We cannot give a general mortality average for myomata in pregnancy because only bad cases are reported, but in bad cases the mortality is very high--50 per cent. for the mother and about 60 per cent. for the children, with almost 30 per cent. of abortions. The majority of women who have myomata go on to delivery without trouble. In some there is much pain or hemorrhage, and these conditions may finally oblige the obstetrician to operate, but the operation should be deferred as long as possible. Where there are signs of necrosis of the tumor, operation is necessary at once to prevent sepsis. Removal of a myoma during pregnancy does not always cause abortion. The statistics are that about 83 per cent. of those operated upon are removed without abortion. In the Mayo Clinic[114] fourteen cases of degenerating fibroids in pregnant wombs were removed and the majority went on to term. The removal is always a very bloody operation, and it requires great surgical skill. Where enucleation of the tumor alone was intended it may finally become necessary to amputate the uterus to stop hemorrhage. [114] _Ibid._ When the case has gone on to labor at term the diagnosis as to position and size of the tumor is to be made, and what the effects will be as to blocking the canal or crushing the tumor so as to bring on sloughing. If a tumor blocking the canal cannot be pushed up out of the way of the child, a cesarean section should be done immediately. In such an outcome as section the experience of the operator must decide whether the tumor is to be removed then or at a more favorable opportunity. It may be necessary to do cesarean section to liberate an incarcerated placenta. Sometimes the fetus is so involved with a gangrenous myoma that enucleation of the tumor will kill or hasten the death of the fetus. When, in such a complication, it is evident that the life of the woman depends on the immediate removal of the tumor, yet a second but evil effect follows from the operation, namely, the unavoidable death of the fetus, the removal is morally licit provided the operator has the proper intention. The death of the child as an effect in this case is only indirectly voluntary from the physical point of view, and only permissively voluntary from the moral aspect.[115] [115] Cf. Ferreres, _Nouvelle Revue Théologique_, September and October, 1912, and the appendix of his book _De Vasectomia Duplici_, Madrid, 1913.