has been said, is never permissi
ble, under any circumstances, if the child is not viable. In
certain conditions, say, when a uterine tumor clearly threatens
the life of the pregnant woman, or if in extrauterine gestation
there is a rupture of the tube, an operation may be permissible,
or even obligatory, which has for its direct end the removal
of the tumor or the stopping of the hemorrhage. If such a
removal or ligation, under these conditions, indirectly causes
the abortion of the inviable fetus, or its death from a lack of
blood, these indirect effects may be reluctantly permitted.
They are cases of an equally immediate double effect, one good
and one evil, where all the requirements are fulfilled. A di
rect abortion of an inviable fetus, however, is never licit even
to save the mother's life, and in abortion the killing is direct
because it is used as a means to an end. In a ruptured ectopic
gestation the primary effect of the physical operation is to li-
gate the torn arteries to save the woman's life here and now;
the secondary effect is the permitted death of the fetus from
the shutting off of the blood supply. In the abortion of a pre
mature fetus the primary effect of the operation is to separate
the placenta from the uterus, to cut off the child's blood supply,
and as a direct consequence of this act, which is essentially
evil, the woman's life is saved. The original act in this abor
tion is evil, and evil may not be done even if good follows.
Even in self-defence against an unjust aggressor Cne may not
kill a man to save his own life — he tries to save his own life
and reluctantly permits the death of the aggressor. In a kill-

AJ30KTION" 111

ing in self-defence there are two distinct effects; in abortion
there is only one effect, and the killing is a means to this one
effect. That you may kill an irresponsible insane man who
is attacking your life, or the life of one entrusted to your
care, is no reason that you may attack a fetus in the womb.
There is no parity. The insane man is a materially unjust
aggressor; the fetus is not an aggressor at all. The mother
placed it where it is; and if any one is an aggressor, she is.
In the abortion you directly kill the fetus and indirectly save
the woman's life, and this indirection uses the death of the
fetus as a means to the end of saving the woman's life. In
killing the insane aggressor you directly save the life of your
self or your ward, and reluctantly permit the death of the
aggressor. The proofs of the essential immorality of direct
homicide have already been established in the general chapter
on Homicide.

The assertion that an undeveloped fetus in the womb is not
as valuable as the mother of a family is beside the question,
and in certain vital distinctions it is untrue. Any human life,
as such, whether in a fetus or an adult, is as valuable as an
other, inasmuch as no one but God has any authority to de
stroy it, except when it has lost its right to existence through
culpable action. Secondly, the quality of motherhood is an
accidental addition to a mother's life, not substantial as is the
life itself. This quality of motherhood does not create any
juridic imbalance of values which justifies the destruction of
the rights inherent in the fetus. That the fetus may not be
able to enjoy these rights if the mother dies is, again, an
irrelevant consideration. There is no question of a com
parison of values. A life is a life, whether in mother or fetus,
and the destruction of an innocent life by any one except its
creator, God, is essentially an evil thing, like blasphemy. An
innocent fetus an hour old may not be directly killed to save
the lives of all the mothers in the world. Insisting on such
comparisons supposes ignorance and sentimental opposition to
truth. It is a good deed to save a mother's life ; but such sav
ing by killing an innocent human being ceases to be good
and becomes indescribably evil, an enormous subversion of

112 THE ETHICS OF MEDICAL HOMICIDE

the order of the natural law, as it is a usurpation of the
dominion over life possessed by God alone. If I owe a man
a vast sum of money and the payment of this debt will ruin
me and my children, it would be a good thing for me and
them to have this creditor put out of the way by death, but
that fact is no justification whatever for me to kill the man.
The fetus in the womb in a case where there is question of
therapeutic abortion is like this creditor: it would be wrell for
the mother to have this fetus out of the way, but that is no
justification whatever for her to kill the fetus, or to let it be
killed by a physician. The physician who kills such a fetus
is exactly like a hired bravo who assassinates a troublesome
creditor for a fee, except that the physician does the nasty
job for less money.

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

If there were anything in the objection that refusal to do
abortion opposes the life of a useless fetus to that of a useful
mother of a family, where would such false logic stop ? If it
held for the taking of life in an unpleasant condition, it
would hold a fortiori in every other less unpleasant condition
where a life would not be at stake. When a note that you had
given falls due and it would bankrupt you to pay it, does this
inconvenience let you out of the difficulty in honor, in the
moral law, or in the civil law? It certainly does not; but it

ABORTION 113

should if the doctrine of the sentimentalists on abortion were
true. An eclamptic woman, or one with hyperemesis gravida-
rum, conceived the child, got into the difficulty, and she and
her physician have no right to tear up the note they have
given to the Creator, especially when such tearing implies
murder. Suppose, again, a woman has done a deed for which
she has in due process of just law been condemned to death;
suppose, also, there is only one man available to put her to
death, and if this man were killed she could escape. Would
her physician be permitted to shoot that executioner to let
her out of the difficulty ? Certainly not. That, however, is
just what the physician does who empties an eclamptic uterus
of an unviable fetus. You may not do essential evil that any
thing under the sun, good, bad, or indifferent, may come of
it

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

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

114 THE ETHICS OF MEDICAL HOMICIDE

she must bear with her evil for the sake of social order and of
eternal right. So must the eclamptic woman.

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

The Mignonette case in 1884, tried in England by Lord
Coleridge, is a good example of evaluation of lives as in
therapeutic abortion, which came to grief. A ship called the
Mignonette foundered 1600 miles from the Cape of Good
Hope, and three of its crew, with a boy, were for a long time
at sea in an open boat without provisions. When they were
almosi starved the boy lay on the bottom of the boat, asleep
or half conscious from weakness. Two of the men plotted to

ABORTION 115

kill the boy for therapeutic purposes; they needed his flesh
to save their own lives. They killed the poor lad just as the
therapeutic abortionist kills a fetus. They got his uncooked
flesh for four days. Later Lord Coleridge got them and he
sentenced both of them to death. Another Lord will get the
therapeutic abortionists.

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

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

In this connection it is necessary to mention again the ques
tion of viability. Langstein reported 12 a study of the growth and
nutrition of 250 prematurely born infants, and he found a con
firmation of what was already known, that a weight of 1000
grammes (2£ pounds) and a full body length of 34 centi
metres (13f inches) are the lowest limits for viability under
proper circumstances. A fetus 1000 grammes in weight and
34 centimetres in length has completed the sixth solar or
calendar month, or the sixth and a half lunar month — it is
beginning its seventh month, not ending it, yet it is viable un
der proper conditions.

The child at term, on a rough average, is from 48 to 52
centimetres (19 to 20£ inches) in length, and it weighs
from about 6f to T£ pounds. It is impossible, however,
to obtain the sizes and weights of infants in utero with scien
tific accuracy, because the date of conception cannot be deter
mined with absolute certainty, and infants in utero vary as
they do after birth. A full-term infant sometimes may weigh

u Berliner klinische Wochenschrift, June 14, 1915.

116 THE ETHICS OF MEDICAL HOMICIDE

only 3£ pounds when the mother is diseased, and at times an
eight-months fetus will weigh as much as 8 pounds.

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

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

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

The Council of Worms, under Hadrian II., in the year
868,15 also judged women who procure abortion as certainly
guilty of murder.

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

Sixtus V., in the Constitution Effraenatam, October 29,
1588, mentions a decree of the Sixth Synod of Constantinople,
in session in 680 and 681, which subjects those who perform
abortion, or kill a fetus, to the punishment inflicted on mur
derers. Sixtus then decreed that any one who effects the
abortion, directly or indirectly, of an immature fetus, whether
the fetus is animated, formed, or not, either by blows, poison,

"Cap. 35.

18 Lib. v, tit. xii, c. 5.

ABOKTION 117

drugs, or potions, or tasks of hard labor imposed on pregnant
women, or any other method, however subtle or obscure it be,
is guilty of murder, and is to be punished accordingly. He
recalls all ecclesiastical privileges from clerics who cause
abortion, and says that they are to be reckoned as murderers
according to the decree of the Council of Trent,17 and he makes
a law that abortionists may never be promoted to orders.

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

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

Gregory XIV., in the constitution Sedes Apostolica, May
31, 1591, gave to priests who have special faculties for the
purpose from the bishop, permission to absolve from this ex
communication, but only in foro conscientiae. Sixtus V. and
Gregory XIV. used the term foetus animatus, in keeping with
the old Aristotelian notion of animation.

Pius IX., in the constitution Apostolicae Sedis Moderar
tioni, deleted the epithet animaius, and extended the excom
munication to all abortions, no matter at what time of the
gestation they occur. He ordered that only the actual physical
abortionist is to be excommunicated, not those who counsel
the crime. Some moralists hold that those who order abor
tion are direct abortionists and fall under this excommunica-'
tion; other moralists oppose this opinion. Pius IX.18 excom
municates procurators of abortion if actual abortion is effected,
and this excommunication is reserved to the bishops, not to
the Pope.

In this decree occur the words "Procuranies abortum, ef-

1T Session xiv, De Reformatione, cap. 7.
18 Sect, iii, cap. ii.

118 THE ETHICS OF MEDICAL HOMICIDE

fedu secuto," and there has been considerable discussion of the
question who are the procurantes, the agents who fall under the
excommunication? Again, are craniotomy, cephalotrypsis, de
capitation, embryotomy, and exenteration, when performed on
the living child, abortions in the sense of the decree, and thus
matter of the excommunication?

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

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

Sabetti-Barrett 10 holds that craniotomy on a living child
and the removal of an inviable extrauterine fetus are not
abortion in the scope of this excommunication, because as a
penal law these operations are not specifically mentioned. All
mutilating operations, like craniotomy and the others enumer
ated above, first kill the fetus, then extract its body from the
womb; abortion first extracts the fetus and then lets its die.
The result is the same, but the operations differ technically,
and a penal law is ad literam. A cleric who procures abor
tion of an inviable fetus at any time of gestation falls under
the excommunication and suspension a sacris perpetually, al
though he probably is not technically irregular canonically if

" Compendium Theologiae Moralis, 1915, n. 1009.

ABORTION 119

he procures the abortion before the Aristotelian date of anima
tion. The bull Effraenatam makes the canonical irregularity
at the Aristotelian date obsolete practically.

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

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

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

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

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

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

III. Is laparotomy in extrauterine gestation licit ?

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

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

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

III. In a case of necessity, a laparotomy to remove an

120 THE ETHICS OF MEDICAL HOMICIDE

ectopic fetus from the mother is licit, provided the lives of
both mother and fetus are, so far as is possible, carefully and
opportunely preserved.20

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

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

The English civil law concerning abortion 21 is:

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

Alfred Susaine Taylor,22 commenting on this law, said:
"Strictly speaking, there is no such thing as justifiable abor
tion; the law recognizes no such possibility. A medical man
must always remember this when he contemplates emptying a
pregnant uterus.

"It is obvious that the only reasons that can be thought of
by an honorable man as justifying the induction of labor are
(1) to save the life of the mother; (2) to save the life of
the child. (Some religions will not contemplate the first rea
son, but that we are not now concerned with.) It cannot be

" "Dummodo et foetus et matris vitae serio et opportune pro-
videatur."

" Statutes 24 and 25, Victoria, cap. 100, sec. 59.

M Principles and Practice of Medical Jurisprudence. London,
1905.

ABORTION" 121

done for the sake of family honor nor for any similar ethical
reason. . . .

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

The law in Pennsylvania 23 is : "If any person, with in
tent to procure the miscarriage of any woman, shall unlaw
fully administer to her any poison, drug, or substance whatso
ever, or shall unlawfully use any instrument, or other means
whatsoever, with the like intent, such person shall be guilty
of felony, and being thereof convicted, shall be sentenced to
pay a fine not exceeding five hundred dollars, and undergo an
imprisonment, by separate or solitary confinement at labor,
not exceeding three years." It makes no difference in Penn
sylvania law whether the child is quickened or not.

The New Jersey, Massachusetts, and Wisconsin laws are
like the Pennsylvania law. The law in Iowa 24 is : "If any
person, with intent to procure the miscarriage of any pregnant
woman, wilfully administer to her any drug or substance what
ever, or, with such intent, use any instrument or other means
whatever, unless such miscarriage shall be necessary to save
her life, he shall be imprisoned in the penitentiary for a term
not exceeding five years, and be fined in a sum not exceeding
one thousand dollars." To the same effect are the laws in
Connecticut, Maine, New York, Ohio, Michigan, Minnesota,
Colorado, Texas, and Maryland.

" Laws of Pennsylvania, Act of March 31, 1860, sec. 88. p. 404.
* Laws of 1897, Iowa Code, 4759.

122 THE ETHICS OF MEDICAL HOMICIDE

Frank Winthrop Draper, professor of legal medicine in
Harvard University,25 commenting on the Massachusetts law
of October, 1903, cap. 212, sees. 15, 16, says: "It is impor
tant to recognize the fact that the law does not make any excep
tion or formal recognition in favor of justifiable operations to
procure premature labor. The statute is general in its applica
tion. It is, of course, obvious that the best sentiment of the
medical profession and of obstetric teachers is favorable to
interference of pregnancy, (1) whenever there is such anatom
ical deviation or mechanical obstruction in the mother's pelvis
that the birth of a child is impossible; or (2) whenever the
mother is suffering from such grave disease that her life is in
imminent peril and can be saved only by the arrest of gesta
tion. Under such conditions the physician is not only war
ranted in inducing premature labor, but is required to do so
by a sense of duty to his patient, with a view thereby to
save one life at least, and, if possible, the lives of both mother
and offspring.

"Nevertheless, as the law now stands, a prudent prac
titioner will not expose himself to any risk, if a few precau
tions will save him. In the event of the death of the mother
and child in such an emergency, the attending physician might
find himself in jeopardy, with the imputation of gross care
lessness and criminal neglect hanging over him, an imputation
which requires years to remove. So the attending physician
should never undertake to do an instrumental operation with
out these precautions: 1. The consent of the patient, with
that of her husband or family. 2. Especially, a consultation
with some other physician or physicians in whom there is full
confidence. Attention to these simple and sensible safeguards,
by making the conduct appear by its candor and openness in
the strongest possible contrast with the secret methods of the
abortionist, may save great embarrassment."

The ethics of this doctrine is, of course, absurd, as has
been shown, and it is cited here only to show how the civil
law considers abortion. Wharton and Stille 26 give the same

" Legal Medicine, 1905.

" Medical Jurisprudence, vol. iii, sec. 526.

ABORTION 123

information in a more technical manner. "It is a general
rule," they say, "independent of statute, that the act of a
physician in aiding a miscarriage is not unlawful, where the
miscarriage was the inevitable result of other causes. And the
act is justified where the circumstances were such as to induce
in the mind of a competent person the belief that a miscarriage
was necessary to preserve the life of the mother. And the
statutes of many of the States penalize the causing, or at
tempting to cause, an abortion, unless necessary to preserve the
life of the woman, or unless advised by a designated number of
physicians to be necessary for such purpose, the absence of
both the necessity and the advice being an essential ingredient
in the crime. The physician by whom the deed is done, how
ever, cannot act as his own adviser in the matter. And an
indictment under the statute must not only allege that the
act was not necessary to preserve the woman's life, but must
also negative the advice of physicians; and such averments
cannot be inserted as an amendment after demurrer.

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

CHAPTER VJ
ECTOPIC GESTATION

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

124

ECT0PIC GESTATION 125

the Ampulla. One of the fimbriae, the Fimbria Ovarica, is
longer than the others, and it forms a shallow gutter which
extends to the ovary.

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

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

There are certain rare abnormalities of the uterus through
imperfect embryological development, and pregnancy in such
a uterus may result in symptoms like those of ectopic gesta
tion. Normally the uterus and vagina are formed by the

126 THE ETHICS OF MEDICAL HOMICIDE

fusion of the two Miillerian ducts. When these ducts do not
fuse perfectly, or when one develops partly, the various kinds
of abnormal wombs and vaginas are the results. There may
be a double uterus with a single or double vagina, a uterus with
a complete or partial septum down the middle, a uterus with
one horn, a uterus with a developed horn and a rudimentary
horn, and the rudimentary horn may be open or shut, and so
on. In many of these conditions the ovum becomes blocked
and rupture follows as in ectopic gestation.

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

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

Hirst says an experienced obstetrical specialist sees from
12 to 24 cases of ectopic pregnancy annually. Kiistner him-
1 Kelly's Operative Gynaecology. New York, 1898.

ECTOPIC GESTATION" 127

self operated on 105 cases in five years. About 78 per cent,
of all ectopic gestations result in tubal abortion and 22 per
cent, in rupture.

Many specialists now are of the opinion that the diagnosis
of ectopic gestation ordinarily is not difficult, but most physi
cians find it very difficult. Before rupture of the tube or a
hemorrhage diagnosis is hardly ever made by any one, and no
pelvic condition gives rise to more diagnostic errors. When
there is rupture or tubal abortion the symptoms may lead the
physician to mistake the condition for uterine abortion. In
uterine abortion the onset of the symptoms is quiet, with grad
ually intensifying and regular pains, resembling labor, in the
lower abdomen. In ectopic pregnancy the symptoms of a rup
ture or tubal abortion arise quickly, with irregular and colicky
or very violent pains, localized on one side. In uterine abor
tion the external hemorrhage is more or less profuse, with clots ;
in ectopic gestation the external hemorrhage is slight or absent ;
the shock in the latter case is out of proportion to the visible
blood loss. Parts of the ovum, or the presence of the whole
ovum, as uterine, are found in ordinary abortion, but in the
ectopic condition the ovum proper does not appear. An intrau-
terine angular pregnancy, or pregnancy in a uterine horn,
causing the upper corner of the womb to bulge sidewise, may be
mistaken for ectopic gestation. Pregnancy in a retroflexed
uterus, tumors of the adnexa, the twisted pedicle of an ovarian
tumor, a burst pyosalpinx, an appendicitis in pregnancy, or a
combined intrauterine and ectopic gestation, also may confuse
the diagnosis. When there is a dangerous hemorrhage from
rupture or tubal abortion the diagnosis is usually made with
out difficulty from the collapse and other signs.

The diagnosis as to whether the fetus in the pelvis is dead
or alive may be made (1) from the absence or presence of
symptoms of tubal rupture during the second and third months,
or of mild symptoms indicating only slight bleeding; (2) from
the continuation and progress of the evidences of pregnancy,
as nausea, mammary changes, fetal movements, or audibility
of the fetal heart; (3) from the presence of a loud uterine
blood souffle; (4) from the absence of toxemia or suppura-

128 THE ETHICS OF MEDICAL HOMICIDE

tion; (5) from a growth of the uterus and a softening of
the cervix; (6) from a gradual increase in the size of the
suspected ectopic fetal tumor. In making the diagnosis great
caution must be observed, as roughness in manipulation may
start hemorrhage or rupture a thinned tube.

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

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

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

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

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

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

3. May a woman in articulo mortis be delivered of a1

ECTOPIC GESTATION 129

viable child if the delivery will somewhat hasten her death ?

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

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

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

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

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

9. May the woman in question 6 be delivered of an in-
viable child, supposing the child to be in articulo mortis?

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

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

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

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

The Holy Office, May 4, 1898, again decreed: "Necessi
tate cogente, licitam esse laparotomiam ad extrahendos e sinu
matris ectopicos conceptus, dummodo et foetus et matris vitae,
quantum fieri potest, serio et opportune provideatur." 2 This

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

decision was not clearly understood, and on March 5, 1902, the
same congregation reported the following question : "Is it ever
licit to remove from the maternal pelvis an ectopic fetus which
is still immature ; that is, which has not yet completed the sixth
month after conception?" The answer was, "No; according
to the decree of May 4, 1898, which prescribes that the life
of the fetus and the mother must as far as possible be care
fully safeguarded. As to the time, according to the same de
cree, the questioner will remember that no premature delivery
is permissible unless it is effected at such a time and by those
methods which in ordinary circumstances safeguard the life
of the mother and fetus." 3

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

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

Again, the killing of the inviable ectopic fetus cannot be

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

ECTOPIC GESTATION 131

justified by maintaining that the fetus is an unjust aggressor
against the life of the mother. An aggressor against life may
be such formally or materially. A formally unjust aggressor
consciously and voluntarily attacks the life of the victim un
justly. This perversion, or evil, in the aggressor's consciously
actuated will sets his own right to life in juridic inferiority to
that of the victim's right to life, and the victim may defend
his own life, even unto the indirect death of the aggressor in
necessity.

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

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

not use against me, but which he probably will, I may not
kill him in self-defence until he actually begins the aggres
sion. The opinion expressed here is the contrary of the
opinion I expressed, in 1906, in Essays in Pastoral Medi~
cine.

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

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

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

CHAPTEK
CESABEAN DELIVERY

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

An abnormal bony pelvic girdle is the most frequent ob
struction to delivery of the fetus. The lower part of the pelvis,
called the pelvis minor or true pelvis, supports the muscles of
the pelvic floor, and gives shape and trend to the parturient
canal. The inlet and outlet of the true pelvis are narrower
than its middle portion and are called the superior and in
ferior straits. The inlet is somewhat cordate in outline, and
normally from front to back, at its so-called conjugate vera,
it averages 11 centimetres (4-& inches) in depth ; from
side to side it measures 13 centimetres (5-J inches) ; obliquely
from the right posteriorly to the left anteriorly it is 12| centi
metres (nearly 5 inches), and the other oblique conjugate is
12 centimetres (4f inches) long. The transverse diameter
of the outlet, from right to left, is 11 centimetres ; the diameter
from front to back, because the coccyx can be pushed back in
labor, is from 9^ (3f inches) to 12 cm. Normal fetal head
measurements average from side to side at the widest part, 9£
cm. (3f inches) ; from the root of the nose to the occiput, 11
cm. ; from the chin to the occiput, 13 cm. ; from the vertex to

133

134 THE ETHICS OF. MEDICAL HOMICIDE

the neck behind, 9^ cm. The size of the fetal head is the
most important factor in delivery, so far as the child is con
cerned, because, as a rule, when the head is delivered the com
pressible trunk follows readily. Normally the child presents
in delivery with the vertex of the head first; other presenta
tions are transitional, abnormal or pathologic. In 48,499 cases
Karl Braun found vertex presentations in 95.9 per cent., and
Schroeder in 250,000 cases found an average of 95 per cent.
The child's head is "engaged" when its largest diameter has
passed the plane of the inlet.

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

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

Often it is extremely difficult to find out the best plan
for delivering a woman who has a contracted pelvis. Where

CESABEAN DELIVERY 135

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

Text-books on obstetrics have a series of rules, based on
pelvic measurements, concerning the indications for cesarean
or other methods of delivery in cases of contracted pelvis, but
the problems are not so simple and uniform as to be always
accurately solved by the data derived from measurements. One
woman with a contracted pelvis may require cesarean delivery ;
another woman with the same measurements may have a nor
mal parturition because the child happens to be small or its
skull compressible. The best pelvic measurement is made with
the fetal head. A difficult decision as to whether a cesarean
delivery is necessary or not comes up in the majority of cases
in primiparae; in multiparae the physician has the experience
from former births to guide him. In over 90 per cent, of
primiparae the fetal head normally is found engaged in the
pelvis in the last week of gestation, and can be felt by a
vaginal examination. In multiparae the head usually is not
engaged until labor begins. If the fetal head does not engage
in a primipara, this fact at once suggests an absolutely or rela-

136 THE ETHICS OF MEDICAL HOMICIDE

tively narrow pelvis. When labor has begun, if the fetal head
cannot be pushed into the true pelvis of a primipara, especially
after anesthesia, the necessity for cesarean delivery may be
clearly evident.

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

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

The varieties of the cesarean delivery as practised at pres-

CESAREAN DELIVERY 13T

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

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

lJour. Amer. Med. Assoc., February 24, 1917.

138 THE ETHICS OF MEDICAL HOMICIDE

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

Before antiseptic surgery began, opening the abdominal
cavity was almost always fatal, and some obstetricians tried to,
get the child out of the uterus in cases where cesarean de
livery is indicated by going in above the pelvis without open
ing the peritoneum. The uterus was incised near its cervical
end. This method, called extraperitoneal cesarean delivery,
has been restored for use in cases where there is some infection
of the uterus and the operator wishes to save the child with
out removing the womb. The technic is more difficult than in
the classic cesarean, and the operation was not kindly re
ceived, but of late some men are having so much success with
it that it is reviving, and rightly so. Baisch 2 says that the
first eleven women he delivered by extraperitoneal cesarean
section recovered more readily than they would from an or
dinary laparotomy. In nineteen cases of transperitoneal but
cervical section he had no trouble, and six of these were in
fected cases. The technic of this low incision protects the
peritoneal cavity better than the classic incision, apparently.
Two of the nineteen women were in slight fever and the uterine
fluids were fetid. Two primiparae forty years of age had been
in labor seventy hours. Eight of the women were able to
leave the clinic on the tenth day. Only one child was lost, and
that was a delayed case. Hofmeier 3 compiled 194 cases of
transperitoneal cervical cesarean section with three deaths.
Kiistner did 110 extraperitoneal cesarean sections with no mor
tality. This makes 304 cases of cesarean cervical section, not
the 'classic operation, with only three deaths, less than 1 per
cent, mortality ; and fully 50 per cent, of these cases were not
surgically clean. From these statistics it is evident that the
cervical operation in the hands of competent surgeons should
be the operation of choice.

The ordinary practitioner, however, is utterly unfitted to
do a cesarean section of any kind. In large cities it is easy

' Zentralblatt f. Gynakologie. Leipsic, October 30, 1915.
1 Munch ener medizinische Wochenschrift, January 4, 1916.

CESABEAN DELIVERY 139

to find a trained surgeon to do the operation, but in small
towns and in country places there is seldom any one available.
The physician who chooses to practise medicine in an isolated
place knows that he will almost certainly be called upon to do
a cesarean section some day, and he should not take up the
responsibility of the general practitioner in such a place until
he is competent to do that operation when life depends upon
him. This is as things should be; but unfortunately a man
who is trained well enough to do major surgery will not live
in a small town if he can get into a large city. The physician
in any case should be able at least to make the diagnosis in
time, before labor sets in, and have the woman sent to the near
est city, if possible. Dr. Bull 4 reported that he had traveled
seventy-five miles to see a woman who was having severe
hemorrhages at term. He found her in a log cabin, with a
centrally implanted placenta (i.e., right across the opening of
the cervix uteri), and she had had three hemorrhages before his
arrival. He narcotized her, took her in a train to a hospital,
delivered her by cesarean section, and saved her and the child.
If he had delivered her by version in the log cabin, he would
almost certainly have lost both the mother and the child.

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

Suppose, however, that the uterus is infected unavoidably.

If this infection has been done by a competent obstetrician

working in a hospital with sterile instruments, it may be safe

to deliver the woman by an extraperitoneal or cervical trans-

* Jour. Amer. Med. Assoc., September 30, 1916.

140 THE ETHICS OF MEDICAL HOMICIDE

peritoneal cesarean section. If the practitioner has tried to
deliver the woman at her home with forceps and has failed,
especially if repeated attempts have been made by the physi
cian and an assistant or consultant, the uterus should be am
putated. It will not do to deliver by a low cesarean and
await developments, because if the infection is serious no
subsequent removal of the uterus will save the woman's life.
The grave mutilation of removing' the uterus is, of course, licit,
as it is the only means of saving the woman's life. Some mor
alists hold that a woman from whom the uterus has been re
moved is impotent, but this question has never been decided
authoritatively, as we shall show in the chapter on Vasectomy;
and until it has been so decided the woman must be given the
benefit of the doubt.

The question of removing the uterus solely to prevent the
danger of subsequent deliveries differs from the condition just
considered. If the woman has had a cesarean delivery for an
absolutely narrow pelvis, her subsequent deliveries must be by
the same method. After a cesarean section there is more or
less danger of rupture at the scar in other labors. Some think
the danger is greater if the placenta becomes implanted on the
scar; others think this implantation does not weaken a good
scar. If the convalescence after the cesarean section already
done has been abnormal, the prognosis for rupture is not good.
Where there has been an abnormal convalescence, each new
pregnancy must be watched closely, and often an early subse
quent cesarean is indicated to prevent rupture. No matter
how well the section has been done, latent gonorrhea may pre
vent perfect healing of the wound. Twins, hydramnios, and
overtime gestation are other causes of rupture. The tendency
with obstetricians in the future will probably be to do the sec
tion toward the cervical end of the uterus ; and as the uterus is
thinnest there, it might be thought that it will be more likely
to break, but Spalding 5 found the contrary true — the ruptur
ing was usually in the thick part of the uterus. Version, high
forceps, uterine tampons, hydrostatic bags, and pituitary ex
tract should be avoided where an old cesarean scar exists, but
'Jour. Amer. Med. Assoc., December 1, 1917.

CESAEEAN DELIVERY 141

Vogt and Kroback have done version a few times without rup
ture. Vogt had one patient with a true conjugate of 6| cm.
(2 A inches) to 7 cm. (2£ inches). She was delivered in
the first three labors by craniotomy; in the fourth by version;
in the fifth and sixth by cesarean section; in the seventh she
had twins one of which was born spontaneously; in the eighth
by version and perforation of the after-coming head; in the
ninth she refused operation and was delivered spontane
ously. Skilful operators have the fewest ruptures after ce
sarean delivery. Olshausen had one in 120 cases, Leopold
none in 232 cases, Schauta none in 177 cases, Kiistner none in
100 cases. Olshausen, in a series of 29 cases, operated on
two patients twice and upon three patients three times. As
early as 1875, Nancrede of Philadelphia had operated the
sixth time on the same woman. In such cases the uterus is
commonly so broadly attached by adhesions to the belly-wall
that it is opened without getting into the peritoneal cavity.
In 150 cases of repeated section collected by Polak in 1909 the
mortality was only 5 per cent.

A woman may not be sterilized by having the uterus re
moved, by fallectomy, or otherwise, solely to obviate danger or
morbidity from subsequent pregnancies and cesarean deliver
ies. Such a sterilization would be a grave mutilation with
out a present excusing danger, and it would render the primary
end of marriage always impossible. Such sterilization of a
woman is in contravention to the decretal of Gregory 6 as given
in the chapter on Vasectomy. It is also against the bull Ef-
fraenatam of Sixtus V., who extended all penalties prescribed
for abortionists to those who give women drugs which cause
sterility, and to those who purposely prevent the development
of the fetus or in any manner abet the deed ; and the penalties
are to be applied to the women themselves who willingly use
these means. These penalties are enumerated in the chapter
on Abortion. The Congregation of the Holy Office, May 22,
1895, answered negatively the following question: "Si sia
lecita la practice sia attiva sia passiva di un procedimento il

Corpus Juris, lib. v, tit. xii, c. 5.

142 THE ETHICS OF MEDICAL HOMICIDE

quale si propone intenzionalmente come fine espresso la ster-
ilizatione della donne ?" 7

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

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

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

CHAPTER VIII

PLACENTA PEAEVIA AND ABRUPTIO PLACENTAE

CESAEEA1ST delivery is used frequently of late in pla
centa praevia. It may be necessary also in abruptio
placentae, gunshot wounds of the abdomen during pregnancy,
sometimes in appendicitis complicating gestation, rarely in pro
lapse of the cord to save the child, and when twins become in
terlocked in delivery. Placenta praevia is a development of
the placenta in that part of the uterus which dilates at the
end of gestation or during delivery. This dilatation, with the
mechanical pressure of the child, detaches the placenta enough
to cause a hemorrhage which may be fatal to the woman if
not checked. The hemorrhages begin sometimes as early as
the sixth month of gestation, but most frequently in the eighth
month. Premature labor is a common effect. The position
of the placenta may cause malposition of the fetus, prolapse of
the cord, weak pains, air embolism into the blood, rupture of the
uterus, sepsis, profound anemia, and other evils. The child
may be premature, puny, have collapsed lungs, hemorrhages, and
it is very likely to be killed in delivery. The mortality of the
women varies, but it averages about 7 per cent ; that of the chil
dren averages 61 per cent.

The tendency with obstetricians is to deliver the child as
soon as the diagnosis has been made. When the bleeding is
slight, and the child is viable, one may delay delivery provided
the woman will remain in bed in a good maternity hospital with
out moving. At home the woman may "flood" and bleed to
death before a physician can reach her. If the woman refuses
to go to a hospital, and to permit the induction of labor, any
physician who has regard for his own reputation will drop the
case and leave the woman to her own devices.

143

144 THE ETHICS OF MEDICAL HOMICIDE

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

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

If the child is not viable the hemorrhage must be stopped
to save the woman's life. As a rule, the hemorrhages are not
dangerous before the seventh month. In the 128 deaths of
Miiller's statistics there was not one before the seventh month
of gestation. Hirst, however, says he has been obliged to
empty the uterus at the fifth month for placenta praevia. The
woman must be kept in bed, the foot of the bed elevated, seda
tives used, and so on, as in threatened abortion, and the va
gina tamponed securely with cotton. If it is evident that the
fetus is dead, it must be extracted as in the case of a viable
fetus. If it is probable that the fetus is alive, it is to be
treated as in a case of inevitable abortion as described in the

PLACENTA PEAEVIA 145

chapter on Abortion. The tamponing of the vagina to stop the
hemorrhage will cause the abortion of the fetus indirectly.
This is another double-effect case, and the tamponing is mor
ally permissible provided the intention is correct.

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

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

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

The removal of the fetus here is not like an artificial abor
tion. In abortion the abortionist separates the placenta from the
uterine sinuses and so kills the fetus; the removal from the
uterus is secondary to that separation which kills. The com
mon notion of moralists that death is caused in abortion by

146 THE ETHICS OF MEDICAL HOMICIDE

taking the child out of the uterus is inexact — tearing loose the
placenta is the real cause. In a removal of the fetus after an
abruptio placentae the death of the fetus is not caused by the
physician at all, but by the force that effected the abruptio.
As the child will be dead before sufficient dilatation of the cer
vix to deliver it can be attained, there is no objection to begin
ning the delivery as soon as the diagnosis is clear.

CHAPTER IX
ABDOMINAL TUMORS IN PREGNANCY

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

Fibroids, called also fibromyomata, fibromata, and myo-
mata, in the uterine muscle or adnexa commonly enlarge dur
ing pregnancy, and if they are big enough and low in the pelvis
may block the parturient canal. These tumors may suppurate,
grow gangrenous, or take on red degeneration ; they may cause
abortion, peritoneal adhesions, pain, or hemorrhage; simulate
threatened abortion; bring on retroflexion of the uterus, pla
centa praevia, abnormal presentations, sometimes weak pains
or pains so strong as to rupture the uterus, and they may check
contraction after delivery so as to start hemorrhage. They

147

148 THE ETHICS OF MEDICAL HOMICIDE

may so kink the uterus as to incarcerate the placenta and cause
sepsis. The percentage of degeneration in fibroids taken gen
erally is 22, according to William Mayo.1

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

We cannot give a general mortality average for myomata
in pregnancy because only bad cases are reported, but in bad
cases the mortality is very high — 50 per cent, for the mother
and about 60 per cent, for the children, with almost 30 per
cent, of abortions. The majority of women who have myo
mata go on to delivery without trouble. In some there is much
pain or hemorrhage, and these conditions may finally oblige
the obstetrician to operate, but the operation should be deferred
as long as possible. Where there are signs of necrosis of the
tumor, operation is necessary at once to prevent sepsis. Re
moval of a myoma during pregnancy does not always cause
abortion. The statistics are that about 83 per cent, of those
operated upon are removed without abortion. In the Mayo
Clinic 2 fourteen cases of degenerating fibroids in pregnant
wombs were removed and the majority went on to term. The
removal is always a very bloody operation, and it requires great
surgical skill. Where enucleation of the tumor alone was in
tended it may finally become necessary to amputate the uterus
to stop hemorrhage.

When the case has gone on to labor at term the diagnosis
as to position and size of the tumor is to be made, and what the
effects will be as to blocking the canal or crushing the tumor
so as to bring on sloughing. If a tumor blocking the canal
cannot be pushed up out of the way of the child, a cesarean
section should be done immediately. ,In such an outcome as

1 Jour. Amcr. Med. Assoc., March 24, 1917.
'Ibid.

ABDOMINAL TUMOKS IN PREGNANCY 149

section the experience of the operator must decide whether the
tumor is to be removed then or at a more favorable opportunity.
It may be necessary to do cesarean section to liberate an in
carcerated placenta.

Sometimes the fetus is so involved with a gangrenous myoma
that enucleation of the tumor will kill or hasten the death
of the fetus. When, in such a complication, it is evident that
the life of the woman depends on the immediate removal of
the tumor, yet a second but evil effect follows from the opera
tion, namely, the unavoidable death of the fetus, the removal
is morally licit provided the operator has the proper intention.
The death of the child as an effect in this case is only indirectly
voluntary from the physical point of view, and only permis-
sively voluntary from the moral aspect.3

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

Most obstetricians advise the removal of an ovarian tumor
in pregnancy as soon as diagnosed, provided it is of a size to
cause difficulty in parturition, but such a removal causes abor
tion in over 20 per cent, of the cases. The expectant treat
ment causes abortion in about 17 per cent. If the child is
viable, Fehling, Martin, Norris, and Do Lee are in favor of
the expectant treatment. Late operators leave weak scars at
labor. When there are symptoms of torsion of the pedicle of the
tumor, infection, incarceration in the pelvis, involvement of the
uterine broad ligament, or overdistention of the belly, the tumor

*Cf. Ferreres, Nouvelle Revue Theologique, September and Octo
ber, 1912, and the appendix of his book De Vasectomia Duplici,
Madrid, 1913.

150 THE ETHICS OF MEDICAL HOMICIDE

must be removed immediately. Whether vaginal puncture or
laparotomy is the better method is to be decided particularly.
Dermoid cysts are likely to bring on sepsis if they are broken in
enucleation, and the diagnosis and operation must be carefully
made. When it is necessary to save the life of the woman to
remove an ovarian tumor, the risk of abortion may be taken
permissively.

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

The diagnosis should be as certain as possible. Karely
nodules which are not cancerous appear in the cervix during
pregnancy, and these are to be examined microscopically.
Snipping out of a piece of the nodule for examination does not
cause abortion. Vaughan of Michigan University, who is a
skilful and careful observer, said 4 that in an investigation of
200 cases of cancer, upon which more than 30,000 differential
blood-counts were made, he discovered a method of diagnosing
the operability of a cancer as follows: He makes a blood-
count and then injects intraperitoneally one c.c. of placental
residue. The next day he begins a series of blood-counts, and
if the number of polymorphonuclear cells decreases the case
is operable, no metastasis has occurred; if there is no change
in the number of the polymorphonucleavs, or an increase with
a corresponding decrease of the large rnononuclears, the case is
inoperable, metastasis has begun.

In cancer of the cervix operability does not mean curability
always. Inoperability signifies that the woman has no chance

4 Jour. Amer. Med. Assoc., December 8, 1917.

ABDOMINAL TUMOKS IN PREGNANCY 151

at all for life and that it is useless to do anything; operability
means that she has one chance in four and that it is worth
while taking the chance. The following conditions may be met :

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

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

3. The case may inoperable and the child inviable.

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

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

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

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

The third case is that of an inoperable cancer and an in-
viable child. There the operation should be deferred, if pos
sible, until the child becomes viable.

The fourth case supposes the cancer is inoperable but the
child viable. In the interest of the child, immediate cesa
rean section is the best thing to do ; it is much better than wait
ing until term. At term this operation will have to be done
anyhow, and the earlier it is done, the better the woman can
stand the strain. There is a risk that she will die from the

152 THE ETHICS OF MEDICAL HOMICIDE

first operation done to deliver the viable child, but she may lic-
itly take this risk, as she might licitly run into a burning house
to save a child, even if not her own. She may also licitly re
fuse the first operation.

CHAPTER X
APPENDICITIS IN PREGNANCY

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

Operation is much less difficult in the first half of gesta
tion than in the latter months. At the beginning of gesta
tion the operation does not, as a rule, cause abortion. Late
in pregnancy appendicitis rapidly goes on to suppuration and
perforation, with a high mortality. Hirst says that where there
is reason to suspect suppuration a median incision should be
made and the pelvic cavity examined for possible areas of in
fection. John Deaver says, "Always cut down on the sore

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154 THE ETHICS OF MEDICAL HOMICIDE

spot and do not handle the uterus." An infected uterus after
cesarean section complicated with appendicitis has to be am
putated.

The diagnosis between appendicitis, ectopic gestation,
twisted ovarian tumors, ureteritis, and ureteral stone is to be
made. In a discussion of a paper by Finley on Appendicitis
in Pregnancy,1 Dr. John Murphy of Chicago, a great author
ity, advised operation as soon as the diagnosis is made, and ho
was of the opinion that this diagnosis is not difficult to make
in pregnancy. Deaver said a diagnosis of catarrhal appendi
citis is not seldom very difficult to make. This form is very
rare in pregnancy. Deaver is not of the same opinion as Mur
phy as to operating as soon as the diagnosis is made in all cases.
Where there is a general peritonitis, operation commonly only
makes matters worse by spreading infection. The mortality
of cases of appendicitis in pregnancy left without operation
is as high as 77 per cent. ; where the cases are operated upon
within forty-eight hours after diagnosis the mortality is G.7
per cent, and it would be better if the operation were done
within twenty-four hours. Finley says that in the fifteen cases
reviewed in his paper the operation did not cause abortion.
Deaver tells us the muscular rigidity in the right groin char
acteristic of appendicitis is often missing in pregnancy, and
that sometimes the pain is on the left side of the belly.
*Jour. Amer. Med. Assoc., December 24, 1912.

CHAPTEK XI

PUEEPERAL INSANITY AND STERILIZATION

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

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

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

The forms of mental disturbance commonest in puerperal
insanity are mania with or without delirium, melancholia, and

155

156 THE ETHICS OF MEDICAL HOMICIDE

dementia. Dementia is the final stage in the cases that become
chronic. Mania is the prevailing type in insanity after labor,
and melancholia in insanity during gestation. The melan
choly of insanity during gestation is often suicidal, and must
always be watched. Religious and erotic symptoms are also
observed.

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

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

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

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

It would not be justifiable: 1. Because it is not licit to

inflict a grave mutilation to avert a possible or probable future
evil. 2. There are other means to escape the danger : a woman
with this tendency is justified in denying the debitum. 3. Once
crazy, always crazy, is an aphorism with much truth in it,
and it is doubtful that sterilization in itself will prevent ul
timate insanity. 4. The conjugal relation of a sterilized wom
an would be no better than onanistic. 5. The sterilization would
fall under the decrees and penalties described at the end of the
chapter on Cesarean Section.

CHAPTER XII

NEPHRITIS IN PREGNANCY

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

Williams l says that in the examination of 1000 pregnant
women at Johns Hopkins Hospital in Baltimore traces of al
bumin were found in 50 per cent, without subsequent serious
disturbance, but where considerable albumin with casts other
than hyaline was seen there were symptoms of toxemia later,
and several of these went on into eclampsia. Fisher 2 held that
red blood-corpuscles in these cases indicate acute nephritis;
and granular and epithelial casts, chronic nephritis. Like the
Johns Hopkins cases, he found albumin in 50 per cent, of his
patients. Albumin in slight quantities is found to be extremely
common toward the end of pregnancy. Meyer,? in an ex-

1 Obstetrics, p. 456.

* Praeger medizinische Wochenschrift, ISO? n. 17.
* Zeitschrift fur Oeburishulfe, bd. 16, n. 2.

158

NEPHRITIS IN PREGNANCY 159

tensive study of the kidney in pregnancy, made at Copenhagen,
found albumin in 5.4 per cent, of the women. During the
last month of gestation 71 per cent, of the women showed albu
min. Premature births occurred in 8 per cent, of the patients
who had had albuminuria, but in 21.5 per cent, of the women
who had had casts. Delicate tests for albumin are used by men
who find these high averages, as a few leucocytes from leucor-
rhoea will give the reaction. Most of these cases have no clini
cal significance.

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

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

The treatment of the nephritides of pregnancy is that de
scribed in chap, xiii for eclamptic symptoms. When albuminuric
retinitis occurs, the medical tendency is to empty the uterus.
All text-books counsel this procedure, but they give no convinc
ing reasons for the advice. If the child is viable the thera
peutic abortion might be done when necessary; if the child is
not viable the operation is, of course, not licit In the ne
phritis of pregnancy it is not certain that emptying the uterus
artificially, with the entailed shock, is the best method of treat
ment; but, as a rule, nephritis is made worse by pregnancy,
and the irritation lessens with the termination of gestation in
some cases, but not in true chronic nephritis. Eclampsia is
more toxic than nephritis, and the treatment may differ in im
portant details: it certainly is doubtful that artificial abortion
in eclampsia is the method of choice at present. I saw a case
of albuminuric retinitis ten years ago, which could not have
been worse. The woman was in the seventh month of gesta-

160 THE ETHICS OF MEDICAL HOMICIDE

tion; she was nearly blind and half comatose. The albumin
in her urine always was so great that it would not fully precipi
tate in a centrifuge tube, and every field under the microscope
was covered with large casts in such enormous quantities that
they were felted together. Yet the woman was carried on to
term by Dr. Joseph O'Malley and delivered of a fully developed
child. She since has had two other children at term who are
perfectly healthy, and she herself could pass a life insurance
examination. This is, of course, only one case, and it is ex
ceptional ; but it is impossible to say what will happen in any
particular case — whether it will go on to death or recovery.

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

NEPHRITIS IN PREGNANCY 161

anemia. The development is insidious, and the etiology is not
known.

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

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

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

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

CIIAPTEK XIII

ECLAMPSIA PAKTUBIENTIUM:

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

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

lMiinchener medizinische Wochenschrift, July 30, 1907.

162

163

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

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

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

If the woman is to die the eclamptic attacks usually in-

164 THE ETHICS OF MEDICAL HOMICIDE

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

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

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

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

If the patient's pulse remains full and hard and below 120,

ECLAMPSIA PARTUKIENTIUM 165

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

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

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

In any of these conditions the proteids should be kept low
in the diet, so that the kidneys may not be overtaxed. To throw

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

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

Olshausen was not in favor of forced delivery. Charpen-
tier 2 held that forced delivery is dangerous and should be ab
solutely proscribed. His statistics of mortality are: after
spontaneous labor, 18.96; after artificial labor, 30.04; after
forced delivery, 40.74.

Lichtenstein 3 reported, from Zweifel's clinic in Leipsic, the
results of 400 cases of eclampsia, and he found that the eclamp-

* Nouvelle Archives d'Obstetrique et de Gynecologic, 1893.
' Archiv fur Gyndkologie, 1911, xcv, 1.

ECLAMPSIA PAKTURIENTIUM 167

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

Lichtenstein 4 describes the expectant treatment by phleb
otomy and narcotics to replace operative interference, and this
method has revolutionized the mortality of the treatment of
eclampsia. In ninety-four cases of eclampsia his mortality
was only 5.3 per cent., and none of the deaths could be ascribed
to the treatment. The infant mortality was 37.3 per cent., as
against his 38.8 per cent, in active operative interference dur
ing preceding years. Werner, in the Second Gynecological
Clinic in the University of Vienna,5 by this new method in
thirty-eight cases of eclampsia had a maternal mortality of 5.2,
as Lichtenstein had, but his infant mortality was only 1-1.65
per cent., an enormous advance for the better. Formerly the
mortality in the Viennese clinic was 15.8 for the women and
44.3 for the children, in a series of 120 cases of eclampsia. A
mortality of 50 per cent, in the children is common in the
old method. In Lichtenstein' s cases there were mental dis-

4 Monatsschrift fur Geburtshulfe und Gynakologie, xxxviii, 2.
Berlin.

* M iinchener medizinische Wochenschrift, November 23, 1915.

168 THE ETHICS OF MEDICAL HOMICIDE

turbances in 2.1 per cent, of the women, as against 6.75 per
cent, in the old method. Eclamptics may go insane and kill
the child after delivery. Lichtenstein treated 74 consecutive
cases without a single death. In 54 per cent, of his cases the
convulsions ceased after one venesection, and 42 per cent, of
the women with ante-partum attacks recovered before labor
came on. Engelmann 8 reported a case where a woman who
had had 188 convulsions recovered after the third venesection.

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

Zinke 7 of Cincinnati has a method which reduces the ma
ternal mortality, but it has an enormous infantile mortality.
He depresses the maternal pulse by veratrum viride, and this
depression is probably the cause of the infantile mortality
through asphyxia. Yeit introduced the use of morphine in
eclampsia, and Winckel the use of chloral. It has been found
that narcotics check the action of toxins on the nuclei of cells,
and in eclampsia the action of narcotics may be of this nature.
Baker of Alabama in 1859 first gave veratrum viride in
eclampsia. The drug lowers arterial tension by depressing the
vasomotor centres and the heart itself. In eclampsia it diverts
blood from the brain and depresses the motor neurons of the
spinal cord. Aconite has the same effect in acute cerebral con
gestion without depressing the vasomotor centres or irritating
the stomach as veratrum viride does.

Cesarean delivery is used frequently of late in eclampsia.
The mortality of the children is lowered somewhat by a cesa-
rean section, but the mortality of the mothers is much worse
than in the expectant method described by Lichtenstein.
Eclamptic women usually have badly affected kidneys, and the
anesthetic used in the section may be a cause of the raised
mortality. Peterson reviewed 500 cases of cesarean section

" Centralbl. f. Gynak. xxxi, 11.

f New York State Journal of Medicine, xiii, 8.

ECLAMPSIA PARTUEIENTITJM 169

for eclampsia 8 done by 259 operators in various countries.
Up to 1908 the maternal mortality was 47.97 per cent, in 198
cases; from 1908 to 1913 it was 25.79 per cent, in 283 cases.
Convulsions ceased in only 54.92 per cent, of the women after
cesarean delivery, and in those cases in which the convulsions
continued the mortality was 31.53 per cent. In 146 cases
where the convulsions ceased the mortality was still 19.8 per
cent, for the mothers. The fetal mortality was 10.69 per cent.,
counting all children who died within three days after delivery
by section. The maternal mortality after cesarean section in
creases with the age of the patient. The cesarean delivery,
then, has a maternal mortality of late of 25.79, with a tendency
to increase as unskilled men attempt it; the expectant method
has a maternal mortality of only 5.3 per cent. The cesarean
delivery has a fetal mortality of 10.69 per cent. ; the expectant,
14.65 per cent. The expectant method is preferable.

* Amer. Jour. Obstetrics and Diseases of Women and Children,
Izix, 6.

CHAPTER XIV

HBAET DISEASES IN PREGNANCY

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

It is difficult to draw the line between normal and abnormal
parturition, but every labor, as women now are in civilized
countries, should be regarded as a grave surgical operation, and
the indications that must be met in a surgical operation are
likely to occur in almost any parturition. The strength of the
patient, the condition of the heart, lungs, kidneys, and blood,
sepsis and antisepsis, the nature and technic of the various op
erations that may be required, and the complications that may
arise, are all to be understood and met conscientiously. ISTo
physician who has any regard for morality and his own repu
tation now will accept an obstetrical case unless he has had the
woman under frequent observation for months before delivery.
If the mother or child dies because of the bungling or surgical
uncleanness of the physician or midwife, — and unfortunately
such deaths occur almost hourly, — this physician or midwife
is guilty of murder. There may be an abnormality of the
uterine or abdominal muscles used in parturition, a dispro
portion between the parturient canal and the child, or various

170

HEAKT DISEASES IN PKEGNANCY 171

accidents of labor; and these conditions are so frequent in oc
currence and so grave that their removal requires great medical
skill, fine discernment, quick and exact judgment, and often
decidedly courageous purpose.

New methods of treatment frequently appear, and the
quack is likely to be among the first by which the new is tried.
The use and abuse of pituitrin is an example of such a method.
About 1909, pituitary extract as a uterine stimulant was first
described and it was immediately taken up by competent men
and more frequently, perhaps, by the quack. The extract is
from the posterior lobe of the pituitary gland, and when in
jected subcutaneously or into a muscle it is a very powerful
oxytocic. In a few minutes the injection markedly increases
the intensity and duration of the pains. The effect lasts for
an hour or an hour and a half. Whitridge Williams 1 says a ju
dicious administration of the drug will do away with the use
of low forceps in from one-third to one-half of the cases, but its
ignorant use places the life of the mother and child in jeopardy.
Mundell 2 found twelve cases of rupture of the uterus, thirty-
four cases of fetal death, and forty-one cases of fetal asphyxia
pallida in which resuscitation was effected only after prolonged
and vigorous efforts, sometimes for over an hour.

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

Comparisons between the fetal mortality after the use of

1 Obstetrics, 4th ed. New York, 1917.
* Jour. Amer. Med. Assoc., June 2, 1917.

172 THE ETHICS OF MEDICAL HOMICIDE

pituitrin or the forceps are erroneous. Quigley 3 contrasted
the fetal mortality in these conditions. In 147 pituitrin cases
it was 2.7 per cent., in about five or six times the number oi
forceps cases it varied from 5.7 to 15.63 per cent.; but wher
ever there is any real need at all for the forceps, pituitrin at
once is contraindicated except in easy low forceps deliveries,
where in the hands of a skilled man pituitrin may safely re
place the forceps to avoid possible instrumental infection of the
uterus. There are contractions of the uterus toward the end
of gestation, before labor proper sets in, which cause what are
called False Pains, and these must not be mistaken for the be
ginning of labor, as unnecessary examinations and meddlesome
interference may bring on great harm. Uterine atony, or
weak pains, may affect the patient in the first stage of labor, in
which the cervix of the uterus should be dilated ; or the second
stage, in which the child is delivered; or the third stage, the
post-partum period, when the placenta is thrown off. Con
tractions of the uterine muscle cause pain, and these contrac
tions themselves are called the Pains. In the first stage weak
pains may prolong the dilatation of the cervix for days and
expose the mother to sepsis or exhaustion, and the child to
consequent danger.

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

One of the causes of weak pains is a diseased heart. Systolic
murmurs at the base of the heart and an accentuated second

'Jour. Amer. Med. Assoc., April 10, 1915.

HEART DISEASES IN PREGNANCY 173

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

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

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

* Diseases of the Heart. New York, 1905.
'Medizin. Klinik, February 25, 1912.

174 THE ETHICS OF MEDICAL HOMICIDE

unless there is chronic decompensation with myodegeneration
and renal or hepatic insufficiency. Expectancy is the rule.
Lusk advises abortion as soon as mitral stenosis is discovered.

Surgeons of the Mayo Clinic, in a report6 on Operative
Risk in Cardiac Disease, hold that a valvular lesion is not a
rational basis for judging a cardiopath so far as prognosis in
a surgical operation is concerned, but this statement is not
true for an obstetrical case. If we except angina pectoris and
related diseases, the four disorders of the heart's mechanism
that surgeons deem the worst risks in operation are auricular
fibrillation, auricular flutter, impaired auriculoventricular con
duction, and impaired intraventricular conduction. These
conditions are usually accompanied by extensive lesions of the
heart muscle.

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

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

* Jour. Amer. Med. Assoc., Lxix, 24.

HEART DISEASES IN PREGNANCY 175

Mayo Clinic, where there is exophthalmic goitre or tonsillitis.

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

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

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

Labor in any cardiac disease requires close watching even
when the compensation is good. There is always a possibility
of collapse in the third stage or during the puerperium. The

176 THE ETHICS OF MEDICAL HOMICIDE

obstetrician must stay by the bedside, and he is to have every
thing ready for a sudden emergency, which is likely to result
in death if not instantly met. All the instruments for oper
ative delivery are to be kept sterilized and ready for immediate
use. When symptoms of imminent collapse appear, delivery
is to be done at once. If a cardiopath collapses in the early
stages of gestation, before the child is viable, the rule explained
in the chapter on Abortion holds — the child may not be killed
by removal to save the woman's life.

Jaschke,7 in his consideration of 1548 pregnant cardiopaths,
found that seven-eighths went to term, and that the women were
prematurely delivered in only about 9 per cent, of the total
number of cases. Therapeutic interruption of pregnancy was
necessary in only about 1 per cent. The high mortality re
ported by many good obstetricians is a proof that the treatment
of cardiac conditions requires an experience in clinical medi
cine and a skill lacking, as a rule, in specialists who are not
internists.

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

f Loc. cit.

CHAPTER XV

HYPEREMESIS GKAVIDAEUM

HYPEEEMESIS GRAVID ARUM, the Pernicious Vom
iting of Pregnancy, is commonly classified among the
toxemias; but as the etiology is not known definitely, this clas
sification is one of convenience more than exactness. Nausea
and vomiting occur so frequently in the early months of gesta
tion that they are deemed almost physiological, but when these
symptoms become very grave and persistent they are undoubt
edly pathologic, and are said to be pernicious, as they may
lead to abortion, or to the death of the woman. In 1813, Sim-
mond first successfully employed artificial abortion to save the
woman in this condition, and thus added a possible moral qual
ity to the disease. Therapeutic abortion was used in 1608,
and Soranus of Ephesus, in the second century, mentions it.

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

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

177

178 THE ETHICS OF MEDICAL HOMICIDE

stomach, and soreness of the thoracic muscles are frequent and
troublesome symptoms. In some cases there is salivation.

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

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

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

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

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

Neurotic and hysteric women are more liable to this dis
ease than the nervously stable. There is a direct communica
tion by the sympathetic and vagus nerves between the stomach
and the uterus and its adnexa, and thus reflex irritations read
ily pass to the stomach. Through this path vomiting is caused
by any unusual distention of the uterus, as when the fetus
grows too rapidly ; or when the size of the ovum is larger than
normal, as in twin pregnancies; or in irritations like hydram-

HYPEEEMESIS GKAVIDAKUM 179

nios, displacement of the uterus, acute anteversions, retrover-
sions, or flexions which pinch and stretch the nerves. Inflam
mations, as metritis, endrometritis, and cervicitis; tumors of
the uterus; diseases of the adnexa or of the pelvic connective
tissue or peritoneum are other sources of reflex vomiting. The
proof that such are causes is that the vomit ceases when the
conditions mentioned are cured. Such conditions exist, how
ever, in women who are not pregnant without causing vomit;
there is therefore some special disposition in the pregnant.

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

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

Toxins from the fetal syncytium appear to be another cause
of the vomit. The syncytium is a mass of protoplasm without
cell demarkation but with nuclei scattered throughout the sub
stance. Sometimes this embryological cellular material starts
to grow after the manner of a cancer, and then it is very malig
nant (syncytioma malignum], but its connection with the per
nicious vomit of pregnancy is more theoretical than estab
lished. In physiological conditions the toxins in the blood are
neutralized by the secretions of the ductless glands of the body,
and in pregnancy probably these same glands by intensified
activity effect the same result. Injection of blood serum taken

from healthy pregnant women has cured cases of toxemic per
nicious vomit, and this makes the theory much more probable.

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

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

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

The treatment is technical, and is given in detail in books
like De Lee's Principles and Practice of Obstetrics.1 Sug
gestion and the environment are important elements in the
treatment. Local anesthetics, mechanical drugs like cerium
oxalate and bismuth, depressomotors, external applications,
and gastric lavage are indicated in the early stages of the dis
ease, but are rather harmful than useful in later stages. Ad
renalin, ten drops of a 1 :1000 solution by mouth, or three drops
hypodermically as doses, often cures. Sergent and Lian re
ported six such cases in one paper in 1913. Hypodermic in
jection of the extract of corpus luteum in 1 c.c. doses has been
effective in some cases. So has the injection of defibrinated
serum from a healthy pregnant woman. Curtis describes the
tcchnic in the Journal of the American Medical Association,
February 28, 1914. The gynecologist must adjust uterine dis-
1 Philadelphia, 1913.

HYPEEEMESIS GKAVIDARU^I 181

placements and heal cervical erosions. The oculist, laryngol-
ogist, and otologist are to remedy refractive errors and remove
irritants in the air passages and the ear.

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

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

CHAPTER XVI
CIIOEEA GBAVIDABUM AND HYSTERIA

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

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

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

It is very important to differentiate infectious chorea from

182

CHOREA GRAVIDARUM AND HYSTERIA 183

hysterical chorea — the latter may or may not be dangerous;
chorea always is dangerous. In hysterical chorea the move
ments are sudden, isolated, and sometimes rhythmical, espe
cially in the fingers ; there are zones of anesthesia, and the per
versity of the hysteric soon manifests itself. The movements
in hysteria are never so intense as to exhaust the patient. In
true chorea the movements are irregular, spasmodic, and in
creased hy motion and voluntary effort, especially if the effort
is sustained; they exhaust the patient.

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

If the fetus is viable and the choreic woman, with a clear
toxic chorea, shows signs of exhaustion from the spasms and
insomnia, or if her mania is becoming fixed and her delusions
are dangerous (such women are likely to kill the infant), or
if she has endocarditis, the uterus should be emptied, as a rule.
If, however, the symptoms show a recession on treatment, the
uterus should not be emptied. Albrecht 1 reported a case of
chorea cured by an injection of serum from a normal pregnant
woman. Each case must be judged by its own characteristics.
The last sacraments should be given as soon as the symptoms
grow grave.

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

The term hysteria has been handed down from the days
when physicians thought there was a connection between uterine
disorders and the set of nervous symptoms grouped about the
1 Zeitschr. f. Geburtshiilfe u. Gynak., Ixxvi, 3, p. 677. Stuttgart.

184: THE ETHICS OF MEDICAL HOMICIDE

title hysteria. It is now etymologically meaningless — men also
grow hysterical. Briquet found 11 male to 204 female hys
terics, and later statistics increase the number of males.

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

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

After the great plague, the Black Death, in the fourteenth
century, there were very remarkable epidemics of imitative
hysteria in Germany and elsewhere. In 1374, at Aix-la-
Chapelle, cro\vds of men and women danced together in the
streets until they fell exhausted in a cataleptic state. These
dances spread over Holland and Belgium and extended to
Cologne and Metz. The "Dancing Plague" broke out again,
in 1418, at Strasburg and in Belgium and along the lower
Rhine. In 1237 there was a similar outbreak among children
at Erfurt and many died from exhaustion. The tarantism in
Italy from the fifteenth to the eighteenth century is another
example of epidemic hysteria. There were epidemics of hys
teria in Tennessee, Kentucky, and a part of Virginia, which

CHOEEA GKAVIDAEUM AND HYSTEKIA 185

began in 1800 and recurred for a number of years. These out
breaks started in revivals and camp meetings. The majority
of the cases were in youths from fifteen to twenty-five years of
age, but the hysteria was observed in persons from six to sixty
years old. The muscles affected were those of the neck, trunk,
and arms, and the convulsions were so strong that the patients
were thrown to the ground and often leaped about like a live
fish tossed out of the water on a bank.

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

There are innumerable physical symptoms of the disease,
but the mental phases have most to do with the treatment. The
hysterical person is characterized by an overmastering desire
to be an object of sympathy, interest, admiration, rather than
by a tendency to baser instincts. The will is weak, the emo
tions explosive, the patient is impulsive and lacking in self-
control. She readily goes from absurd laughter into floods of
tears. She simulates pains and other symptoms of disease, and

186 THE ETHICS OF MEDICAL HOMICIDE

she is always a liar, no matter what her state in life, from
nurse-girl to nun.

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

CHAPTER XVII
ACUTE YELLOW ATROPHY OF THE LIVER IN PREGNANCY

A JUTE yellow atrophy of the liver in pregnancy was for
merly called Icterus Gravis. The disease is not neces
sarily connected with pregnancy, but half the cases are in preg
nant women, and with them it may appear at any time in ges
tation or shortly after delivery. Pernicious vomiting, eclamp
sia, sepsis, chloroform poisoning, typhoid, osteomyelitis, diph
theria, erysipelas, alcoholism, or phosphorus poisoning in preg
nant women may end in this acute yellow atrophy. Bendig *
reported two cases, both fatal, which were caused by syphilis.

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

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

The prognosis is always bad. The fetus nearly always dies.
If the fetus is viable the uterus should be emptied at once even
if the woman is so near death that the procedure appears use
less : it may at least give a chance to baptize the infant. Sup-

1 M unchener medizinische Wochenschrift, August, 1915.

187

pose in a particular case a consultant or the physician in charge
holds that the mother is so ill that therapeutic abortion will
only hasten her death, yet the fetal heart-sounds can be heard
through her abdominal wall. In that case I should be in favor
of performing the abortion to baptize the infant, reluctantly
permitting the chance of hastening the mother's death. But
this hastening is by no means certain.

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

CHAPTER XVIII
INFECTIOUS DISEASES IN PBEGNANCY

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

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

The communication between the fetal and the maternal
blood systems is as indirect as that between the air in a man's

189

190 THE ETHICS OF MEDICAL HOMICIDE

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

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

Some bacteria do not get through to the fetus, but a few
do get in. Tubercle bacilli were found in the fetus by Birch-
Hirschfeld l in 1891, and Schmorl 2 demonstrated them in 50
per cent, of the placentas in one series of examinations. Bar
and Renon 3 found them in the blood of the umbilical cord in
two of five cases. Actual congenital tuberculosis is possible,
though very exceptional: the bacteria either pass through the
wall between mother and fetus, or destroy this wall and then

1 Arbciten d. pathologisch. Instit. zu Leipsig. Jena, 1891.
1 Miinchener medizinische Wochenschrift, 1904, vol. li, p. 1676.
1 L'Obstetrique, vol. i, p. 69.

INFECTIOUS DISEASES IN PKEGNANCY 191

get in. Smallpox, measles, and scarlatina, the causes of which
have not yet been demonstrated; typhoid, cholera Asiatica,
pneumonia, bubonic plague, erysipelas, pus infection, anthrax,
syphilis, febris recurrens, and malaria have already been dem
onstrated in the fetus. Lynch of Johns Hopkins collected six
teen cases of typhoid in the fetus. I found the typhoid bacillus
in the liver and kidneys of a still-born fetus whose mother was
ill with typhoid fever; this case was not among those collected
by Lynch.

The majority of writers give unfavorable prognoses for
typhoid in pregnancy. Abortion or premature labor is ex
tremely common, with great danger to the mother's life. When
labor begins in these cases the last sacraments should be ad
ministered early. Therapeutic abortion in typhoid is very
likely to cause death, yet a number of women recover after
abortion. As regards the woman's life, cases of premature
labor have a worse prognosis than early abortion. The greatest
danger is while the fever is high, and abortion is commoner in
the first week of fever than in the second or third. In pro
tracted typhoid abortion is likely to occur in the fourth week
or later. After defervescence the prognosis is better, but there
is always danger. Different physicians have markedly vary
ing results. There is no medical condition where skill in the
physician counts more than in typhoid; it is the supreme test
of the therapeutist. Sacquin4 collected from various sources
the statistics of 233 cases of pregnancy during typhoid, and
abortion or premature labor occurred in 150 of these, with
death in 16 per cent. Many skilful men have a mortality as
low as 3 per cent, in typhoid not complicated with pregnancy.

The subject of typhoid is too vast for complete treatment
here : the article on Typhoid in the American edition of Noth-
nagel's Encyclopedia of Practical Medicine covers 472 large
octavo pages. A very important point is not to mistake typhoid
for a septicemia in its early stage. A Widal reaction should
be made in apparently septic cases to exclude typhoid. Some
times, however, a streptococcic infection will give a positive

4 These. Nancy, 1885.

192 THE ETHICS OF MEDICAL HOMICIDE

Widal, and there may be a mixed typhoid and streptococcic in
fection.

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

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

The efficiency and necessity of vaccination against small
pox, which is as virulent now as it ever was, is so certainly
established that a parent or guardian who neglects or refuses
to have children vaccinated when exposed to the disease is
guilty of homicide through neglect if an unvaccinated child

INFECTIOUS DISEASES IN PREGNANCY 193

under his care dies of smallpox. Revaccination is necessary
every eighth year if smallpox reappears. Agitation against vac
cination is not mere ignorance: it is a dangerous crime, ex
actly like loosing a mad dog; and it is combined with the in
solence of ignorance. Persons who have seen smallpox are
very much afraid of it, because it is one of the most dreadful
afflictions humanity is exposed to; those who have not seen it,
yet say they are not afraid of it, are mere fools.

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

Pneumonia in pregnancy is a rare but very dangerous dis
ease. In one series of 13,611 pregnancies there were 120 cases
of pneumonia — eight-tenths of one per cent. ; in another series
of 1842 pregnancies two and three-tenths had pneumonia.
Wallich,5 in a study of the mortality of this condition, found
that pneumonia causes abortion in one-third of the cases that
occur during the first six months of gestation, and in two-thirds
of the cases that happen between the sixth month and term.
On the third day of the pneumonia the abortions are most
likely to occur. The maternal mortality varies between 50 and
100 per cent, in the groups studied, and the fetal mortality is
80 per cent, in general, but about 40 per cent, for viable fetuses.
The large size of the uterus in the last months of pregnancy
interferes with the descent of the diaphragm in respiration, and
the heart is likely to fail. The more advanced the pregnancy,
the greater the danger to both mother and child from pneu
monia. Among the dangers to the child is the imperfect oxy-
genation of its blood, and in a few cases the pneumococci reach
the fetus.

Randall, in a study of 190 pregnant women who had pneu
monia, found a somewhat lower mortality than that observed
by Wallich. In Randall's series 70 died (36.7 per cent.) ; of

• Annales de Gynecologic. June, 1889

104 THE ETHICS OF MEDICAL HOMICIDE

118 who did not abort, only 12 died (10.7 per cent.). In a
second group of 352 cases abortion happened in 58.8 per cent
Of 144 patients in the first six months of gestation, 22.08 per
cent, died, but of those that aborted 52.08 per cent. died.
Again, of 164 cases in the last three months, 30.49 per cent,
died, but 70.12 per cent, died of those that aborted during these
three months. Of 82 that aborted, 87.8 per cent. died. The
mortality in women under 25 years of age was 13.33 per cent. ;
in women from 25 to 35 years, 23.2 per cent.; over 35, 22 per
cent.

Pneumonia in pregnancy is made worse by the mechanical
interference with respiration brought about by the enlarge
ment of the uterus, and the heart, which is overburdened in
ordinary pneumonia, is still more exhausted by the additional
strain of pregnancy in the pneumonia of gestation; moreover,
the lungs, which are obliged to do enhanced labor in pregnancy
in eliminating, are clogged by the pneumonia; it would seem,
then, that, if the fetus is viable, the womb should be emptied
to give the mother a better chance for recovery. Statistics,
however, are against therapeutic abortion. The evacuation of
the uterus determines blood to the inflamed lungs, which are
already overburdened. The exhaustion of labor weakens the
patient, and makes her liable to general septic infection. Mat-
ton 6 found that in eighteen cases where pregnancy was arti
ficially interrupted, nine women died (50 per cent.) ; while in
twenty cases where no interference was attempted, only one
woman died. This comparison is not exact, perhaps, because
we do not know the gravity of the infection in each group,
but in any consideration the difference is remarkable. In a
group studied by Chatelain 7 the results in natural and arti
ficial delivery were virtually the same. Inasmuch as thera
peutic abortion at the best is no better than non-interference,
there is no justification for therapeutic abortion, unless in un
usual circumstances.

Pneumonia is an infectious disease, and a pregnant woman
should, for her own sake and the sake of the fetus, avoid ex-

* Jour, de Med. de Bruxelles, 1872, p. 412.

T Hid., 1970, vol. 1, pp. 430, 516, and vol. li, p. 11.

INFECTIOUS DISEASES IN PKEGNANC^ 195

posure to infection. When the disease is present the last sacra
ments should not be deferred, as it may be impossible to make
a confession when near death.

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

There is no clear proof that pregnant women are especially
liable to infection by influenza, but there is always a notable
fall in the birth-rate after marked epidemics of the disease.
This has been observed in France, Germany, and Switzerland.
When it does occur in pregnancy it is likely to cause abortion.
Pasquier, as early as 1410, noticed this fact. The disease is
likely to cause hemorrhage from the uterus in non-gravid
women, especially in those who are past the climacteric, and
menorrhagia in younger women who are not pregnant. Moel-
ler 8 found abortion or premature labor in 28.3 per cent, of
twenty-one severe cases. In severe influenza where there is
diffuse capillary bronchitis, pleuropneuinoiiia, or spasmodic
cough, abortion is most likely to occur, and such abortion is
always dangerous. The hemorrhages in abortions from influ
enza are often alarmingly profuse.

In threatened respiratory or cardiac failure in influenza
complicating pregnancy there may be question of therapeutic
abortion, but in such an event great care must be taken to avoid
exhaustion and shock. The child should be extracted; the
woman should not be made to labor. One of the important

* Dcutsch. med. Wochenscli., 1900, No. 28.

196 THE ETHICS OF MEDICAL HOMICIDE

moral considerations in this matter of influenza and preg
nancy is that the woman commits grave sin if she needlessly
exposes herself to infection, because of the danger to the child's
life and the risk of its loss without baptism, and also because
of the danger to her own life.

Scarlatina (Italian scarlattina, Low Latin febris scarla
tina), or Scarlet Fever, is very rare in pregnancy. Popularly,
scarlatina is used for a light form of scarlet fever, as varioloid
is used for a light attack of smallpox; but physicians do not
make this distinction between scarlatina and scarlet fever: they
use the terms synonymously. In Nothnagel's Encyclopedia of
Practical Medicine Juergensen has an elaborate discussion off
the differentiation between genuine scarlet fever in the puer-
perium and the relatively frequent septic erythema found in
that state, but the received opinion now is that real scarlet
fever is very rare in pregnancy. Those who report large num
bers of scarlet fever cases in pregnancy err in diagnosis.

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

Measles in pregnancy is also very rare, but when it does
occur it is a serious disease. Gestation is interrupted in 55
per cent, of the cases, and the mortality is 15 per cent, for the
women. The same moral and related conditions that obtain
in scarlatina are found in measles. There is a marked tend
ency to hemorrhage and pneumonia. Of eleven cases re
ported by Klotz,9 nine aborted.

In epidemics of Asiatic cholera the mortality among preg
nant women is extremely high. In the Hamburg epidemic of
1897, fifty-seven per cent, of the pregnant women affected died.
Abortion is very frequent because of the hemorrhagic endome-
tritis. The mortality for all patients in Asiatic cholera is very
* Archiv. f. Gyn., vol. xxix, p. 448.

INFECTIOUS DISEASES IN PKEGNANCY 197

great — almost 50 per cent, at the beginning of the epidemic.

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

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

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

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

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

198 THE ETHICS OF MEDICAL HOMICIDE

said 39 per cent, of these women thought the disease began
during pregnancy or the puerperium.

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

Pregnancy in consumptive women is not necessarily detri
mental to each particular patient, nor is it, as a rule, a justi
fication for emptying the uterus of even the viable fetus. Even
when the tubercular condition grows worse during pregnancy
it is not always possible to prove that the pregnancy itself is
the cause of the deterioration. If the woman conceives in the
final stage of pulmonary tuberculosis she will die, whether she
goes on to term or not. Bonney 10 describes three cases of ad
vanced pulmonary tuberculosis which were cured during preg
nancy, by the bodily changes peculiar to that condition, but
such results are altogether exceptional.

Artificially induced premature labor sometimes causes more
damage than normal parturition at term. Much depends upon

"Pulmonary Tuberculosis, p. 550. Philadelphia, 1908.

INFECTIOUS DISEASES IN PREGNANCY 199

the methods used for the induction of the abortion. The in
sertion of bougies, catheters, or sounds is always contraindi-
cated in advanced tuberculosis. Hirst of the University of
Pennsylvania n thinks the notion that tubercular women im
prove in pregnancy is "a superstition," and that such women
should neither marry nor have children. De Lee 12 holds that
tubercular women should not marry because the woman is likely
to infect her husband and children. He thinks the disease
grows worse in pregnancy, and that hemorrhage is frequent ex
cept in chronic ulcerative tuberculosis. In this last condition
pregnancy does not ordinarily aggravate the condition. In tu
bercular laryngitis complicating pregnancy, Kiittner found the
mortality to be 90 per cent. Such laryngitis is usually fatal,
whether pregnancy is present or not. When there is a miscar
riage in tuberculosis, the infection often becomes florid and re
sembles pneumonia. Advanced cases have a tedious and dan
gerous labor, with dyspnoea and occasionally hemorrhage or
cardiac exhaustion. Edema of the lungs is not infrequent.

Williams of Johns Hopkins University, in the 1903 edition
of his Obstetrics, tells of a woman who died of tuberculous peri
tonitis a short time after parturition. The uterus was studded
with tubercles and its interior was covered with tuberculous
ulcers. The tubercle bacillus had been found in cultures taken
from the interior of the uterus during life. Her child was
born perfectly healthy and remained so. Williams says in the
same place that the induction of premature labor because of
tuberculosis is justifiable only in the interests of the child, and
this only in those rare cases in which the woman is so ill that
she probably will die before term. Norris 13 of Philadelphia
agrees with Williams that induction of premature labor is use
less, and he says all authorities unite in this opinion.

A tubercular woman should not nurse her infant because
she will infect it and exhaust herself. Infants are very sus
ceptible to tuberculosis. Birch-Hi rschf eld, in 1891, first dem
onstrated tuberculosis in the fetus, and Schmorl found it in

11 A Text-look of Obstetrics, p. 427. Philadelphia, 1912.
a The Principles and Practice of Obstetrics, p. 480. Philadelphia,
1913.

11 Pennsylvania Medical Journal, February, 1916.

200 THE ETHICS OF MEDICAL HOMICIDE

the placenta in 50 per cent, of a series of cases that he ex
amined. Infection of the child in uiero, however, is extremely
rare even by the placental way. There is a high death-rate
from tuberculosis among infants, but the infection is postnatal.
Dietrich of Berlin found that the death-rate from tuberculosis
among children in Prussia is higher during the first year of
life than in any other year.

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

CHAPTEK XIX

SYPHILIS IN PREGNANCY AND MARRIAGE

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

Inoculation with syphilis before conception almost always
results in abortion. In 130 women studied by Le Pileur there
were 3.8 per cent, still-births before infection by syphilis, but
78 per cent, after infection. In premature labor the child is,
as a rule, born dead ; less frequently it is born syphilitic ; still
less frequently it is born apparently sound, but the syphilis
appears later; in a few cases, when the maternal syphilis is
old, the child may be born normal. Interruption of gestation
is the commonest symptom in syphilis complicating pregnancy.

201

202 THE ETHICS OF MEDICAL HOMICIDE

The labor itself is affected: the pains are weak and tardy.
Abnormal presentations occur frequently when the fetus is
dead. Chancres on the cervix may cause obstruction, and there
may be indurations so dense as to necessitate cesarean delivery.
The perineum may become so friable as to tear, as De Lee
says, "like wet paper."

When the mother is infected at the time of conception the
child is always syphilitic. If the mother is infected early in
pregnancy the child is almost always infected. If she is in
fected late in pregnancy the child may escape infection. Men
with tertiary syphilis have begotten children without, to all
clinical appearance, inoculating the wife. In such a case the
mother may nurse the child with safety to herself, but the
child will infect a wet nurse other than its own mother, and
in very rare instances mothers in this condition have been
floridly infected. The condition here described is called Colles's
Law.1 The doctrine of Colles's Law has fallen into dis
use because we can now demonstrate by the "Wassermann re
action that almost all apparently healthy mothers of this class
are in reality infected. The term now used is "Syphilis by
Conception." 2 The virus passes through the fetal placenta to
the mother, although immunizing substances are held back by
the placenta. A fetus cannot make immunizing bodies before
its eighth month, and on that account the earlier the fetus is
infected, the more likely it is to die. Recently, however, some
scanty testimony has been collected which sustains Colles's
Law in a few cases. Ledermann reported three cases, and
Nonne others, in which the wives of men with tabes or paralysis
bore syphilitic children and yet never responded positively
themselves to the Wassermann test, or showed any symptoms
suggesting syphilis. To this list Kroon 3 adds a case corre
sponding fully to the requirements of Colles's Law. A woman
of twenty-eight years who had had eight abortions was de
livered of a child with undoubted congenital, syphilis. The
child's father had been infected with syphilis twelve years be-

1 From Abraham Colles, Dublin, 1837.

•Wolff, 1879.

1 Nederlandisch Tijdschrift voor OeneesJcunde, i, 9.

SYPHILIS IK PREGNANCY AND MARRIAGE 203

fore. The woman showed no signs of syphilis, two Wasser-
mann tests were negative, and she nursed the child without
injury to herself.

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

Wolff * studied a group of nine syphilitic women and their
children. There were sixty-six pregnancies, but only thirty-
three viable children were born. Of these last fourteen died
in childhood, three committed suicide at twelve, twenty, and
twenty-eight years of age; and of the thirteen still living only
two were normal. The others are all feeble-minded, epileptic,
hysteric, or otherwise neurotic. Post 5 tabulated the mortality
in thirty syphilitic families in which there were 168 preg
nancies. Of these fifty-three ended in still-birth or miscar
riage and there were forty-four early deaths — a total loss of
57 per cent. Of the children that were born alive 38 per cent,
are now dead, and of the seventy-one that are alive only thirty-
nine are apparently healthy. There are very many cases of
diseased children and adults with serious lesions of obscure
etiology, and in a great number of instances of anemia, mal
nutrition, extreme nervousness, aortitis, bone diseases, vague
pain, and similar conditions, the origin is congenital syphilis.
Stoll,8 in sixty-eight such cases, found a positive luetin syphi
litic reaction, and a positive Wassermann in 17 per cent.

4 Zeitschr. f. klinisch. Med., vol. Ixxvi. Berlin.

* Boston Med. and Surg. Jour., vol. clvii, n. 4.

* Jour. Amer. Med. Assoc., October 31, 1914.

204 THE ETHICS OE MEDICAL HOMICIDE

Gottheil,7 professor of dermatology and syphilography in
Fordham University, holds that if a man has gone through a
modern treatment for syphilis, given hy a competent physician
and extended over three years, and if during the fourth year,
without treatment, he repeatedly shows a negative Wasser-
mann reaction, he may marry. That is the common opinion
of physicians, hut it is decidedly erroneous.

In one series of 562 cases of hereditary syphilis observed hy
the great syphilographer Fournier, sixty children, or over 10
per cent., were infected more than six years after the primary
parental inoculation. He tells of one woman who had nineteen
consecutive still-births from syphilis. Gowers 8 says: "There
is no evidence that the disease ever is or ever has been cured,
the word 'disease' being hero used to designate that which
causes the various manifestations of the malady." This state
ment is too sweeping, but it is very near the truth.

Brulms recently reported the outcome of the Wassermann
test repeated about yearly from 1908 to 1915 in one hundred
private cases infected with syphilis ten or more years before
the time of the report. In forty-two the test was constantly
negative; in thirty-two, positive at first but negative later; in
seven, constantly positive notwithstanding repeated courses of
treatment; in three, positive at first, then long negative, but
finally changing to positive again; in eight, negative at first,
then positive, and finally negative; and in eight, negative at
first but finally positive. The last three groups are particularly
significant. In some the long negative reaction, for five or six
years, indicated cure, and physicians would pronounce such
cases positively cured; but suddenly they changed to a positive
reaction without any clinical manifestations showing at the
time. After renewed courses of treatment in the following two
years the reaction became negative. Among the cases with con
stant negative reaction there were some who developed brain
syphilis, or tabes, proving that they wrere not cured despite the
absence of clinical manifestations of the disease and the nega-

T Forchheimer's Therapeusis of Internal Diseases, vol. ii, p. 421.
New York, 1913.

"Syphilis and the Nervous System, 1892.

SYPHILIS IN PREGNANCY AND MARRIAGE 205

tive Wassermann reactions. Professor Blaschko of Berlin, at
the seventeenth International Medical Congress in 1913, in the
presence of Ehrlich, Wassermann and Hata, said no one could
even talk of a cure of syphilis until an interval of ten years
without symptoms had occurred. Where a blood Wassermann
is negative a spinal fluid reaction may be positive.

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

These and other facts strongly indicate that the form of
syphilis which ends in tabes or paresis remains infectious over
a much longer time than ordinary syphilis does. No one has
cured either tabes or paresis. Raven reported in 1914 an in
vestigation of ninety families in each of which a case of
metalues had developed. The interval between the date of in
fection and the marriage was known in about half of these, and
it was four years in two families, five years in one, and from
six to twenty-one years in ten! Fournier, in 4400 cases of
syphilis, saw three cases where the tertiary symptoms appeared
fifty years after infection, and in one case fifty-five years after
infection. Bonnet9 reported such a case which came to him
for treatment fifty-four years after infection. The man had no
children.

Syphilis that affects the nervous system as in tabes and
paresis is an incurable syphilis, and there is no means whereby
any physician, no matter how skilful he may be, can tell whether
or not a given patient has such an infection. The physician,
then, who tells a syphilitic that he or she is cured and lets such
a person marry is responsible for all the evils that result from
his rashness. Once a syphilitic, not necessarily always a syphi
litic; but once a syphilitic, possibly and probably always a

* Lyon Med., Novembe: 7, 1907.

syphilitic, and that no matter what the treatment or the lack
of clinical symptoms. Damaged goods of this kind are to be
looked upon as damaged goods forever.

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

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

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

SYPHILIS IN PKEGNANCY AND MARRIAGE 207

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

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

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

Again, there are various kinds of secrets. St. Alphonsus
Liguori 10 classifies secrets in three groups: (1) natural; (2)
promised; (3) entrusted secrets. A natural secret is one which
obliges us in justice to observe it if divulging it will gravely
injure any one in reputation or possessions. We are not obliged
to observe a secret of this kind at the risk of our lives unless
the damage from the divulging would affect the community
gravely. A promised secret obliges to silence either gravely or
lightly, according to the intention of the promiser. Where
reasonable doubt exists as to grave obligation, such obligation
does not exist. A promise to secrecy made even under oath is
not binding if one is obliged in justice to reveal the secret;
therefore we must testify to the crime of another when a judge
legitimately demands our testimony, even if we have promised
not to tell anything. If a secret is entrusted to one, and divulg
ing would cause grave damage, but justice, or similar circum
stances, do not oblige us to reveal it, we are bound to observe
it even when questioned by legitimate authority. Then we may
answer we know nothing about it, at least for revelation. St.
Alphonsus's text is : "Potes respondere te nihil scire, scilicet ad
revelandum." His meaning seems to be: "You may say you

" Theologia Moralis, iv, n. 970 et seq.

208 THE ETHICS OF MEDICAL HOMICIDE

know nothing about the matter inquired into." Any other
signification would bo futile. To say literally, "I do not know
anything I may tell," would only expose one to punishment
for contempt. He seems to make the answer a conventional
denial, like the "not guilty" of a criminal. A judge may not
abrogate the natural right by which an entrusted secret is pro
tected, unless the secret is already known in some other way,
or there is a just cause for revealing it.11

When an entrusted secret, however, which is also called a
strict or absolutely natural secret, is imparted expressly or
tacitly, say, to physicians, lawyers, or priests, and becomes a
professional secret, it obliges more strictly than any other.
There are four conditions under which such an entrusted secret
may be revealed, at least without mortal sin (except by a con
fessor) : (1) If we have the presumed consent of the principal.
(2) If the material of the secret is trivial, or if it is known
from another source, or is already public. Is it a mortal sin
to divulge a grave entrusted secret to a responsible person who
is under the same bond ? St. Alphonsus, De Lugo, and others
say probably it is not, provided the secret is not divulged to
the particular person from whom the principal wished it to be
concealed. The term probably here is technical and refers more
to the absolute truth of an assertion than to its practical ap
plication. (3) One might reveal such a secret without mortal
sin, through inadvertence or thoughtlessness, or under the sup
position that it is not a grave secret. Some moralists hold,
however, that to excuse from mortal sin, the revealer must be
certain that the matter of the secret is not grave. (4) Such a
secret may be revealed if keeping it would cause public injury,
or injury to an innocent person, or injury to the person to
whom the secret has been entrusted; then the law of charity
demands that it be revealed. Therefore, even if one has bound
himself under oath, he may reveal the secret — always excepting
a priest or confessor. This is the common doctrine of moral
theologians. It is for the common good of human society that
entrusted secrets be absolutely kept unless so grave a damage
befalls another from such observance that it becomes more con-
" Cf. De Lugo, De Justitia et Jure, disp. 14, n. 141.

SYPHILIS IN PREGNANCY AND MARRIAGE 200

ducive to the public good to reveal than to conceal. To let an
infective syphilitic, for example, spread his contagion merely
because an entrusted secret should be kept is a much greater
damage to the public than a good.

Barrett 12 says a physician may not divulge the diseases
of a family to an insurance company unless the family as
sents ; he may not tell the man before marriage that the woman
had been operated upon, say, for ovariotomy, unless the woman
gives permission ; nor may he let the woman know, before mar
riage, of those diseases of the man which are not contagious.
He says further that if a man has had syphilis and is now com
pletely cured, the physician may not reveal this previous con
dition to the woman.

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

Secondly, I deny most emphatically that any physician can
tell that a man who once has had syphilis is completely cured
and is not a source of infection. The facts I have cited in this
chapter prove conclusively that once a syphilitic always prob
ably a syphilitic, and the risk is always so great that the phy
sician is obliged first to insist that the man does not marry,
and if the man persists the physician may let the woman
know. If preparations for the marriage have been made pub
licly, the physician will, as a rule, for his pains from the woman
and her family get only a rebuff and the woman will later get
her syphilis more or less certainly. If the man is actively in
fective the physician is bound to let the woman know, through

u Sabetti-Barrett, Compend. Theol. Moral., n. 565. New York,
1915.

her confessor if no other way presents, provided the man can
not be frightened out of his scoundrel ism. If nothing else
avails, the physician would be justified in reporting such a
man to the Board of Health or the sanitary police. Barrett
says the physician may be excused from divulging that the man
has infective syphilis if such a revelation would cause the phy
sician to lose the confidence of his patients. It never does have
such an effect, although physicians constantly expose such cases
in the interests of humanity. Because a man who is apparently
cured of syphilis may or may not infect the woman, this doubt
probably excuses the physician from the strict obligation of
divulging the condition, although he may tell her if he wishes
to do so, salvo meliore consilio, as far as the release from strict
obligation to divulge is concerned.

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

The fact that in these cases of active or latent syphilis the
disease has been acquired criminally does not in itself affect
the state of the question one way or another — a criminal syphi
litic has a right to his reputation and goods despite his moral
condition; but even where the disease has been acquired with
out moral guilt the syphilitic is always a formally or mate
rially unjust aggressor in a prospective marriage to an inno
cent and uninfected woman, and is to be treated accordingly.
If a woman may kill an unjust aggressor in defence of her
chastity, and if quod liceat per se licet per alium, her natural
protectors, kin, physician, and so on, may at least divulge the
secret of the man's condition in defence of her from a fate
which in many respects is worse than rape.

In keeping with this matter of entrusted secrets it is worth
noting that physicians should remember that the case histories
they leave after them at death, or which they leave unguarded

211

in their offices, are likely to be read by some third party who
has no right to the secrets they contain. Case histories which
the patients would not have divulged should be kept in cipher
so far as proper names and addresses are concerned.

CHAPTER XX

GONOEEHEA IN MAEEIAGE

GONORRHEA is caused by the gonococcus discovered
by Neisser in 1879. The name was given to the dis
ease in the second century by Galen, who supposed that the
condition is a spermatorrhea. The infection begins as a sur
face inflammation and gradually penetrates more or less deeply
into the underlying tissues. In the male, gonorrhea may affect
any part of the body; and when the disease is chronic it is a
Bource of infection for years. If a man who has had gonorrhea
wishes to marry after careful treatment, most physicians will
permit him to do so if he passes the customary tests which
indicate cure, but he is always dangerous. The tests are: (1)
the microscopic and cultural examinations of the centrifugalized
morning urine — the washings from the urethra must be nega
tive after repeated trials and over a space of months; (2) the
microscopic and cultural examinations of urethral spontaneous
and artificial discharges must be negative in the same man
ner; (3) the microscopic and cultural findings of the secretion
expressed from the prostate and seminal vesicles must be nega
tive in the same manner; (4) urethroscopic examinations of the
anterior and posterior urethra must show no unhealed lesions;
(5) the complement fixation test is to be repeatedly negative.
The complement fixation test is like a "Wassermann reaction,
but the antigen should be polyvalent. This test does not give
a positive reaction where no gonorrhea is present, but it is often
negative where the gonococcus is present. Hence a positive re
sult has value, but a negative result has little or no value. All
these tests are to be tried repeatedly, and if negative for months,
the physician may say the man is probably cured, but no phy
sician can guarantee the cure so as to take the responsibility of

212

213

the decision. Not one physician in five hundred can make
these tests himself, because physicians in general lack the spe
cial training and the means to make them. As the effects of
gonorrheic infection in a woman are so appalling, any woman
who wittingly marries a man who has had gonorrhea is very
rash, and the man who takes the risk of infecting such a woman
is a rascal.

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

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

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

In the acute stage of tubal infection the tubes become
elongated and swollen, and the mucous surfaces within are cov
ered with a seropurulent exudate. This condition is called sal-
pinx or salpingitis. When the condition advances so far that
the external abdominal ostium of the tube is closed, a pyosal
pinx forms. The pyosalpinx may be quite large. A hydro
salpinx is like a pyosalpinx, with both tubal ends sealed, ex
cept that its content is a serous or watery fluid. When infected
material escapes through the distal end of the tube, perioophori-
tis develops, and the ovary becomes adherent to the tube and
other adnexa. More commonly only the surface of the ovary

214 THE ETHICS OF MEDICAL HOMICIDE

is affected, but frequently the infection gets into the body of
the ovary and causes oophoritis. The ovary then swells and
there is a tendency to the formation of retention and other
cysts, or an abscess of the ovary. A tuboovarian cyst is a hydro-
salpinx in communication with an ovarian retention cyst, and
a tuboovarian abscess is a like formation.

Gonorrhea, especially in women, is likely to be very chronic.
Emil Noeggerath, who in 1872 published a book1 which
changed the medical doctrine on the disease, said of women,
"Once infected, always infected." Morris 2 reports a case where
the gonococcus was latent in a man for twenty years, and he
then infected his wife and wished to divorce her until he found
that he himself was at fault. Sax 3 reported an infection after
fourteen years; MacMunn,4 one after fifteen years. These are
exceptional durations in the male for virulence, though not for
continuance of the diplococcus.

Neisser, who discovered the cause of gonorrhea, holds that,
with the exception of measles, gonorrhea is the most widespread
of all maladies. By sterilizing men and women and by abor
tion it holds down the birth-rate more than any other disease.
The number of deaths from the consequences of gonorrhea
(pelvic abscess, peritonitis, septicemia, endocarditis, and so on)
is enormous. Morris thinks that 12,000 prostitutes die an
nually from the effects of gonorrhea alone. Woodruff 5 holds
that 60,000 is nearer the truth. The estimate, too, is that 50
per cent, of all pelvic inflammatory diseases in women is gonor-
rheic; and Neisser, Bumm, and Fiirbinger hold that from
20 to 50 per cent, of childless marriages are due to gonorrhea.
Probably more than 20 per cent, of all the blindness in the
world is from the same cause. The Committee of Seven,6 in
1901, after examining most of the hospital records in New
York and hearing from 4750 physicians, estimated that there
were more than 220,000 venereal patients in New York City.

1 Die latent? Gonorrhoea in weib. Geschlect. Bonn.

'Gonorrhea in Women, p. 123. Philadelphia, 1913.

'Trans. Amer. Urological Assoc., vol. iii.

* Lancet, November 24, 1906.

6 Expansion of Races. New York, 1909.

9 Medical News, December 21, 1909.

215

Bierhoff 7 reckoned that in 1910 there were about 800,000
gonorrheics in that city. In 1906, in Baltimore, there were
3310 cases of the infectious diseases like measles, diphtheria,
scarlet fever, and tuberculosis combined, but 9450 cases of
venereal diseases. In New York City, in round numbers, there
are annually about 41,000 cases of infectious diseases, ex
cluding the venereal group, but 243,000 cases of venereal dis
eases — over five times more cases of venereal diseases than of
all the other infectious diseases together. Of 12,000,000 per
sons insured in Germany, 750,000 annually are infected with
venereal diseases. In the United States navy between 1904
and 1908, with an average of 43,165 men in the navy and
marine corps, there were 32,852 admissions to the hospitals for
venereal diseases, and of these 11,526 were cases of gonorrhea.
This report is far below the actual numbers, as only men in
capacitated for work are included in the list. In the English
navy in 1906 the daily number of men rendered inefficient by
venereal diseases was 867. In the total relative number of
venereal diseases the American army and navy, before the pres
ent war, were the worst in the world, the Japanese navy next,
the English army and navy next.

Sullivan and Spaulding 8 reported on the prevalence and
effects of gonorrhea in 522 women and girls in a Massachu
setts reformatory for women. Of these women 75.7 per cent,
had gonorrhea by positive diagnosis. The average length of
time the infection had existed when diagnosed was four years
and five months, but one woman had had the disease for twenty-
six years, and seven had had it for over twenty years. In
82.7 per cent, there had been no cessation of the clinical symp
toms from the time of infection to the time of diagnosis. Of
the total number 68 per cent, had pelvic inflammation on one
side, and 27 per cent, had it on both sides. There were 41
per cent, of the cases which had had surgical operations or
which required such treatment.

Of 63 women committed for alcoholism 52.4 per cent, had
gonorrhea, 42.8 per cent, had syphilis, and 9.6 per cent, had

New York Med. Jour., November 12, 1910.
8 Jour. Amer. Med. Assoc., January 8, 1916.

216 THE ETHICS OF MEDICAL HOMICIDE

doubtful syphilis; but of 400 women who had been at some
time prostitutes 98.2 per cent, had gonorrhea, 65.5 per cent,
had syphilis, and 9.5 per cent, had doubtful syphilis. Of 119
mental defectives among these women, 90.8 per cent, had gonor
rhea, 61.3 per cent, had syphilis, and 6.7 per cent, had doubt
ful syphilis.

Dr. Thomas Haines9 reported on 365 cases of boys and
girls under eighteen years of age committed to an Ohio re
formatory, and of these 20.8 per cent, had syphilis, and it was
mostly acquired syphilis, not congenital — over one-fourth of the
boys were so affected. McNeil 10 examined 1200 adult negroes
in Galveston, Texas, for syphilis and found the disease in 30 per
cent, of the 1200.

Howard Kelly n estimated that venereal diseases cost the
United States three billion dollars annually, and Norris thinks
this estimate too low. The ravages of the disease are so fright
ful, physically and morally, that any one who spreads it by in
fection, especially of an innocent woman, is guilty of the gravest
moral injustice. Morrow 12 thinks that 250,000 married women
in the United States are suffering from gonorrhea. As most
of these unfortunate women are infected by immoral husbands,
and as the invalidism and suffering they undergo are indescrib
able and cure is often impossible, the physician who permits a
gonorrheic to marry without a protest is responsible for the evil
as an accomplice; and, as has been said, once a gonorrheic,
probably always a gonorrheic.

Pelvic inflammatory disease includes in the uterus and its
adnexa alone metritis, salpingitis, oophoritis, pelvic peritonitis,
cellulitis, lymphangitis, and perimetritis. Pus may rupture
into the pelvic cavity and set up local or general peritonitis or
septicemia. It may burrow through from behind the uterus
into the vagina, rectum, or other parts of the intestines, or into
the bladder, and leave fistulas. Pus has been known to get
through the abdominal wall itself. When the disease advances
beyond the tubes there is, as a rule, invalidism until after the

' Jour. Amer. Med. Assoc., January 8, 1916.
10 Jour. Amer. Med. Assoc., September 30, 1916.
u Jour. Amer. Med. Assoc., October 6, 1912.
" Social Diseases and Marriage, 1904.

GONOEEHEA IN MAEEIAGE 217

menopause, although the woman may be cured by surgery.
Even skilled surgery does not always cure, because it is prac
tically impossible to get rid of the gonococcus once it has been
fixed in the tissues.

In cases where the gonorrheic or other bacterial infection
has been chronic in the uterine adnexa, palliative treatment will
in a certain percentage of cases make surgical intervention un
necessary, and when such treatment does not avail we must de
cide between the total removal of organs and the partial removal.
Partial removal is called conservative surgery, and the term
conservative is used as a synonym of preservative. Prochow-
nick 13 reported 420 cases where pus in the tubes or ovaries was
let out extraperitoneally, and no organs were removed. Of
these cases, one hundred and sixty, or 38 per cent., were per
manently cured. Fourteen of the one hundred and sixty who
had received only one treatment subsequently gave birth to chil
dren, and three aborted. After a second treatment twenty-
seven remained well and three became pregnant, of whom one
aborted. Olshausen,14 a great authority in gynecology, used the
palliative treatment, and he commonly waited for nine months
after the infection and until the temperature was normal.
Goth 15 reported excellent results in seven hundred cases of pel
vic disease treated by the palliative method. The chief ob
jections to this method are the time required to get the result,
and the difficulty of controlling the patients and their chron
ically diseased husbands, who reinfect them despite the med
ical prohibition of marital intercourse.

In cases of chronic pelvic peritonitis the question comes up
frequently whether the womb and both tubes and ovaries should
be removed wholly or in part. The text-books decide the question
without any heed whatever to the notion of the morality of
mutilation as such. They take into account the age of the pa
tient, whether she has children or is desirous of maternity,
whether or not she supports herself by manual labor, her tem-

" Monatschrift f. Geburt. u. Gyna., 1909, n. 20.
"Zeitschr. f. Geb. u. Gyn., 1907, vol. lix, n. 1.
"Archiv. f. Qyn., vol. xcii, n. 2.

218 THE ETHICS OF MEDICAL HOMICIDE

perament and character, and the results attained by men who
have tried various methods of operating.

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

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

If one tube is infected from the uterus many gynecologists
are inclined to remove both tubes. "When a single tube is af
fected the cause is seldom the gonococcus, but some other bac
teria which are not persistent. "When both tubes are affected
the cause is commonly the gonococcus, and attempts at preser
vation then fail, as a rule. Norris, who is a reliable authority,

GONORRHEA IN MAKKIAGE 219

holds that "the only cases in which a salpingostomy is justifiable
is on old, non-active hydrosalpinges, and in those cases of tu-
bal occlusion or phimosis resulting from extratubal inflamma
tion, such as sometimes result from appendicitis or ectopic
pregnancies." 16 When a tube is shut, if it can be opened the
opening tends to close again. A few cases of subsequent preg
nancy have occurred after salpingostomy, but such a result is
exceptional, because the origin is usually the gonococcus, which
destroys tissue and is very persistent.

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

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

Castration in the male or ovariotomy in the female stops
all production of spermin and ovarin. In man the prostate
gland also ceases its function after castration, and vasectomy
lessens the production of spermin. In castration or spaying,
again, when we remove the power of producing spermin or
ovarin, that function of the testes and ovaries whereby the body
is immunized against poisoning by its own effete material is
also inhibited, and evil effects arise from this waste material.
These toxins act just as would an excess of spermin or ovarin

" Gonorrhea in Women, p. 285. Philadelphia, 1913.

220 THE ETHICS OF MEDICAL HOMICIDE

— they congest the cranial nerve centres, excite fever, neuroses,
or temporary sexual erethism. This excitement may gradually
subside as equilibrium is restored and neutralization effected,
through a compensatory overproduction of the internal secre
tions by the other glands remaining in the body. Cimoroni 17
found after ovariotomy an increase in size of the pituitary
body with dilatation of the blood-vessels. Goldstein 18 reported
a case of gigantism from overactivity of the pituitary gland
after castration. Acromegaly in cases where there was no
castration has been accompanied by atrophy of testicles and
ovaries. Cecca 19 found like effects in the thyroid, and sev
eral have observed these effects in the adrenals. All these re
sults have also been produced experimentally on animals.

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

Gordon 20 reported on 112 cases of ob'phorectomy. Of these
thirty-four had had before operation various symptoms of neur
asthenia, hysteria, or psychasthenia, and vague abdominal dis
turbances. Surgeons in each of these thirty-four cases blamed
the ovaries for the symptoms; and although these organs were
not diseased in any degree, the surgeons removed them. In
twenty-five of these cases there was no improvement whatever;

" Policlinico, 1907, p. 16.

18 Miinchener medizinischc Wochenschrift, April 8, 1913.

"Soc. Med.-Chir. de Bologne, 1904.

K Jour. Amer. Med. Assoc., October 17, 1914.

GONORRHEA IN MARRIAGE 221

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

When the ovaries must be removed for diseases like cystic
degeneration or abscess, the surgeon leaves, if possible, part of
an ovary, or he engrafts part of an ovary in the abdominal
wound, under the skin, or elsewhere. This grafting is bene
ficial in many cases, but it has little or no effect in many others.
The graft is absorbed and it disappears in a year or two, but
before it is absorbed it makes the onset of the surgical meno
pause gradual and thus prevents much suffering. In thirty-
two cases reported by Chalfant 21 the graft gave evidence of
functioning in five of seventeen women from whom the uterus
and ovaries had been removed; in others it acted for months

* Surgery, Gynecology, and Obstetrics, November, 1915. Chicago.

and then failed; in others it lessened the unfavorable symp
toms ; in others it had no effect at all. Stocker 22 reported two
successful implantations of ovarian grafts and one testicular
graft.

Giles 23 says that in his series of 157 cases of double ob'phor-
ectomy severe mental depression occurred in various groups in
from 10 to 33 per cent., and two women became insane. Sex
instinct was abolished in 16 per cent. Dickinson 24 found, in
200 cases where one or both ovaries had been removed, that
not more than 20 per cent, fell into the surgical menopause
even when the uterus had been taken out; but Giles, in 50 re
movals of one ovary, found irregularity, diminution, or cessa
tion of the menses in 16 per cent. Carmichael, Valtorta, and
Mcllroy 25 discovered in animals a compensatory hypertrophy
of the remaining ovary after one ovary had been removed. The
internal function and nutrition seem to depend upon the ova
rian secretion, as atrophy occurs after bilateral oophorectomy.
In all operations upon or near the ovaries there is likelihood
of interference with the blood supply of the ovary, either by
including ovarian arteries in the ligatures, or by tension of
these vessels, which occludes them, or by malposition and pro
lapse of the ovary, which kinks them: these accidents result in
degeneration or retention cysts. In most cases of pelvic peri
tonitis the uterus is retrodisplaced, and this position prevents
cure until it is corrected.

When there is pus in the ovary, resection, in the opinion
of gynecologists at present, is not an advisable operation; the
ovary should be removed. Watkins,20 however, says he resects
small ovarian abscesses in young women with good results. In
resection the blood supply is, as has been said, usually disturbed,
and the cause for the operation is, as a rule, the gonococcus,
and both these circumstances make the prognosis bad. The
stitches necessarily used in resection operations are an addi-

" Correspondenz-Blatt f. Schweizer Aertze, February 12, 1916.
"Jour. Obstet. and Gynecol. of Brit. Empire, March and April,
1910.

" Trans. Amer. Gyn. Soc., vol. xxxvi, p. 324.
15 Norris, Gonorrhea in Women, p. 289.
*Jour. Amer. Med. Assoc., January, 1913.

223

tional source of irritation. Turetta 27 speaks in favor of re
section in certain cases. A single retention cyst may be re
sected, especially when pedunculated. Boldt 28 had only one
bad result in forty-five resections where a part of the ovary
was saved. If the blood supply after the resection is evidently
to be poor, resection is useless. Skill in surgical technic has
much to do with success in all these cases. When the uterus
is removed because of tumors, even near the time of the meno
pause, if one or both ovaries can be left in, this should be done.
In such conservative operations Dickinson found 80 per cent, of
the patients free from nervous disturbance at the time of the
menopause.

Polak 29 describes an operation for the preservation of the
menstrual function in double suppurative disease of the tubes
and chronic metritis. He maintains that even if only one tube
is infected, both should be removed because this apparently
sound second tube will later, almost as a rule, show infection —
probably by extension from the fundus of the uterus inside.
Ordinarily inflammation of the tubes happens to be bilateral.
0wing to the persistence of the gonococcus in the uterine muscle,
surgeons are inclined to the removal of the whole uterus and
both tubes. After such an operation menstruation ceases, and
in the removal of the uterus the blood supply to the ovary is
interfered with so that the ovaries degenerate. The consequent
artificial menopause has a decidedly injurious effect on the
woman's general physical and mental health. The parts of the
uterus permanently infected by chronic gonorrhea are the cer
vical region, the fundus and the partes interstitiales of the
Fallopian tubes. Polak advises that in cases where surgeons
usually remove the tubes and the whole uterus they should in
stead cure the cervical infection by the cautery and take out
the tubes, but in place of the removal of the whole uterus they
should cut out a wedge including the fundus and the partes in
terstitiales of the tubes. This leaves the body of the uterus
and does not injure the circulation to the ovaries. In the last

" Jl Policlinico, January 3, 1919.

" Trans. Amer. Gynecol. Soc., vol. xxxiv, p. 327. Philadelphia,
1909.

"Jour. Amer. Med. Assoc., December 8, 1917.

224 THE ETHICS OF MEDICAL HOMICIDE

seventeen cases thus operated upon by him he had success.

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

In conservative surgery of the uterus and adnexa for pelvic
inflammatory diseases, the results attained by four skilled sur
geons are: Giles cured 90 per cent, of 132 cases; Polak cured
35 per cent, of 300 cases; Robins cured 100 per cent, of 20
cases; Norris cured 73 per cent, of 191 cases. Polak's pa
tients became pregnant after operation much oftener than those
of the other operators. Seventeen per cent, of his patients,
from whom he removed one ovary and resected the other, be
came pregnant. Giles found that of his married patients un
der fifty years of age at the time of the operation 25 per cent,
became pregnant and went to term. They bore twenty-five chil
dren. Five of these also miscarried. In sixty-eight of Nor-
ris's cases seventeen were delivered of living children after the
operation ; three had two children each, one had three children,
and there were seven miscarriages. In one of his cases where
he removed one ovary and both tubes, the woman bore a healthy
full-term child two years after the operation. Dudley 30 found
that about 10 per cent, of 2168 cases of resection became preg
nant after operation. Ectopic gestation is likely to occur in a
few cases after conservative operations. Giles had seven such
cases in his series of 132 operations, Polak one, and Norris two.

When it is necessary to remove the uterus, the choice be
tween supravaginal hysterectomy, where the cervix is left in
after the destruction of its mucosa, and panhysterectomy,

"Jour. Amer. Med. Assoc., vol. xli, n. 24.

GONORRHEA IN MARRIAGE 225

where the cervix and the body of the uterus are removed, of
fers no moral problem except the necessity of deciding upon
what will be best for the woman. Rupture of a pus tube is a
very dangerous accident — all the patients suffering from such a
rupture die if not operated upon, and fifty per cent, die even
after operation. A physician may do this damage by ignorant
or careless examination, and he may be morally responsible for
the death. The accident happens not unfrequently from mari
tal congress, and if the husband has been warned by a physician
but does not heed this warning, he is guilty of murder if the
woman dies after rupture of the pus tube.

Pregnant women are more liable to infection by the gono-
coccus than non-gravid women, because of the increased blood
supply to the generative organs in gestation, and the softening
of these organs. For the same reason, latent gonorrhea is
likely to become active and to spread during pregnancy. A like
activity and extension of latent gonorrhea often occurs during
menstruation. Women with gonorrhea are commonly sterile
— this is the chief reason why prostitutes are usually sterile.
In married women gonorrhea may cause dyspareunia; it may
bring on abortion through endometritis ; it may shut the tubes
and prevent conception; it may destroy the ovaries.

The disease is extremely frequent during pregnancy.
Gurd 31 isolated the gonococcus in 52 of 113 pregnant women
who came to his dispensary service because of pelvic rjain.
Leopold, Stephenson, Fruhinholtz, and many others estimated
that about 20 per cent, of all pregnant women have gonorrhea,
but more recent observers think that from 5 to 10 per cent, is
nearer the truth.

When a pregnant woman has gonorrhea great care must be
taken in treatment to prevent abortion. Powerful antiseptics
in the cervix, or dilatation of the cervix, are not permissible,
and operative interference is to be delayed as long as possible
— in each instance to avoid abortion. The vaginal douche as a
routine treatment is not used now by obstetricians in these
cases. When the gonorrhea is in the uterus douches of hot bi
chloride solution, 1 to 10,000, are used twice daily during the

n Montreal Med. Jour., vol. xxxvii.

226 THE ETHICS OF MEDICAL HOMICIDE

last few weeks of gestation, with the intention of saving the
infant's eyes from infection during delivery. After delivery
the cavity of the uterus should not be entered with instruments
lest infection be carried in, unless absolute necessity requires
this instrumental procedure. Post-partum gonorrheal sepsis is
differentiated from other septic conditions chiefly by the his
tory of gonorrhea in the husband, by bacteriological examina
tions, and by the technical differentiation of symptoms.

The moral guilt of a person who infects another with gon
orrhea is affected by the extent of the physical injury done.
Gonorrhea causes, besides the effects already described: (1)
chronic cystitis, with all the suffering, loss of work, and danger
of renal infection in such a condition; (2) lymphadenitis of the
inguinal canal, and rarely of other places; (3) proctitis, or in
flammation of the rectum, especially in women and young chil
dren; (4) ophthalmia, vaginitis, and proctitis in infants and
children, and metastatic conjunctivitis; (5) stomatitis or in
flammation of the mouth in adults and children; (6) nasal gon
orrhea (a doubtful condition) ; (7) gonorrheal septicemia, bac-
teremia, or toxemia, which may affect any organ in the entire
body; (8) bone and joint lesions: (a) gonorrheal arthritis in
any joint in the body (this condition may be fatal, or it may
leave permanent disability, or it may disappear) ; (&) tenosyn-
ovitis, or pain, swelling, and edema along affected tendon
sheaths; (e) gonorrheal periostitis, where the bone and peri
osteum near a joint are affected; (d) perichondritis and chon-
dritis, a rare condition, where cartilage is attacked; (9) endo
carditis, or inflammation of the lining membrane of the heart
(one of the most frequent secondary lesions of gonorrhea) ;
(10) pericarditis, or inflammation of the sac which contains
the heart; (11) myocarditis, an inflammation of the heart mus
cle itself, usually as an extension of endocarditis; (12) aortitis,
or inflammation of the aorta — a rare condition; (13) phlebitis,
an inflammation of the veins — a very rare condition; (14)
thrombosis, or blocking of a blood-vessel by exudate (this may
be fatal) ; (15) skin lesions, as erythema, erythema nodosum,
bullous and hemorrhagic eruptions, hyperceratosis, and ulcers;
(16) gonorrhea of the lungs in septicemia; (17) gonorrheal

GONORRHEA IN MARRIAGE 227

pleurisy in septicemia; (18) gonorrheal nephritis, which is fre
quent in gonorrheal septicemia — the condition is often fatal;
(19) perinephritis, a very rare condition; (20) gonorrhea of
the nervous system, as neuritis or neuralgia, or neuroses, which
vary from slight melancholia to severe mental disturbances;
(21) parotiditis, a very rare condition; (22) otitis, or inflam
mation of the middle ear, a very rare condition; (23) sup
puration in muscles, or under the skin; (24) wound septicemia;
(25) venereal warts; and (26) epididymitis, which often
causes not only sterility but impotence.

Campbell 32 reported a gonorrheal infection of a compound
fracture at the ankle — it required four months to get the wound
free of the infection. Gonorrheal obliterating epididymitis is
quite common. Delbet and Chevassu 33 found 114 cases of
male sterility in 131 cases of epididymitis. More than half
of such cases are left permanently sterile, and if the function
of the testicle cannot be restored by the surgeon the patient
is impotent, and any marriage he would make, •
is rendered void. These two surgeons have restored function
in six such cases by uniting the vas with the epididymis by
Martin's operation. It is much easier to restore function after
vasectomy than after obliterating epididymitis.

There are frequent cases of arthritic rheumatism in which
the source of the infection is a chronic gonorrhea of the seminal
vesicles. Fuller 34 has done 101 vesiculotomies for this con
dition, and of these twenty-three were gonorrheal. In these
twenty-three the excision of the infected vesicles cured the rheu
matism. In vesiculotomy great care must be taken not to cut
the vas def erens. If it is cut the man is impotent until the vas
is restored, and it would be a very difficult operation to reunite
the vas if cut near the vesicles.

Of all the gonorrheal aifections of the body the most dan
gerous and important are the cardiac inflammations and oph
thalmia neonatorum. This ophthalmia is a purulent infection
of the external parts of the eye in infants. It may be caused

"New York Medical Journal, February 22, 1908.

83 Canadian Presse Medic., July, 1908.

"New York Medical Journal, May 30, 1908

228 THE ETHICS OF MEDICAL HOMICIDE

by many kinds of toxic bacteria, but the worst cases are from
the diphtheria bacillus (a very rare condition) and the gon-
ococcus (a very frequent condition). Before 1881, when Crede
introduced prophylactic treatment for ophthalmia neonatorum,
every maternity hospital had a department isolated for the care
of babies suffering with this disease. At the present day, how
ever, despite the precautions taken, this disease is quite com
mon. Pennsylvania and New York alone spent $242,000 an
nually for the support of asylums for the blind, and about 40
per cent, of the children in these institutions were blinded by
gonorrheal ophthalmia. The United States spends $1,800,-
000 yearly on victims of ophthalmia neonatorum. Stephen-
son 35 tells us that in the practice of forty-one oculists who re
ported to him the gonococcus was found in 67.14 per cent, of
their 1658 cases of ophthalmia. Mayou found the gonococcus in
63.5 per cent, of 1483 cases.

There is an infection of the child's eyes by gonococci pos
sible even while the cHild is in the womb, but this is very ex
ceptional ; the infection happens in the vagina during delivery,
as a rule. When the child's head is born its lids and eyelashes
should be cleansed with vaseline, or 1 to 5000 bichloride, or car-
bolized oil, before the eyes are opened to put in the silver nitrate
solution. This solution should be made from a pure drug or it
will injure the eyes. A one per cent, solution is strong enough
for routine work, but if the gonococcus is suspected, or if it is
known that the mother has gonorrhea, then the lids of the in
fant must be everted and touched everywhere with a five per
cent, solution of silver nitrate. This is neutralized with a salt
solution and washed out before the lids are turned back. It is
rash to trust any of the albuminoid preparations of silver, like
argyrol, silvol, or protargol, in gonorrhea or suspected gonorrhea
of the eyes.

If the child develops ophthalmia the treatment should be
turned over to an oculist when possible. When a child can
have a day and a night nurse, this method should be adopted,
but ordinarily there is no nurse except some woman about the
house or the mother. In such cases one eye, commonly the

15 Ophthalmia Neonatorum. London. 1907.

GONORRHEA IK MARRIAGE 229

right, does better than the other because the first eye treated
is opened readily, but after the infant has been irritated it
shuts the eyes so strongly that it is difficult to open them at all.
The first eye treated is habitually the same. The nurse should
begin to treat the eyes alternately on this account, or wait to
treat the second eye until after the baby has quieted down.
Iced compresses should be used, but not so long as to chill the
eye very much — five to ten minutes at a time is enough. If
the physician himself makes the applications of silver nitrate,
the nurse should use some silver salt like argyrol. Three to
eight grains of zinc sulphate to eight ounces of boric solution
is a good regular eye-wash in these cases. Atropine must also
be instilled to protect the iris. If only one eye is affected, the
other eye should be protected under a watch glass sealed over
it. All persons who have gonorrhea, or who treat gonorrhea,
must be warned of the danger they are in of infecting their
own eyes.

A new treatment of gonorrhea is described by Weiss.38
The gonococci are killed by a temperature of 107.6 degrees
Fahrenheit, and in eleven cases Weiss subjected men to a
hot bath for forty to fifty-five minutes, with the temperature
of the water gradually increased from 104 to 110 degrees
Fahrenheit. In one instance the body temperature was raised
to 108.5 degrees F. in a forty-minute bath and the gonococci
disappeared at once. In the other cases the body temperature
did not go up so high, but the vitality of the gonococcus was
evidently reduced, and under a few local injections they all
disappeared.

" M iinchener medizinische Wochenschrift, November 2, 1915.

CHAPTEK XXI
DIABETES IN PKEGNANCY

DIABETES MELLITUS is rare in pregnancy, but when
it does occur the disease is fatal in three-fourths of the
children, and it hastens the death of the woman, according to
the common opinion of obstetricians, but this opinion is dis
puted. In making the diagnosis we must exclude lactosuria and
other pseudodiabetic conditions. A sugar reaction which is
often mistaken for the glycosuria of true diabetes is from lactose
in excessive milk secretion. This lactosuria is harmless. Again,
when women are taking tonics or cough mixtures containing
derivatives of wild cherry their urine may give a sugar reaction
from the phloridzin of the wild cherry. The phloridzin so acts
on the epithelium of the kidneys that it lets the blood-sugar es
cape into the urine. Medical writers who report diabetes in
large numbers of pregnant women mistake these reactions for
the reaction of true glycosuria.

In the genuine diabetes of pregnancy there is a high mor
tality. Offergeld,1 in sixty cases, found that the women died
within two and a half years, and that 76 per cent, of the chil
dren were lost. Diabetics commonly are sterile from atrophy
of the uterus and ovaries: in a series of 114 diabetic married
women, Lacorche found only seven pregnancies. In a third of
such as do become pregnant abortion or premature labor occurs.
Coma happens in 30 per cent, of these pregnancies, and it is
almost always fatal. Delivery frequently causes collapse, coma,
or sudden death. The liver in any gestation has more work than
it has in the unimpregnated state, but a diabetic liver is unfit
for almost any normal function. If albuminuria is found the
prognosis becomes very bad. Diabetic women have poor re
sistance against a tubercular infection. Half their children

1 Archiv. f. Gyn., bd. 86, n. 1.

230

DIABETES IN PKEGNANCY 231

are still-born, and 10 per cent, more die within a few days after
birth (many of these children are diabetic).

There is some evidence of heredity in diabetes — it is likely
"to run in a family." Heiberg 2 reported one family in which
five of thirteen children had diabetes ; in another, four of eight
children, the mother, two of the mother's brothers, and the
maternal grandfather had diabetes. In another, two brothers,
the father, and grandfather died of it. I know of a case where
the only two sons and the father in a family died of it. Hei
berg did not find any essential difference in the histology be
tween the hereditary cases and those which were not hereditary.

Joslin 3 reported seven cases of diabetes associated with
pregnancy. Four of the seven are now dead, one by suicide,
one from uremia, one from coma, one from tuberculosis. Of
the three living one is in good conditoin, one is not well and
she has lost two of three children, and one is very ill with dia
betes. In persons beyond middle age diabetes with proper
treatment may go on for from ten to fifteen years before it is
fatal, but it quickly kills young patients. A young woman at
the marriageable age who has diabetes will die anyhow in two
or three years, and if she marries and becomes pregnant she will
die very probably in her first pregnancy.

When the child is viable, and the diabetic mother shows
albuminuria, progressive weakness, or diacetic acid in marked
quantity, it may be necessary to perform therapeutic abortion ;
but if this is done no anesthetic may be used, and great pre
cautions should be taken to avert physical and mental shock.
Even ergot acts badly with these cases. The last sacraments
should be given in good time, especially if coma threatens.
When labor begins in a diabetic and everything appears to be
normal the sacraments should be given, because there is always
danger of sudden collapse and death.

1 Deutsche medizinische Wochenschrift, xlii, 9.

1 Boston Medical and Surgical Journal, November 25, 1915.

CHAPTEK XXII
CHILDBIRTH IN TWILIGHT SLEEP

A METHOD of effecting painless childbirth through the
use of scopolamine and morphine was first used in 1902
by Steinbuechel, and in 1906 Gauss, of the University of Frei
burg in Baden, reported a series of five hundred obstetrical cases
in which scopolamine and morphine had been used. The wom
an's condition was called in Freiburg a Dammerschlaf, a Twi
light Sleep, because she is somnolent and forgetful of pain.
In 1903 the chief obstetricians in several of the leading Amer
ican and German universities tried the drugs, but they quickly
abandoned the method because they found it dangerous and
unscientific. The process was exploited here by McClure's
Magazine,1 The Ladies' Home Journal, and other lay periodi
cals. The articles in these magazines were written by
persons who are not physicians, and their erroneous state
ments are misleading. The Ladies' Home Journal, however,
while favoring the method, published letters from several lead
ing obstetricians in the United States, all of whom are opposed
to the use of these drugs during parturition because they had
tried them and found them unscientific. The method is illicit
morally, and it is unscientific.

Obstetricians divide a parturition into three stages. In
most primiparae and many multiparae there is a prodromal
stage, in which false labor pains (dolor es praesagientes} are
the most evident symptom. When the real labor sets in there
are rhythmic uterine contractions about every fifteen min
utes, which cause pain to the woman by the pressure of the
fetus on the uterine nerves — dolores praeparantes. From the
time the pains become rhythmic, and are effective in dilating

1 June, 1911.

232

CHILDBIRTH IN TWILIGHT SLEEP 233

the neck and mouth of the womb, until the mouth of the womb
is completely stretched and flush with the vaginal wall, thus
completing the continuous parturient canal, is the first stage
of labor. The fetal enveloping membranes (the "bag of
waters") usually rupture at the end of this stage, but some
times the bag bursts before the end, or as late as the second
stage of labor. The first period is the stage of dilatation.

The second stage extends from the end of the dilatation un
til the expulsion of the child is completed. This is the stage
of expulsion.

The third stage lasts from the delivery of the child until
after the expulsion of the placenta and membranes and the re
traction of the uterus has ended — the period of the afterbirth.

Normal parturition is always painful to the woman. As
the labor progresses the pains gradually grow more intense,
and the interval between them shorter. After a few hours the
pain is strong enough to cause the woman to cry out, but there
is a great variety in the endurance of these pains, as the wom
en's characters differ. Neurotic women begin to scream and act
hysterically even in the early part of the first stage. When the
pains are fully developed each lasts about half a minute.

In most cases the infant comes out head first, but almost
any part of its body may present. Before the advancing child
part of the liquor amnii within the fetal enveloping membranes
is forced down into the neck of the womb, and causes dilata
tion. In primiparae especially the bag of waters may rupture
prematurely and thus cause what is called a dry labor, which
is commonly tedious and painful. Often operative interference
is required in dry labors.

In the second stage the pains are stronger, recur every two
or three minutes, and are expulsive. The woman then strives
to expel the child. She strains violently with the abdominal
muscles — literally labors; her pulse is high, the veins of her
neck stand out, her face is turgid, and her body is covered with
sweat. When at last the head of the child is driven out the
woman feels as if she were being torn asunder in the dolores
conquassantes. The pain is so great that the woman may faint
from it, but that is not the rule. After a pause the shoulders

234 THE ETHICS OF MEDICAL HOMICIDE

are forced out, and then the trunk in one long convulsive ef
fort. The umbilical cord is tied and cut, and the child is born.

After from five to twenty minutes the womb begins to con
tract again, but the pains (dolores ad secundum partum} are
not nearly so intense as they were during labor. Then in from
fifteen minutes to about three hours the placenta is expelled.

The pains of labor are so evident that the expulsive con
tractions of the uterus, of which the pains are symptoms, are
themselves called "the pains." These pains in all scientific ex
actness of statement are, as has been said, agonizing. "In do-
lore paries filios" is a very literal text. The scopolamine-mor-
phine method was devised with the intention of mitigating
them, or mercifully rendering the woman unconscious of them
during at least a part of the labor. If she is unconscious of pain
she is thus saved also from shock and depression, which render
her susceptible to infection. Such results certainly are im
measurably valuable if attainable without taint of moral evil,
but as the method stands just now, they are not free from that
taint.

Scopolamine hydrobromide, one of the drugs used in this
method, is an alkaloid obtained from the roots of Scopolia (or
Scopola) carniolica, and it cannot be differentiated chemically
from hyoscine hydrobromide, which is made from henbane and
other plants of the Solanaceae group. Rusby was of the opin
ion that scopolamine is really a mixture of hyoscine, hyoscya-
mine, and atropine: one-tenth hyoscine and nine-tenths hyos-
cyaniine and atropine. Cushny and others find different pro
portions of these alkaloids. As the leaves of Scopolia are used
to adulterate the belladonna leaves from which atropine is de
rived, hyoscine and scopolamine are substituted for each other —
if, indeed, there is an any real difference between them. Some
of the largest drug-houses in Germany before the war supplied
hyoscine and scopolamine from the same stock bottle — the name
depended on the asker. Even in a pure state hyoscine and
scopolamine have the same chemical formula (C17H211S[04),
and their physiological action is the same. Each can exist in
three isomeric forms, and in one of these forms they turn polar
ized light to the left, in another to the right, while in a third

235

form they do not affect the light at all. The higher the rotatory
power of the drugs, the more active they are physiologically.
The levorotatory scopolamine has, according to Cushny, Peebles,
and Hug, double the action of the inactive scopolamine on the
cardiac inhibitory fibres of the vagus, but the levoactive and the
inactive scopolamine produce the same effect on the central
nervous system. The drug on the market is usually composed
of a mixture of the levoactive and the inactive forms, and as
one or the other predominates the results differ: the rotatory
power of a given specimen should be known. Old solutions
of scopolamine decompose and give rise to toxic substances.
Gauss attributed post-partum hemorrhages in the women and as
phyxia in infants to these decomposition products, but he
avoided these untoward effects somewhat by cutting down the
morphine dose. He had five infant deaths before he cut down
the morphine, and 25 per cent, of the children were intoxicated.
The chief action of scopolamine or hyoscine is upon the cere
bral cortex, producing sleep, which is accompanied often by a
low delirium. They depress the centre of respiration, and have
a depressant effect also on that part of the spinal cord which
governs the motions of the body. They intensify the action
of morphine and other narcotics.

Morphine, which is used to prevent pain, is the chief drug
in the twilight sleep method, and it is greatly intensified in ac
tion by the presence of scopolamine. When, however, morphine
and scopolamine are given to a pregnant woman hypodermically,
these drugs are at once carried by the blood to the fetus. Chil
dren for years after birth all withstand the action of morphine
badly, and a fetus in utero may be overwhelmed by it. Just
in this fact lies the chief moral crux in the use of the twilight
sleep method of obstetrical delivery. The woman may go on
to the end more or less safely in competent hands, but if con
stant watch is not kept at the bedside by a skilled observer the
infant is liable to be killed, and the danger comes to it not solely
from the drug directly — it may be drowned in the amniotic
fluid, its condition may be masked by the restlessness of the
mother, which prevents proper observation: when a woman is
plunging all over the bed, as is extremely common in twilight

sleep, the pulse-rate of the baby cannot bo properly watched.

If the mother happens to be particularly susceptible to scopo-
lamine or morphine, the first will cause delirium and the sec
ond coma; or the respirations may become arhythmic and be
reduced to only five or six a minute. The kidneys may be af
fected by the morphine so as to bring on total suppression of
urine. Labor is prolonged, and it may be very much pro
longed. In some women uterine atony is induced by the mor
phine, with very dangerous consequent post-partum hemorrhage.
Morphine relaxes all musculature, and it relaxes the muscle
of the arterial walls and so disposes to hemorrhage. There is
little or no premonitory symptom of these idiosyncrasies (except
in the case of an injured kidney) to inform the physician that
he should avoid the scopolamine-morphine treatment.

Dr. Polak, professor of obstetrics at the Long Island College
Hospital, reported 2 on 155 cases of the twilight sleep method,
and he is in favor of it under several restrictions. He uses the
drugs from ampules which contain one two-hundredth of a grain
of scopolamine and half a grain of narcophin, which is a pro
prietary drug said to be composed of the meconate of morphine
with the meconate of narcotin in molecular proportion. Mor
phine itself is a tribasic meconate, and narcotin, of course,
another opium derivative. The American Council on Phar
macy and Chemistry was unable to accept the claims made for
narcophin.3 Polak says he finds no difference between mor
phine and narcophin.

In the twilight sleep treatment the patient, especially if she
is a primipara, should be definitely in labor before any injec
tion is given. She should have pains occurring at regular in
tervals, preferably every four or five minutes, before the first
injection of scopolamine and morphine is administered; that
is, the first stage of labor should be well advanced. Gauss
gives one-sixth of a grain of morphine at the first injection, and
Polak nearly three-fourths of a grain of narcophin, with one
two-hundredth of a grain of scopolamine. If the woman is a

" Long Island Medical Journal, December, 1914, and American
Journal of Obstetrics, May, 1915.

'Jour. Amer. Med. Assoc., November 21, 1914.

CHILDBIRTH IN TWILIGHT SLEEP 237

multipara, Polak begins the treatment at the very beginning of
the pains. The patient is kept in bed, in a darkened room, re
moved from all noise and excitement. Some stop the ears and
blindfold the patient, and, according to Baer of Chicago, the
women are put into restraining sheets as a routine practice in
certain clinics to keep them from infecting themselves. The
ordinary practice is to give a half dose of scopolamine an hour
after the first dose and about every two hours thereafter, ac
cording to the indications. The morphine may be discontinued,
or used approximately every six hours in a long labor. Smaller
doses are required if the first is given early in the labor, and
larger if the pains have been well developed. In these latter
cases the danger to the child is, of course, greater.

The condition of the patient's pulse, respiration, pupillary
reaction, and the frequency and character of the uterine con
tractions are constantly watched, to guard against poisoning.
Fonyo 4 reported two fatal poisonings by the scopolamine-mor-
phine method as used in surgery. Both were operations for the
delivery of women by laparotomy, and in each case the centre of
respiration was overwhelmed. In each of these operations only
one-hundredth of a grain of scopolamine and one-third of a
grain of morphine had been used, but chloroform was adminis
tered later. Robinson recently reported the fatal poisoning of a
negress by scopolamine, and Chandler of Philadelphia two more
where one thirty-third of a grain of scopolamine had been used.
One-ninetieth of a grain given hypodermically has caused severe
toxic disturbance which lasted for twenty-eight hours, and Root5
reported a case where one three-hundredth of a grain given by
mouth poisoned violently.

In Freiburg, Gauss tests the consciousness of the women
about every half hour by showing them some object, and if
they remember having seen this object he gives an additional
dose of scopolamine. Polak says this memory test is not nec
essary: even if the patient gives outward evidence of pain by
cries and motion, she is apparently but very dimly conscious
in his opinion.

* Zentralblatt f. Gyndkologie, September 19, 1914. Leipsic.
' Therapeutic Gazette, vol. ii.

238 THE ETHICS OF MEDICAL HOMICIDE

The progress of the delivery must be constantly watched by
repeated extraabdominal or rectal examinations, following the
fetal shoulder as it rotates — and not by vaginal examinations
—to avoid sepsis. The fetal heart must be auscultated every
half hour at most, between and during the pains. If the child's
pulse grows arhythmic or slow between pains, these are bad
prognostic signs. All use of the drugs is to be discontinued,
and the child is to be delivered at once to save its life, by the
most suitable method and route.

Polak holds that the solutions of the drugs must be abso
lutely pure, and that hyoscine cannot be substituted for scopo-
lamine, but that narcophin is no better than morphine: the
American preparations have produced delirium. As I have
shown, no one can possibly tell the difference between hyoscine
and scopolamine, even by chemical analysis. All we can do
is to take the druggist's word that the drug at hand was made
from Scopolia and not from Ilyoscyamus niger. It does not
make any difference which is the source of the supply.

Polak says the morphine shortens the first stage of labor
by softening the cervix, but that the treatment lengthens the
second stage. Other observers have not found that it shortens
the first period. He tells us that if this second stage — that is,
the time from the full dilatation of the os until the delivery
of the child — lasts over an hour in multiparae, or over two
hours in primiparae, delivery must be effected by the Kristeller
expression or by low forceps. In the Kristeller expression the
child is pushed out of the canal by the hands of the physician
applied to the fundus uteri. It should be a method of last
resort, because there is danger of rupturing the uterus, of tear
ing the placenta loose, or of crushing an ovary.

In his report Polak says he has had no failures; the pa
tients had no recollection of the labor; in the first series of
fifty-one the children showed no sign of asphyxiation or even
cyanosis except in two cases. In this first series one patient
had a long second stage and the child had to be resuscitated.
There were, he said, no post-partum hemorrhages; no low for
ceps; the placentas were delivered without difficulty; none of
the women showed signs of tire or exhaustion the next day; in

CHILDBIRTH IN TWILIGHT SLEEP 239

fact, they were better off than the women who have normal
labor. This report is different from that made by other men
just as competent, and in exactly the same circumstances; even
Gauss confesses many failures. The lay journals say Gauss
had no failures, but he himself should know. In April, 1915,
I was told in New York City that there had been no failures
tliere, yet in May, Dr. Broadhead, professor of obstetrics at
the Postgraduate School of Medicine in that city, after ob
serving seventy-two cases confessed 6 several failures where the
child was concerned. One Catholic woman, a member of the
executive committee in a Twilight Sleep League of married and
unmarried women, was killed in Brooklyn by the method in
the summer of 1915.

Dr. Charles M. Green, professor of obstetrics in Harvard
University, tells us: 7 "My own observations, published in 1903,
led me at the time to favor this therapeutic means of producing
the 'Twilight Sleep,' and removing the consciousness of pain, or
at least preventing all remembrance of it. I have long since
abandoned this agent, however, for two reasons: First, because
it has apparently been the cause, occasionally, of fetal asphyxia.
Second, because the effect of the drug on the mother is often
uncertain, and unless used with great care may cause unfavor
able or dangerous results. Moreover, we have other and safer
measures for the relief of pain in labor. So I have given up
teaching the use of scopolamine in my lectures."

Dr. Williams, professor of obstetrics in Johns Hopkins Uni
versity, and the author of a book on obstetrics which is very
valuable, says : 8 "We have used the scopolamine treatment of
childbirth in two separate series of cases at the Johns Hopkins
Hospital, but in neither series were the results satisfactory, nor
did they in any way approach the claims made for the treatment.
We expect to do more with it next year." In the fourth edi
tion of his Obstetrics, published in 1917, he thinks that the
twilight sleep method will fall into disuse, or at least that its
use will be restricted to a small group of neurotic patients.

'The Postgraduate, May, 1915.
* Ladies' Home Journal.
8 Ibid.

240 THE ETHICS OF MEDICAL HOMICIDE

From bis experience, he says, the method is not adapted for
private practice.

Dr. Hirst, professor of obstetrics in the University of
Pennsylvania, tried the scopolamine treatment in the maternity
hospital of the university in about 300 cases at three different
times. He tried it first in 1903, but he found that if sufficient
morphine is given to abolish pain there is danger of hemorrhage
in the mother and of asphyxia in the child. At a meeting of
the Obstetrical Society of Philadelphia 9 Hirst, commenting on
a paper by Polak, said : "I am sorry to say I cannot agree with
my friend Dr. Polak in his conclusions ... I had to dis
continue morphia and scopolamine because there were too many
cases of post-partum hemorrhage, too many cases in which for
ceps had to be used, too many asphyxiated babies. So I am not
an enthusiast for 'twilight sleep.' '

Dr. Joseph B. De Lee, professor of obstetrics in the North
western University Medical School, Chicago, and the author
of a book on obstetrics which is now one of the best we have in
English, tells us 10 that the impressions he received from study
ing ten cases of childbirth in Professor Kronig's clinic at
Freiburg were "decidedly unfavorable to the method of
'Twilight Sleep.' ' In all the ten cases, he testifies, the
birth pains were weakened, and labor prolonged — in two
instances for forty-eight hours. In three cases pituitrin,
which is in itself a dangerous drug to use before the uterus has
been almost emptied, had to be given to save the child from im
minent asphyxia. In five of the cases forceps had to be used
owing to the paralyzing effects of the drug, and all these forceps
cases were extensively lacerated. Several of the women be
came so delirious and violent that ether had to be used to
quiet them, with the result that the infants were born "nar
cotized and asphyxiated to a degree." One child had convul
sions for several days.

The complete failure in these ten cases is so obvious as to
be a scandal, although De Lee does not say so. He aban-

* Proceedings printed in American Journal of Obstetrics, May,
1915.

10 Ladies' Home Journal.

CHILDBIRTH IN TWILIGHT SLEEP 2-il

doned the use of the method twelve years ago, and in 1913
he visited the maternities at Berlin, Vienna, Munich, and
Heidelberg, and found that all had tried the method and had
rejected it.

Several so-called detoxicated substitutes for morphine, like
"tocanalgine" and "analgine," have been tried ; but these turned
out to be morphine, and to be equal in strength to morphine
as we ordinarily have it. These were the drugs that were ad
vocated in the Cosmopolitan Magazine as "having nothing to
do with the morphine-scopolamine treatment originating some
years ago in Freiburg." They are morphine treacherously
disguised, and the assertions in the Cosmopolitan were never
retracted when attention was called to the untruth by the Jour
nal of the American Medical Association. In the American
Journal of Obstetrics for May, 1915, is a full description of
these drugs (page 772).

Dr. Joseph Baer reported n sixty cases of the morphine-
scopolamine treatment at the Michael Reese Maternity Hos
pital in Chicago, and his results were diametrically opposed
to those Dr. Polak himself obtains. The rooms used were
large, and had cork-lined sound-proof walls and doors; ob
stetricians and specially trained nurses were present day and
night. The circumstances, then, were the best that could be
had.

He used Merck's scopolamine at first, and later a solution
made up after the formula of Straub of Freiburg, which is
more stable. His doses of morphine were from one-eighth to
one-fourth of a grain; Gauss uses one-eighth to one-sixth of a
grain ; Polak, as much as three-fourths of a grain of narcophin
for his first dose.

Baer's series ended on February 5, 1915, and of his sixty
cases only five were successful. Three of the successful cases
received one-fiftieth of a grain of scopolamine in all, and some
of the unsuccessful cases got as high as one-sixteenth of a
grain, with only wild delirium as a result.

The labor was lengthened by about seven hours over un
treated cases. As to the amnesia, in twenty-six cases the mem-
11 Jour. Amer. Med. Assoc., May 22, 1915, Ixiv, 21, p. 1723.

242 THE ETHICS OF MEDICAL HOMICIDE

ory was not dulled at all, although they received more scopola-
mine than thirty-nine cases in which the memory was cloudy.

Thirty-two women had unbearable thirst throughout the
labor, and nothing would slake this thirst. Their incessant
cries for water were very distressing to the attendants. Head
ache was present in twenty-seven cases and vertigo in thirty-
one, and the headache, which was very intense in some women,
lasted for several days after delivery.

Pain was diminished in thirty-nine cases, absent in one,
as severe as in the average untreated woman in nineteen, and
increased in one. That is, only one woman in sixty did not
suffer the pain for which the treatment was devised. The
reason evidently is that his dose of morphine was too small,
yet if he went above this dose he ran the risk of post-partum
hemorrhage and of narcotizing the baby. As it was, he had
seven post-partum hemorrhages, but in a series of sixty un-
selected normal delivery cases he had only one hemorrhage.

Restlessness was present in eighteen cases, and delirium in
nine; six of these women had to be wrapped in restraining
sheets, and one had to be shackled for four days after she had
overpowered a nurse in an effort to jump out of a window. It
took three attendants to get her into the strait-jacket. Chand
ler of Philadelphia saw a woman in a like delirium who was
shackled only after six attendants together had tackled her.
Two physicians in the Chicago maternity were severely beaten
by women in a twilight sleep delirium.

Baer says the serious risk of self-infection during labor
through the uncontrollable motion of these women is a source
of constant anxiety. They sit cross-legged, and the heel infects
them with coli communis from the expressed feces. The dazed
women constantly try to get at the vague pain with their hands,
and on this account, according to Baer, some clinics that prac
tise the twilight sleep method keep all the women in strait-
jackets, but they omit to publish this fact.

One of Baer's patients died from a ruptured uterus, and
ner dead baby was taken from her belly-cavity. The drug will
mask symptoms in a case like this. Sudden cessation of puer
peral pain as a symptom of rupture, and the peculiar pain of

CHILDBIRTH IN TWILIGHT SLEEP 243

a premature loosening of the placenta, are both covered from
observation by the drugs, the darkening of the room, and the
tossing of the patient, which prevent proper examinations.

One patient had a mitral insufficiency and myocarditis.
This should be an ideal case for the treatment, according to
the twilight sleep men. The woman, however, after three doses
of the scopolamine developed pulmonary edema. Her child
was delivered in asphyxia pallida and resuscitated with diffi
culty.

Thirteen of the children did not breathe at delivery, six
were asphyctic, and two cases relapsed into asphyxia. One
child was killed, as we said, when the mother's uterus rup
tured. Avarffy 12 had one fatal case in fifty, and Chrobak one
in one hundred and seven.

Eight of the women had blurred vision after delivery,
which lasted for over twenty-four hours; two had marked
delirium for from two to four days after childbirth. As to
exhaustion after labor, Baer says he found no difference between
the twilight sleep women and the normal cases.

Some advocates of the twilight sleep method say that there
is less use of the forceps in this method than in normal de
livery. At Freiburg, for example, operative delivery has been
"reduced" to six or seven per cent. Six per cent., as a mat
ter of truth, is two per cent, above the normal average for
forceps delivery in eighteen German maternities. In 95,025
deliveries in these hospitals the average forceps delivery was
4.5 per cent., and some were small teaching hospitals where
the forceps were used on any provocation for class demonstra
tion. The twilight sleep method has a much higher operative
delivery, and this varies, of course, according to the skill and
judgment of the operators.

Holmes, one of the first in Chicago to try the newly re
vived method, says 13 that in July, 1914, before the great war
broke out, there were twenty-five malpractice suits pending in
one German city as a result of the morphine-scopolamine fad.
He quotes a noted obstetrician on this subject: "If you will

" Gynakol. Rundschau, 1909, iii.

u American Journal of Obstetrics, May, 1915.

244 THE ETHICS OF MEDICAL HOMICIDE

use the method, have the patient in the best hospital possible,
with all the appurtenances requisite for the revival of the
child ; if you do not know, learn at once the differences between
asphyxia, oligoapneia, and narcotic poisoning, and the methods
of treating them; get the best and the most reliable product
called scopolamine; and then be sure you are in a position to
be adequately defended by a lawyer versed in malpractice
suits."

This is the state of the question. Two or three men in
the best circumstances say they get one hundred perfect results ;
other men, equally or far more skilled and in equally favorable
circumstances, get one hundred results which are anything but
successful, often a disgrace to science, and undoubtedly im
moral. They are immoral because they risk human life in an
attempt to ease a physiological pain, and this is not a sufficient
reason; moreover, these attempts fail oftener than they suc
ceed. The second group of practitioners have no motive except
honesty to induce them to make their unfavorable reports of
failure. The reports of the two groups are directly contra
dictory, and the judgment is thus a matter of motives. Tes
timony from women who have gone through the process is not
to be taken into account. They were dazed, and in any case
they are not competent to judge a matter which is wholly
technical.

We know the limitation of morphine and scopolamine and
we cannot improve their use. If enough is given to still pain,
we take a criminal risk; if we do not give enough to remove
the sense of pain, why not use the safer nitrous oxide, ether,
and chloroform? If enough morphine and scopolamine are
administered early in labor to a multipara, the labor is com
monly stopped; if this dosage is given after the pains are
developed, the baby is born, as a rule, before they take effect.

CHAPTER XXIII

VASECTOMY, OR STERILIZATION, BY STATE LAW

THE State of Indiana in 1907 enacted a vasectomy law
which obliges the superintendents of some prisons and
asylums to appoint two surgeons whose office is to sterilize
sexually criminals, idiots, imbeciles, and similar persons, if
these surgeons, in consultation with the chief physician of the
institution, deem the propagation of children by such so-called
degenerates detrimental to society. The same law has been
incorporated in the statutes by New York, New Jersey, Wash
ington, Iowa, Nevada, Wisconsin, Connecticut, California,
Utah, Kansas, Oregon, and Minnesota. The law has been
proposed several times in the Legislature of Pennsylvania, but
it was vetoed twice and held up once in the Assembly.

In New Jersey there was question of sterilizing an epileptic
girl, and the Supreme Court of that State J decided in 1913
that the law is contrary to the State and Federal constitutions.
In 1916 Probate Judge Lapeer of Michigan declared the law
as passed in his State in 1913 unconstitutional, but the State
appealed against this decision. The Supreme Court of Wash
ington 2 decided in favor of the law in a case where a man
convicted of rape was sentenced by the trial judge to life im
prisonment and to vasectomy as a punishment. The constitu
tionality of the Iowa law is on appeal to the United States
Supreme Court after a Federal judge had declared it uncon
stitutional. The law in Indiana was put into effect in hun
dreds of cases, but Governor Marshall set the law in abey
ance. Two Federal judges in Kansas said the law is uncon-

1 Smith vs. Board of Examiners of the Feeble-minded, 88 alt. B,
968

* State vs. Feilen, 126 Pac. R. 75.

245

246 THE ETHICS OF MEDICAL HOMICIDE

stitutional and granted an injunction against its application in
a particular case. In 1808 the superintendent of a Kansan in
stitution for the feeble-minded castrated forty-eight boys. Up
to April, 1916, about twenty-five feeble-minded boys in the Wis
consin institution at Chippewa Falls were sterilized, and the
authorities then said they intended to sterilize the girls. The
laT.v has been advocated by alienists in Switzerland, and French
and English physicians have advocated it.

The reason given by the advocates of this law is the alarm
ing prevalence of feeble-mindedness with its tendency to crim
inality; and as, they say, heredity accounts for 65 per cent, cf
feeble-mindedness, the feeble-minded should be prevented from
propagating their kind. Sweden, with 5,500,000 inhabitants,
has 18,000 insane, 14,000 idiots, 20,000 imbeciles, and 7,000
epileptics. Much of this degeneracy is due to the notorious
alcoholism of the Swedes, which only lately has been brought
under some control. Pennsylvania had about 17,000 feeble
minded in 1913. In a single county almshouse in that State
were 105 women who had given birth to 101 defective children.
One feeble-minded couple in the same State had 19 defective
children; two other families had 9 imbeciles and 7 idiots. In
New Jersey the history of 480 individuals of the famous "Kal-
likak" family (a pseudonym), descended from a feeble-minded
woman who lived at the time of the Revolutionary War, has
been traced out, and of these descendants only 40 were nor
mal. New York State has 32,000 known feeble-minded per
sons. One State school for the feeble-minded in Indiana in
1908 had 1054 inmates. There are 6000 mentally defective
children in the schools of Chicago. An investigation made in
Illinois about 1907 brought out the conclusion that all the de
fectives and delinquents in that State at the time could be
traced to 150 families. Poehlmann of Bonn traced the de
scendants of one female drunkard through six generations in
800 individuals, and of these 107 were illegitimate, 102 were
beggars, 181 were prostitutes, 76 were criminals in a grave
degree, 7 were murderers, and they had cost the State
$1,206,000. The Jukes sisters, two illegitimate prostitutes in
New York State, in five generations bred 709 criminals. Fifty-

VASECTOMY BY STATE LAW 247

two per cent, of the women were prostitutes, whereas the or
dinary ratio of prostitutes to other women is 1.66 per cent.
Alcoholics engender degenerates. In three generations of 215
French alcoholic families, Legrand found that 60 per cent, of
the children were degenerates. Bourneville found that 62 per
cent, of 1000 idiotic, epileptic, and feeble-minded children in
Paris had alcoholic parents.

Hereditary transmission is certainly a cause also of many
diseases of the nervous system. Friedrich's ataxia is heredi
tary. It is an incurable progressive incoordination of the limbs,
tongue, larynx, and eyes, which attacks commonly between the
tenth and the twentieth year, and the patient dies from some
intercurrent disease, usually an infection. Progressive mus
cular dystrophy is also hereditary and incurable. The legs and
trunk atrophy, and death comes from an intercurrent disease.
Kelated to this malady are hereditary progressive neurotic
muscular atrophy, progressive spinal muscular atrophy in in
fants, and progressive spinal amyotrophy in adults. Amaurotic
(amaurosis, blindness) family idiocy is hereditary, and the
child dies at about two years of age. Huntington's chorea
appears in every generation of an affected family. Its symp
toms show between the ages of thirty and forty years, and it
progresses from choreic and ataxic signs to dementia and death.
The death is often by suicide. In eastern Long Island, south
western Connecticut, and eastern Massachusetts 962 cases were
all traced back to six persons, three of whom were probably
brothers, who came to America in the seventeenth century. In
the 3000 relatives of these choreics were 39 cases of epilepsy,
51 cases of cerebral inflammation, 41 cases of hydrocephaly, 73
feeble-minded children, and other evidences of neuroses. The
heredity in this disease is apparently Mendelian. Besides
the diseases enumerated here, there are several pathologic con
ditions of the eyes which are hereditary — presenile cataract,
stationary night blindness, and retinitis pigmentosa. If the
persons who have these diseases are sexually sterile, evidently
the heredity so far as they are concerned will be cut across;
hence the advocates of legal sterilization wish to have these
patients sterilized to protect society.

248 THE ETHICS OF MEDICAL HOMICIDE

The surgical operation by which the man is sterilized ac
cording to the State laws mentioned above is an interruption of
the continuity of the vasa deferentia near the testicles. This
interruption may be a severing of each vas, a cutting out of a
part of each vas, or a ligation of the vasa. The term vasectomy
is now used loosely to cover all these methods. The vas defer-
ens, or seminal duct, passes from the testicle up along the
groin on each side, in through the belly-wall by the inguinal
canal, down along the pelvis and under the bladder, where it
opens into the bottom of the urethra a short distance in front
of the bladder exit. Each vas is about two feet in length, and
it has a diameter of one-tenth of an inch throughout the greater
part of its length, but its lumen is extremely narrow.

There are two essential parts in the semen, the spermatozoa
and the carrying liquid. The spermatozoa, which fructify the
ovum, are formed in the testicle ; the liquid, which is the essen
tial vehicle of the spermatozoa, and without which the sper
matozoa are inert and sterile, is secreted, except a few drops
from the testicles, at the distal end of the vasa deferentia under
the base of the bladder, in the seminal vesicles, the prostate
gland, and Cowper's and Littre's glands. The semen is made
up of 90 per cent, water and 10 per cent, solids, and in these
solids is the nitrogenous base called spermin, which is produced
by the interstitial cells of the testicles and the prostate gland.
Ovarin, secreted from the ovaries, corresponds in the woman
to spermin in the man. The ductless glands, and some that
have ducts, produce secretions which sustain the tone of the
blood-vessels and neutralize the toxins from waste substances
while these are in the body before excretion. An excess of
spermin or ovarin causes congestion of the cerebrum and cere
bellum and the nerve centres there, with consequent sexual
erethism. When there is a pathologic sexual erethism from an
excess of spermin or ovarin, vasectomy, castration, spaying, or
the menopause cuts off this excess and the erethism disappears.
Sometimes the waste product toxins excite the patient when the
spermin or ovarin has been eliminated, just as the excess of
spermin or ovarin excites, and the neurotic disturbance or

VASECTOMY BY STATE LAW 249

sexual erethism continues until compensation by other glands
neutralizes the irritating substance.

The testicles in man are by no means the sole organ of
generation. There are at least seventeen distinct organs in the
male generative system. The seminal vesicles with the pros
tate gland are as necessary in generation as the testicles, as
their removal sterilizes the spermatozoa and prevents the for
mation of the liquid vehicle. Castration effects an atrophy
of several parts of the generative tract, and an irremediable
degeneration ; vasectomy cuts off the spermatozoa but causes no
atrophy or degeneration, and the condition is remediable. Dr.
Edward Martin of Philadelphia found active living spermato
zoa in a testicle that had been ligated off for twenty years.

Running along the vasa deferentia, within the sheath of
the two spermatic cords, are the spermatic arteries, the pam-
piniform plexus of veins, and the deferential arteries. These
vessels, with the vas deferens and the sheath enveloping the
bundle, make up the spermatic cord. In vasectomy, under local
anesthesia, a slit is made through the skin of the scrotum be
hind, the sheath of the spermatic cord is opened, and the vas
is isolated and tied or cut. The skin wound is left to heal.
This operation is repeated on the second vas. If the blood
vessels in the cord are ligated or cut with the vas, the testicle
will atrophy; if the vas alone is operated upon, the testicle
is not injured. The person upon whom vasectomy has been
done is conscious of no change. The semen is discharged
as before the operation, but in a slightly less quantity, and it
is, of course, sterile from the lack of spermatozoa.

Dr. Carrington of Virginia reported, in 1910,3 twelve cases
of vasectomy on convicts. He said ten of this dozen had been
confirmed masturbators, and all were cured by vasectomy. One
masturbating epileptic was cured of both conditions. Two dan
gerous homicides were rendered harmless and peaceable. One
of these two homicides was a negro under a long sentence for
murder. He grew insane in prison, and while insane killed
a second person. A confirmed masturbator and sodomist, and
a dangerous savage, he became lucid and relapsed into insanity

* Virginia Medical Semi-monthly, vols. xiv, xv.

several times. A year after vasectomy he was "a sleek, fat,
docile, intelligent fellow, a trusty about the yard."

Dr. Sharp of Indianapolis, after ten years' experience with
the operation, during which time he did 456 vasectomies, says:4
"There is no atrophy of the testicle, no cystic degeneration, no
disturbed mental or nervous condition following." He says,
further, that 176 men in the Indiana Reformatory asked him
to perform the operation on them. Vasectomy tends to check
masturbation, and the minds of the masturbators frequently
improve after the operation.

If a man has been sterilized by vasectomy, restoration of
function and removal of the sterility seems practically always
possible. If a ligature has been used, releasing the ligature
restores function. Dr. William T. Belfield of Chicago 5 re
stored function fully by removing the ligature eight weeks
after it had been applied. In a letter to me, Dr. Belfield said :
"My observation accords with the general experimental and
clinical experience that the restoration of the lumen after
vasectomy or ligation, or both, is more certain than the lasting
occlusion of the vasa by these measures. The perseverance of
natural forces in restoring the lumen of the vas — and the suc
cess achieved over such obstacles as silk ligatures — is surpris
ing until one reflects upon the natural factors favoring such
restoration. In one case I tied a waxed (to avoid cutting
through) silk ligature tightly around the sheath of each vas;
a specimen examined a month later was devoid of sperms; one
six months later contained plenty of them. I cut down upon
the ligatures, found them in place and neatly encysted, and re
moved them. Evidently the pressure from behind had squeezed
a passage on at least one side. The gynecologists have learned
that ligatures around the Fallopian tubes are apt to cut through,
whereupon the tubal lumen is restored, though pressure must
be less than in the vas. Even when a piece of the vas has
been excised cases of spontaneous restoration have been ob
served in men and dogs." 8

4 Jour. Amer. Med. Assoc., December 4, 1909.
*Jour. Amer. Med. Assoc., October 19, 1912.
* Belfield, loc. cit.

251

When the ends of a cut vas are released from cicatricial
tissue, these ends may be sutured together ; but as the lumen of
the vas is extremely small, there is sometimes obliteration by
occlusion at the juncture. Christian and Sanderson 7 de
scribed a method of preventing this obliteration. A piece of
No. O twenty-day catgut is inserted three-eighths of an inch
into each end of the vas, and these ends are brought together
by two catgut sutures, leaving the inserted catgut in the canal.
The ends heal together and the catgut in the canal is absorbed.
This method has been used successfully to join the cut end of
a Fallopian tube.

Gemelli 8 did vasectomy on eleven dogs and seven cats ;
about six months later he reunited the cut ends, and on dis
section found restoration perfect, anatomically and function
ally, in the eighteen animals. The vas deferens in these ani
mals is smaller than in man; and therefore offers greater dif
ficulty in the suturing. He used no inserted catgut, but told
me he employed the method Carrel applies in joining cut ar
teries. In one case, where the dissection was broad, he suc
cessfully inserted a piece of a vas taken from another animal.
Whether there is occlusion or not after end-to-end suturing de
pends largely on the skill of the surgeon.

Dr. Edward Martin of the Pennsylvania University 9 and
Delbet 10 have removed sterility by effecting a patulous anas
tomosis between the vas and the epididymis, and this method is
applicable after vasectomy by cutting, but it is not successful,
as a rule. It has been done effectively where the vas had no
stricture. McKenna,11 in five attempts on men, succeeded once.
Fiirbringer 12 said that in his experience with a thousand cases
of double epididymis, the condition is incurable in 80 per cent,
of the gonorrheal infections.

' Jour. Amer. Med. Assoc., December 13, 1913.
8 La Scuola Cattolica, November, 1911.

* University of Pennsylvania Medical Bulletin, 1902, p. 388; 1903,
xv, 2; Therapeutic Gazette, December 15, 1909.

10 Revue de Therapeutique Medico-chirurgicale, January 15, 1912.

11 Journal Amer. Med. Assoc., January 20, 1915.
13 Deutsche med. Wochenschrift, xxxix, 29.

252 THE ETHICS OF MEDICAL HOMICIDE

Apart from the so-called vasectomy law, gynecologists quite
frequently sterilize women who have chronic heart disease,
tuberculosis, nephritis, diabetes, or hereditary mental taints.
Some men, like Spinelli, Cramer, Polak, and others, would
sterilize also in chronic anemia, persistent albuminuria,
epilepsy, syphilis, contracted pelvis, diseases of metabolism,
infections, and cirrhosis of the liver. There are several meth
ods of sterilizing women — removal of the ovaries, ligation of
the Fallopian tubes, resection of portions of the tubes, resection
of the whole tube on each side, cutting the tubes and burying
the cut end in the tissues by various methods, and destruction
of the lining of the uterus by vaporization or the thermocautery.
De Tarnowsky 1S describes the various methods. Some liga-
tions and short resections have failed to sterilize. When the
ovaries or uterus are removed, or the major part of the tubes
are resected, or the lining of the uterus has been destroyed, the
sterilization is permanent. Almost certainly function could be
restored where the resection of the tubes is not too destructive.
Apart from the matter of mutilation, the effects of double
oophorectomy are very grave,14 and removal of the uterus or
the ovaries merely for sterilization is not only immoral, but al
together unjustifiable scientifically.

A phase of this subject which is important and has occa
sioned much discussion is whether vasectomy causes sexual
impotence or not. From a medical point of view, there is no
question of impotence; physicians would say it causes sterility
only. Most canonists, however, hold that the condition after
vasectomy is technically impotence in the canonical sense. Fer-
reres of Tortosa, a leading Spanish canonist, in several articles
in the Ecclesiastical Review, in Razon y Fe (xxviii, 376; xxxi,
496), and in his book De Vasectomia Duplici (Madrid, 1913),
opposed my opinion published in 1912 and 1913, which then
was that vasectomy does not cause canonical impotence. De
Smet of Bruges 15 holds that it causes impotence. So do

"Jour. Amer. Med. Assoc., April 19, 1913.

14 See the chapter on Gonorrhea.

18 Ecclesiastical Review, September, 1912.

VASECTOMY BY STATE LAW 253

Ojetti,18 Rene Michaud,17 Wouters,18 Eschbach,19 Capello,20
Stucchi,21 De Becker, Vermeersch, De Villers, and Salsmans of
the University of Louvain, and others. Gemelli of Milan 22
agreed with me. The weight of authority is certainly in favor
of the notion of impotence, but the arguments are by no means
convincing, as virtually every canonist who has discussed the
question has made gross misstatements of the physical facts in
the case.

If a man or woman is impotent, the disability is an impedi-
mentum juris naiuralis, and as such it would nullify any mar
riage, no matter what the dispensation. There are two opin
ions among moralists as to the essence of canonical impotence.

I. Some hold that any permanent obstruction to fecunda
tion, no matter in what stage of the physiological process or in
what part of the genital tract it occurs, constitutes impotence.
They maintain that a woman whose ovaries or uterus have been
removed is impotent. Roman Congregations have promulgated
several decrees in peculiar cases permitting the marriage of
spayed women; but, these moralists say, it is not clear that in
those special cases the entire ovary on each side of the whole
uterus was taken out; they hold there is doubt as to the fact.
And, since there is disagreement of moralists, the Holy Office or
other congregations would give the same decision because of the
dubium juris.

April 2, 1909, the Congregation on the Discipline of the
Sacraments decreed that the marriage of a Spanish woman,
from whom, according to the physician in charge of the case,
the uterus and both ovaries had certainly been removed, should
not be prevented.

February 3, 1887, the Holy Office made the same decree in
the case of a woman from whom the uterus and both ovaries had
been removed.

19 Synopsis Rerum Moralium et Juris Pontificii, 31st ed., n. 2425.
" Nouvelle Revue Theologique.

w Nederlandische Katholische Stemmen, January 15, 1911.
" Analecta Ecclesiastica, September, 1911, and La Scuola Catto-
lica, February, 1912.

"La Scuola Cattolica, February, 1912.
*Ilid., November, 1911.
" Ibid., November, 1911.

254 THE ETHICS OF MEDICAL HOMICIDE

July 23, 1890, the Holy Office made the like decree under
the same conditions.

July 31, 1895, the Holy Office permitted the marriage of
a woman from whom both ovaries had been removed.

Another case, in 1902, in which the physician was not cer
tain that the whole ovary on each side had been removed, was
decided in the same manner.

There have been, then, four decisions so far permitting the
marriage of women who lacked both ovaries, and three of these
women lacked the uterus also. The Congregation of the
Council has made four decisions in recent time forbidding the
marriage of women because of impotence; March 21, 1863,
a case in which there was neither vagina nor uterus; January
24, 1871, a case in which the vagina was only two inches in
depth; September 7, 1895, a case in which the vagina was ob
literated in greater part; December 16, 1899, a case in which
the vagina was only five centimetres in depth.

That a woman who certainly lacks both ovaries is canonic-
ally impotent is the opinion of Antonelli,23 Lehmkuhl,24 Eos-
set,25 Alberti,26 Bucceroni,27 and others. These men meet the
decisions of the congregations concerning the spayed women by
saying it is not certain the whole ovarian tissue or the entire
uterus was removed, although as a matter of fact the physician
in one case testified explicitly that both ovaries and the whole
uterus were undoubtedly removed. That a woman lacking
both ovaries is not impotent is the opinion of Gasparri, D'An-
nibale, Genicot, Berardi, Aertnys, Tanquerey, Ojetti, De Smet,
and others.28

II. The second opinion on impotence is that this condi
tion is caused exclusively by those permanent disabilities which
exist in the copula itself. If the sexual act contains in itself
all that is essential to generation, if the copula is de se apta ad

** Medicina Pastoralis, vol. ii, n. 43.
** Theologia Moralis, 8th ed., ii, n. 744.
15 De Matrimonio.
" Theologia Pastoralis, p. iv, n. 88.
" Theologia Moralis, ii, n. 994.

K See Ferreres, De Vasectomia Duplici necnon de Matrimonio Mu-
lieris Excisae, p. 110. Madrid, 1913.

VASECTOMY BY STATE LAW 255

generationem, prescinding from all antecedent and subsequent,
temporary or permanent, obstructions to generation, there is
no impotence. In this opinion the woman without ovaries is
not impotent, but the vasectomized man is ; in the first opinion
both the mulier excisa and the vasectomized man are impotent.
The second group says the vasectomized man is incapable of
performing an act de se apta ad generationem because his semen
lacks the essential spermatozoa. If one objects that the spayed
woman, who is not impotent according to some moralists that
so interpret the decisions of the congregations, lacks the essen
tial ovum, so that she cannot perform an act de se apta ad
generationem because she has nothing to generate with, they
answer that her copula is per se apta, that there happens in it
everything which takes place in a copula from which gen
eration actually follows. The vasectomized man cannot go
through the form of the act with all the elements which, so far
as the act is concerned, are required and sufficient for genera
tion because he lacks the spermatozoa, but the mulier excisa
can. His inability is intrinsic to the act, it vitiates the very
substance of the act; her inability to present ova is not in
trinsic to the act, they say. All that is necessary in her
case is that she be capable of receiving the semen.

Marriage was instituted to beget children; that is the
proper end of the contract, its basic justification. Whenever the
debitum is used it must be with the intention of generating
children. Even the use of marriage as a remedy of con
cupiscence is so secondary an end that it alone is not enough
to legitimize marriage. Because a woman does not always
have ova present in the tubes, — and there is no means of
knowing just when the ova are present, — it is justifiable to re
peat the conjugal act until the woman is impregnated; sec
ondarily and dcpendently, the repetition may be a remedy of
concupiscence. The sexual act does not form either the sper
matozoa or the ova; these pre-exist. The spermatozoa are
always released in a normal sexual act; the ova are not always
present when the spermatozoa are released. A copula which
is perfectly de se apta ad generationem supposes not at the
time the presence of both sperm and ovum, but it does sup-

pose the possibility of the ovum, otherwise generation is ut
terly impossible; and every copula becomes justifiable solely
because there is a hope that it may be present. It is a mere
quibble to say that an act is de se apta ad generationem if by
no possibility generation ever can take place; nevertheless the
congregations in four cases have apparently judged to the
contrary. In these special decisions, however, Rosset, Antonelli,
Bucceroni, and Palmieri hold there was a doubt in the minds
of the members of the congregation as to the complete removal
of the ovaries or uterus. Bucceroni expressly states 29 that the
Cardinal Secretary of the Holy Office told him personally the
members of the congregation supposed in the particular cases
that generation could follow. Therefore these decisions do not
say that the mulier excisa in general is not impotent or potent ;
they merely gave the women of these cases the benefit of the
doubt. The question is entirely open so far as these decisions
are concerned.

Those who hold that vasectomy causes canonical impotence
say also the constitution of Sixtus V. forbidding the marriage
of eunuchs is applicable necessarily to the vasectomized man,
because the semen from the vasectomized man, inasmuch as it
lacks spermatozoa, is not genuine semen, and Sixtus V. said
eunuchs cannot produce true semen. The relevant passage in
the constitution is: "Cum frequenter in istis regionibus
eunuchi et spadones, qui utroque teste carent, et ideo certum
ac manifestum est eos verum semen emittere non posse; quia
impura carnis tentigine atque iminundis complexibus cum
mulieribus se comiscent, et humorem forsan quemdam similem
semini, licet ad generationem et ad matrimonii causam minime
aptam, effundunt, matrimonium . . . contrahere praesumant
. . . mandamus ut conjugia per dictos et alios quoscumque
eunuchos . . . contrahi prohibeas."

Sixtus V. says here: (1) that eunuchs "who lack both tes
ticles certainly and evidently cannot emit true semen" ; (2) that
"although eunuchs may perhaps produce a kind of liquid re
sembling semen, this is by no means fit for generation or mar
riage"; (3) therefore eunuchs are forbidden to marry. The
" Theologia Noralis, 5th ed., vol. ii, p. 391, n. 994.

VASECTOMY BY STATE LAW 257

effects of castration in the eunuch are: (a) that all spermato
zoa are absent; (&) that, as a consequence of the absence of the
testicles, the power of penetration is lost; (c) that, as another
consequence, the liquor setmnis, which normally is formed in
the seminal vesicles, the prostate and other glands, is no longer
secreted. The eunuch, then, is completely impotent, in the full
sense of the term. Ferreres is of the opinion, erroneously, that
eunuchs, as a rule, have the power of penetration and of
emitting a humor semini similis, and that amputation of the
penis is requisite to cause impotence in eunuchs. There are
only five authentic cases of temporary apparent potence in
eunuchs in modern medical records, and these are explicable as
cases of erethism from waste-product intoxication.

The canonists who hold that the vasectomized man is im
potent interpret the words of Sixtus V. to fit their opinion,
although the vasectomized man has all the sexual potency of
the normal man except that his spermatozoa are occluded. The
potestas coeundi is not lost in any degree; neither he nor the
woman is conscious of any change whatever. Only the micro
scope can tell that the spermatozoa are absent if the fact that
ho has been vasectomized is not told. Moreover, if vasectomy
has been done by mere cutting without considerable resection,
and especially if the vasa have been shut by ligation alone, no
one can be certain that the occlusion is either certain or per
manent. There is always doubt that the spermatozoa are pres
ent if the microscope is not used, and these canonists all dis
claim the use of the microscope in such circumstances. The
argument Ferreres uses, to the effect that the absence of sper
matozoa is seriously injurious to the woman, is a supposition
of his own arising from an erroneous notion of potency in the
vasectomized. This absence is not injurious to her, but it is
probably injurious to the vasectomized man because of the
partial ejaculation. Onanism, which is different, is decidedly
injurious to both the man and the woman.

Onanism, coitus interruptus, or withdrawal before ejacula
tion, which takes place extra vas, is intended to prevent im
pregnation. In the normal sexual act the male genital tract
suddenly becomes congested with blood through nervous action

258 THE ETHICS OF MEDICAL HOMICIDE

of centres in the lumbar cord and the cerebrum. Cowper's and
Littre's glands secret an alkaline fluid which neutralizes the
acid urine in the urethra and thus prevents killing of the sper
matozoa. Muscular peristaltic action presses out the sperma
tozoa and the secretions of the seminal vesicles and the pros
tate. When the act is normal there is a complete emptying of
the tract of semen and of the blood engorgement; in coitus
interruptus there is incomplete ejaculation and only partial
deplethorization. The seminal vesicles remain distended, and
this distention, with the congestion of the prostate, causes con
tinual excitation of the sexual centres without relief. There is
irritability and exhaustion of the centres, and this state brings
on premature ejaculation and final impotentia coeuiidi. Other
common effects arc tenesmus of the urinary bladder, incon
tinence of urine, nocturnal pollutions, sexual neurasthenia, pain
in the legs, over the eyes, and in almost any part of the body,
general weakness, headache, vertigo, cardiac palpitation, neu
rotic dyspepsia, and a train of psychic symptoms which not sel
dom end in suicide.

In the woman there is the like blood engorgement and a
pouring out of the secretions of Bartholin's and the other glands,
but deplethorization takes place later in the woman than in the
man, and for this reason the woman suffers more from coitus
interruptus than the man does. In onanism, as in masturba
tion, after the diseased conditions have beeen established it is
extremely difficult to induce the patient to resist the almost
overwhelming irritation.

The canonists have interpreted the text of Sixtus V. to the
effect that the eunuch is impotent precisely and solely because
he cannot produce semen "elaboratum in testibus." No man
produces semen elaboratum in testibus — more than 93 per cent,
of the semen is produced entirely outside the testicle; nothing
but the spermatozoa and two or three drops of a lubricating fluid
are produced in the testicles. The eunuch really is impotent
because the removal of the testicles and their nervous system
so breaks the genital circuit, which consists of at least seven
teen distinct parts, that erection is prevented, the formation of
spermatozoa is impossible, the secretion of the essential vehicle

VASECTOMY BY STATE LAW 259

of the sperm and of the fluids which render it fertile is cut
off. The eunuch cannot penetrate and he cannot form any
semen; he is impotent; the vasectomized man can penetrate,
and he forms a semen which is sterile.

I think now the vasectomized man is really impotent for the
reason that I think the mulier excim is impotent, but he is not
impotent because of the constitution of Sixtus V., which is not
relevant at all to his case.

If the vasectomized man is impotent, the following cases
are also impotent:

1. A man whose germ-cells have been destroyed by the
action of the X-ray.

2. A man with double permanent occluding epididymitis.

3. A man whose vasa deferentia open into the ureters and
not into the urethra.

4. A man whose vasa are shut by surgical operations for
stone, or cysts of the prostate, or seminal vesicles.

5. A man whose seminal vesicles are shut by concretions,
cysts, or tumors.

6. A man with bilateral cryptorchidism.

7. A man with a tuberculous condition of the testicles.

8. A man with absolute neurotic aspermia.

9. A man with congenital lack of development of the tes
ticles or vasa.

Sterility in the male would exist only in advanced diabetes,
general tuberculosis, senility, or in cases of absent or diseased
prostate gland or seminal vesicles.

Here it is worth noting that since the copula must be nat
ural, fit for generation in the natural manner, artificial im
pregnation by the use of instruments is immoral, and forbid
den by a decree of the Holy Office, promulgated March 24,
1897. Artificial impregnation does not effect a copula which
is by its nature proper to generation, but is an act contrary
to nature, one from which generation does not follow in a
natural manner, secundum communem speciem actus. It sup
poses deliberate pollution and semination outside the vagina,
both of which actions are intrinsically evil.

In discussing tho morality of vasectomy the following points
must be considered:

1. In what degree of mutilation is vasectomy ?

2. Vasectomy may be done either at the request or by
the permission of the vasectomized person; or by order of the
State.

(a) If done by the request or permission of the vasectom
ized person, it may be either (1) as a means to use
the debitum without the inconvenience of having chil
dren; or (2) as a therapeutic measure to cure some
malady.

(&) If done by order of the State, it may be (1) a pun
ishment; or (2) a prophylactic measure to avert
physical or moral evil in society.

If vasectomy causes canonical impotence, that fact adds a
special moral quality. The weight of authority is on the side
that it does cause canonical impotence, as has already been
mentioned.

A slight mutilation, in the sense of the term as commonly
used, can be any permanent effect of a wound, bruise, or sim
ilar cause, from a mere scar to an amputation or other injury
whereby any member of the body is rendered unfit for normal
action. That the causal wound or injury is trivial in itself,
apart from its effect, as in vasectomy, has little or no direct
bearing on the morality of the mutilation. It is possible to
have a very gross mutilation without extensive wounding. We
can blind a man permanently by putting the point of a fine
cambric needle one-twentieth of an inch within the pupil.

Vasectomy is a grave mutilation because (1) it removes
from the man the power of generation; (2) it inhibits the
function of the testicle, which is an important organ of the
body. Although they are not the entire organ of generation,
the testicles are together a complete organ in themselves, the
function of which is to produce the spermatozoa essential to
the procreation of the human species. If by a wound one
inhibits the function of the testicles, he gravely mutilates the
human body, for a grave mutilation is nothing but an inhibi-

VASECTOMY BY STATE LAW 261

tion of the function of a distinct organ through a wound.

A mutilation of this kind, since it frustrates the production
and action of the human generative semen and prevents gen
eration, is what is technically called a mortal sin against na
ture, unless there is sufficient cause to necessitate the frustra
tion, such as to save life, to restore as a sole means the health
of the whole body, to protect society, or a similar reason. What
is said here of vasectomy is true for fallectomy or other methods
of sterilizing the woman. Fallectomy, however, is in itself a
dangerous operation, and oophorectomy is never justifiable as
a mere method of sterilization because of its very injurious
effects on the whole body and mind of the woman.

Among the decretals of Gregory in Corpus Juris (lib. v, tit.
xii, c. 5) is the following canon: "If any one, for the sake of
indulging lust, or through revenge, does anything to a man or
woman, or gives them anything to drink, whereby they cannot
generate, or conceive, or bear children, he is to be treated as a
homicide." Any one who sterilizes a man by vasectomy or a
woman by fallectomy or oophorectomy, for an improper mo
tive, ipso facto falls under this decree, and is before the canon
law classed in the same category as a murderer; that is, the
agent is deemed guilty of a grave crime against nature.

If a man has vasectomy done upon himself, his intention
may be (1) to use the debitum without the inconvenience of
having children; or (2) to avert from a wife with a narrow
pelvis the dangers of the cesarean section or other obstetrical
operation to herself and the child ; or (3) to avoid the transmis
sion to possible offspring of a hereditary disease like Hunting-
ton's chorea or one of the others mentioned at the beginning of
this chapter ; or (4) to cure himself of some malady.

1. If vasectomy is done merely to be able to use the de
bitum without the inconvenience of having children, it is evi
dently illicit. It is in that condition the same as onanism; it
is contrary to the basic justification of marriage; it is a frus
tration of nature ; and so on.

2. If it is done to safeguard a wife with a narrow pelvis
it is a means, evil in itself, used directly to effect a good end ;
and a good end, or any end or effect, never justifies a direct

evil means or cause. There is in reality no such thing as a
good effect from an evil means or cause; the evil means or
cause essentially and substantially vitiates the effect. There is
no question here of a double effect, one good and one evil,
wherein the good effect is intended and the evil permitted, both
coming with equal directness from the single causal act. On tho
contrary, from the vasectomy here there is the single direct
effect that the man is sterilized, and then directly from this
sterility comes the desired effect, the protection of the wife.
For exactly the same reason, vasectomy done to prevent the
transmission of a hereditary disease is illicit; it is an evil
means used directly to effect an end intended. In artificial
abortion when the fetus is inviable the act done is to empty the
uterus, and this act itself kills the fetus, which is not an unjust
aggressor, and is murder. This murder may save the mother's
life, but the end does not justify the means. The vasectomy to
protect the mother's life or to avert an evil heredity is a parallel
case.30

The fourth case supposes that the vasectomy was done to
cure the man of some malady. If there were a malady that
endangered the patient's life, or destroyed the health of the
body and it could be cured by vasectomy, the operation would
of course be licit for the reasons given in the chapter on Gen
eral Principles concerning Mutilation. Dr. Carrington tells
us 31 that he did vasectomy on an epileptic convict and cured
him. Such a cure is doubtful as to permanence. He describes
two dangerous insane negro homicides who were rendered harm
less by vasectomy. In cases like those of the homicides any one
responsible for them would probably be justified in having the
operation done, although these two cases are the only direct
ones on record. Epileptics sometimes show a homicidal tend
ency, but it is doubtful that vasectomy would help them. The
operation of vasectomy as a cure for bodily ill has a very limited
field. There are very many conditions in women where it is
necessary to remove the ovaries or the tubes to save life, or to

10 See the chapter on General Principles concerning Mutilation
for an explanation of the act with a double effect.
31 Virginia Medical Semi-monthly, vols. xiv, xv.

VASECTOMY BY STATE LAW 263

cure chronic invalidism of an unbearable nature. These con
ditions are discussed in the chapter on Gonorrhea. There is
no objection to the removal of a tube or an ovary when such
removal is absolutely necessary, but the necessity must be
clearly evident. There is a tendency in some surgeons to
mutilate women in this manner without sufficient reason or to
follow out a therapeutic theory.

Men, like Sharp, who have done hundreds of vasectomies,
say the operation commonly removes the inclination to mas
turbation. Masturbation is, as a rule, a moral condition, but
it can, like alcoholism, come to have a large physical element.
Idiots almost unexceptionally have this vice, and in them there
is no morality possible. If by vasectomy they can be cured of
this vice, which injures their health and is a social indecency
and a source of sin in observers, the operation would be licit in
their case. When the patient is morally responsible vasectomy
would not be licit, as there is no adequation between a physical
evil like sterilization and a moral vice. There are cases of
pathological sexual erethism which are so violent that the pa
tients must be put into strait-jackets to prevent constant mas
turbation. The semen of such patients is usually devoid of sper
matozoa. If the patient is confined in a strait-jacket he will
die, and vasectomy, according to Sharp, will quiet such a man.
Vasectomy would be permissible in these circumstances.

The question has arisen in the case of a sane masturbator
who is neurotic, weak-willed, and a confirmed addict to his
vice, whether or not his vasa might be tied off by ligatures,
temporarily, with the intention of removing the ligature later
and restoring function. I think not. Even temporary sterili
zation is sterilization, a grave mutilation, while it lasts, and
the condition is really moral fundamentally, and therefore not
a fitting object for physical remedies.

When vasectomy is done by the State, it is done either as a
penal or as a prophylactic measure. As a general statement we
can say the State in certain conditions has the right to kill or
mutilate a criminal in defence of the social order; but even
then any punishment, to be justifiable, must be effective and
necessary, and it has to be either reformative, exemplary, or

264 THE ETHICS OF MEDICAL HOMICIDE

reparative 'in regard to the crime for which it is inflicted.
Capital punishment and mutilation are effective usually, and
are necessary for the preservation of society. The natural law
permits the State to preserve itself against the unjust encroach
ments of individuals by curtailing their rights in so far as
that curtailment is effective and necessary: since the natural
law requires the existence of civil society, it must allow what
is necessary for the preservation of that society. There is no
question here of a good end justifying evil means; the means
which otherwise would be evil in these conditions become good.
Homicide and mutilation are not mere killing or mere maiming,
but unjust killing or unjust maiming. Killing or maiming is
not intrinsically wrong under all circumstances, as lying,
blasphemy, and some other crimes are; nevertheless, as a pun
ishment by maiming, vasectomy is ordinarily wrong, and there
fore a law making it an ordinary mode of punishment for cer
tain whole classes of criminals, or all criminals, is unjust.

It is wrong because as a punishment it is neither effective
nor necessary nor reformatory nor exemplary nor reparative —
it lacks every quality of a justifiable punishment. In Dr.
Sharp's list of vasectomies done in Indiana prisons, 176 opera
tions were done on men who voluntarily asked for vasectomy.
There is no pain, no inconvenience caused by the operation, no
sexual change perceptible, but a fitting of the criminal to in
dulge his lust without the various inconveniences of impreg
nation. Instead of being reformatory, it is conducive to crime.
I find only one man who objected to vasectomy.32 In this man
vasectomy was added to life imprisonment as a punishment for
rape.

The legislators in the States which have passed the vasec
tomy law all seem to have been influenced by the pseudoscien-
tific notion that criminality is a hereditary condition, a physical
disease, and not a matter of volition. This Lombrosan absurd
ity is now held by no physical scientist, and from an ethical
point of view it is nonsense. Moreover, if the State vasectom-
ized all the criminals in the jails, this method would not ap
preciably affect the supply of criminals, nor reach an appre-

85 State of Washington vs. Feilen, 126 Pac. R. 75.

265

ciable minority of the criminal class, as the most dangerous
criminals are not in jails.

The operation is not a punishment to the men upon whom
it is done, but it is an unnecessary deprivation of an essential
right of these men, an excessive, ill-ordered attack on a primary
right of man, and an act of violence against human nature
and its Author without adequate reason. The law is against
the natural order because it directly deprives a man, and that
against his will, of functions which are at times a moral neces
sity to him, and puts him into the occasion of sin. Vasectomy
does not remove his venereal desires, but gives opportunity to
lust; it turns the conjugal relation into mere onanism and de
grades marriage into a crime. Other conditions, like military
service, in which necessity obliges the State to place its citi
zens and thus prevent the conjugal relation, cause an indirect
temporary prevention, reluctantly permitted, not directly in
tended. Vasectomy is an evil directly intended.

It is to the interest of the State to prevent the transmission
of hereditary disease, and in doing so it may to a certain de
gree curtail the natural liberty of its citizens. When the peril
is great, as in a plague, the State may isolate infected individ
uals, and thus indirectly, but temporarily, prevent a natural
right — namely, the conjugal relation. It may even perpetually
isolate, as in leprosy. Vasectomy, however, is a direct pre
vention without reason, and it is done as a direct evil means
to effect a so-called end which it never attains.

A man with Huntington's chorea, if married and if he has
children, will surely transmit the disease to some of these chil
dren, and they to their children. Vasectomy on him will pre
vent a propagation of his kind but will cure no disease. More
over, he is not a criminal and not amenable to punishment.
The bad effect, sterilization, must be perpetual in his case or
it is foolish, but the sterilization is not a punishment, nor a
means of saving the health of the patient. Whatever good
comes of the act comes out of an evil cause. If such a man
persists in marrying, his marriage might be prevented, but that
is different from mutilating him.

The State has no direct dominion over the lives or members

266 THE ETHICS OF MEDICAL HOMICIDE

of its citizens, nor are citizens naturally mere instruments for
the good of the government; on the contrary, the government
exists solely for the good and utility of the citizen. The State
may not take the life of an innocent person, nor mutilate him,
unless these acts are necessary either (1) to protect the life
or rights of individuals; or (2) to preserve the social life of
the commonwealth. Now, neither of these two requisites is
present when there is question of vasectomizing a man.

The right or life of no individual is at stake. The rights
of the possible children, yet unborn, are not injured, because,
as these children are not in existence, they have no rights.
Should they come into being, it is always better to be, even
though diseased, than not to be. The methods of cattle-breed
ers in dealing with human beings is not a virtue in the State,
but an outrage and a degradation of human nature.

The rights of the wife are not injured, because she per
sonally receives no injury; and if her possible children have
chorea, for example, she either voluntarily took that risk when
she married, or if she did not, through ignorance, there are other
means to avoid the trouble than the evil of sterilization, which
in itself would render the use of marriage onanistic. If the
husband has syphilis, gonorrhea, leprosy, tuberculosis, or any
other infectious disease, vasectomy is no protection for the
wife.

May a physician employed by the State in a prison, an insti
tution for the feeble-minded, or a like place, do vasectomy
at the command of the law? Certainly he may not, except in
those rare cases where vasectomy is permissible as described
above.

The advocates of freakish legislation harp on the asser
tion that insanity and imbecility are increasing alarmingly, and
as a consequence the entire nation is degenerating. To cure this
evil we are to mutilate certain criminals and the mentally de^
fective. It is not true that insanity and mental imbecility
are increasing in a very marked degree in the TJnited States.
The number of inhabitants in this country is increasing rapidly,
and as there are more people here than there were a few years
ago, the number of the insane and the mentally defective has

VASECTOMY BY STATE LAW 267

increased purl passu, but the percentage does not increase to
any degree that calls for immoral and ineffective legislation.
Only of late years have the State governments begun to clas
sify, diagnose, and gather up the insane and the imbecile,
whom we always have had with us, and these processes have
brought the defectives into the light.

Our late immigrants are not equal in race, in mental and
moral strength, to the old northern European immigrants. In
Philadelphia the foreign-born population is 24.7 per cent of
the whole, but that foreign-born population gives us 44 per cent,
of the indigent insane. In New York State 27 per cent, of
the registered insane are not American citizens. What we need
here is not sterilization, but a better control of the immigrant,
a keeping out of the unfit. Again, our insanity percentage is
increased avoidably by the undoubted increase of insanity
among negroes. We are accountable for this because we do not
care for our helpless negroes. These people are prevented by
trades-unions from learning and working at elevating trades,
and they are thus forced unjustly into a poverty and degrada
tion which lead to vice and mental deterioration. The cure is
not a jail surgeon's scalpel, evidently.

A system of education that ignores the will, upon which
morality and virtue are based, and substitutes a sham intellec
tuality as elaborated by ignorant boards of education and ad
ministered by emotional, half-educated women, together with a
lack of genuine religion, is a prolific source of mental and
moral deterioration and consequent degeneracy in the physical
and moral orders. 0ur American public-school system is such,
and its deity is the unwashed and crassly depraved god Demos,
whose bible is the evening newspaper. If we could civilize our
schools, we should have no mention of legislation by vagary.

BIBLIOGRAPHY

Ecclesiastical Review, vols. xlii, xliii, xliv, xlvi, xlvii, xlviii,

passim. Philadelphia.

Gemelli. La Scuola Cattolica, November, 1911. Milan.
Stucchi. Ibid.

268 THE ETHICS OF MEDICAL HOMICIDE

Eschbach. Ibid., February, 1912 ; Analecta Ecclesiastica, Sep
tember and October, 1911.

Capello. La Scuola Cattolica, February, 1912.

Michaud. Nouvelle Revue Theologique. Paris, 1914.

Schmidt. Zeitschrift fiir katholische Theologie, nn. 1 and 4,
1911.

Ferreres. De Vasectomia Duplici necnon de Matrimonio
Mulieris Excisae. Madrid, 1913.

De Smet. Collationes Brugenses, December, 1910.

Wouters. Nederlandische kathol. Stemmen, January 15,
1911.

Waffelaert. De Virtutibus Cardinalibus, vol. ii. Bruges,
1889.

Sharp. Journal of the American Medical Association, Decem
ber 4, 1909. This is the article which started the entire
vasectomy controversy.

Barker. Maryland Medical Journal, April, 1910.

Bell. Hereditary Criminality. Medico-Legal Journal, vol.
xvii. New York.

Desfosses. Presse Med., vol. xviii.

Rentoul. St. Thomas Hospital Gazette, vol. xx. London.

Swift. Maine Medical Association Journal, December, 1914.

Lydston. Medical Record, November 8, 1913. New York.

CHAPTER XXIV
THE ETHICS OF BIRTH CONTROL

A COROLLARY of the doctrine which treats of the
destruction in medical practice of existent human life,
is a consideration of what is called Birth Control, or the crim
inal prevention of possible human life by onanistic contracep
tive methods. There has been an agitation for several years
past in western and northwestern Europe and in the United
States to bring about the repeal of laws which forbid the
spreading of information on the methods of preventing con
ception. The laws which the agitators wish to have abrogated
declare that contraceptive information is indecent and should
be classed with the circulation of obscene literature, porno
graphic pictures, and instruction in abortion. The birth con
trol advocates pay no attention to accusations like those
expressed in the laws, or to those made by persons who have
accurate notions of morality and common decency, but assert
that the spread of contraceptive information tends to benefit
the individual and human society.

Birth control as advocated by its perpetrators is intrin
sically contrary to the natural law, and therefore immoral; it
mentally and physically debases those that are guilty of the
practice; it does not benefit the poor as its advocates claim
it does; the arguments urged by its supporters are foolish and
frequently deliberate untruths ; and it is destructive of society
and the state. Broadly speaking the natural law rests on the
principle that order, reason, justice, what is congruous with
the nature of a being or faculty and tends to its perfection in
being or action, should prevail, and that disorder, unreason,
injustice, the unnatural, must be avoided. The right order
of nature as established by the Supreme Creator of nature is
the standard of action; what is contrary to that order is evil,

269

270 THE ETHICS OF MEDICAL HOMICIDE

wrong, destructive, criminal, injurious, or the like, in different
circumstances, but altogether these deordinate conditions must
be removed, not accepted. Morality also depends on these
facts. Morality is merely the observance of the natural law,
and immorality is revolt against that law.

Since the natural law evidently prescribes that man must
live in society and that the human race which constitutes this
society, is to be preserved by the generation of new human
beings who will replace those that die, or are made useless by
disease or other accident, whatever tends to this sustention of
humanity according to the natural law, and in the proper con
ditions, is good, and whatever tends to the destruction of
humanity is evil and to be avoided.

The generation of new replacing human beings must take
place only in the state of marriage, because thus solely the
wife and the child are protected, the children are educated
physically, mentally and morally, and the degradation and
bestiality of promiscuous sexual relationship are averted. The
first and principal end of marriage is the procreation of chil
dren. That end of marriage must be the end on which is
founded primarily the natural necessity for this contract, but
the natural necessity for the contract is the propagation of
the human kind through lawful generation and education. Mar
riage, too, in its very nature is fitted for that chief end, and
for that end it was instituted by the Author of nature — a
stable, perpetual association of the sexes for the attainment of
what is requisite for the propagation of mankind. There are
secondary ends of marriage, such as a reciprocal love and help
of the husband and wife, and also that aspect of marriage
which makes it a restraint upon promiscuous lust. These last,
however, are not enough to justify marriage in themselves with
out the first or chief end, which is the procreation of children.

Whatever is subversive of the end of marriage, and that is
the propagation of mankind, is subversive of the very founda
tion of human society, is contrary to the nature of man, frus
trates the primal function of nature, and is therefore essentially
and always evil, as bestiality, sodomy, or incest are evil. Such
is birth control as ordinarily practised. Birth control if it is

THE ETHICS OF BIRTH CONTROL

effective through a reciprocal consent of a wedded couple, for
grave reason, and solely by mutual abstention from the debitum
may be in certain conditions an indifferent act morally. If,
however, birth control is effected by contraceptive drugs, or
like methods, it is a crime against nature, and always a crime
which no circumstance can excuse, no more than no circumstance
can excuse bestiality, sodomy, or incest. Secondly, marriage,
which was instituted primarily to perpetuate the creative act
of God, when such practices prevail degenerates to mere con
cubinage, a gratification of lust protected from the police.
Such practices, moreover, lower man and woman below the
brutes, because brutes do not frustrate the natural law except
in the case of the male rat and a few other low grade rodents
and boar pigs. Onan is the patron of Birth Control advocates.
The Book of Genesis said Onan, the son of Judah, "did a
detestable thing, therefore the Lord slew him."

These are the fundamental reasons those of us recognize
who do not wish that the ignorant and vicious should be taught
to act contrary to the natural law. Furthermore, there is
always another way out of the difficulties, mostly imaginary,
the birth control advocates conjure up. Granting that all the
difficulties from multiple births are real, no end justifies essen
tially evil means, and a subversion of the natural law is always
essentially evil. War, homicide, and like acts are not always
evil ; under certain circumstances both war and homicide may
be holy deeds; but to act contrary to nature is never justifiable
in any condition. If I owe a man a large sum of money it
may be to the advantage of myself or my children that this
man be removed, but that good end does not justify murder;
no more does any condition of poverty justify a contraceptive
act against nature, especially when such an act is never the
sole means of evasion. We must protect the married state,
but in America we are destroying it. Human society had its
origin in marriage, and it depends on marriage for its preserva
tion, but our American divorce laws have made marriage a
travesty. In New York alone in 1016 there were 74,893
women divorced, nearly twenty-eight times as many as were

272 THE ETHICS OF MEDICAL HOMICIDE

divorced in England and Wales in that year, and over forty-
nine per cent, of these women were childless, very significantly.
Probably ninety-five per cent, of the childless women had used
contraceptive methods, yet there are few forces better able to
hold the marriage knot tied as it should be tied than a child's
fingers. In England and Wales, too, in 1916, forty per cent,
of the divorced couples were also birth controllers, at least they
had no children. Pennsylvania is much more shameless than
New York in granting divorces for no reason at all.

Among the arguments used by those in favor of spreading
contraceptive information is that large families keep the labor
ing classes down to low living standards, and it would be bet
ter for those families and the state that these children were
not born. Large families as such do not keep the laboring
classes down to low standards of living; bad legislation which
allows profiteering, which criminally permits extortion in the
prices of food, clothing, in taxes, rents, the cost of coal, and the
like, which does not force employers to give laborers an honest
price for labor, or check the extortions of monopolists, and a
hundred similar economic deeds of injustice, together with a
parental shiftlessness, unthrift, alcoholism, lack of education
through neglect, and so on indefinitely, are the causes. Big
families have more wages than small families, and as a rule
they do better than the small families when the children are
old enough to work. Society is at fault, not the size of the
family; the active and the passive selfish are at fault, not the
babies ; the liars, hypocrites, and the buttoned pockets are at
fault, not the holy innocents ; the professional meddlers in the
business of better folk are the nuisance, not the blessed children,
who are the brightest things in this darkened world until we
spoil them, and make them like ourselves instead of better.
One decent mother is worth a hundred shirkers who raise noth
ing but lap dogs.

The children of large families, the birth controllers say,
are more aiflicted by infectious diseases than those of small
families. I was for years in charge of the infectious diseases
Bureau of the Washington Health Department, and I have had
ample opportunity here and in Europe to study this matter.

THE ETHICS OF BIRTH CONTROL 273

Large families in proper economic positions are not different
from small families as regards the infectious diseases. These
diseases spread among the poor because the houses of the poor
are commonly owned by land sharks and politicians who laugh
at health regulations ; our health departments can not get enough
money away from the political ringleaders in power to employ
capable sanitary experts; our laws for the regulation of medi
cal practice and education are a disgrace to our civilization,
and every town is swarming with quacks who can not recognize
even smallpox when they see it. The fault here is in our
selves not in the large families. Control the professional poli
ticians and quacks and there will be no occasion for foolish talk
about birth control.

Again, the children of poor but large families, we are told,
have slight or no chance to rise in the social order. Benjamin
Franklin, however, one of the greatest men America has pro
duced, was the youngest of seventeen children in a poor family ;
Lyman Beecher, a poor man, had eleven children, and every
man and woman among them became famous; Theodore
Schwann, the father of the cell doctrine and of all modern
biology, was one of thirteen poor children; John Mueller, one
of the greatest of modern scientists, and the Father of German
medicine, was one of five children of a very poor family;
Emerson was one of five sons, so was Farragut; John Wesley
the founder of Methodism, was the eighteenth child of his
parents; Ignatius Loyola was the eighth; Saint Catherine of
Sienna, among the greatest women intellectually and morally
that Europe ever produced, was the twenty-fourth child of her
parents. This list can be extended indefinitely from the
biographical dictionaries. Every enormous fortune made in
America was built up originally by a man who arose from the
depths — Rockefeller, Carnegie, Vanderbilt, Astor, Ryan, Have-
meyer, Schwab, Ford, Gould, and so on. Poverty is a necessary
foundation for a great fortune. The great soldiers of the world
almost without exception rose from the ranks of poverty —
Napoleon, Washington, Sheridan, Grant, Sherman, Pershing,
De Lacy in Russia, Prim in Spain, O'Higgins in Chili, Stone
wall Jackson, and others. The powerful Dukes of Tetuan in

274 THE ETHICS OF MEDICAL HOMICIDE

Spain came from an Irish adventurer, the fifth of eight sons
of a poor man. Big families make for strength of character
in the struggle for existence; the solitary child in a family is
pampered, spoiled.

Advocates of birth control say that Holland has had a
Neornalthusian League openly operative since 1881, with fifty-
two clinics where contraceptive information is publicly given.
As a direct consequence, and solely from the work of this
League, Holland has a dropping death rate and an increase
in population, and even the stature of the Dutch has increased
four inches since 1881. The main objection to these state
ments about Holland is that they are absolutely false in every
particular except that the population of Holland has increased
— from other causes. Before the great war every civilized
nation had a dropping death rate and an increase in population
except France where birth control worked against the increase
made by the progress of preventive medicine and a diffusion of
sanitary methods. The assertion about the fifty-two clinics in
Holland wras investigated. An army officer sent out by the
committee searched fourteen days before he could find even
one secret birth control propaganda station. The present prime
minister of Holland, de Beerenbrouk, is an earnest Catholic
man, and if anyone talks birth control in Holland during his
administration he guarantees them a long term in jail. There
was really a Neomalthusian League with 6,704 members, now
greatly decreased in number, in the northern Protestant prov
inces of Holland. As a matter of fact just where this league
exists the birth rate decreased and the death rate increased
and where it did not exist the direct opposite is true. As to
the increase of four inches in stature — since this is a physical
impossibility the spinner of the original yarn was an ignorant
romancer, lacking plausibility in his untruth. "Where there is
birth control there are no children to increase or maintain the
population, but the New York birth controller who invented the
Dutch story says that in Holland where there are no children
born through birth control the population increases through
birth control.

The birth control movement assumes that the world suffers

THE ETHICS OF BIRTH CONTROL 275

from overpopulation. It does not; it suffers from incorrect
distribution of populations, and no doctrine of birth control
will ever affect this fact. All the authorities on the statistics
of population tell us it requires an average of four children
to each family to keep the population even stationary, not to
talk of overcrowding. Two children reaching maturity replace
their parents, and because of the high mortality in infancy, and
the large number of the unmarried and the birth controllers
and abortionists, four children are needed to a family to make
a new generation as large as the old. An average of one, two,
or even three children to a family means a loss in population,
unless the loss is supplied, as in the United States, by immi
gration. An average of five or six children means an increase
in the population. Having none or two children to a family
and relying on immigration to preserve the nations means
political annihilation, as can be readily shown. In New York
State in 1919 instead of the required four children to keep
the population stationary, as far as the native Americans are
concerned, there was one child to every ten families.

The American nation was founded and built up wholly
by Nordic races, immigrants from Great Britain and Ireland,
Germany, and a few from France, Holland and Sweden. All
our national traditions are from these Nordic immigrants, our
notions of self government, our peculiar democracy, our con
stitution, our language and literature. These Nordic peoples
are dying out here in appalling numbers for two chief reasons,
one of wThich is birth control and the other is the American
climate. The civilization which affects us has always existed
along a geographical belt reaching from the British Isles to
above Home, and covering Great Britain, Ireland, France,
Spain, middle and western Germany, and Italy to below Flor
ence. The Grecian civilization was not indigenous, but the
result of a Nordic occupation, and it ceased centuries before
Christ. Huntington of Yale and several others have shown,
by studying the production of thousands of piece workers and
students over a long time, that man does his best work physic
ally and mentally under four climatic conditions : a mean tern-

276 THE ETHICS OF MEDICAL HOMICIDE

perature of about sixty-two degrees Fahrenheit for physical
work and about forty degrees for mental work ; secondly, there
must be a humidity of about seventy-five per cent. ; thirdly, the
climate must be variable, be that of the belt of cyclonic storms ;
fourthly, there must be a quantity of sunlight such as that
found in the European racial habitat of the person considered.
These conditions are found curiously in exactly these degrees
in the civilized parts of Europe and not elsewhere. Above
and below that area they are lacking and there has never been
any civilization where they are wanting. The reason physical
and mental productivity lessen annually with us in December,
January, and February is because these climatic conditions are
absent during these three months.

Again, men are differentiated into races, thrive, develop,
and reach and maintain mental and physical perfection w-ithin
well defined climatic areas. Nature preserves the race that
has acquired through countless ages acclimatization in a given
environment, and kills off very quickly immigrants coming
from far north or south of the given latitudes. The natural
geographical position for the black man is from the equator
to the thirtieth parallel of north or south latitude. The thirtieth
parallel in America runs through upper Florida, southern Louis
iana, and the lowest third of Texas. From the thirtieth to
the thirty-fifth parallel is the zone of the brown man, like the
Malay. The thirty-fifth parallel runs along the southern border
of North Carolina and Tennessee, through the middle of
Arkansas, New Mexico, Arizona, and the lowest third of Cali
fornia. From the thirty-fifth to the forty-fifth parallel is the
zone of the brune Mediterranean races. The forty-fifth paral
lel passes near Halifax, Bangor in Maine, Ogdensburg, Ottawa,
and St. Paul. In Europe it runs near Bordeaux, Turin, Bosnia,
and the Crimea. New York is as far south as Naples, Phila
delphia is sixty miles south of Naples, and has the sun of
southern Italy. The Nordic races that we are interested in as
our origins all live above the United States, and the summer
temperatures they have been accustomed to are above the
United States. An immigrant coming from northern Ireland to
Philadelphia moves southward a thousand miles; a Norwegian

THE ETHICS OF BIRTH CONTROL 277

going to Texas moves southward two thousand miles, and his
family disappears as a rule in two generations.

In historic times there have been sudden movements south
ward of European races for about seven hundred miles and
all ended disastrously. The Lombards went south from upper
Prussia to middle Italy at the level of Boston and disappeared
in two hundred years. The Teutonic Goths went from the
Baltic to Italy and Spain. They lasted sixty-two years in
Italy. Eighty thousand Vandals with their families went down
from Brandenburg to North Africa at the level of Virginia.
They were annihilated by the climate in one hundred and eight
years. The Burgundians disappeared in sixty years from
Greece, as the Celts who had carried the Homeric sagas to
Greece also disappeared. Rome was great while the Nordic
Cisalpine Celt ruled it, and died forever with the Celt. Italian
art ended at Florence, the southern boundary of Cisalpine Gaul.
The Slav disappeared the same way from southeastern Europe
and left only language traces to the Turanian and Semite there.
No European race of pure blood has ever had grandchildren
in the tropics.

The northern races of Europe die out with amazing rapidity
in the northern United States. The Irish death rate at the
level of New York is double the death rate in Ireland under
much worse economic conditions ; the death rate of the southern
Italian and the southern Russian is much better in New York
than it is in their European racial habitats.

In 1910 our English immigration was only six per cent,
of the whole, and the Irish immigration is now negligible
because there are no more people in Ireland to leave it, but we
have seven million Slavs who came in during the ten years before
the war. We have three million southern Italians, three mil
lion Poles, and hundreds of thousands of nondescript folk from
all the back alleys of the old world. At an army camp in
Massachusetts during the late war there were thirty languages
other than English spoken, and seven thousand men there
never had heard the term Anglo-Saxon. The extreme southern,
eastern, and southeastern European hordes are overwhelming us,
and these hordes never knew a single political principle that

278 THE ETHICS OF MEDICAL HOMICIDE

even remotely resembles what we understand as American prin
ciples. They come of races who were ruled, if they had any
rule at all, by despots, but we shall make "Anglo-Saxons,"
Americans, or whatever you like to call the final metamorphosis
we effect, out of these barbarians. Never ! Even in a millenium.
Centuries from today the Slav here will be a Slav, the Sicilian a
Sicilian, the Russian a Russian, all with a veneer of American
slang on the tongue of an eternal racial character. Whole
counties of Pennsylvania are filled with Germans who have
been here since before the Revolution and they have not so much
as learned English yet. The Nordic peoples die out here. Only
the dark-skinned southern Germans last with us ; the sun kills
out the red and blond in two or three generations. I recently
went over fifty Irish families which I knew perfectly, and they
have degenerated eighty-six per cent, numerically and otherwise
in my own lifetime: killed off by the climate which keeps our
southern states empty of white men. By two American censuses
and one English we know that fifty per cent, of Washington's
army was born in Ireland, but there are no Irish in the revolu
tionary societies because the Revolutionary Irish have disap
peared.

If there is any chance at all for our civilization, flimsy as
it is, this world must be ruled by the Nordic European races,
not by the southern, eastern and southeastern European bar
barian Semite. We must rule for our own sake and for their
sake ; they can not rule anything. If we do not rule them, then
welcome the final curtain as soon as possible. How can we
rule America, not to think of the rest of the world, unless we
have Nordic children to take our place, and how can we have
such children if we let sex-brained misfits run about spread
ing contraceptive drivel ? The rascal that preaches such
doctrine is a traitor to America, the worst enemy our country
ever has had, more treacherous than any spy that sneaked in
among us during the war just past. The French have had their
lesson in birth control, and we should learn from their mis
fortune. In the first six months of 1914 when Europe was
still at peace the total number of births in France was 381,-
398 ; a decrease of 4,000 on the year 1913. At the same time

THE ETHICS OF BIRTH CONTROL 279

the deaths increased 20,845. Thus the population of France
during the first six months of 1914 decreased 24,816. For the
past thirty years the birth rate of that country has steadily
decreased by contraceptive methods, while the death rate has
increased proportionately to the number of inhabitants. Jan
uary, 1916, found France with about seven hundred thousand
less people than she had in January, 1914, and then came the
horrible carnage of the great war. No matter what change of
heart war may bring to France no increase in her population
can be expected for many years yet to come. She is daily crying
out to the world for treaties to protect her from Germany, de
spite the prostration of Germany, because she knows Germany
had a birth rate of two males for her one, and for twenty
years to come Germany probably can put twice as many men
into the field as France can. If France will give over her
unclean birth control she will not need to whine for protection.
The advocates of birth control assert that it lessens venereal
diseases. It does not; it increases the spread of venereal
disease. The more reasonable among the birth control propa
gandists are anxious lest their public talks suggest temptation
to the young. There is at present for youth the deterrent of
the natural consequences of lust; with birth control knowledge
spread broadcast that check is removed and promiscuity will
become more general, because safer socially. Venereal dis
eases will spread also as incontinence spreads. Nowhere in
the world has the crime of birth control been practised as in
France nor for a longer time, and in that country together
with the lowest birth rate in the world there is the highest
death rate from venereal diseases according to Dr. Dublin the
statistician of the New York Metropolitan Life Insurance
Company. Not long ago one of the leading medical writers
of France, Doyen, said in the Academy of Medicine in Paris
that syphilis is the chief cause of death in France. France
now asserts she has given over birth control, but that is a hard
disease to cure after it has been established. Unchastity is its
own punishment, and if France goes the way of those nations
that have died along the pathway of civilization, and great

280 THE ETHICS OF MEDICAL HOMICIDE

•would be the pity, she has nothing to blame for it but this
abominal moral leprosy, birth control. She is as striking an
example of the insanity of birth control as Kussia is of the
insanity of communism.

INDEX

Abnormal pelves, 133, 134 135
Abortion, 91

after fifth month, 102

agents of, 117

American law on, 119

causes of, 92

civil law on, 121

Council of Lerida on, 115

Council of Worms on, 115

decretal of Gregory on, 115

direct, 109

excommunication for, 116, 117

Gregory XIV on, 116

habitual, 98

Holy Office decrees on, 118

homicide in, 110

incomplete, 101

inevitable, 101

irregularity and, 117

morality of, 109-114

morphine in, 101

paternal causes of, 95

Pius IX on, 116

precautions against, 105, 106

prognosis after, 100

sepsis after, 105

SLxtus V on, 115

statistics of, 97, 98

symptoms of, 99

syphilis and, 107

tampon, use of, 103

therapeutic, 107, 109

threatened, 99

treatment of, 102

violence and, 94
Abruptio placentae, 144

causes of, 144

effects of, 144
Acute yellow atrophy of the liver,

186

Aggressor, 17, 19
Amnion, 52
Amphiaster, 44
Anaesthesia and the fetus, 93
Analgine, 240

Animal heat, 71
Animal life, 48
Animation, 33, 39

Aristotle on, 39

biologists on, 49

Conklin on, 73

Fienus on, 35

Greek fathers on, 33

Greek philosophers on, 33

St. Alphonsus on, 39

St. Anselm on, 35

St. Augustine on, 34

St. Gregory of Nyssa on, 35

St. Thomas on, 35

Zacchias on, 36

Aortic stenosis in pregnancy, 175
Apparent death, 82
Appendicitis in pregnancy, 152
Archenteron, 50
Artificial impregnation, 258
Attraction sphere, 40

Baer on twilight sleep, 240
Baptism of monsters, 80
Beginning of life, 33
Blameless defence, 18
Blastocyst, 50
Blastulas, 50

Braxton-Hicks version, 143
Bright's disease in pregnancy, 157
Broad ligament, 124

Cancers in pregnancy, 149

morality of operation, 150
Canonical irregularity, 23, 24, 25
Capital punishment, 31
Carrington's vasectomies, 248
Catalepsy, 85

in pregnancy, 160
Cell, 40

bridges, 60

differentiation, 67, 68

division, 41, 42

heredity, 45

life, 48

281

282

INDEX

Cell, motion, 70

reduction, 45

union, 65, 66
Centrosome, 40
Cesarean delivery, 132

amputation of the uterus after,
138

indications for, 132

morality of, 136, 137

repeated sections, 140

sterilizations and, 139, 140, 141
Chemico-vital changes, 70, 71
Cholera in pregnancy, 195
Chorea gravidarum, 181
Chorion, 51
Chromosome, 42

numbers of, 43
Chromatin, 41
Circumstances, 3

Citizen as member of the State, 31
Coelom, 51

Coition in gestation, 95, 96, 97
Congenital tuberculosis, 189
Conscience, 12

Constitution Effraenatam, 115
Contingent being, 1
Contracted pelves, 133
Craniotomy and excommunication,
117

DammerscJilaf, 231
Death, signs of, 89, 90
De Lugo on the State, 31
Development of the body, 56
Diagnosis, percentage of correct,

21

Diabetes in pregnancy, 229
Differentiation by position, 68, 69
Division, direct and indirect, 42
Double effects, 18, 26
Double monsters, 78, 79
Dry labor, 109

Eclampsia parturientium, 161

abortion in, 165

expectant treatment of, 166

forced delivery in, 165

mortality, 163, 168

Lichtenstein's method in, 166

precautions against, 164

symptoms of, 161

veratrum viride in, 167
Ectoderm, 50

derivatives of, 51

Ectopic gestation, 123

decrees of the Holy Office on,
128, 129

diagnosis of, 126, 127

morality of operations, 129, 130
Effects of an action, 6
Egg shell, 47
Embryo, 33

growth of, 50

stages of, 52
End of an action, 4
End of life, 82
Endoderm, 50
Endomclritis, 93
Eutelechy, 60

Erysipelas in pregnancy, 196
Eunuchs, 255, 256
Euthanasia, 1

Fallopian tubes, 123
Fecundation, 124
Fetus, 33

and the dead mother, 87

at term, 54

months, 53, 54, 55

stages, 53
Fibrillation, 174
Fibroids, 146
Fission theory, 77
Form, 60

Gemmule theory, 58
Germ cells, 44
God's existence, 2
Gonorrhoea in marriage, 211

abortion and, 224

blindness and, 226

conservative surgery for, 217

effects, 212, 213, 215, 216, 225,
226

operations for, 216

professional secret and, 212

tests of cure, 211

treatment by heat, 228
Good, 3
Grippe, 194

Happiness, 2

Hastening of death, 111

Hebosteotomy, 135

Heart beat, 83

Heart block, 173

Heart diseases in labor, 172, 174

Heart diseases in pregnancy, 169

283

Heart diseases in pregnancy,

Mayo clinic on, 173
Heart, origin of, 52
Homicide, 13

accidental, 19

arguments against, 14, 15, 16, 17

bibliography of, 22

direct and indirect, 13

self-defence and, 17, 18, 19
Human terata, 78
Hyperemesis gravidarum, 176
Hysteria,

imitative, 183

major and minor, 184

marriage and, 185

in pregnancy, 181, 182, 183

Icterus gravis, 186
Impotence, 258

opinions on, 252
Infectious diseases in pregnancy,

188

Influenza in pregnancy, 194
Insanity,

puerperal, 154

spread of, 266

Kant on morality, 29
Karyokinesis, 41

La grippe in pregnancy, 194

Law, definition of, 28

Life in separated tissues, 73, 74

Malaria in pregnancy, 196

Male generative system, 248

Male pronucleus, 49

Maniacal chorea, 182

Marriage, end of, 254

Mayhem, 23

Means of an action, 5

Measles in pregnancy, 195

Mesoderm, 50

Metabolism of the cell, 69, 70, 72

Metaphases of mitosis, 44

Midwives, 138

Mignonette case, 113

Mitosis, 41

Miscarriage, 91

Mitral regurgitation in pregnancy,

174
Monsters, 75

by displacement, 78

multiple, 76

Morality, 3

determinants of, 3
Morphine,

effects on fetus, 234

effects in labor, 234, 235
Morula, 50
Mutilation, 23

argument against, 26, 27

argument for, 27

civil law on, 23

direct and indirect, 26

Molina on, 24

St. Alphonsus on, 25

State and, 28, 29, 30, 31, 32

self-mutilation, 26

Suarez on, 24
Myomata in pregnancy, 146

effects of, 147

fetus and, 148

mortality of, 147

Natural law, 2, 12
Necessary being, 1
Nephritis in pregnancy, 157

treatment of, 158

varieties of, 158
Nervous system, 51
Nucleus, 40, 46

Object of an action, 3
Onanism, 256

Operations during pregnancy, 94
Operative risk in cardiopaths, 173
Ophthalmia neonatorum, 226, 227,

228
Organs, origin of, 51

of the body, 64
Ovaries,

removal of, 218, 223

resection of, 221

Ovarian tumors in pregnancy, 148
Ovarian, 247
Ovariotomy,

decrees of the Holy Office on,
252, 253

effects of, 219

impotence and, 252, 254, 255

psychoses after, 219, 220, 221
Ovum, 33, 47
Oxidation, 72

Pangens, 68
Paresis, 204
Parturition, 169, 231, 232, 233

284

INDEX

Partus cesamis, 132
Pathogenesis, 48, 49
Pelvic diameters, 132
Penal law, 31

Pernicious vomit of pregnancy,
176

abortion for, 180

causes and symptoms, 177

diagnosis of, 179

treatment, 179
Pituitrin, 170
Placental infection, 188
Placental osmosis, 189
Placenta praevia, 142
Plastid, 40

Pneumonia in pregnancy, 192, 192
Polak's operation on the tubes, 222
Polar body, 46
Porro's operation, 136
Preformationists, 56
Premature infants, 55
Premature labor, 98, 108
Probabilism, 6
Prophases of mitosis, 44
Protoplasmic bridges, 67
Puerperal insanity, 154

prognosis, 155

sterilization and, 154
Pyelitis in pregnancy, 160

Quacks, 22

Resuscitation, 83, 84

methods of, 88
Right and wrong, 3
Rupture of Fallopian tube, 125

Sacraments in apparent death, 82
Salpingectomy, 217
Salpingostomy, 217
Salpingotomy, 217
Scarlatina in pregnancy, 195
Scopolamine, 233
Secrets, 206, 207
Segmentation cavity, 50
Segmentation nucleus, 49
Self-defence, 17, 18
Semen, 247
Sixtus V, bull of, 255
Smallpox in pregnancy, 191
Soul, 60

Spaltungstheorie, 76
Spermatozoon, 46, 47, 48
Spermin, 247

Spindle, 44
Spireme, 43
State,

citizen and, 30

dominion of, 28, 29

end of, 29

Sterilization of women, 251
Substantial form, 60, 62, 75
Suicide, 7

arguments against, 7-12
Suspended animation, 85
Syncytium, 52, 66
Symphyseotomy, 135
Syphilis,

abortion in, 200

curability of, 203

fetal, 201

incurability of, 204

marriage and, 205

nervous system affections, 204

pregnancy in, 200, 202

professional secret in, 206

Tabes, 204

Telophases in mitosis, 44

Terata, 75

Tetrads, 46

Tocanalgine, 240

Tonics, 48

Traducianism, 34

Trophoblast, 50

Tubal abortion, 125

Tuberculosis in pregnancy, 196,
197, 198

Tumors in pregnancy, 146

Tumors and premature labor, 109

Twilight sleep, 231

authorities opposed to, 238, 239
effects of, 240, 241, 242, 243
methods used, 235, 236, 237

Twins, 76

Two-celled stage of the embryo, 65

Typhoid in the fetus, 190

Typhoid in pregnancy, 196

Typhus in pregnancy, 196

Unity of the soul, 65
Uterine adnexa, 123
Uterus, abnormalities of, 124
anatomy of, 123

Vaccination, 191

Vas defercns, restoration of, 249,
250

INDEX

285

Vasectomy, 244

arguments against, 260-265

bibliography, 266, 267

bull of Sixtus V and, 255,

256

effects of, 248, 249
grave mutilation, 259
hereditary disease and, 264
impotence and, 251
morality of, 259
not a punishment, 263, 264
operation for, 247
reasons for the operation, 245,

246

Vasectomy, State and, 244
State surgeon and, 265

Venereal diseases,

prevalence of, 213, 214, 215

Verwachsungstheorie, 76

Viability of the fetus, 54, 114

Vital principle, 58, 61

Vital processes, 69

Weak pains, 171
Weismann's theories, 49, 56

Yellow atrophy of the liver, 186
Yolk sac, 52

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