To say that marriage is also a licit remedy of concupiscence is no excuse. Marriage is such only in a secondary sense, and this secondary end is necessarily subordinate to the primary end, and coexistent with that primary end, which is the generation of children. Even when a surgeon is doing a Porro operation, his main intention may not be to sterilize the woman. He must directly intend to save her life by removing the infected uterus, and reluctantly permit the sterilization as an evil part of the double effect coming from the causal amputation. CHAPTER VIII PLACENTA PRAEVIA AND ABRUPTIO PLACENTAE Cesarean delivery is used frequently of late in placenta praevia. It may be necessary also in abruptio placentae, gunshot wounds of the abdomen during pregnancy, sometimes in appendicitis complicating gestation, rarely in prolapse of the cord to save the child, and when twins become interlocked in delivery. Placenta praevia is a development of the placenta in that part of the uterus which dilates at the end of gestation or during delivery. This dilatation, with the mechanical pressure of the child, detaches the placenta enough to cause a hemorrhage which may be fatal to the woman if not checked. The hemorrhages begin sometimes as early as the sixth month of gestation, but most frequently in the eighth month. Premature labor is a common effect. The position of the placenta may cause malposition of the fetus, prolapse of the cord, weak pains, air embolism into the blood, rupture of the uterus, sepsis, profound anemia, and other evils. The child may be premature, puny, have collapsed lungs, hemorrhages, and it is very likely to be killed in delivery. The mortality of the women varies, but it averages about 7 per cent; that of the children averages 61 per cent. The tendency with obstetricians is to deliver the child as soon as the diagnosis has been made. When the bleeding is slight, and the child is viable, one may delay delivery provided the woman will remain in bed in a good maternity hospital without moving. At home the woman may "flood" and bleed to death before a physician can reach her. If the woman refuses to go to a hospital, and to permit the induction of labor, any physician who has regard for his own reputation will drop the case and leave the woman to her own devices.