{"collection":"scripture-revelation","full_text_available":true,"graph_url":"https://unchartedknowledge.5gfusion.net/v2/api/page/gutenberg_39036/graph","html_url":"https://unchartedknowledge.5gfusion.net/v2/page/gutenberg_39036","id":"gutenberg_39036","license":"Public Domain (US)","rights_basis":"gutenberg_metadata_copyright_false","source":"gutenberg","source_url":"https://www.gutenberg.org/ebooks/39036","summary":null,"tags":["Category: Health & Medicine","Category: Philosophy & Ethics","Category: Religion/Spirituality","First aid in illness and injury","Medicine"],"text":"Produced by Don Kostuch\n\n\n\n\n[Transcriber's notes]\n  This is derived from the Internet Archive:\n   http://www.archive.org/details/essaysinpastora00walsgoog\n\n  Page numbers in this book are indicated by numbers enclosed in curly\n  braces, e.g. {99}. They have been located where page breaks occurred\n  in the original book.\n\n  Obvious spelling errors have been corrected but \"inventive\" and\n  inconsistent spelling is left unchanged.\n\n[End Transcriber's notes]\n\n\n{iii}\n\n\nESSAYS IN PASTORAL MEDICINE\n\n\nBY\n\n\nAUSTIN OMALLEY, M.D., Ph.D., LL.D,\n\nPATHOLOGIST AND OPHTHALMOLOGIST\nTO SAINT AGNES'S HOSPITAL\nPHILADELPHIA\n\nand\n\nJAMES J. WALSH, M.D., Ph.D., LL.D.\n\nADJUNCT PROFESSOR OF MEDICINE AT THE NEW YORK POLYCLINIC SCHOOL\nFOR GRADUATES IN MEDICINE; PROFESSOR OF NERVOUS\nDISEASES AND OF THE HISTORY OF MEDICINE\nFORDHAM UNIVERSITY, NEW YORK\n\n\n\nLONGMANS, GREEN, AND CO.\n\n91 AND 93 FIFTH AVENUE, NEW YORK\n\nLONDON AND BOMBAY\n\n1906\n\n{iv}\n\n_Copyright, 1906_\n\nBy Longmans, Green, and Co.\n\n_All rights reserved._\n\n\n\nTHE UNIVERSITY PRESS, CAMBRIDGE, U. S. A.\n\n\n\n\n\n\n{v}\n\nPREFACE\n\nThe term Pastoral Medicine is somewhat difficult to define because it\ncomprises unrelated material ranging from disinfection to foeticide.\nIt presents that part of medicine which is of import to a pastor in\nhis cure, and those divisions of ethics and moral theology which\nconcern a physician in his practice. It sets forth facts and\nprinciples whereby the physician himself or his pastor may direct the\noperator's conscience whenever medicine takes on a moral quality, and\nit also explains to the pastor, who must often minister to a mind\ndiseased, certain medical truths which will soften harsh judgments,\nand other facts, which may be indifferent morally but which assist him\nin the proper conduct of his work, especially as an educator. Pastoral\nmedicine is not to be confused with the code of rules commonly called\nmedical ethics.\n\nThe material of pastoral medicine requires constantly renewed\ndiscussion, because medicine in general is progressive enough\nfrequently to devise better methods of diagnosis and treatment, and\nthus the postulates of the moral questions involved are changed. This\ndiscussion, however, is not easily made. The facts upon which the\nethical part of pastoral medicine rests are furnished by the physician\nfor the consideration and judgment of the moralist--the physician\neducated after modern methods knows little or nothing of ethics and\ncan not himself make accurate moral decisions. The moralist, on the\nother hand, is commonly a poor counsellor to the physician, because\nlong training in medicine is needed before the physical data of the\nmoral decisions is comprehended. The physician, therefore, is at a\nloss to determine what he may or may not do in {vi} cases that involve\nthe greatest moral responsibility, and the priest is a hesitating\nguide because the moral theologies do not convincingly present the\ndoctrine in these cases.\n\nNow and then such subjects have been proposed for discussion to a\ngroup of physicians and moralists, but usually no practical conclusion\nhas been reached because one side did not understand the other. In\n1898 there was a series of articles on ectopic gestation in the\n_American Ecclesiastical Review_, in which moralists like Lehmkuhl,\nSabetti, Aertnys, and Holaind, and some of the leading gynaecologists\nof America considered the questions but arrived at no decision. The\nphysicians did not understand certain questions, other questions were\non obsolete medical practice, essential questions were omitted, and\nfrom the data the moralists came to opposed conclusions.\n\nWe find also in moral theologies deductions drawn from false medical\nsources. Reasons are given, for example, to justify the use of a large\nquantity of alcoholic liquor at a dose in cases of great pain, typhoid\nfever, snake-poisoning, and other diseases, in the supposition that\nsuch doses will benefit or cure the patient, whereas the physician\nthat would follow that treatment would be guilty of malpractice. There\nwas recently in America a discussion on the relation of oeophorectomy\nto the _impedimentum impotentiae_. One side held that a lack of\novaries constitutes impotence; the other side, that it does not. The\ndiscussion was useful because it incidentally gathered the full\ndoctrine of the moralists on this subject, but from the medical point\nof view there is no connection whatever between these conditions.\n\nA small number of books on pastoral medicine have been written by\nclergymen that were not physicians, and a few German books by\nphysicians that were also moralists. Those by the physicians draw\nconclusions from antiquated medical practice, or they are mere popular\ntreatises on hygiene; those by the clergymen have some value on the\nethical side, but they are incomplete because the authors had not the\nnecessary medical knowledge. The essays offered in this book by no\n{vii} means cover the entire field of pastoral medicine, but as far as\nthey go we have endeavoured to offer the medical doctrine of the\npresent day on the questions considered, and that as completely as is\nnecessary to draw the moral inferences.\n\nSince, then, so many of the questions of pastoral medicine are not\ndefined, physicians are likely to follow the doctrine of the standard\nmedical books, which without exception advise them to take the life of\na dangerous foetus almost as unconcernedly as they might prescribe an\nactive drug, or in any case to put utility before justice. There is,\ntherefore, an urgent necessity that competent men fix that shifting\npart of ethics and moral theology called pastoral medicine, and these\nessays are presented as a temporary bridge to serve in crossing a\ncorner of the bog until better engineers lay down a permanent\ncauseway.\n\nSome may think that the authors are inclined toward an exaggerated\ncharity in suggesting the measure of responsibility for many human\nactions, but the physician that is brought much in contact with those\nsuffering from mental defects of various kinds soon learns how easily\ncomplete responsibility becomes marred. Responsibility is dependent\nentirely upon free will; and while the great principle of free will\nremains solid in truth, no two men are free in exactly the same\nmanner. Physical conditions have not a little to do with modifications\nof freedom of the will. To point out this fact to the clergyman and\nthe physician has been our intention, for a proper appreciation of it\nwill widen the bounds of charity and save many that are more sinned\nagainst than sinning from the injury of grievous misjudgment. It is\nbetter to run the risk of exculpating a few individuals whose\nresponsibility is not entirely clear when the application of the same\nprinciples lifts many others above the rash judgment of those that can\nbe of most help to them.\n\n{viii}\n\n{ix}\n\nCONTENTS\n\n_The Authorship of the respective Essays is indicated by the signature\nat the end of each Essay_.\n\nChapter               Page\n\nI. Ectopic Gestation 1\n\nII. Pelvic Tumours in Pregnancy 40\n\nIII. Abortion, Miscarriage, and Premature Labour   48\n\nIV. The Caesarean Section and Craniotomy   55\n\nV. Maternal Impressions 60\n\nVI. Human Terata and the Sacraments 69\n\nVII. Social Medicine 88\n\nVIII. Some Aspects of Intoxication 105\n\nIX. Heredity, Physical Disease, and Moral Weakness 120\n\nX. Hypnotism, Suggestion, and Crime 129\n\nXI. Unexpected Death 135\n\nXII. Unexpected Death in Special Diseases   150\n\nXIII. The Moment of Death 164\n\nXIV. The Priest in Infectious Diseases 168\n\nXV. Infectious Diseases in Schools 187\n\nXVI. School Hygiene 202\n\nXVII. Mental Diseases and Spiritual Direction   211\n\nXVIII. Neurasthenia 230\n\nXIX. Hysteria 235\n\nXX. Menstrual Diseases 240\n\nXXI. Chronic Disease and Responsibility 245\n\n{x}\n\nXXII. Epilepsy and Responsibility 251\n\nXXIII. Psychic Epilepsy and Secondary Personality  259\n\nXXIV. Impulse and Responsibility 266\n\nXXV. Criminology and the Habitual Criminal  271\n\nXXVI. Paranoia, a Study in Cranks 282\n\nXXVII. Suicides 306\n\nXXVIII. Venereal Diseases and Marriage 311\n\nXXIX. Social Diseases 317\n\nXXX. De Impedimento Matrimonii Dirimente Impotentia 326\n\nAPPENDIX. Bloody Sweat 347\n\nINDEX 357\n\n{1}\n\nESSAYS IN PASTORAL MEDICINE\n\n\nI\n\nECTOPIC GESTATION\n\n\nEctopic gestation is gestation in the uterine adnexa, the peritoneal\ncavity, or the horn of an abnormal or rudimentary uterus. It is\nopposed to natural uterine gestation, and, since it includes pregnancy\nin an abnormal uterus, it is a more comprehensive term than\nextrauterine pregnancy.\n\nIn this article the morality involved in the surgical treatment of\nectopic gestation is considered; and to have the data requisite for\njudgment it is necessary to describe in outline the anatomy of the\nuterine adnexa and the growth of the foetus; to explain the varieties,\neffects, diagnosis, and treatment of ectopic gestation; to present the\ncases of this condition, or rather this disease, as they occur in\nmedical practice; to set forth some of the moral principles or laws\nthat govern medical practice, especially where there is question of\nlife and death; and finally to apply these principles to the cases\noffered for investigation.\n\nThe uterus is in the pelvic cavity, between the bladder and the rectum\nand above the vagina, into which it opens. It is a hollow,\npear-shaped, muscular organ, somewhat flattened, and about three\ninches long, two inches broad, and one inch thick. The base or fundus\nis upward, and the neck is downward. Passing out horizontally from the\ncorners or horns of the uterus, which are at its base, are the two\nFallopian Tubes, one on either side. These are about five inches in\nlength and somewhat convoluted. They are true tubes, opening into the\nuterus, and they are about one-sixteenth of an inch in diameter along\nthe greater part of their extent The ends farthest {2} from the uterus\nare fringed and funnel-shaped; and this funnel-end, called the\nInfundibulum or the Fimbriated Extremity, opens into the abdominal or\nperitoneal cavity. Near the Fimbriated Extremity of each tube is an\nOvary,--an oval body about one and a half inches long by\nthree-quarters of an inch in width.\n\n\n  [Illustration]\n  The Uterus and its Adnexa\n\n  _F U_, Fundus or Base of the Uterus. _F T, P T_, Fallopian Tubes. On\n  the left of the reader the Fimbriated Extremity of the tube is\n  lifted up to show it. _O, O_, Ovaries. _B L, B L_, Broad Ligament.\n  _R_, Rectum. _B_, Bladder.\n\n\nFor convenience in description, each tube is divided into four parts:\n(1) the Uterine Portion, which is that part included in the wall of\nthe uterus itself; it extends from the outer end of the horn into the\nupper angle of the uterine cavity, and its lumen is so small it will\nadmit only a very fine probe; (2) the Isthmus, or the narrow part of\nthe tube which lies nearest the uterus; it gradually opens into the\nwider part called (3) the Ampulla; (4) the Infundibulum, or the\nfunnel-shaped end of the Ampulla. This part is fimbriated, as has been\nsaid, and one of the fimbriae--the Fimbria Ovarica--which is longer\nthan the others, forms a shallow gutter which extends to the ovary.\n\n{3}\n\nThe uterus, tubes, and ovaries lie in a septum which reaches across\nthe pelvis from hip to hip. This septum is called the Broad Ligament.\nIf a man's soft felt hat, of the kind called a \"Fedora\" hat, is held\ncrown downward with one hand at the front and the other at the back of\nthe rim, it will represent the pelvic cavity, and the fold along the\ncrown of the hat coming up into this cavity is very like the Broad\nLigament. As the crown is held downward, the uterus would be in the\nmiddle, its fundus upward, and, of course, altogether outside the hat,\nbut in the crown fold. The tubes and ovaries would also be outside the\nhat and in the crown fold, and the fimbriated extremities would open\nby holes into the hat's interior.\n\nThe ovum breaks through the surface of the ovary, passes, probably on\na capillary layer of fluid, into the fimbriated extremity of the tube,\nand then is moved along slowly through the tube into the uterus.\nOvulation and menstruation occur about the same time, but often one\nantedates the other a few days. In exceptional cases they may occur\nindependently.\n\nIf the ovum produced is not fecundated, it gradually shrivels up, and\npasses off through the uterus and the vagina. Fecundation of the ovum\nrarely occurs in the uterus, but ordinarily in the Fallopian tube,\naccording to the general opinion of physiologists. After fecundation\nthe ovum is pushed on into the uterus in from five to seven days,\nwhere it fastens to the wall and develops. Hyrtl (_Kollmann's Lehrbuch\nder Entwickelungsgeschichte des Menschen_, Jena, 1898) speaks of a\ncase in which the ovum appeared to reach the uterus in three days. If\nthe fecundated ovum is blocked or held in the Fallopian tube, the\nembryo grows where the ovum stops, and we have a case of Ectopic\nGestation.\n\nThe average time of normal human gestation is ten lunar months or\nforty weeks. At the moment the pronucleus of the spermatozoon fuses\nwith the pronucleus of the ovum in the Fallopian tube and makes the\nsegmentation nucleus, in my opinion, the soul of the child enters, and\npersonality exists as absolutely as it does in a child after birth. It\nis as much a murder, as such, to unjustly destroy this microscopic\nfecundated ovum as it is to kill the child after birth. This is the\nopinion of every embryologist I have consulted on the {4} subject,\nwith the exception of one who said he did not know when the soul\nenters.\n\nTechnically the product of conception is called the Ovum for the first\ntwo weeks of pregnancy; during the third and fourth weeks it is called\nthe Embryo, and after the fifth week the Foetus. During the fourth\nweek the embryo begins to draw nourishment from the maternal blood\nthrough its umbilical vessels, but before that time it obtains\nnourishment by osmosis.\n\nThe foetus at the end of the eighth week is about one inch in length;\nat the end of the fourth lunar month it is from four to six inches\nlong, and its sex may be distinguished. At the end of twenty-four\nweeks, if the normal foetus is born it will attempt to breathe and to\nmove its limbs, but it dies in a short time. At the end of\ntwenty-eight weeks of gestation if it is born it moves its limbs\nfreely and cries weakly. It is nearly fifteen inches in length and\nweighs about three pounds. Such an infant might be deemed viable, but\nits chances for life are extremely precarious, even in most expert\nhands and with the help of an incubator. At the end of thirty-two\nweeks of gestation a foetus if born may be raised with skilful care,\nbut the chances are not promising. It is viable. At the end of forty\nweeks the child is at term.\n\nIn 1876 Parry collected 500 cases of extrauterine pregnancy from\nmedical literature, but when Tait in 1883 first operated on a case of\nruptured tubal pregnancy attention was called to the subject. It was\nbetter understood as coeliotomies (opening the abdomen) became common,\nand in 1892 Schrenck collected 610 cases that had been reported during\nthe preceding five years. Kuestner alone has operated on 105 cases in\nfive years.\n\nThere has been much discussion among physicians as to the causes that\narrest the fertilized ovum in the tube, but whatever these causes may\nbe they do not affect the moral questions which come up in this\narticle. There may be mechanical obstruction from peritoneal\nadhesions, or abnormal conditions resulting from inflammatory diseases\nof the tubes, ovaries, and the pelvic peritoneum, but no general cause\nthat will explain all cases can be ascribed.\n\n{5}\n\nTait denied the possibility of Ovarian Pregnancy, or a pregnancy where\nthe ovum fastened to the ovary itself and developed there, but five\nfully established cases of this kind have been reported. Dr. J.\nWhitridge Williams, professor of Obstetrics at the Johns Hopkins\nUniversity, in his textbook on Obstetrics (New York, 1903), collects\ntwenty-five cases of ovarian pregnancy, where five cases are certain\ndiagnoses, thirteen highly probable, and seven fairly probable. In\nthese twenty-five cases ten foetuses reached full term, but four of\nthe five certain cases ruptured at early periods.\n\nIt was formerly thought that primary abdominal pregnancy is quite\ncommon; that is, that the ovum is implanted on some organ within the\nabdomen itself, apart from the uterine adnexa. This is now looked upon\nas very doubtful, and such cases are probably secondary; that is,\nsecondary to a pre-existing tubal pregnancy which has ruptured without\ngreat maternal hemorrhage and let the foetus grow within the\nperitoneal cavity.\n\nThe common form of extrauterine pregnancy is the Tubal Pregnancy. The\novum may be stopped in any one of the three parts of the tube, and we\nfind Interstitial, Isthmic, or Ampullar Pregnancy. From these primary\ntypes, by rupture, secondary forms sometimes arise,--Tubo-abdominal,\nTubo-ovarian, and Broad-ligament Pregnancy.\n\nThe interstitial form, that is, where the ovum is arrested in that\npart of the tube which passes through the wall of the uterus itself,\nis the rarest of the tubal pregnancies. Rosenthal (_Ein Fall\nintranturaler Schwangerschaft. Centralbl. f. Gyn._ 1297-1305) found it\nin only three per centum of 1324 cases of tubal pregnancy. Some deem\nthe Isthmic variety the commonest. Dr. Howard Kelly (_Operative\nGynaecology_) says he never met a case of Interstitial or Ovarian\npregnancy in his practice. The interstitial form is especially liable\nto rupture with suddenly fatal hemorrhage.\n\nAbout one-fourth of the cases of tubal pregnancy end within the first\ntwelve weeks by rupture of the Fallopian tube. If the embryo is\nimplanted in the interstitial end of the tube, the rupture (into the\nuterus, or into the abdominal cavity, or into the broad ligament)\ntakes place later,--about the fourth month, or even considerably after\nthat time. The reason for {6} the delay here is that the uterus grows\nwith the foetus. If the foetus breaks into the uterus (a very rare\noccurrence), it is either expelled through the vagina almost\nimmediately or it goes on like a normal pregnancy.\n\nTait was of the opinion that every case of tubal pregnancy results in\na rupture of the tube not later than the twelfth week, but this\nopinion is no longer held. Very rarely a tubal pregnancy goes on\nwithout rupture to full term, as in the cases reported by Williams,\nSaxtorph, Spiegelberg, Chiari, and a few others.\n\nThree-fourths, about seventy-eight per centum, of the cases of tubal\npregnancy result in what is technically called \"tubal abortion\"\ninstead of rupture. In tubal abortion the connection between the\nembryo and the tube-wall is broken by effusion of blood. If the\nseparation is complete the effused blood pushes the embryo out through\nthe fimbriated end of the tube into the abdominal cavity, and then the\nhemorrhage of the mother commonly ceases. Such an extrusion of the\nfoetus is called a complete tubal abortion. If the connection between\nthe foetus and the tube-wall is only partly severed, the ovum remains\nin the tube, and the maternal hemorrhage goes on. This is called\nincomplete tubal abortion.\n\nIn incomplete tubal abortion the maternal blood may slowly trickle\nfrom the fimbriated extremity of the tube into the abdominal cavity,\nbecome encapsulated, and thus form an haematocele. If the fimbriated\nextremity of the tube is blocked, the blood accumulates in the tube\nand makes an haematosalpynx.\n\nIn complete tubal abortion the foetus dies; in incomplete tubal\nabortion the viability might depend on the injury done the placenta,\nbut in almost every case of even incomplete tubal abortion the foetus\ndies as a result of its separation from the tubal wall, or from\ncompression after the bleeding.\n\nIn cases of rupture of the tube in extrauterine pregnancy, if the\nfoetus with its attachments is expelled from the tube into the\nperitoneal cavity or into the broad ligament, the embryo dies.\n\nIf the foetus or embryo itself alone is expelled into the abdominal\ncavity and the placenta remains attached to the wall of the tube and\ncommunicates with the foetus by the umbilical cord which runs through\nthe tear in the tube, the foetus may {7} possibly live, provided the\nmother does not die from hemorrhage. If the foetus goes on growing in\nthis case, we have an abdominal pregnancy. One such case is reported\nby Both where a fully developed foetus was found in the abdominal\ncavity even lacking all its membranes, which had been left in the\ntube, but a foetus will not live apart from its membranes within the\nmaternal body.\n\nWhen an embryo or foetus ruptures the tube and goes into the broad\nligament, it may live or die according to the injury done its\nattachments to the tubal wall, but it ordinarily dies. Sometimes such\na broad-ligament pregnancy ruptures again into the abdominal cavity.\nBecause the bleeding is more likely to be confined within the folds of\nthe broad ligament, the immediate danger of maternal death from\nhemorrhage is less in this than in other forms of rupture.\n\nConcerning tubo-abdominal pregnancy the only remark to be made is\nthat, owing to adhesions, it is often surgically difficult to remove\nsuch a growth.\n\nIf the foetus is expelled after rupture into the peritoneal cavity it\ndies, and if the hemorrhage does not kill the mother the dead foetus\nif small is absorbed; if large it becomes mummified, or it hardens\ninto a lithopoedion, or it turns into a yellowish greasy mass called\nadipocere, or it putrefies. A lithopoedion may be carried for years.\nThere are more than thirty cases reported which were carried from\ntwenty to thirty years in the abdomen, and one case where a\nlithopoedion was carried for fifty years.\n\nIf the foetus putrefies it causes fatal septicaemia in the mother, or\na perforating abscess, unless it is successfully removed.\n\nThere are various abnormalities of the uterus, and in these pregnancy\nresembles in effect extrauterine pregnancy. An abnormal uterus may be\nunicornis, didelphys, pseudodidelphys, bicornis duplex, bicornis\nseptus, bicornis subseptus, bicornis unicollis, or bicornis unicollis\nwith a rudimentary horn. The impregnated ovum may fasten in the\nrudimentary horn and be blocked there; then the usual result is\nrupture within the first four months, with fatal hemorrhage unless the\nbleeding is immediately checked by coeliotomy and ligation.\n\n{8}\n\nAs to diagnosis in Ectopic Gestation, Williams (_op. cit._), one of\nthe authorities at present on the subject, says: \"A positive diagnosis\nis occasionally made before rupture, but in the vast majority of cases\nthe condition escapes recognition until symptoms of collapse point to\nthe probability of rupture or abortion. In advanced cases careful\nexamination will usually disclose the real condition of affairs, and\nwhen full term has been passed the history is so characteristic that\nmistakes should hardly occur.\"\n\nIn the _American Ecclesiastical Review_ for January, 1898 (vol. ix.,\nn. i), Father Rene I. Holaind, S. J., published the answers of many\nphysicians to six questions concerning extrauterine pregnancy. Among\nthese physicians were Thomas Addis Emmet, Barton Cooke Hirst, Howard\nA. Kelly, W. T. Lusk, T. Galliard Thomas, Mordecai Price and his\nbrother Joseph Price, William Goodell, and Lawson Tait,--all eminent\nauthorities on this subject. The second question submitted was:\n\"During pregnancy, at what time and by what means can a differential\ndiagnosis be made between _intra_ and _extra-uterine_ pregnancy, and\nbetween abnormal gestation and pelvic or other tumour?\"\n\nIn answer to this question Dr. Emmet said: \"There can be no absolute\ncertainty as to the existence of pregnancy in any case until the\npulsation of the foetal heart can be detected. [After the eighteenth\nor twentieth week of gestation.] . . . A diagnosis is difficult in all\ncases of abnormal pregnancy, but an expert can, within a reasonable\ndegree of certainty, arrive at a knowledge of the existing conditions\nbetween the second and third month.\"\n\nDr. Hirst said: \"In almost all cases of advanced gestation the\ndifferential diagnosis can be made. In early cases it is not always\npossible unless conditions be favourable.\"\n\nDr. Howard A. Kelly said: \"The differential diagnosis between intra\nand extrauterine pregnancy can usually be made from the sixth week up\nto the end of pregnancy. It is more easily made from the tenth to the\ntwelfth week on.\" Writing in the _American Text Book of Obstetrics_\n(Philadelphia, 1896), he says: \"In the atypical cases, on the\ncontrary, a positive diagnosis is often difficult or even impossible.\n. . . {9} The diagnosis of ectopic gestation after the death of the\nfoetus is largely dependent upon the clinical history; if this be\ndeficient, the diagnosis is frequently impossible.\"\n\nDr. Lusk said: \".... The frequent discovery of the dead ovum in a tube\nwhen there has been no suspicion of pregnancy shows the difficulty of\na diagnosis.\" In his text-book (_The Science and Art of Midwifery_,\nNew York, 1890) is this remark: \"Sometimes the diagnosis can only be\ndecided by the introduction of the sound or a finger into the uterus,\nthe physician assuming the risk of premature labour, should he find\nhis supposition of extrauterine pregnancy an error.\" This means that\nsometimes the diagnosis is impossible without running the risk of\ncausing abortion of a normal uterine pregnancy.\n\nDr. Thomas said, \"After the second month the diagnosis is perfectly\npossible.\" This was also the opinion of Dr. Mordecai Price; and Dr.\nJoseph Price holds that the diagnosis can be made \"after the third\nmonth, by exclusion.\" Dr. John F. Roderer, quoting Lawson Tait, says\nthat \"the diagnosis between intra and extrauterine pregnancy can not\nbe made with certainty before rupture, nor can it be determined\nexactly whether an enlargement of the tube is either an ectopic\npregnancy or some form of tumour.\"\n\nDr. Goodell's opinion was, \"A differential diagnosis can rarely be\nmade positively at any stage of extrauterine pregnancy.\"\n\nThe diagnosis, then, is difficult; and for the ordinary practitioner,\nthe average physician, who does perhaps ninety-five per centum of the\nmedical work of the world, the diagnosis is often impossible. There is\nno greater expert than Dr. Thomas Addis Emmet, and he says the\ndiagnosis is difficult. Others hold that the diagnosis can be clearly\nmade, and they speak truly as regards themselves, but ordinary skill\nfinds the diagnosis almost impossible in many cases. Mordecai Price\n(_The Pennsylvania Medical Journal_, vol. viii. p. 223) in one year\nsaw four cases which he and other physicians diagnosed as ectopic\npregnancies with rupture of the tube. When the abdomen had been\nopened, uterine pregnancy was discovered with a ruptured tube in each\ncase, and all the women died.\n\n{10}\n\nThe first positive diagnosis of unruptured tubal pregnancy was made by\nVeit in 1883, and the first one made in America was by Janvrin in\n1886, eight years before Father Holaind's article was written. Before\n1883, only eleven years in advance of the same article, when Lawson\nTait performed the first coeliotomy for the purpose of checking\nhemorrhage from a ruptured tubal gestation, extrauterine pregnancy was\nas mysterious as the old \"inflammation of the bowels,\" which turned\nout afterward to be appendicitis. Hence common skill in the difficult\ndiagnosis of ectopic gestation can not be looked for.\n\nThe doctrine given in all the leading medical works at present\nconcerning the treatment of extrauterine pregnancy is this:\n\n  1. As soon as an extrauterine pregnancy is discovered remove the\n  foetus through an opening made in the mother's abdominal wall. Do\n  not use electricity or the injection of poisons into the foetal sac,\n  or the incandescent knife. Emmet and a few others approved of the\n  use of electricity at times, but this is against the teaching of the\n  great majority of writers at present. The reason for removing the\n  foetus at once is that it is apt at any moment to cause rupture and\n  fatal hemorrhage before surgical aid can be effective.\n\n  2. In a case of rupture with free hemorrhage and collapse the only\n  operation advised is an immediate coeliotomy to stop the bleeding by\n  ligatures. The rupture should not be approached through the vaginal\n  wall according to the common doctrine, but through the abdominal\n  wall.\n\n  3. If there is a rupture in which the bleeding is confined and there\n  is no collapse, do not operate at once unless the haematocele\n  increases steadily or shows signs of suppuration. Sometimes\n  evacuation of the haematocele through the vaginal wall is possible.\n\n  4. In the later months of an extrauterine pregnancy, whether the\n  case is intraligamentous or abdominal, perform coeliotomy as soon as\n  the diagnosis has been made, and remove the foetus, because there is\n  always danger of sudden and fatal hemorrhage before the surgeon can\n  reach the source of the bleeding. What is to be done in a case where\n  the surgeon is certain before operating that the foetus is {11}\n  dead, has interest only for the physician, and it involves no moral\n  question.\n\nOperating for extrauterine pregnancy maybe a simple coeliotomy, if any\ncoeliotomy is really simple, but it commonly is the most dangerous\noperation for the mother that the gynaecologist is called upon to\nperform.\n\nThe discussion of the moral questions that arise in cases of ectopic\ngestation which began in volume ix. of the _American Ecclesiastical\nReview_ was very valuable, but as the moralists had not full data to\nwork on their decision as a whole is not satisfactory. The original\ncases presented are in part obsolete in the medical practice of\nto-day, and important physical conditions were not disclosed in some\nof the other parts of the cases. Father Holaind tentatively agreed\nwith Father Lehmkuhl in one decision, Fathers Eschbach and Sabetti\ndirectly attacked Father Lehmkuhl's reasons, and Father Aertnys\nindirectly opposed Father Sabetti's chief argument. These men are all\neminent authorities, but as each, except Father Holaind, was\ndissatisfied with the arguments advanced by the others, and as their\ndata were incomplete, we can not rest the case on their decision.\n\nIn Father Holaind's fifth question, if I understand it correctly, he\nseemed to think it possible to baptize a foetus through the opening in\nthe mother's abdominal wall while it lies in the abdominal cavity\nbefore surgical removal. He mentions antiseptic precautions in the\nbaptism, which would have no meaning if the foetus were out of the\nabdomen.\n\nBaptism would not be possible in that case: the priest could not get\nat the foetus, he ordinarily could not even see it, and certainly no\nsurgeon would permit the attempt. There would be no time for the\nattempt in a rupture case, even if the foetus could be seen; and there\nwould be no advantage gained by baptizing the foetus in the abdominal\ncavity where the conditions gave time to do so. If it is alive it will\nlive long enough for baptism after removal from the abdomen, provided,\nof course, it is baptized immediately in the operating room. That it\ndoes not breathe is no proof of immediate death. It is not unusual for\na full-term child not to breathe for even an hour or longer after\nbirth.\n\n{12}\n\nIf Father Holaind had not in view baptism within the abdominal cavity,\nthe question has this meaning: What is the most effective method after\nthe foetus has been removed from the abdomen to open its enveloping\nmembranes so as to give it a chance for a life lasting long enough to\nallow baptism?\n\nThe best method is to slit the membranes with a scalpel or scissors as\nquickly as possible. The envelopes, cord, and placenta are essential\nparts of the foetus itself, and they grow from itself, not from the\nmother. They take the place of the lungs and the alimentary tract,\nwhich do not come into action until after normal birth. It would be\nworth discussing whether a baptism on the intact foetal envelopes is\nvalid, were it not that we may not apply probabilism in such a case.\nThe remaining matter brought out in Father Holaind's questions will be\nconsidered in the course of this article.\n\nBefore presenting the cases of ectopic gestation that occur in medical\npractice, the fundamental ethical principles that are to be applied in\njudging the morality of the surgeon's interference should be given.\n\nThe morality of any action is determined, (1) by the object of the\naction; (2) by the circumstances that accompany the action; (3) by the\nend the agent had in view.\n\n  1. The term _object_ has various meanings, but here it means the deed\n  performed in the action, the thing which the will chooses. That deed\n  by its very nature may be good, or it may be bad, or it may be\n  indifferent morally. In themselves to help the afflicted is a good\n  action, to blaspheme is a bad action, to walk is an indifferent\n  action. Some bad actions are absolutely bad, they never can become\n  good or indifferent (blasphemy or adultery, for example); others, as\n  stealing, are evil because of a lack of right in the agent: these\n  may become good by acquiring the missing right. Others are evil\n  because of the danger necessarily connected with their\n  performance,--the danger of sin connected with them, or the\n  unnecessary peril to life. An action to have the moral quality must\n  be voluntary, deliberate; and mere repugnance in doing an act does\n  not in itself make the act involuntary.\n\n  2. Circumstances sometimes, though not always, can add a {13} new\n  element of good or evil to an action. The circumstances of an action\n  are the agent, the object, the place in which the action is done,\n  the means used, the end in view, the method observed in using the\n  means, the time in which the deed is done. If a judge in his\n  official position tells a sheriff to hang a criminal, and a private\n  citizen gives the same command, the actions are very different\n  morally because of the circumstances of the agent giving the\n  command. The object--it changes the morality of the deed if a man\n  steals a cent or a thousand dollars. The place--what might be merely\n  a filthy action in a house might be a sacrilege in a church. The\n  means--to support a family by labour or by thievery. The end in\n  view--to give alms in obedience to divine command or to give them\n  to buy votes. The method observed in using means--kindly, say, or\n  cruelly. The time--to do manual labour on Sunday or on Monday. Some\n  circumstances aggravate the evil in a deed, some extenuate it.\n  Others may so colour a deed that they specify the deed, make the\n  action some special virtue or vice. The circumstance that a murderer\n  is the son of the man he kills specifies the deed as parricide.\n\nThe end also determines the morality of an action (see St Thomas,\n_Sum. Theol_. I. 2., q. xviii., a. 4 and 7). Since the end is the\nfirst thing in the intention of the agent, he passes from the object\nwished for in the end to choosing the means for obtaining it. Without\nthe end the means can not exist as such. There are occasions when an\nend is only a circumstance: for example, if it is a concomitant end.\nWhen an end is a, _finis extrinsecus operantis_, when it is in keeping\nwith right reason or discordant thereto, it may become a determinant\nof morality.\n\nIn every voluntary, or human, act there is an interior and an exterior\nact of the will, and each of these acts has its own object. The end is\nthe proper object of the interior act of the will; the exterior object\nacted upon is the object of the exterior act of the will; and as this\nexterior act specifies the morality, so does the interior\nobject--which is the end--specify it, and even more importantly than\nthe exterior object does.\n\nThe will uses the body as an instrument on the external {14} object,\nand the action of the body is connected with morality only through the\nwill. We judge the morality of a blow, not by the physical stroke, but\nfrom the intention of the striker. The exterior object of the will is,\nin a way, the matter of the morality, and the interior object of the\nwill, or the end, is the form. Aristotle (_Ethics_, lib. v., cap. 2)\nsays: \"He that steals that he may commit adultery, is, absolutely\nspeaking, more an adulterer than a thief.\" The thievery is a means to\nthe principal end, and it is this principal end that chiefly specifies\nor informs the action.\n\nThe means used to obtain an end are very important in a consideration\nof the morality of an act. There are four classes of means,--the good,\nthe bad, the indifferent, and the excusable.\n\nGood means may be absolutely good, but commonly they are liable to\nbecome vitiated by circumstances,--almsgiving is an example. Some\nmeans are bad always and inexcusable,--lying, for example. The\nexcusable means are those which are bad, but justifiable through\ncircumstances. To save a man's life by cutting off his leg is an\nexcusable means.\n\nThe existence of excusable means whereby some good actions are\neffected does not establish the assertion that the end justifies the\nmeans. The end sometimes may incriminate or sanctify indifferent\nmeans, but it does not in itself justify all means. The means, like\nother circumstances, are accidents of an action, but they are in an\naction just as much as colour is in a man. Colour is not of a man's\nessence, but you can not have a man without colour.\n\nThe effect of an action, the result or product of an effective cause\nor agency, may in itself be an end or an object or a circumstance, and\nit has influence in the determination of morality. Sometimes an act\nhas two effects, one good and the other bad; and that such an action\nbe lawful it is necessary (1) that the action itself be good or\nindifferent; (2) that the good effect be intended and the evil effect\nbe not intended (chosen) but only reluctantly permitted; (3) that the\nevil effect be not a means to secure the good effect; (4) that there\nbe present a motive sufficiently grave to excuse or counterbalance the\nbad effect. {15} St. Thomas (_Sum. Theol_. 2. 2. q. 64, a. 7) Speaking\nof killing a man in self-defence, says: \"Nihil prohibet unius actus\nesse duos effectus, quorum alter solum sit in intentione, alius vero\nsit praeter intentionem. Morales autem actus recipiunt speciem\nsecundum id quod intenditur, non autem ab eo quod est praeter\nintentionem, cum sit per accidens.\"\n\nThat an act, therefore, be morally good, or justifiable, (a) the whole\ntrain of the tendency of the will must be good; that is, (1) the\nobject, (2) the end, (3) and the circumstances must be good; or (b)\nthe intention should be good, and the remaining elements in the train\nof will-tendency are to be indifferent. That an act be morally bad it\nis enough that the object, the end, or the circumstances be\ninexcusably bad.\n\nThere may be honest doubt as to the existence of evil in the\ncircumstances or the end, and here enters the matter of probability;\nbut apart from this, some general rules of morality that govern all\ncases may be formulated:\n\n  1. An intention or end which is gravely evil always makes the entire\n  action evil and unjustifiable.\n\n  2. An intention or end which is slightly evil, if it is the entire\n  end of an action, makes the whole action evil but not gravely\n  evil--makes it, say, a venial sin and not a mortal sin.\n\n  3. If an intention or end which is venially evil accompanies\n  secondarily a good intention or end, and is rather a motive than the\n  real effective agent in attracting the will, this venial evil does\n  not vitiate the whole goodness or righteousness of the main action.\n  Compare the remarks made above in discussing an action that has a\n  double effect, partly good and partly bad.\n\n  4. Circumstances that are gravely evil practically vitiate the\n  entire action, but circumstances which are venially evil do not\n  always vitiate the entire action.\n\nMuch might be said here concerning conscience as a judge of the\nmorality in an act, but this discussion is not necessary for our\npresent purpose. Like other men, physicians often confuse conscience\nwith inclination, or at best with unfounded opinion. When conscience\nis to be a rule of action it must {16} have at the least moral\ncertitude; or, what is different but practically the same thing, the\nopinion of conscience must be at the least genuinely probable. The\nterm \"probable\" is used here in a technical sense, and it will be so\nused throughout the remainder of this article.\n\nThe doctrine of Probabilism is connected with the promulgation of law.\nA law, according to St. Thomas (_op. cit._ I. 2., q. 90, a. 4) is:\n\"Ordinatio rationis ad bonum commune ab eo qui curam habet\ncommunitatis promulgata.\" Sometimes it is not evident whether or not a\nlaw binds in a particular case, and in such a condition, that is, in\nwhich there is question solely of the existence, interpretation, or\napplication of a law, we may follow a probable opinion which assures\nus the act is licit, although the opinion which says the act is\nillicit may be just as probable or even more probable. This is the\nfundamental proposition of Probabilism, which is the doctrine\nespecially of St. Alphonsus Liguori, but it was held centuries before\nhis time. As the church has never condemned this doctrine, but rather\ntacitly approved of it, Catholics may safely follow it, and those that\nare not Catholics will find it very reasonable.\n\nA law which is doubtful after honest and capable investigation has not\nbeen sufficiently promulgated, and therefore it can not impose a\ncertain obligation because it lacks an essential element of a law.\nWhen we have used such moral diligence of inquiry as the gravity of a\nmatter calls for, but still the applicability of the law is doubtful\nin the action in view, the law does not bind; and what a law does not\nforbid it leaves open.\n\nProbabilism is not permissible when there is question of the worth of\nan action as compared with another, or of issues like the physical\nconsequences of an act. If a physician knows a remedy for a disease\nthat is certainly efficacious and another that is probably\nefficacious, he may not choose the probable cure, at the least in a\ngrave illness. Probabilism has to do with the existence,\ninterpretation, or applicability of a law, as I said, not with the\ndifferentiation of actions.\n\nThe term probable means provable, not guessed at, or jumped at without\nreason. There must be sound reason {17} adduced to constitute\nprobability. The doubt must be founded on a positive opinion against\nthe existence, interpretation, or application of the law. It must be\nmore than mere negative doubt, more than ignorance, more than vague\nsuspicion, especially must it be more than a sentimental impression.\nThere is a mental condition, which easily passes over into disease,\nwherein a man habitually can not make up his mind. This flabbiness has\nnothing to do with Probabilism. The opinion against a law to\nconstitute Probabilism must be solid. It must rest upon an intrinsic\nreason from the nature of the case, or an extrinsic reason from\nauthority,--always supposing the authority cited is really an\nauthority. Many men sitting upon the supreme bench in the Court of\nScience and called authorities by friends and newspapers, are only\nfools in good company.\n\nThe probability must also be comparative. What seems to be a very good\nreason when standing alone may be very weak when compared with a\nreason on the other side. When we have weighed the arguments on both\nsides, and we still have good reason left for standing by our opinion,\nour opinion is probable. The probability is, moreover, to be\npractical. It must have considered all the circumstances of the case.\n\nThe principles presented here have been arranged, as we said, with a\nview toward application in judging the morality of actions that may\noccur in cases of ectopic gestation, and we shall apply the doctrine\nof probabilism in the question, does the commandment \"Thou shalt not\nkill\" bind in certain cases of ectopic pregnancy? It is also necessary\nto add the principles underlying our duty to preserve human life.\n\n  1. It is never lawful directly or indirectly to kill an innocent\n  man. \"Insontem et justum non occides\" (Exod. xxiii. 7). An\n  _innocent_ man is one that has not by any human act done harm to\n  another man or to society commensurate with the loss of his life.\n  _Directly_ means to kill either as an end, say, for revenge, or as a\n  means toward an end.\n\n  A man is a person, an intelligent being, therefore free, and\n  autocentric; he belongs to no one except to God, who made {18} him;\n  he is by that very fact distinguished from brutes or things which\n  may belong to another. Now, if you kill a man, you destroy his human\n  nature by separating his soul and body, you subordinate and\n  sacrifice him wholly to yourself, make him entirely yours, which is\n  unjust. Even the state has no right to kill an innocent man. A\n  foetus in the womb, only a few hours old, is as much a human being\n  as a man fifty years of age, and this natural law holds for the\n  foetus as for the man.\n\n  2. It is, however, lawful _indirectly_ to kill a man provided this\n  man is an unjust aggressor. Cardinal de Lugo (_De Just. et Jure_,\n  10, 149) and others hold you may even _directly_ kill an unjust\n  aggressor. _Indirectly_ here means incidentally. An effect happens\n  indirectly when it is neither intended as an end nor a means, but\n  happens as a circumstance unavoidably attached to the end or means\n  intended.\n\nWe may not, however, kill an innocent man even indirectly, because no\nend is proportionate to the sacrifice of an innocent man's life, but\nthe case of an unjust aggressor differs from that of an innocent man.\nBy an unjust aggressor is meant some one that outside the due course\nof law threatens your life or the equivalent of your life, or the life\nof some one you should or may protect. You may stop such an aggressor,\nand if you happen to kill him while trying to stop him, there is no\nmoral wrong involved. This aggressor may be formally or only\nmaterially unjust: he may be a normal man with a formal intention to\nkill you or your ward, or a murderous lunatic that tries to kill you\nor your ward, but he must be _unjust_ either formally or materially.\n\nIt is natural for every being to maintain itself in existence, to\nresist destruction. This is a primary law of nature. As Father Holaind\nwell said (_Amer. Eccl. Rev._, January, 1894): \"The ethical foundation\nof self-defence is this: Justice requires a sort of moral equation,\nand if a right prevails it must be superior to the right which it\nholds in abeyance. At the outset both the aggressor and his intended\nvictim have equal rights to life, but the fact of the former using his\nown life for the destruction of a fellow man places him in a condition\nof juridic inferiority with regard to the latter. If we may be {19}\nallowed so to express it, the moral power of the aggressor is equal to\nhis inborn right to life, less the unrighteous use which he makes of\nit, whilst the moral power of the intended victim remains in its\nintegrity and has consequently a higher juridic value. When the person\nassailed cannot defend himself, his right _can_ and sometimes _must_\nbe exercised by those who are bound in justice or charity to protect\nthe innocent. At the dawn of human life the physician or surgeon\nstands as the natural protector both of the mother and of the child;\nhe is beholden to both.\n\n\"The right of self-defence is not annulled by the fact that the\naggressor is irresponsible. The absence of knowledge saves him from\nmoral guilt, but it does not alter the character of the act,\nconsidered objectively and in itself; it is yet an unjust aggression,\nand in the conflict, the life assailed has yet a superior juridic\nvalue. The right of killing in self-defence is not based on the ill\nwill of the aggressor but on the illegitimate character of the\naggression. Now, an aggressor is _at least materially unjust_ whenever\nhe perpetrates an act destructive of the right of another.\"\n\nMark the words \"right of another,\" at the end of the quotation. In a\ncase of pregnancy at term in a woman with a contracted pelvis the\nfoetus would be a contributing instrument of death to the mother,\nsupposing there were no artificial means of delivering her, but such a\nchild is not an aggressor even materially unjust. The child itself is\nnormal, it has a natural right to be where it is, it did not put\nitself where it is; the mother's contracting uterus crushing the child\nagainst her narrow pelvic arch is the direct agency that kills the\nwoman, and the child is only an inert instrument used by the\ncontracting uterus. In such a case the mother might be considered an\naggressor materially unjust against the life of the child rather than\nthat the child is the aggressor.\n\nLehmkuhl (_Compendium Theologiae Moralis_, 1891, p. 238) says:\n\"Medicus graviter peccat ... si media abortus procurat: nisi quando ad\nsalvandam matrem ex probabili opinione liceat.\" On page 188 he says:\n\"Ex consulto abortum inducere, etiam liceri videtur in praesenti vitae\n{20} maternae discrimine, quod per solam foetus immaturi ejectionem\navert! possit . . . Idque videtur applicari posse ad matrem quae tarn\narcta est ut tempus praematuri partus exspectare non possit.\"\n\nBy _foetus immaturus_ here he means an unviable foetus, as is evident\nfrom the context. If this probabilism of Father Lehmkuhl's stands (but\nit does not), a decision in most of the cases that occur in ectopic\ngestation would be easily made, but even he himself would not take\nresponsibility in the matter, and that before the decision of the Holy\nOffice which defined abortion. Since this decision, made July 24,\n1895, Lehmkuhl has entirely withdrawn his opinion.\n\nOn May 4, 1898, the Holy Office published the following decree, which\nwas approved by the Pope:\n\n  BEATISSIME PATER,--Episcopus Sinaloen. ad pedes S. V. provolutus,\n  humiliter petit resolutionem insequentium dubiorum:\n\n  I. Eritne licita partus acceleratio quoties ex mulieris arctitudine\n  impossibilis evaderet foetus egressio suo naturali tempore?\n\n  II. Et si mulieris arctitudo talis sit, ut neque partus prematurus\n  possibilis censeatur, licebitne abortum provocare aut caesariam suo\n  tempore perficere operationem?\n\n  III. Estne licita laparotomia quando agitur de pregnatione\n  extra-uterina, seu de ectopicis conceptibus?\n\n  Feria iv, die 4 Mali, 1898.\n\n  In Congregatione habita, etc . . . EE. ac RR. Patres rescribendum\n  censuerunt:\n\n  Ad I. Partus accelerationem per se illicitam non esse, duromodo\n  perficiatur justis de causis et eo tempore ac modis, quibus ex\n  ordinariis contingentibus matris et foetus vitae consulatur.\n\n  Ad II. Quoad primam partem, _negative_, juxta decretum, Feria iv.,\n  24 Julii, 1895, de abortus illiceitate.--Ad secundam vero quod\n  spectat: nihil obstare quominus mulier de qua agitur caesareae\n  operationi suo tempore subjiciatur.\n\n  Ad III. Necessitate cogente, licitam esse laparotomiam ad\n  extra-hendos e sinu matris ectopicos conceptos, dummodo et foetus et\n  matris vitae, quantum fieri potest, serio et opportune provideatur.\n\n  In sequenti Feria vi., die 6 ejusdem mensis et anni . . . SSmus\n  responsiones EE. ac RR. Patrum approbavit.\n\n{21}\n\nThe third question proposed by the bishop is:\n\n\"Is laparotomy licit when performed for extrauterine pregnancy or\nectopic gestation?\"\n\nThe approved answer of the Holy Office to this question is:\n\n\"In a case of necessity, laparotomy for the purpose of removing an\nectopic foetus (_conceptus_) from the abdomen of the mother is licit,\nprovided the lives of both the foetus and the mother, as far as is\npossible, are carefully and fitly guarded.\"\n\nThe expression, \"dummodo et foetus et matris vitae, quantum fieri\npotest, serio et opportune provideatur,\" is capable of various\ntranslations and interpretations.\n\nThe words might have this meaning: \"In a case of necessity you may do\nlaparotomy and remove an ectopic gestation, provided you do not kill\neither the mother or the foetus.\" If that is the interpretation, the\ndecree means that we may never remove an unviable ectopic foetus when\nwe know that the foetus is alive, because removal will kill it.\n\nThe sentence can also be translated in this sense: \"In a case of\nnecessity, you may do laparotomy and remove an ectopic foetus from the\nmother, provided you take full care to save mother and child if that\nis possible.\"\n\nIf that is the signification, it is evidently very different from the\nfirst interpretation. It would mean: do the laparotomy, remove the\nfoetus, and if you possibly can save both mother and foetus do so, but\nif you can not, take the best means you can to save one or the other.\n\nIf the decree refers only to cases in which the foetus is viable, it\nwould appear to be unnecessary--we need no decree of the Holy Office\nto let us do a laparotomy to remove a viable foetus. If it does not\nrefer to a viable foetus, it refers to an unviable foetus, but to\nremove an unviable foetus is to either kill it or to hasten its death.\n\nGenicot (_Institutiones Theologiae Moralis_, Louvain, 1902, vol. i. p.\n358) has this interpretation of the decree:\n\n\"In conceptione extra-uterina licebit sane recurrere ad laparotomiam\nsimilemve operationem, quando aliqua etiam tenuissima spes affulget\nsalvandi infantem, simul ac mater fere certo liberabitur. . . . Ubi\nvero nulla spes hujusmodi {22} affulget, neque in hoc casu licebit\nabortum directe inducere, etiamsi foetus certo moriturus sit antequam\nin lucem edatur, et baptismum recipere nequeat. Etenim S. Inqu., dum\nprovocat ad responsum 19 August, 1888, satis indicat abortus\ninductionem a se haberi tamquam operationem directe occisivam foetus\nideoque semper illicitam.\"\n\nThere is no question of an _abortion_ in a laparotomy for extrauterine\ngestation; abortion is altogether a different operation in method and\nnature. Secondly, the other decree of the Holy Office to which he\nrefers speaks of a direct killing of the foetus, but there is no\ndirect killing of the foetus in the operation for ectopic gestation,\nnor is the indirect hastening of the foetus's death a means to an end.\nThe decree on abortion is so clear it leaves no room for doubt.\n\nCardinal Monaco, in the _Epistola ad Archiepiscopum Camarcensem_,\nAugust 19, 1889, says the Holy Office decreed that \"In scholis\ncatholicis tuto doceri non posse licitam esse operationem chirurgicam\nquam _craniotomiam_ appellant, sicut declaratum fuit die 28 Maii,\n1884, et quamcumque chirurgicam operationem directe occisivam foetus\nvel matris gestantis.\"\n\nNote the words \"_directe_ occisivam.\" Craniotomy is a direct killing,\nand a direct killing used as a means to an end; moreover it is an\naltogether unnecessary killing. Artificial abortion in the case of an\nunviable foetus is also a direct killing as a means to save the\nmother's life, but the removal of an unviable ectopic foetus is\nneither a direct killing, nor is it a means toward any end.\n\nSince the meaning of the decree concerning laparotomy in extrauterine\npregnancy is by no means clear, we may discuss the question until the\nlaw has been fully promulgated, ready to conform to the real meaning\nof the decree whenever it is explained. In that spirit we may now\nconsider the cases that occur in ectopic gestation.\n\nCase I. A surgeon is called in to treat a woman and he finds her in a\nstate of collapse. He makes a diagnosis of tubal pregnancy, which has\ngone on to rupture with hemorrhage, and the bleeding will evidently be\nfatal to the mother unless it is checked. Practically the only chance\nof saving the {23} mother's life is coeliotomy and the ligation of her\nopen arteries. Dr. Howard Kelly (_Operative Gynaecology_, vol. ii. p.\n437) says: \"When the hemorrhage is sudden and excessive the patient\nfalls in collapse; but, in spite of these alarming symptoms, she may\nsurvive a succession of similar attacks and the foetus and sac may\ncontinue to develop.\" This exception complicates the case slightly. If\nthe surgeon were absolutely certain that the only possible chance to\nsave the woman's life is coeliotomy and haemostasis, the case would be\nsomewhat different from one in which there is some chance of escape by\nspontaneous haemostasis. That chance, however, is so slight, and so\nfar beyond any means we have for forecasting, that it is mere luck,\nand it is to be neglected. The surgeon may safely consider the patient\nin the gravest actual danger.\n\n(a) Before he opens the abdomen he can not tell whether the foetus is\nalive or not; but the stronger probability is that it is not, and the\ncertainty is that it has no chance at all to remain alive more than a\nfew minutes or hours, unless the surgeon is willing to trust to sheer\nluck in the expectation that he may happen to have one of Dr. Kelly's\nexceptions before him.\n\n(b) The operation to save the mother is this: as quickly as possible\nhe makes a vertical slit from four to six inches long through the\nwoman's belly-wall. Then commonly the free blood begins to run out, or\nit may even spurt out some feet into the air. The surgeon can see\nnothing for the blood and the presence of the entrails. If the blood\nis not freshly welling up he bails it out with his hands or a ladle;\nif it is spurting he at once thrusts in his hand, feels for the foetal\nsac, lifts it up, and puts on clamps near the uterus on one side and\nnear the pelvic brim on the other. This stops the hemorrhage, and he\ncan then work more leisurely, but unfortunately this also stops the\nflow of blood to the foetus. He can not first examine the foetus and\nthen stop the hemorrhage. He can not back out even if he finds a live\nfoetus without letting the mother die on the table.\n\n(c) If the placenta is already loose from the Fallopian tube the child\nis dead or it will die in a few seconds or minutes. If it was not\nloose the lifting out may tear it loose, and this {24} tearing loose\nwill hasten the death of the foetus a few minutes (but give a chance\nfor baptising it).\n\n(d) If the lifting out does not tear loose the supposedly fixed\nplacenta, the foetus either will die anyhow if the mother dies, or it\nwill die if the mother lives, because to save her the surgeon must put\nligatures just where the flow of blood will be shut off from the\nfoetus. Commonly there is no time to even look for the foetus until\nafter the maternal arteries have been closed.\n\n(e) The same conditions could exist in the rupture of a pregnancy in a\nrudimentary uterine horn as in a rupture in tubal gestation.\n\nWhat is the surgeon to do in a case like this? Fathers Holaind (_Amer.\nEccl. Rev._, January, 1894, in a note on p. 39), Lehmkuhl and Sabetti\nsay: do coeliotomy, ligate the mother's arteries, remove and baptise\nthe foetus.\n\nThe analysis of the case is this: (i) The _action_ is the stopping of\na fatal hemorrhage in a woman, and possibly, though not certainly, an\nindirect incidental hastening of a foetus's inevitable death.\n\n(2) The _object of the action_ is the haemostasis, which is good, and\nthe possible indirect hastening of the foetus's death, which is evil,\nbut, as we shall see, excusable evil.\n\n(3) The _end of the action_ is to save the mother's life--a good end.\n\n(4) The _circumstances are_: (a) that possibly, through mere luck, the\nwoman's condition is not necessarily hopeless: a few women have\nescaped in this seemingly imminent peril--but that chance of escape is\nnot soundly probable; the stronger probability by far is on the side\nof a fatal issue; therefore the chance for escape may be neglected,\nand the woman's case may be regarded as hopeless if operation is\nforegone.\n\n(b) The quickest possible work on the surgeon's part is necessary, and\nthere is no time or chance to examine the foetus's condition before\ntying the maternal arteries. Before he opens the mother's abdomen he\ncan tell nothing whatever of the foetus's condition, but the\nprobability is all in favour of the fact that the foetus is already\ndead or moribund.\n\n(c) The _means_ are coeliotomy, and the ligation of the {25} uterine\nand ovarian arteries to stop the mother's bleeding. This ligation, in\nthe contingency that the foetus is still attached to the Fallopian\ntube, will also shut off the blood from the foetus, yet the uncertain\nshutting off of the foetal blood-supply is not intended by the surgeon\nas a means toward his end in any degree direct or indirect, but it is\nan evil circumstance associated with the action which may hasten the\nfoetal death--even here the hastening is uncertain.\n\n(5) The _action has two effects_,--one, the saving of the mother, is\ndirectly intended and evidently good; the other, the possible indirect\nhastening of the foetus's death, may or may not be evil. The moral\ncentre of the whole case is this possible hastening of the foetus's\ndeath. If that possible hastening is licit the whole action is licit;\nif it is not permissible it will vitiate the entire action.\n\nSuppose that there is no doubt that the ligation of the maternal\narteries in this case really hastens the foetus's death some minutes:\nit would still be an indirect volition. Father Lehmkuhl also calls it\nindirect and licit. Father Sabetti denied that it is indirect, but he\nheld that it is licit for another reason. Sabetti said (_Aner. Eccl.\nRev_., August, 1894): \"It is evidently false to say that a means which\nis _directly_ adopted for obtaining an end is only _indirectly_\ncontained in the intention of the agent who so adopts it.\" That is\ntrue, but the minor proposition in a syllogism drawn from that\nstatement is to be emphatically denied. The cutting off of the foetal\nblood is a fact associated with the means, not a means direct or\nindirect toward the end, which is to save the mother--the means to\nsave the mother is the stopping of her bleeding.\n\nThis is not hair-splitting in the opprobrious sense of that term. The\nbases of all sins are absolutely abstract principles, and because\nabstract principles can not be pinched or weighed, they have often\nlittle meaning for the opposition in an argument. There is only the\nwidth of a hair between Heaven and Hell at many places along the\nfrontier, and there is only the difference between a direct or an\nindirect volition separating murder and a good deed. The best ethics\nfrequently consists in delicate hair-splitting; and despite the\nprotests of sentimentalists, one of the most valuable benefits of\nMoral Science is {26} to show us how to handle moral poisons for good\npurposes, as a physician uses the material poisons, opium and aconite.\n\nIf the foetus in this case of rupture in ectopic gestation were a\nmaterially unjust aggressor on the mother's life, the indirect\nhastening of its death would be justifiable according to all\nmoralists, and the direct hastening would be licit according to\nCardinal de Lugo, who was, in the opinion of St. Alphonsus, \"post D.\nThomam inter alios theologos facile princeps\"\n(_Th. Mor._, lib. 4. n. 552).\n\nSabetti held that the foetus is a materially unjust aggressor. His\nreason for this opinion is that the extrauterine foetus is not in a\nposition in which it has a right to be. If it were in the uterus, its\nnatural position, it would have a right to its position. Ectopic\ngestation is a disease, not a physiological condition.\n\nFather Aertnys (_Amer. Eccl,_ Rev., July, 1893) denies that the foetus\nis an aggressor materially unjust. He says: \"Nequaquam enim mortem\nintentat matri, sed actione, quam non ipse sed corpus matris producit,\nconatur ad lucem pervenire, et iste conatus non nisi ex naturali\nconcursu rerum fit matri causa mortis. Infans ergo non est _aggressor_\net multo minus est _aggressor injustus_. Hinc nego paritatem cum\nhomine mente capto, qui delirans alteri mortem intentat; hic enim agit\nmotus a sua voluntate, licet absque culpa, et ponit actiones in se\ninjustas, utpote ad necandum directe intentas.\"\n\nIn the same periodical (January, 1894) while repeating this statement\nhe says: \"Sive in utero existat sive alibi reconditus sit [sc.\nfoetus], nequaquam mortem intentat matri, siquidem non ipse actione\npropria conatur egredi, sed corpus matris infantem expellit et haec\nexpulsio a matre emanans fit matri causa mortis.\"\n\nWhat Father Aertnys says in these two passages is true of an\nintrauterine foetus, but it is altogether erroneous when applied to an\nextrauterine foetus, of which alone there is question here. In\nextrauterine pregnancy the uterus or any other part of the maternal\nbody does not \"try to expel\" the foetus; the uterus has nothing at all\nto do with the case--the very name of the condition is _extra_-uterine\npregnancy. If an ectopic gestation {27} goes on to term (a very rare\nhappening), there will be false labour and uterine contractions, and\nthese cease after a time without effect one way or the other; but in\nall cases of rupture and the like the uterus is outside the question\nand the mother is passive. There is no attempt by the mother in\nextrauterine pregnancy at expulsion either before rupture or at any\nother time unless the dead foetus putrefies, and the maternal tissues\n\"try to expel\" it as a foreign body by breaking down into an abscess.\nThe foetus simply grows, and its bulk bursts the tube. If it were in\nthe uterus, the uterus would enlarge synchronously with the foetus and\nthere would be no rupture, but the tube will not give beyond a certain\npoint, therefore it bursts.\n\nIn normal uterine pregnancy at term the uterus and other maternal\nmuscles are the active factors in expelling the foetus--the foetus is\npassive. In ectopic gestation the foetus is active, the mother is\npassive, and there is no attempt at expulsion from either side. In\nthis case the foetus in the tube through the action of its own vital\nprinciple draws nourishment from the mother and grows gradually larger\ntill it bursts the tube (it may even move its arms and legs if\nadvanced), and this rupture tears open arteries wherethrough the\nmother bleeds, commonly to death. This is evidently material\naggression.\n\nFather Aertnys says the foetus differs from the murderous lunatic in\nthis, that the madman is moved by his will, although blamelessly, in\ndoing unjust actions directly intended as homicidal. The fact that the\nlunatic uses his will has no weight whatever in permitting me to\ndefend my life against him, it is an accidental thing outside the\nquestion; but Father Aertnys in mentioning the madman's will means\nsolely, if I understand him, that the madman is really an active\naggressor. The foetus, however, is also an active aggressor without\nusing its will. I might fall from a height toward a man and certainly\nendanger his life while I was not using my will at all, not conscious\nof the man's presence under me, or even while I was using all the\npower of my will against the result. In any of these cases I should be\na materially unjust aggressor; and if in trying to prevent my body\nfrom killing him the man killed me, he would be blameless.\n\n{28}\n\nNow, in the first place, the tubal foetus is an aggressor; and since,\nsecondly, its position is unnatural, monstrous, a disease, a thing not\nintended by nature, it has no right to its position, and it is\ntherefore a materially unjust aggressor. Since it is an aggressor on\nthe very life of the mother in a place where it should not be, the\nsurgeon therefore may at the least stop the fatal bleeding it causes.\nIf the foetus dies as an unwished for, though permitted, consequence\nof this haemostasis, the surgeon may lament this result, but he is\nblameless.\n\nThe foetus was blocked in its unnatural position through a defect in\nthe mother, nevertheless it remains a materially unjust aggressor. If\nI by an accidental blow had made a man insane, and later this lunatic\ntried to kill me, I, or my legitimate protector, might lawfully kill\nthe lunatic in defence of my life. This is an exact parallel to the\ncase of the mother and the extrauterine foetus.\n\nThe extrauterine foetus is not like a foetus in a craniotomy case.\nWhere there might be question of craniotomy the foetus is not an\nunjust aggressor even materially, as has been said: first, because it\nis not an aggressor in any manner, it is altogether passive; secondly,\nit has a perfectly natural right to be where it is. In ectopic\ngestation with fatal rupture the foetus is, first, an active\naggressor; secondly, it has no right to be where it is. In craniotomy\nthe foetus is killed as a direct means toward the end that its head\nmay be reduced and extracted and the mother saved; in extrauterine\ngestation with fatal rupture the foetus is incidentally killed as a\nconsequence of the haemostasis, and not as a means in any sense of the\nterm. In craniotomy the child is wantonly killed since there are other\nmeans of saving the mother; in extrauterine pregnancy with fatal\nrupture the hastening of the death of the child is unfortunately\nassociated with the only possible means we have to save the mother.\n\nIn Case I., therefore, we have an action that has an object partly\ngood and partly, very probably, not evil; the end intended is good;\nthe circumstances are justifiable or indifferent; consequently in Case\nI. the surgeon may do coeliotomy, tie the uterine and ovarian\narteries, and if the foetus {29} happens to be alive he may\nreluctantly and indirectly permit the hastening of its death after\nattempting to baptise it.\n\nCase II. The conditions presented in Case I. are the ordinary and most\ncommon that the surgeon meets with in treating ectopic gestation, but\nother conditions may be found.\n\nSuppose the surgeon, before operation, diagnoses a case of ectopic\ngestation, but that he can not tell whether or not the foetus is\nalive. The probability leans toward the side that the foetus is alive,\nbecause there is no indubitable history, as physicians say, of\nmaternal symptoms that indicate rupture.\n\nMedical authorities tell him to do coeliotomy at once, ligate the\nuterine and ovarian arteries, and remove the foetus. Would he\ncertainly or probably be justified in following out this medical\ndoctrine?\n\nThe mother is in actual, _very probable_ danger of death, but not in\nactual, _certain_ danger of death. She may possibly escape if\noperation is deferred; she has a negligible chance of escape if no\noperation is performed after the death of the foetus; coeliotomy and\nligation of the uterine and ovarian arteries give her by far the\nsurest chance of escape, so sure an opportunity for escape when\nperformed early that it can scarcely be called a mere chance.\n\nIf operation is deferred the chances for rupture are about 22 per\ncentum, say, one and a half in five chances, and all ruptures are not\nnecessarily fatal. The chances of the mother's death, however, are\nmuch higher than that, because death can come in ectopic pregnancy\nfrom causes other than rupture. From 63.1 to 68.8 per centum (say,\n66.3 per centum) of ectopic gestations treated by the expectant method\nresult in death to the mother--just two-thirds of the women die. A.\nMartin in a series of 265 cases of ectopic gestation where the\nexpectant treatment was employed found a maternal mortality of 63.1\nper centum; Parry in 500 similar cases found a mortality of 67.2 per\ncentum; and Schauta in 241 cases a mortality of 68.8 per centum.\n\nIn the 87 years between 1809 and 1896, 77 cases of coeliotomy for the\ndelivery of _viable_ ectopic foetuses were reported {30} in all\nmedical literature with a maternal mortality of about 58.3 per centum.\nBetween 1809 and 1888 there were 37 coeliotomies with a maternal\nmortality of 86.5 per centum. Between 1889 and 1896 there were 40 such\noperations, with a maternal mortality reduced to 32.5 per centum by\nmodern surgical methods.\n\nThe results as regards the children were almost the same in the two\nseries, and perhaps a little better in the latter series. In the first\nseries the 37 children were alive at delivery: the length of time in\nwhich three of these children lived is not given; three more were\nalive but they did not breathe; the others lived from a few seconds to\ndays, weeks, months or years. One was well at six months, another at\none year, another at seven and a half years, another in its fourteenth\nyear, another in its fifteenth year. In the second series the results\nas regards the children were, as has been said, almost the same. The\n40 cases that were reported from 1889 to 1896 are the standard for\nthis phase of ectopic gestation, because they come under the diagnosis\nand treatment of the present day. They represent closely all such\ncases that occurred in the entire world between 1889 and 1896, because\nphysicians report these operations to medical societies, and active\nphysicians are almost without exception members of such\nsocieties--outside the civilised world these operations do not take\nplace. In the seven years there were annually less than six cases of\ncoeliotomy for ectopic gestation at term in the world, therefore\noperations at term may be neglected in discussing Case II., and the\nargument may be confined to the ordinary cases of expectant treatment.\nSchrenck in 1892 collected 610 cases of ectopic gestation which had\nbeen reported between 1887 and 1892; during the same time there were\n23 cases (less than 4 per centum) of operations for the delivery of\nviable foetuses.\n\nIf the physician that has made the diagnosis in this Case II. leaves\nthe patient, she may have a fatal hemorrhage at any moment. Dr. Howard\nKelly reports (_Operative Gynaecology_, vol. ii. p. 438) a fatal\nhemorrhage in two days from rupture where the foetus was only as large\nas a Lima bean. The hemorrhage may be so suddenly fatal that the woman\ndrops {31} to the floor unconscious just as if she had been shot. Dr.\nHarris (_International Cyclop. of Surgery_, vol. vi. p. 784) tells of\na case where three of the best obstetricians in Philadelphia met in\nconsultation daily for 16 days expectantly watching development, but\nthe woman died from hemorrhage in thirty minutes before any of these\nphysicians could be called to her aid. Death may be brought about by\nanaemia after repeated hemorrhages. Some hemorrhages can be mistaken\nfor colic by the physician, and this error will defer until too late\nthe treatment for hemorrhage.\n\nIf the woman is living in a hospital where there is a resident surgeon\nwith instruments ready, she has a better chance than if she is in her\nown house. Even if she has a surgeon within call the outcome of the\ncase for her will depend largely on his skill, his presence of mind,\nthe preparedness of his instruments, the general condition of the\npatient, and many other circumstances.\n\nThe instruments, ligatures, gauzes, solutions, dressing, etc., for\ncoeliotomy are multitudinous, and all must be sterile, or the woman\nwill be killed by septicaemia even if the hemorrhage is stopped. It is\nalmost impossible to keep a set of instruments and the other things\nused in a coeliotomy always sterile and ready for instant use.\n\nThe skin surface of the patient's abdomen must be sterilised, or pus\ninfection will get into the peritoneum through the wound. In all\nordinary coeliotomies this surface is carefully sterilised by a long\nprocess the night before the operation, a protective dressing is put\non, and the sterilisation is repeated the next day just before the\noperation. This is so important that its voluntary omission is\nmalpractice. In the hurried operation for tubal rupture there would be\nno time for sterilisation of the abdominal skin surface, and probably\nno time to sterilise the instruments and other things used, especially\nthe surgeon's hands.\n\nThe surgeon to do any coeliotomy needs assistant physicians--one to\nanaesthetise the patient, and at the least one other to work with him\nin the operation. He should have three or four physicians and one or\ntwo nurses. He can not do a coeliotomy alone. Hence the patient in a\nruptured {32} extrauterine pregnancy must have at the very least two\nphysicians within call.\n\nThe woman, then, in Case II. before operation has one chance in three\nof life if no operation is done until the child is viable, and if she\nremains alive till the child is viable (when she must be operated\nupon) her chances for life will be no better, judging from modern\nstatistics.\n\nAt any moment, therefore, she is in actual peril of death by two\nchances in three, and probably more if all special circumstances are\nconsidered. The foetus is a materially unjust aggressor in this case\nbefore rupture or other similar mishap, as it was in Case I., but not\nto the same extent. In Case II. it is a materially unjust aggressor as\ntwo is to three; in Case I. it is a materially unjust aggressor as\nthree is to three.\n\nIf a lunatic is just about to fire three cartridges at me, I may know\nthe chances are only two in three, or even only one in three, that he\nwill hit me fatally, nevertheless I may licitly kill him to stop the\nfiring and save my life. The mother in Case II. is in exactly similar\ndanger of life.\n\nThe objection that the danger to my life from the action of the\nlunatic exists _hic et nunc_ and that the danger to the mother's life\ndoes not threaten _hic et nunc_, is not of any weight. She is in\nactual danger _hic et nunc_, even while the surgeon is in the room\nexamining her. Moreover, the matter of time here is accidental. If you\ngive a man a poison that may kill him in ten hours, or one that may\nkill him in ten days, the action is essentially the same.\n\nI am of the opinion that if this second case were proposed to moral\ntheologians many of them would decide that the surgeon should explain\nthe case fully to the patient or her family, and if immediate\noperation were insisted upon he should withdraw from the case.\nNevertheless, as far as I can see, he has sound probabilism on the\nside that operation is justifiable.\n\nBut, it may be objected, in Case I. the surgeon ligated the uterine\nand ovarian arteries to stop an actual hemorrhage, and he permitted\nthe death of the foetus; in Case II. there is no hemorrhage yet, there\nmay possibly be none at all. I answer {33} that in Case II. if he\noperates he ties the two arteries to forestall an imminent hemorrhage\nwhich might begin within the next hour if it were not securely shut\noff, and to forestall sepsis by leisurely and proper precautions, and\nexactly as in the first case he permits the death of the foetus, he\nindirectly kills an unjust aggressor. If the lunatic is aiming at me I\ndo not have to wait until he begins firing to licitly shoot at him.\nThe sooner I shoot, _servato moderamine inculpatae tutelae_, the more\nprudent my action.\n\nTo put it in another form--in Case II. the surgeon is standing before\na dam (the stretched Fallopian tube) that is threatening to break at\nany moment and cause death to a woman below it, because there is a\nlunatic (the foetus) behind it tearing away the masonry. If the\nsurgeon shunts off the water just above the dam (the ligation of the\narteries), he will suddenly let the lunatic who is tearing away the\nmasonry fall down to the rocks at the bottom of the dam and be killed.\nMay he let the lunatic fall? Certainly he may. But perhaps the lunatic\nwill not succeed in tearing away the masonry. He is well provided with\ntools to do so; the chances are even two in three that he will\nsucceed. Is he or the woman to be given the benefit of the doubt? The\nwoman, by all means; she has a doubt worth in juridic value at the\nleast twice as much as that which the lunatic has.\n\nIn any case of ectopic gestation the foetus has a very faint chance\nindeed of even living long enough for baptism if the expectant\ntreatment is employed. We have seen that between November 1809 and\nNovember 1896 there were reported 77 cases of operation for the\ndelivery of viable foetuses. Eleven of these children survived, 67\ndied within a few months, and many of these died just after delivery.\nStill, probably all might have been baptised. Judging, however, from\nthe geographical distribution of the cases (see Kelly's _Operative\nGynaecology_, vol. ii. p. 458) and the names of the operators, only\nabout 14 of these children received baptism.\n\nNow, since Schrenck found 610 ectopic gestations reported in five\nyears, this indicates that the average number of cases of ectopic\ngestation which occur in the civilised world is at the least 122 a\nyear, for many more (twice as many, at the lowest {34} estimate) are\nnot diagnosed or not reported when diagnosed. In the 80 years, then,\nbetween 1809 and 1896 there were at the least 9760 cases of ectopic\ngestation in the civilised world; in the uncivilised countries there\nwere certainly as many more with not a child saved, or even brought\nout of the pelvic cavity. To be sure, by rejecting perhaps a third of\nthe cases through bad diagnoses and neglect of reports, there were\n20,000 cases; and in all these hardly 20 children baptised--one in a\nthousand.\n\nModern surgical methods and improved diagnosis will do little to\nbetter the condition, from the nature of the disease. Between 1893 and\n1896 there were 21 cases of operation for the delivery of viable\nfoetuses reported, and this list is approximately correct, because the\nsurgeons that operate on such material are men that as a rule report\ntheir work even when it is to their discredit. In these 21 cases, 6\nmothers, 28 per centum died, 72 per centum recovered. Even if modern\nsurgery should save all the mothers who had escaped until the foetus\nwas viable, and should bring all the children to baptism, there would\nnot be more than about 7 such cases in the world annually. Increased\nskill in diagnosis would raise the number of children brought to\nbaptism, but it would more than proportionately raise the whole number\nof ectopic gestations discovered. If 10 foetuses were brought from the\npelvic cavity alive in the 130 cases of ectopic gestation of the year,\nthe chances for an extrauterine foetus to only reach baptism at a\nviable age (not to live after baptism) are only 7 in 100 at a most\nliberal estimate. Statistics are unreliable, of course, but I am\ngiving odds of two to one. The foetus has a much better chance for\nbaptism if the coeliotomy is done as early in the pregnancy as\npossible, but it has a negligible chance of life in any case. Since\nthe creation of man there have been less than 15 extrauterine children\nsaved, and of these 15 four were less than a year old when reported,\nand three under five years of age: the oldest was fifteen years of\nage, and all were weaklings.\n\nThe practical rule, then, is that the ectopic foetus will die anyhow,\nand operation only _indirectly_ (mark the word) accelerates the\ninevitable death of a materially unjust aggressor, {35} while it gives\nthe mother the best chance for her life, which is in very grave peril.\n\nCase III. The surgeon before operation diagnoses with the help of\nconsultors extrauterine pregnancy, but he or they can not tell whether\nthe foetus is alive or not. What should he do?\n\nIn my opinion he may operate with much more solid probability than\nthat which exists in Case II. If the argument is more for the death of\nthe foetus than for its life, this, of course, strengthens the\npermissibility of the operation.\n\n(1) The danger to the mother is exactly the same,_caeteris paribus_,\nas in Case II.; (2) the foetus is only probably alive. An actual\ndanger to life is opposed to the probable life of a materially unjust\naggressor; therefore the surgeon may probably operate at once.\nProbable here is used in the technical sense of the term.\n\nCase IV. The following case is given because a similar one was\nproposed in the articles in the _American Ecclesiastical Review_, but\nit is not a practical case.\n\nThe surgeon, after consultation, does not know whether the growth in a\nwoman's pelvis is a malignant tumour or a sac containing an\nextrauterine foetus. If the growth is a malignant tumour, the woman is\nin actual and certain danger of life, her death is a mere matter of\ntime if a malignant tumour is not removed, and the sooner the tumour\nis removed the better. If operation is deferred, metastases of the\ntumour will have occurred, and operation will be too late. The\nindication when we find a malignant tumour is, if it is not already\ntoo late to operate, to take it out at once.\n\nIf the surgeon thinks that the growth may possibly be a foetus, and he\nputs off the operation until a time when certain signs of pregnancy\nshould be present to establish a diagnosis of gestation, or their lack\nto establish a diagnosis of tumour, it would almost surely be too late\nto operate in the event the growth turned out to be a malignant\ntumour.\n\nAs has been said, the case is not practical, because malignant tumours\nof the tube are so very rare that they are not to be looked for,--only\none or two have been observed. {36} Malignant tumours about the tube\nshould be diagnosed. Supposing, however, the case to stand, it offers\nin favour of operation a probabilism stronger than that in any case\nexcept Case I., because the mother's danger is graver, and the\nargument concerning the foetus is the same as that in Case III.\n\nCase V. Suppose a doubtful case like Case III. or Case IV., but after\nthe surgeon has opened the abdomen he finds a foetus evidently alive.\nThis is an improbable but a possible case. Case V. then becomes like\nCase II. with the addition of another grave danger to the lives of\nboth the mother and the foetus, which is the coeliotomy already\nperformed. The suggestion that the surgeon can leave the woman, back\nout of the case, is absurd. If he closes the abdomen, the coeliotomy\nmay cause tubal abortion, the wound might have to be opened again in a\nfew hours or a few days, and the mother would be left in much greater\nperil than she was in Case II. For the reasons already given, he\nshould go on with the operation.\n\nCase VI. Suppose a case like Case V. in every particular except that\nwhen the surgeon finds the foetus he can not tell whether it is alive\nor not. He should,_ a fortiori_, finish the operation.\n\nCase VII. A case of ectopic gestation is diagnosed, the conditions are\nexplained to the woman, and she refuses to be operated upon. Is she\njustified? The probability is one to two that she will escape death if\nshe waits, and much less than one to two if she finally refuses\noperation. The moralists would tell her she may refuse operation.\n\nCase VIII. Let us suppose a case where a Fallopian tube either has its\nlumen so narrowed by a gonorrhoeal inflammation that although the\nspermatozoa may pass through and fecundate the ovum this fecundated\novum can not get out to the uterus; or, secondly, that the gonorrhoeal\ninfection has completely shut the tube, yet migratory fecundation has\noccurred through the route of the other tube and the passage along the\nfundus of the uterus to the ovary of the infected side. In either case\nan ectopic gestation begins.\n\nThe first case is improbable from a medical point of view, {37} and\nthe second is barely possible. Gonorrhoeal infection of the tubes is\ncommon enough, but when it occurs it usually shuts the tube up\npermanently. In chronic salpingitis at times the ovarian end of the\ntube is not wholly closed at once, and since the body of the ovary is\nvery rarely affected by gonorrhoea, there is a possibility worth\nconsidering of a tubal pregnancy through migration to occur.\n\nIn such a condition the woman might have been infected with\ngonorrhoea, first, before her marriage through fornication or\naccident; second, after her marriage through adultery or accident;\nthird, after the marriage by her husband.\n\nIf she had been infected through fornication or adultery, she is\naccountable for the foreseen consequences of her sin, and she has put\nan impediment for which she is responsible before the embryo. Suppose\nthe physician knows these facts. Then the excuse for indirectly\nhastening the death of the foetus does not, at first sight, seem to\nexist, because the foetus is apparently not a materially unjust\naggressor. It could easily happen that a surgeon's refusal to operate\nin a case like this would cause the death of the mother and foetus.\nShould he let both perish? Is he to let the mother die for the sake of\nstaving off for a half-hour the certain death of a useless embryo the\nsize of a pigeon's egg? It is not a useless embryo the size of a\npigeon's egg, but a human being, the most important thing on earth,\nand a human being shut off from life and baptism as a direct\nconsequence of that woman's brutal sensuality. But the woman may be\nthe mother of other helpless children. What is to be done? Let us\nrecur to the example of the homicidal maniac.\n\nIf I accidently by a blow make a man insane and that insane man\nafterward tries to kill me, I or my protector may permit his death to\nsave my life. If I maliciously make a man insane and he afterward\ntries to kill me, may I or my protector kill him in my defence? Some\nmay say that I may not because I have lost all juridic superiority\nover the madman as a consequence of my sin against him. That position,\nhowever, does not seem to be correct.\n\nIf it is correct, parity makes the assertion true that the foetus in\nthe case supposed above may not be indirectly {38} killed to save the\nmother. If it is not true, the foetus may be indirectly destroyed.\nDoes my sin against the insane man give him a right to kill me? By no\nmeans. Nothing but defence of life or its equivalent gives any private\nindividual the right to kill another. The man might kill me before\nthis aggression of mine, in defence of his sanity, but after the fact\nsuch a killing would be mere revenge, or an _actus hominis_, not a\nright.\n\nThe woman, we suppose, has maliciously put the foetus in its position\nof material aggressor, but has the foetus the right to kill her? No;\nthe foetus is an individual not acting in self-defence, it is merely\ngrowing. Has the woman or the surgeon, her protector, the right to\npermit the death of the foetus to defend the woman's life? I think\nthey have, because the foetus here also is, from its unnatural\nposition, a materially unjust aggressor.\n\nBut, you say, this is a vicious circle. You justify the permitted\ndeath of the foetus in Case I. because it is a materially unjust\naggressor, and it is a materially unjust aggressor because it is in an\nunnatural position where it has no right to be; but in the present\ncase the mother put it in the unnatural position, and it therefore has\na right to be where it is. No: the consequence does not follow. The\nfact that the mother put the foetus in its unnatural position does not\ngive the foetus a _right_ to be in that position, although it\nconstitutes a ground for her punishment by proper authority. You\nobject again, if this woman has a right to permit the death of the\nfoetus to save her own life, how may she be punished for that death?\nShe will not be punished for the actual coeliotomy which indirectly\ncaused the death of the foetus, but she will be punished for the sin\nof putting that child in a position in which it had to be killed. This\nseems to be a distinction without a difference. As far as the mother\nis concerned, _transeat _; but it is a real distinction as far as the\nsurgeon is concerned.\n\nIf the woman's condition is a result of accidental infection before or\nafter marriage, the case goes into the class of those discussed above,\nand operation is justifiable.\n\nIf her infection comes after her marriage adulterously, her {39} sin\nis the greater, but the operation is justifiable for the reasons which\nwere given in the case of culpable infection before marriage.\n\nIf she had been infected by her husband, the operation is\njustifiable--the father is accountable for the foetus's death.\n\nFortunately the entire case is so nearly hypothetical that it is\nlittle more than mere words.\n\nAUSTIN OMALLEY.\n\n\n{40}\n\nII\n\nPELVIC TUMOURS IN PREGNANCY\n\n\nTumours of the uterus and its adnexa at times, though rarely,\ncomplicate pregnancy, and they may involve certain moral questions\nthat have been little discussed. The tumours that cause difficulty are\novarian and uterine.\n\nCystic ovarian tumours commonly do not prevent impregnation, if there\nhas been an absence of inflammation. When these cysts are small they\nmay not disturb pregnancy or delivery; large cysts can, however,\nbecome a source of danger. They may sink into the pelvis and block the\nchannel of delivery needed by the child at term; they may have their\npedicles twisted, and thus become gangrenous and septic. Big cysts of\nthe ovary may during the growth of the pregnant uterus press upon the\nportal vein, or the diaphragm, or they may burst or cause sepsis.\nLitzman, in 56 cases of ovarian tumours complicating pregnancy, had\nonly 10 normal deliveries; and Remy held that 23 per centum of these\ncases, when left untouched, result in death to the mothers. Stratz\nsays the mortality is 32 per centum, and it has gone as high as 40 per\ncentum. Some physicians teach that any ovarian cyst found complicating\npregnancy should be removed surgically. Other authorities hold that\nthey should all be treated expectantly: if they threaten the life of\nthe mother, they should be tapped by a trocar through the belly-wall\nor the vagina, and removed only after labour. This second operation is\nsafe, and I think it should prevail.\n\nSuch cysts have often been removed during pregnancy. Orgler reported\n146 ovariotomies (removal of the ovaries) performed during gestation\nwith only four maternal deaths--2.7 per centum. If the operation had\nnot been performed {41} about 32 per centum of these women would have\ndied. The chance against saving the child in such an operation is the\ncrux. If there is no operation 17 per centum of the cases result in\nabortion and the loss of the child, as Remy found from a consideration\nof 321 cases. In Orgler's series of 146 ovariotomies, where he lost\nonly 2.7 per centum of the mothers, and saved about 30 per centum that\nwould have died (97 per centum in all); he lost 32 children through\nabortion caused by the ovariotomies, or 22.5 per centum; whereas by\nthe expectant method (without tapping) only 17 per centum of the\nchildren were lost.\n\nBovee of Washington, however, reported 38 cases of removal of the\novaries during pregnancy with one maternal death and only four\nabortions, or 12.6 per centum. That is considerably less than the loss\nby the expectant method without tapping. As Bovee succeeded, other men\nnow do, but it would be far better to attempt tapping first. The\nearlier in the pregnancy either tapping or removal is done the better.\n\nFibroid tumours of the uterus, complicating pregnancy, occur in about\n0.6 per centum of pregnancies, and they usually go on without causing\ntrouble; but again these tumours may block the pelvic outlet, they may\ndangerously press upon abdominal viscera and the diaphragm; some\nwriters hold they may become inflamed and degenerate with sloughing\nand gangrene, and thus bring about sepsis and death to the mother and\nchild. That they become gangrenous must very rarely happen; the\nincreased blood supply should prevent gangrene, but cause an increase\nin the size of the fibroma.\n\nA group of gynaecologists maintain that when fibromata cause dangerous\nsymptoms in pregnancy the uterus should be taken out in part or wholly\nif the tumour is so deeply involved in the uterine wall that it can\nnot be separated. This operation, of course, kills the foetus. At\ntimes the child is viable, and a precedent caesarean section will save\nit. Surgeons do not remove fibromata merely as a precaution, as they\nsometimes do in the case of ovarian cysts. Other surgeons say it is\nsafe to wait. If the channel of delivery is blocked, these men wait\ntill term and then do caesarean {42} section; in other cases the\ntumour will often be lifted up out of the way during the later stages\nof gestation or labour.\n\nIn those very rare cases where it is necessary to remove the uterus\nwholly or in part before the child is viable, and thereby also to kill\nthe foetus, the operation at first glance seems in no wise to differ\nin nature from a craniotomy upon a living child. The condition,\nhowever, is commonly worse than one in which a craniotomy is\nindicated, because in the latter condition we have a viable child, and\nthe caesarean section to solve the difficulty, but in the former we\nhave a child not viable, and therefore the caesarean section would be\nuseless, except for the opportunity it might give for baptism of the\nchild. In such a case must the surgeon let the mother die lest he\nhasten the death of a non-viable child?\n\nThe action reduces to this, that the surgeon by operating would permit\na hastening of the inevitable death of the foetus while saving the\nmother's life, but the child is not an unjust aggressor, not even a\nmaterially unjust aggressor. It has a right to be where it is. The\nonly excuse for hastening its death is to save the mother's\nlife,--there is no question of self-defence; but deliberately to\nhasten the death of a human being a second of time, except it be done\nby an individual in self-defence against an unjust aggressor, or by\nthe state for legitimate cause, is murder. It seems probable, however,\nthat there is something to be said in favour of the unavoidable\nhysterectomy (removal of the womb) in a pregnancy complicated with\nuterine fibromata that undoubtedly endanger life.\n\nSuch cases differ from craniotomy, or the direct killing of a foetus\n(which were formally forbidden by the Holy Office on May 28, 1884, and\nAugust 19, 1888, and always forbidden by the natural law) in several\nfactors: first, in craniotomy the child is _directly_ killed, although\nit is not an aggressor, in the hysterectomy it is permitted to die, it\nis _indirectly_ killed; secondly, in craniotomy there is a viable\nchild, in the hysterectomy, an unviable child; thirdly, in craniotomy\nthere is a killing that is a means toward the end of saving the\nmother's life, in the hysterectomy there is a permitted hastening of\nthe foetus's death, and this is only a circumstance inseparably joined\nto the act; fourthly, in craniotomy the killing is utterly {43}\nuncalled for, because the caesarean section, or symphyseotomy (a\ntemporary dividing of the pubic joint to get more room) will do\ninstead, in the hysterectomy, because the child is not viable, there\nis no alternate way out of the difficulty; fifthly, formal judgment\nhas been pronounced by the Holy Office in craniotomy, no formal\njudgment has been made as regards this hysterectomy.\n\nSuppose A and B are on a boat hoisting a weighty object to a ship; the\ntackle breaks, the falling weight mortally hurts B, and wedges him\nfast to the wrecked boat. The boat is about to sink and drown both\nmen, but if A tips off the weight, and with it unavoidably the\nentangled B, A can float to safety. A will indirectly hasten the\ninevitable death of B by throwing off the weight which will drag him\ndown. May A do so? Very probably he may.\n\nTwo swimmers, A and B, are trying to save C, who dies in the water,\nand as he dies he grips A and B so tightly they can not shake the\ncorpse off. A is weak, and he will soon sink and drown owing to the\nweight of the corpse; B also will later go down with A and C. A,\nhowever, cuts his clothing loose from the grip of the corpse (or some\none in a boat does so who can do no more) and A is saved; but thus\nimmediately B is drowned, owing to the fact that the full weight of\nthe corpse is upon him. Is A, or the man in the boat, justified?\nProbably they are. A is the mother, B the foetus, C the diseased\nuterus, the man in the boat is the surgeon. The mother has herself cut\naway from the uterus and the foetus's death is hastened.\n\nAgain, take an example used by Father Ricaby in his _Moral\nPhilosophy_, p. 205 (London, 1901). He supposes a visitor to a quarry\nto be standing on a ledge of rock which a quarryman had occasion to\nblast, and the quarry man saw that \"unless that piece of rock where\nthe visitor stood were blown up instantly, a catastrophe would happen\nelsewhere, which would be the death of many men, and if there were no\ntime to warn the visitor to clear off who could blame him if he\napplied the explosive? The means of averting the catastrophe would be,\nnot that visitor's death, but the blowing up of the rock. The presence\nor absence of the visitor, his death {44} or escape, is all one to the\nend intended: it has no bearing thereon at all.\"\n\nIf these examples of indirect killing are allowable, why may not the\nsurgeon in the rare example presented here remove the uterus and\nindirectly permit the hastening of the foetus's death? That hastening\nof death is not an end, nor a means toward an end, but a circumstance\nonly reluctantly and indirectly willed. The end is to save the\nmother's life, and the means is the removal of a septic or impacted\nuterus.\n\nIt may be objected that an artificial abortion wherein the womb is\nemptied of an unviable foetus to save the mother's life is only an\nindirect hastening of this foetus's death, but there is a difference:\nin abortion the removal of the foetus is the means whereby the end is\nattained, in the hysterectomy the removal of the _tumour_ is the means\nwhereby the end is attained. This argument is advanced only\ntentatively and with diffidence, that the matter may be discussed and\nsettled by authority.\n\nSometimes carcinoma (a cancer) complicates pregnancy--once in 2000\ncases is above the average. A carcinoma is a malignant tumour, and the\nmalignancy is made much worse by the stimulus of pregnancy with its\nincreased blood supply. The maternal deaths from carcinoma of the\nuterus during pregnancy is, according to the latest and most\nfavourable statistics, 30 per centum. The mortality of the children is\nfrom 50 to 63 per centum.\n\nNow, first, if an artificial abortion is induced while the foetus is\nunviable, the foetus is lost and the mother's condition is not\nmaterially improved.\n\nSecondly, if curettement (a scraping away with a sharp spoonlike\ninstrument), cauterization, or amputation of the uterine cervix are\nperformed, the mother is helped very little, if at all, and consequent\nabortion is frequent.\n\nThirdly, if caesarean section is done at term the child has a good\nchance (Sanger saved 16 of 18 children thus in one series: over 88 per\ncentum), but this operation nearly always kills the mother when cancer\nis present, unless the entire uterus can be removed, and often it can\nnot be removed; that {45} is, the case is inoperable and removal is\nuseless owing to extension of the cancer into the surrounding tissues.\n\nFourthly, if the mother's condition is hopeless, a caesarean section\ngives the child a chance for life, but the operation will hasten the\nmother's death in nearly every case.\n\nThe first and second cases here are not practical. If the surgeon can\nremove the uterus at term after a caesarean section, that is the most\nreasonable operation for the mother and child, and it offers no moral\ndifficulty.\n\nIf the mother's condition is so bad that the uterus may not be\nremoved, the chances are that her death will be hastened by caesarean\nsection, but if caesarean section is not done, from 50 to 63 per\ncentum is the ratio against the saving of the child. I do not think a\ngeneral rule can be given as regards the certainty of hastening the\nmaternal death: the reckoning is to be made to meet the particular\ncondition. It seems, however, probable that in every case of\ninoperable carcinoma of the uterus complicating pregnancy a caesarean\nsection would hasten the maternal death. She will die anyhow from the\ncancer, but in certain cases she may live longer if the section is not\ndone.\n\nIf, again, a carcinoma of the uterus is inoperable at term, the\ndelivery of the child may be impossible without caesarean section,\nfrom uterine inertia, or the opposition of the dense inflamed tissues,\nor the friability of these tissues. In such a case without the section\nshe would die, and die probably sooner than with it. The operation\nwould possibly slightly prolong her life, by, say, a few hours or\ndays, and it certainly would give the child a very good chance for its\nlife. She may, of course, die upon the operating table, but she would\ndie in childbed without the section.\n\nThe case is different from the ordinary caesarean section done because\nof a narrow pelvic bony girdle. In the latter condition the chances\nthat the mother will live are very high if the surgeon is competent,\nbut in the carcinoma case she will die no matter who the surgeon may\nbe, and very probably, or almost certainly, her death will be hastened\nby the operation in the majority of cases.\n\nIf the condition is such that the woman can not be delivered {46}\nwithout the section, I see no difficulty against operation, because\nthe surgeon can not, as far as I know, say positively whether he will\nhasten the maternal death or not, and in the circumstances he may take\nadvantage of the doubt.\n\nIf the woman with an inoperable carcinoma uteri may be delivered\n_without_ section, should such a delivery be chosen although it raises\nthe chances of mortality as regards the child from about 12 per centum\nto at the least 50 per centum? It is a matter of a very probable\nhastening of the mother's death as weighed against the safety of the\nchild--the child has about one chance in two of life without the\nsection, and, say, seven chances in eight with the section. The\noperation is far preferable as regards the child alone, but not\npreferable as regards the mother alone. Is it then allowable?\n\nIn the hysterectomy for fibroma already considered, the mother is\nsaved and the child's inevitable death is certainly hastened; in the\ncaesarean section the child is most probably saved, and the mother's\ninevitable death is most probably hastened; we might say, in some\ncases, that her death is undoubtedly hastened. If in the carcinoma\ncase here the child had no chance whatever for delivery except by the\ncaesarean section, while the mother's death would be probably or\ncertainly hastened, she might legitimately consent to the operation or\nshe might legitimately refuse the operation.\n\nThe child, however, has, as we said, one chance of delivery in two\nwithout the section, while the mother's death will very probably be\nhastened. If the mother's death would certainly be hastened by the\nsection, her death, although it would be a circumstance and indirect,\nnot an end nor a means, would not have counterbalanced against it\nnecessarily the saving of the child's life, because the child has one\nchance in two in any event. In such an hypothesis the operation seems\nto be unjustifiable.\n\nIf, however, the hastening of the mother's death is only probable and\nnot certain, may we oppose that probability to the advantage that must\naccrue to the child through the section? If the doubt that her death\nwill be hastened is soundly probable, the woman may consent to the\noperation. She risks through charity the hastening of her own death\nfor a great {47} advantage to the child, but she may risk legitimately\nimmediate death in major surgical operations for an advantage less\nthan the saving of life itself. She may have her skull opened for the\nremoval of a depressed bone that is causing paralysis, she may have\nher knee-joint opened for the wiring of a patella to prevent lameness,\nbut both these operations always immediately endanger life. She may go\ninto a burning house, jump into a river, and so on, to save her child\nfrom possible injury.\n\nAUSTIN OMALLEY.\n\n{48}\n\nIII\n\nABORTION, MISCARRIAGE AND PREMATURE LABOUR\n\nIf pregnancy ends in the emptying of the uterus before the sixteenth\nweek of gestation, the condition is called an abortion; if this\nhappens between the sixteenth and the twenty-eighth weeks, it is\nmiscarriage; if the child is born after the twenty-eighth week but\nbefore full term, the birth is premature. The term \"abortion\" in the\npopular mind carries with it the notion of criminal interference, and\nthe word \"miscarriage\" is used for both abortion and miscarriage by\nthe laity; physicians, on the other hand, commonly use the term\n\"abortion\" for both abortion and miscarriage. These conditions may\noccur spontaneously or they may be induced artificially.\n\nSpontaneous abortions are very frequent; perhaps one in every five or\nsix pregnancies is the proportion: the writer has known a single\nphysician, not a specialist in obstetrics, to be called to three in\none day and that in private practice. From 150 to 200 children in\nevery 1000 that are conceived never get a chance for baptism. In the\nearly months of pregnancy the foetus is usually dead before expulsion\ntakes place. Twisting of the cord, hydramnios, syphilis, an acute\ninfectious disease in the mother, poisonings of the mother by metals\nand the like substances, maternal cardiac and renal diseases, chronic\ninflammations and displacements of the womb, and violent emotions are\nsome of the causes of abortion. In certain women a slight exertion, a\nmisstep, a fall, a ride over a rough road, the _debitum conjugale_,\nand similar causes bring on abortion; in other women almost no shock\nis enough to make them miscarry. Inflammations and displacements of\n{49} the womb cause most of the abortions in the first four months,\nand after that time syphilis and Bright's disease are the chief forces\nat work.\n\nIf a woman in early pregnancy begins to lose blood from the uterus,\nand has pain in her back and lower abdomen, abortion is threatened; if\nthis hemorrhage is marked, and the cervix is dilated, the abortion\nwill very probably occur; and the escape of the _liquor amnii_ renders\nthe abortion unavoidable. In this latter case the vagina and the\ncervical canal are packed with sterile gauze to check the hemorrhage,\nand after twenty-four hours it is removed. Then commonly the entire\novum comes away with the gauze, or what remains of it is taken out\nwith a curette.\n\nValvular lesions of the heart in pregnancy make a maternal mortality\nof about 28 per centum, according to Guerard, and when compensation is\nlost the mortality may run from 48 to even 100 per centum with\ndifferent physicians and different cases. The prognosis is good as\nlong as compensation is retained, but very bad if this fails. In the\nlatter condition premature labour is indicated, or the early removal\nof the viable child. Catholic physicians may not induce artificial\nabortion of an unviable foetus. The decree of the Holy Office\nconcerning this matter is as follows:\n\n  Beatissime Pater,--Stephanus . . . Archiepiscopus Cameracensis . . .\n  Quae sequuntur humiliter exponit:\n\n  Titus medicus, cum ad praegnantem graviter decumbentem vocabatur,\n  passim animadvertebat lethalis morbi causam aliam non subesse\n  praeter ipsam praegnationem, hoc est, foetus in utero praesentia,\n  una igitur, ut matrem a certa atque imminenti morte salvaret,\n  praesto ipsi erat via, procurandi scilicet abortum seu foetus et\n  ejectionem. Viam hanc consueto ipse inibat, adhibitis tamen mediis\n  et operationibus, per se atque immediate non quidem ad id\n  tendentibus, ut in materno sinu foetum occiderent, sed solummodo ut\n  vivus, si fieri posset, ad lucem ederetur, quamvis proxime\n  moriturus, utpote qui immaturus omnino adhuc esset.\n\n  Jamvero lectis quae die 19 Augusti, 1888, Sancta Sedes ad\n  Cameracenses Archiepiscopos rescripsit: _tuto doceri non posse_\n  licitam esse quamcumque operationem directe occisivam foetus, etiam\n  si hoc necessarium foret ad matrem salvandam: dubiis haeret Titius\n  circa {50} liceitatem operationum chirurgicarum, quibus non raro\n  ipse abortum hucusque procurabat, ut praegnantes graviter\n  aegrotantes salvaret.\n\n  Quare ut conscientiae suae consulat supplex Titius petit: utrum\n  enuntiatas operationes in repetitis dictis circumstantiis instaurare\n  tuto possit.\n\n  Feria iv, die 24 Julii, 1895.\n\n  In Congregatione generali S. Romanae et Universalis Inquisitionis .\n  . . Emi ac Rmi Domini Cardinales . . . respondendum decreverunt:\n  _Negative_, juxta alias decreta, diei scilicet 28 Maii, 1884, et 19\n  Augusti, 1888.\n\n  . . . Sanctissimus Dominus noster . . . approbavit.\n\nOther documents referring to the same matter are the following:\n\n  Epistola ad Archiepiscopum Cameracensem. . . . Anno 1886,\n  Amplitudinis tuae Praedecessor dubia nonnulla hinc supremae\n  Congregationi proposuit circa liceitatem quarumdem operationum\n  chirurgicarum craniotomiae affinium. Quibus sedulo perpensis,\n  Eminentissimi ac Reverendissimi Patres Cardinales una mecum\n  Inquisitores Generales, feria iv, die 14 currentis mensis,\n  respondendum mandaverunt:\n\n  In scholis catholicis tuto doceri non posse licitam esse operationem\n  chirurgicam quam craniotomiam appellant, sicut declaratum fuit die\n  28 Maii, 1884, et quamcumque chirurgicam operationem directe\n  occisivam foetus vel matris gestantis.\n\n  Idque notum facio Amplitudini tuae, ut significes professoribus\n  facultatis medicae Universitatis catholicae Insulensis. . . .\n\n  Romae, die 19 Augusti, 1889. . . .\n\n  R. CARD. MONACO.\n\nThe date of this response here is 1889, but in the preceding decree it\nis given as 1888. In the _Acta Sanctae Sedis_ the date is 1889.\n\nAnother letter from Cardinal Monaco is this:\n\n  Eme et Rme Dne,--Emi PP. mecum Inquisitores generales in\n  Congregatione habita feria iv, die 28 labentis Maii, ad examen\n  revocarunt dubium ab Eminentia tua propositum--An tuto doceri possit\n  in scholis catholicis licitam esse operationem chirurgicam, quam\n  Craniotomiam appellant, quando scilicet, ea omissa, mater et infans\n  perituri sint, ea e contra admissa, salvanda sit mater, infante\n  pereunte?\n\n{51}\n\n  --Ac omnibus diu et mature perpensis, habita quoque ratione eorum\n  quae hac in re a peritis catholicis viris conscripta ac ab Eminentia\n  tua hinc Congregationi transmissa sunt, respondendum esse duxerunt:\n  _Tuto doceri non posse_.\n\n  Quam responsionem cum SSmus D. N. in audientia ejusdem feriae ac\n  diei plene confirmaverit, Eminentiae tuae communico. . . .\n\n  R. CARD. MONACO.\n  Romae, 31 Mail, 1884.\n\n  Emo Archiepiscopo Lugdunensi.\n\nAnother decree concerning abortion is in part as follows:\n\n  Beatissime Pater,--Episcopus Sinaloen. ad pedes S.V. provolutus,\n  humiliter petit resolutionem insequentium dubiorum:\n\n  I. Eritne licita partus acceleratio quoties ex mulieris arctitudine\n  impossibilis evaderet foetus egressio suo naturali tempore?\n\n  II. Et si mulieris arctitudo talis sit, ut neque partus praematurus\n  possibilis censeatur, licibitne abortum provocare aut caesaream suo\n  tempore perficere operationem? . . .\n\n  Feria iv, die 4 Mail, 1898.\n\n  In Congregatione habita, etc. . . . EE. ac RR. Patres rescribendum\n  censuerunt:\n\n  Ad I. Partus accelerationem per se illicitam non esse, dummodo\n  perficiatur justis de causis et eo tempore ac modis, quibus ex\n  ordinariis contingentibus matris et foetus vitae consulatur.\n\n  Ad II. Quoad primam partem, _negative_, juxta decretum Feria iv, 24\n  Julii, 1895, de abortus illiceitate. Ad secundum vero quod spectat;\n  nihil obstare quominus mulier de qua agitur caesareae operationi suo\n  tempore subjiciatur. . . .\n\n  In sequenti Feria vi, die 6 ejusdem mensis et anni . . . SSmus\n  responsiones EE. ac RR. Patrum approbavit.\n\nPyelonephritis (an inflammation of the kidney where pus is present),\nfrom the pressure of the pregnant uterus, is a condition which\nsometimes obliges the physician to bring about premature labour to\nsave the mother. The symptoms usually appear in the latter half of\ngestation.\n\nChorea (\"St. Vitus' Dance\"), when it develops during pregnancy, has a\nmaternal mortality of from 17 to 22 per centum. It may cause death\nbefore the child is viable, and to empty {52} the uterus will stop the\nsymptoms. Here the decrees of the Holy Office will occasionally\nprevent the Catholic physician from interfering.\n\nIf a grave surgical operation is imperatively indicated during\npregnancy, and may not be put off until after delivery, it should be\nundertaken in many cases, because modern technique commonly does not\nbring about an abortion; but, in general, no rule can be given--each\ncase must be judged separately.\n\nIf a pregnant woman has at the same time considerable albumen in her\nurine and a low excretion of urea, her condition is very dangerous. To\nempty her uterus will, in most cases, relieve the renal trouble, but\nin any case premature labour is not to be induced rashly: many women\nescape, when by all the rules they should die.\n\nEclampsia is a very grave complication of pregnancy, and it was\nformerly supposed to be uraemia. The disease is characterized by\nconvulsions, loss of consciousness, and coma. It occurs, commonly, in\nthe second half of gestation, but it has been observed as early as the\nthird month. About 70 to 80 per centum of the cases are in primiparous\nwomen. The convulsions may come on altogether unexpectedly, but\ncommonly the attack begins with symptoms of toxaemia. Eclampsia may\noccur before, during, or after parturition. When it comes before term\nit usually ends in spontaneous or artificial abortion, but at times\nthe woman dies undelivered. Now and then she may recover and be\ndelivered at term.\n\nThe kidneys are usually affected, even in those cases in which\nalbuminous urine is not found. There is also a hemorrhagic\ninflammation of the liver; and oedema and congestion of the brain,\nwith or without apoplexy, are other symptoms of the disease. There are\nother lesions, but the chief are in the kidneys, liver, and brain.\n\nThe aetiology of the disease is not yet known, and there are very many\ntheories offered to explain it. The prognosis is always serious, and\nthe condition is one of the most dangerous found in pregnancy. The\nmortality varies, but it is about from 20 to 25 per centum in the\nwomen, and from 33 to 50 per centum in the children. It is impossible\nto determine {53} the prognosis in particular cases, but a large\nnumber of quickly recurring convulsive seizures, with a weak, thready\npulse, and a high temperature usually indicate a fatal ending.\nApoplexy, oedema of the lungs, and paralysis also, as a rule, end in\ndeath.\n\nIf the uterus is emptied during the convulsions, these cease either\nimmediately or soon after delivery, in from 66 to 93 per centum of the\ncases, and the maternal mortality then is about 11 per centum. With\nthe expectant treatment, in convulsive cases, about 28 per centum of\nthe women die, although a use of aconite in these cases may better the\nprognosis.\n\nPernicious vomiting (hyperemesis gravidarum) is another complication\nof pregnancy, which sometimes results fatally if the uterus is not\nemptied. There are cases, especially those with high fever, which end\nin death despite all treatment. Here, again, the aetiology of the\ndisease is not known. There is commonly an element of hysteria in the\ncondition, and in such a case moral suggestion often has a curative\neffect Any bodily irritation is to be removed. Eye-strain alone is\nenough to cause persistent vomiting. It is very difficult to decide\nwhen premature labour is absolutely indicated, because some very bad\ncases recover spontaneously when all hope is lost.\n\nHydramnios, or an excessive quantity of _liquor amnii,_ may so distend\nthe uterus as to cause grave danger to maternal life, and if the child\nis viable the uterus should be emptied.\n\nIntrauterine hemorrhage brought on by a premature separation of the\nplacenta is a very dangerous condition: 32 to 50 per centum of the\nmothers die, and 85 to 94 per centum of the children. In a marked\nhemorrhage the only way to save the mother is to empty the uterus, so\nthat it may contract and thus close the patulous vessels.\n\nPlacenta praevia is a placenta implanted in the neighbourhood of the\ninternal os of the uterine neck. This is a very perilous condition,\ncalling for the induction of premature labour. The medical treatment\nis artificial abortion as soon as the condition is diagnosed in any\nstage of gestation; but this is, of course, in conflict with the\ndecrees of the Holy Office. Under expectant treatment about 40 per\ncentum of {54} the mothers die, and 66 per centum of the children.\nThose children that are born alive commonly die within ten days after\ndelivery. The great foetal mortality is due to premature birth and\nasphyxiation. Skilful obstetricians get much better results, but\nskilful obstetricians are unfortunately rare.\n\nWhen the grave complications enumerated above occur in the early\nmonths of pregnancy, before the foetus is viable, the Catholic\nphysician, since by the natural law and the decisions of the Holy\nOffice he is forbidden to induce artificial abortion, must withdraw\nfrom the case. If there is no other physician to attend to the woman,\nhe must let her die. He can not withdraw without explanation, and in\nmany cases the explanation of the condition will promptly result in\nthe calling in of a physician who has no scruple in inducing this\nabortion, no matter how reputable he may be. The universal medical\ndoctrine is to induce abortion in cases where abortion will save the\nmother's life and the foetus is \"too young to amount to anything.\"\nThis is looked upon as legitimate abortion by the very best men that\ndo not recognise the authority of the Holy Office: they deem the\nposition of the Catholic physician in these cases as altogether\nerroneous, or even criminal.\n\nThe position of the Catholic moralists on craniotomy has turned the\nattention of many non-Catholic physicians to the immorality of the\nact, which formerly was deemed entirely permissible. Probably the same\ngood result will be effected in the matter of abortion.\n\nAUSTIN OMALLEY.\n\n{55}\n\nTHE CAESAREAN SECTION AND CRANIOTOMY\n\nIn the caesarean section the infant is delivered through an incision\nin the abdominal or uterine walls. The operation, according to one\nopinion, takes its name from Caius Julius Caesar, who, it is said, was\nbrought into the world in this manner, _\"a caeso matris utero\"_; this,\nhowever, is a myth.\n\nUp to 1876 the maternal mortality from the operation was about 52 per\ncentum. Between 1787 and 1876 in the city of Paris there was not one\nsuccessful caesarean section as far as the mothers were concerned. At\npresent on an average less than 10 per centum of the women are lost,\nand expert surgeons have better results. Up to about 1902 Zweifel had\nmade 76 such sections with only one death, and Reynolds, 23 with no\ndeath. Leopold has performed the operation four times on the same\nwoman, and Ahlfeld and Birnbaum have reported instances where the same\nwoman has had five caesarean sections performed upon her. The\noperation is, of course, capital, and always most serious, even in\ncity hospitals.\n\nThe indication for the operation is chiefly a narrow pelvis, which\nblocks the delivery of the child. There are no reliable statistics as\nto the frequency of narrow pelves in the United States; but Dr.\nWilliams, of the Johns Hopkins University Hospital, in a series of\n2133 cases found 6.9 per centum in white women and 18.82 in negroes.\nNormally the average female pelvis, at its narrowest diameter, is 11\ncentimetres wide. This part is called the conjugata vera, and it is\nthe diameter from the promontory of the sacrum behind to a point on\nthe inner surface of the symphysis pubis in front.\n\nIn delivery much depends upon the size of the child, and in each case\nthe obstetrician waits until he sees that delivery {56} is impossible\nby natural means before he resorts to the caesarean section or other\noperative interference. Of two women with pelves of the same\ncontraction one may require the section and the other may have a\nnormal labour. A bisischial diameter at the outlet of the parturient\ncanal of 7 centimetres or less is an indication for section; so are\ncertain tumours that block the delivery of the child.\n\nWhen the conjugata vera is less than 7 centimetres in flat pelves, or\n7.5 centimetres in generally contracted pelves, the treatment varies\nin the customary medical practice according as the child is alive or\ndead, and it varies as the condition of the mother. The common medical\ndoctrine will first be given here before the moral questions that may\nbe involved are mentioned.\n\nIf the deformity is diagnosed during pregnancy, the woman is sent to a\nhospital, the caesarean section is performed, and thus all the\nchildren, and nearly all the mothers, are saved. When the narrowness\nof the pelvis is discovered only during labour, the treatment varies\nwith the condition. If the woman is not septic, and has not been\nrepeatedly examined by the vagina, and if the surroundings are\nfavourable, caesarean section is done; if she is septic, the\nindications are for the section, or symphyseotomy or craniotomy. Where\nthe conjugata vera is below 5 centimetres in length, the caesarean\nsection is the only method to get the child out, dead or alive, and\nafter the child has been delivered, the uterus, if septic, is removed.\nIf the conjugata vera is at the least 7 centimetres long,\nsymphyseotomy may be done; if the conjugata vera is above 5\ncentimetres, the mother septic, and the child dead or dying,\ncraniotomy is indicated. Even if the child is not dying, some\nobstetricians will do craniotomy.\n\nIn cases where the conjugata vera is above 7 centimetres in flat\npelves and 7.5 centimetres in generally contracted pelves, the\ntreatment can not be reduced to general rules. Delivery without\noperation occurs in many of these cases, but commonly the condition is\nobscure to the physician for some time. We can measure the pelves, but\nthe size of the child's head is not satisfactorily measurable.\n\nIf the conjugata vera is from 10 to 9 centimetres, or from {57} 9.5 to\n8.5 centimetres, labour without operation is the rule, and the child\ncan usually be delivered by forceps. Should the child die during\nlabour in these cases, it is best delivered by craniotomy, unless the\nlonger diameter of its head has already passed the narrowest part of\nthe pelvis.\n\nWhen the conjugata vera is from 8.9 to 7.5 centimetres, about 50 per\ncentum of the women will be delivered with forceps, but the other half\nwill not. After about two hours of the second stage of labour delivery\nby forceps is tried, but prolonged traction is not applied.\nOccasionally delivery will come when least expected, but often it will\nnot. If the head sticks, caesarean section is done in favourable\ncircumstances, and craniotomy in unfavourable circumstances. If there\nis ground for supposing that septic infection of the mother has begun,\nthe conditions are explained, and if she wishes to have the caesarean\nsection done the risk is left to her. When the breech or face of the\nchild presents in contracted pelves, the condition is especially\nunfavourable for the child.\n\nThere are very many varieties of deformed pelves, but the same rules\napply to them as to those already mentioned, except that the caesarean\nsection is oftener indicated. Difficulty also not seldom occurs in\nwomen with normal pelves from an excessive size in the child through\nprolonged pregnancy, bigness of one or both parents, or the advanced\nage or multiparity of the mother. The child's head alone may be of\nexcessive size. Some monsters offer difficulty in delivery from size\nor shape, but, of course, they are human beings, and are to be\nconsidered as such in delivery. The technique of the caesarean section\nhas only a medical signification, and it need not be described here.\n\nSymphyseotomy is an operation in which the joint of the pelvis at the\nsymphysis pubis is cut, and the pelvis is allowed to gape so as to let\nout the child. The operation has fallen into disrepute. The mortality\nas regards the mother is about the same as in the caesarean section,\nbut the mortality of the children is higher. In symphyseotomy the\ninfantile mortality is about 9 per centum, while in the caesarean\nsection it is practically nothing. If in symphyseotomy an error is\nmade in estimating the size of the pelvis or the child's head--and\n{58} such an error is often possible--the child will be killed, but in\nthe caesarean section these errors make no difference. After the\ncaesarean section the woman recovers promptly; after the symphyseotomy\nshe recovers very slowly, and she may receive permanent injury.\n\nCraniotomy is an operation wherein the head of the child is reduced in\nsize to render delivery possible. The skull is perforated and the\nbrain is broken up and removed or crushed out. Embryotomy is a similar\noperation wherein the viscera of the child are removed through an\nincision made in its thorax or belly (evisceration), or the head of\nthe child is cut off (decapitation). There are numerous instruments\nand methods for performing craniotomy and embryotomy, but they all\nopen the skull or belly, remove the brain or viscera, and then extract\nthe child's body.\n\nIf the infant is hydrocephalic and is alive, the advocates of the\noperation warn us to be careful after opening the head to push the\nperforator into the base of the skull and stir it around well, so as\nto be sure the child will not be born alive. Pernice has recently\nreported a case of hydrocephalus which was delivered by craniotomy,\nbut the operator did not work his perforator efficiently, and the\nchild recovered, and grew up an idiot. A similar case occurred in\nBaltimore.\n\nThe indications for craniotomy among those that advocate its\noccasional use (and they are many) is in those cases in which the\nwoman is so infected that caesarean section is dangerous, or where a\nchild is hydrocephalic, or where an after-coming head is jammed (in\nthis case even a caesarean section will not effect delivery), or in\nthe case of a narrow pelvis and a moribund child, or finally in the\npractice of a country physician, who can not in an emergency get an\nassistant to do a caesarean section. One man can do craniotomy, but it\nrequires three to perform the caesarean section. If the woman's narrow\npelvis has a conjugata vera of five or more centimetres, craniotomy,\nif properly done, is not dangerous to the mother. With a conjugata\nvera less than 5 centimetres it is more fatal than the caesarean\nsection. If the women are septic, the mortality in {59} craniotomy is\nfrom 10 to 15 per centum; in caesarean section about 25 per centum.\n\nAs to the morality of craniotomy on the living or moribund child, it\nis not permissible under any possible circumstances: a consideration\nof the ethical principles set forth in the article on Ectopic\nGestation will make this assertion clear.\n\nThe Congregation of the Holy Office on August 19, 1888, decreed that\n\"In scholis catholicis tuto doceri non posse licitam esse operationem\nchirurgicam quam Craniotomiam appellunt.\" They gave a similar decision\nMay 28, 1884, and they repeated the prohibition, with the papal\napprobation, on July 24, 1895. The text of these decrees may be found\nin the article on abortion, miscarriage, and premature labour.\n\nThe Porro operation consists essentially in a removal of the uterus\nafter caesarean section to prevent further conceptions. As a means to\nprevent conception it is altogether unjustifiable, because repeated\ncaesarean sections in the same woman, if the surgeon is at all\ncompetent, are practically no more dangerous than normal labour.\n\nAUSTIN OMALLEY.\n\n\n{60}\n\nV\n\nMATERNAL IMPRESSIONS\n\n\nThere is a wide-spread persuasion that a child, while carried in the\nwomb of its mother, may be marked as the result of incidents that\nproduce violent impressions upon her nervous system. This is so old a\nconviction in the human race and would seem to be substantiated by so\nmuch evidence that it is extremely difficult to convince people that\nthere is no scientific basis for it. As a matter of fact, however,\nthere is something mysterious about the way in which certain things\nthat happen to the mother seem to affect the child _in utero_. As the\nresult of the common belief in the truth of maternal impressions,\nmothers sometimes are prone to blame themselves for not having been\nsufficiently circumspect during the time of their pregnancy, and\naccordingly they may seek advice and consolation in the matter from\nclergymen. Women sometimes become very much depressed as a consequence\nof an unfortunate event of this kind, and as the simple truth is the\nbest possible source of consolation, it would seem that a special\nchapter should be given to the subject in a work of this kind.\n\nThe evidence for the truth of the theory of maternal impression is\nalmost entirely due to peculiar coincidences. James I. of England, the\nson of Mary Queen of Scots, could never stand, according to Sir Walter\nScott, the sight of a drawn sword with equanimity, and it is said even\nthat he nearly fainted at his coronation because of an unexpected\nglimpse of some naked blades in the hands of courtiers. This\npeculiarity was attributed to the fact that his mother, while carrying\nhim _in utero,_ had witnessed the violent death of her secretary, the\nunfortunate David Rizzio. There have been, however, any {61} number of\nmen who paled at the sight of a drawn sword before and since James I.,\nwith regard to whom no such circumstantial story could be told to\naccount for it. There have been any number of women that have\nwitnessed bloody murders under circumstances quite as heartrending as\nthose surrounding Mary Queen of Scots and her secretary, and yet their\noffspring, though at the time _in utero_, have not been disturbed at\nthe sight of drawn swords, nor of blood or any other circumstance\nconnected with the deep impression that must have been produced on\ntheir mothers.\n\nThere is, of course, a striking instance related in the Old Testament,\nwhich seems to make it very clear that a belief in maternal\nimpressions existed from the very earliest times among the Israelites.\nThe story of Jacob is well known: \"Jacob took him rods of green poplar\nand of the hazel and chestnut tree and pilled white streaks in them\nand made the white appear which was in the rods, and he set the rods\nwhich he had pilled before the flocks in the watering troughs when the\nflocks came to drink, and the flocks conceived before the rods and\nbrought forth cattle, ring-streaked, speckled and spotted.\" In this\ncase it seems evident that Jacob was not looking for a miracle, but\nwas expecting that a law of nature would be fulfilled in the matter,\nthe influence of the unusual sight upon the animal mothers proving\nsufficient to have a definite effect upon their unborn offspring. The\nmost ardent advocates of the power of maternal impressions would\nscarcely concede the existence of as much influence as this of the\nmother's mind over the child unborn, otherwise there would surely be a\nvery absurd collection of anomalous births in the race.\n\nOn the other hand, it is generally conceded that the mother's habitual\ntemper of mind and the thoughts with which she occupies herself may\ninfluence her unborn offspring to a most marked degree. The story is\ntold of a child-murderer who delighted in fiendish deeds of cruelty\nand had murdered many people in cold blood, that his mother, the wife\nof a butcher, had delighted in watching the operation of slaughtering\nduring the course of her pregnancy. There are any number of women,\nhowever, who have, by the necessities {62} of their occupation, had to\nwitness the shedding of animal blood under such circumstances and yet\nwithout any special effect being noticeable in their offspring. It has\nbeen said that the opposite is also true, and that if a woman occupies\nherself with high and lofty thoughts, with noble deeds and unselfish\ndevotion to others and if she occupies her mind and senses with the\ngreat works of art, a correspondingly beneficial effect will be noted\nupon the character of the foetus. These are, however, abstruse\nspeculations leading to conclusions not founded upon actual\nobservation, but upon theorising over the supposed fitness of things.\n\nCoincidence plays such a large part in the matter of supposed maternal\nimpressions that it is impossible to decide how much there is of fact\nand of consequence in the many stories that are told. Most women are a\nlittle afraid, as the time of their labour approaches, lest something\nor other--usually of an indefinite nature--that has happened during\ntheir pregnancy, may cause the marking of their child. When they find\nthat the child is perfectly normal, they breathe a sigh of relief and\nforget all about it. If any anomaly is noted, however, then they are\nsure to connect it with some incident during pregnancy, and\nimagination is apt to lend details that confirm the supposed\nconnection. On the other hand, there are not a few cases in which such\nanomalies have occurred, and good, sensible mothers have been unable\nto recall anything that might possibly serve to account for the\npeculiarity noticed in the child, though corresponding peculiarities\nin other children were supposed to be readily traceable to maternal\nimpression. Even where there has been no foreboding of evil results,\nsomething or other that has occurred during the pregnancy will often\nbe magnified enough by memory to account for the supposed maternal\nimpression.\n\nDoctors are very familiar with this tendency to make up stories to\naccount for various deformities. It used to be considered that\nhip-joint disease and Pott's disease were the result of injuries in\nearly life. They are now known to be due to tuberculous processes not\nnecessarily and indeed only very seldom connected with injuries of any\nkind. Mothers are {63} nearly always able to account in some way,\nhowever, for the beginnings of the disease in some accident that has\nhappened. Young children are apt to have so many falls that some one\nof them is picked out as the probable cause of the disease that\nsubsequently manifests itself in the joints. It is just this state of\naffairs that occurs with regard to supposed maternal impression. Some\nincident that would be otherwise unthought of is magnified into an\naccident that caused a serious nervous shock, and consequently led to\nthe marking of the child.\n\nIn general it may be said for the clergyman's direction, that if women\nhave, as is sometimes the case, a morbid sense of their guiltiness\nwith regard to some maternal impression that has set a mark upon their\nchild, such a state of feeling may very well be rendered less poignant\nby a frank statement of the present attitude of mind of most\nphysicians with regard to the possible effects of maternal\nimpressions. Scepticism is much more the rule than it used to be, and\nas time goes on fewer and fewer of the cases that used to be\nconsidered so inexplicable in the direct relationship that seemed to\nexist between maternal impression and deformity in the child are\nreported. Fifty years ago nearly all the authorities on this subject\nwere agreed in considering that maternal impressions did play some\npart, though they could not explain just how, in the production of\ncertain deformities. Now we venture to say that most of the thinking\nphysicians who have occupied themselves with this subject would\nscarcely hesitate to say that they were utterly incredulous of any\nsuch effects being produced. The lack of any direct nervous or blood\nconnection between mother and child is the basis for such disbelief,\nand is of itself the best argument against the old tradition.\n\nWith regard to mental defects, as a rule, not so much is said as for\nbodily defects. Bodily deformities are noted at once after birth, and\nthen the mother recalls some incident of the pregnancy to account for\nthem. Mental defects are, however, noticed much later, and are not so\nlikely to be considered as connected with incidents of the puerperal\nperiod. There is no doubt that if the mother has had to pass through a\nseries of emotional strains, or has suffered from severe {64} shocks,\nchildren are likely to be born with diminished mental capacity. This\nis, however, not difficult to understand, since such incidents produce\ndisturbances of the nervous system of the mother, and consequently\nalso of her nutrition, and this is prone to be reflected in the\nchild's condition, especially in that most delicate part of the\nchild's organism, the brain. Hence it is that children born during the\nsiege of Paris, or shortly after, were defective to such a marked\ndegree that they were spoken of as \"children of the siege,\" and this\nwas considered to be quite sufficient explanation of nervous\npeculiarities later in life.\n\nBaron Larrey, the distinguished French surgeon, made a report with\nregard to the children born after the siege of Landau in 1793. Of 92\nchildren, 16 died at birth, 33 died within ten months, 8 showed marked\nsigns of mental defects, most of them to the extent of idiocy, and two\nwere born with several broken bones. In this case, however, it is well\nknown that besides the shock of the danger consequent to the siege and\nthe fear and distress of the women with regard to their husbands and\nrelatives, there were added many privations and physical sufferings.\nThe nutrition of the mothers was seriously disturbed by these, and it\nmight well be expected that the children should suffer severely. The\nstatistics of such events are not available in general, and when an\neffort is made to establish a cause for idiocy under other\ncircumstances, none is usually found. Out of nearly five hundred cases\nof idiots whose histories were carefully traced in Scotland, in only\nsix was there any question of maternal impressions having been the\ncause of the condition.\n\nOf course there are many very wonderful coincidences that seem to\nconfirm the idea that impressions made upon the mother's mind are\nsometimes communicated to the child in her womb. That they are not\nmore than coincidences, however, is rather easy to demonstrate in most\ncases, since, as a matter of fact, at the time when the incident\noccurred which is supposed to have caused the deformity in the foetus,\nthe stage of development of the intrauterine child has passed long\nbeyond the period when formative defects could occur. For instance, it\nsometimes happens that the child-bearing woman {65} sees an accident\nespecially to the father of the child involving the loss of a limb.\nIf, by chance the child should be born with a missing member, as\nsometimes happens, then there would seem almost to be no doubt of a\ndirect connection between the accident witnessed, the effect produced\nupon the mother's mind, and the consequent deformity.\n\nWe know now that the formation of the limbs of the foetus is complete\nby the end of the third month. At this time the woman is scarcely more\nthan conscious of the fact that she is pregnant, and it is not during\nthis early period, as a rule, but during a much later period, that\nmaternal impressions are supposed to have their influence. It is only\nsuch maternal impressions as occur very early in pregnancy, before the\ntenth week as a rule, that could possibly have any effect in the\nproduction of such deformities. It is by no means infrequent, however,\nto have children born lacking one or both limbs. Sometimes nothing but\nthe stumps of limbs remain. In such cases it is now well known that\nintrauterine amputation has taken place. Some of the membranes that\nsurround the child, especially the amnion, become separated into bands\nwhich surround tightly the growing members of the foetus and by\nshutting off the blood supply through constant pressure, lead to the\ndropping off of all that portion of the member lying below the band.\n\nNot infrequently it happens that when a child is born thus deformed,\nthe mother, by carefully searching her memory, can find some dreadful\nstory that she has read, some accident that she has seen or heard of,\nand that has produced a seriously depressing effect upon her at the\ntime, to which she now attributes the deformity that has occurred.\nUntil the unfortunate appearance of her child was reported to her, she\nhad no idea of any possible connection between the story and the\nbodily state of her intrauterine child. In not a few cases, however,\nthe most faithful searching of the memory fails to show anything which\ncould, by any possible connection, be made accountable for the\ndeformity; and these cases, we may say at once, are in a majority.\n\nNot a little of a popular notion with regard to the influence of\nmaternal impression is due to the repetition of certain {66} village\ngossip which by no means loses its point or effectiveness passing from\nmouth to mouth. On the other hand, maternal impressions have been\nexploited by novelists, who have found that the morbid curiosity of\nwomen particularly with regard to this subject may make their stories\nmore widely read. Lucas Malet, who, in spite of the apparently\nmasculine pseudonym, is really the late Rev. Charles Kingsley's\ndaughter, has recently called renewed attention to this subject by her\nnovel \"Sir Richard Calmady.\" In this the hero is born with both his\nlower limbs missing from just below the knees. The author has been\ncareful, however, with regard to the details of the supposed maternal\nimpression to which this deformity is attributed. A young married\nwoman in the early part of her first pregnancy has her husband, whom\nshe loves very dearly, brought back to her with both his limbs taken\noff by a shocking accident which resulted fatally. It is not\nimpossible, some physicians might think, to consider that so severe a\nshock could produce a very deleterious effect upon the foetus. That\nthe result should so exactly copy the scene which was brought under\nthe eyes of the young mother is, however, beyond credence.\nOccasionally such stories, supposedly on medical authority, find their\nway into the newspapers, usually from distant parts of the country.\nCertain parts of Texas particularly seem to be a fruitful source of\nsuch stories for newspaper correspondents when there is a dearth of\nother news. Farmers in thinly settled parts of the country lose a foot\nin a reaping machine or a hand in the hay-cutting machine when there\nis no one near to help them but their wives, with the result that the\nshock to their wives proves the occasion of a similar deformity in an\nas yet unborn child. Careful investigation of such cases, however, has\ninvariably shown that either they were completely false or that the\ndetails showed that whatever had happened was at most a coincidence\nand never a direct causative factor in the subsequent deformity.\n\nThe greatest difficulty in the mind of the medical man, with regard to\nthe possibility of maternal impression being communicated in any way\nto the foetus, is, as we have said, his knowledge of the anatomy of\nmother and foetus. While it is {67} generally supposed that the mother\nis very intimately connected with her child _in utero,_ the actual\nconnection is by no means so direct as might be expected from the\npopular impression. It is usually considered that the mother's blood\nflows in the child's veins; but this is absolutely false. The child's\nblood is formed independently of the mother's blood quite as is that\nof the chick in the egg. At all times the blood of the child remains\nquite different in constitution to that of its mother. It contains\nmany more red cells than does her blood and differs in other very\neasily recognisable ways. Mother and child are connected by means of\nan organ known as the placenta, which is attached very closely to the\nuterine wall and from which through the cord the blood of the foetus\ncirculates. This placenta constitutes the so-called afterbirth. The\nmother's blood flows in one portion of it, that of the child in\nanother, and they always remain distinct and separate from each other.\nThe gases necessary for the child's life diffuse through the membrane\nwhich separates the two different bloods, and the salts and soluble\nproteids necessary for the child's nutrition, as well as the water\nnecessary for its vital processes, all pass through this membrane, but\nat no time is there any direct blood connection between mother and\nchild. Indeed, for a large part of the formative period of the foetus\nlife, that is, during the first two months of its existence, the ovum\nis not very closely attached to the uterus at all, but grows by means\nof the vital power which it has within itself.\n\nNor is there any direct nervous connection between mother and child;\nindeed, there are no nerves at all in the placenta, and none in the\ncord through which all communications between mother and child must\npass. It seems impossible to explain, then, how maternal impressions\ncan so effectively pass from mother to child; and indeed, the whole\nsubject, when looked at in this way, is apt to be considered\nlegendary, and the facts adduced in support of the theory of maternal\nimpressions are practically sure to be thought mere coincidences. A\nlittle knowledge here might seem to justify many things that more\ncomplete knowledge fails to be able to find any reasons for.\n\n{68}\n\nThere is no doubt, however, that the mother's environment during\npregnancy is in general very important for the perfect development of\nthe intrauterine child. Many more deformed births are reported after\ntimes of stress and trial, as, for example, after the sieges of great\ncities, notably the siege of Paris in 1871, and such scenes of\ndesolation as occurred during the thirty years' war in Germany. These\nare, however, not direct, but indirect effects of maternal\nimpressions. The development of the human being _in utero_ is an\nextremely complicated process. Any disturbance of it, however slight,\nis sure to be followed by serious consequences. Disturbances of\nnutrition, such as are consequent upon the deprivation that has to be\nendured in times of war or during sieges, is of itself sufficient\nseriously to disturb even the uterine life of the child. In these\ncases, however, there will be no traceable connection between the form\nof the maternal impression and the type of deformity that occurs. This\nis, however, the essence of the old theory of the direct effect of\nmaternal impressions, and consequently that theory must fall to the\nground.\n\nFrom all that has been said, however, it becomes very clear that as\nfar as possible women should be shielded from the effect of various\nnervous shocks during their pregnancy, and that they owe it to\nthemselves and their offspring to be careful with regard to any morbid\nmanifestations of feeling that they may detect in themselves.\n\nJAMES J. WALSH.\n\n{69}\n\nVI\n\nHUMAN TERATA AND THE SACRAMENTS\n\nTeratology ([Greek text], a monster) is a part of biology that treats\nof deviation from a normal development in man and the lower animals.\nThe name was adopted in 1822 by the elder Saint-Hilaire, who then\nattempted to separate the results of modern exact methods of research\nfrom the myths and loose descriptions of monsters found in the\nwritings of old authors. Cicero (_De Divinatione_) derives the term\nmonster from the proper preternatural signification looked for in the\noccurrence of these abnormal beings: \"Monstra, ostenta, portenta,\nprodigia appellantur, quoniam monstrant, ostendunt, portendunt et\npredicunt.\"\n\nAt the end of the seventeenth century Malpighi and Grew discovered\nthat plant tissue is entirely made up of microscopic spaces enclosing\nfluid; they called these spaces _cells_. Different investigators found\nthat animal tissue is also composed of cells; and between 1835 and\n1839 Schwann and Schleiden formulated the law that every metazoic\norganism is made of cells, and starts from a cell.\n\nIn 1672 de Graaf discovered the mammalian ovum, in 1675 Ludwig Ham\nfound spermatozoa, in 1827 von Baer recognised the human ovum, but not\nuntil 1875 was the important fact established that fertilisation is\neffected by the fusion of the male and female pronuclei. This was\ndemonstrated by Oscar Hertwig from observation of the ova of\nstarfishes.\n\nMammalian ova, owing to an almost complete lack of yolk, are all\nsmall. The egg of a whale is about the size of a fern-seed, but the\nyolked eggs of birds are large--that of the great auk was 7.5 inches\nlong. In man the ovum is from 0.18 to 0.2 mm. in diameter, scarcely\nvisible to the {70} naked eye, and the spermatozoon is extremely\nminute. The human spermatozoon is only fifty-four thousandths of a\nmillimetre in length, and from forty-one to fifty-three thousandths of\na millimetre are taken up by its flagellum. The essential part is from\nfour to six thousandths of a millimetre in length (Dr. L. N. Boston,\n_Journ, of Applied Microscopy_, vol. iv. p. 1360). A line of 18 human\nspermatozoa would reach only across the head of an ordinary pin. These\nspermatozoa have the power of locomotion in alkaline fluid. Henle\nfound they can travel one centimetre in three minutes.\n\n  The human ovum and spermatozoon are single cells, and the principal\n  parts of a typical cell are the cytoplasm (called also the\n  protoplasm), and, within this, the nucleus and centrosome. The\n  centrosome is efficient in the process of cell-division. A few cells\n  have also an outer envelope or membrane, and this part is well\n  developed in the ovum.\n\n  The nucleus is the centre of activity in a cell. In the resting\n  state it is surrounded by a membrane, and within the membrane is an\n  intra-nuclear network made up of chromatin and linin--the chromatin\n  is an important element. The meshes of this network are probably\n  filled with fluid.\n\n  During the stages preparatory to the mitotic, or indirect, division\n  of a cell into two cells (one of the methods of reproduction) the\n  chromatin segregates in typical cases into two groups of loops, and\n  each group has equal portions of the chromatin. When the chromatin\n  is in this shape, a loop is called a chromosome.\n\n  The chromosomes are very important. They occur in constant definite\n  numbers in the somatic cells of the various species of many animals\n  and plants, and it is probable that each species of plant and animal\n  has its own characteristic number of chromosomes. Wilson (_The Cell\n  in Development and Inheritance,_ New York, 1890) gives a list of 72\n  species in which the number has been determined. Man has probably 16\n  chromosomes in the somatic cell, and the mature male and female germ\n  cells in man contribute eight chromosomes each to the nucleus of the\n  impregnated ovum.\n\nThe chromosomes transmit the physical bases of heredity from one\ngeneration to the next, and the heritages from the two parents are\nequal except in cases of prepotency. Every cell {71} in the human body\nis derived from the father and the mother equally. The fact that the\nwoman carries a child for months in her womb means only that she\nemploys a peculiar method of feeding and protecting it. After its\nbirth she feeds it from her breasts, before birth through its\numbilical vessels, but she originally gives only the eight chromosomes\nas the father does, and the child's vital principle builds up the body\nfrom this foundation. The popular notion that the foetus in the womb\nis formed through some process of literal abstraction from the\nmaternal tissues is no more true than that the infant is so built up\nwhile it is suckling; both processes are merely different methods of\nfeeding.\n\nAll the chromosomes from the fathers of at least 200 men could fit\nsimultaneously on the head of one pin, yet virtually, not merely\npotentially, half the bodily substance of that multitude, and all the\nphysical characteristics derived from the 200 fathers, are indubitably\ncontained in those chromosomes and nowhere else, unless by a special\ncreation they are infused with the new soul, which seems to be an\naltogether unreasonable alternative. This statement concerning the\nminuteness of the chromosomes is not speculation--they can readily be\nseen and measured with the aid of the microscope.\n\nA human being, then, obtains eight microscopic chromosomes from his\nfather and eight from his mother, positively nothing more except food;\nyet he develops into a man with a body made up of countless millions\nof cells which expand into more than 200 bones in the skeleton and\nover 200 muscles,--into the fascias, ligaments, tendons, the great and\nsmall glands, the lymph and blood systems, the respiratory and\nalimentary tracts, the skin and its appendages, and a nervous system,\nwhich alone furnishes material for years of study if we would learn\nits anatomy fully. Not only all this, but the man commonly closely\nresembles his father or his mother, or some other ancestor, in\npersonal appearance, in certain physical tendencies, in graces or\nblemishes; and furthermore, he shows inherited racial characteristics.\n\nIf a father is prepotent, he may have a greater effect in producing\nthe formed child than the mother has, and _vice versa,_ as when a son\nclosely resembles his father or his mother. {72} Prepotency, moreover,\nmay extend down through generations and centuries. In the streets of\nPalermo to-day typical Normans may be seen, despite the intermarriages\nof centuries, who are the descendants of those male Normans that went\ndown to Sicily with Tancred. There are Romans there, too, and\nSaracens. When the Belgae--a race of tall, red-bearded men, with\nelliptical skulls--went from the continent of Europe to Ireland,\nprobably six centuries before our era, they conquered the aborigines,\na gentle, brune race of lower stature. These Belgae became the\nancestors of the chieftain class, and their physical type persists\nuntil to-day; so does that of the Pictish aborigines. Daniel O'Connell\nhad a typical Belgic body. Other big, blond Irishmen are Norse or\nDanish in remote origin.\n\n  How is the extremely complex human body with its various physical\n  characteristics built up from the nucleus of a fecundated cell, the\n  ovum? The endeavour to answer this question has brought out most\n  ingenious speculation from nearly all the great biologists of modern\n  times. The question is the foundation of the theories of heredity,\n  and it is also fundamental in the theories of evolution.\n\n  The human ovum is a flattened spherical cell, made up of a very\n  delicate cell-wall, called the vitelline membrane; outside this is a\n  comparatively thick membrane, the zona pellucida, which is properly\n  not a part of the cell. Within the vitelline membrane is a granular\n  cytoplasm, the vitellus (yolk), and in this lies the nucleus, which\n  in the old text-books was called the germinal vesicle. This nucleus\n  contains a nucleolus.\n\n  The human spermatozoon consists of a flattened head which has a thin\n  protoplasmic cap extending down two-thirds of its length. In the\n  head is the nucleus with the chromatin. Beyond the head is the neck,\n  which contains the anterior and posterior centrosomes. Behind the\n  neck is the tail, or flagellum, in three parts,--the middle piece,\n  the principal part, and the end piece. From the neck to the end of\n  the tail centrally runs a bundle of fibrils, the axial filament. In\n  the middle piece these fibrils are wrapped within a single spiral\n  filament which winds from the neck down to the annulus at the\n  beginning of the principal part, and lies in a clear fluid. Without\n  the spiral filament, along the middle piece, is the mitochondria, a\n  finely granular protoplasmic layer. The principal part of the tail\n  consists of the axial {73} filament enclosed in an involucrum, and\n  the end piece is made up of this filament without the involucrum.\n\n  The head and neck of the spermatozoon, which contain the nucleus and\n  centrosomes, are the essential parts, and the middle piece and the\n  remainder of the tail appear to be used solely for locomotion and\n  penetration. When the head penetrates the ovum, the tail is detached\n  and rejected.\n\n  Our knowledge of the initial stages in the development of a human\n  embryo is derived indirectly from the observation of other mammals.\n  There are nine early human embryos reported, and the average\n  probable age of these is twelve days. Breuss' specimen was probably\n  ten days old (_Wiener med. Wochenblatt,_ 1877). Peters (_Einbettung\n  des mensch. Eies,_ 1899) found a smaller embryo than this. The\n  Breuss ovum was 5 mm. in length; Peters' was 3 by 1.5 by 1.5 mm.,\n  but the probable age was not given. There have been numerous embryos\n  more than twelve days old observed, and since the process after the\n  twelfth day is identical in man and the higher mammals, there is no\n  doubt that the first stages are also the same.\n\n  The segmentation that makes new cells is complicated, and the\n  outcome of the division is a ball of cells. In eggs which have a\n  large yolk, like those of birds, the cells form a round body resting\n  on the surface of the yolk, but in mammalian ova a hollow ball of\n  cells, or a _Morula,_ results, which lines the internal surface of\n  the cellular envelope. The ovum absorbs moisture by osmosis and\n  enlarges, and about the twelfth day after the germ-nuclei have begun\n  to divide, the Morula, or hollow ball of cells, called also the\n  _Blastodermic Vesicle,_ is formed.\n\n  The next stage in development is the establishment of two primary\n  germinal layers, called together the _Gastrula_, The outer layer is\n  the _Ectoderm_ or the _Epiblast,_ and the inner layer is the\n  _Endoderm_ or _Hypoblast_. In a Morula the smaller cells, which\n  contain less yolk-material, gradually grow around the larger\n  yolk-containing cells to form the Gastrula.\n\n Between the Ectoderm and the Endoderm a layer of cells called the\n _Mesoderm_ or _Mesoblast_ is next formed, and from these three layers\n all the parts of the embryo are built up. From the outer Ectoderm and\n the inner Endoderm those organs arise which are in the body, outer\n and inner,--as the nervous system and the outer skin from the\n Ectoderm, the inner entrails, the lungs and liver, from the Endoderm.\n From the Mesoderm come the inner skin, the bones and muscles.\n\n  By this time the embryo is a minute longitudinal streak at the {74}\n  surface of one pole of the ovum. The \"Primitive Trace\" is like a\n  long inverted letter U, the legs of which are in apposition. The\n  Primitive Trace becomes a circular flattened disc; and it grows into\n  a cylindrical body by the juncture of the free margins which fold\n  downward and inward and meet in the median line, and this closes in\n  the pelvic, abdominal, thoracic, pharyngeal, and oral cavities. The\n  legs and arms bud from this cylinder later. While the ventral\n  cylinder is growing, another longitudinal cylinder is formed along\n  the upper surface of the embryo, which will contain the brain and\n  the spinal column. The subsequent development of the embryo and\n  foetus need not be known for an understanding of the material\n  considered in treating here of terata.\n\nHuman terata occur in certain rather definite, types of erroneous\ndevelopment, and the classification of Hirst and Piersol (_Human\nMonstrosities_, Philadelphia, 1891), which is a combination and change\nof the classifications of Geoffrey Saint-Hilaire, Klebs, and Foerster,\nis the most satisfactory. There are four great groups of abnormally\ndeveloped human beings: (1) Hemiteratic; (2) Heterotaxic; (3)\nHermaphroditic; (4) Monstrous.\n\nHemiterata are giants, dwarfs, persons showing anomalies in shape, in\ncolour, in closure of embryonic clefts, in absence or excess of\ndigits, or having other defects. This group does not come under\ndiscussion here, but attention should be called to the fact that women\nwho are dwarfs are to be warned before marriage that they cannot be\ndelivered normally,--that the caesarean section or symphyseotomy will\nbe necessary, or that certain physicians will practise craniotomy in\ndelivering them.\n\nThe Heterotaxic group comprises persons whose left or right visceral\norgans are reversed in position through abnormal embryonic\ndevelopment; the liver is on the left side, the heart points to the\nright, and so on.\n\nOf the next group, the Hermaphroditic, it may be said that a true\nhermaphrodite, in the full sense of the term, has not been found; but\nthere have been several examples of individuals who had an ovary and a\ntesticle, and other rudimentary sexual organs that belonged to both\nmale and female. Forms of apparent doubling are common, and in case of\ndoubt as to sex the probability leans toward the {75} masculine side.\nAs to marriage in such cases, questions may arise that are to be\nsettled by the anatomist. In dealing with double monsters it is\nsometimes difficult or impossible to determine whether we have to do\nwith one or two individuals, and this difficulty has serious weight,\nespecially in the administration of baptism. It is improbable that\nthere is a doubling of personality in hermaphrodites. A striking\ncharacteristic of compound terata is that the individuals are always\nof the same sex; moreover, the embryonal development of reproductive\norgans in general is such as almost to preclude a question of duality\nof personality.\n\nTerata, more properly so called, are divided into single, double, and\ntriple monsters. Single monsters may be autositic, or independent of\nanother embryo or foetus; or they may be omphalositic, that is,\ndependent upon another embryo or foetus, which is commonly well\ndeveloped, and which supplies blood for both through the umbilical\nvessels. When an omphalosite exists, the other foetus is called, in\nthis case also, the autosite.\n\nThe first order of autositic single monsters contains four genera with\neight species, and under these species are thirty-four varieties. They\nmay have imperfect limbs, no limbs, one eye in the middle of the\nforehead (_cyclops_), fused lower limbs (_siren_), and so on. Some of\nthese monsters show a strong resemblance to lower animals, but there\nis no record that is in any degree scientific of a hybrid between a\nhuman being and a lower animal.\n\nThere are two genera of the omphalositic single monsters, with four\nspecies. One of the twins, the autosite, is commonly a normal child;\nthe other, the omphalosite, may be as small as a child's fist, and be\nvery much deformed. Of these omphalosites the _paracephalus_ has an\nimperfect head, commonly no heart, and the lungs are absent or\nrudimentary. The _acephalus_ has no head, and commonly no arms; the\n_asomata_ is a head more or less developed, with a sac below\ncontaining rudiments of the trunk organs. The Acephalus is very\nrare--the rarest of all monsters except the Tricephalus. There is a\nfourth kind--the _foetus anideus_. This is a shapeless mass of flesh\ncovered with skin. There may be a {76} slight prominence with a tuft\nof hair on it at one end of the mass to indicate the head. In this\nmonster there are more traces of bodily organs than might be expected.\nThese four kinds of omphalosites are either dead when born, or they\ndie as soon as the placental circulation is cut off. If there is any\nprobability of life, the physician should give them baptism before the\nplacental circulation is stopped.\n\n  Nothing satisfactory is known concerning the etiology of single\n  monsters. Landau, and other authorities as great as he is, reject\n  the theory that maternal impressions from fright or exposure to the\n  sight of hideous deformity are the cause of terata. I think the\n  father is accountable for terata as often as the mother is. Barnes,\n  an English physician, and others claim they find that terata are\n  frequent in consanguineous marriages, but I have not been able to\n  verify the assertion.\n\n  It seems a theory may be offered to explain the single terata. In\n  1888 Roux of Breslau by puncturing one blastomere of a frog's egg in\n  the two-cell stage killed the punctured blastomere without affecting\n  the other. The punctured blastomere remained inactive, but the other\n  developed into a complete _half_ embryo.\n\n  Crampton by separating and isolating the blastomeres in the two-cell\n  stage obtained a half embryo; and Zoja by isolating blastomeres of\n  the medusae, Clytia and Laodice, got _dwarfed_ larvae.\n\n  Wilson succeeded by the separation through shaking of the\n  blastomeres in the two-cell and four-cell stages in developing\n  Amphioxus larvae, which were half the natural size for the two-cell\n  blastomeres, and commonly half the normal size from the four-cell\n  blastomeres, yet in the latter some of the larvae were of the normal\n  size but imperfect From the eight-cell stage he got only _imperfect_.\n  larvae. Similar results were obtained by other operators with\n  various eggs.\n\n  Driesch and Morgan by removing part of the cytoplasm from a\n  fertilized egg of the ctenophore, Beroe, produced imperfect larvae\n  showing certain defects which represent the parts removed.\n\n  In these cases of injured and isolated blastomeres we have, it seems\n  to me, a plausible theory for the etiology of single terata. The\n  blastomeres in the human ovum may perhaps be injured in part by\n  toxins from the mother, or they may be defective through disease in\n  the ovum or the spermatozoon. They also may possibly be displaced\n  traumatically, but this seems to be doubtful.\n\n  There are three theories concerning the origin of omphalositic {77}\n  terata. Ahlfeld (_Missbildungen des Menschen_, Leipsic, 1882) holds\n  that the autosite is stronger than the omphalosite, and as a\n  consequence the foetal circulation in the omphalosite is reversed,\n  and development is thus checked. Dareste (_Production artificielle\n  des monstruosites_, Paris, 1876), Panum (_Beitrag zur Kenntniss der\n  physiol. Bedeut. der angeboren Missbildungen, Virchow's Archiv.,_\n  1878), Perls (_Lehrbuch der allgem. Pathologie_) and Breus (_Wiener\n  med. Jahrbuch_, 1882) maintain there is an inherent original defect\n  in the omphalositic child which prevents development of the\n  blood-vessels, and that Ahlfeld's theory of an indirect umbilical\n  connection of the omphalosite to the placenta is not probable; if it\n  were, omphalosites would be very common, because one of twins is\n  nearly always stronger than the other. Hirst and Piersol (_op. cit_)\n  combine these theories. This kind of monster is certainly an\n  imperfectly developed human individual, and even the Foetus Anideus\n  should receive at the least conditional baptism.\n\nThe next group comprises the composite monsters. Normal twins may\narise from the fertilisation of one ovum and of two distinct ova. In\n506 cases examined by Ahlfeld he found that 66 twin births came from\nsingle ova. Twins from a single ovum are always of the same sex, and\nthey are not easily distinguished one from the other. Triplets may\narise from one, two, or three ova. The elder Saint-Hilaire thought\nthat composite monsters arise from the fusion of two impregnated ova,\nbut this opinion is now generally rejected. Composite terata in every\ninstance arise from a single ovum.\n\n  There is a divergence of opinion, however, as to the origin of a\n  composite monster in the single ovum. Some authorities maintain that\n  these monsters arise from the union of two originally separate\n  primitive traces. This supposes primitive duality followed by fusion\n  (_Verwachsungstheorie_). Other writers hold that there is originally\n  one primitive trace, and that composite terata are the product of a\n  more or less extensive cleavage of this single blastoderm. This\n  supposes primitive unity followed by fission (_Spaltungstheorie_).\n  Here, as in the case of normal development, the argument is founded\n  on analogy. The earliest stage in the development of a human double\n  monster observed was at the fourth week after\n  fertilisation--Ahlfeld's case.\n\n  B. Schultze (_U. anomale Duplicitaet der Axenorgane, Virchow's\n  Archiv._) and Panum and Dareste (_op. cit._) hold the fusion\n  theory-- {78} the fusion of two separate blastoderms in one ovum.\n  Panum and Dareste have seen two separate normal blastoderms on one\n  ovum. Allen Thompson in 1844 (_London and Edinburgh Monthly Journal\n  of Medical Science_), Wolff, von Baer, and Reichert also observed\n  two embryos in one ovum. Dareste is of the opinion that the fusion\n  of two separate ova is impossible. The fission theory--the fission\n  of a single blastoderm to make a composite monster--is supported by\n  Wolff, J. F. Meckel, von Baer, J. Mueller, Valentine, Bischoff, and\n  others, especially by Ahlfeld. Ahlfeld says that this single\n  blastoderm is split by pressure.\n\n  Gerlach also (_Die Entstehungsweise der Doppelmissbildungen, etc.,_\n  Stuttgart, 1882) admits fission, but he contends that it is not so\n  simple a process as Ahlfeld thinks it is. It is not a passive\n  cleavage, but a result of a force in the cell-mass existing before\n  differentiation. Gerlach calls fission at the anterior or head-end\n  of the single blastoderm, _bifurcation_; and he has actually\n  observed such bifurcation in a chick embryo of sixteen hours (_U. d.\n  Entstehungsweise der vorderen Verdoppelung. Deutsche Archiv. f.\n  klin, Med.,_ 1887). In this case the first change noticed was a\n  broadening of the anterior end of the primitive streak; next a\n  forked divergence appeared, and this became more pronounced; until\n  by the twenty-sixth hour the bifurcation was half as long as the\n  undivided posterior part. From each anterior end of the diverging\n  branches a distinct head-process extended. Allen Thompson (_loc.\n  cit._) in 1844 saw a goose-egg, which had been incubated for five\n  days, in which was a double monster divided to the neck.\n\n  Beyond this observation by Gerlach we have the fact, which seems to\n  make for the fission theory, that no matter how unequally nourished\n  or how variable in extent, the union between the halves of double\n  monsters is always symmetric--exactly the same parts of each twin\n  are joined. This seems to exclude a fortuitous growing together of\n  dissimilar areas or cell-masses, for non-parasitic double terata at\n  the least. Born ( _U. d. Furchung des Eies bei Doppelbildungen,\n  Breslauer Aerztl. Zeitschr._, 1887), in a study of fish ova, found\n  that ova which produce double monsters begin with a segmentation\n  like that of the single normal ovum.\n\n  If fission is complete homogeneous twins are the result; these twins\n  are of the same sex and very similar in appearance. Incomplete\n  fission, as has been said, gives rise to double or triple terata. If\n  one of the teratic twin embryos is stronger than the other, the\n  various combinations of enclosure and parasitism may result,\n  although the origin of parasitic double terata is not convincingly\n  clear. A triple {79} monster, according to the fission theory,\n  arises from a double incomplete cleavage of the primitive trace. Dr.\n  Ephraim Cutter has observed teratic composite spermatozoa which, he\n  thinks, probably have influence in producing composite monsters.\n\nThere are three orders of the double autositic monsters: _Terata\nKatadidyma,_ in which the embryonal fission was at the cerebral end;\nthe _Terata Anadidyma_, divided below; the _Terata Anakatadidyma_,\ndivided above and below, but joined at the middle of the body. There\nare four genera of the Terata Katadidyma with many species. The first\ngenus is the _Diprosopus,_ the double-faced. The doubling varies from\nthe finding of two complete faces to a slight trace of duplex\nformation in one head. Foerster in 500 human monsters observed 29 cases\nof diprosopi.\n\nThere are six species of diprosopi: 1. _D. Diophthalmus,_ which has\nonly two eyes, but there is a doubling of the nose. 2. _D. Distomus_,\nwhich has two mouths, two lower jaws, two tongues, one pharynx, and\none oesophagus. 3. _D. Triophthalmus_, which has three eyes, and the\ndoubling of the face is more complete. There are only two ears. 4. _D.\nTetrophthalmus_, which has four eyes and two well-separated faces. 5.\n_D. Triotus_ is like the last, but it has three ears. 6. _D. Tetrotus_\nhas four ears, four eyes, and there is some doubling at the pharynx.\nTwo oesophaguses enter one stomach in this species commonly. D.\nTetrotus is rare--only one example in man is known. In all diprosopi\nthere is only one trunk, one pair of arms, and one pair of legs. Sir\nJames Paget had a photograph, made in 1856, of a living diprosopus,\nthe second face of which had a mouth, nose, eye, part of an ear, and a\nbrain (?) of its own. The two faces acted simultaneously, suckled,\nsneezed, yawned together.\n\nAre diprosopi twins? An answer to this question will be clearer after\na description of other composite terata.\n\nThe second genus of the Terata Katadidyma is the _Dicephalus_. This\ngenus comprises five species, which have in each case two heads, with\nseparate necks commonly. There are two vertebral columns, which\nusually are separate down to the sacrum, and they converge at the\nlower end. {80} In the interior organs doubling will be found\ncorresponding to the degree of separation of the trunks. In all the\nspecies of this genus there are one umbilicus and one cord.\n\nThe first species of the Dicephalus is the _Dicephalus Dibrachius_--a\ntwo-armed, double-headed monster. In this species most of the viscera\nare single, but the right and left halves of each viscus are supplied\nby the respective foetuses, and the entrail does not become\nindistinguishably single until near the lower end of the ileum. There\nmay be two ordinary kidneys and a third smaller one, two pancreatic\nglands, and two gall-bladders. Such a monster may be monauchenous or\ndiauchenous.\n\nThe next species is the _Dicephalus Tribrachius Dipus_--two heads,\nthree arms, and two legs. There is also a _Dicephalus Tribrachius\nTripus_ (three arms and three legs), _D. Tetrabrachius Dipus_ (four\narms and two legs), and _D. Tetrabrachius Tripus_ (four arms and three\nlegs). In all these cases there is no doubt of the presence of twins,\nunless there might be some doubt as to dual personality in the\nDicephalus Dibrachius. In the Dicephalus Tetrabrachius Dipus and the\nDicephalus Tetrabrachius Tripus there is almost complete duplication\nof the internal organs, and the halves of the composite body belong\nevidently to individuals distinct in thought, volition, and character.\nEach brain controls only its own half of the body. There are four\nlungs, two hearts (sometimes in one pericardium), two stomachs, two\nintestinal canals down to the colon or lower, two livers (sometimes\njoined), four kidneys (or three, one of which is small), two bladders,\nemptied at different times through a common urethra.\n\nDicephali are somewhat common. Foerster found 140 among 500 specimens\nof monsters. They are rarely born alive. The best known cases of\ndicephali that lived for any length of time are:\n\n1. Peter and Paul, of Florence, born in 1316, lived thirty days.\n\n2. The Scotch Brothers, born in 1490, lived twenty-eight years. They\nwere at the court of James III. Above the point of union the twins\nwere independent in sensation and action, but below the point all\nsensation and action were {81} common. One died before the other, and\nthe second \"succumbed to infection from putrefaction\" a few days\nlater.\n\n3. The Wuertemberg Sisters, born in 1498.\n\n4. The twins, Justina and Dorothea, born in 1627, lived six weeks.\n\n5. Boy twins at Padua, born in 1691, lived to be baptised.\n\n6. Rita-Cristina, born at Sassari in Sardinia in 1829. They lived\neight months. These children had a common trunk below the breast, one\npelvis, and one pair of legs. Rita was feeble and quiet, Cristina\nvigorous and lively. They suckled at different times; and sensation in\nthe heads and arms was individual, but below the junction it was\ncommon. Rita died of bronchitis, and during Rita's final illness\nCristina was healthy; but when Rita died, Cristina, who was suckling\nat the time, suddenly expired. They had two hearts in one pericardium,\nthe digestive tracts did not fuse until the lowest third of the ileum\nwas reached. The livers were fused, the vertebral columns were\ndistinct throughout. These twins were baptised separately.\n\n7. Marie-Rose Drouin, born in Montreal in 1878. They lived seven\nmonths. Marie died of cholera infantum; and Rose then died, although\nshe had not been directly affected by the disease. These twins were\nlike Rita-Cristina anatomically except that they had no legs. The\nrespirations and heart-pulsations differed, and one child slept while\nthe other child cried.\n\n8. The Tocci boys, born in Turin in 1877. In 1882 they were strong and\nhealthy, and they may be living still. They resembled Rita-Cristina\nanatomically in every respect. Each boy had control of the leg on his\nown side, but not of the other leg, consequently they could not walk.\nTheir sensations above the juncture were distinct, and their thoughts\nand emotions differed.\n\nIn the Paris _L'union medicale_ there is an account of a bicephalic\nstill-born monster, born at Alexandria in 1848, which, according to\nthe report, had on one side a typical negro head and on the other side\na typical Egyptian fellah head. This report is probably not authentic;\nbut if it is, it would be difficult to reconcile it with the fission\ntheory. {82} Supposing the report true, the case would have to be one\n(1) of superimpregnation wherein (2) a spermatozoon from each source\npenetrated the same ovum, (3) a bicephalic monster resulted, with (4)\ndistinct racial characteristics. All this is extremely improbable.\n\nSuperimpregnation has happened. There are cases where negresses have\ngiven birth to twins, one of which was a negro and the other a\nmulatto. Instances are cited in books on Legal Medicine like those of\nTidy and Beck. In Flint's Physiology a case is recorded in which a\nmulatto woman in Kent County, Virginia, married to a negro, gave birth\nto twins, in 1867, one of which was a negro much blacker than the\nmother, and the other a white child, with long, light, silky hair, and\na \"brilliant complexion.\" The white child's nose was shaped like the\nmother's, but there was no other resemblance. Even supposing this to\nbe a case of superimpregnation, that does not fully explain the\nextreme whiteness of one child and the extreme blackness of the other.\n\nSuperfoetation is also possible. Tidy (_Legal Medicine_) gives a case:\n\"Mary Anne Bigaud, at thirty-seven, on April 30th, 1748, gave birth to\na full-term mature boy, which survived its birth two and a half\nmonths, and to a second mature child (girl) on September 16th, 1748,\nwhich lived for one year.\" The second child was born four and a half\nmonths after the first, and both were \"nine-months\" children. It was\nproved after death in this case that the mother had not a double\nuterus, and the report is vouched for by Professor Eisenman, and by\nLeriche, surgeon-major of the Strasburg Military Hospital. Several\nother cases of superfoetation are given by Bonnar (_Edin. Med.\nJourn.,_ January, 1865).\n\nThe third genus of Terata Katadidyma is the _Ischiopagus_. These twins\nare divided so much from above downward that the heads are at almost\nopposite ends of the double body. They are joined at the coccyges and\nsacra, and the spinal columns have nearly the same axis. The trunk\norgans are complete and separate, except that they are commonly fused\nin the pelvis. There may be two, three, or four legs, given off at\nright angles to the pelvis. This kind of monster is not rare. Foerster\ncollected twenty cases, and nine new examples {83} were reported in\nthe _Index Medicus_ between 1879 and 1893. Ischiopagic twins were born\nin County Roscommon, Ireland, in 1827, and baptised separately. The\nJones Twins, born in Typhon County, Indiana, in 1889, lived for about\ntwo years; they were ischiopagi, and they had the very unusual\nquality, it is said, that they differed in complexion and the colour\nof eyes and hair. A case was reported in _American Medicine_,\nSeptember, 1903.\n\nClassed with the Katadidyma is the genus _Pygopagus_, although it has\nfour legs. This form is very rare. The twins are joined only by the\nlatero-posterior aspects of the sacra and coccyges, so that the two\nindividuals are placed almost back to back. The trunk organs are\nindependent, except for some fusion near the point of juncture.\nExamples of this class are the Hungarian Sisters, born at Szony in\n1701, who lived to womanhood; the negresses Millie-Christine, born in\n1851, and who were recently living in North Carolina; and the Blazek\nSisters of Bohemia. The negresses had common sensation in the legs,\nbut Millie could not localise what part of Christine's legs was\ntouched, and _vice versa_.\n\nThe second group of the double autositic monsters are _Terata\nAnadidyma_--terata divided from below upward. The first genus is the\n_Dipygus_. This has a single body above, but a double pelvis with\ndouble lower extremities in the typical cases. There is an exact\ndescription of a double monster of this kind in the Gaelic _Annals of\nthe Four Masters_ as early as the year 727 of this era. The chronicler\nsays in that year on Dalkey Island near Dublin, \"There was a cow seen\nwhich had one head and one body as far as her shoulders, two bodies\nfrom her shoulders hindward, and two tails. She had eight legs, and\nshe was milked three times a day.\"\n\nA perfect human Dipygus with two equally developed pairs of legs is\nunknown. Catherine Kaufmann, who was born in 1876, and who died in\n1878, had a double pelvis with double pelvic organs in part, but she\nhad only one pair of legs. There is a similar anomaly said to be\nliving in Philadelphia at present. Blanche Dumas, born in 1860, had a\ndouble pelvis, double pelvic organs, and three legs. Mrs. B., born in\n1868, {84} had four legs--the two inner ones were smaller than the\nouter pair. Her spinal column was divided up to the third lumbar\nvertebra. Her double pelvic organs acted independently. There are\nliving male examples of this form of monster.\n\nThe next genus is the _Syncephalus_, called also _Janus_ and\n_Janiceps_. Its lower body is double up to the umbilicus, the trunk\nsingle above that point; the head shows signs of doubling, and there\nare four legs and four arms; the bodies grow front to front. The head\nusually is large, therefore this monster is born dead.\n\nAnother genus is the _Craniopagus_--twins joined only by the skull or\nscalp. There are three species, named from the place of\nunion--_Craniopagus Frontalis, C. Parietalis_, and _C. Occipitalis_.\n\nA third group of double autositic monsters are the _Terata\nAnakatadidyma_, which are divided above and below, but joined from the\nnavel to the head. There are three genera. The first, the\n_Prosopothoracopagus_, is joined at the upper abdomen, the chest, and\nthe faces; the spinal columns are separate. The faces are imperfect,\nthe jaws are united; there is a broad neck with one oesophagus, and\nthere is one stomach and one duodenum. This is a rare form, and it can\nnot exist out of the uterus.\n\nA second genus, the _Thoracopagus_, has a thorax in common, and the\ninner legs may be united. It is, as a rule, still-born.\n\nThe next genus is the _Omphalopagus_, in which the twins are joined\nfrom the navel to the bottom of the chest. This double monster has the\nslightest union of all, and it is very rare. The Siamese Twins were\nomphalopagi. They quarrelled; one became a drunkard and the other\nremained temperate. They married two women, and Chang had ten\nchildren, and Eng twelve. Chang died while Eng was asleep, and the\nlatter died two hours after he had waked and learned of his brother's\ndeath.\n\nThere is a genus, the _Rachipagus_, the examples of which are joined\nbehind like the class Terata Anakatadidyma that are joined in front.\n\n{85}\n\nFour known attempts have been made to separate double monsters\nsurgically, but all failed owing to crude surgery; modern methods\nmight be successful in some cases.\n\nThe second order of double monsters comprises the parasitic class.\nThere are three genera of these terata, with five species and\nseventeen varieties. The chief of these only will be mentioned. The\n_Heterotypus_ is a parasitic child which hangs from the abdominal wall\nof the principal subject. Varieties of this species are the\n_Heteropagus_, which is a parasite with head and arms; the\n_Heterodelphus_, which has no head; the _Heterodymus_, which has a\nhead, neck, and thorax. The _Heteralitis_ is a second species, in\nwhich the parasite is inserted at a distance from the navel of the\nautosite. The _Epicomus_ is the only example, and it consists of a\nparasitic supernumerary head. The _Polypnathus_ is a parasite attached\nto the jaw of the autosite. When fastened to the upper jaw, it is an\n_Epignathus_; at the lower jaw it is an _Hypognathns_. Another group\nis made up of terata having parasitic legs which are attached to\ndifferent parts of the autosite,--to the pelvis, the head, the\nabdomen, and so on. Finally, there is the _Endocyma_, which is a\nparasite enclosed within the body of an autosite.\n\nParasites are nourished through the blood supply of the autosite, and\nthe parasites usually are incapable of motion. The autosite can feel\nwhen the parasite is touched, and in some cases the autosite can\nlocalise the touch. In India, in 1783, a child was born which had a\nsupernumerary head attached to the autositic head, crown to crown; it\nlived four years. The parasite's eyes were always partly open, but\nthey appeared to be incapable of intelligent vision. They contracted\nunder strong light, and when the autosite was suddenly awakened both\nsets of eyes moved.\n\nGould and Pyle (_Anomalies and Curiosities of Medicine_) give an\naccount of an Italian boy, aged eight years, who had a small parasitic\nhead protruding from near the left third rib. Sensibility was common.\nEach of the heads received baptism (one was called John and the other\nMatthew), and there was question as to whether extreme unction should\nbe administered to the parasitic head. A similar case occurred in {86}\nEngland in 1880 (_British Med. Journal_), and the parasitic head could\nbe pinched without attracting the attention of the autosite.\n\nTeratologists now exclude Dermoid Cysts from the lists of terata. The\nhair, teeth, and particles of bone found in these cysts are looked\nupon as the development of abnormal ectodermic and endodermic cells,\nrather than as evidence of a separate personality.\n\nThere is only one well-authenticated case of a triple monster, and\nthis happened in Italy in 1831. The monster had a single broad body\nwith three distinct heads and two necks. It was killed in delivery.\n\nIn Katadidyma (terata divided from above downward), when we have\ndicephali, ischiopagi, or pygopagi, there are evidently two\nindividuals present. Is the Diprosopus, however, the two-faced\nmonster, possessed of one or two souls? The cases vary, as we said,\nfrom examples with two distinct faces and four ears to cases that have\nmerely two noses. What portion of a human body is required to contain\na new soul? That is an interesting question for the psychologist and a\nvery practical one for the moralist, and no moralist has yet attempted\nto solve it. The presence of a brain is not essential, because\nacephalous monsters develop without brain, and they are born alive;\nthey have a vital principle which is identical with the soul.\n\nAmong the Terata Anadidyma (divided from below upward) the Syncephalus\nand the Craniopagus are unquestionably two persons. Is the Dipygus\n(single down to the navel, double below) one or two persons? Mrs. B.,\nthe example already given, was as double below the navel as any\nDicephalus is above that point. She had features so well ordered in\nunity that she was a pretty woman, but that unity ceased at her waist.\nWas her husband unknowingly a bigamist? I think he was. After a\nconsideration of the fission of terata, and the non-essential quality\nof the brain, why should fission that started at the feet differ from\nfission that started at the head?\n\nIn the _Rituale Romanum Pauli V._ (tit. ii. cap. i. nn. 18, 19, 20,\n21), the following directions for the baptising of terata are given:\n\n{87}\n\n  18. In monstris vero baptizandis, si casus eveniat, magna cautio\n  adhibenda est, de quo si opus fuerit, Ordinarius loci; vel alii\n  periti consulantur, nisi mortis periculum immineat.\n\n  19. Monstrum, quod humanam speciem non praeseferat, baptizari non\n  debet; de quo si dubium fuerit, baptizetur sub hac conditione: _Si\n  tu es homo, ego te baptizo,_ etc.\n\n  20. lllud vero, de quo dubium est, una ne, aut plures sint personae,\n  non baptizetur, donec id discernatur: discerni autem potest, si\n  habeat unum vel plura capita, unum vel plura pectora; tunc enim\n  totidem erunt corda et animae, hominesque distincti, et eo casu\n  singuli seorsum sunt baptizandi, unicuique dicendo: _Ego te\n  baptizo_, etc Si vero periculum mortis immineat, tempusque non\n  suppetat, ut singuli separatim baptizentur, potent minister\n  singulorum capitibus aquam infundens omnes simul baptizari, dicendo:\n  _Ego vos baptizo_, in nomine Patris, et Filii, et Spiritus sancti.\n  Quam tamen formam in iis solum, et in aliis similibus mortis\n  periculis, ad plures simul baptizandos, et ubi tempus non patitur,\n  ut singuli separatim baptizentur, alias numquam, licet adhibere.\n\n  21. Quando vero non est certum in monstro esse duas personas, ut\n  quia duo capita et duo pectora non habet distincta; tunc debet\n  primum unus absolute baptizari, et postea alter sub conditione, hoc\n  modo: _Si non es baptizatus, ego te baptizo in nomine Patris, et\n  Filii, et Spiritus sancti._\n\n   AUSTIN OMALLEY.\n\n\n{88}\n\nVII\n\nSOCIAL MEDICINE\n\n\nThe influence of the clergyman or the charitable visitor in matters of\nhealth and sanitation can scarcely be overestimated. The removal of\nprejudices with regard to sanitary regulations for the prevention of\ndisease and modern advances in the treatment of disease is an\nimportant social duty. There is no doubt that if this influence be\nproperly directed, sanitary measures of various kinds will be much\nmore readily enforced and the precautions necessary to prevent the\nspread of serious infectious ailments more faithfully observed. As\nthis amelioration of sanitary conditions will affect mainly the poor,\nlessening their suffering and adding to their possibilities of\nhappiness, its accomplishment becomes a great Christian duty,\nobligatory on all those who are interested in the uplifting of the\npoorer classes.\n\nProfessor Virchow, the distinguished German pathologist, used to say\nthat popular medicine was in all ages at least fifty years behind\nscientific medicine. He had himself discovered the principles of\ncellular pathology nearly half a century before his death, yet he\ndeclared that the popular mind still believed in the old doctrines of\nhumoral pathology,--that is, that the conditions of health and\ndisease depended on the constitution of the fluids of the body (the\nblood, the bile, the mucus, and so forth), and had not generally\naccepted modern advances in medical knowledge of the underlying basis\nof disease in the solid tissues. There is no doubt that many\nold-fashioned notions long since discredited by physicians are still\nvery generally accepted by the popular mind, and even the intelligent\nclasses sometimes harbour convictions with regard to the good or evil\neffects of habits {89} of life, diet, and the operation of drugs of\nvarious kinds that are entirely contrary to present-day medical\nknowledge.\n\nIt is extremely important, then, that the clergyman or charitable\nvisitor, in giving views on medical matters, which are sure to have\nmuch more weight than he perhaps attributes to them himself, should be\ncareful not to make statements for which he has not good authority in\nmodern medical science. It is very easy, in a matter of this kind, to\nstate principles that are not the result of education, properly so\ncalled, but are gleaned from early false impressions obtained one\nknows not how or where, entirely without definite consciousness as to\ntheir real origin. The physician himself finds that he is compelled to\nbe careful of this same tendency to put too much stress on traditions\nwith regard to health which he imbibed before he began to study\nmedicine. It is perhaps not so surprising, then, to hear physicians\ncomplain often that clergymen instead of being a help are sometimes a\nhindrance to the enforcement of modern hygienic rules, because they\nstill cling to old-fogy notions of hygiene and sanitation retained\nfrom a defective early training. Owing to the influence that the\nclergyman is sure to exert, this becomes an extremely important\nmatter. Great harm may be done and the  physician discredited, almost\nwithout a realisation, on the part of the clergyman, that he is\ninterfering in another's department. Sympathetic coordination of\nclerical and medical efforts would accomplish much good that is now\nunfortunately left undone.\n\nThere is no doubt that for the important crusade against tuberculosis,\nfor instance, the aid of the clergyman will accomplish much for the\nreduction of the death rate from this disease. What is needed at the\npresent moment is a universal conviction that tuberculosis is not an\nhereditary but a communicable disease. This does not mean that it is\nvirulently contagious and that as a result sufferers from tuberculosis\nmust at once be segregated from other members of the family and from\nthe community generally; but it does mean that careful precautions\nmust be taken with regard to the disposal of sputum, with the\nenforcement of the most exacting cleanliness on the part of\nconsumptives themselves. {90} It also means that the person suffering\nfrom the disease should not sleep with those as yet unaffected, nor be\nallowed to live in very close contact, especially with children or\nsusceptible individuals.\n\nThe persuasion that tuberculosis is not hereditary will do much to\nencourage patients suffering from the disease to feel that they are\nnot hopelessly doomed. At the present time it is not unusual to find\npatients so discouraged, when told that they have tuberculosis, that\nit is almost impossible to secure a favourable reaction to any mode of\ntreatment. They have seen members of families die one after another,\nor they have heard stories of the inevitable way in which consumption\nwiped families out of existence, and they give up hope and become\nquite cast down. Needless to say, while in this condition any\ntreatment is practically hopeless. On the other hand, the conviction\nthat tuberculosis is only an infectious disease, quite curable in the\nmajority of cases if taken in time, is of itself a most important aid\nin the treatment of the disease, since courage and faith are the\nprincipal requirements for successfully combating the affection.\n\nWe have had any number of newly invented remedies for consumption in\nthe last twenty-five years. Scarcely a year has passed in which some\nnew form of treatment, often eventually proved to be the resuggestion\nof an old therapeutic method, has not been heralded as a positive cure\nfor consumption. In every case the first patients treated by the\ndiscoverer of the new remedy have rapidly improved under his care. In\nthe hands of others, however, such results have not been obtained, or\nonly for a very short time at the beginning of the treatment. After a\ntime the new remedy failed in its inventor's hands. The true reason\nfor the improvement was then seen to be, not the remedy suggested, but\nthe favourable influence on the mind of consumptives produced by the\nfaith of the inventor in his remedy, and their reaction to this\npowerful suggestion when they were put under proper conditions of an\nabundance of fresh air and a plentiful diet.\n\nThis shows, too, the reasonableness of the modern treatment of\nconsumption, which consists not in the giving of {91} drugs, but in\nsecuring for the patient a plenty of fresh air for many hours a day\nand the encouragement to consume a liberal amount of nutritious food.\nMost of the much advertised remedies for consumption are really\nharmful rather than beneficent. Many of them are ordinary cough\nmixtures containing considerable opium, which lessens the cough, it is\ntrue, but also lessens the appetite and locks up the bowels. Besides,\nthe cough is nature's method of removing material from the lungs which\nhas become disintegrated, and if allowed to remain will certainly\nbring about the spread of the infection in the pulmonary tissues.\nCough is a natural protective reaction to be encouraged, and is not in\nitself a source of evil needing to be suppressed. If cough is\nbothering the patient so much at night as to cause loss of sleep, then\nit is necessary to make a choice between two evils and somewhat to\nsuppress the cough, even though it involves certain other\ninconvenience to the patient. All these so-called consumption cures\ncontain materials that are almost sure to disturb the appetite and\nupset the stomach. The fate of a consumptive patient absolutely\ndepends on his stomach; just as little, then, of medicine must be\nemployed as possible. This will indicate the necessity for clergymen\nrather advising against than in favour of these proprietary medicines\nwhich have been definitely known to do so much harm in recent years.\nMany a patient delays an appeal to medical aid so long, as the result\nof trusting to such medicines, that a curable case of consumption\nbecomes incurable, or else develops to such a condition as to require\nyears of treatment on the fresh-air, abundant-food plan, where months\nwould have sufficed before.\n\nA very interesting phase of social medicine is the ease and confidence\ndisplayed by people, often of more than ordinary intelligence, in\nrecommending various proprietary medicines of which they know nothing\nexcept the fact that someone says he, or more often she, was cured of\nsomething or other by their use. A chance remark like this to a\nsufferer becomes a high recommendation. The hardest problem the doctor\nhas before him is to find out what is really the matter with his\npatients. Not infrequently people having apparently the same set of\nsymptoms are suffering from quite different {92} ailments. A symptom\nlike a sore throat, for instance, may very well be due to any one of\nat least a half-dozen of causes, most of which require their own\npeculiar treatment. When the affection under consideration is as\nindefinite as a tired feeling, or indigestion, or some one of the many\nailments included under the term biliousness or kidney trouble, from\nwhich people are supposed to suffer, then the diagnosis problem\nbecomes by far the most serious question in the case, and is often\nvery difficult. The trained physician prudently hesitates, but the\ninexpert in medicine steps in and quite volubly announces what the\nailment is in his opinion, and what will probably do it good. A little\nknowledge is indeed a dangerous thing in medical matters. If it be\nremembered that there is a very general impression among medical men\nnow, as the result of recent acquisitions of scientific information\nwith regard to the origin, pathological basis, and course of disease,\nthat very probably more harm than good has been done by the\nadministration of medicines in the past, not only the futility of lay\n(or clerical) prescribing will be manifest, but also somewhat of the\namount of harm that may be done.\n\nIt is often a matter for painful surprise, then, to find that\nclergymen and members of religious communities allow their names to be\nused in the recommendation of remedies of whose composition they know\nnothing, for a disease of which they know less, if possible. This evil\nbecomes especially poignant when the columns of our reputable\nreligious press are allowed to be used for the purpose of exploiting\nthe public in these matters. The remedies most often recommended are\nthe so-called tonics. These are best represented by the sarsaparillas,\nand by various cures for catarrh, indigestion, and kindred indefinite\nills, of which there are a great many on the market. These are not\nsecret remedies, since their composition is well known by those of the\nmedical profession who care to secure the information. Some six years\nago an analysis of most of them was made by the Massachusetts State\nBoard of Health.   [Footnote 1]\n\n  [Footnote 1: 28th Annual Report Mass. Board of Health; food and drug\n  inspection, 1897.]\n\nThe principal active agent in all of these   remedies was {93} found\nto be alcohol. In most of them it exists in a proportion about equal\nto that in which it is supposed to occur in ordinary whiskey. Some of\nthem are even stronger in alcoholic contents than the whiskey usually\nsold in our large cities. This matter has seemed so important that we\ngive the official figures of the Board of Health.\n\n\nTABLE\n\nFrom the Report of the Massachusetts Board of Health\n\n_Tonics and Bitters_\n\nThe following were examined for the purpose of ascertaining the\npercentage of alcohol in each. Some of them have been recommended as\ntemperance drinks!\n\n       Per cent, of Alcohol (by volume).\n\n  \"Best\" Tonic    7.6\n  Carter's Physical Extract    22.0\n  Hooker's Wigwam Tonic   20.7\n  Hoofland's German Tonic   29.3\n  Hop Tonic   7.0\n  Howe's Arabian Tonic, \"not a rum drink\"   13.2\n  Jackson's Golden Seal Tonic   19.6\n  Liebig Company's Coca Beef Tonic   23.2\n  Mensman's Peptonized Beef Tonic   16.5\n  Parker's Tonic, \"purely vegetable,\" \"recommended for inebriates\"   41.6\n  Schenck's Sea Weed Tonic, \"entirely harmless\"   19.5\n  Atwood's Quinine Tonic Bitters     29.2\n  L. T. Atwood's Jaundice Bitters   22.3\n  Moses Atwood's Jaundice Bitters   17. 1\n  Baxter's Mandrake Bitters   16.5\n  Boker's Stomach Bitters   42.6\n  Brown's Iron Bitters   19.7\n  Burdock Blood Bitters   25.2\n  Carter's Scotch Bitters   17.6\n  Colton's Bitters   27.1\n  Copp's White Mountain Bitters, \"not an alcoholic beverage\" 6.0\n  Drake's Plantation Bitters   33.2\n  Flint's Quaker Bitters   21.4\n  Goodhue's Bitters 16.1\n  Greene's Nervura   17.2\n{94}\n  Hartshorn's Bitters   22.2\n  Hoofland's German Bitters, \"entirely vegetable and free from\n          alcoholic stimulant\"   25.6\n\n  Hop Bitters 12.0\n  Hostetter's Stomach Bitters   44.3\n  Kaufmann's Sulphur Bitters, \"contains no alcohol.\" As\n      a matter of fact, it contains 20.5 per cent, of alcohol\n      and no sulphur   20.5\n\n  Kingsley's Iron Tonic 14.9\n  Langley's Bitters   18.1\n  Liverpool's Mexican Tonic Bitters   22.4\n  Paine's Celery Compound   21.0\n  Pierce's Indian Restorative Bitters   6.1\n  Puritana   22.0\n  Porter's Stomach Bitters   27.9\n  Pulmonine   16.0\n  Rush's Bitters   35.0\n  Richardson's Concentrated Sherry Wine Bitters   47.5\n  Secor's Cinchona Bitters   13.1\n  Shonyo's German Bitters   21.5\n  Job Sweet's Strengthening Bitters   29.0\n  Thurston's Old Continental Bitters   11.4\n  Walker's Vinegar Bitters, \"contains no spirit\"   6.1\n  Warner's Safe Tonic Bitters   35.7\n  Warren's Bilious Bitters   21.5\n  Wheeler's Tonic Sherry Wine Bitters   18.8\n  Wheat Bitters   13.6\n  Faith Whitcomb's Nerve Bitters   20.3\n  Dr. Williams' Vegetable Jaundice Bitters   18.5\n  Whiskol, \"a non-intoxicating stimulant, whiskey without its sting\"   28.2\n  Colden's Liquid Beef Tonic,\n      \"recommended for treatment of the alcoholic habit\"   26.5\n\n  Ayer's Sarsaparilla   26.2\n  Thayer's Compound Extract of Sarsaparilla   21.5\n  Hood's Sarsaparilla   18.8\n  Allen's Sarsaparilla   13.5\n  Dana's Sarsaparilla   13.5\n  Brown's Sarsaparilla   13.5\n  Corbett's Shaker Sarsaparilla   8.8\n  Radway's Resolvent   7.9\n\n  The dose recommended upon the labels of the foregoing preparations\n  varies from a teaspoonful to a wineglassful, and the frequency also\n  varies from one to four times a day, \"increased as needed.\"\n\n  Many so-called tonics not on this list are also known to contain\n  alcohol, {95} though not as yet officially analysed so as to give\n  exact figures. Most of the cure-alls for women's ills contain\n  alcohol in noteworthy amounts, this being in fact usually the only\n  active ingredient in them.\n\nAs the analyst of the State Board of Health of Massachusetts is a\nthoroughly competent chemist, and as these figures have now been\nbefore the public for over five years without any contradiction on the\npart of the manufacturers of these remedies, though it is evident how\nundesirable the truth of the matter is from an advertising standpoint,\nthere can no longer be any question as to the authoritativeness of the\nproportions of the alcohol in the remedies as given.\n\nIt is rather sad to think of mothers giving these remedies to their\nchildren, hopeful of the good they may accomplish, when, as a matter\nof fact, it would be so much simpler and just the same in the end, to\ngive them, instead of a tablespoonful of the favourite sarsaparilla,\nwhatever it might be, a tablespoonful of dilute whiskey. As was noted\nin the volumes on the _Physiological Aspects of the Liquor Problem_\npublished recently by a sub-committee of the Committee of Fifty for\nthe investigation of the liquor problem, not a few prominent total\nabstinence advocates have put themselves on record as recommending\nthese remedies, though there can be no possible doubt of the great\nharm likely to arise from their use. There are many physicians who\nfeel sure that some of the alcoholic habits in women, whose origin it\nhas been hard to account for, were really contracted during this\nsecret \"tippling\" process under the form of a tonic remedy. Everyone\nknows that any tonic, in order to be effective, has to be gradually\nincreased, so it is not surprising that in many cases physicians have\nheard of patients taking six to ten tablespoonfuls of some tonic\nremedy every day. This would be the equivalent, in some cases, of from\nthree to five ounces of whiskey--a rather liberal allowance even for a\nconfirmed whiskey drinker.\n\nAs noted by the Massachusetts Board of Health, the dose recommended\nupon the labels varies considerably, but practically all agree in\nsuggesting that the amount of the remedy taken shall be increased as\nneeded. A simple presentation of this subject will surely be\nsufficient to arouse clergymen {96} to a proper sense of their duty in\nthis matter. Senators, judges of Supreme Courts, Congressmen, and even\nuniversity professors and teachers may be so benefited by dilute\nwhiskey, taken early and often, as to be tempted to furnish\ntestimonials for them (for a due consideration usually), but clergymen\nshould at least know something of the consequences of their act before\ncommitting themselves.\n\nAn almost precisely similar state of affairs obtains with regard to\nanother class of favourite popular remedies. A number of so-called\nblood-purifying remedies have been recommended at various times, and\nhere, as in other things, it is surprising to find how many\nintelligent people lend themselves to the exploitation of the public\nin the interests of the proprietary vender, who cares only to sell,\nand cares very little what effect his remedies may produce. Most of\nthe sarsaparillas are said to be blood purifiers. It is surprising\nwhat vogue this word \"sarsaparilla\" has obtained. A little more than\nhalf a century ago a German chemist and pharmacist announced that the\nsarsaparilla plant contained certain principles that could be\nextracted by boiling, and that form excellent remedies for atonic and\nanaemic conditions. This announcement was received by the medical\nprofession very kindly, and immediate tests as to the efficacy of the\nnew remedy were made. As a result of these tests, within a few years\nthe inefficacy of sarsaparilla became very clear. It is almost\nentirely without effect upon the human system. In the meantime,\nhowever, the word \"sarsaparilla\" was one to conjure with for the\npopular mind, and the sarsaparilla remedies began to be manufactured.\nMillions have been made on them and out of the public. The only active\nagent as regards tonic qualities which they contain is, as we have\nsaid, alcohol. Most of them however, contain at least one other\nwell-known drug likely to be at least as harmful as alcohol. This is\niodide of potash. Very few of the so-called sarsaparillas are without\na notable proportion of this strong mineral salt, as the Massachusetts\nBoard of Health said.\n\n\"With but few exceptions they contain a considerable percentage of a\nvery active and powerful remedy, the iodide of potassium. The sale of\nsuch an article in unlimited {97} quantities by druggists, grocers,\nand others is censurable. More than this, the method of its sale is\ndishonest, since the unwary purchaser is led to believe that he is\npurchasing a harmless vegetable remedy, namely, sarsaparilla.\n\n\"It may be seriously questioned whether the blood of persons who take\niodide of potassium continuously is not decidedly impoverished,\ninstead of being purified, as is claimed by the manufacturers. It is\nnot uncommon to find persons who have used continuously six, eight, or\nten pint bottles of one of these preparations.\n\n\"Unlike sarsaparilla, the iodide of potassium is classed among poisons\nby nearly every writer upon toxicology.\"\n\nPractically all the proprietary remedies have their most potent\nprinciple in the supposed mystery of their composition. As a matter of\nfact, all are simple prescriptions, well known to physicians, and\nowing their successful treatment of many ills much more to the\nprinter's ink used to secure their sale than to any pharmaceutical\ningredient which they contain. No important remedy has ever been put\non the market by advertising methods. Exposure of the charlatanry of\nsuch methods will not, however, cause an interruption of their sale.\nLong ago Barnum said that people wish to be humbugged, and there is no\ndoubt that they have been, are, and will be humbugged just to the\nextent to which they lay themselves open to the alluring methods of\nthe advertiser. It does seem too bad, however, that the influence of\nthe clergymen and of religious as well as charitable visitors--an\ninfluence acquired because of the confidential position they occupy\nand the feeling of good faith their mode of life inspires--should be\nabused for the encouragement and extension of what is manifestly a\ngreat evil.\n\nAlcohol and iodide of potash are not the only drugs likely to do harm\nthat are incorporated in proprietary medicines. Great complaints have\nrecently been made with regard to the spread of the cocaine habit in\nthis country. Not a few of the remedies that are supposed to give\nimmediate relief to colds in the head contain cocaine in dangerous\namounts; and there seems no doubt that in many cases the drug habit\nfor this substance has been acquired innocently and {98} unconsciously\nat first by the use of such preparations. These are only the more\nnotable evils likely to result from the indiscriminate employment of\nmedicines of whose composition there is complete ignorance, and of\nwhose effect there can be only the judgment dependent upon the\nsubjective feelings of the patient. It must not be forgotten that the\npatient's feelings are for the moment often favourably influenced by\nsome substance that may do no good to the ailment, though making the\npatient less sensitive to any symptoms from which he was suffering;\nbut in the end doing positive harm, because of the contraction of the\nalcohol or some drug habit, or because the suppression of symptoms may\nbe the very worst thing for the patients, since it allows the\nunderlying ailment to progress to a serious stage without forcing them\nto have it treated _in radice_.\n\nThese are only a few examples that show very well the inadvisability\nof recommending in any way medicines of which one does not know the\nexact contents. The present writer has had one example of how utterly\ndisingenuous, though one feels much more like calling it rascally, the\nmanufacturers of so-called patent medicines or proprietary remedies\nmay be. One of the remedies widely advertised for the cure of\nepilepsy, or fits, is announced always as containing no harmful drugs,\nno bromide of potash. The manufacturer of the remedy was asked how he\ncould say any such thing, since it was very evident even to the taste\nthat the remedy contained bromides. \"Oh,\" he said, \"yes, it contains\nsodium bromide, but not bromide of potash.\" Almost needless to say,\nsodium bromide is at least as harmful as potassium bromide, and the\nadvertisement is entirely for purposes of deception.\n\nThe poor epileptics have been a source of revenue for quacks and\ncharlatans as long as history runs. At the present time one not\ninfrequently finds testimonials from convents, asylums, reformatories,\nand the like, asserting the value of some particularly advertised\nremedy for this disease. All these remedies contain bromides. The\ntreatment of epilepsy is now better understood by physicians and it is\ngenerally recognised that the two things that epileptic {99} patients\nneed are outdoor air and as far as possible all freedom from\nresponsibility. Bromides will, for a time, control the number and\nfrequency of the attacks, but if used indiscriminately, and especially\nif employed without any proper realisation of their possibilities for\nharm, these salts are almost sure to make the condition of the patient\nmuch worse than before, to bring on a state in which mental symptoms\npredominate over physical, and in which the patient may go into\ndementia, or some form of mental alienation. Especially is this true\nwith regard to epileptic children. Continuous dosing with drugs of any\nkind is sure to do them harm rather than good. Care for their diet and\nrest and the removal of all sources of disturbance of their digestive\ntract is more important than any other method of treatment.\n\nThe poor children have to suffer many things from many people. People\nhesitate, as a rule, to accept recommendations with regard to the\nadministration of drugs to their animals when the person who gives the\nrecommendation is known not to be an expert in the matter. Almost any\nsuggestion, however, with regard to the dosing of their children is\nlikely to be followed by loving but indiscreet mothers. It is well\nknown now, and in many cases is admitted, that the so-called soothing\nsyrups so often given to children contain opium in quite appreciable\nquantities. Needless to say, nothing much worse than this could\npossibly be given to children. The child soon becomes accustomed to\nits daily dose of opium and craves the repetition of it. It will not\nsleep without it, and as this adds to the sales of the remedy, this\nspecial ingredient continues to put money in the pockets of the\nmanufacturers, but at the expense of the nervous stability of the\nchild, and lack of resisting power later in life. It would be hard to\nsay how many of the nervous wrecks so commonly met with in young\nadults now are to be attributed to this unfortunate state of affairs\nearly in life; but undoubtedly this evil has had much to do with the\nnoticeable increase in the nervousness of our people. The more nervous\nthe heredity of the child, the more it must be guarded against such\nmistaken methods of inducing sleep, or the result is sure to be\nserious.\n\n{100}\n\nScarcely too much can be said in condemnation of most of the\nproprietary remedies for constipation, though it is in this department\nof medication that the non-medical are freest with their advice.\nFirst, the cheapest possible drugs are selected by the manufacturers\nof such remedies. Secondly, those drugs especially are employed which,\nwhile producing the desired immediate effect, are always followed by a\nreaction which requires further use of the medicine. One finds\ntestimonials, however, from all classes of the community, even from\nclergymen, with regard to such remedies, though at the last\ninternational medical congress it was confidently asserted, by three\nof the most prominent specialists in digestive diseases in the world,\nthat the modern problems in digestive disturbances are so much more\nintricate than they used to be, and the affections which develop are\nso much more difficult of treatment, because of the use of these\nunsuitable remedies, and the consequent habituation to drugs, which\nhas been acquired during the prolonged period of their employment.\n\nIn recent years catarrh has become the word that is supposed to\nattract popular attention most, and accordingly is the watchword of\nthe proprietary medicine manufacturer. A long time ago, that is, about\nhalf a century ago, catarrh was supposed really to mean something in\nmedicine. Those were the days of humoral pathology, when disturbances\nof secretion were supposed to be the basis of all disease.\nAccordingly, whenever there was an excessive discharge from the nose,\na patient was said to be suffering from catarrh, and as the nasal\nsecretion was supposed to be connected in some way with the brain, it\nis easy to understand how significant such a pathological condition\nmight well be thought. In more recent years, the word \"catarrh\" has\nstill been employed by physicians who thoughtlessly employ terms that\nthey think will be better understood by the laity, owing to their\nfamiliarity with them, though they have been outlived in medicine.\nFrom representing an affection of the nose, catarrh, as a consequence,\nhas come to be employed for an excess of secretion from any mucous\nmembrane. Accordingly we hear of catarrh of the stomach, catarrh of\nthe bladder, or catarrh of the {101} bile-ducts, and there has come to\nthe general public a notion that catarrh is an all-pervading affection\nwhose ravages must be prevented, at all hazards, and whose beginning\nmust be the signal for prompt medical treatment.\n\nAs a matter of fact, catarrh, when it means anything, means only that\nstage of inflammation in which there is an increased secretion and\nwhich represents an inflammatory condition so mild as often to be\ndescribed as only hyperaemic, that is, due to an increase of blood in\nthe part. It is rather easy to understand that if more blood flows\nthrough a mucous membrane, there will be greater secretion from it\nthan would normally be the case. This is what happens in the\nproduction of catarrh. As a rule, it is only a passing congestion\nwithout any lasting changes in the tissue. Catarrh may, however,\ncontinue to be present if the irritation, which originally caused the\ncongestion, be allowed to continue. It is this irritation, however,\nwhich needs to be treated, and not the catarrhal inflammation, which\nis only a symptom of it. The three most used words in popular\nmedicine,--catarrh, rheumatism, and gout,--when traced to their\netymological signification, mean the same thing. Catarrh means a\nflowing down, rheumatism a state of flowing, both being formed from\nthe Greek verb [Greek text], to flow, while gout is derived from the\nLatin word _gutta_, a drop, which hints at the excess of fluid that is\nsupposed to be the basis of the disease.\n\nFor these three diseases, however, the most varied remedies have been\nproposed, and practically entirely without success, when tested, in a\nlarge number of cases. As a matter of fact, under the two words\ncatarrh and rheumatism, there is grouped a series of affections very\ndifferent from one another, and requiring very different treatment.\nThe important thing is not so much the suggestion of a remedy as the\nrecognition of the particular cause which in one case is producing an\nexcess of secretion and in the other is giving rise to the so-called\nrheumatic pain. When the exact cause can be found, it is usually not\nso difficult to succeed in preventing the recurrence of the\ntroublesome symptoms. It is with regard to these two diseases,\nhowever, that in non-medical circles even intelligent men are ready to\ngive advice. They constitute {102} the most puzzling problem that the\nphysician has to deal with, but the non-medical mind waives the\ndifficulty and suggests the remedy. In this matter one is forcibly\nreminded of a famous expression of Josh Billings, who used to say, \"It\nis not so much the ignorance of mankind that makes them ridiculous as\nthe knowing so many things that are not so.\"\n\nClergymen, lawyers, members of Congress, and of various state\nlegislatures, all permit their portraits to appear, advertising the\nmerits of some trumped-up cure for catarrh or rheumatism. It is\ninteresting to realise, then, that in most cases, according to expert\ntestimony, the remedy they recommend so highly consists of nothing\nmore than diluted alcohol flavoured so as to taste like medicine. The\nonly real effect is the alcoholic exhilaration which follows its\ningestion and gives the sense of well being, because of which the\ntestimonials are provided. As one of the medical journals said\nrecently, it would be very interesting to make a list of the men and\nwomen throughout the country who, by permitting their portraits and\nrecommendations to be used in the advertisements of various patent\nmedicines, have practically confessed that they like to take their\nwhiskey rather dilute but mixed with a little bitters. The whole\nquestion illustrates the tendency of the proprietary medicine man to\nexploit some phase of medicine long after it has ceased to be of\ninterest to the medical profession.\n\nWith regard to all of these things clergymen may do a great\nhumanitarian work by protecting the poor from the efforts of\nadvertising remedy-makers to get their hard-earned money. It is\nsometimes said that long years have been spent in the preparation of a\nremedy. This not only is never true, but never has been true in the\nhistory of proprietary medicines. Some one who has an eye to business\ngets hold of a prescription of which he knows nothing, but of which\nhis advertising agents are able to say much, and the result is\nsometimes a fortune for the advertiser. There is always a pretence of\nphilanthropy, but it is the mask of heartless hypocrisy. Unfortunately\nmany of our religious journals are tempted by the promptly paid bills\nof such manufacturing concerns to print their advertisements. They are\naiding in a {103} deliberate swindle, and if this were better\nunderstood there would be much less suffering and fewer vain hopes.\nThe best-managed newspapers and magazines in the country are now\nabsolutely refusing all medical advertisements. This is the only\nproper attitude in the matter, for there is a place to advertise\nmedicines, if they are worthy, and that place is the medical journals.\nIf the popular advertising could be reduced, we should soon have much\nless of the proprietary medicine evil.\n\nThere are many ways in which clergymen by their example, their advice,\nand their influence can be of great assistance to practitioners of\nmedicine. It is very sad, then, to find that some of them, having\nelabourated theories of their own on certain subjects, or having taken\nup with peculiar notions, are in opposition to the accepted medical\nteaching of the world. Occasionally they are found among the ranks of\nthe anti-vaccinationists, though if there is anything that has been\ndemonstrated to a certainty, it is that vaccination has practically\neradicated smallpox, considering the frequency of the disease a\ncentury ago, and that it would absolutely eradicate it, if the\npractice could be made universal. Statistics are at hand to\ndemonstrate this beyond all possibility of doubt. There are a certain\nnumber of people, however, who apparently, out of a desire for\nsingularity as much as anything else, refuse to accept the evidence.\nIt is very unfortunate to find clergymen among them, for it tends to\nbring the clerical judgment into disrepute.\n\nNearly the same thing might be said of antitoxin for diphtheria.\nClergymen seem to consider it necessary for them to have their minds\nmade up as to whether the use of diphtheria antitoxin is advisable or\nnot. If they have once committed themselves to the expression of the\nopinion that antitoxin is of no value, then no amount of evidence will\nsucceed in changing their opinion. Under these circumstances it\nbecomes extremely difficult at times for physicians to succeed in\nhaving families permit them to treat their patients after the manner\nin which they are convinced the treatment should be carried on. If\nsuch clergymen would only realise that the clergyman has, as a rule,\nmuch less right to express {104} opinions on medical subjects than has\nthe physician to air views with regard to theological principles,\nthere would be much less friction, and it would be better for patients\nin the end.\n\nThere are certain sanitary regulations that clergymen should not only\nnot oppose, but endeavour, by every means in their power, to have\nthose who respect their opinions follow out as carefully as possible.\nSuch sanitary regulations have in the past twenty-five years\npractically cut down the death rate of our large cities a half. There\nis no greater source of alleviation for the physical evils, at least\nthose which afflict the lower classes, than the due enforcement of\nmodern sanitation. There are prejudices, however, that must be\novercome, and the clergyman should be found beside the doctor, helping\nhim rather than opposing him, as is sometimes the case.\n\nJAMES J. WALSH.\n\n\n{105}\n\nVIII\n\nSOME ASPECTS OF INTOXICATION\n\nThere are various drugs that, through acute or chronic poisoning from\ntheir use, cause mental disturbance,--alcohol, chloral, cannabis\nindica, somnal, sulphonal, paraldehyde, ether, chloroform, antipyrin,\nphenacetin, trional, chloralamid, iodoform, atropine, hyoscyamus,\nsalicylic acid, quinine, lead, arsenic, mercury, opium and morphine,\nthe bromides, cocaine, and others. Of these intoxicants alcohol always\nhas been most commonly used by western nations, but the moral aspects\nof alcoholism have not been shown with sufficient insistence. There\nare many sots in human society much less reprehensible than to the\nunskilled observer they appear to be; others are more blameworthy.\n\nMorality, as far as the agent is concerned, apart from the nature and\ncircumstances of the deed, supposes, first, voluntary acts, or acts\nthat proceed from the will with a knowledge of the end toward which\nthe acts tend; and, secondly, free acts, or acts that under given\nconditions may or may not be willed. If by unavoidable chance one\nstumbles against a man standing at the edge of a wharf, knocks him\ninto the water, and drowns him, the act has no element of morality in\nit, because it is not voluntary and free. If a mind is diseased, and,\nimpelled by a mad notion of persecution, it brings about a like\nkilling, there is no question of morality, because the agent is not\nfree, and when fully analysed his action is not voluntary.\n\nAn act is more or less voluntary and free, and therefore more or less\nmoral, as the agent is affected by ignorance, passionate desire, fear,\nor disease. Ignorance, fear, and disease may be such as to remove all\nquality of morality from an act. {106} Certain diseases or\npathological conditions, especially of the nervous system, can take\nout of an act the elements of voluntariness and freedom that are\nnecessary to make the act moral or immoral, provided, however, these\npathological conditions are not brought on through the fault of the\nsubject in which they exist. If a man voluntarily becomes drunk with\nalcohol, or some other drug, he is, of course, accountable for the\nevil he may unconsciously do while under the influence of that drug,\nand if he begets an idiot or a criminal imbecile in his drunkenness,\nhe must atone somewhere for the blinded soul of his child. Here,\nagain, there are certain extenuating circumstances, because very few\ndrunkards are fully conscious of the extent of the evil in alcoholism.\n\nApart from the other requirements that go to make an act moral, the\nagent must be sane; that the act be immoral, he must be sane or\ninsane, either temporarily or permanently, through his own fault; that\nit be devoid of morality an act must be a mere _actus hominis_, or it\nmust be the act of a person blamelessly insane. If a man knows that an\nalcoholic is liable to beget a criminal imbecile solely because of the\nalcoholism,--and most men are aware of that fact,--this father or\ngrandfather is more or less accountable for every larceny, rape, and\nmurder done by the imbecile. The law, therefore, should put the\nimbecile into safe keeping, then seek out the father and hang him.\n\nInsanity is a common condition, but it has not been satisfactorily\ndefined. It supposes an appreciable unsoundness of the will, memory,\nand understanding, or of one or two of these faculties, but no\nalienist has given a short differentiation of that unsoundness. Where\nshall we draw the line between the weak but responsible will and the\ninsane will? What degree of opacity between intellect and the world\nseparates the ignorant man from the lunatic? The extremes of sanity\nand insanity are readily recognisable, but the intermediate degrees\nare not clear. There is no test to apply to all cases; each must be\ndiagnosed from its peculiar symptoms, but the will of an insane man is\nalways weak. It can not deny or defer the gratification of a desire,\nnor can it keep up an effort. Even in its lightest forms insanity is\nselfish and {107} impolite, because it lacks the force of will\nnecessary to take trouble. It foregoes great future benefit for slight\npresent gratification. The insane man is idle, or busy only in work\nthat he likes, in pleasurable activity. A marked quality of sanity is\nthe capacity for sustained work, and the man that shirks work merely\nbecause he does not like it is gratifying himself dangerously.\n\nThese defects are found commonly in sane persons, but the lunatic can\nnot rise from them, and he adds to the defects of will a warped\nintellect. He can not adjust himself to his surroundings, and the\nfault is in himself, not in the circumstances. His intellect may be\nbrilliant, but it sooner or later shows a taint. The insane man is not\na free, rational agent.\n\nAlcoholism readily passes over into unmistakable insanity, and it\nalmost always is the cause of nervous degeneration in the children\nborn within its influence. This, is a phase of the evil not\nsufficiently insisted upon by those that plead for total abstinence.\n\nChronic poisoning by alcohol induces hardening and calcification in\nthe walls of the arteries, degeneration of the nerve cells and\ndendrites, wasting or overgrowth of the heart muscle, and fatty\ndegeneration of the liver and kidneys. The nerve centres that control\nthe circulation of the blood are paralysed by it, and, as a sequence,\nthe arteries and capillaries are diminished in calibre. This state in\nturn obstructs the flow of the blood, and the body is not nourished,\nnor are the waste and poisonous results of metabolism carried off as\nthey should be. Alcohol prevents the haemoglobin of the blood from\ndoing its office, which is to supply oxygen and remove carbon dioxid.\nIt absorbs the necessary water from the tissues, and thus it acts as a\ncorroding poison. It is also a functional toxin, because it depresses\nthe activity of organs by injuring the innervation. The poison affects\nthe brain, and as the cerebral gray matter, especially its pyramidal\ncells, are the physical instruments of thought, will, and memory, or\nthe means of communication between the soul and the outer world, the\nexercise of these spiritual functions is checked or inhibited by it.\n\nA tendency to excess in the use of alcohol commonly {108} manifests\nitself before the thirtieth year, and in some cases it may be removed\nat the alcoholic climacteric, which is from the fortieth to the\nsixty-fifth year. Those that become drunkards are usually of a\nneuropathic constitution, through inheritance or abuse. Severe\ndiseases, like influenza, syphilis, typhoid; injuries to the head,\nsunstroke, shock, worry; the disturbance that may accompany puberty,\npregnancy, lactation, and so on,--cause a nervous depression which is\nsoothed by alcohol, and thus a habit is fixed. The reckless\nprescription of alcohol by some physicians is another cause of the\nhabit, and the use of proprietary medicines is a still more prolific\nsource of drunkenness and the consequent misfortune.\n\nCider, beer, ale, and porter contain from 4 to 6 per centum of real\nalcohol; light wines, red and white, and natural sherry, 10 to 12 per\ncentum; strong sherry and port, 16 to 18 per centum; brandy, 39 to 47\nper centum by weight, or 46 to 55 per centum by volume; and whiskey,\n44 to 50 per centum by weight, or 50 to 58 per centum by volume. The\neffect of these liquors on the body is due primarily to alcohol, and\nsecondarily to ethereal derivatives of alcohol. Some owe a part of\ntheir effect to non-volatile substances,--beer from which all alcohol\nhas been boiled can still affect the body in a marked degree.\n\nThe chemist of the Massachusetts State Board of Health (Document No.\n34) gives the percentage of alcohol in the common proprietary\nmedicines, and these percentages will be found in the article on\n_Social Medicine_.\n\nThe weakest of these compounds are twice as strong in alcohol as beer,\nand they treacherously bring about the habit of drunkenness in\ndisposed persons who may be very desirous to avoid such a calamity.\n\nSome men and women are quickly destroyed by alcohol; others resist it\nmore or less successfully for a lifetime, as far as mere existence is\nconcerned. Alcoholism is one of the commonest causes of insanity, but\nit is often an effect of insanity. It may be an early symptom of\nparesis, or a part of the maniacal stage of circular insanity. In\npoisoning by alcohol the higher nerve centres are first affected and\nthe {109} lowest last. The sense of human dignity and of morality, the\nexercise of the intellect, are more or less inhibited before the\nmotive muscles are affected.\n\nThe usual effect of alcoholic poisoning is boisterous exaltation of\nmind, but there is a depressed type of drunkenness which weeps. Some\npatients at once are subjected by hallucinations and delusions, others\nare so depressed that they have a suicidal tendency, others may have a\nmaniacal frenzy that is destructive or homicidal. In these neuropathic\nconditions muscular co-ordination is commonly well preserved--the\npatient is \"drunk in the head and sober in the legs.\"\n\nIn alcoholism the mental changes are gradual and progressive. The\nintellect is blunted, the judgment becomes foolish, the moral sense is\ndulled. The drunkard is always a liar. Delusions not infrequently\noccur, and it is one of the common symptoms of alcoholic insanity to\nsuspect a wife or husband of conjugal infidelity. If a man that is a\ndrunkard accuses his wife of infidelity, the chances are fifty to one\nthat she is innocent and that he is in the first stages of insanity.\nThis symptom is characteristic also of cocaine intoxication.\n\nAnother mental disturbance of acute alcoholism is _delirium tremens_,\nwhich is inexactly called _mania a potu_ by some writers. _Delirium\ntremens_ is not a form of mania, but an acute hallucinatory confusion,\nin which the consciousness is much more impaired than it is in a\nmania. _Mania a potu_ is a real mania, and it is transient commonly,\nalthough it may leave permanent mental weakness with delusions.\n\nIn chronic alcoholism a paranoid condition may occur, and this often\nis incurable. This psychosis may come on suddenly or gradually. In\ntrue paranoia the delusions are systematised, but in this alcoholic\npseudoparanoia the enfeebled intellect can not build up coherently\neven a delusion. The alcoholic hallucinations are visual and auditory,\nand we find delusions of persecution, especially of a sexual nature.\nThe patient hears all kinds of insulting remarks made by \"voices.\"\nThese voices often come from his own belly. His enemies send poisonous\nor foul odours into his room at night, and the groundless suspicions\nof his wife's infidelity take most outrageous forms of expression. He\nwill swear {110} he has _seen_ her misdeeds. Often the baseless\nsuspicions of his wife begin before any other noticeable impairment of\nintellect, and are not recognised as delusions. The first step a\npriest should take in investigating accusations of conjugal infidelity\nis to find out whether the accuser is a tippler or not.\n\nThe delusions of persecution lead to attacks on the supposed enemies\nwhich often are homicidal. Occasionally alcoholic insanity takes on a\nparetic form, or it may be epileptic. Ten per centum of alcoholics are\nepileptic. When the children of alcoholics are epileptic, the\nconvulsions begin in these children about four years earlier than in\nchildren that are epileptics from other causes. If epilepsy is latent,\nalcoholism will start it into action.\n\nAlcoholism sometimes produces a condition of waking trance followed by\namnesia (lack of memory). In such a state the drunkard may transfer\nproperty, carry out complicated professional actions, commit crime,\ntake long journeys, travel for days, and so act that no one notices\nhis disordered mental condition. Then suddenly he awakens and he has\nno recollection whatever of what has happened during this trance. He\nappears to be conscious, but to have no memory of his consciousness.\nThere is another alcoholic amnesia, found especially in those that\ndrink much during the morning hours, where there is instantaneous\nforgetfulness. If you ask one of these men to shut a door, for\nexample, he will forget between his chair and the door what he started\nto do. This condition is difficult to cure even after the use of\nalcohol has been relinquished.\n\nDipsomania is a form of impulsive degenerative insanity, and it is\nprobably epileptic in origin. After a few days of insomnia and loss of\nappetite for food, there is an irresistible impulse to drink alcoholic\nliquor and to indulge in other excess. The patient drinks until all\nmeans of getting alcohol are exhausted. He will take crude alcohol,\nbay rum, cologne, the alcohol that is about pathologic specimens in a\nhospital museum. The attack lasts from one to two weeks, and is\nfollowed by depression and a feeling of remorse. The onsets are\nirregular in occurrence, and between them the patient may {111} be\ntemperate or have even an extreme distaste for alcohol. This form of\ndisease is not infrequent among professional men and clergymen, and it\nis impossible to find out just how far the patient is responsible for\nhis condition. If bishops would investigate the alcoholic tendencies\nof the _families_ of candidates for seminaries, and reject all that\nhave this taint, there would be much less scandal. It is a serious\nerror of judgment to ordain a seminarian that has even once been under\nthe influence of alcohol, and those seminarians that cover up the\ntippling of a companion, because he is a good fellow, are guilty of\nfar-reaching crime. The fact is worth investigation whether or not a\nliquor dealer who never drinks alcohol, but who lives for years in the\npresence of volatilised alcohol, has much of the alcoholic degeneracy\nand a tendency to beget neurotic children. Certainly the fumes of wood\nalcohol have killed workmen that went down only once into a vat\ncontaining these fumes, and other alcohols in the form of vapour\nshould have deleterious effects. Fere produced monsters in chickens by\nexposing eggs to the vapour of alcohol.\n\nIn judging a drunkard, it must be remembered that in many forms of\nalcoholism, after the condition is well established, the patient has\nlittle more freedom of will than a brute has. If he is accountable for\nthe habit, he is blamable for the crime that follows. If he is not\naccountable, and it is often very difficult to prove that he is, he is\nto be treated as a blamelessly insane man. In proper surroundings, and\nwith skilful direction, a child born with a tendency, or more exactly\na temptation, to dipsomania or other alcoholic neurosis can be saved,\nbut commonly the circumstances of such a child's life are the worst\nimaginable. These children must never take alcohol, even as a\nmedicine, and they must not be pushed in school to nervous exhaustion.\nA tendency to unchastity can \"run in families,\" like a disposition\ntoward alcoholism, but the disgrace in yielding to this vicious bias\nkeeps many such unfortunates clean. It is to be regretted that public\nopinion can not give the same aid in alcoholic predisposition.\n\nA confirmed alcoholic should be prevented, if possible, from marriage,\nbecause his sins will be visited upon his posterity. {112} The first\nchildren of an alcoholic may be mentally sound, the younger children\nare more or less mentally weak, the youngest are not uncommonly\nimbeciles, or idiots, or under shock they grow insane. Fortunately\nmany of the children of alcoholics die at an early age, and the family\nof a drunkard very seldom lasts beyond four generations. In the first\ngeneration moral depravity and alcoholic excess are found; in the\nsecond, chronic drunkenness and mania; in the third, melancholia,\nhypochondria, impulsive and homicidal ideas; in the fourth, idiocy,\nimbecility, and extinction of the family. The lower the social caste\nof the drunkard, the greater the liability of meeting these blights.\n\nPriests should take a deep interest in societies established for the\npromotion of temperance, and the only temperance for most persons is\ntotal abstinence. No man knows what latent tendency to alcoholism he\nmay have, especially in America, where great grandfathers are unknown\nand the climate and life are trying on the nervous system. The\nadulterated liquors sold everywhere at present make the danger greater\nthan it ever was. Whatever may be the truth as regards heredity, there\nis no doubt concerning the strong influence of environment; therefore\nget into the temperance societies the children of alcoholic parents,\nof parents that are shiftless, hysterical, irritable. If a man has a\nviolent temper or if he is unchaste, get him and his children into the\nsociety to check the downward drift. A bad temper is a neurotic taint,\nand it commonly is a first step toward alcoholism. Do not forget to\nwarn the people against patent medicines that contain alcohol.\n\nIf you go over the list of the families in a parish, it is startling\nto find how few there are without one or more \"black sheep.\" The human\nblack sheep, in a good environment, is always physically imperfect,\nand never so black as the gossips paint him. He may be a powerful\nfootball player, but there is something wrong with his gray matter. He\nis morally deaf, he was born so, and he is to be excused if he can not\nalways hear the still, small voice. This may sound like lax doctrine,\nbut it is true, nevertheless.\n\nWe must recognise that moral weakness is very often, {113} partly at\nleast, a physical defect, and there is no such state as \"moral\ninsanity\" where the intellect is normal. Now, I do not wish to be\nquoted as holding that all moral depravity has a physical basis; most\nof it is the unalloyed stuff; the Lombroso criminal is not a\nscientific fact; but there is a moral condition very frequently met\nwith which is largely physical in origin. Given so many grains of\ncocaine or morphine or so many ounces of alcohol, and you can make a\nliar of a man once on the way toward sanctity. Given an attack of\nhysteria in a holy nun, and she at once becomes a liar, an altogether\nblameless liar, but no influence that does not remove the physical\ncause will cure the lying.\n\nThe morally weak do not at present obtain enough religious\ninstruction. Their religion is more a matter of inheritance and habit\nthan of positive energy. It is \"in the bones,\" sometimes in the fists,\nrather than in the soul. They prefer the Sunday newspaper to the\nSunday sermon. The remedy here seems to be in making the Sunday school\nsolidly interesting and its teaching impressive.\n\nAlcoholism in the parents, especially drunkenness at the moment of\nconception, is one of the chief causes of idiocy in children. Fere, as\nwas said before, by injecting a few drops of alcohol beneath the shell\nof hens' eggs, or by exposing the eggs to the vapour of alcohol, could\nproduce monsters almost invariably. In 1000 cases of idiocy at the\nBicetre, Bourneville found a history of alcoholism in 620, or 62 per\ncentum: in the fathers of 471, in the mothers of 84, in both parents\nof 65; and in one-half of the remaining 38 per centum no history was\nobtainable--probably most of these also had the alcoholic taint. The\nadministration of alcohol to infants, of gin and whiskey, of essences\nof peppermint and anise, to relieve colic or induce sleep, and the\ndosing with opiates like paregoric, are also well-established causes\nof idiocy.\n\nThe idiot is practically dead, except for the trouble he gives in\ncaring for him; but another unfortunate, the imbecile, most commonly\nthe offspring of alcoholics, is often capable of great mischief. The\nhigher grades of imbeciles, those nearest the normal, are almost\ninvariably criminals. Not all criminals, of course, are imbeciles, but\na vast number of petty and brutal {114} criminals are imbeciles. We\nkeep these unfortunates most of their lives in jail, while we fine\ntheir drunken fathers, the cause of the imbecility, \"five dollars and\ncosts.\"\n\nImbecility has grades,--from marked lack of intellectual power, a\nstage little beyond idiocy, up to the presence of a mind capable of\nfair education,--but in all cases there is real defect, either of\nintellect or of will. Sometimes, where the will is so weak that the\npatient becomes a criminal in spite of all training, the intellect is\npractically normal to the superficial observer.\n\nThe grades of imbecility can not be clearly marked off from one\nanother, but, roughly speaking, there are three. The lowest grade of\nimbeciles understands simple commands, and has a slight manual\ndexterity. They express themselves by signs and in monosyllables. They\ncan not concentrate attention upon anything, nor can they be taught to\nread or write. Careful training can advance them so far that they may\ndo rough, menial work, and they are industrious when directed by a\npresent superior. They are inclined to masturbation. If they are not\nteased, they are quiet; if annoyed, they may become dangerous.\n\nImbeciles of the middle grade can converse in a narrow vocabulary, and\nthey commonly stammer. They may be taught to read monosyllables; they\ncan not do even the simplest sum in addition, yet they show a certain\nshrewdness. They are irritable and quarrelsome, inclined to lying and\nstealing, and they have no sense of shame. They will not do any\nregular work, but change from one occupation to another. They may have\nsexual instincts and cause trouble on that account. They are slow to\nunderstand, their memories are defective, and they are always very\nvain. Their belly and what they shall wear are the chief things in\ntheir lives. They are less criminal than the highest grade of\nimbeciles.\n\nThe third class, the high-grade imbecile, is the most important,\nbecause he is commonly a criminal. His intellect is below the average,\nand his will is very flabby. He learns little at school, and what he\ndoes learn is acquired slowly. He reads and writes badly and he may be\nable to add simple {115} columns of numbers, but he can not multiply\nor divide. Sometimes such an imbecile has a remarkable facility in\ngetting a speaking knowledge of two or three languages, and he may\nlearn a trade. There is a high-grade imbecile that is cunning and\nshrewd, but he has no will, and he is a criminal. As imbeciles\napproach the normal in intellect they recede from it in abnormality of\nwill.\n\nAutopsies on imbeciles show an infantile development of the forebrain.\nImprisonment does no good in these cases. They are not taught anything\nin prison, not even a trade, because the labour organisations and the\nprotected industries will not permit prison labour. They should be\nconfined so that they will not pervert youth and propagate their kind.\nIt is impossible to say how far a given imbecile is morally\naccountable for what he does, but the accountability is not full in\nthe best cases. A neurasthenic, however, is not to be mistaken for an\nimbecile. A neurasthenic person may have a tender conscience, an\nimbecile has no conscience. In imbecility the fault is in the will,\nrather than in the intellect, in the middle and highest grades. Many\nwomen, especially, that are hopeless fools intellectually have strong\nwills, but an imbecile never has a strong will except in the sense\nthat stubbornness is strength. Stubbornness is perverted strength.\n\n_Morphine and Cocaine Intoxication_,--Morphine, an alkaloid of opium,\nis used very extensively as an intoxicant. Since 1890 the importation\nof opium into the United States has increased fourfold, although\nphysicians are now using less opium than they formerly did.\n\nThe insomnia, worry, moral distress, which bring on the alcoholic\nhabit in some persons, lead to morphinism in others. Some physicians,\nby carelessly prescribing morphine for neuralgia, migraine,\ndysmenorrhoea, or any pain, make their patients slaves of this drug.\n\nThe degenerative effects of morphine are not so great nor so rapid as\nthose of alcohol. It does not shorten life so much as alcohol does,\nnor are the children of a person addicted to the use of the drug so\nliable to idiocy and imbecility. The mind is enfeebled--slowly in some\ncases, rapidly in others. The patient will resort to almost any means\nto obtain the {116} drug, if he is deprived of it. Authorities hold\nthat he will lie without reason, merely for the perverse pleasure in\ndeceiving, that he is uncertain and treacherous, with a dull\nconscience and morbid impulses. There are exceptions to this in cases\nwhere the drug is easily obtained by the patients. Opium and morphine\ndiminish the sexual appetite in males, even to impotence. The bodily\nchanges are slow but profound.\n\nWhen a user of morphine has been deprived of the drug for from ten to\nfifteen hours, he becomes so weak he can not stand; he gets diarrhoea\nwith cramps; he sweats, trembles, and collapses. Later, mental\ndisturbance comes on. He grows delirious, sees insects and small\nanimals, as the delirium tremens patient does, and his suffering is\nvery great. It is extremely difficult, and commonly impossible, to\ncure the morphine disease after it has been firmly established, and a\ndeliberate acceptance of the habit is evidently a grave vice. Where a\npatient has become addicted to the use of the drug, through the fault\nof a physician, or through ignorance, the treatment from the social\npoint of view of such a patient is commonly cruel.\n\nCocaine intoxication is much worse than morphinism. It is a new\nexcess, which was unknown before 1886. Many users of morphine can\ncarry on business, but the cocaine _habitue_ can not do so. He is\nalways extremely busy doing nothing. He writes long letters which are\nnever finished. He changes from work to work, and even his\nconversation wanders. His bodily weight decreases rapidly, even\none-third of his whole weight may be lost within a few weeks. The skin\nhangs in folds and is of a dirty yellow colour, the facial appearance\nis that of extreme distress, and the muscles are feeble. Fainting,\nirregular cardiac action, sweating, and insomnia are other symptoms.\n\nInsanity is an occasional sequence, with hallucinations, especially of\nhearing. Such a patient hears roaring noises and voices; his secret\nthoughts are shouted out, he thinks, to crowds; loud screams, shrieks\nof murder, and similar noises appall him. Again, he sees swarms of\nflies, ants, roaches, which cover him and crawl into his mouth,\nnostrils, {117} and ears. He feels bugs crawling under his skin, and\nhe has a multitude of similar interesting experiences.\n\nSuch patients grow homicidal. Like alcoholics, they are jealous and\nsuspicious of their wives, but, unlike the alcoholic, the cocaine user\nis commonly reticent; he is not willing to talk of his troubles.\n\nThe prognosis is always bad, even in the best cases. This drug can be\nwithdrawn from a patient more rapidly than is possible in chronic\npoisoning from morphine, but a relapse is to be expected.\n\nIn dipsomania, morphinomania, and other drug habits, and in the cases\nof vicious and degenerate children, many encouragingly good results\nhave been reported from the use of hypnotism. Forel, Voisin, Ladame,\nTatzel, Hirt, Nielson, de Jong, Liebeault, Bernheim, van Eeden, van\nRenterghem, Hamilton Osgood, Wetterstrand, Schrenck-Notzing,\nKraft-Ebbing, Francis Cruise, Lloyd Tuckey, Kingsbury, Woods, and\nothers have undoubtedly cured dipsomania by hypnosis.\n\nWetterstrand alone cured 37 of 51 cases of morphinism by hypnosis. One\nof these patients had been using morphine for fourteen years and\nmorphine with cocaine for an additional four years. All his cases\nexcept one were treated at home--they were not obliged to go to a\nhospital or sanitarium.\n\nAs to vicious children: Liebeault in 1887 recorded 77 cases, 45 of\nwhom were boys and 32 girls. By hypnosis 56 of these were cured, 9\nimproved, 12 were not affected.\n\nAs to the so-called dangers of hypnotism in the hands of skilled\nphysicians, there are none. Forel said: \"Liebeault, Bernheim,\nWetterstrand, van Eeden, de Jong, I myself, and the other followers of\nthe Nancy school, declare absolutely that, although we have seen many\nthousands of hypnotised persons, we have never observed a single case\nof mental or physical harm caused by hypnosis.\" Travelling mountebanks\nthat hypnotise in public can do harm, and they should be prevented\nfrom so doing. On the continent of Europe only physicians are\npermitted to use hypnosis.\n\nFor a bibliography of hypnosis as a curative agent, see _Allbutt's\nSystem of Medicine_, vol. viii. p. 428 (The Macmillan Co.).\n\n{118}\n\nIn Genicot's _Theologiae Moralis Institutiones_, vol. i. p. 162\n(Louvain, 1902), is the following passage: \"Videtur licitum ebrietatem\ninducere ad morbum depellendum, si quando practicum est, ex gr. ad\ntyphum depellendum, vel ad coercendam vim veneni quod e serpentis\nmorsu haustum sit (Sabetti. N. 149). Similiter, per se licebit sensus\nsopire ope ebrietatis ad magnos dolores levandos: nullum enim\ndiscrimen morale videtur inter hoc medium et alia, ex gr.\nchloroformium, quae adhiberi solent.\"\n\nThat is, Father Genicot permitted alcoholic intoxication to cure\ntyphus or typhoid (typhoid is called typhus abdominalis in Europe) and\nsnake bite, or to quiet great pain, as chloroform is used, in his\nopinion. This doctrine would be correct morally if from a medical\npoint of view alcoholic intoxication cured typhus, typhoid, or snake\nbite, but it does not. Alcoholic liquors are necessary in some stages\nor forms of typhus and typhoid, and they must be administered\nskilfully; but to induce alcoholic intoxication in any pathological\ncondition is always to add a grave poison to the disease already at\nwork. The very name of the condition is _intoxication_, poisoning. You\ncan end a toothache by removing a man's jaw, but the practice is not\nto be encouraged.\n\nIn America, when a person is bitten by a rattlesnake or copperhead,\nthe first aid to the injured is commonly a pint of whiskey. You might\nbetter rub milk on the patient's bootheels, because the milk is\nharmless, but the pint of whiskey is anything but harmless; and one is\nas good as the other as far as curing the snake bite is concerned.\nWhiskey is popularly supposed to be a good medicine in all the ills of\nhumanity. It is a good medicine in certain cases and a very bad\nmedicine in others. A snake bite is a startling evil, and while far\nfrom a physician the early settlers gave the patient the only medicine\nthey had, whiskey, and if a little is good a great deal is better. As\nthe \"bite\" of the North American snakes is frequently not fatal, some\nearly victims grew well in spite of the snake venom and the added\nwhiskey poisoning; therefore a pint of whiskey cured them, _post hoc\nergo propter hoc_. Thus the \"cure\" became fixed in the popular\nignorance, and some moral theologians, without investigating the {119}\nmatter, fixed it deeper. The venom of the East Indian cobra and of\nother tropical and subtropical snakes would not be affected in the\nslightest degree by all the whiskey in Kentucky. The only hope in such\ncases, is in Calmette's antitoxin, administered within an hour or two\nafter the poisoning.\n\nSnake venom paralyses the muscles of respiration, and the patient\nceases to breathe. A little whiskey may do good--whiskey pushed to\nintoxication is very injurious. Artificial respiration, if needed, as\nin a case of attempted resuscitation after partial drowning, with\nskilful stimulation by a physician, and the use of an antitoxin, are\nthe main parts of the treatment in snake poisoning; but to pour a pint\nof whiskey into the victim is cruel ignorance. Patients often come\ninto dispensaries showing bitten wounds which are stuffed with hair\nfrom the dog that did the biting; whiskey causes a man to see snakes,\ntherefore use \"hair from the dog that bit you.\" This may be good\nhomoeopathy, but it is not medicine.\n\nThe making a man drunk with alcohol \"to remove great pain\" is a\ntreatment not used by reputable physicians: there are many correct\nmedical methods of removing pain, but a big draught of whiskey is not\none of them. Even in a case where a physician can not be found, it is\nusually questionable whether the effect of alcoholic intoxication\nwould not be worse than the irritation of the pain; and if it were\nnot, where is the line to be drawn? Some male and female old ladies\ncan work up \"great pain\" from a colic. The bigger and stronger a man\nis, especially if he has never been ill before, the greater his\n\"agony\" when he is having a tooth filled.\n\nAUSTIN OMALLEY.\n\n\n{120}\n\nIX\n\nHEREDITY, PHYSICAL DISEASE, AND MORAL WEAKNESS\n\n\nHeredity is a very vexed question, with regard to which most varied\nopinions are held even by those apparently justified in having\nopinions, so that it is evident we are as yet only crossing the\nthreshold of definite knowledge and are not near anything like the\nclear view that many people have imagined. The most striking proof of\nthis inchoateness of scientific knowledge of heredity is the fact that\nwithin five years the work of a monk in Austria, done about forty\nyears ago, which has lain utterly unrecognised ever since, has come to\nbe accepted as the most striking bit of progress made--almost the only\nreal scientific knowledge with regard to heredity that was acquired\nduring the whole nineteenth century. Father Gregor Mendel's work\n[Footnote 2] was done with regard to the pea plants in his monastery\ngarden, and it revolutionised all the supposedly scientific thinking\nwith regard to heredity that has been current in biology for half a\ncentury.\n\n  [Footnote 2: _See American Ecclesiastical Review_, Jan. 1904; Walsh,\n  _A New Outlook in Heredity_. ]\n\nThis serves very well to show how far in advance of observed facts\ntheories of heredity have gone. There is undoubtedly a very\nsignificant influence exerted over life and its functions by the\nspecial powers that are transmitted by heredity. How far this\ninfluence extends, however, and how much it may be said to rule\ndetails of existence, of action and in human beings, that complex of\nelements we call character, is entirely a matter of conjecture, and\nthe {121} belief in its extent, or limitation, depends absolutely on\nthe tendency of the individual mind to accept or discredit certain\ntheories in heredity which have had great vogue.\n\nUntil within a very few years it was considered a matter of common\nexperience and observation that under some circumstances, at least,\nacquired characteristics were transmitted by heredity. That is to say,\nit has been definitely asserted as probable, and by many even\nintelligent people considered absolutely certain, that modifications\nof a living being undergone during the course of its existence might\ninfluence the progeny of that being in various but very definite ways.\nIt was not, of course, thought that if a man lost an arm and\nsubsequently begot a child, the child would be born without an arm,\nbut slighter modifications of the organism were somehow supposed to be\ntransmissible; and, on the other hand, modifications which affect\nimportant organic structures of the body were somehow thought to have\na definite effect, by transmission, upon corresponding portions of the\nprogeny.\n\nWhen this theory is stated thus baldly, very few people confess their\nbelief in it, yet how many there are who find ample justification for\nsuch expressions as, \"His father suffered from rheumatism and it is\nnot surprising then that he should have it\"; \"Her mother had heart\ntrouble and we've always been afraid she would suffer in the same\nway.\" We are only just beginning to get beyond the period in which\nconsumption was thought to be directly and almost inevitably\ninherited. With regard to mental ailments this was frankly conceded by\nnearly every one. If the direct ancestry suffered from mental disease\nof some kind, then it is not considered surprising that the immediate\ndescendants should be mentally affected in some way. Physicians are\nquite as prone as those without medical training to make loose\nstatements of this kind.\n\nOf course there is a reason for the confusion that exists in this\nmatter. Oliver Wendell Holmes once said that he could cure any patient\nthat came to him for treatment, if he but applied to him in time. For\nproper success, however, he considered that many of his patients would\nhave had to come to him in the persons of their great grandfathers. As\n{122} a matter of fact, many of the supposed hereditary influences\nthat are traced only to a father or a mother are family conditions\nthat have existed many generations, and that were probably originally\nacquired, but the moment of whose acquisition cannot be definitely\ndetermined. We know that the Hapsburg lip has been a distinguishing\nfeature, a persistently recurring peculiarity, in some of the members\nof the Austrian ruling family in nearly every generation for seven\ncenturies. How much farther back than that it goes we have no way of\ndetermining. It is a family affair, a characteristic which became a\nmatter of heredity perhaps ten centuries ago, but the mode of its\noriginal acquisition is a mystery.\n\nThere is no really great scientist in biology at the present moment\nwho teaches the hereditary transmission of acquired characteristics.\nModifications of the organism that become matter for heredity have\nexisted for many generations and we cannot tell just how they began.\nThere is no doubt that there is some hereditary influence, for\ninsanity in the same family is likely to keep recurring in successive\ngenerations. More than this, affections of certain less important\norgans are evidently a common trait in certain family strains. There\nis no doubt that in some families stomach affections are the rule in\nsuccessive generations. It is very hard to say, however, just when\nsuch defective organisation became a family trait. The tendency to\nnervous affections is undoubtedly a similar family affair. Certain\naffections have been hereditary traits for many generations. An\nexcellent example of this is the so-called Huntingdon's chorea, which\nseveral generations of American doctors, of the name of Huntingdon, by\nfollowing carefully the history of certain families on Long Island,\nsucceeded in tracing through four generations.\n\nThe habits of life of a father or a grandfather may so weaken the\nphysical constitution of his descendants as to make them less capable\nof resisting infections in the physical order, or in the moral order\nof withstanding trials and temptations, and the allurement to abuse of\nnervous excitement to which they may be subjected. That some acquired\npathological condition, however, as stomach trouble, or heart {123}\ntrouble, or affection of the liver or of the brain, should be directly\ntransmitted, is quite as nonsensical as that the loss of an arm should\nbe a subject for hereditary transmission. On investigation it will be\nfound that the pathological conditions of immediate ancestors are\nthemselves only a manifestation of family traits that have existed for\nmany generations. The possibility of inheritance must therefore always\nbe borne in mind. We are utterly unable as yet to understand how such\nfamily traits are originally developed, since, in ordinary experience,\nat least, acquired characteristics are not the subject of inheritance\nor transmission, and consequently it becomes difficult to understand\nhow they ever became impressed upon the family constitution.\n\nNotwithstanding this general principle with regard to heredity, there\nare a number of striking observations which show that even unimportant\npeculiarities may occur from generation to generation, though it is\nnot always easy to decide where the peculiarity originated. The\nwell-known example of the occurrence of six toes has already been\nmentioned, and is an oft-quoted bit of evidence as regards hereditary\ntransmission. An extra finger on the hand, or some portion of an extra\nfinger, at least, comes in the same category. Not long since it was\npointed out that harelip is another of these peculiarities that\nreadily lends itself to hereditary transmission. Recently there was\nthe report of a family into which there were born four girls with\nharelip and cleft palate, and three boys not showing any trace of\nthese deformities.\n\nOften when in such cases there is no definite history of harelip, it\nis found that in either one of the parents there is a very high arched\npalate and a thin upper lip, showing that the normal occlusion of the\ncleft which exists here during foetal development is not quite\nperfect, and this peculiarity may be traced for several generations\nback, with an occasional occurrence of harelip as an exaggerated\nexample of the faulty tendency not to produce sufficient tissue in\nthis neighbourhood for the proper closure of the embryonic cleft.\n\nAn even more striking manifestation of a physical anomaly, as a family\ntrait, is the condition known as hemophilia. This {124} tendency to\nbleed easily, so that a slight scratch, or the pulling of a tooth, may\ngive rise to fatal hemorrhage, occurs, as a rule, only in males, but\nis transmitted through the female line. It is in the mother's male\nrelatives that the history of its previous occurrence is found, and\nthe tendency usually can be traced through several generations, until\nit is lost in vague tradition. It is no wonder, with such examples\nbefore them as six-toedness, harelip, and hemophilia, that physicians\nhave been ready to accept heredity of qualities in the moral order,\ntraits of character and disposition, and pathological tendencies to\ncrime or passion or indulgence.\n\nOne of the most frequently discussed conditions of supposed\npathological inheritance of this order is dipsomania. Everyone has\nheard it said, \"Poor fellow, how can he help it; his father was a\ndrunkard before him.\" As we have already said, in such direct cases\ninheritance is absolutely unproven. An alcoholic father may transmit a\nvery weak physical constitution to his children, and this may prove\ninadequate to enable them to withstand the emotional strain and worry\nof modern great city life, and, as a consequence, they may take to\nalcohol for consolation until the habit is formed, and then the\ncraving for stimulants supplies the place of any hereditary influence\nthat may be supposed to be needed.\n\nOf course there are cases of the drink habit in which, after a number\nof generations of family history of alcoholism, an individual seems to\nhave the craving for stimulants born in him. In such cases it is not\nunusual to find that the patient, for such he must be considered, is\nable to avoid indulgence in liquor entirely, except at certain times.\nEvery physician of any large experience has had under his care\ndipsomaniacs who had no difficulty in keeping away from liquor for\nweeks, or even months, but who had regularly recurring periods,\nsometimes as far apart as every three months, when they had an\nirresistible craving for stimulants come over them. The regularity of\nthe interval in these cases is often very remarkable. Here, of course,\nwe may be in the presence of some as yet not well-understood\nperiodical law of cell life, with consequent depression, and then the\nirresistible craving for stimulation. {125} As a rule, however, it\nwould seem that in most of these cases suggestion has great influence.\nAs we have said elsewhere, with regard to suicide, when a man has\nconstantly before his mind's eye the fact that a father, perhaps a\ngrandfather, or other members of the family, have committed suicide,\nhe is likely to be much more easily led to the thought of this way of\nescaping hard conditions in life than are other individuals. The man\nwho knows that the fact that his father indulged too freely in\nstimulants will be looked upon by many as an excuse for his deviations\nin this matter is likely to be more easily led to take an occasional\ndrink at moments of depression, or for friendship's sake, though he\nrealises that it so weakens his will power over himself that he is\nlikely to take too much before he stops.\n\nThe passage in _Julius Caesar_ (Act. I. sc. 2) in which Cassius says:\n\n  \"The fault, dear Brutus, is not in our stars, but in ourselves,\"\n\nillustrates one phase of the subject. There are, of course, many other\nthings besides the drink habit, with regard to which men are prone to\nfind excuses in heredity, and to consider that somehow their ancestral\ntendencies make them not quite responsible for actions commonly\nconsidered the result of malice or passion, rather than hereditary\ninfluence, and our great English poet, knowing men so well, has stated\nthe truth forcibly.\n\nIn _King Lear_ there is an often quoted passage which properly\nstigmatises the opinion in this matter held by those who would find\nexcuses for wrong-doing in hereditary qualities:\n\n  \"This is the excellent foppery of the world, that, when we are sick\n  in fortune,--often the surfeit of our own behaviour,--we make guilty\n  of our disasters the sun, the moon, and the stars; as if we were\n  villains by necessity; fools by heavenly compulsion; knaves,\n  thieves, and treachers by spherical predominance; drunkards, liars,\n  and adulterers by an enforced obedience of planetary influence; and\n  all that we are evil in, by a divine thrusting on; an admirable\n  evasion of whore-master man, to lay his goatish disposition to the\n  charge of a star!\"\n\n{126}\n\nOne phase of the question of hereditary tendencies to inebriety is\nextremely interesting from a physiological and sociological point of\nview. As the result of carefully gathered statistics, there seems to\nbe no doubt now that when children are conceived while the parents, or\neither of them, is in a state of drunkenness, the offspring is very\nlikely to be of low-grade physical constitution and often of very\nneurotic tendencies. In France, particularly in the case of a number\nof insane children and idiots, histories of this nature have been\nobtained in confirmation of this unfortunate factor as an element in\ndegeneracy. In general it may be said that about one-third of the\nadmissions to homes for children of low intelligence, as well as to\ninsane asylums, are due to this cause.\n\nThere is in this, of course, an added motive for temperance, and it\nwould seem that parents should be warned of the danger to which they\nare subjecting their offspring by excessive indulgence in alcohol,\nwhen it may be followed by such serious and lasting results to the\nbeings on whom their love and affection will be expended in the\nfuture. This phase of alcoholic excess has never been taught as\ninsistently as its importance would demand, perhaps because of the\ndelicacy of the subjects which it involves; but it is too significant\na factor in making or marring progress in the development of the race\nto allow any pusillanimous motives to prevent the spread of precious\nknowledge.  [Footnote 3]\n\n  [Footnote 3: The present conditions that obtain with regard to the\n  celebration of marriages are very prone to have a certain amount of\n  intoxication as their result. Perhaps, then, it is a fortunate\n  thing, as has often been said, that the first child is not born\n  until some considerable time after it might normally be expected. It\n  has been said more than once, however, that first children are a\n  little more likely to have certain degenerative defects than are\n  others, and a connection has been found between certain abuses of\n  stimulants and incidental exhaustion to account for this. One of the\n  most amusing things to Li Hung Chang, on his travels through our\n  country, was the curious publicity we give to everything connected\n  with marriage, while presumably our Christian ideas should rather\n  counsel a veiling of the mysteries, religious and physical,\n  connected with it. Certain it is that the present tendency towards\n  farewell dinners at clubs, and other festivities of various kinds,\n  are not at all likely to result in benefit to the presumably\n  hoped-for offspring.]\n\nThe only real light that has been thrown on the puzzling details of\nheredity has come from work in the same field in which Mendel made his\nground-breaking observations. {127} De Vries, the professor of botany\nat the University of Amsterdam, has succeeded in showing that new\nspecies of plants may be made to arise by careful attention to certain\nanomalous plants which occur from generation to generation. These\nplants breed true, that is, maintain their own peculiarities. To begin\nwith, they are quite different from the parent plants, and the\ndifference is perpetuated by inbreeding.\n\nSo far the problem of the origin of species has been supposed to\ndepend upon the normal variation that is noticed in plants and\nanimals. All living things differ from one another, even though they\nmay belong to the same species, and differ sometimes in remarkable\ndegrees. This continuous variation was supposed to account for the\norigin of new species when it became excessive. It has become well\nrecognised now, however, that such differences gradually disappear in\nthe course of the normal multiplication of plants and animals. The\ntendency is much more towards the disappearance than the maintenance\nof peculiarities.\n\nThere are certain discontinuous variations, however--sports, as they\nare called--in plants which differ very markedly in some quality from\nothers, and these have the tendency to perpetuate themselves. Just why\nthese sports occur is not known, nor how. They occur in a certain\nsmall percentage of all normal plants, but may die out, though it\ntakes but little encouragement to succeed in helping them to maintain\nthemselves. It is this that De Vries has done, and thus has succeeded\nin raising what would be called new species of plants.\n\nThis same thing would seem to occur in human beings. Some definite\nvariation occurs as a consequence of a peculiar embryologic process.\nThis becomes stamped upon the genital material and appears in the\nsubsequent generations. It does not occur as a consequence of\npathological changes nor of mere embryonic faults; it is almost as if\nit were something introduced from without. Once having found an\nentrance, however, it affects the germinal material and thus\nperpetuates itself.\n\nWith regard to plants, it has been suggested that the only explanation\navailable for the occurrence of sports is that there is a purposeful\nintroduction of them as the result of the laws of nature, and that it\nis thus that evolution is intentionally {128} brought about. This is,\nof course, a scientific reversion to teleology once more, but the\nquestion of teleological influences has been discussed more seriously\nin the last few years in biological circles than ever before.\nUnfortunately for the coincident evolution argument involved in human\nbeings, the peculiarities introduced, which become the subject of\ninheritance, do not make for the development, but rather for the\ndegeneracy, of the race. Even such peculiarities as six toes can\nscarcely be said to add any special feature of advantage to man in his\nstruggle against his environment.\n\nIt is agreed by many of our best authorities in biology, zoology, and\nbotany, by such men as Professor Wilson of Columbia University,\nProfessor Thomas Hunt Morgan of Bryn Mawr, Professor Castle of Harvard\nUniversity, Professor Bailly of Cornell University, Professor Michael\nGuyer of the University of Cincinnati, Professor Spillmann, who is the\nAgrostologtst of the United States Government, and Professor Bateson\nof the University of Cambridge, England, that these principles of\nheredity enunciated by Father Mendel will undoubtedly revolutionise\nthe modern knowledge of the subject. In the meantime, however, all the\nold theories are in abeyance. Darwin's work and Weissmann's brilliant\ntheories and observations must give way, while the application of\nthese new laws is being worked out to their fullest extent. While the\ninfluence of heredity can not be denied, there is undoubtedly a\ntendency to overestimate the influence on the physical being of the\npower of hereditary transmission, and, on the other hand, to\nunderestimate the influence of this same force as regards disposition\nand character. There is no doubt now that the physical basis\ninfluences the exercise of the will, and that consequently\nresponsibility is not infrequently modified by the hampering influence\nof unfortunate physical qualities. This truth makes for that larger\ncharity in the judgment of the actions of others which enables\nphysicians to realise how much men are to be pitied, while its failure\nof recognition by the \"unco guid\" not only causes suffering, but in\nthe end adds to the amount of evil.\n\nJAMES J. WALSH.\n\n\n{129}\n\nX\n\nHYPNOTISM, SUGGESTION, AND CRIME\n\n\nIn recent years a quasi-unconscious state, induced by suggestion and\ncalled the hypnotic trance, has come to occupy a very important place\nin the popular mind. Hypnotism, as the general consideration of this\nstate is known, has attracted not a little attention, as well from\nphysicians as from those interested in psychology. The hypnotic\n(Greek, [Greek text], sleep) trance is a condition in which voluntary\nbrain activity is almost completely in abeyance, though the mind is\nable passively to receive many impressions from the external world.\nThere are very curious limitations in the effect of the hypnotic state\nupon the various senses. While visual sensations, and, as a rule also,\nimpressions from the tactile sense, lose their significance, or are\ntranslated according to the will of the person active in producing the\nhypnotic state, or of some person present making suggestions, auditory\nsensations are quite normally perceived. The patient has all the\nappearance of being asleep, though motions, and even locomotion, are\noften possible, and are performed as if the patient were walking in\nsleep.\n\nThe hypnotic state is a partial sleep, then, of the motor side of the\nnervous system and of portions of the sensory nervous system. Certain\nof the higher intellectual powers, however, are entirely awake, and\ncapable of being impressed through the hearing, and thus hypnotic\nsuggestion has a place. For a time, under the influence of Charcot and\nhis disciples, there was a very generally accepted opinion that the\nhypnotic trance was a pathological condition, somewhat allied to the\ncataleptic phase of major hysteria. It is well known that persons\nsuffering from severe attacks of hysteria {130} may, while apparently\nunconscious, yet receive suggestions through the hearing. On the other\nhand, the production of cataleptic and other strained attitudes, in\nthe maintenance of which fatigue seems to play no part, is possible by\nmeans of hypnotic suggestion in susceptible individuals.\n\nFurther investigation, however, seems to have shown that the hypnotic\nstate is rather to be considered as a quasi-physiological condition,\nsomewhat related to sleep, all the mystery of which is not as yet\nunderstood. This is not surprising when we realise that such a normal\nand absolutely physiological condition as healthy sleep is yet without\na satisfactory explanation on the part of physiologists. Hypnotism is\nrecognised now as having a certain limited power for good, though the\nbenefit derived from it is apt to be temporary, and the operator loses\nhis power after a time,--not so much failing to produce the hypnotic\ncondition, as failing to have his suggestions favourably accepted by\nthe subject While the Nancy school of hypnotism insisted that most\npeople were susceptible to the hypnotic trance, it is now generally\nconsidered that something less than 40 per centum of ordinary\nindividuals can be brought under its influence.\n\nMuch has been said of the dangers of hypnotism. There seems no doubt\nthat very nervous persons are likely to be hurt by repeated recourse\nto the hypnotic condition. After a time they are likely to live most\nof their lives in a half-dreamy condition, in which initiative and\nspontaneous activity becomes more difficult than before. Where persons\nhave been hypnotised by means of the flash of a bright object, or by\nsome other special means, it sometimes happens that accidentally some\nsimilar object may send them into hypnotic trance. After a time, too,\nauto-hypnotism becomes possible, and much of the individual's waking\ntime is occupied with efforts to keep himself from going into the\nhypnotic trance. These are, however, very extreme cases, likely to\noccur only in those who are not of strong mentality in the beginning.\nUnfortunately these are the individuals who are most likely to be made\nthe subjects of repeated and prolonged hypnotic experimentation on the\npart of unscrupulous charlatans.\n\nFor the great majority of those that are susceptible to the {131}\nhypnotic condition, there is very little danger. We now have on record\nthe experiences of men who have seriously devoted many years to the\nstudy of hypnotic phenomena. There is entire agreement among these men\nthat the possible dangers of hypnotism have been exaggerated. Indeed,\nit may be as well to say at once that most of what has been written\nwith regard to the dangers of hypnotism has come from those who have\nleast practical experience with the condition. Dr. Milne Bramwell,\nwho, for a quarter of a century, has had a very extensive experience\nwith hypnotism in its many phases, in his recent book on hypnotism,\ndeliberately speaks of the \"so-called dangers\" of hypnotism. He has\nnever seen any evil effects, though he has been practising hypnotism\nvery freely on all kinds of patients for over twenty years.\n\nIt is on the experience of such serious, disinterested observers that\nwe must rely for our ultimate conclusions as to hypnotism, rather than\non the claims of pseudo-experts who like to magnify their own powers,\nor on popular magazine articles, or still less the Sunday newspapers,\nthe writers for which are mainly interested in producing a sensation.\nIt seems probable that in the next few years hypnotism will occupy a\nless prominent place in popular interest than it has in the recent\npast. Interest in hypnotism runs in cycles, reaching a maximum about\nonce a generation, and we are on the downward swing of the last wave\nof popular attention to this subject.\n\nA subject that has attracted much attention, whenever hypnotism has\nbeen under discussion, has been the possibility of crime being\ncommitted under the influence of hypnotic suggestion. The best\nauthorities in hypnotism seem to be agreed that subjects can not be\nbrought by hypnotic influence to perform actions that are directly\ncontrary to their own feeling of right and wrong. The supposed\nexceptions to this rule are rather newspaper sensations than real\ncompelled crimes. There is no doubt, however, that a tendency to the\nperformance of certain wrong actions, so that the normal\ndisinclination to their performance becomes much less than before, may\nbe cultivated by a series of hypnotic as well as by waking\nsuggestions. Where the individual influenced is {132} already\ncharacterised by weakness of will in certain directions, the added\nweight of the motives furnished by hypnotic suggestion may prove\nsufficient to turn the scale of responsibility. It is probably because\nof such influence that a recent case in France has attracted\nworld-wide attention.\n\nIn general, however, it may be said that normal individuals can not be\nbrought to the commission of crime by hypnotic suggestion, and the\nplea of irresponsibility, for this reason, is not worthy of\nconsideration. There are phases of this important problem, however,\nwhich require further careful study. Undoubtedly some of the so-called\ninherited tendencies to the commission of crime are really instances\nof the influence of auto-suggestion that has kept the possibility of\nsome criminal act constantly before the mind. Some of the cases of\nhereditary dipsomania are almost surely of this character. Persons\nwhose parents have been the subject of inebriety lose something of\ntheir own will power to keep away from intoxicating drink by the\nreflection that it is hopeless for them to struggle against an\ninherited tendency.\n\nA series of cases have been reported in which suicide has occurred in\nsuccessive generations in the same family at about the same time of\nlife. There seems no doubt that suggestion must have great influence\nin such cases. In one well-authenticated report, mentioned in the\nchapter on suicides, the members of the family were officers in the\nGerman army, and the eldest son, the family representative, committed\nsuicide within the same five years of life, in four successive\ngenerations. The last member of the family had refused to marry,\nbecause of this doom hanging over the house, and had often referred to\nthe possibility of suicide in his own case. In his early years he\nseemed to have the idea that he might escape the family fate, but\nafter middle life he settled down irretrievably to the persuasion that\nhe would inevitably go like the others.\n\nHere, in America, a rather striking example of this has recently been\nthe subject of sensational newspaper reports. A notorious gambler,\nwhose career had seen many ups and downs, finally found himself in a\ncondition where, strange as it may seem, legal restriction made it\nimpossible for him to {133} continue his usually lucrative profession.\nThree members of his immediate family, two brothers and his mother,\nhad committed suicide. To friends he had sometimes spoken of this sad\nhistory of family self-murder, but always with a calm rationality\nwhich seemed to indicate that he hoped to avoid any such fate. When\nwell on in years, however, with his means of livelihood taken from\nhim, he, too, took the family path out of difficulties and shot\nhimself at the door of the man who had been most instrumental in\ntaking away from him his occupation. It seems not unlikely, from the\ncircumstances of the case, that a double crime, homicide, as well as\nsuicide would have been reported, only for the fortuitous circumstance\nthat the other man was not in at a time when usually he was to be\nfound at his office.\n\nIn such cases as these it seems reasonably clear that long-continued\nfamiliarity with a given idea produces an auto-suggestion which\nfinally overcomes the natural abhorrence even of suicide. Something\ncan be done for such unfortunates by suggestion in the opposite\ndirection, and by taking care that as far as possible they are not\nallowed to brood over the fate they consider impending. At times of\nstress and emotional strain, relatives and friends must be\nparticularly careful in their watch over them. It is never advisable\nthat they should take up such professions as those of broker or\npolitician, or speculator, since the emotional states connected with\nsuch occupations are likely to prove too much for their mental\nequilibrium.\n\nPractically all physicians that have given any attention to the\nsubject are convinced that not a few of the suicides, which are now so\nalarmingly on the increase in this country, are due to the frequent\nreading in newspapers of the accounts of suicides. As we have said\nelsewhere, brooding over the details of these is very likely to lessen\nthe natural abhorrence of self-murder in persons that are predisposed,\nby melancholic dispositions, to such an act. The publication of cases\nof suicide can do no possible good, while it undoubtedly does, in this\nway, work incalculable harm. This is especially true with regard to\nsuicides among young people, that is, individuals under twenty-five\nyears of age. The saddest feature of recent {134} statistics with\nregard to suicide is that this crime has become proportionately much\nmore frequent among young men and young girls, and even children, than\nit was two or three decades ago. It has been noted, too, in many cases\nthat a previous suicide in the family seems to have familiarised the\nyoung mind with the idea of self-destruction and thus suggested its\ncommission.\n\nOn the other hand, among young people especially, it has been noted\nthat there is frequently an imitative element in suicides. Three or\nfour suicides, practically with the same details, will occur, within a\nfew days of each other. Suicides at all ages are especially likely to\noccur in groups, and are often cited to exemplify the truth of the old\naxiom that evils never come singly. It is especially among young\npeople, however, that this relationship to previous suicides can be\ntraced, and there is no doubt that it is the unfortunate publicity\ngiven to suicide, with the consequent suggestive influence, which\nconstitutes the most important factor in these cases. All the\ninfluence that clergymen can exert, then, must be wielded to suppress\nthis, as well as the many other evils which flow from sensational\njournalism.\n\nJAMES J. WALSH.\n\n\n{135}\n\nXI\n\nUNEXPECTED DEATH\n\nUnexpected death and its problems constitute the principal reason why\nthere should be a pastoral medicine, and why the clergyman must keep\nhimself in close touch with advances in medicine. To have an ailing\nmember of a congregation die unexpectedly, that is, without the rites\nof the Church, when perhaps there has been some warning as to the\npossibility of such an accident, can not but be a source of the\ngravest concern in pastoral work. Sudden death can be anticipated in\nmany diseases that are acute, while in chronic forms of disease the\nsufferer can be prepared for its possibility by the administration of\nthe sacraments at regular intervals. There is, however, an old proverb\nwhich says that death always comes unexpectedly; and even with all the\nmodern advance in medicine, this still contains a modicum of truth. As\nan unprepared death is an occasion of the most poignant regret to the\nfriends of the deceased and to the attending clergyman, it is with the\nidea of furnishing some data by which the occurrence of death without\ndue anticipation may be rendered more infrequent, that the following\nmedical points on the possibilities of a fatal termination in certain\ndiseases have been brought together. Unfortunately, even with all our\nprogress in modern medicine, they must be far from adequate for all\ncases.\n\nNeedless to say, the only rational standpoint in this matter must be\nthat it is better to be sure than to be sorry. The impression is very\nprevalent now that at least the sacraments of Penance and the Holy\nEucharist should be administered to the sick whenever there is even\nthe possibility of a fatal termination of the illness. Extreme Unction\nis more usually delayed until there is some positive sign of {136}\napproaching dissolution. Delay in its administration, however, not\ninfrequently leads to this sacrament being given when the patient is\nunable to appreciate its significance. This would seem to be very far\nfrom the intention of the Church. The idea has been constantly kept in\nmind, then, so to advise the clergyman with regard to the liability of\na fatal termination as to secure, if possible, the administration of\nExtreme Unction while the patient is still in the full possession of\nhis senses.\n\nAssured prognosis, that is, positive foresight as to the course of any\ndisease, is the most difficult problem in medicine. Nearly 2400 years\nago, when Hippocrates wrote his chapter on the progress of diseases,\nhe stated that the hardest question to answer in the practice of\nmedicine is, will the patient live? That special chapter of his book\nremains, according to our best authorities, down even to our own day,\na valuable document in medical literature. It can be read by young or\nold in medical practice with profit. While our knowledge of the course\nof disease has advanced very much, the wise old Greek physician\nanticipated most of the principles on which our present knowledge of\nprognosis is founded. This fact in itself will serve to show how\nunsatisfactory must be any absolute conclusion as to the termination\nof any given disease. Our forecasts are founded on empirical\ndata,--that is, they are the result of a series of observations,--and\nthe underlying basis of all the phenomena is the individual human\nbeing, whose constitution it is impossible to know adequately, and\nwhose reaction to disease it is impossible, therefore, to state with\nabsolute certainty.\n\nWith this warning as to the element of doubt that exists in all\nprognosis, we may proceed to the consideration of certain organic\naffections which make sudden death frequent.\n\nAt the beginning of the present century, Bichat, a distinguished\nFrench physician who revolutionised medical practice, said that health\nand the favourable or unfavourable termination of disease depends on\nthe condition of three sets of organs--the brain, the heart, and the\nlungs. This was what he called the vital tripod. It was not until\nnearly thirty years after Bichat's death that Bright, an English {137}\nphysician, taught the medical profession to recognise kidney disease.\nSince his time we have learned that even more important than Bichat's\nvital tripod, as regards health and the termination of disease, is the\ncondition of the kidneys. We shall consider affections of these four\norgans, and their influence on the human system and intercurrent\ndisease, in the order of their importance.\n\nWhen kidney disease exists the individual's resistive vitality is much\nlowered. The kidneys are the organs which serve to excrete poisons\nthat find their way into the circulation. When the kidneys fail to\nact, these poisons are retained. As a result other important organs,\nnotably the nervous system and the heart, suffer severely because of\nthe irritating effect of the retained poison. A patient with kidney\ndisease runs a very serious risk in any infectious fever, no matter\nhow mild, and such patients should always be completely prepared for a\nfatal termination when they acquire any of these diseases.\n\nNephritic patients bear operations very badly. The shock to the\nnervous system incident upon operation always throws a certain amount\nmore than usual of excrementitious material into the circulation.\nDiseased kidneys do not fulfil their function of removing this at\nonce, and the result is an irritated and fatigued nervous system.\nAnaesthetics, that is, chloroform and ether, are not well tolerated\nwhen nephritis exists, and this adds to the danger of operation in\nsuch patients. No matter how simple or short the operation that is to\nbe performed on a person suffering from kidney disease, if an\nanaesthetic is to be administered it would be well to prepare the\npatient for an untoward event that may occur.\n\nKidney disease is often extremely insidious. It may develop absolutely\nwithout the patient's knowledge, even though he might be deemed to be\nin a position to have at least some suspicion of its existence. The\nstory is told of more than one professor of medicine who has presented\nhis own urine to his class for examination in order that they might\nhave the opportunity of studying normal urine, only to find to his\npainful surprise that albumen was present and that he was the subject\nof latent Bright's disease. In these cases it is {138} impossible to\nforesee results. They constitute a large number of the cases in which\npatients, seemingly in good health, succumb rather easily and\nunexpectedly to some simple disease, like grippe or dysentery. It is\nwell to take the precaution, then, to ask the attending physician what\nthe condition of the kidneys is in such cases. If there are anomalous\nsymptoms, this precaution becomes doubly necessary. Even such simple\ninfectious diseases as mumps or chicken-pox may cause a fatal issue\nwhere the kidneys are not in a condition to do their normal work of\nexcretion.\n\nAn important class of cases for the clergyman are those which are\npicked up on the street. As a rule, these patients are comatose\nbecause of the presence of kidney disease. A certain proportion of\nthem are unconscious because of apoplexy. Very often the patients have\nhad some preliminary symptoms of their approaching collapse, though\nthese were not sufficient to make them think that any serious danger\nthreatened. As a consequence, they will not infrequently have had\nrecourse to some stimulant. It seems unfortunately to be almost a\nrule, when such cases are picked up, if there is the odour of alcohol\non their breath, to consider that the condition is due to alcoholism.\nEvery year, in our large cities, some deaths are reported in the cells\nof the station houses because a serious illness was mistaken for\nalcoholism as a result of the odour of the breath. Needless to say,\nthen, the odour of alcohol on the breath of a person in coma should\nnot deter a clergyman from waiting for a time to be sure his\nministrations may not be needed for something much more serious than\nalcoholism.\n\nPatients suffering from kidney disease bear extremes of cold and heat\nvery badly. In cold weather the fact that the blood is driven from the\nsurface of the body lessens the excretory function of the skin, and\nthis throws the work of this important organ, so helpful an auxiliary\nin excretion, back upon the kidneys. Besides, congestions of internal\norgans are not infrequent during cold, damp seasons, and these bring\non exacerbations of previously existing ailments that may make fatal\ncomplications. In summer intense heat leads to many more changes in\nthe tissues, and so provides more material to {139} be excreted than\nin temperate weather. Patients picked up on the street, then, at such\ntime, will usually be found to be suffering from kidney disease.\nThough in profound coma, such patients seldom die without recovering\nconsciousness. Not infrequently, after the primary stroke of the coma,\nthere is, in an hour or two, a period in which the patient becomes\nalmost completely rational. This period of consciousness does not last\nlong, in many cases, and should be taken immediate advantage of, yet\nwithout unduly disturbing the patient.\n\nThere is a well-known tendency in kidney disease to the production of\noedema, that is, to the outflow of the watery constituents of the\nblood into certain loose tissues of the body. This is easily\nrecognised, and constitutes a valuable sign of kidney disease in the\nswelling of the eyelids and of the feet, that occurs so often in\npatients suffering from kidney trouble. The usual rule is, if the\noedema begins in the face, it is due to the kidneys; if in the feet,\nto the heart. The cause in the latter case is the sluggish circulation\ndue to the weakness of the heart muscle, which delays the blood so\nlong in the extremities that its watery elements find their way out\ninto the tissues. In kidney disease this tendency to oedema\nconstitutes a distinct danger that may involve sudden death in certain\naffections. In patients suffering from kidney disease any acute sore\nthroat involving the larynx and causing hoarseness may be followed by\nwhat is called oedema of the glottis. This is often fatal in a very\nshort time. The glottis is the opening between the vocal cords through\nwhich respiration is carried on. This opening is but small, and\nswelling of the surrounding tissues readily encroaches upon it, and\nsoon causes difficulty of breathing. If the swelling is not relieved\nwithout delay, death takes place from asphyxiation. This was probably\nthe cause of death in George Washington. In almost the same way any\nacute affection of the lungs that occurs in a patient suffering from\nkidney disease may be followed by oedema of the lungs. The outflow of\nserum from the blood vessels into the loose tissues of the lungs so\nencroaches upon the space available for breathing, and at the same\ntime so reduces the elasticity of lung tissue, that {140} respiration\nbecomes impossible, and death takes place in a few hours. This is\noften the cause of unexpected death after operations. The kidney\naffection in the patient is so slight as to have been unsuspected, or\nto have been considered of not sufficient importance to render the\noperation especially dangerous.\n\nAfter kidney disease the most important factor in the production of\nunexpected death is heart disease. In about 60 per centum of the\npatients who die suddenly, in the midst of seemingly good-health,\ndeath is due to heart disease. All forms of heart disease may be\nconsidered under two heads--the congenital and the acquired. The\ncongenital form of heart disease usually causes death in early years.\nIf such patients survive the fourth or fifth year, they are usually\ncarried off by some slight intercurrent disease shortly after puberty.\nA few cases of congenital heart disease, however, live on to a good\nold age and seem not to be seriously inconvenienced by their heart\ntrouble. Most of the acquired heart disease, that is, at least 65 per\ncentum of it, is due to rheumatism. All of the infectious fevers,\nhowever, may cause heart disease, and scarlet fever especially is\nprone to do so; heart complications occurring in about one out of\nevery ten cases. The probabilities of sudden death in a case of heart\ndisease depend on what valve is affected and what the condition of the\nheart muscle is. Most of the cases of sudden death occur in disease of\nthe aortic valves, that is, of the valves that prevent the blood from\nflowing back from the heart after it has been pumped out. Diseases of\nthe other side of the heart, the mitral valve, cause lingering illness\nuntil the heart muscle becomes diseased, when sudden death usually\ncloses the scene.\n\nDiseases of the aortic valves of the heart cause visible pulsations of\nthe arteries, especially of those in the neck. This readily attracts\nattention if one is on the lookout for it. Deaths in heart disease,\nwhether sudden or in the midst of apparent health, or as the terminal\nstage after confinement to bed because of weak heart, are apt to occur\nparticularly during continued cold or hot spells. Each of the\nblizzards that we have had in recent years has been the occasion for a\n{141} markedly increased mortality in all forms of heart disease. The\ncold itself is exhaustive, and the heavy fall of snow, by delaying\ncars and modes of conveyance generally, is very apt to give occasion\nfor considerably more exertion than usual. Besides, cold closes up the\nperipheral capillaries and makes the pumping work of the heart much\nharder than before. At times of continued cold, in our large cities\nparticularly, the ordinary arrangements for heating the house fail to\nkeep it at a constant temperature, and this proves a source of\nexhaustion to cardiac patients.\n\nHeated spells, if prolonged, always cause an increased mortality in\nsuch patients, because heat is relaxant and this leads to exhaustion.\nPatients who have been nursed faithfully through a severe winter will\nsometimes succumb to the first few successive days of hot weather that\nare likely to come at the end of May or the beginning of June. The\ndeaths that occur during the hot spells of July and August are more\nlooked for and accordingly prove not so unexpected.\n\nThe warning symptom in heart disease that the patient is giving out is\nthe development of irregularity and rapidity of the pulse. On the\nother hand, when a pulse has been running rapidly for weeks and then\ndrops to below the regular rate, to 50 or 60, a fatal termination may\nbe looked for at almost any time, though, of course, the patient may\nrally. The prognosis of heart cases is extremely difficult. Confined\nto bed and evidently seriously ill, they may continue in reasonably\ngood condition for months, and then some indiscretion in diet, which\ncauses a dilation of the stomach with gas, pushes the diaphragm up\nagainst the heart, adds a mechanical impediment to the physical\ndifficulties the organ is already labouring under, and a sudden\ntermination may ensue. As a rule, lingering heart cases terminate\nsuddenly and often with little warning of the approach of death.\n\nAn interesting set of heart symptoms, for the physician as well as the\nclergyman, are those which occur in what is called angina pectoris,\nheart pang, or heart anguish. Serious angina pectoris occurs in\nelderly people whose arteries are degenerate. Its main symptom is a\nfeeling of discomfort which develops in the praecordia,--the region\nover the heart. {142} This discomfort may often increase to positive\ncutting pain. The pain is often referred to the shoulder, and runs\ndown the left arm. This set of symptoms is accompanied by an intense\nsense of impending death. When the patient's arteries are degenerated,\nthis train of symptoms must always be considered of ominous\nsignificance. A readily visible sign of arterial degeneration can\nsometimes be noted in the tortuous prominent temporal artery just\nabove the temple.\n\nHeberden, an English physician, a little over a century ago, pointed\nout that there existed in cases of true angina pectoris a degeneration\nof the coronary arteries. These are the arteries which supply the\nheart itself with blood. As might naturally be expected, their\ndegeneration seriously impairs the function of the heart muscle. The\nfirst patient in whom the condition was diagnosed during life was the\ndistinguished anatomist, John Hunter. Hunter was of a rather irascible\ntemperament, and after he had had several of these attacks, and a\nconsultation with Heberden convinced him of their significance, he is\nsaid to have remarked, \"I am at the mercy of any villain who rouses my\ntemper.\" Sure enough. Hunter died in a sudden fit of anger within the\nyear after making the remark. Charcot, the distinguished neurologist,\nsuffered from attacks of angina pectoris, and was asked by his family\nto consult a distinguished heart specialist for them. He said: \"Either\nI have degenerated heart arteries, or I have not. I believe that I\nhave not, and that my attacks are due to a nervous condition of my\nheart. If I should consult the physician you mention, and he were to\ntell me that my attacks are due to degeneration of the heart, he would\nadvise my giving up work. That I am not ready to do, and so I prefer\nto take my own assurance in the matter.\" A few years later he was\nfound one morning dead in bed. In many of the cases of death in bed,\nespecially where some complaint of pain has been heard during the\nnight, death is due to that condition of the heart arteries which\ncauses angina pectoris, though it may be the first attack which proves\nfatal.\n\nThere is a condition similar to angina pectoris, sometimes called\npseudo-angina, or false heart pang, which occurs in individuals from\nfifteen to thirty years of age. It is often a {143} source of great\nworry. It occurs in young persons of a nervous temperament who have\nbeen overworked or overworried and have run down in weight. There are\nalways accompanying signs of gastric disturbance. The casual factor of\nthe symptoms seems to be a more or less sudden dilation of the stomach\nwith gas. As the stomach lies just below the heart, only separated\nfrom it by the comparatively thin layer of diaphragm, the heart is\npushed up and its action interfered with. In healthy individuals this\ncauses no more than a passing sense of discomfort and some heart\npalpitation. That it is which sends so many young patients to\nphysicians with the persuasion that they have heart disease, when they\nhave nothing more than indigestion. In nervous individuals, however,\nthis interference with the heart action disturbs the nervous mechanism\nof the heart, which is very intricate and delicate, and gives rise to\nthe symptoms of false \"heart pang.\" One of these symptoms is always,\nas in true angina pectoris, an impending sense of death. This can not\nbe shaken off, and is not merely an imagination of the patient.\nPseudo-angina is, however, not a dangerous affection. Patients can\nusually be assured that there is no danger of death. This assurance is\nnot absolute, however. For some of these cases have congenital defects\nin their coronary arteries, and the nervous system of the heart\nitself, which make them liable to sudden death. It is sometimes\nimpossible to differentiate such cases of organic heart defects from\nthe ordinary functional heart disturbance due to indigestion, which\ncauses simple curable pseudo-angina. Young patients may usually be\ndisabused of their nervousness in the matter, but absolute assurance\ncan not be given until the case has been under observation for some\ntime.\n\nAfter the heart, the head is the most important factor in sudden\ndeath. The most frequent form of death from intra-cranial causes is\napoplexy. Apoplexy, as the name indicates--a breaking out--is due to\na rupture of one of the arteries of the brain, and a consequent\nflowing out of blood into the brain tissue. The presence of the exuded\nblood causes pressure upon important nerve tracts, and so gives rise\nto unconsciousness, to paralysis, and to the other symptoms which are\n{144} noted in apoplexy. There are a number of symptoms that act as\nwarnings of the approach of apoplexy. First, it occurs only in those\nbeyond middle life, that is, in individuals over forty-five, and in\nthese only where there is marked degeneration of arteries. The\ndegeneration of the arteries can be easily noted, as a rule, in other\nparts of the body. The condition known as arterio-sclerosis, that is,\narterial hardening, can be detected by the finger at the wrist, or by\nthe eye in the branch of the temporal artery, which can so frequently\nbe seen to take its sinuous course on the forehead behind and above\nthe eye. At the wrist the thickened artery is felt as a cord that can\nbe rolled under the finger. It is not straight as in health, but is\ntortuous, because the overgrowth in the walls, which makes it thick,\nhas also made it longer than normal, thus producing tortuosity.\n\nBesides these objective signs, as they are called, there are certain\nsubjective signs, that is, signs easily recognised by the patient\nhimself, which should put him on his guard, and at the same time serve\nas a warning to the clergyman, should he hear of their presence. These\nsigns are recurring dizziness, or vertigo, not clearly associated with\ngastric disturbance; tendency of the limbs, and especially the fingers\nand toes, to go to sleep easily, and when there is no external cause\nfor this condition; tendency to faintness and to dizziness when the\npatient rises in the morning, especially if he assumes the erect\nposition suddenly; tendency to vertigo when the patient stoops, as to\ntie a shoe, or pick up something from the floor, and the like;\nfinally, certain changes in the patient's disposition, with a loss of\nmemory for things that are recent, though the memory may be retained\nfor the happenings of years before. When several of these symptoms\noccur, patients who are well on in years should take warning of the\nfact that they are liable at any time to have a stroke. Needless to\nsay, this has no reference to the cases of young nervous persons who\nmay readily imagine that they have some or all of these symptoms.\nApoplexy is typically the disease of those over fifty years of age.\n\nThere may even occasionally be slight losses of power in the hand or\nfoot that point to the occurrence of small hemorrhages in the brain,\nthat is, slight preliminary \"strokes.\"\n\n{145}\n\nPatients that have had these symptoms should not, as a rule, be\nallowed to leave home unattended. If the apoplexy occurs in the street\nthey are liable to be mishandled by those ignorant of their true\ncondition. The clergyman is usually summoned at once in these cases\nand may reach the stricken individual before the physician. Some\nwords, then, with regard to the general management of such patients\nwill not be out of place. As a rule, when a patient is taken with some\nsudden illness which causes him to fall down unconscious, the first\nthing done is to dash water in his face, force a stimulant down his\nthroat, put his head low down, and loosen the clothing around his\nneck. Most of these proceedings are the very worst things that could\nbe done for a patient suffering from apoplexy. The rough handling,\nparticularly, and the administration of a stimulant, will surely do\nharm. The water on the face will certainly do no good.\n\nApoplectic patients can be recognised from those who are merely in a\nfainting fit, first, by the fact that they are usually old, while the\nfainters are young; and secondly, by the manner of the breathing. In a\nfaint the breathing is shallow and faint, not easily seen. In apoplexy\nit is apt to be deep and long. It may be irregular, and it is always\naccompanied by a blowing outward and inward of the cheeks, and\nespecially of the side of the face which is paralysed, as a\nconsequence of a hemorrhage into the brain.\n\nThe lips are forced outward and drawn inward during the respiration.\nIn such cases the patient should be moved as little as possible;\nstimulants should be avoided, and the head should be placed higher\nthan the rest of the body, so as to make the hemorrhage into the brain\nas small as possible, by calling in the assistance of gravity to keep\nthe heart from sending too much blood into the head. Besides this\nplacing the head high, there is only one other helpful measure that\neven the physician can practise, except in rare cases, that is, to put\nan ice-bag on the head. For this a cloth dipped in cool water may be\nused in an emergency. Of course, as soon as the doctor arrives, the\npatient should be left entirely to his care.\n\nThe artery that ruptures in the brain, in cases of apoplexy, {146} is\npractically always the same. Its scientific name is the\nlenticulo-striate artery, but it is oftener called by the name given\nit by Charcot--the artery of cerebral hemorrhage. The reason why\narteries in the brain rupture rather than arteries in other organs is\nthat in the brain, in order to avoid the demoralising effect of too\nsudden changes of blood pressure upon the nervous substance, the\ncerebral arteries are terminal, are not connected directly with a\nnetwork of finer arteries as in the rest of the body, but gradually\nbecome smaller and smaller, and end in the capillary network which is\nthe beginning of the venous vascular system. This special artery\nruptures, because it is almost on a direct line from the heart, and so\nblood pressure is higher in it than in other brain arteries.\n\nThe tradition that people with short necks are a little more liable to\napoplexy than are those of longer cervical development has a certain\namount of truth in it, though not near so much as is often claimed for\nit. Another predisposing element to apoplexy is undoubtedly heredity.\nFamilies have been traced in which, for five successive generations,\nthere have been attacks of apoplexy between fifty-five and sixty years\nof age. Short-necked people, with any history of apoplexy in the\nfamily, should especially be careful, if they have any of the\nsymptoms--dizziness, sleepy fingers, etc.--that we have already\nnoted.\n\nThere is a tradition that the third stroke of apoplexy is always\nfatal. This is without foundation in experience, though of course the\nliability of death increases with each stroke, and few patients\nsurvive the third attack. I remember seeing in Mendel's clinic, in\nBerlin, a man who was suffering from his seventh stroke and promised\nto recover to have another. Each successive stroke is much more\ndangerous to life than the preceding one, however. In general, the\nprognosis of an apoplexy, that is to say what the ultimate result will\nbe, is impossible. The patient may come to in an hour or two, and may\nnot come out of the coma at all. There is no way of deciding how large\nthe artery is that is ruptured, nor how much blood has been effused\ninto the brain, nor how much damage has been done to important nerve\ncentres. Nor is there any {147} effective way of stopping the\neffusion, though certain things seem to be of some benefit in this\nmatter. We can only wait, assured that, in most of the cases, the\npatient will have a return of consciousness, at least for a time.\n\nNext to apoplexy, injuries of the head are most important. The\nsymptoms presented by the patient will often be nearly the same as\nthose of apoplexy. If the skull is fractured, and the depressed bone\nis exerting pressure upon the brain substance, there is a similar\nstate of affairs to that which exists in apoplexy. Any return to\nconsciousness must be taken advantage of for the administration of the\nSacraments. As a rule, it is impossible to tell the extent of the\ninjury or to forecast the ultimate result.\n\nA very characteristic set of symptoms develops sometimes after\ninjuries in the temporal region or just above it. For a short time up\nto an hour or two after the injury, the patient is unconscious. Then\nhe comes to for a while, but relapses into unconsciousness, from which\nhe will usually not recover except after an operation. The explanation\nof this succession of symptoms is that the primary unconsciousness is\ndue to shock--concussion or shaking up of the brain. The injury has,\nhowever, also caused a rupture of an important artery which occurs in\none of the membranes of the brain in this region, the middle meningeal\nartery. During the state of shock blood pressure is low and hemorrhage\nis not severe. When consciousness is regained, blood pressure goes up\nand the laceration of the middle meningeal artery, already spoken of,\nprovides an opening for the exit of considerable blood, which clots in\nthis region and presses upon the brain, causing the subsequent\nunconsciousness. As a rule, the patient's only hope is in operation\nwith ligature of the torn artery. The condition is always very\nserious, and complete precautions as to the possibility of fatal\ntermination should be taken, as soon as consciousness is regained\nafter the blow, in any case where the head injury has been severe\nenough to cause more than a momentary loss of self-possession. No one\ncan tell whether there may be further change or not, and if this\nhappens it will be in the form of an unconsciousness gradually\ndeepening until relieved by operation or ended by death.\n\n{148}\n\nTumours of the brain often produce death, but usually give abundant\nwarning of their presence. The symptoms by which the physician\ndiagnoses the presence of a brain tumour are vertigo, headache,\nvomiting, usually some eye trouble, and frequently some interference\nwith the motion of some part of the body, because of pressure exerted\nupon the nerve centres which preside over its motions. Brain tumours\nare especially liable to develop in two classes of cases--in patients\nwho are suffering from tuberculosis in its terminal stages or from\nsyphilis. Where patients are known to have either of these diseases\nand present any two of the symptoms of brain tumour that I have\nmentioned, it is well to suggest at least the preliminary preparation\nfor a fatal termination. Sometimes states of intense persistent pain,\nor of mental disturbance, develop in these cases and make the\nadministration of the Sacraments unsatisfactory.\n\nMeningitis is a fatal affection which sometimes causes sudden death,\nbut more frequently produces unconsciousness without very much\nwarning, and the unconsciousness lasts until the death of the patient.\nMeningitis is seen much more frequently in children than in the adult.\nOrdinarily it is due to tuberculosis. Sometimes, however, there are\nepidemics of cerebrospinal meningitis--spotted fever, as it used to be\ncalled. In about one-half the cases this affection is fatal.\nUnfortunately this disease gives very little warning of its approach\nin many cases before unconsciousness sets in. We have had renewed\nepidemics of the disease in the eastern part of the United States in\nrecent years, and the affection is likely to occur more frequently for\nsome time to come. The first hint of the onset of the disease during\nan epidemic should be the signal for the administration of all the\nrites of the Church.\n\nOf late years we have learned that the pneumococcus, that is, the\nbacterium which causes pneumonia, may produce a fatal form of\nmeningitis. The first symptom of meningitis is usually a stiffness of\nthe muscles at the back of the neck. If this stiffness becomes very\nmarked in a patient suffering from tuberculosis, or who has, or has\nrecently had, pneumonia, or at a time when there is any reason to\nsuspect that epidemic cerebrospinal meningitis exists in a\nneighbourhood, the {149} prognosis of the case is always very serious.\nEvery precaution should be taken to prepare the patient for the worst.\nUnconsciousness may ensue at any moment and no opportunity for\nsatisfactory administration of the consolations of religion be\nafterwards afforded.\n\nWhile Bichat put the lungs down as one of the vital tripod on which\nthe continuance of life depends, affections of these organs very\nseldom lead to sudden or unexpected death. Pulmonary affections\nusually run a very chronic course. Acute bronchitis, however,\noccurring in a patient with kidney trouble, may lead to the\ndevelopment of oedema of the lungs, and death will usually ensue in a\nfew hours. It may be well to note here that individuals who have what\nare called clubbed fingers, or as the Germans picturesquely put it,\ndrumstick fingers, that is, fingers with bulbous ends, the finger\nbeyond the last joint being larger than the preceding part, nearly\nalways have some chronic affection within the thorax. This means that\nthere is some organic affection of the heart or lungs which has lasted\nfor many years. The existence of such condition makes them distinctly\nmore vulnerable to any serious intercurrent disease, and this sign\nalone may be enough to put the attending physician on his guard as to\nthe possibility of fatal complications in the case.\n\nJAMES J. WALSH.\n\n\n{150}\n\nXII\n\nUNEXPECTED DEATH IN SPECIAL DISEASES\n\n\nBesides the general systemic conditions in which sudden death may\noccur without anticipation, there are certain specific diseases of\nwhich unexpected death is sometimes a feature. For the clergyman to\nknow the condition in which the sudden fatal termination is liable to\noccur is to be forearmed against the possibility of death without the\nSacraments, or their enforced administration in haste, when the\nrecipient is in a very unsatisfactory condition of mind and body. It\nhas been said that if a normally healthy individual reaches the age of\ntwenty-five he is reasonably sure to live to a good old age, provided\nhe does not meet with an accident or catch typhoid fever or pneumonia.\n\nPneumonia is an extremely important affection as regards its\nprognosis. From 15 to 20 per centum of sufferers from the disease die;\nthat is to say, about one in six of those attacked by the disease will\nnot recover. It is a little more fatal in women than in men. It is\nespecially serious for the very young and the old.\n\nHealthy adults in middle life very rarely die from the disease. The\nprognosis of any individual case, it has been well said, depends on\nwhat the patient takes with him into the pneumonia. Serious affections\nof important organs nearly always cause fatal complications. If the\nheart is affected before the pneumonia is acquired, then the prognosis\nis very unfavourable, and a fatal termination is almost inevitable. If\nthe kidneys are seriously diseased beforehand, death is almost the\nrule. Pneumonia developing during the course of pregnancy is fatal in\nmore than one-half of the cases. At one time it was suggested that\npremature delivery of pregnant {151} pneumonia patients might save at\nleast the mother's life. Experience in Germany, however, has shown\nthat, far from making the prognosis more favourable, the induction of\npremature labour makes the outlook a little worse for the patient.\nPrevious affections of the lungs, emphysema, or tuberculosis, are\nprone to make the prognosis of pneumonia much more unfavourable than\nunder ordinary circumstances.\n\nDeteriorated conditions of the blood, anaemia, chlorosis--such as\noccurs so commonly in young women--is prone to make the outlook in\npneumonia more serious. Pneumonia of the upper lobes of the lungs is\nmore apt to be followed by complications, and is therefore more\nserious than pneumonia of the lower lobes. Secondary pneumonia--that\nis, inflammation of the lungs which develops as a complication of some\nother disease--is much more unfavourable than primary pneumonia which\ndevelops in the midst of health. The amount of lung involved is of\ncourse a serious factor in the prognosis. If the whole of one lung is\nconsolidated, or if considerable portions of both lungs are thus\naffected, the prognosis becomes extremely unfavourable.\n\nIn persons of alcoholic habits the result of pneumonia is always to be\ndreaded. The more liberal has been the consumption of alcohol, as a\nrule, the less hope is there of a prompt, uncomplicated recovery.\nStimulants are of the greatest importance in pneumonia, and the less\nthe patient has taken of them before the development of his pulmonary\naffection the more effective are they when the crisis of the disease\ncomes. The less the alcohol that has been taken habitually before the\ndevelopment of pneumonia, the more surely will it do the work expected\nof it during the course of the pneumonia. It must be borne in mind\nthat cases of pneumonia that occur in institutions, asylums,\nhospitals, and the like, and in crowded quarters in tenement houses or\nlodging houses, have a distinctly worse prognosis than those treated\nin private houses, and the priest must accordingly be more on his\nguard and give the Sacraments early.\n\nIn pneumonia, as in typhoid fever, so-called walking cases always have\na serious prognosis. They occur in very strong patients who resist,\nnot the invasion of the disease, but its {152} weakening influence,\nand keep on their feet for several days, despite the presence of\nsymptoms that require them to be in bed. When a patient walks into a\ndoctor's office in the third or fourth day of a pneumonia with most of\none lung consolidated, exhaustion of the heart and of the nervous\nsystem, under these unfavourable conditions, will usually have made\nhis resistive vitality very low. Such cases should be given the\nSacraments early, while in the full possession of their senses.\nConditions sometimes develop rather unexpectedly in which the\nadministration of the Sacraments becomes unsatisfactory, because of\nthe collapsed state of the patient.\n\nThis same advice holds with regard to walking cases of typhoid fever.\nWhere strong patients suffering from the disease have insisted on\nbeing around on their feet for from six to ten days at the beginning\nof the affection, the prognosis becomes very unfavourable.\nComplications, such as hemorrhage or perforation of the intestine,\noccur about the beginning of the third week, and often prove fatal.\nAll typhoid fever patients should receive at least the Sacraments\nnecessary to give a sense of security to the priest and their friends\nduring the course of the second week, even though they may seemingly\nbe in excellent condition. When typhoid fever is fatal the\ncomplications occur suddenly, often without much warning; and if\nintestinal perforation, for instance, takes place, the peritonitis\nwhich develops makes the patient's condition very unsuitable for the\nreception of the Sacraments in a proper state of mind.\n\nTyphoid fever patients sometimes die suddenly in collapse when they\nare convalescent. The toxine of the typhoid bacillus often affects the\nheart, and causes what is called cloudy swelling of its muscular\nfibres. This decreases very notably their functional ability. Any\nsudden exertion, even sitting up in bed, may cause the heart to stop\nunder such circumstances. The modern custom in hospitals is not to\nallow typhoid patients to sit up in convalescence until the head of\nthe bed has been raised gradually for several days so as to accustom\nthe heart to pumping blood up the hill to the brain. Priests must be\ncareful, then, when they call to see convalescent typhoid patients,\nnot to permit them to sit up {153} to greet them. The doctor's\ndirections in this matter should be followed very carefully.\n\nThis sudden fatal collapse may occur after any of the infectious\ndiseases. It is seen not infrequently after diphtheria. It occurs more\nrarely after scarlet fever, and even after some of the milder\nchildren's diseases. In rheumatism, especially where a heart\ncomplication has occurred, this rule with regard to sudden movements\nis extremely important Rheumatism is itself not a fatal disease, yet\nthere are certain cases in which very high temperature sets in, causes\ndelirium, and death ensues at times before the patient recovers\nconsciousness. Where rheumatic patients show a tendency to run high\ntemperatures, that is, 104 deg. or higher, it is well to be prepared for\nthis emergency.\n\nAppendicitis is very much talked about in our day; but the fatal\naffection represented by the new word is no more frequent than it was\nhalf a century ago, or, for that matter, twenty-five centuries ago.\nPeople died of inflammation of the bowels and peritonitis then; and as\nthe appendix was not known as the origin of the trouble, the fateful\nname was not the spectre that it is now. Practically all abdominal\ncolic--and this means 90 per centum of all the acute pain which\nfollows gastro-intestinal disturbance in young or middle-aged\nadults--is due to appendicitis. It comes on, as a rule, in the midst\nof good health. It is very treacherous, and when the patient is\napparently but slightly ill, a sudden turn for the worse may assert\nitself, and an intensely painful and prostrating condition develop.\nWhere symptoms of appendicitis are present, it is the part of safety\nto have the patient receive at least the Sacraments of Penance and the\nHoly Eucharist. When peritonitis develops, vomiting is the rule. Hence\nthe advisability of prompt administration of Holy Communion. Extreme\nUnction can be given with some satisfaction, even during the disturbed\nperiod which follows a beginning peritonitis. For the peritonitis that\nsometimes results from appendicitis there is no hope of recovery\nexcept by operation. Operation, to be successful, must follow the\nperforation of the appendix not later than by a few hours.\n\n{154}\n\nEarly pregnancy, that is, the first eight to ten weeks of gestation,\nis sometimes complicated by a set of symptoms the most prominent of\nwhich are sudden very acute pains in the lower part of the abdomen,\nfollowed by intense prostration, and then by the symptoms of internal\nbleeding,--namely, a soft pulse, pallor with cold extremities, sighing\nrespiration, and marked tendency to faintness. When symptoms like\nthese occur during the first three months of pregnancy, they signify,\nalmost without exception, rupture of an extrauterine gestation-sac.\nExcept where operation can be performed at once, these cases are\nalmost invariably fatal. Extrauterine pregnancy occurs with greatest\nfrequency in women who, having had one or more children, then have a\nperiod of five or more years without children, followed by pregnancy.\nUndoubtedly, extrauterine pregnancy, the knowledge of which is the\nresult of medical advance in very recent years, and appendicitis,\nwhich is the growth of the last twelve years, were prominent factors\nin the production of many inexplicable deaths in history. These were\nnot infrequently set down as due to poison.\n\nAcute indigestion in elderly people is sometimes followed by sudden\ndeath. Observations in this matter have somehow become much more\nfrequent of late years, and many of the so-called cases of heart\nfailure belong to this group. The important nerve trunk that carries\nnervous fibres to the heart bears fibres to the digestive tract, the\noesophagus, the stomach, the intestines, the liver as well, and also\nto the larynx and lungs. There is a certain intercommunication between\nthe impulses which pass along these various nerve fibres. Intense\nirritation of the nerve endings in any one of these organs may be\nreflected back upon the heart. Curiously enough the nerve fibres to\nthe heart that run in this trunk are many of them inhibitory; that is\nto say, they lessen the function of the heart or cause it to stop\nbeating entirely. If an intense nervous irritation is set up in the\nstomach, reflex nervous impulses may cause the heart to stop\ncompletely and never resume its work.\n\nTypical cases of this kind often occur during the first cold days of\nthe winter time. Elderly people come to their meals cold and chilly,\nyet with appetite increased by the bracing air. They sit down at once,\ntake a larger meal than usual, and then develop severe gastritis\nduring the night. This is {155} relieved by purging and vomiting, and\nthe pain yields to the administration of morphine. Their condition\nimproves and all danger seems past, when, on sitting up suddenly the\nnext day, or, if left alone, getting up to get something for\nthemselves, they collapse and are dead before help can come to them.\nDeaths like this sometimes occur in dysentery also, the reason being\nthe intense nervous reflex from the irritated intestinal nerve endings\nwhich exerts its influence upon the heart nerves.\n\nCertain diseases practically always end in sudden death and must be\ntaken special care of by the priest for this reason. Aneurism, for\ninstance, is one of these. An aneurism is a widening or dilatation at\nsome point of an artery. The most important aneurisms occur in the\narch of the aorta, that is, in the large curved artery which comes\ndirectly from the heart itself and of which all the other arteries are\nbranches. Aneurisms develop, according to the expression of a\ndistinguished American physician, in the special votaries of three\nheathen divinities, Vulcan, Bacchus, and Venus,--that is, in those who\nhave worked too hard, in those who have drunk too hard, and in those\nwho have devoted themselves too much to the pleasures of the flesh.\nThe most important factor of all is, however, the contraction of\nvenereal disease, especially of that form known as syphilis.\n\nThe termination of aneurism cases is usually by rupture with profuse\nhemorrhage. Death takes place in a moment or two. Aneurisms often\ncause intense pain, which is sometimes thought to be rheumatic in\norigin. If the aneurism, in its enlargement, meets with bony\nstructure, it produces absorption of the bone by pressure upon it and\nso finds a way even through the bone to the overlying skin. This\nprocess is always intensely painful, and shortly after the aneurism\nappears at the surface the pressure upon the skin causes it to become\nthin and the aneurism may rupture externally.\n\nAddison's Disease always ends suddenly. This is a rare affection,\ndescribed by Addison, an English physician, some fifty years ago,\nwhich develops in individuals whose suprarenal capsules are\ndegenerated. The suprarenal capsules are little bodies of half-moon\nshape which lie above the kidneys. {156} Their degeneration produces a\ngreat lowering of blood pressure. The patient becomes intensely weak,\nmuscular movement becomes impossible, intellectual processes cause\ngreat fatigue, and finally blood pressure becomes so low that fatal\ncollapse ensues from lack of blood in the brain. The external symptoms\nof these cases is a pigmentation, that is, a very dark discolouration\nof the skin, which develops rather early in the disease. The tongue\nespecially becomes a very dark brown. Areas of pigmentation also occur\nwhere the skin is irritated,--at the wrists from the irritation of the\ncoat sleeves, at the edge of the hair from the irritation of the hat.\nDr. S. Weir Mitchell, in his _Autobiography of a Quack_, has described\none of these cases very strikingly. The hero of the tale is found dead\none morning by the nurse in the hospital, after he has been feeling\nquite as well as usual for some time.\n\nIt must not be forgotten that patients who are burned extensively very\nfrequently die shortly after the accident. A burn that involves more\nthan one-half of the body, no matter how superficial the burning may\nbe, will always have a fatal termination. Deep burns in one part,\nunless it is some very vital part, are not so serious as extensive\nsuperficial burns. Patients with extensive burns frequently remain in\nencouragingly good condition for several days, and then have a sudden\nchange for the worse. Sometimes death takes place in coma. Sometimes\nit takes place as the result of a perforation of the duodenum. These\nperforations of duodenal ulcers may take place as late as a week to\nten days after the burn. They are always followed by symptoms of\nperitonitis and the condition of intense prostration which this brings\non. Such cases need to be prepared for the worst after the first acute\nsymptoms of the burn have subsided, when a certain amount of peace of\nmind is restored.\n\nCirrhosis of the liver not infrequently causes sudden death. Cirrhosis\nis an affection in which a large part of the liver substance proper\ndegenerates, and its place is taken by connective tissue. It is\ntypically a disease of people of alcoholic habit. It occurs in those\nwho are engaged in the sale of spirits, though the alcoholic\nabsorption does not take place {157} through the skin, but in a much\nmore direct way. It is most frequent in people who take strong spirits\non an empty stomach. Those who are much exposed to changes of\ntemperature are especially liable to form such habits. It is found\nmost frequently in the drivers of wagons and cars, in policemen, and\nin sea-captains, sailors, and the like. When cirrhosis causes sudden\ndeath, it is nearly always by hemorrhage. The hemorrhage takes place\nfrom the oesophagus, some of the large veins of which have become\ndilated until the thin walls are unable to retain the blood. The\ndilatation is due to interference with the venous circulation in the\nliver.\n\nOf late years pathologists and medical men, especially those who are\ninterested in children's diseases, have devoted considerable time to\nthe study of certain cases of sudden death, which have long been very\nmysterious. Infants often die while in apparent good health without\nany adequate reason that can be found, even on the most careful\nautopsy. Children of an older growth sometimes die suddenly as the\nresult of some slight shock or fright, or they die after the\nadministration of a few whiffs of chloroform, given to help in the\nperformance of some simple surgical operation, or they die at the\nbeginning of some infectious fever which they ought to be able to\nwithstand without any difficulty. A distinguished pathologist at\nVienna, Professor Paltauf, who was the coroner's physician of the city\nand had a large number of these sudden deaths to investigate, found\nthat in most of the cases one abnormal condition was constantly\npresent. This consisted in an enlargement of the lymph glands all over\nthe body. The lymph glands in the neck were involved, also the tonsils\nand lymphoid tissue at the back of the throat, the series of lymph\nglands in the groin, and, finally, there was a hypertrophy of the\nlymphoid tissue that occurs all along the intestinal tract. This\ncondition of hypertrophy of lymphoid tissue has come to be known as\nthe lymphatic diathesis or constitution. It is nearly always\naccompanied by a distinct hypertrophy of the thymus gland. The thymus\ngland is an organ which occurs in the upper part of the thorax of the\nchild, but which atrophies and practically disappears after the age of\ntwo years. In these cases it is from twice to three {158} times its\nnormal size in the infant, and in older children it is\npersistent--that is, retains its primary size, though in the ordinary\ncourse of nature it should atrophy. This lymphatic diathesis\nundoubtedly has considerable to do with the sudden deaths which occur\nin these patients. What the exact connection is we do not as yet\ndefinitely know. Unfortunately, moreover, this lymphatic constitution\ngives no sure sign of its existence before the occurrence of the fatal\ntermination. Enlargement of the glands of the neck and of the groin,\nwith some enlargement of the tonsils, occurs in delicate children\nwithout necessarily being symptoms of the lymphatic diathesis. The\nenlargement or persistence of the thymus can be better recognised, and\ndoctors now seldom fail to notice it. Where any suspicion of such a\ncondition exists in children of from eight to sixteen or seventeen\nyears of age, proper precautions must be taken to prevent sudden fatal\ntermination of any even mild disease without due preparation.\nUndoubtedly many of the cases of sudden death under chloroform and\nether in children and young persons are due to the existence of this\nlymphatic diathesis.\n\nDiseases, like tuberculosis and cancer, that run a long but assuredly\nfatal course, usually terminate unexpectedly. The tuberculous patient\nparticularly will almost surely be planning for next year the day\nbefore he dies. This condition of euphoria, that is, of sense of well\nbeing, was recognised as associated with tuberculosis as far back as\nwe have any history of the disease. Hippocrates pointed out as one of\nthe symptoms of consumption the _spes phthisical_ or consumptive hope.\nIf the patient has been very much run down, death may take place from\nthrombosis of some of the arteries. If the thrombosis takes place in\nthe brain, consciousness will be lost, and the patient will often die\nwithout recovering it. Patients often develop tubercles in their brain\nas the result of a spread of the disease beyond the lungs, and then,\nas a rule, death will take place in the midst of a paralysis, which\nmay be accompanied by loss of consciousness that lasts for several\ndays or a week or more.\n\nCancer patients also die suddenly, or at least unexpectedly, at the\nend. Very often in them, as in tuberculosis, {159} thrombosis plays an\nimportant role in the fatal termination. In cancer of the stomach,\nperitonitis from perforation of the stomach may close the scene. The\nfatal termination in cancer of the uterus is often brought about by\nthe development of uraemic symptoms. The new growth in the pelvis\ninvolves the ureters, prevents the free egress of urine, and so causes\nthe retention in the system of poisonous substances that should be\nexcreted. Cancer in other parts of the body often causes death by\nmetastatic cancers, that is, offshoots of the original cancer which\noccur in other organs. Usually these are in the liver, but sometimes\nthey are in the brain, and sometimes in the bones that surround the\nspinal cord. In the course of their growth they cause pressure\nsymptoms upon the nervous system, and this leads to death. If patients\nbecome very much weakened, as is not infrequently the case, thrombosis\noccurs, and portions of the clots may be shot into the pulmonary\nveins, and cause death in this way.\n\nTwo affections which are quite common, one of them usually involving\nno danger at all, sometimes cause sudden death. They are varicose\nveins and a discharging ear. Varicose veins are the enlarged veins\nwhich occur on the limbs of a great many elderly people. If these\npeople become run down in health and then exhaust themselves by\noverwork, the circulation through these enlarged veins is sometimes so\nimpeded that clotting--thrombosis, as it is called--occurs. If a\nportion of the clot becomes detached, and is carried off into the\ncirculation, a so-called embolus, this may cause sudden death, either\nby its effect upon the heart, or more usually upon the lungs.\n\nMiddle-ear disease causes death, either by producing an abscess of the\nbrain, or by causing thrombosis of some of the large veins within the\nskull. The dangers involved in a discharge from the ear are now well\nrecognised. Insurance companies refuse to take risks on the lives of\npersons affected by chronic otitis media, as it is called\nscientifically. Such persons may run along in perfect good health for\nyears without accident, but a sudden stoppage of the flow may be the\nsignal for the formation of the brain abscess, with almost inevitable\ndeath.\n\n{160}\n\nCertain severe forms of the infectious fevers are very often fatal.\nThese forms are popularly known as black fevers, that is, black\nmeasles, black scarlet fever, etc. These fulminant forms occur\nespecially in camps, barracks, orphan asylums, jails, and the like,\nwhere the hygienic conditions of the patients have been very poor, and\nwhere the resistive vitality has, as a consequence, become greatly\nlowered. The black spots that occur on such patients are really due to\nsmall hemorrhages into the skin. The hemorrhages are caused by a lack\nof resistance in the blood-vessels and by a change in the constitution\nof the blood that allows it to escape easily from the vessels. Where\nsuch cases occur, patients should be fully prepared for the worst As a\nrule, the mortality is from 40 to 70 per centum.\n\nAcute pancreatitis is a uniformly fatal disease, though fortunately it\nis rare. It occurs much more frequently, however, than used to be\nthought. It occurs in persons over thirty who have been for some years\naddicted to the use of alcohol. The symptoms of the disease are severe\npain in the upper left zone of the abdomen, that is, above and to the\nleft of the umbilicus. This is accompanied by nausea and vomiting.\nCollapse ensues and death takes place on the second to the fourth day\nof the affection. This disease may have important medico-legal\nbearings. Some slight injury in the abdomen, as from a blow or a kick,\nmay precipitate an attack in predisposed individuals. Accusation of\nmurder may result. The mental attitude of the physician and the\nclergyman with regard to such cases must be very conservative. No\nopinion as to possible culpability should be ventured.\n\nCholelithiasis, that is, stone in the bile duct, may not only cause\nsevere pain, but may lead to rupture of the duct and a rapidly fatal\ntermination. Owing to the practice of wearing corsets, gall-stones\noccur much more commonly in women than in men. Twenty-five per centum\nof all women over 60 years of age are found to have gall-stones. While\nthese cases suffer from intense pain they are very seldom fatal. But\nit must not be forgotten that a fatal issue can take place either from\ncollapse and stoppage of the heart, because of the intensity of the\npain, or from perforative peritonitis.\n\n{161}\n\nThe perforation of a gastric ulcer may cause symptoms which rapidly\nplace the patient in a condition in which the administration of the\nSacraments is very unsatisfactory. Gastric ulcers occur especially in\nyoung women, usually in those who follow some indoor occupation. Its\nfavourite victims are cooks, though laundresses, seamstresses, and\neven clerks in stores, suffer from it much more than those engaged in\nother occupations. It occurs by preference in anaemic or chlorotic\nwomen. Sometimes, however, as in the case of cooks, the patients may\nseem to be in good health. Acute pain in the stomach region, followed\nby symptoms of collapse, should in such persons be a signal for the\nadministration of all the Sacraments. Fatal peritonitis soon brings on\na state of painful uneasiness ill adapted to the proper dispositions\nfor the Sacraments.\n\nTwo diseases that are fortunately very rare, but which are almost\nuniformly fatal, deserve to be mentioned here. In both of them the\nsymptoms of the disease are manifested through the nervous system.\nThey are tetanus and hydrophobia. Tetanus occurs as a consequence\nespecially of a wound which has been contaminated by the street dirt\nof a large city, or the refuse of a farm. It follows deep wounds such\nas are made by a hayrake or a pitchfork; or seared wounds, such as are\nmade by a toy pistol. A serum for the treatment of the disease has\nbeen discovered, but unfortunately the first symptom of tetanus is not\nthe first symptom of the disease, but the preliminary symptom of the\nterminal stage of the disease, the affection of the nervous system.\nPractically all cases of acute tetanus terminate fatally. As soon as a\npatient exhibits the characteristic symptoms, the lockjaw, the stiff\nneck, and the rigid muscles, all the Sacraments should be\nadministered. In tetanus, as a rule, consciousness is preserved until\nvery late in the disease. In severe cases, however, a convulsive state\nof intense irritability develops in which the slightest sound or\neffort brings on a series of spasmodic seizures. Patients must be\nprepared, then, early in the disease, if possible.\n\nRabies or hydrophobia is a disease which claims a certain number of\nvictims every year in our large cities. {162} Its symptoms are the\noccurrence of fever and disquietude, with spasmodic convulsions of the\nmuscles of the throat whenever an attempt is made to swallow. These\nsymptoms come on from three to fifteen days after the bite of a mad\ndog. Unless the Pasteur treatment has been taken shortly after the\nbite of the animal was inflicted, no treatment that present-day\nmedicine possesses is able to affect the course of the disease, and\npatients nearly always die. Their preparation, then, is a matter of\nnecessity as soon as the first assured symptoms of the disease show\nthemselves.  [Footnote 4]\n\n  [Footnote 4: One cannot help but add a word here as to the cause of\n  the disease, because clergymen can by their advice do something to\n  remedy the evil which lies at the root of the infliction.\n  Hydrophobia is due to stray dogs. In practically every case the\n  fatal bite is inflicted by some animal that no one in the\n  neighbourhood claims. Bites by pet dogs are rarely fatal. If\n  clergymen would use their influence to suppress the dog nuisance we\n  would soon have an end of hydrophobia.]\n\nAlcoholic subjects are very liable to unexpected death from a good\nmany causes. Patients suffering from delirium tremens, for instance,\nmay die suddenly in the midst of a paroxysm of excitement. Such a\ntermination is not frequent, but it has occurred often enough to make\nit the custom, at asylums for inebriates, to warn friends who bring\npatients of the liability of such an accident. It is not so apt to\nhappen during a first attack of delirium tremens as during subsequent\nattacks. It is most frequent among those whose addiction to alcohol\nfor years has caused repeated paroxysms of delirium tremens. The cause\nof the sudden death is usually heart failure. This term means nothing\nin itself, but it expresses the fact that a degenerated heart finally\nrefuses to act. Alcoholic poison in the circulation has led to fibroid\ndegeneration of the muscular elements of the heart and made them\nincapable of proper function, or at least has greatly hampered their\naction, and the heart ceases to beat.\n\nIt must be borne in mind that chronic alcoholism makes a number of\nserious organic diseases run a latent course. The patient is apt to\nattribute his symptoms to the after effects of the abuse of alcohol.\nUnless the doctor who is called in makes a very careful examination,\nserious kidney disease or even advanced pneumonia may not be\ndiscovered. Alcoholic subjects bear pneumonia very badly, and the\npreliminary {163} symptoms of the disease are often completely\nconcealed by the symptoms due to the patient's alcoholism. Other\ninfectious diseases, as typhoid fever, tuberculosis, and even various\nforms of meningitis, may run a very insidious course and give but very\nslight warning of their presence. The result is that these diseases\nare very frequently fatal in alcoholic subjects.\n\nOld inebriates bear operations badly, and the mortality after any\noperation in such subjects is distinctly higher than in normal\nindividuals. One reason for this is that considerably more ether or\nchloroform is required to produce narcosis in alcoholic subjects than\nin ordinary individuals. Ether and chloroform are very irritant to the\nkidneys. The kidneys are prone to be affected more or less in old\nalcoholic subjects. Death from oedema of the lungs or from some form\nof pneumonia is not infrequent in these post-operative cases, and\ngives as a rule but little warning of its approach.\n\nIt is clear, then, that alcoholic subjects must be prepared with\nspecial care whenever disease is actually present or an operation is\nto be performed. Too great care can scarcely be exercised in their\nregard. What would seem overcaution will save many a heartburn to\nfriends and priest, for it is in alcoholic subjects especially that\nsome of the saddest cases of unexpected death without preparation\noccur.\n\nJAMES J. WALSH.\n\n\n{164}\n\nXIII\n\nTHE MOMENT OF DEATH\n\nIt not infrequently happens that a priest reaches a patient who has\njust died. Conditional absolution, baptism, or other spiritual\nministration might have been offered if there were signs of life, but\nthe heart and lungs are still, \"the patient is dead,\" and the priest\nleaves the place without doing anything. Yet the patient may not\nreally be dead.\n\nOur knowledge of the precise time the soul leaves the body is very\nimperfect. There is, we are aware, a close connection between the\nvital functions of the body, taken together or singly, and cellular\nactivity. If the cells are not destroyed, a vital function sometimes\nmay be restored after its cessation, but if the cells are destroyed up\nto a certain extent, the vital function is not recoverable. For\nexample, if the various bodily cells of a patient dead from diphtheria\nare examined microscopically, it will be found that the diphtheria\ntoxin has disintegrated the nuclei of these cells. What number of\ncells proportionate to the whole in, say, the heart should be\ndestroyed before the vitality of that organ is lost, is not clearly\nknown. Where the cells are intact, or nearly so, mere absence of\nrespiration, or of even the heart movement, are not absolute proof of\ndeath. Numerous cases are found in medical records of persons that had\nbeen lying under water for many minutes, up to even an hour, but who\nwere restored to life by patient and skilful efforts; and of late\nremarkable restorations after what was practically death, under\nanaesthesia and otherwise, have been reported. The technique consists\nchiefly in rhythmical compression of the heart, commonly after\nsurgical exposure of that organ, with artificial respiration, and, in\nCrile's method, peripheral resistance is {165} employed to raise the\nblood pressure. Ludwig in 1842, experimented in cardiac massage, and\nProfessor Schiff at Florence was the first to apply the method to\nhuman subjects. Kemp and Gardner, in the _New York Medical Journal_,\nMay 7, 1904, described various methods used in attempting\nresuscitation.\n\nProfessor W. W. Keen of Philadelphia has collected the records of the\nchief cases of resuscitation after apparent death (see _The\nTherapeutic Gazette_, April, 1904), and some of these are the\nfollowing: Dr. Christian Igelstrud of Tromsoe, Norway, in 1901, was\noperating upon a woman, 43 years of age, for cancer. During the\noperation, which was a coeliotomy, she collapsed and her heart ceased\nbeating. After the usual means for resuscitation had been\nineffectively tried, her heart was laid bare. Igelstrud took hold of\nthe heart with his hand and made rhythmic pressure upon it. In about\none minute the heart began to pulsate. The patient was discharged from\nthe hospital five weeks afterward.\n\nTuffier (_Bull, et mem. soc. de chir._, 1898, p. 937) in 1898 had a\npatient whose heart stopped after an operation for appendicitis. The\nsurgeon had left the operating room, but he returned, laid bare the\nheart, pressed it rhythmically, and after two minutes it began to move\nagain. The patient breathed regularly, his eyes opened, the dilated\npupils contracted, and he turned his head. After the opening over the\nheart had been closed, however, he died.\n\nPrus (_Wiener klin. Woch._, no. 21, 1900, p. 486) by the same method\nstarted contractions of the heart after 15 minutes in a man that had\nhanged himself. The effort at resuscitation was made two hours after\nthe suicide had been discovered, but the recovery did not go beyond\nimperfect movements of the heart, which gradually ceased.\n\nMaag (_Centralbl. f. Chir._, 1901, p. 20) reports the case of a man\nwho under chloroform anaesthesia ceased breathing and whose heart\nstopped. After 10 minutes the patient was pulseless, without\nrespiration, cyanotic, and cold. The heart was exposed and compressed\nrhythmically; it was restored to action, and he began to breathe. He\nremained alive for 12 hours, seemingly asleep; then he died.\n\n{166}\n\nStarling and Lane (_Lancet_, Nov. 22, 1902, p. 1397) were operating\nupon a man 65 years of age. The heart and respiration ceased. Lane put\nhis hand into the abdominal incision and squeezed the heart through\nthe diaphragm. After twelve minutes of artificial respiration the\nlungs and heart began to act. The patient afterward was discharged\nfrom the hospital cured.\n\nSick (_Centralblatt f. Chirurgie_, Sept. 5, 1903, p. 981) reports a\nvery remarkable case. A boy of 15 years of age died upon the operating\ntable. _Three quarters of an hour_ after the heart had ceased to beat\nit was laid bare. The flaps did not bleed, the pericardium was\nbloodless, the heart was motionless, relaxed, and cold. After a\nquarter of an hour, during which the heart was compressed, and\nartificial respiration was kept up, that is, one hour after what any\nphysician would call death, the heart was beating and respiration was\nrestored. Two hours later the boy became conscious and complained of\ngreat thirst and dyspnoea. He remained in this condition for\ntwenty-seven hours, and during that time his speech was indistinct but\nintelligible. He then died.\n\nDr. George W. Crile, of Cleveland, Ohio, reports the case of a woman\nwhose heart movement and respiration had ceased for six minutes. She\nwas restored completely, even without exposing the heart. Dr. Crile\nuses an inflated rubber suit on the patient to raise the blood\npressure by peripheral resistance--he does not expose the heart. He\nhad another case, a man 38 years of age, who \"died during operation,\nwas resuscitated, and died again two hours later.\"\n\nTwo Hungarian labourers, whose skulls had been crushed in the same\naccident, were brought into Dr. Crile's clinic in a dying condition.\nThe heart of one of these men ceased beating as he was brought into\nthe operating room. After nine minutes the surgeons began to work upon\nhim to resuscitate him. They succeeded, but he lived for only 28\nminutes.\n\nThey then examined the other man and found him dead. Just 45 minutes\nafter this second patient had been brought into the operating room the\neffort to resuscitate him began. As he had not been observed while the\nphysicians had been engaged with the first man, they do not know when\nhis heart {167} had ceased to beat, but he certainly was dead in the\nopinion of skilled observers. They resuscitated him so well that he\nmoved his head away from the operator who was relieving the depression\nof the skull, but he died again in 34 minutes.\n\nThese cases are not what is commonly called conditions of suspended\nanimation. All the patients would have been pronounced dead by any\nphysician, and if they had been left untouched, they surely never\nwould have been revived.\n\nThere have been about thirty attempts made by surgeons to restore\npatients who were dead in the full acceptance of the term as used at\npresent. Four of these attempts resulted in complete success, others\nin a partial recovery, and many were without positive result. The\nnumber of complete and partial resuscitations, however, are enough to\njustify a priest in giving conditional absolution or baptism within an\nhour, or even two hours, after a patient has to all appearance died,\nespecially in accident cases. We do not know when the soul enters the\nbody, and there is the same doubt as to the moment when the soul\nleaves the body. In these latter cases we should give the patient the\nbenefit of the doubt.\n\nAUSTIN OMALLEY.\n\n\n{168}\n\nXIV\n\nTHE PRIEST IN INFECTIOUS DISEASES\n\nThe subject of infection is complicated, and the medical doctrine\nconcerning it is far from certainty despite the multitude of facts\npresented by bacteriologists, chemists, pathologists, and clinicians.\nBefore the days of bacteriology the term _Infectious_ commonly was\napplied to diseases produced by no known or definable influence of any\nperson on another, but wherein common climatic or other widespread\nconditions were thought to be chiefly instrumental in the diffusion.\nThe contagious disease was one transmitted by contact with the\npatient, either directly by touch, or indirectly through the use of\nthe same articles.\n\nNow we know that many diseases called infectious are caused by\nmicro-organisms, and we group others under this class because we hold\ntheoretically that they have their origin in microbes not yet\nisolated. Hence we define an infectious disease as one which is caused\nby a living pathogenic micro-organism, which enters the tissues from\nwithout, and is capable of multiplying therein. These micro-organisms\nhave a time of incubation during which a poison is made in the\ntissues, and this brings about the intoxication we call the disease.\n\nInfection is a general term that includes contagion; and contagious\ndiseases are infective diseases that may be transmitted directly or\nindirectly from patient to patient.\n\nThe pathological micro-organisms with which we shall deal in this\narticle are (1) the Schizomycetes or Fission-Fungi, which are\nmicroscopical organisms that multiply by fission, and are commonly\nknown as Bacteria; and (2) a few Protozoa, which are animal\nmicro-organisms.\n\nThe bacteria are classed with plants because, like plants, {169} they\nderive nourishment from both organic and inorganic material. They have\nno seeds or flowers, but many of them are reproduced by spores. They\nconsist of cells, single or grouped, which when spherical are called\n_cocci_, when rod-shaped, _bacilli_, when spiral, _spirilla_. There\nare various subdivisions of these groups. We do not know whether\nbacterial cells have nuclei or not.\n\nA micro-organism is a _parasite_ when it can live in animal tissues.\nIt is a _saphrophyte_ when it can exist outside animal tissues. If a\nparasite cannot exist outside animal tissues, it is an _obligatory\nparasite_; if it can, it is a _facultative saphrophyte_. Similarly the\nsaphrophytes are classed as obligatory saphrophytes and facultative\nparasites. Pathological micro-organisms have very complicated products\nwhich are in large part poisonous.\n\nBacteriologists require seven conditions to prove a micro-organism the\n_specific_ cause of a given disease, and all these conditions have been\nfulfilled for anthrax, diphtheria, and tetanus. The specificity has\nbeen satisfactorily settled for glanders, malaria, tuberculosis,\nactinomycosis, gonorrhoea, and malignant oedema. It has been\npractically settled for typhoid, influenza, the Madura disease, and\nthe bubonic plague; and incompletely defined for leprosy, relapsing\nfever, and Malta fever.\n\nThere are certain diseases which are not called specific, because they\nmay be produced by various micro-organisms. These are pneumonia,\nosteomyelitis, septicaemia, pymaeia, endocarditis, meningitis,\nerysipelas, angina Ludovici, broncho-pneumonia, and similar maladies.\nCholera and dysentery also might be grouped with these, as cholera\nappears to be produced by various vibrios and dysentery by different\namoebae.\n\nThere are other infective diseases, in which we have not yet found the\ncausative micro-organism, but we presume its existence. These are:\nrabies, syphilis, yellow fever, dengue, typhus, mumps, whooping-cough,\nsmallpox, measles, scarlet fever, and others among the exanthemata.\n\nMalaria and similar diseases are caused by plasmodia, which are\nprotozoa and not bacteria.\n\n{170}\n\nThe priest is almost as frequently exposed to the danger arising from\ncontagion as the physician is, and a priest that often ministers to\nthe sick is liable to grow imprudently indifferent to danger. For one\npriest that is too much afraid of disease we find a hundred that have\nnot sufficient dread.\n\nNo matter what medical science may say to the contrary, many priests\nhold that they have often left smallpox cases, for example, without\ndisinfecting themselves, and that they have not spread the disease.\nThis is a very rash assertion. It is absolutely certain that smallpox\nhas been communicated to susceptible persons by those coming from\npatients ill with that disease merely passing the susceptible man on\nthe street. The number of persons that will not take smallpox when\nexposed to it is very large. In Washington in 1895, during an epidemic\nof smallpox, 187 persons, to my personal knowledge, were exposed to\none group of 39 smallpox patients without taking the disease. The\nunharmed had been present in sick-rooms or had even nursed the\npatients, not knowing that the disease was smallpox. In this epidemic\neight persons lived in the same rooms with, or visited frequently, two\npatients that afterward died of virulent smallpox, and none of the\neight took the disease. One of these eight, however, went into a\ndramshop, had one glass of beer and left immediately, and in fourteen\ndays afterward (the average time of incubation) we took the barkeeper\nto the smallpox hospital. This barkeeper had not been exposed to\nsmallpox except by contact with the man mentioned here. There were\nabout 60 cases of smallpox in that epidemic, and we traced every one\nto direct or indirect contact with one initial case.\n\nIf we were infected by every exposure to contagious disease the world\nwould be depopulated. It is true that you cannot give some persons\ndiphtheria if you actually put the Klebs-Loeffler bacillus into their\nmouths, and nurses and physicians in consumptive wards have the\ntubercle bacillus in their nostrils without ill effect. So for many\ndiseases; but it unfortunately remains true that there are susceptible\npersons everywhere who will at once take a disease when they are\nexposed to it.\n\n{171}\n\nImmunity changes in the same person. Starvation, fatigue, loss of\nblood, unsuitable diet, exposure to heat, cold, and moisture, and\nother influences lessen the power of resistance to infection. Men vary\nalmost as do the lower animals as regards infection. The quantity of\ntetanus toxin that will kill 400 horses will not bother a hen;\nAlgerian sheep and the white rat are not affected by anthrax, but\nother sheep and the brown rat are very susceptible; a hog will not\ntake glanders, man and a horse will; men, cattle, and monkeys have\ntuberculosis, dogs and goats do not; white men with few exceptions are\nsusceptible to yellow fever and malaria, negroes are practically\nimmune; negroes readily succumb to the fatal sleeping sickness, white\nmen are almost immune; and similar differences are observable in the\nsame race or family.\n\nThe question of immunity to infectious disease is very difficult to\nmake clear because it is so technical, and it is only a theory at\nbest. The poison of an infectious disease kills by splitting and\ndestroying the nuclei of the body's cells. The toxic products of the\nmicro-organisms seem to become chemically united with certain\nmolecules of the body cells and to inhibit the normal function of\nthese molecules. According to Erlich's theory there are other\nmolecules in cells which neutralise toxic molecules, and when the\nneutralising molecules appear in excess the patient recovers. These\nneutralising bodies are called antitoxins.\n\nSome antitoxins are always present in cells, and where the normal\nquantity of these is used up in neutralising toxins, other antitoxic\nbodies are formed, until finally the excess of these is thrown off\ninto the blood serum. After they are called into being by the\nexcitation of some toxic products, like those of the typhoid bacillus\nfor example, the antitoxins remain in the blood for years, ready to\nneutralise at once any influx of fresh infection. In other diseases,\nlike diphtheria and pneumonia, they are soon lost,--hence the\nrecurrence of such diseases. The acquired antitoxin lasts after\nsmallpox, vaccinia, yellow fever, scarlet fever, measles, typhoid,\nmumps, and whooping-cough; it is very transient after pneumonia,\ninfluenza, diphtheria, erysipelas, and cholera.\n\n{172}\n\nIn serum therapy antitoxins are artificially excited into being in the\nblood of beasts. This artificially prepared antitoxin is injected into\nthe blood of, say, a diphtheria patient, and the poison is at once\nneutralised, instead of leaving the patient to make his own antitoxin\nand letting him perhaps fail in the effort.\n\nThe antitoxin produced in the contest of the body cells against some\ndiseases will not only neutralise the toxin of a particular disease,\nbut it will also neutralise the toxin of a second disease. By\nvaccinating a person we inoculate him with vaccinia or cowpox. His\nbody cells make an antitoxin which neutralises the toxin or virus of\ncowpox, he recovers from this light disease, and the antitoxin now\nremaining in his body prevents for years another successful\ninoculation with cowpox. It does more: in 90 per centum of cases it\nwill prevent successful infection with smallpox.\n\nSmallpox (the pocks, pokes or pockets of matter,--opposed to the great\npox or syphilis) has been known from very early times--probably even\nfrom 1200 B.C. The name \"small pokkes\" was first used in England in\n1518. The disease was brought to America in 1507.\n\nIt may be communicated from the sick to the healthy (1) by persons\nsuffering with the disease; (2) by bodies of persons that have died of\nsmallpox; (3) by infected articles; (4) by healthy third persons; (5)\nby the air, to persons living even at some distance; (6) by\ninoculation. The poison enters the body by the mucous membrane of the\nnose, mouth, or respiratory tract, and probably through the mucous\nmembrane of the stomach and through the broken skin.\n\nPatients can communicate the disease probably during the period of\nincubation (from 5 to 20 days after exposure to the disease--commonly\nabout 14 days); and certainly from the initial stage until no trace is\nleft of the final skin-desquamation. The infection is most active\nduring the formation and duration of the pocks. The mildest smallpox\nin one person can cause malignant smallpox in another, and _vice\nversa_. The mortality in the unvaccinated is between 40 and 50 per\ncentum.\n\nA typical case of confluent smallpox at its height is the {173}\nugliest disease in appearance and stench and almost in substance,\nknown to medicine. Anyone liable to infection by it, or likely to\ncarry it to others, who says he is \"not afraid of it,\" has either\nnever seen it and he is talking childish nonsense, or he has seen it\nand he is a fool.\n\nThe face is a bloated mass of corruption; the eyes are swollen shut;\nthe nose, cheeks, lips, and neck are puffed out enormously; the mouth\nis a large sore, ulcerous, and spittle trickles from it ceaselessly.\nThe fever is up to 103 or 105 degrees; there is an unquenchable\nthirst, a vile stench, sleeplessness; often delirium is the only\nrelief, and there is one chance in two of a disfigured recovery.\nTobacco, alcoholic liquor and a walk in the fresh air will not\ndisinfect the visitor to such a disease. Years ago I investigated in\nthe laboratory the popular notion that tobacco is a disinfectant. I\nfound that bacteria, the diphtheria bacillus and swarms of others more\ndelicate, will grow as well in the presence of a large piece of \"Navy\nPlug,\" as when tobacco is absent. Chewing tobacco, whiskey, a walk in\nthe fresh air as disinfectants, the Sioux medicine-man's powwow, the\nhind leg of a rabbit as a charm, are all in the same category.\n\nThe first and chief protection against smallpox is vaccination.\nVaccination does not always prevent infection by smallpox, but it does\nprevent it in more than 90 per centum of exposures to the disease.\nWelch reported in 1894 that the death-rate in one series of 5,000\ncases of smallpox was 58 per centum in the unvaccinated, and 16 per\ncentum in the vaccinated, but the vaccinated took the disease in less\nthan 10 per centum of the exposures. During the Franco-German War in\n1870-1871, the Germans who had a million vaccinated men lost 458\nsoldiers from smallpox while a great epidemic of smallpox was existing\nin Germany; the French, who were indifferent to vaccination, during\nthe same time lost 23,400 men from this disease alone. In the United\nStates, where there is no compulsory vaccination except such attempts\nas school boards make, there were between July and December, 1903,\n13,739 cases of smallpox; in Germany, where there is a compulsory\n{174} vaccination law, there was no smallpox at all, during the same\ntime, except 14 cases in two seaports, Bremen and Kiel, whither the\ninfection had been brought from without.\n\nBefore 1874 there had been no compulsory vaccination law in Germany\nexcept for the army. In 1871, 143,000 Germans died of smallpox. Since\nthe law went into effect in 1874 the disease has been stamped out,\nuntil there was between July and December, 1903, only one death from\nsmallpox in Germany.\n\nThe chart on page 175 will show very graphically the effect of\nvaccination upon smallpox.\n\nIn October, 1898, smallpox was endemic in Puerto Rico; in December,\n1898, it was epidemic; in January, 1899, it was all over the island\nand spreading rapidly. In February, 1899, compulsory vaccination was\nbegun and carried out for only four months, when 860,000 vaccinations\nhad been made in a population of about 960,000 people. The death-rate\nfrom smallpox dropped from 621 a year to 2.\n\nDuring the century preceding Jenner's discovery of vaccination,\naccording to Neimeyer's calculation 400,000 people died of smallpox\neach year in Europe. Bernouilli, a trustworthy statistician, says that\nduring that same century, \"Fully two-thirds of all children born in\nEurope were, sooner or later, attacked by smallpox, and on an average\none-twelfth of all children born succumbed to the disease.\"\n\nEarly in the sixteenth century 3,500,000 people in Mexico had smallpox\n(Prescott's _Conquest of Mexico_). In 1707, in Iceland, 18,000 of the\npopulation of 50,000 died of smallpox; and in 1891, 25,000 persons in\nGuatemala died of this disease. In 1875 there were anti-vaccination\nriots in Montreal, and as a consequence most of the younger\ninhabitants of that city were not vaccinated. In 1885, smallpox was\nbrought in from Chicago; 3,164 persons died of the disease; of these\n2,717 were children under ten years of age, and thousands had the\ndisease.\n\n{175}\n\n[Illustration: ]\n\nPRUSSIA.--With compulsory vaccination and\ncompulsory revaccination at the age of 12.\n\nHOLLAND--With compulsory vaccination of children before entering a school.\n\nAUSTRIA.--Without compulsory vaccination.\n\n\n{176}\n\nVaccination may render one immune to smallpox for many years, but if\nthe disease is epidemic it is well to renew the vaccination after\nabout eight years. In normal vaccination, where the lymph has been\nderived from a reliable source, on the third or fourth day pale red\npapules develop at the point of inoculation, and about the tenth day\nthese have become pustules. The vesicles dry gradually, and between\nthe fourteenth and twentieth days the scab falls off, leaving a pitted\nscar. About the fifth day an aureola of inflammation forms around the\npocks, from a quarter of an inch to two inches in extent, and the\ninflamed area may be somewhat sore. A shield should be kept over the\nvaccination spot for two days, and this is then to be replaced by a\npiece of sterile gauze held in place by narrow strips of\nsticking-plaster above and below the inflamed area. Sometimes hives\nand other rashes occur in vaccination, but they are unimportant.\n\nWhere there is a very sore arm or other trouble, the cause may be a\npre-existing unhealthy condition, like scrofula for example, or the\npatient has scratched the pocks, or infected them from his clothing,\nor the vaccine lymph was unsterile. A careless and dirty vaccinator\nmight infect an arm with pus organisms. If good glycerinated lymph,\nnot too fresh or too old, is used, there is seldom any trouble; but in\nany case all the annoyance that may come from vaccination is\ninfinitesimal when compared with the smallpox it averts.\n\nWe may take a smallpox case as a typical contagious disease in which\nthe priest is to give the last Sacraments; and the disinfection and\nother precautions observed in such a visit will serve for any other\nvery contagious disease. For only typhus and one or two other maladies\nare the precautions so elaborate as those needed in smallpox.\n\nThere is a dress, called \"Dr. Hawes' Antiseptic Suit,\" and in time of\nepidemics a priest should have one of these suits, or one made after\nit as a pattern--they can be obtained in the shops for two or three\ndollars. They cover the entire person, even the shoes, and they make\nunnecessary the changing of clothing and the disinfection of the\nexposed parts of the body. The hands of the priest may be left bare\nafter fastening the sleeves of the suit about the wrists, or he may\nwear surgeon's thin rubber gloves. In visiting a patient that has any\nof the contagious diseases mentioned in this chapter, the priest\nshould never touch {177} his own face with his hands after he has\nentered the sick-room until he has washed them in a bichloride of\nmercury solution.\n\nA ritual should not be taken into a smallpox room, because a book\ncannot be disinfected without rendering it useless. The priest should\nmemorise the prayers and ceremonial, or write them out on paper which\ncan be burned in the hospital or the patient's house.\n\nThe priest may be obliged to administer baptism, to hear confession,\nto give the Viaticum and Extreme Unction. Before going to visit a\nsmallpox patient let him find out from the physician in attendance\nwhether the patient can receive the Viaticum, whether he can swallow\nit or not, whether he can open his mouth enough to take it. Ask also\nabout the possibility of vomiting. Only a very small particle is to be\nbrought in the pyx.\n\nThe leather cover for the pyx should not be taken into a smallpox\nroom. Set the pyx inside a corporal, wrap the corporal in paper, and\nput this package into the pocket of the Hawes suit before entering the\nroom.\n\nAs to the use of a stole,--the moralists say \"graviter peccatur ab eo\nqui sine urgente necessitate sine ulla sacra veste unctionem\nadministrat.\" There is a grave necessity here for doing away with the\nstole because of the difficulty in disinfecting it, unless you have\none made that can be put into boiling water for ten minutes before you\nleave the patient's house.\n\nThe oil-stocks should contain only as much oil as is necessary for the\nsingle occasion, because what remains, with the cotton, should be\nburned in the patient's house.\n\nDo not remain in the room longer than you must unless you have had\nsmallpox. If there is any prayer or ceremonial that can be omitted, by\nall means leave it out. Lehmkuhl says that the penitential psalms and\nthe litanies may be omitted. Baptise by the short form.\n\nSt. Alphonsus Liguori (_Theol. Mor._, lib. 5, tr. 5, n. 710) tells us\nthere is no obligation to anoint both eyes and both ears, \"si adsit\npericulum infectionis,\" but danger of infection is not materially\nincreased by anointing both sides. {178} Lehmkuhl adds, \"excepta\ndispensatione Sedis Apostolicae addatur unctio pedum.\" When the feet\nare to be anointed do not touch the bed-clothing,--tell the nurse to\nuncover the feet.\n\nSt. Alphonsus (_loc. cit.,_ n. 729) speaking of extreme unction has\nthese words: \"Pastor ratione officii tenetur sub mortali dare lis qui\npetunt, nisi justa causa excuset: etiam tempore pestis, modo possit\nabsque periculo vitae; cum eo non teneri docent _Tann. Dian._,\" etc.\nIf you have not had smallpox you certainly risk your life by going\ninto the room of a smallpox patient, and the danger of infection is\ngreater in typhus; but suppose a pastor were inclined to take\nadvantage of the excuse, he would be obliged at any risk to go into\nsuch a room to hear confession or to baptise, and if he hears\nconfession he may as well stay for the anointing.\n\nIf you anoint a patient that has confluent smallpox you probably can\nnot wipe away the oil, because the skin will be pustular. Wipe the\noil-stock carefully; then all cotton used should be wrapped in paper\nand burned in the paper before you leave the house. After anointing,\nyou had better wash your hands carefully in water in which a\nbichloride of mercury tablet has been dissolved--do not use soap and\ndo not put the bichloride in a metal vessel. Wash your hands thus\nbefore you leave the sick-room.\n\nIf the patient can receive the Viaticum let him lie on his back, and\nyou should drop the Host into his mouth without touching him with your\nhand. St. Alphonsus says: \"non licet tempore pestis porrigere\nEucharistiam medio aliquo instrumento . . . sed manu danda est\" There\nis no need of an instrument. If there are any crumbs left in the pyx\nmake the patient take them. St. Alphonsus says this may be done, and\nit would be almost certain infection to take them yourself if you have\nnot had smallpox recently. Let as little ablution water as possible be\ngiven to the patient.\n\nWhen you leave the room, put the pyx, oil-stocks, corporal, and stole\nin a pan of water and boil them for ten minutes. This will disinfect\nthem thoroughly and will not injure them in any way. Then take off the\nHawes suit as near the street-door as possible and wet it with\nbichloride {179} solution. Wash your hands again in the bichloride\nsolution and rinse off the bichloride; take the pyx, oil-stocks,\ncorporal, and stole and leave immediately. Do not touch the door-knob\nwhen going out--let some one open the door for you--and do not shake\nhands with any one.\n\nTyphus fever is now rare in America, but there was an outbreak in New\nYork City in 1881. This was the fever that killed multitudes of Irish\nemigrants about the middle of the nineteenth century. It is called\nalso spotted fever, camp, jail, ship, and hospital fever, and it has\nmany other names. The name typhus is from [Greek text], a smoke or\nfog, and it indicates the befogged, stuporous condition of the\npatient. Typhoid fever is so called because it has some resemblance to\ntyphus.\n\nThe specific cause of typhus is unknown, but the contagion develops\nand reproduces itself in the body of the patient. It is thought that\nthe contagion exists in the secretions and excretions of the body and\nin the exhalations from the lungs and skin. The infection can\ncertainly be carried by clothing, dust, furniture, conveyances of all\nkinds, and dead bodies, and it remains active for months. It may be\ntransmitted through the air for short distances, not nearly so far as\nthe air will carry the contagion of smallpox. In well-ventilated rooms\nthere is less danger of infection, and a typhus patient should have at\nleast 1,500 cubic feet of air space. The contagion may be transmitted\nin all stages of the disease and during convalescence.\n\nPhysical weakness, anxiety and worry, improper food, and poverty, are\ndisposing conditions for infection by typhus. The mortality is about\n10 per centum--much less than that of smallpox.\n\nIn giving the last Sacraments to a typhus patient exactly the same\nmethod should be followed as that observed for a smallpox patient.\nKeep as far from the patient as possible. After you touch him in\nanointing or in giving other Sacraments step away from him to say the\nnecessary words. Do not stand between him and an open fireplace,\nwindow, door, or ventilator.\n\nRelapsing fever, or famine fever, caused by Obermeier's {180}\nspirillum, is sometimes associated with typhus. It has a mortality\nthat can go up to 14 per centum in unfavourable circumstances, but the\ndisease is not more contagious than typhoid under hygienic\nsurroundings. Wash the hands in bichloride solution after visiting a\ncase, and do not touch the door-knob or things in the room.\n\nRabies (called also hydrophobia in man) is a rare disease. It is\ncommunicable by inoculation, but it is very doubtful that the disease\nhas been communicated from man to man. The saliva from a person\nsuffering with rabies if injected into a warm-blooded animal will\ncause rabies, and on that account it is prudent to use care in\ntouching such a patient in administering the last Sacraments. The\nvirus might enter through an abrasion on the priest's hand.\n\nThere is a false hydrophobia observed in excitable persons that have\nbeen bitten by a dog thought to be mad. The dog that has genuine\nrabies grows sullen, it hides in comers, and it snaps at everything\npresented to it A sticky, frothy mucus drivels from its mouth and its\neyes become red. It will run straight ahead, snapping at anything it\nmeets; it swallows small stones, chips, and similar objects; it does\nnot avoid water. It howls, grows lean, and its hind legs and lower jaw\nbecome paralysed.\n\nIn man there is a premonitory stage; a furious stage, which lasts from\nabout a day to three days; then a final paralytic stage. It is well to\nwait for the paralytic stage before anointing the patient, because in\nthe other stages the slightest touch causes violent spasms. Confessors\nshould note that the virus of rabies excites the sexual centres.\n\nScarlatina or scarlet fever first appeared in North America in\nMassachusetts in 1735. It is especially an April disease here. One\nattack commonly makes the person immune for life. It is a disease of\nchildren, but it attacks adults, and it is fatal among children old\nenough to receive the last Sacraments. Some epidemics are very\nmalignant; and in such times all the precautions mentioned in speaking\nof the visitation of smallpox patients should be observed. The\ncontagion is spread just as that of smallpox is spread, except that it\nis not carried through the air so far.\n\n{181}\n\nDiphtheria is a disease of children, but it also can be fatal to\nadults and to children old enough to receive the last Sacraments. It\nis caused by the Klebs-Loeffler bacillus, and it most frequently\nattacks the throat and nostrils. It can start in a cut in the skin, or\non any mucous surface, as the inside of the eyelid. The contagion is\nnot in the breath, but it can be coughed out. It is in the saliva of\nthe patient and it gets on his hands and on what he and the nurse\ntouch. It is not nearly so infectious as smallpox and scarlet fever.\n\nIn visiting such a patient the priest should be careful not to touch\nanything in the room, and he should wash his hands in the bichloride\nsolution after a visit. He must also wet the soles of his shoes with\nthe solution. He should be very careful lest a child suddenly cough\nfine sputum containing the bacillus into his eyes. Diphtheria in the\neyes would destroy sight, and I have seen a pair of spectacles save a\nman in a case like that. A detailed description of the disinfection in\ndiphtheria is given in the chapter on Infectious Diseases in Schools.\n\nGlanders is sometimes transmitted from beasts to man, and it is almost\nalways fatal in the human subject. The disease is caused by the\nglanders bacillus. Horses, asses, dogs, cats, goats, and sheep are\nsusceptible to the disease; pigs are somewhat susceptible; cattle and\nbirds are immune. The infection is in the discharge from the nose of\nthe patient and on the skin eruptions. The same precautions are to be\ntaken as are needed in a diphtheria case.\n\nInfluenza, called popularly the grippe, is caused by the bacillus\ninfluenzae, which was isolated by Pfeiffer in 1891. The bacillus is\nfound in the nasal secretions and in sputum; it dies in from twelve to\ntwenty-four hours when dried. The disease is contagious, and it is\noften fatal in alcoholics, the overworked and harassed, and in those\nthat have chronic diseases. In any case it is a serious malady.\nDisinfect the hands after visiting a case.\n\nDengue becomes epidemic at times, especially in the Southern States.\nThe disease is very severe, painful, and depressant, but the mortality\nis quite low except in complication with other maladies. Its cause is\nnot known. It is {182} very contagious and has symptoms which belong\nto the class of disease in which are scarlatina and measles. The\npriest should act as in a case of scarlatina.\n\nThere is a form of pneumonia which spreads so widely and rapidly that\nit is called epidemic pneumonia. In visiting patients afflicted with\nthis disease the priest should act as in a diphtheria case.\n\nEpidemic cerebrospinal meningitis is a very fatal disease at times in\nAmerica. Even those patients that survive are frequently made blind or\ndeaf, or are left injured otherwise. The malignant type is nearly\nalways fatal. In some epidemics the mortality is as high as 75 per\ncentum. The visiting priest should act as in a case of diphtheria,\nalthough the danger of direct infection is not great.\n\nTuberculosis is a chronic febrile disease, caused by the bacillus\ntuberculosis, a parasitic micro-organism discovered by Koch in 1882.\nOne-seventh of mankind die by this disease. The bacillus remains\nvirulent a long time after it leaves the human body, but it is soon\nkilled by sunlight.\n\nTuberculosis of the lungs is spread especially through sputum. In the\nroom occupied by the patient, the clothes, furniture, walls, doors,\nand floor are infected by the bacilli coughed out, even when the\nconsumptive is careful to disinfect the sputum, and, by the way, he\nrarely is careful. When the priest visits a consumptive's room he\nshould disinfect his hands with bichloride.\n\nLeprosy is caused by the lepra bacillus, discovered by Hansen in 1871.\nIt is present in many parts of the body, especially in the glands and\nnervous tissues, and it is found in the mucosa of the mouth and in the\nnasal secretions. It is very profusely distributed in the corium of\nthe skin. The name comes from [Greek text], scaly.\n\nLeprosy is present here and there along the Mississippi valley from\nMinnesota and Wisconsin to Louisiana. It is found also in California,\nFlorida, and the Dakotas, in the Philippines, the West Indies, and the\nworst infected part of the world is the Hawaiian Islands.\n\nThe bacillus has not been found in rooms used by lepers, nor in the\nsoil of their graves. Inoculation by leprous {183} material has failed\nso far undoubtedly to cause leprosy. There is much dispute concerning\nthe contagiousness of this disease. The Dominican Sisters nursing in\nthe Trinidad asylum have been in constant contact with the lepers for\nabout thirty years but none of them has yet contracted the disease.\nZambaco Pasha tells of a family which has lived in the leper asylum at\nConstantinople for three generations and no one in the family has been\ninfected. Father Damien, however, in Molokai, and Father Boglioli, in\nNew Orleans, did contract the disease. There have been cases of\ninfection from man to man, but ordinarily it seems that some unknown\nfactor must be present to insure infection.\n\nA priest need have no more fear in visiting a case of leprosy than he\nshould have in visiting a case of tuberculosis--not so much. He may\nwash his hands in bichloride solution after anointing a leper, but it\nis scarcely necessary to do even that.\n\nActinomycosis ([Greek text], ray-fungus) is a disease caused by\nactinomyces, a micro-organism that partly resembles a bacterium and\npartly a fungus. The disease can be fatal. It is very improbable that\nit ever passes from man to man, but as a matter of prudence the priest\nshould wash his hands in bichloride after anointing such a patient.\n\nSepticaemia, or blood-poisoning, can be brought about by different\npyogenetic bacteria,--the varieties of the staphylococci (irregularly\ngrouped cocci), streptococci (chain-cocci), pneumococci, and others.\nThe danger of infection is so slight that it may be neglected.\n\nErysipelas can be fatal, especially in alcoholics, the aged, and in\nchronic diseases. Erysipelas is contagious, especially if the bacteria\nget into an abrasion in the skin. Patients having this disease\nsometimes grow delirious and violent, and the priest should be careful\nhow he handles them. Disinfect the hands after anointing such a\npatient.\n\nTetanus, or lockjaw, is not communicable except by inoculation. The\nbacillus, which was isolated by Kitasato, the Japanese bacteriologist,\nin 1889, is found everywhere in soil, hay dust, floors, on old nails,\nespecially on the floors of old wooden slaughter-houses. It grows best\nin deep wounds {184} where it is shut off from the oxygen of the air.\nHence the danger of treading upon a nail that has been lying near the\nground.\n\nBeriberi, a disease observed especially among seamen, appears at times\nin our coast towns. It is always a very serious malady and sometimes\nit is rapidly fatal. The infective agent, which is not known, is not\nundoubtedly communicable from man to man, but it is carried from place\nto place, and it clings to ships and buildings; it thrives in hot,\nmoist, crowded places. The priest should disinfect his hands after\nvisiting a case.\n\nAnthrax, called also wool-sorter's disease and splenic fever, is a\nvery fatal disease, and the bacillus is communicable to any one\nthrough an abrasion of the skin, through the intestines by swallowing\nit, or through the lungs by breathing it in in dust. Disinfect the\nhands and the shoes after visiting a patient. Be careful not to touch\nanything in his room.\n\nThe bacteria that cause typhoid fever, Asiatic cholera (which has been\nepidemic in America) and epidemic dysentery must get on the hands, or\non food, or in water, and thus reach the mouth and be swallowed before\nthey produce these diseases. Act in cholera as in anthrax, and\ndisinfect the hands after visiting a case of typhoid.\n\nThe bubonic plague, the most fatal of all epidemic diseases, has\nalready appeared in California and Mexico. It is caused by a specific\nbacillus isolated by Kitasato and Yersin in 1894. The disease is\ncommunicated by contact and it is seemingly also miasmatic.\n\nThe terrible plague of the Black Death that swept over Europe from\n1347 to 1350 was a malignant form of the bubonic plague. Over\n1,200,000 people died in Germany, and Italy suffered much more. In\nVienna for some time about 1000 people a day died and were buried in\ngreat trenches. Venice lost 100,000 inhabitants, and London lost more\nthan that. In both Padua and Florence only one-third of the\ninhabitants were left alive; at Avignon the Rhone was consecrated so\nthat bodies might be thrown into it for burial; and ships drifted\nabout the coasts of Europe {185} with dead crews. Hecker, in his study\nof this plague, says that nearly one-fourth of the population of\nEurope died in that visitation. Civilisation was wellnigh overthrown\nin the panic. In Germany, Italy, and France the Jews were accused of\npoisoning the wells and thus causing the plague, and they were\nslaughtered by thousands. At Strasburg 2000 Jews were burned to death\nin one holocaust; at other places, as at Eslingen, in despair the Jews\nset fire to their synagogues and destroyed themselves. The Great\nPlague of London in 1665, in which 70,000 persons died, was also the\nbubonic plague.\n\nThe mortality is about 90 per centum in some epidemics. The bacillus\nleaves the body in the faeces, flies carry it to food, it thus gets to\nrats and mice, and it is carried from place to place. Rats, however,\nare commonly infected as if by a miasm before the disease appears in\nman. There is dispute as to the communicability of the plague from man\nto man by contact with fomites, but it is practically certain the\ndisease can be thus transmitted. Kitasato once succeeded in producing\nthe disease in animals by inoculation with dust taken in an infected\nhouse. Merely touching a patient does not apparently convey infection,\nyet some authorities hold that in time of epidemic the contagion is\ntransmitted even through the air, especially on the ground floor of\nhouses. Perhaps mosquitoes are the medium of infection, as they are\ninclined to fly low.\n\nIn visiting a case of bubonic plague the priest should be as cautious\nas if he were attending a smallpox patient. After death by smallpox,\nplague, typhus, cholera, scarlatina, diphtheria, and measles the\nfunerals should be private and the bodies should not be taken to the\nchurch.\n\nMalta Fever, or bilious remittent fever, is found in some of the\nislands taken from Spain. It has a low mortality and is not\ncontagious. Bruce in 1887 isolated the bacterium that causes it.\n\nWe do not know the cause of yellow fever despite the claims of\nSanarelli that he has isolated the specific micro-organism. Recently\nAmerican physicians discovered that it is transmitted from man to man\nby mosquitoes that belong {186} to the genus Stegomyia, the Stegomyia\nFasciata especially. If a yellow fever patient is put into a room in\nwhich the mosquitoes have been killed and the doors and windows are\nscreened, he is as harmless, as far as contagion is concerned, as a\nman with a broken leg. The disease is not spread by fomites.\n\nMalaria is caused by plasmodia, which are protozoa, not bacteria, and\nit is carried from case to case by mosquitoes of the genus Anopheles.\nSo certain are we that this is the mode of infection that the\nexpression \"no anopheles, no malaria\" has almost become a medical\naxiom. A bite from an anopheles mosquito does not cause malaria unless\nthe particular mosquito has previously bitten a malaria patient.\n\nThe stegomyia flies and bites in the early afternoon and again at\nnight, the anopheles flies and bites after sunset. In visiting a case\nof pernicious malaria or one of yellow fever avoid the bites of\nmosquitoes by gloves and a piece of netting, and there is no danger\nwhatever.\n\nThe stegomyia mosquitoes are tropical and subtropical, but they can\nlive as far north as Philadelphia and even farther. The anopheles is\nespecially a northern insect. The ordinary culex mosquito, when it\nalights upon a wall, stands with its body parallel to the wall, as a\nhouse-fly stands; the anopheles mosquito stands with its tail raised\nfrom the wall at an angle. A mosquito lays its eggs in any pool of\nstill water, and the \"wrigglers\" seen in an open rain-barrel are the\nlarvae from these eggs. The larvae come to the surface of the water to\nget air, and they may be smothered with petroleum; but the only\neffective way to get rid of malaria and yellow fever is to drain or\nfill pools of water and marshes. Mosquitoes will breed also in the\nsmall still bights along the edges of running streams; in old tomato\ncans that contain rain water; in any still water, fresh or salt.\n\nAUSTIN OMALLEY.\n\n\n{187}\n\nXV\n\nINFECTIOUS DISEASES IN SCHOOLS\n\nCases of diphtheria, scarlet fever, measles, and even smallpox are not\nseldom found in schoolrooms, and much anxiety can be averted and the\nspread of infection can be wholly or in great part averted by a\nknowledge of disinfection.\n\nThe laity will often follow the advice of a priest in matters of\nhygiene when they are inclined to rebel against the regulations of\nhealth departments and the suggestions of physicians, therefore a\npreliminary explanation of methods for the prevention of infection in\nthe family will be advantageous; prevention in the family is also\nintimately connected with prevention in the school. Methods useful in\nthe family are useful also in convents and boarding-schools.\n\nAs regards diphtheria, the chief causes of the spread of this disease\nare mistaken diagnosis, imperfect isolation, incomplete disinfection,\nand, paradoxical though it may seem, a lack of susceptibility to the\ndisease in a large number of children.\n\nMany physicians are still under the grave error that diphtheria can\nalways be recognised without the aid of the microscope, and that\nmembranous croup commonly kills. All scientific writers upon\ndiphtheria agree that it is caused by the Klebs-Loeffler bacillus.\nThey also hold that there is a disease called membranous croup, as\ndistinct from diphtheria as typhoid is, but that membranous croup is a\ncomparatively harmless and non-contagious disease. Two per centum is a\nliberal mortality in membranous croup, yet a certain class of\nphysicians are constantly reporting deaths from this disease. In a\nseries of 286 cases (not deaths) diagnosed as membranous croup by\nphysicians of New York {188} City a few years ago, Park found the\ndiphtheria bacillus in 229, or 80 per centum. I have never examined\nthe throat of a child dead from so-called membranous croup in which I\ndid not find the diphtheria bacillus. This is the experience of almost\nevery bacteriologist who has had to do with diphtheria. Some men\nreport deaths from diphtheria as thrush! These deaths might just as\ntruthfully be attributed to the wearing of linen collars.\n\nOn the other hand, according to Baginsky of Berlin, Martin of Paris,\nPark of New York, and Morse of Boston, from 20 to 50 per centum of the\ncases admitted even to diphtheria hospitals have not diphtheria at\nall. Bacteriologists find that about 35 per centum of the cases\nreported by physicians to be diphtheria are really nothing but\ntonsilitis or pharyngitis, with now and then a case of membranous\ncroup. Without a bacteriological diagnosis, therefore, 35 families in\neach 100 quarantined (where quarantine laws exist) are unjustly\nquarantined and subjected to the trouble and expense of useless\ndisinfection. The suffering this can cause to a poor family, whose\nsmall business is often ruined by quarantine, is a matter for very\nserious consideration. Again, no matter what experience a physician\nmay have had, he can not in many cases differentiate diphtheria in its\nearly stages, or in children of good resisting power, from\ncomparatively harmless throat affections. The extraordinary resisting\npower against diphtheria shown by some children and adults has been\ndescribed by Wassermann (_Zeitschrift f. Hyg._, 19 B., 3 H.). He found\none series of 17 children, from one and a half to eleven years of age,\nand 34 adults, in which 11 children and 28 adults were not only immune\nto diphtheria, but some of them had enough antitoxin in their blood to\nneutralise a tenfold fatal dose of diphtheria toxin. This explains\nmany mysterious outbreaks of diphtheria: such immune persons are\ninfected and they carry about the disease unconsciously because they\nare not ill themselves. I have seen a mother kiss a child dying of\nmalignant diphtheria and the woman did not get even a sore throat, but\nI know of another case exactly like this in which the mother died from\nthe infection.\n\n{189}\n\nThere are bad cases of diphtheria which the experienced physician can\ndiagnose as soon as he enters the patient's room without even looking\nat the throat, but the lighter cases that are dangerous are not easily\nrecognised. I have seen two children of a family in Washington\nattacked with a slight throat soreness after one child had died of\ndiphtheria in the house. The cases of these two children would never\neven suggest diphtheria if that first child had not had the disease.\nBoth these patients died within ten days of syncope without the\nformation of any membrane, but the diphtheria bacillus was present\nmicroscopically. To the moment of death there was nothing in the\nsymptoms of these two children to show diphtheria to the naked eye.\nFrom a personal experience with more than 800 cases of diphtheria in\nhospitals and as a medical inspector, I feel certain that light\nattacks of diphtheria can not be diagnosed without the aid of the\nmicroscope.\n\nThe immunity mentioned above explains the fact that the Klebs-Loeffler\nbacillus is sometimes found in healthy throats, and the person that\nhas such a throat is really more dangerous than a patient that is ill\nwith diphtheria, because we cannot guard ourselves against him.\nSchool-children at times have what appears to be mere sore throat but\nwhich is really diphtheria in the naturally immune.\n\nAll cases of sore throat in school-children should be examined\nbacteriologically, but unfortunately the bacteriological examination\nfor diphtheria is a complicated process which requires an expert\nbacteriologist and a laboratory. The cost of a laboratory fitted for\nthis diagnosis alone is not great, but it is not easy to persuade\nsmall city governments that they need such plants.\n\nThe only resource, then, is to treat every suspicious case of sore\nthroat as if the disease were really diphtheria, until a diagnosis is\nestablished as near the truth as possible. Children that are afflicted\nwith throat inflammations should be kept from school. The people\nshould be taught the necessity of isolation and disinfection; they\nshould be warned against patent disinfectants, and told to ask\ncompetent physicians to advise them in disinfection.\n\n{190}\n\nDiphtheria is not directly caused by unhygienic surroundings. A\ndisregard for hygiene disposes a child for infection if the child is\nexposed to the bacillus. The specific germ must be introduced into the\npatient's mouth or nostrils. When a child is infected with diphtheria\nthe breath is not a medium of contagion. The sputum, spat out or\ncoughed out, is a means whereby the disease is spread. The bacillus is\nin the patient's mouth and nostrils; it gets upon his hands by\ncontact, upon eating utensils, upon whatever touches the mouth of the\nsick person. The bacillus does not float in the air of even the\nsick-room, except in those cases where dried sputum is stirred up by\nsweeping or attrition of other kinds.\n\nIn a boarding-school or family when a diphtheria patient is found,\nselect a room set off as far as possible from the rooms commonly used,\nand before putting the patient into this room remove all curtains,\nupholstered furniture and carpets from it that are not so cheap or so\nworn that they may be destroyed after the patient's convalescence, or\nwhich are of such texture that they will not be destroyed by water or\ndisinfection by heat. In any case the less there is in the room the\neasier the disinfection will be.\n\nUse the mattress upon which the patient had slept before you\ndiscovered the nature of the disease. Books should be removed, because\nan infected book can not be disinfected except upon the outside. The\nroom is not to be swept while the patient is in it,--dust may be wiped\nup with a damp cloth. The cloth is to be disinfected before it is sent\nout of the room.\n\nThe popular notions regarding sulphur as a disinfectant after\ndiphtheria are erroneous. Sulphur fumes in certain definite quantities\nwill disinfect after smallpox, scarlet fever, measles, and some other\ndiseases; these fumes will also kill the diphtheria bacillus, if the\nbacillus is wet and exposed directly; but if it is buried in sputum or\nin clothing the fumes will have no effect whatever upon it. The\ndisinfectants to use are acid bichloride of mercury and heat.\nFormaldehyde does not penetrate well enough to be reliable in\ndiphtheria.\n\n{191}\n\nWhen the patient is taken to the room prepared, let a mixture of one\nounce of bichloride of mercury in the powdered form, in two ounces of\ncommon hydrochloric acid (not the dilute hydrochloric acid used in\nmedicine), be obtained. This is a violent poison, and it must be kept\nout of the reach of children and careless persons. Two teaspoonfuls of\nthis solution in an ordinary wooden bucket filled with water to within\ntwo inches of the rim makes the disinfecting mixture. A wooden washtub\nnearly filled with this disinfectant, mixed in the bucket as directed,\nshould be kept near the door of the room, and all towels, sheets, and\nsoiled linen must be soaked in this tub for twenty-four hours. After\nthat any one may handle these articles with perfect safety. The\narticles that have been soaked for twenty-four hours should be rinsed\nin ordinary water to remove the acid, and they may then be washed. The\nnurse should not touch the outside of the tub with infected articles\nwhile putting these in the disinfectant. Do not make the disinfectant\nstronger than directed here, or it will destroy the articles soaked in\nit, and for the same reason do not leave them in it longer than\ntwenty-four hours.\n\nIf the attendant can be kept isolated with the patient there will be\nless liability of carrying the infection through the house. In a\nmajority of cases in families, however, the mother is obliged to care\nfor the patient and to attend also to her household duties. In the\nlast case, let her keep near the door of the room a cotton wrapper\nwhich can be put on over her dress whenever she enters the room. She\nhad better tie a towel over her hair. In the room a china-stone basin\nshould be kept, containing a gallon of water, in which there is a\nteaspoonful of the acid bichloride. Every time the attendant touches\nthe patient let her wash her hands in this mixture, using no soap. She\nshould remove her finger rings or they will be blackened. The patient\nshould not be handled except when absolutely necessary, to avoid\nneedless exposure to infection; it is also injurious to a child ill\nwith diphtheria to lift it up. The nurse's covering wrapper should be\nsoaked in the tub as often as possible. Some ignorant persons give as\nan excuse for a lack of care in {192} handling patients having\ncontagious diseases like diphtheria, that they are not afraid of the\ninfection. Fear has nothing to do with the matter.\n\nFood is to be taken to the door of the sick-room by some one other\nthan the attendant. The tray should not be carried into the room.\nAfter the meal, take to the door a pan containing water, and let the\nattendant set the dishes, knives and forks, and the food handled by\nthe child, under the water without touching the rim or sides of the\ndish-pan. Then any one may carry the pan to the kitchen, where it is\nto be set upon the stove, and the water holding the dishes and the\nrejected food is boiled for an hour. After that process the contents\nof the pan are safe, and they may be handled for washing. Cloths used\nin wiping the mouth of the patient are to be wrapped in paper and\nburned. Dejecta should be covered with fresh chlorinated lime, one\npart to two of water.\n\nAfter the patient begins to convalesce the danger of infection grows\ngreater. When the membrane has disappeared, and the child is able to\nrun about the room, the attendant ceases commonly to use the\nthroat-spray because the process is troublesome. In such cases the\ndiphtheria bacillus remains in the patient's mouth for some time--from\na few days to weeks. During the most of this time the child is as\ndangerous to others as it was while it was ill. In one case in my own\nexperience, the bacillus remained present for eleven weeks from the\ndate of diagnosis, and I then lost sight of the child. In the tenth\nweek the bacillus present when in pure culture killed a guinea-pig in\nthirty-six hours. This is, of course, an exceptional occurrence; but\nthe routine practice is to keep the patient isolated for three weeks\nafter the membrane has disappeared, unless a bacteriological\nexamination shows that the bacillus is absent. The bacillus remains\nafter the use of antitoxin just as if antitoxin had not been used.\n\nWhen a child is to be released from the sick-room, bathe it carefully\nwith soaped warm water, washing out the hair and under the\nfinger-nails carefully. Then wet a towel with the disinfectant (the\nacid bichloride of mercury,--a {193} teaspoonful to a gallon of water)\nand go over the body with it; afterward rinse with ordinary water. Do\nnot let the disinfectant enter the child's mouth or eyes. Next,\nwithout allowing the child to touch anything in the room, especially\navoiding the door-knob, send it to another room and dress it in\nclothing that has not been near the sick-room. If, after this process,\nother children are infected, the explanation is that the child had\nbeen released too soon--before the bacillus had disappeared.\n\nIt commonly happens that a child has been going about the house for\nsome days before a physician has been called in. In that event you\nhave the house to disinfect. You must then wet with bichloride\neverything the child has touched, and boil all eating utensils.\n\nAs to the disinfection of the room and its contents: the irritation of\ndiphtheria causes a large quantity of saliva to flow from the\npatient's mouth; this infected saliva runs down upon the pillows and\nsoaks into them. It may also soak into the mattress. If a town has a\nsteam disinfecting plant, there is no trouble in dealing with bedding\nand carpets after diphtheria and other contagious diseases; such a\nplant, however, costs at the least $6000. It is safer, in the absence\nof steam disinfection, to destroy pillows by fire; but if these are\nopened and the filling put into tubs or barrels containing two\nteaspoonfuls of the acid bichloride of mercury to each gallon of water\nand soaked for about two days they will be safe. The ticking in this\ncase should be boiled in a wash-boiler, and the filling is to be\nrinsed before drying. The mattress is less liable to infection but it\nmay be infected. If a piece of oil-cloth or rubber sheeting is spread\nbeneath the bed-clothes under the patient and the mattress is kept\nwell covered during the course of the disease, the filling of the tick\nwill most probably be not infected. The loss of a good feather or hair\nmattress is considerable in the house of a poor man, and these often\nmay be saved. To disinfect the surface of a mattress place it on\nchairs in a small room or in a closet and pour upon a cloth under it\n500 cc. of formalin for each 1000 cubic feet of air-space in the room\nor closet--multiply the length by the height by {194} the width of the\nroom or closet to get the cubic feet of air-space. Leave the room or\ncloset shut tightly for twenty-four hours. The Trenner-Lee\nformaldehyde disinfector is a good apparatus for disinfecting. The\nsmaller size costs twenty-five dollars.\n\nIf anything is to be sent out of a room to be burned, spread a piece\nof old carpet, bagging, or similar useless cloth outside the room\ndoor, set on this the articles to be destroyed, wrap them carefully in\nthe fabric, tying all with cords; then take the bundle outside the\ntown in a covered wagon, pour kerosene oil on the package without\nopening it, and set it afire. Afterward wash the wagon with the acid\nbichloride.\n\nWet the furniture and floors of the room with the acid bichloride. Do\nnot merely sprinkle the solution about, flood everything with it,\nbecause the germ is killed only by direct contact; and remember that a\ndiphtheria bacillus magnified 800 times is not larger than the eye of\na needle. The bichloride will spoil gilt picture-frames, therefore use\na 10 per centum solution of pure carbolic acid on these and all other\nmetallic surfaces. Coins should be boiled, and paper money should be\ndipped in the 10 per centum carbolic acid solution and dried at a\nstove. Money is frequently found in smallpox rooms under the patient's\npillow.\n\nFormalin is the best disinfectant for wall-paper unless the child has\nspat upon it--then use the bichloride. Sometimes the bichloride will\nnot injure the wall-paper, but if there are gilt figures upon it these\nwill be blackened. Sulphur fumes are no better than formalin--not so\ngood, and they injure and blacken tinted and gilded wall-paper, silks,\nsatins, and other fabrics. If you determine to have the room\nrepapered, wet it with bichloride before you bring in the workmen.\n\nIt is difficult to disinfect a carpet except by steam, and on this\naccount the carpet should be removed from the room before the patient\nis brought into it. If it has been kept in the room, wet it thoroughly\nwith the bichloride, when you are disinfecting, if you can not have it\ndisinfected by hot steam. The wetting commonly spoils the carpet,\nconsequently it may be necessary to bum it.\n\n{195}\n\nKeep cats, dogs, and especially kittens, out of a diphtheria room.\nKittens will take the disease easily, and cats and dogs will carry\nabout the contagion. If a valuable dog should get into the room,\ndisinfect its hair thoroughly with the acid bichloride and then rinse\nthe hair. Be careful to disinfect its feet.\n\nWhile using the bichloride do not forget the window-panes, the\ndoor-knobs, and that part of the chair-legs which touches the floor.\nAfter you have used the bichloride expose the room to the gas from\nformalin. Hang up sheets wet with 500 c.c. of formalin for each 1000\ncubic feet of air-space, and close all keyholes and cracks; then leave\nthe room shut for twenty-four hours.\n\nAs to the use of antitoxin as a preventive and cure for diphtheria,\ntoo much praise cannot be given to that wonderful discovery. Reliable\ndiphtheria antitoxin, used in proper quantity and early enough, is\nalmost an absolute cure. Where it fails it has been used too late or\nnot in the proper dose. In any case its only evil effect may be an\nattack of nettle-rash or hives. The few deaths that have occurred in\nits use were caused by an ignorant use of the syringe. If you find a\nphysician opposed to the use of antitoxin this simply means that he is\na quack. One serious disadvantage in the use of antitoxin is that it\nleaves the dangerous bacillus in the throat of the patient about as\nlong as an unaided convalescence would leave it. The membrane often\nwill disappear in twenty-four hours where antitoxin has been used, and\nthe child will be playing about the floor. Then the mother will say\nthe child never had diphtheria; she will not disinfect, and she will\nlet the child run about the house.\n\nThe free book system that prevails in some schools is a prolific\nsource of infection. Books are infected at home or by children from\ninfected houses, and mixed with other books in the school. The\ndiphtheria bacillus will cling to a book for at least a year. If books\nare given to the children, give them outright; do not let the books be\nmixed in the schoolroom.\n\nDrinking-cups used in common are another source of {196} infection.\nLet each child have its own tin cup. The clothes-rack in a school also\nspreads infection. Room enough should be given to each hook to keep\nthe hat and coat of one child from touching those of another, and a\nwooden partition standing out from the wall about eight inches should\nseparate hook from hook. The janitor should wash the clothes-racks\nwith the acid bichloride solution every time he sweeps.\n\nSuppose a child having diphtheria is found in school, or one is\ndiscovered as coming from a house where he was in contact with\ndiphtheria. The discovery is made commonly after the child has been\nspreading infection for some days. Do not frighten the youngster, but\nfind out from him what parts of the school-building he has been\nvisiting. Then send him and the other children home. Rooms in which\nthe child has not been are not infected, and only that which he has\ntouched is infected in any case. Wet everything in the building and\nouthouses with which he possibly could have come in contact with the\nacid bichloride. Burn his books and papers, or, if this action may\ncause difficulty with parents, let him take his books home and inform\nthe health officer of that fact. When he returns to school be sure of\nthe history of his books. Use formalin or sulphur in the infected\nrooms, and classes may be begun again the next day. If within the week\nany child shows signs of sore throat send it home immediately.\n\nSulphur must be burned when used as a disinfectant, and to be\neffectual four pounds should be burned for every 1000 cubic feet of\nair-space in the room. A teaspoonful of sulphur when burned will fill\na house with choking, dangerous fumes, but two pounds of sulphur\nburned in an ordinary bedroom will have no effect whatever on the\ndiphtheria bacillus and very little on any other disease. Sprinkling\ndisinfectants about a house, and setting saucers containing\ndisinfectants in rooms is nonsense--the quantity must be sufficient\nand be in actual contact with the contagion. A deodorant does not\ndisinfect because it removes a stench.\n\nTo burn sulphur set a coal-hod or an old tin pan on two bricks in the\nmiddle of the room, but see that there are no {197} holes in the\nbottom of the hod or pan through which burning sulphur could drip to\nthe floor. For a like reason see that the pan is not too narrow nor\ntoo shallow. It is safer to set the bricks in a tub filled with water\nup to the top of the bricks. Use powdered sulphur in preference to the\ncakes sold by the druggists, and fire this sulphur with a red coal.\nThe room should be moist with steam when the sulphur is set afire so\nthat the fumes will act effectually. Leave it shut tightly for\ntwenty-four hours.\n\nIn the Northern States diphtheria is most prevalent in October,\nNovember, and December; scarlet fever is an April disease, but it may\noccur at any time. It is easier to spread the infection of scarlet\nfever and measles than that of diphtheria, but it is not so difficult\nto disinfect after scarlet fever and measles as after diphtheria. The\ncontagion of scarlet fever does not resist the fumes of sulphur or\nformalin. Disinfect a room after scarlet fever as for diphtheria but\nbe sure to use also either sulphur or formalin because the contagion\ncan float about a room. Eruptive contagious diseases like scarlet\nfever, smallpox, and measles so affect the skin that during\nconvalescence the cuticle scales off. In severe cases of smallpox and\nscarlet fever the entire outer skin of the hand may peel off like a\nglove. The contagion is always found in the scaling skin. As the\npatient grows stronger the scales become finer, until at last they lie\nas mere mealy dust in the hollows of the elbows or other parts of the\nbody. Down to the very last these scales are infectious, and they will\nretain the infection for months, probably for a year or more. The\nscales float in the air of a sick-room, fall on the clothing of\nvisitors, are carried away by the shoes of those that leave the room.\nThe scaling may continue for three weeks--it commonly does. These\nthree diseases are infectious before the scaling begins, sometimes\nbefore the rash is well out. A very light attack of any of these\ndiseases in one child may infect another fatally. Insist upon keeping\na scarlet fever or measles patient out of school until all scaling has\nceased.\n\nChickenpox is almost a harmless disease, but it is more infectious\nthan even measles. Be cautious with it because {198} nearly every\nepidemic of smallpox begins through some one mistaking smallpox for\nchickenpox, although there is little or no similarity between the\ndiseases.\n\nA child with tuberculosis of the lungs or a child infected with acute\nsyphilis should not be permitted to go to school under any\ncircumstance.\n\nIn the chapter on The Priest in Infectious Diseases will be found an\naccount of the necessity of vaccination as a precaution against\nsmallpox.\n\nTinea Favosa, or favus, is a contagious and a very stubborn disease of\nthe skin, caused by the fungus _Achorion Schoenleinii_. It produces\nyellowish crusts about the hairs of the scalp and other parts of the\nbody, and it destroys the hair. It attacks also the finger-nails and\nthe skin that is without hair. In the later stages of the disease\nthere is a foul odour. It is one of the most difficult of the\nscalp-diseases to cure; months and sometimes years are required to get\nrid of it.\n\nA child with tinea should be kept away from school; and his desk and\nwhat he touches should be washed with the bichloride of mercury\nsolution. Burn his books and papers.\n\nRingworm is a kind of tinea, and it is caused by various mould fungi.\nTinea Tonsurans is ringworm of the scalp; Tinea Circinata is ringworm\nof the body; Barber's Itch is another form; there is also a ringworm\nof the finger-nails; and Pityriasis Versicolor is still another form.\nAll are contagious, and some are difficult to cure because the\nparasite gets down between the skin and the hair-follicles and an\nantiseptic can not reach it. Children affected with these diseases\nshould be kept away from school until they have been cured.\n\nThe presence of lice and of the Acarus Scabiei can bring about acute\nand severe skin eruptions. The Acarus Scabiei causes itch, but\nfortunately it is rare in America. These parasites go from person to\nperson, hence a child having either should be kept from school until\nhe is clean. A thorough washing will remove lice if they have not yet\ninflamed the skin, but itch requires a more vigorous {199} treatment.\nThe desks of such patients should be disinfected and their clothing\nshould be baked. They will probably be reinfected at home if the\ntreatment is not applied to other members of the family.\n\nContagious Impetigo, or porrigo, as it was formerly called, is a skin\ndisease common among children, and it may affect adults. It appears to\nbe of parasitic origin, but the specific organism that causes it has\nnot been isolated. The lesions in this disease are commonly\ndiscrete--separate one from another--but they may be crowded together.\nThey are vesico-pustular and they are sunken at the top in the typical\nform. If they are not broken by scratching, they dry into a yellowish\ncrust. The disease affects only the skin, but as it is contagious a\nchild affected with it should be kept from school until cured. The\ndesk and articles used by the child should be disinfected, and his\nbooks are to be burned.\n\nWhooping-cough is very infectious, and, contrary to the popular\nopinion, it is frequently a fatal disease. There is a period of\nincubation for from seven to ten days, then a catarrhal stage follows\nin which the child has the symptoms of an ordinary \"cold.\" In about\nanother week the dry cough becomes paroxysmal with the characteristic\n\"whoop\" when the air is drawn in after the fit of coughing. When there\nis an epidemic of whooping-cough, children with \"colds\" should be sent\nhome from school. The objects used by a child that has whooping-cough\nshould be disinfected, and its books and papers are to be burnt.\n\nMumps can be a serious and a very painful disease and it is infectious\nto a marked degree. The specific organism is not known. Boys are more\nliable to this disease than girls are, and recurrence is rare. After a\nperiod of incubation, which lasts from two to three weeks, there is\nfever, pain under one ear, and the parotid gland swells. The disease\nis commonly mild, but it may affect a child seriously. The patient is\nto be quarantined, what it has touched should be disinfected, and its\nbooks are to be burnt.\n\nThere are a number of infectious eye diseases that occur among\nschool-children. Acute Contagious Conjunctivitis, {200} or \"pink eye,\"\nis one of the most important. One form of acute Contagious\nConjunctivitis is caused by the Koch-Weeks Bacillus; it is \"pink eye,\"\nproperly so called, and it is very infectious. Objects handled by the\npatient can infect others and spread the disease. The attack is\nsevere, but the prognosis for full recovery is good. The child should\nbe strictly quarantined until all secretion from the eyes has ceased,\nand whatever he has touched is to be carefully disinfected.\n\nAnother form of Acute Infectious Conjunctivitis, less contagious than\nthat caused by the Koch-Weeks bacillus, is brought about by the\nintroduction into the eye of the bacteria that give rise to pneumonia.\nCommonly the pneumonia bacteria do not cause conjunctivitis unless the\npatient is susceptible in a special manner. As it is difficult to\ndifferentiate this second form from the first, the same precaution\nshould be used.\n\nTrachoma, called also granular conjunctivitis, Egyptian ophthalmia,\nand military ophthalmia, is a very serious inflammatory disease of the\nexternal eye which has of late years become prevalent in American\ncities, whither it has been brought by immigrants from eastern and\nsoutheastern Europe. Persons that have this disease on landing in the\nUnited States are deported, but despite this precaution it has crept\nin and is now endemic. It is contagious, and when well established it\nis extremely difficult to cure. If untreated it lasts for years and it\nmay destroy the cornea and consequently the sight. A trachomatous\nchild should be kept from school until it has been cured, and that\ncure will take a very long time.\n\nThe Gonococcus can be carried into the eye by handling objects like\nsoap, towels, wash-basins, which have been used by persons afflicted\nwith gonorrhoea. The infection of the eye is very severe and\ndangerous, and the usual quarantine is to be observed. The ophthalmia\nof the new-born is gonorrhoeal.\n\nThe Diphtheria Bacillus also may get into the eye, and set up a\nprimary infection there. A membranous conjunctivitis, too, is at times\ninduced by pus organisms. {201} Xerosis Epithelialis, tuberculosis,\nleprosy, and syphilis may affect the eye primarily, and additional\nforms of eye-diseases are found that are infectious. The general rule,\nthen, is that children with any inflammation of the eyes are to be\nkept out of school until a physician pronounces them harmless.\n\nAUSTIN OMALLEY.\n\n{202}\n\nXVI\n\nSCHOOL HYGIENE\n\n\nPriests have to put up buildings for parochial schools, colleges,\nseminaries, orphan asylums, convents, and the like, but in such work\nsanitation is commonly given only a passing thought in connection with\nsewer-traps and these are left to the wisdom of a plumber. The\nphysical welfare of youth is almost as important as its mental\ntraining, and there are many factors beside sewer-traps involved in\nthe effort to sustain it.\n\nIf there is freedom of choice as regards the site of a schoolhouse or\nsimilar building, the top of a small elevation is to be selected. Such\na position affords the best natural drainage, removes dampness, avoids\ninundations, gives full sunlight and the purer air. The top of a high\nhill may be too exposed to the wind.\n\nNext to the top of a knoll, the southerly slope of a hill is to be\nchosen. The building should not be overshadowed by a hill, especially\non the western side. Trees are not to be planted close to a building\nin which children live, and ivy and similar plants should not be\npermitted to cover the walls.\n\nIf a building is set in a hollow it will be surrounded with chill air\nand mists in the cold seasons, even if a costly drainage system keeps\nthe cellar and basement dry.\n\nA gravelly or sandy soil beneath a building is the best, provided this\nsoil is not already saturated with organic matter, or is not close\nabove a dense layer of clay or rock. Clay, marl, peat, and made soils\nshould be avoided if possible, because they are full of organic\nmatter; they are cold, and they infect the ground air. Rock does not\nmake a good building site--its seams carry water.\n\n{203}\n\nThe subsoil should be drained four or six feet below the cellar floor,\nand this floor is to be laid in concrete and cement. At the level of\nthe ground there should be a course of hollow vitrified brick to\nexclude dampness and to give ventilation.\n\nLimestone walls conduct more heat in and out than an equal thickness\nof glass, bricks, plastering, and wainscoting. The porosity of the\nbuilding material determines the interchange of the air through the\nwalls, and it affects the temperature of the rooms. If there is water\nin the pores of the walls heat is conducted rapidly, but air is not\npermitted to pass. Brick as a building material has many\ndisadvantages, but on the whole it is best for schools, and it resists\nfire better than most stones. The harder the brick the better it\nis--vitrified brick is the best. Hard-pressed brick of a light colour\nmakes an excellent outer wall-surface.\n\nIt is very doubtful that sewer gas escaping into a house will directly\ncarry the micro-organisms of diseases like typhoid and diphtheria, but\nsuch gas is poisonous, depressant, and it renders the inmates of a\nhouse liable to disease; lessens their power of resistance. The\ntyphoid bacillus and other bacteria can, of course, be carried into a\ncellar by the seeping in of drainage water. Infants kept in the upper\nstory of a house in hot weather are more liable to intestinal diseases\nthan are those that live on the lower floors, but here the weakening\nagent is heat. Tuberculosis, scrofula, rheumatism, neuralgias,\nbronchial, and kidney affections are made worse in damp houses.\n\nThe chief defects in plumbing and drainage are the following: (1)\nEarthen pipe drains become broken or their joints leak, and they\nsaturate the ground under a house with sewage. (2) Tree roots break\nand clog drain pipes. (3) The pipes sometimes have not fall enough.\n(4) Drains without running traps admit sewer gas. (5) Rats burrow\nalong a drain pipe from the sewer into the house and admit sewer gas.\n(6) When the soil pipe from a water-closet is exposed in cold weather\nit may freeze up or be clogged by urinary deposits. (7) Rats gnaw\nthrough lead pipes and joints. (8) Two or more closets or sinks with\nunventilated {204} traps on the same pipe will siphon back sewage. (9)\nOverflow pipes sometimes have no traps and they let in gas. (10) Ash\npits near a house carry moisture to walls, (11) Cesspools leak through\nthe soil.\n\nIn planning a school-building the classrooms and the study-halls are\nthe first things to be considered. The classrooms should be oblong,\nwith the aisles running lengthwise. Each child should have at the\nleast 15 square feet of floor space and 200 cubic feet of air space. A\nroom 30 by 25 feet with a ceiling 13 feet from the floor will serve\nfor 48 pupils and no more. This is the best size for a room when\nblackboards and maps are used in teaching, because a larger room sets\nthe children in the back seats too far away to see without eye-strain.\n\nDormitories should have at the least 300 cubic feet of air space for\neach child, and great care is to be taken in the ventilation. Children\nabout 10 years of age require 11 hours of sleep; under 13 years,\n10-1/2 hours; under 15 years, 10 hours; under 17 years, 9-1/2 hours;\nunder 19 years, 9 hours. Do not make children get out of bed before\nseven o'clock in the morning; do not let them study before breakfast,\nand do not force them to work after half-past eight or nine o'clock at\nnight until they are at the least 17 years of age. The hours for work\nshould be:\n\nAges       Hours of work a week\n\nFrom\n5 to 6         6\n6 to 7        9\n7 to 8      12\n8 to 10    15\n10 to 12   20\n12 to 14   25\n14 to 15   30\n15 to 16   35\n16 to 17   40\n17 to 18   45\n18 to 19   50\n\nWork given for punishment must be included in these hours. No one,\neven an adult, should study for more than two hours at a time without\nan intermission for a few {205} minutes. In a boarding-school no one\nunder any pretext, even on rainy days, should be permitted to study\nduring recreation hours, and the deprivation of recreation to make up\nlessons is a relic of barbarism. If a teacher can not get class work\ndone except by shutting up children during recreation hours, remove\nthe teacher or expel the pupil.\n\nThe amount of glazed window surface admitting light to a classroom or\nstudy-hall should be from one-sixth to one-fourth the floor space of\nthe room, and this must be increased if the light is obstructed by\nneighbouring houses or trees. The light is to be admitted on the left\nside of the pupils,--all other windows should be counted as\nventilators only. Windows facing the children or the teacher are to be\navoided. In rooms fourteen feet high a desk twenty-four feet from a\nwindow is insufficiently lighted. The larger the panes of glass the\nbetter, and the external appearance of windows is to be sacrificed to\ngood lighting. If screens are used to protect the glass from\nstone-throwing, allowance is to be made for the light the screens cut\noff.\n\nIf a room can not have enough light from the left side alone, put the\nadditional windows on the right so that their lower sills will be\neight feet from the floor; and be careful in this case that the light\nfrom the right is not brighter than that from the left.\n\nWindows should have as little space as possible between them to avoid\nalternate bands of shadow and light. Set them up as near the ceiling\nas possible, since the higher they are the better the illumination;\nand they should not be arched at the top. The lower window sills may\nbe about four feet from the floor. When window shades are used to cut\noff direct sunlight, they should be somewhat darker in colour than the\nwalls.\n\nIf artificial light is used in boarding-schools in the study-halls,\nthe best light is one that is as near in colour as possible to the\nwhite light of the sun, and ample, but not glaring. It should be\nsteady, and it should not give out great heat nor injurious products\nof combustion. Hence the electric light is the best; after that, gas\nthrough Welsbach {206} or Siemens burners. Well refined kerosene oil\ngives a good light, but it is always dangerous. Acetylene gas is now\nused in a safe apparatus, and it also is an excellent light.\n\nNo colour that absorbs light should be used on the walls. Pale\ngreenish gray, nearly white, is the most satisfactory colour. There\nshould be no wall paper, curtains, or hangings of any kind in a school\nor college building. The wall decorations should be as plain as\npossible, with no roughened places to catch dust.\n\nStairways are to be well lighted; they should be at the least five\nfeet wide, and have landings half-way between each story. Diagonal or\nspiral stairways are dangerous. Steps with six-inch risers and\neleven-inch treads are the easiest for children, but\nsix-and-a-half-inch risers may be used in high schools and colleges.\n\nCarbonic acid in the air of a classroom is an index of impurity.\nExternal air has about three parts of carbonic acid in 10,000 parts of\nair, and above seven parts in 10,000 is injurious. Each person exhales\nabout fourteen cubic feet of carbonic acid gas in an hour. There is no\neasy method of determining the quantity of carbonic acid gas present\nin a room, and we must therefore arrange the ventilation so that about\n3000 cubic feet of fresh air an hour will be supplied to each person\nin the house.\n\nBeside carbonic acid there are other impurities in house air, as dust,\nmicro-organisms of disease, exhalations from bodies, sewer gas, and\nthe like, which accumulate and do injury when the ventilation is\ndefective.\n\nIf every person in a house has 1000 cubic feet of air space, natural\nventilation will suffice ordinarily, but artificial ventilation is\nneeded in schoolrooms and dormitories. The subject of ventilation can\nnot be satisfactorily discussed in a short article, and those that are\ninterested in school building should leave the matter to a competent\narchitect, or study books and articles like J. S. Billings'\n_Ventilation and Heating_, Pettenkofer's _Ueber Luft in den Schulen_,\nand Kober's article on House Sanitation in the _Reference Handbook of\nthe Medical Sciences_.\n\n{207}\n\nThe proper heating of a schoolroom is a matter so generally understood\nthat there is no need for special remark here, except this, that\nprovision for proper humidity in the heated air is commonly neglected.\n\nCheap water-closets do not save money--they get out of order too\neasily. The pan, valve, and plunger hoppers are not to be tolerated.\nThe only kind to use are short-hopper closets with a trap that opens\ninto the soil-pipe above the floor. These may have valve-lifters\nattached to the seats, because children forget to flush the hoppers.\nThe ventilation of the water-closets should be separate from that of\nthe main building. In country places where vaults are used, there\nshould be a supply of dry loam kept, and enough of this to cover the\nfresh contents should be thrown into the vaults every evening.\n\nChildren are seemingly always thirsty, and they should be allowed to\nhave all the drinking water they want if the source is free from\ntyphoid germs and infection by organic matter. Common cups are an\nabomination, and a prolific cause of contagious diseases. Each child\nshould have its own cup.\n\nThe rules for desks and seats for children are these:\n\n1. The height of the seat should be about two-sevenths of that of the\nbody.\n\n2. The width of the seat should be about one-fifth of the length of\nthe body, or three-fourths the length of the thigh. Do not keep\nunfortunate little children's feet dangling all through their school\nyears to save a few pennies on school furniture.\n\n3. The seat should slope downward a little toward the back, be\nslightly concave, and have rounded edges in front.\n\n4. There must be a back-rest.\n\n5. The child, when sitting erect, should be able to place both\nforearms on the desk without raising or lowering the shoulders. This\nis a very important rule.\n\n6. The seat must be correctly placed as regards the distance of its\nfront edge from the corresponding edge of the desk.\n\n7. The desk slope should be 15 degrees.\n\n{208}\n\nBadly constructed desks cause eye-strain and marked distortions of the\nspine. Desks should be adjustable in height, especially for growing\nchildren. School-children grow most rapidly between the ages of twelve\nand sixteen years--nearly two inches a year--and the desks and seats\nshould be adjusted twice a year at the least. If a child is moved to\nanother desk an adjustment is to be made at once.\n\nTo counteract the bad effect of long sitting, even at properly\nadjusted desks, children should be frequently sent to blackboards, and\nat regular intervals a few minutes are to be given to \"setting up\"\nexercises.\n\nGreat attention should be paid to the eyesight of children. Those that\ncomplain of headache should have their eyes examined. The lines in\nschool books should be not more than four inches in length, and they\nare to be printed in clear, well-leaded type. Slates are dirty and\nunsanitary: let the children write on paper that has a dull finish.\n\nTeachers should prevent lounging positions at desks, especially\nstooping. They are not, however, to try to make children under fifteen\nyears of age sit still. The youngsters can not remain immovable, and\nthe effort to make them do so is irritating to no purpose.\n\nNervous children need outdoor exercise more than anything else. When\nnervousness takes the form of religious scrupulosity in\nschool-children and novices do not immediately apply a moral theology\nto them--call in a physician that has common-sense, because there is a\nnervous scrupulosity which is much more frequently met with than the\npurely spiritual form. Aridity in prayer, a loss of sensible devotion,\nand similar troubles have to do with advance in the spiritual life,\nbut they more commonly have to do with the liver in persons that are\nnot nearly so important spiritually as they fancy they are; and in\nthese cases the cook is the particular devil at fault, if they have\nexercise enough.\n\nOne of the chief sanitary evils in our boarding-schools, convents, and\nsimilar institutions, is the stupid sameness in the food which may be\notherwise unobjectionable. The meat, for example, may be good, but the\ncollege and seminary cook sends it into the refectory chilled and\nclammy, or hot and overdone. In any case it is everlastingly the {209}\nsame. Children can predict a dinner's ingredients a month in advance.\n\nGive children meat twice a day; white flour in their bread, because it\nis digested better than whole flour; all the sugar they want at meals;\nmilk rather than tea, and tea rather than coffee; but let it be tea,\nnot a dose of tannic acid.\n\nThe physical education of girls is neglected. Their general education\nis effeminate rather than feminine. If a convent faculty grows bold\nand \"modern\" it hires a teacher of gymnastics, puts an \"extra\" on the\nbill of expense, and ten or twelve wealthy girls play at gymnastics if\nthey are not too lazy. Even if the whole school is obliged to attend\nthe club-swinging and posturing and the other nonsense, little good is\ndone. Girls should be kept out of doors for their exercise, and fresh\nair is much cheaper than a gymnastic teacher. If school-girls were\nforced into the open air more, they would not have time for munching\ncaramels over the erotic spasms of Araminta and Reginald in the\npopular novel, and there would be advantage in the change. The absence\nof daily, regular, and sufficient exercise renders girls listless,\nanaemic, sallow, foul-breathed, melancholy, stooped, irritable.\n\nDo not permit boys under eighteen years of age to go into regular\ntraining for college track-teams. Their hearts are not strong enough\nfor the strain.\n\nBoys should not use tobacco in any form, but it is useless to try to\nmake them believe this statement. Tobacco stunts a boy, causes\ndyspepsia, and renders his mind dull. The measurements made for years\nat Yale, Amherst, and other colleges, by physical directors, show\nremarkable reduction in the height and chest expansion in tobacco\nusers as compared with boys that do not smoke. Cigarette smoking would\nnot be different from other smoking if it did not so readily tend to\nexcess. Cigarette smoke is inhaled more than the smoke from cigars and\npipes, and thus more of the injurious ingredients of tobacco are\nabsorbed.\n\n{210}\n\nIf a boy will smoke let him use a good long-cut tobacco which has\nlittle or no Perique tobacco in it, in a \"Remington,\" \"Edison,\" or\nsimilar wooden pipe. These are pipes with stems of large calibre, and\nin the stem there is a roll of absorbent paper or pith which keeps the\npipe clean. Cigars, no matter how costly they may be, are too strong\nfor a boy and for most men. A poor cigar irritates the throat aside\nfrom the regular effect of the tobacco, especially if there is much\nnitre in the wrapper. Meerschaum pipes are dirty and too strong. The\ntongue is irritated by a pipe that has a small bore in the mouthpiece:\nuse a mouthpiece that has as large a bore as possible. Cigar smokers\nshould, after cutting off the end of a cigar, blow the dust out of it\nfrom the lighting end to avoid inhaling this irritating dust.\n\nAUSTIN OMALLEY.\n\n\n{211}\n\nXVII\n\nMENTAL DISEASES AND SPIRITUAL DIRECTION\n\n\nIt is a well-recognised fact that persons suffering from many forms of\nbeginning mental disease are likely to be affected by an exaggeration\nof religious sentiment. An unaccountable increase in piety is\nsometimes the first warning of approaching mental deterioration. It is\nnot hard to understand why this should be, since religious feelings\noccupy so prominent a place in the minds of the majority of people,\nand the removal of proper control over mental operations of all kinds\nleads to an exaggeration, especially of those that have meant most for\nthe individual before. Supposed religious vocations, especially when\nof sudden development, are sometimes no more than an index of\ndisturbed mentality. Every confessor of lengthy experience has had\nsome examples of this. This makes it important that clergymen should\nhave a knowledge of at least the first principles on which the\ndiagnosis of mental diseases is made. Superiors of religious\ncommunities, and especially those that have to decide as to the\nsuitability of those applying for entrance to, or already in probation\nfor, the religious life, need even more than others a definite\nknowledge of the beginning symptoms of the various mental diseases,\nand of the types of individuals that are most prone to suffer from\nthem.\n\nBesides, confessors and religious friends and advisers often gain the\nconfidence of the mentally diseased much more fully than any one else.\nIt is to them especially that the earliest symptoms of beginning\nmental disturbance are liable to be first manifested. After all, a\npastor's and a {212} confessor's duty is bound up with the welfare of\nhis spiritual children in every sense; and it would be supremely\nserviceable to the patients themselves and to their friends, if these\nearliest symptoms could be recognised and properly appreciated, and\ndue warning thus given of the approach of further mental\ndeterioration.\n\nThe mental diseases that are of special interest in this respect are\nthe so-called idiopathic insanities. Idiopathic is a word we medical\nmen use to conceal our ignorance of the cause of disease. Idiopathic\ndiseases are those that have come of themselves, that is, without\nascertainable cause. As a matter of fact, the most important group of\nmental diseases develop without presenting any alteration of the brain\nsubstance, so far as can be detected by our present-day methods of\nexamination. The initial symptoms of these diseases, then, are of\ngreat importance, and not readily recognisable unless looked for\nespecially. There is no physical change to attract attention, and the\nchange of disposition and mental condition is often insidious and only\nto be recognised by some one who is in the confidence of the patient.\nIt is in these idiopathic insanities, then, that the careful\nobservation of the clergyman is of special significance. Needless to\nsay, powers of observation to be of service must be trained.\n\nWhile there are no known changes in the brain tissues in these\ndiseases, it seems not improbable that the development of our\nknowledge of brain anatomy, which is especially active at the present\ntime, will very soon demonstrate the minute lesions that are the basis\nof these mental disturbances. It seems not unlikely that the\nunderlying cause of so-called idiopathic insanity is usually some\nchange within the brain cells. Hints of the truth of this conjecture\nare already at hand. Meantime the actual observation of this class of\npatients in asylums and institutions, private and public, and the\ncollation of the observations of authorities in psychiatry from all\nover the world, have thrown a great deal of light on these forms of\nmental disease. We know much more of the initial symptoms and of\nincipient conditions that threaten the development of mental {213}\ndisequilibration than we did twenty-five years ago. With regard to\nprognosis especially, recent publications have added considerably to\nour knowledge, although it must be confessed that they have rendered\nour judgment of such cases much less hopeful.\n\nThe ordinary forms of mental diseases have sometimes been considered\nas passing incidents in the lives of patients suffering from such\ndisorders. While it was generally understood that severe cases were\napt to have recurrences, and that after persistence of mental symptoms\nfor a certain length of time the outlook as regards eventual absolute\ncure is rather dubious, yet the general prognosis of such simple\nstates as melancholia or simple mania was not considered to be\ndistinctly unfavourable. Patients might very well recover their mental\nsensibility after even a severe attack, and never have a relapse.\n\nIt was something of an unpleasant surprise to the medical world, a few\nyears ago, when one of the most distinguished authorities in Europe on\nthe subject of mental diseases, Professor Kraepelin, of the University\nof Heidelberg, stated in his text-book of psychiatry, that among a\nthousand cases of acute mania he has observed only one in which the\nsymptoms did not recur. Professor Berkley, of Johns Hopkins\nUniversity, Baltimore, a conservative American authority, in\ndiscussing this subject of relapses after single occurrences of mania,\nis evidently of the opinion that Professor Kraepelin's opinion in the\nmatter presents the inevitable conclusion that must be drawn from\nrecent advances in the clinical knowledge of maniacal conditions.\n\"Simple mania,\" he says, \"is, according to the statistics now at hand,\nan exceedingly rare form of mental disease, and the physician should\ntherefore be cautious in making a prognosis of final recovery.\nRelapses after a number of years, when stability is apparently\nassured, are frequent, as every one interested in mental medicine\nknows only too well.\"\n\nThe more experience the specialist in mental diseases has, the less\nliable he is to give an opinion that will assure friends of the\npatient that relapses may not occur after any form of disturbed\nmentality. While this is true in mania, {214} it is almost more\ngenerally admitted with regard to melancholia. Most patients who have\none attack of severe depression of spirits will surely have others if\nthey are placed in circumstances that encourage the development of\nmelancholic ideas. Any severe emotional strain will be followed by at\nleast some symptoms of greater depression than would be expected from\nthe normal person under the same conditions.\n\nProfessor Kraepelin has pointed out that in about one out of six cases\nthe patients who came to him supposedly for the treatment of primary\nattacks of melancholia proved to be really suffering from a relapse of\nsevere mental depression. The careful investigation of the history of\nthese cases showed that they had suffered from previous attacks of\ndepression, though sometimes these were so slight as not to have\nattracted any special attention from the medical attendant,--if\nindeed one had been called in the case--and at times even failed to\noccasion more than a passing remark on the part of friends with whom\nthe patient was living.\n\nThe most frequent form of idiopathic insanity is melancholia. The\ndisease is characterised by depression of spirits. Professor Berkley's\ndefinition, besides being scientifically exact, is popularly\nintelligible. According to him, \"Melancholia is a simple, affective\ninsanity in persons not necessarily burdened by neuropathic heredity,\ncharacterised by mental pain which is excessive, out of all adequate\nproportion to its cause, and accompanied by a more or less\nwell-defined inhibition of the mental faculties.\" This latter part of\nthe definition is extremely important. In extreme cases patients are\nable to accomplish no other mental acts beyond those which concern the\nsupposed cause of their depression. Their lack of attention to other\nthings is the measure of the mental disturbance. Their minds\nconstantly revolve about one source of discouragement. They become\nabsolutely introspective and their surroundings fail utterly, in\npronounced cases, to produce any reaction in them. In milder cases\nthis involves an increasing neglect of whatever occupation the patient\nmay have, solely for the purpose of giving up time to the\ncontemplation of the cause of his depression.\n\nIt is not easy always to recognise the limits between a {215}\ndepression of spirits that is not entirely abnormal and a\ncorresponding state of mind that is manifestly due to insanity. When\nmisfortunes occur, individuals will be mentally depressed. Sorrow has\nin it necessarily no element of mental alienation. It is only when it\nbecomes excessive that observers realise that there is disturbance of\nthe mental faculties, causing the undue persistence and the\nexaggeration of the grief.\n\nFor example, a mother loses an only son in the prime of manhood and at\nthe height of his career. It will not be surprising if, for a\nconsiderable period, she is unable to take up once more the thread of\nlife where it was so rudely interrupted. For weeks she may react very\nlittle to her surroundings and may prove to be so moody as to arouse\nsuspicion of her mental condition. After a time, however, she begins\nto have some of her old interest in affairs around her. Her depression\nof spirits may not entirely disappear for long years, perhaps never;\nbut her affective state does not go beyond a simple sorrow. On the\nother hand, under the same circumstances, a mother may give way to\ntransports of grief that after a while settle down into a persistent\nstate of dejection. Every thought, every word, every motive, has a\nsorrowful aspect to her. After a time she may begin to think and even\nto state that the misfortune of the loss of her son has come because\nof her own exceeding wickedness. She may consider it a punishment from\non high and think that she has committed the unpardonable sin and\nabsolutely refuse any consolation in the matter. This state of mind is\ndistinctly abnormal, and if it persists for some time must lead to the\npatient's being kept under careful surveillance.\n\nThe immediate cause of the development of such a melancholic state is\nalways some unfortunate event in the course of life. Worry and sorrow\nare important causative factors. Mostly, however, these causes are\nonly capable of producing their serious effects upon the mental state\nof predisposed individuals, or at times when the health of the subject\nis decidedly below the normal. Emotional disturbances are not liable\nto have such serious effects, except when anaemia, or continued\ndyspepsia, or some serious nutritive drain upon {216} the system, like\nfrequently continued hemorrhages, persistent dysenteric conditions, or\ntoo prolonged lactation, have brought the system into a condition of\nlowered vital resistance. Unfortunately, in ordinary life these\nrun-down physical conditions are prone to be associated with the worry\nand overwork that precede disaster.\n\nThe effect of grief as a cause of melancholia may best be realised\nfrom the fact that in something over one-half of all the cases of\nmelancholia the death of a near relative, father or mother, or even\nmore frequently husband or wife, or child, is found in the clinical\nhistory of the patient shortly before the development of the mental\ndisturbance. Serious business troubles, however, loss of property,\nactual want of proper nourishment, failure to succeed in some project\non which the mind has been set, and similar conditions, so common in\nour modern hurried life, are also capable of producing the mental\ndepression that assumes an insane character in certain individuals.\n\nFor the development of melancholia a predisposition seems to be\nnecessary. Most people can suffer the reverses of fortune, the\naccidents of life, and the griefs of loss of friends and relatives,\nwithout mental disequilibration. Certain predisposing factors are well\nknown. Heredity, for instance, is extremely important. Melancholic\nconditions are frequently found in successive generations of the same\nfamily. While heredity is not as prominent a feature in melancholia as\nin other forms of insanity, the direct descent of a special form of\nmelancholic mental disturbance from one generation to another is noted\nmore frequently than in any other form of insanity.\n\nWomen are more often the subjects of melancholia than are men. This is\nespecially true in the earlier and in the later periods of life. In\nthe years between twenty and thirty-five the proportion of cases in\neach sex is more nearly equal. The two conditions, the establishment\nof the sexual functions, that is, the important systemic changes\nincident to puberty, and the obliteration of the sexual function at\nthe menopause, with its consequent physical disturbances, are\nespecially important in predisposing to the occurrence of {217}\nmelancholia in women. Their mental functions are less stable\nnaturally, and are subject to greater physical strains and stresses.\nChildbirth and lactation are also important factors in the causation\nof the condition. Long-continued lactation--that is, beyond the\nphysiological limit of about nine months--is especially a frequent\ncause. The development of the mental disturbance in this case is\nalways preceded by a state of intense anaemia, in which the skin\nassumes a pasty paleness, and other physical signs give warning of the\ndanger. Lactation is sometimes prolonged for no better reason than the\nhope to avoid pregnancy. Usually we may say this method fails of its\npurpose and pregnancy and lactation together work serious harm.\n\nIn young people particularly, homesickness is a not uncommon cause of\nmelancholia. It is especially liable to produce the condition if young\npeople at a distance from home are subjected to serious mental and\nphysical strain at a time when the food provided for them is either\ninsufficient or unsuitable, or when disturbances of their digestive\nsystems make it impossible for them properly to assimilate it. A\nnumber of instructive examples of this condition have occurred in the\nlast few years among our young soldiers in the Philippines. To the\nphysical strain necessarily incident to campaigning, especially in\nyoung men unaccustomed to the life of the soldier, there was added the\nserious trial of the tropical climate and the unusual and not\nover-abundant or varied diet provided by the army rations.\n\nAutointoxication is said to play a prominent role in the causation of\nmelancholia. This supposes that there is a manufacture of poisonous\nmaterials within the system, whose transference to the nervous tissues\ncauses functional disturbance of these delicate organs. Such poisons\nare especially liable to be manufactured when digestive disturbances\nhave existed for long periods of time, or when chronic alcoholism is a\nfeature of the case. The ordinary depressed condition so familiar in\nour dyspeptic friends and that develops so commonly as the result of\nindigestion, is an example of the depressing effect of toxic\nsubstances upon nervous tissues and mental states.\n\n{218}\n\nMelancholia does not develop as a rule without some warning of what\nmay be looked for. Nutritive disturbances are nearly always prominent\nfeatures in the case for some time before any mental peculiarities are\nnoticed. Professor Berkley remarks that a feeling of woe and of\nuneasiness seems to be the way by which the brain expresses its sense\nof the lack of proper nourishment. Usually there has been distinct\ndigestive disturbance for some months. There is apt to be loss of\nappetite. There may be some slight yellowness in the whites of the\neyes. Commonly there has been an increasing disregard for the\npatient's usual habits, especially in the matter of exercise and\nfriendly intercourse. There is a disposition to sit apart and brood by\nthe hour, and a well-marked tendency to avoid friends and even members\nof the family, with an utter disinclination to meet strangers.\n\nOne of the marked features of the disease in women is a tendency to\nuntidiness. Women lose all regard for their personal appearance and\nfail to arrange their clothes properly. Men who have been specially\nneat in their personal appearance take on slouchy, careless habits,\nallow their clothes to become soiled and dirty, and have evidently\nforgotten all their old customs in this matter.\n\nThe symptoms are not always continuous. There is often a rhythmic\nalteration of intensity of symptoms that corresponds more or less to\nthe physiological rhythm of life. In ordinary circumstances human\ntemperature is highest in the afternoon and vital processes are most\nactive at this time. The lowest temperatures occur in the morning,\nespecially in the early hours; and it is at this time that vital\nprocesses are least active and the general condition is most\ndepressed. It is not surprising, then, to find that melancholic\npatients are liable to suffer from deeper mental depression during the\nmorning hours. In suicidal cases it is especially in the morning hours\nthat patients need the closest surveillance.\n\nIn a certain number of cases of melancholia, instead of the quiet,\noften absolute immobility of the patients, there is a form of the\ndisease characterised by the presence of incessant movement and an\nagitated state of countenance, {219} that disclose their disturbed\nmental conditions. In melancholia, as a rule, sleep is very much\ndisturbed, and at times patients do not sleep at all. In the agitated\nform of melancholia, the patient is often quiet only when under the\ninfluence of a sleeping-potion. Patients may tear their hair,\ndisarrange their clothing, strike themselves, hit their heads against\nthe wall, sigh and sob, and repeat some phrase that indicates their\ndeep depression. They are apt to reiterate such expressions as \"I am\nlost,\" \"I am damned.\"\n\nThis is a much more serious form of melancholia than the quiet kind.\nThe mental faculties are much more completely unbalanced, and the\nprognosis of the case is more unfavourable. There may be recovery\nwithin a very short time, and this recovery may be more or less\ncomplete. Usually, however, the condition becomes chronic and runs for\nmany years. Such patients may sometimes be distracted sufficiently\nfrom their state of depression to smile and manifest pleasure in other\nways. Usually, however, this diversion is only temporary and they\nrecur to their darker moods until some new and specially striking\nnotion distracts their thoughts once more.\n\nWith regard to melancholia the most important feature is the tendency\nto suicide. This is apt to be present in any case, however mild, and\nmay assert itself unexpectedly at any moment. Where there is suspicion\nof the existence of melancholia, patients must be under constant\nsurveillance; and, as a rule, they should be under the supervision of\nsome one accustomed to the difficulties that such cases may present.\nPatients are often extremely ingenious in the methods by which they\nobtain the opportunities necessary for the commission of suicide. For\ninstance, a man who has been calm in his depression and has shown no\nspecial suicidal tendencies may make his preparations apparently to\nshave and then use his razor with fatal success. In a recent case in\nNew York City, a woman under the surveillance of a new, though trained\nnurse, asked the nurse to step from the room for a moment. When the\nnurse came back three minutes later, the woman was crushed to death on\nthe sidewalk seven stories below. A male patient asks an attendant\n{220} to step from the room for a moment for reasons of delicacy, and\ntakes the opportunity to possess himself of some sharp instrument or\nof some poison. At times, during the night, patients rise up while\nattendants doze for a few minutes, and find the means to hang\nthemselves without the production of the slightest noise.\n\nThese unfortunate suicides are happening every day. They are the\nsaddest possible blow to a family. Only the most careful watchfulness\nwill prevent their occurrence. Clergymen should add the weight of\ntheir authority to that of the medical attendant in insisting, when\nsuch patients are kept at home, that they shall be guarded every\nmoment. As a rule melancholic patients should be treated in an\ninstitution. Their chances of ultimate complete recovery, and, more\nimportant still, of speedier recovery than at home are much better\nunder the routine of institution life and the care of trained\nattendants.\n\nNearly three-fourths of the patients who suffer from melancholia will\nrecover from a first attack under proper care. Subsequent attacks make\nthe prognosis much more unfavourable. Not more than one-half will\nrecover from a second attack, and, although melancholia is often\nspoken of as a mild form of intellectual disturbance, recurring\nattacks give a proportionately worse and worse outlook for the\npatient.\n\nIf the general condition of the patient, that is, the physical health,\nis very much run down when the mental disturbance commences, then the\noutlook is much better than if the mental disturbance should occur\nwhen the patient is enjoying ordinarily good health. Thin, anaemic\npatients, contrary to what might be expected, usually recover and\noften their recovery is permanent. The first favourable sign in the\ncase is an improvement in physical health. This is very shortly\nfollowed by an almost corresponding improvement in the mental\ncondition. When the patient has reached the normal physical condition,\nthe mental disturbance has usually disappeared.\n\nIt is an extremely unfavourable sign, however, to have run-down\npatients gradually improve in physical health {221} without\ncommensurate improvement in their mental condition. This is nearly\nalways a positive index that the mental disturbance will continue for\na long while, may not be recovered from completely, or may degenerate\ninto a condition of dementia with more or less complete loss of mental\nfaculties.\n\nThe severe forms of melancholia are apt to be associated with\ndelusions. Fear becomes a prominent factor, and the patient is afraid\nof every one who approaches, or concentrates his timidity with regard\nto certain persons or things. Delusions of persecution are not\nunusual, and this sometimes leads to homicidal tendencies. After\nenduring supposed persecution for as long as he considers it possible,\nthe melancholic turns on his persecutors and inflicts bodily harm. The\nsimplest actions, even efforts to benefit the patient by enforcement\nof the regulations of the physician, may be misconstrued into serious\nattempts at personal injury, for which the patient may execute summary\nvengeance. At times the hallucinations take on the character of the\nsupposition that attempts to poison them are being made. The patient\nmay conceal his supposed knowledge of these attempts until a\nfavourable opportunity presents itself for revenging them. On the\nother hand, it is not an unusual thing to have melancholic patients\ncommit homicide with the idea of putting friends out of a wicked\nworld. The stories so common in the newspapers of husbands who kill\nwives and children, of mothers who murder their children, are often\nfounded on some such delusion as this. A mother argues with herself,\nthat her own unworthiness is to be visited on her children, and that\nthey are to be still more unhappy than she is. Out of maternal\nsolicitude, then, but in an acute excess of melancholia, she puts them\nout of existence and ends her own life at the same time.\n\nWhen the melancholia is founded on supposed incurable ills in the\nbody, patients are sometimes known to mutilate themselves, or to have\nrecourse to alcohol, or some narcotic drug, in order to relieve them\nof their pain, which is mostly imaginary, and make life somewhat more\nlivable during its continuance. Alcoholic excesses are especially\ncommon in {222} cases of recurrent or periodical melancholia. Many of\nthe cases of so-called periodical dipsomania are really due to\nrecurring attacks of severe depression of spirits, in which men take\nto alcohol as some relief for their intense feelings of inward pain\nand discouragement.\n\nOne of the most characteristic symptoms of melancholia is the refusal\nto take food. Sometimes this refusal is the consequence of an\nexpressed or concealed desire to commit suicide. In many cases the\nrefusal of food is associated with the patient's melancholic\ndelusions. If the patient is hypochondriac, food is not taken because\nthe stomach is supposed not to be able to digest it, or because it\nwould never pass through the system. At times the delusions are in the\nmoral sphere and the patient is too wicked to eat, or must fast for a\nlong period or perhaps for the rest of life, with the idea of doing\npenance. As a matter of fact the refusal to eat is associated with the\nlowered state of function all through the system, which is the basis\nof the melancholic condition. This causes loss of appetite and\nlowering of the digestive function with a certain amount of nausea\neven at the thought of food, so that it is scarcely any wonder that\npatients refuse to take food. Needless to say, they must be made to\neat. This often requires the insertion of a stomach tube and forced\nfeeding. And as it must be done regularly, it is accomplished much\nmore easily at an institution than at home.\n\nThe other most common type of functional mental disease is mania. This\nis a form of insanity characterised by exaltation of spirits with a\nrapid flow of ideas and a distinct tendency to muscular agitation. It\nis almost exactly the opposite of melancholia in every symptom.\nOriginally, of course, mania meant any form of madness. Then it became\ngradually limited to those forms of insanity which differed from\nmelancholia. Now it has come to have a meaning as an acute attack of\nmental exaltation. It is necessary to remember this development of\nsignification in reading the older literature on the subject of mental\ndisturbance.\n\nProfessor Berkley calls attention to the fact that Shakespeare's\nstatement, \"Melancholy is the nurse of frenzy,\" may have been founded\nupon the observation that there are {223} few cases of mental\nexaltation without a forerunning stage of depression. It is\ncharacteristic of the acuity of observation of the poet whose works\nhave created so much discussion as to his early training, that this\nassociation of mental states, which became an accepted scientific\ntruth only during the last century, should have been anticipated in a\npassing remark in the development of a dramatic character. Melancholia\nprecedes mania so constantly that it is not an unusual mistake in\ndiagnosis to consider a patient melancholic when an outbreak of mania\nis really preparing.\n\nMania is sometimes said to break out suddenly. As a matter of fact\nthere are always preliminary symptoms; though these are of such a\ngeneral nature that they may have escaped observation. The patient's\nhistory generally shows that there has been loss of appetite and\nconsequent loss in weight, commonly accompanied by constipation and\nheadache with increasing inability to sleep. Usually these symptoms\nhave been present at least for some weeks or a month or more. Then the\npatient brightens up. Instead of the brooding so common before, there\nis a tendency to talkativeness; the eye is bright; the expression\nlively; in the midst of his loquacity the patient becomes facetious\nand jocular. The backward before become enterprising. Undertakings are\nattempted that are evidently far beyond the power, pecuniary or\nmental, of the individual. Active employment is sought, and, where\nthis fails, restless to and fro movement becomes the habit.\n\nFriends notice this change in disposition, and also note a certain\nlack of connection in the ideas. There is apt to be a distinct change\nof disposition. A man who has been very loath to make friends before,\nnow becomes easy in his manner toward strangers and takes many people\ninto his confidence. In the severer forms motion becomes constant; the\narms are thrown around; to and fro movement at least is kept up; the\nvoice becomes loud and is constantly used. Patients can not be kept\nquiet, and, as a consequence of their constant movement, their\ntemperature rises and loss of sleep makes them weaker and weaker until\nperhaps physical exhaustion ensues.\n\n{224}\n\nThe causes of mania are not always so distinctly traceable as those of\nmelancholia. Heredity is an important factor. This is, however, not so\nmuch a question of actual direct inheritance of mental disturbance\nfrom the preceding generation, as a family trait of mental weakness\nthat can be traced through many generations. Direct inheritance of\nacquired peculiarities no scientific thinker now admits. Family\npeculiarities, however, are traceable through many generations. So\nstriking a peculiarity as the possession of six fingers or six toes\nhas been traced through a majority of the members of as many as five\ngenerations in a single family. And as has been said other family\ntraits can be traced back in the same way.\n\nIt would not be entirely surprising, then, if mental peculiarities and\na predisposition to mental disturbance should be also a matter of\ninheritance. It is well known now that the physical condition of the\nbrain substance may have much to do with the intellectual functions.\nInjuries to certain parts of the brain may cause special changes even\nof personal disposition. In the famous crowbar case, in which an iron\ndrill over four feet in length was driven through one side of the\nhead, it was noted that the man, who had been somewhat morose before,\nwas inclined to be more amiable afterwards, but also had a tendency to\nbe bibulous in his habits.\n\nGerman clinicians have recently pointed out that the existence of an\nexcess of pressure on the frontal lobes of the brain, such as is\nproduced by the presence of a tumour, may cause a tendency to make\nlittle jokes. This symptom is known as \"Witzelsucht.\" It is considered\nof distinct significance and value in localising tumours of the brain.\nThe question of the type of the witticisms and particularly a tendency\nto obscenity are noted as a special diagnostic aid in the recognition\nof the character of these tumours by at least three prominent German\nmedical observers.\n\nIf modifications of the brain substance can produce changes of\ndisposition and temperament, it is easy to understand how temperament\nand disposition may be a matter of inheritance. If we inherit a\nfather's nose and a mother's eyes, {225} the minutest conformations of\nbrain substance may also be inherited. It is on these, to a certain\nextent at least, that the general outlines of the disposition depend.\nIt would not be surprising to find, then, a disposition to mental\nunsteadiness as the result of the transmission of brain peculiarities.\nHere, as in everything else, there is question, not merely of parental\ninfluence, but of the inheritance of the family traits, some of which\nare skipped in certain generations.\n\nWhen melancholia and mania are said to be due to heredity as one of\nthe principal causes, the meaning intended is that in certain families\nthe brain tissues are liable to be transmitted in somewhat impaired\ncondition, and that through these brain tissues the mind will either\nnot act properly, or under the stress of violent emotion, the loss of\nfriends by death, or the loss of fortune, or serious disappointments\nin life, or a love affair, the already tottering mental condition will\nbe overturned. In a word, it is not the direct transmission of\ninsanity, but of a predisposition to the development of insanity under\nstresses and strains that is a matter of family inheritance. This is\nconsidered true now not only of mental but of all diseases. Not\nconsumption, but the predisposition to it is inherited.\n\nThese considerations make clear how important this matter of heredity\nis. Physicians and students of anthropology are so much concerned\nabout the increase of insanity as the result of the intermarriage of\ndefectives that we are constantly reading in the newspapers of\nattempts at the legal regulations of marriage, so as to prevent\nfurther racial degeneration. Under present circumstances, any such\nlegal regulation is probably impossible; but it seems perfectly clear\nthat clerical influence should be brought to bear to discourage, as\nfar as possible, intermarriage among those of even slightly disturbed\nmental heredity. Especially must any such idea as the possible\nbeneficial influence of matrimony (for there are popular traditions to\nthis effect) be unhesitatingly rejected and it must not be allowed to\ntempt those interested to look on such intermarriage with\nindifference.\n\n{226}\n\nAnother and more serious question for the clergyman is that of the\nvocation in life of those who are weak mentally. By vocation is meant\nnot only religious calling, but the occupation in life generally.\nYoung people of unstable mentality and especially those of insane\nheredity should be advised against taking up such professions as that\nof actor or actress, or broker, or other life duties that entail\nexcitement and mental strain. As far as possible they should be\ndiscouraged from taking up city life, and should be advised to live\nquietly in the country.\n\nMania is apt to follow certain severe infectious diseases in delicate\nindividuals. Pneumonia, for instance, or typhoid fever or chorea, and\nsometimes consumption or rheumatism, may be followed by a period of\nmaniacal excitement. Severe injury to the brain or the pressure due to\nthe presence of a brain tumour, may also be a cause of mania. A\ncertain number of good authorities in mental diseases have called\nattention to the fact that mania is a little more liable to occur in\npatients who are suffering from heart disease. By this is meant in\npersons who have some organic lesion of the valvular mechanism of the\nheart. This leads to disturbance of the circulation and interferes\nwith cerebral nutrition, thus predisposing to functional brain\ndisturbance.\n\nWhile melancholia occurs very frequently in older people, mania is\nalmost essentially a mental disease of the young. The vast majority of\ncases occur between the twelfth and thirty-fifth year. The subjects of\nthe disease are usually those who possess what is called the sanguine\ntemperament, that is, hopeful, enthusiastic people, easily excited and\naroused, easily cast down. Mania is much more common in females than\nin males.\n\nOne of the important characteristics of mania is the super-excitation\nof the sexual faculty. In many individuals the first sign of their\nmental disequilibration noticed by friends is a tendency to sexual\nexcess. This is true of women as well as of men, and the extent to\nwhich this may manifest itself is almost unlimited. At the beginning\nof the disease this symptom is often a source of serious\nmisunderstanding, and may be the cause of family disruption. Usually,\nbefore {227} there are any open insane manifestations, there are\ndefinite symptoms that would point to a pathological excitement in the\nsexual sphere.\n\nOne of the most striking characteristics of maniacal patients is the\nanaesthesia that often develops and is maintained in spite of the most\nserious injury. Because of this, maniacal patients should be guarded\nwith quite as much care as those suffering from melancholia. I have\nseen a patient who, during an attack of acute mania, had put her hand\nover a lighted gas jet, holding it there until the tissues were\ncompletely charred. The burner was behind an iron grating, but she\nsucceeded in reaching it. Neither from this dreadful burning itself,\nnor during the after dressings, did she complain of the slightest\npain. Because of this anaesthetic condition and the consequent lack of\ncomplaint, maniacal patients often suffer from severe internal trouble\nwithout the medical attendant having any suspicion of its existence.\nThere are few conditions that are more painful, for instance, than\nperitonitis, yet maniacal patients have been known to suffer and die\nfrom peritonitis, due to intestinal or gastric perforation, without a\nsingle complaint.\n\nUnexpected death frequently occurs in mania because of the failure to\nrecognise the existence of serious pathological conditions. Pneumonia\nmay develop, for instance, without the slightest complaint on the part\nof the patient and go rapidly on to a fatal termination during the\nexhaustion incident to the constant movement, it being utterly\nimpossible to confine the patient to bed. Meningitis may develop in\nthe same way and proceed to a fatal issue without the patient's making\nany complaint or any sign that will call attention to its existence.\nIn the meantime, the patient may be constantly in the wildest motion\nand so add to the exhausting effect of the organic disease.\n\nThe prognosis of acute mania is not unfavourable. Patients suffering\nfrom a first attack will recover completely in eight cases out of ten.\nNotwithstanding complete recovery, relapses are prone to occur\nwhenever the patient undergoes a severe emotional strain. As a rule\nnot nearly so much mental disturbance is required to produce a second\nattack {228} as the first one, so that patients require great care. In\na certain number of cases recovery is incomplete; persistent delusions\nremain, and there may even be some weakness of intelligence. Paranoia,\nas it is called, mild delusional insanity, may assert itself and then\nmay persist for the rest of life. Notwithstanding this, patients may\nget along in life reasonably well, though their mental condition is\ndecidedly below the normal.\n\nIn a certain number of cases, after the period of excitement\ndisappears, a certain amount of dementia is noticed. This consists of\na distinct lowering of the intelligence, though without the presence\nof any special delusion. This dementia progresses until finally there\nis a state of almost complete obliteration of the mental faculties.\nThe prognosis as to life in cases of mania is very good. Very few\npatients die during an attack of acute mania. At times there is a\ndevelopment of tuberculosis that proves fatal, because of the\nrestlessness of the individual. Pneumonia or typhoid fever may also\nprove fatal.\n\nBesides mania or melancholia, there is a third form of functional\nmental disease, which is a combination of these two forms. It is\nusually spoken of as circular insanity. The patient has usually first\nan attack of melancholia, then an attack of mania, and then after an\ninterval melancholia and mania once more. We have said that most cases\nof mania develop after a distinct stage of depression of spirits, so\nthat successive attacks of mania take partly the character of circular\ninsanity. This latter disease, however, is an index of a much more\ndegenerated mental state of the individual than is either mania or\nmelancholia alone. When it occurs, the prognosis as to future sanity\nfor any lengthy interval is unfavourable. A series of attacks\nalternately of depression and excitement finally make it necessary to\nconfine the patient to an institution.\n\nAs might be expected in this severer form of mental disturbance,\nheredity plays an especially important part in circular insanity. At\nleast 70 per centum of the patients affected show a family history of\ninsanity in some forms. In this disease direct inheritance of this\nparticular form of {229} mental disturbance is noticeably frequent.\nThe patients who develop this form of insanity usually show marked\nsigns of degeneration, even before any attack of absolute mental\ndisturbance has occurred. Wounds of the head, alcoholism, and epilepsy\nare prominent factors in the production of circular insanity. This\nonly means that the predisposition to mental disequilibration is so\nstrong that but very little is required to disturb the intellectual\nequilibrium.\n\nFortunately, circular insanity is rare. In 40,000 cases of insanity in\nNew York State, only 96 cases of this form were noted. Mild types of\nthe disease are not, however, very rare. Many otherwise sane people\nhave alternating periods of hopeful excitement and of discouraging\ndepression, not momentary but enduring for weeks at a time, which are\nreally due to the same functional disturbances that in people of less\nstable mentality produce absolute insanity. These cases are of special\ninterest to the clergyman and to directors of consciences.\n\nJAMES J. WALSH.\n\n\n{230}\n\nXVIII\n\nNEURASTHENIA\n\nNeurasthenia, or nerve-weakness, \"the vapours\" of the old novelists\nand dramatists, is a very common malady, and it gives the clergyman\ntrouble by the turmoil it causes in families, religious communities,\nin themselves, and elsewhere. Whether the condition is a distinct\ndisease or not, and that question has been voluminously discussed, is\nnot altogether an important matter, but that there is such a group of\nsymptoms is unfortunately a weighty fact. It takes so many forms that\nit is bewildering, and therefore not readily reduced to unity.\n\nThe cerebral form often exists independently. There is such a thing as\n\"brain fag,\" although many complainants may have very little material\nfor the fag to work on. Often such a patient is robust, even an\nathlete, and his assertions meet with ridicule or abuse instead of\ntreatment. If the patient is a woman she is not seldom called\n\"hysterical.\" She is not hysterical. Hysteria, by the way, is as\ndistinct a trouble as a broken leg, and far more serious, and not a\nsynonym for perverseness, as the term is popularly used.\n\nIn the cerebral form, business, reading, study \"go into one ear and\nout the other.\" The patient's memory fails him temporarily just when\nhe may need it most, say, in a speech or sermon; a fly buzzing on a\npane is a calamity and a source of profanity; a flat note in the\nchoir-singing is ample reason for doubting the divine origin of the\nchurch, and every petty trouble that whisks its harmless tail across\nhis floor makes him seek the table-top. I have known a whole convent\nof nuns, who were closely shut in, with bad ventilation and a worse\ncook, until all were more or less neurasthenic, almost {231}\ndisintegrated by the presence of a lamb sent in as a pet; not because\nof the bleating or any ordinary reason, but solely because of the\nhideous incongruity and indecency in the fact that the lamb was a\nmale.\n\nThe cerebral neurasthenic makes rash, impetuous changes in his mode of\nlife. He leaves a religious order because the coffee is weak, he\nresigns an important post in a bank because the president uses snuff,\nhe abandons medicine for trade because the curate meddled in the\ntreatment of two of his patients. He takes on anxiety, locks up the\nhouse six times over the same night; meals are eaten in awed silence\nby his trembling children; altogether he is an unmitigated nuisance.\n\nHe may get religious scruples. If he is a priest he takes an hour to\nan hour and a half to say a low mass, and most of that time is spent\nin searching the corporal for imaginary particles or in drying the dry\nchalice. He rereads his breviary until he is exhausted. Because moral\ntheologians say that certain scruples are from the devil, he is\nconvinced that the devil takes a particular interest in his case. The\ndevil did probably take a special interest in his father's or\ngrandfather's lack of scrupulosity, for his condition is commonly a\nresult of alcoholism in an ancestor.\n\nThere are three chief types of neurasthenics: in one class is the\nperson that appears robust, and is really so except in his nervous\nsystem, which lacks a governor. Such patients have little more than a\ntroubled appearance to draw the attention of a chance observer to\ntheir condition.\n\nA second class is made up of eloquent narrators of their troubles.\nThey try all the physicians in turn, then the homoeopaths and\nosteopaths and similar quacks, and they add patent medicines\nprescribed by themselves. They are petulant, capricious, and despite\ntheir apparent energy they accomplish nothing.\n\nThe third class are silent, limp, clammy-handed; they are brought\nagainst their will to see the physician; they are sulky; bitter and\nunreasoning haters; inclined to melancholy. They may have a tendency\neven to suicide, but this is somewhat rare. Neurasthenics are not so\nliable to insanity as is popularly supposed, but such an outcome is\npossible in certain {232} cases. If their vague fears go on into a\nmore or less fixed delusion there is cause for anxiety lest insanity\nresult, but care should be taken here to be sure the delusion is\nreally irremovable.\n\nSome neurasthenics are afraid to cross an open square or a wide\nstreet, others dread any closed apartment. Vertigo is common; so is\ninsomnia. Insomnia is almost a constant symptom. The patient may have\nnaps or he may have uninterrupted vigils. Sometimes there is a heavy\nbut unrefreshing sleep. Sleepless patients are thrown into distracting\nrage by the barking of a neighbour's dog, the howling of cats, or the\ncackling of a successful hen, and they haunt the magistrates' courts\nin efforts to suppress such noises. They put cotton in their ears,\nwear heavy nightcaps, stop clocks, board up windows in search of\nsleep, which is not found.\n\nThese patients commonly have an enduring feeling of weight or\nconstriction in the head, especially at the occiput,--a headache that\nis not actual pain. They also have vertigo, which is independent of\nany aural disease, and this is transient, showing itself on abrupt\nchanges of position.\n\nAnother phase of neurasthenia is spinal. These cases have pain in the\nback and their legs give out. The back-pain is a diffuse ache, or it\nmanifests itself on pressure at certain spots along the spine. There\nmay be severe pain at the coccyx, especially in women. The walking may\nsimulate paralytic forms if hysteria is mixed with the neurasthenia.\nCardiac symptoms are often prominent, especially palpitation, but\nthere is a nervous excitation of the heart rather than any definite\nlesion.\n\nThe gastro-intestinal symptoms are often important. Pain referred to\nthe stomach and acidity are common, the tongue is coated, the faeces\nscybalous. Digestion is torpid. Sometimes there is nervous diarrhoea.\nA list of the belly symptoms described by some neurasthenics is\ninterminable.\n\nWe often find a sexual form, which is the worst of all and the hardest\nto cure. It is commonly connected with masturbation. Such\nneurasthenics are shameless in the description of their nastiness. It\nis better to keep them from marriage unless they are cured, and they\nare not to be foisted off on {233} any one as husband or wife to\neffect a cure. Allbutt says of them: \"I fear that some of our\n'criminal psychologists' are encouraging many sorts of prurient\ndebauchees by dignifying the tales of their vice with the name of\nscience, a course of conduct which is in the worst interests both of\nthese persons themselves and of our own profession. It were a curious\ninquiry how it comes that sexual perversions are so 'scientific' a\nstudy, while the brutalities of the thieves' kitchen or the wiles of\nother pests of society lie in comparative neglect.\"\n\nPhysical, intellectual, or emotional strain can cause neurasthenia\nsuddenly or gradually. Where it comes on without obvious cause there\nis commonly a bad family history of nervousness or alcoholism. Anaemia\nmakes it worse; eye-strain, too, is a provoking factor. In some cases\na renal congestion is the cause. In many cases a lack of restraint,\nbad education, uncontrolled passion, are a marked influence in fixing\nthe neurasthenic habit. A sedulous parent nags at a neurasthenic child\nthat is too weak for exertion until the child's susceptibility to\ncorrection is blunted. Instead of treatment and help the child\nreceives cuffs and abuse, and hell-fire is held up before him until he\ndeems all religious talk dust and ashes. Encouragement will sometimes\ndo more good than all the threats in the _via purgativa_. Nagging\nnever cured anything except a tendency toward virtue, and it always\ndeepens neurasthenia. Be careful in the selection of a confessor for a\nneurasthenic child. Get one that does not believe in kicking a soul\ninto paradise.\n\nThe treatment of neurasthenia is difficult. Traveling about in search\nof health is not advisable. The Weir Mitchell Rest Cure is very\neffective in many bad cases, but it is costly, and if not correctly\napplied it is useless. It is the only cure for some patients. Sea air\nhelps a certain class of neurasthenics, but it makes others worse--it\nis bad for the dyspeptic neurasthenic. A chronic rhinitis, a\nrefractive error of the eyes, a displacement of the uterus, a\ncongested kidney, a floating kidney, a tight prepuce, and similar\nteasing disorders must be cured before the neurasthenia can be\nremoved; often the neurasthenia disappears with this cure.\n\nTraumatic neurasthenia is like simple neurasthenia in {234} most\ndetails. It is called also nerve shock, spinal irritation, railway\nspine. There is always a causative shock or injury, which is followed\nat once or after an interval by the symptoms of neurasthenia. In acute\ntraumatic neurasthenia there may be, in addition to the symptoms\nobserved in simple neurasthenia, high fever, and such a fever has been\nobserved to go as high as 113 degrees Fahrenheit.\n\nAUSTIN OMALLEY.\n\n\n{235}\n\nXIX\n\nHYSTERIA\n\nThe term Hysteria ([Greek text] uterus) has been handed down from the\ndays when physicians thought there was a connection between\nwomb-disorders and the set of nervous symptoms grouped under the title\nhysteria. It is now etymologically meaningless,--men also grow\nhysterical. Briquet found 11 male to 204 female hysterics, and later\nstatistics increase the number of males.\n\nThe disease is not readily definable. The patient is usually a young\nemotional woman, oftenest between 15 and 20 years of age. She commonly\nhas anaesthetic spots on her body, concentric limitations of the field\nof vision, and hystero-genetic zones, or tender points, which, when\npressed, appear to inhibit the hysterical fit. The symptoms enumerated\nhere are not, however, found in every case of hysteria, and it is\ndifficult at times to diagnose the disease.\n\nThe various manifestations of hysteria are (1) apt to come and go\nsuddenly. A severe paralysis that suddenly disappears for a time is\nhysterical; (2) even if they last for years they may be suddenly\ncured; (3) they are dominated more by mental and moral influences than\nare the symptoms of any other disease; (4) we find no organic lesion\nwith which we can connect the symptoms.\n\nThe conditions that bring about hysteria are hysteria in a parent, or\ninsanity, alcoholism, or some similar neurotic taint in an ancestor.\nThere is no direct connection between hysteria and the disorders of\nthe sexual organs.\n\nImmediate causes are acute depressive emotions, shocks from danger,\nsudden grief, severe revulsions of feeling, as from disappointment in\nlove; and, secondly, cumulative {236} emotional disturbance, as from\nworry, poverty, ill treatment, unhappy marriage, or religious\nrevivals. Certain diseased conditions, as anaemia, chronic\nintoxications, pelvic trouble, cause hysteria, or, more exactly, start\nit into activity where it is latent. It is also communicated by\nimitation and it may become epidemic.\n\nAfter the great plague, the Black Death, in the fourteenth century,\nthere were very remarkable epidemics of imitative hysteria in Germany\nand elsewhere. In 1374, at Aix-la-Chapelle, crowds of men and women\ndanced together in the streets until they fell exhausted in a\ncataleptic state. These dances spread over Holland and Belgium and\nwent to Cologne and Metz. It is said that in Metz there were 1100 of\nthe dancers seen at the same time.\n\nThe \"Dancing Plague\" broke out again in 1418 at Strasburg, in Belgium,\nand along the Lower Rhine.\n\n  \"Viel hundert fingen zu Strassburg an\n  Zu tanzen und springen Frau und Mann,\n  Am offnen Markt, Gassen und Strassen;\n  Tag und Nacht ihrer viel nicht assen,\n  Bis ihn das Wuethen wieder gelag.\n  St. Vits Tanz ward genannt die Plag.\"\n\nBeckmann (_Historia des Fuerstenthums Anhalt_. Zerbst. 1710) tells of a\nsimilar outbreak in 1237, wherein nearly a hundred children were\nseized by the disease at Erfurt, and they went along the road to\nArnstadt, dancing and jumping hysterically. A number of these children\ndied of exhaustion. The same infection is often at work in the fury of\na mob, the panic of a beaten army, and it probably was an element in\nthe Children's Crusade.\n\nThe Tarantism so common in Italy from the fifteenth to the eighteenth\ncentury is another example of epidemic hysteria. The Bubonic Plague\nravaged Italy sixteen times between 1119 and 1340, and smallpox was at\nwork when the black death could find no fresh victims. As a\nconsequence of economic disturbance and fear the people were generally\nneurasthenic, and a slight shock was enough at times to set whole\nvillages into hysterical convulsions.\n\n{237}\n\nIn 1787, at Hodden Bridge in Lancashire, England, a girl in a cotton\nmill threw a mouse upon another girl that had a great dread of this\nanimal. The frightened girl was thrown into a hysterical convulsion\nwhich lasted for hours. The next day three girls that had watched her\nwere in convulsions, the following day six more, and two days later\nfourteen more girls and a man were in fits. American white and negro\ncamp-meetings result in similar outbreaks, and the French\n_Convulsionnaires_, who did outrageous things from 1731 to 1790, were\nalso afflicted with imitative hysteria. The Cornish Jumpers, founded\nin 1760 by Harris Rowland and William Williams, and the American\nBarkers were also hysterical. The Barkers in the meetings would run\nabout on all fours growling, \"to show the degeneration of their human\nnature,\" and they would end in almost general fits of imitative\nhysteria.\n\nThere was an epidemic of hysteria in Tennessee, Kentucky, and a part\nof Virginia, which began in 1800 and lasted for a number of years. It\nstarted at revivals. The majority of the cases were in persons from 15\nto 25 years of age, although it was observed in every age from 6 years\nto 60. The muscles affected were those of the neck, trunk, and arms.\nThe contractions were so violent that the patients were thrown to the\nground, and their motions there exactly resembled those of a live fish\nthrown out of the water upon the land.\n\nThere are numerous theories formulated to explain hysteria; some are\ningenious, especially that of Janet, but none is convincing.\nConvulsions, tremors, paralyses of various forms and degrees are\ncommon in hysteria. In major hysteria the patient falls into a\nconvulsion gently. There is checked breathing, up to apparent danger\nof suffocation. Then follows a furious convulsion, even with bloody\nfroth at the mouth, but there is a trace of wilfulness or purpose in\nthe movements. Next may come a stage of opisthotonos, where the body\nis bent back in a rigid arch till the patient rests on her heels and\nhead only, and this is followed by relaxation and recurrence of the\ncontortions. An ecstatic phase succeeds this, at times in the\nso-called crucifix position, with outbursts of various emotions, and a\nfinal regaining of a {238} normal state. Any of these stages, however,\nmay constitute the whole fit.\n\nIn minor hysteria there is commonly a sensation of a rising ball in\nthe throat (the _globus hystericus_). There may be uncontrollable\nlaughter or weeping. Muscular rigidity is frequently found. The\npatient, especially if she is a child, may mimic dogs and other\nanimals. The snarling, biting, and barking of false hydrophobia are\nhysterical; these symptoms do not occur in real hydrophobia.\n\nThere are almost innumerable physical symptoms of the disease, which\nare chiefly of medical interest, but the mental phases are such as to\ninvolve questions of morality. The hysterical character is marked by\nan overmastering desire to be an object of general sympathy,\nadmiration, or interest, rather than by a tendency to baser\nindulgence. The will is weak, the emotions explosive, the patient is\nimpulsive and lacking in self-control. She is a \"giggler,\" who goes\nfrom absurd laughter into floods of tears. The desire for sympathy and\nattention makes the patient exaggerate her symptoms or simulate\ndiseases and conditions that do not exist in her case. Hysterics will\nswallow pins or stick them into their flesh to force attention.\nSometimes the simulation of disease is not willed. If there are a\nnumber of hysterical girls in a hospital ward and one develops, say, a\npeculiar paralysis, within two or three hours every hysterical woman\nin the room will have the same paralysis,--not pretended, but real,\nalthough temporary. It must be remembered that the disease, with all\nits perversity, is as much a fact as pneumonia, and the element of\nsham is only one of its symptoms. Some authorities go so far as to\nhold that a woman who will not lie is not hysterical. They invent most\nextraordinary slanders against even their own immediate family, and it\nis never prudent to believe an accusation made by an hysterical\npatient, no matter how plausible the story.\n\nAcquired hysteria in many cases may be cured, but the congenital\ncondition is practically hopeless, yet the latter kind may be kept\nfrom violent outbreaks.\n\nWe can not prevent drunkards, epileptics, and lunatics from\npropagating their kind, and therefore we shall still have the {239}\nhysteric with us. The child that has a bad ancestry and shows\nhysterical tendencies should be carefully reared. If it has an\nhysterical father or mother it should, if possible, be removed from\nthis evil influence. Keep it from long hours of mechanical work that\nleaves opportunity for dreaming. Shut out novels and \"art for art's\nsake,\" especially music. Give it a practical education. Teach it\nobedience, self-control, and truthfulness. Harden its will by exercise\nat things it does not like, and do not coddle it. Do not marry off an\nhysterical girl to cure her. Do not inflict her presence upon some\nunfortunate young man because he is a good citizen. Marriage will not\ncure hysteria,--the worst cases are married women, and they beget\nother hysterics in spreading succession.\n\nWhen the disease shows itself offer no sympathy,--do not try to put\nout a fire with oil. When a \"good, pious girl\" grows hysterical, the\nchief obstacles to her cure are untactful and sympathetic visits from\nfriends, lay and clerical. A visit from the pastor, because of his\nimportance, is always harmful, and if the bishop drives up in his\ncarriage so that the neighbours may see him, all the physicians in the\ncity can not help her. If you wish to keep an hysterical girl in her\nvapours, get her a physician that will grow excited over her, take the\ndear child out of school and weep above her couch, let the family and\nits friends assure the unfortunate attending physician in her presence\nthat he is heartless, and she will stay hysterical to her soul's\ncontent.\n\nIf you wish to control the attack, or even remove the disease under\ncertain conditions, call in an experienced physician, leave the\ntreatment to him, and pay no attention to her. Do not make light of\nthe disease, do not speak of it at all. There are attacks that may be\ncured by the razor-strop or a bucket of cold water, but these are\nexceptional. They are new cases or old professional offenders. Rough\ntreatment is not so good as patient tact, but at times roughness is\nthe only cure.\n\nAUSTIN OMALLEY.\n\n\n{240}\n\nXX\n\nMENSTRUAL DISEASES\n\nMenstruation is a periodic discharge of blood from the uterus and the\nFallopian tubes. It occurs every twenty-eight or thirty days, and it\nlasts from puberty to the menopause, or the cessation of the\nmenses,--about the forty-fifth year of age.\n\nThere is a connection between menstruation and the production of the\nhuman ovum. During the first stage of menstruation the mucous membrane\nlining the uterus swells to twice or thrice its normal thickness, and\nthis growth is a preparation for the reception of the ovum, which, as\na rule, is given off by one of the ovaries at this time and passes out\ninto the uterus. Menstruation and ovulation ordinarily occur\nsimultaneously, but they may be independent and take place at\ndifferent times. If, during this stage, the ovum is impregnated,\npregnancy begins, and menstruation ceases until some time after\nchildbirth. In married women conception is more likely to be effected\nduring the first stage of menstruation than during the interval of\nquiescence; the contrary is almost the exception. Impregnation,\nhowever, is likely to occur in the spring more than at other seasons,\nand this fact coincides with the advent of spring in various\nlatitudes.\n\nIf the ovum is not impregnated, the material that made the uterine\nmucous membrane thick during the first week of menstruation\ndegenerates and passes off, constituting the menstrual flow. This\nstage lasts about five days. A reparative period of about four days\nfollows, and then a period of quiescence until the next menstruation\ncommences.\n\nMenstruation is first observed about the fourteenth year, but it may\nstart earlier or later. In general, it comes on {241} earlier in warm\nclimates, and later in the extreme north. The menstruation, too, is\nlikely to show sooner in the labouring classes than in girls who do\nnot work.\n\nEven in normal menstruation there is often a marked physiological\nexcitation which affects the entire person. Very commonly a nervous\ndisturbance and sensitiveness are observed, and in women that are not\nrobust there may be mental depression and irritability. The\ntemperature will rise a half degree, and drop to the normal height on\nthe day preceding the flow.\n\nThere are derangements of menstruation which are symptoms of various\ndiseases. Amenorrhoea is an absence of menstruation in conditions\nother than pregnancy or lactation. Absolute amenorrhoea is a complete\nabsence of menstruation for several months; relative amenorrhoea is\ndelayed, scant menstruation.\n\nAmenorrhoea is common during convalescence from acute diseases; it is\nalso a result of chronic diseases of the liver, stomach, intestines,\nkidneys, and especially of the lungs; it complicates anaemia, malaria,\nrheumatism, and other general pathological conditions. Fright, grief,\ngreat anxiety, mental shock cause amenorrhoea; so do homesickness and\nmany forms of insanity.\n\nThere are also local causes of this condition: imperfect development\nof the uterus or the organs connected therewith, and inflammations of\nthese organs or of the pelvic wall.\n\nOpposed to amenorrhoea is menorrhagia, or an excessive menstrual flow.\nMetrorrhagia, or hemorrhage from the uterus at any time, is a term\nconfounded with menorrhagia, which is an inordinate menstrual loss of\nuterine blood, but the distinction is not important. Menorrhagia and\nmetrorrhagia commonly have an identical cause and they frequently\ncoexist. They are found in chronic diseases of the heart, lungs,\nliver, and other organs; they are an outcome of prolonged lactation,\nand of local affections of the uterus and its appendages. Any\ncondition also that deranges the blood may cause menorrhagia or\nmetrorrhagia; so do malignant tumours of the uterus, uterine\ndisplacements, lacerations that {242} occur in childbirth, and\npsychical influences, as fright, anxiety, and other strong emotions.\n\nDysmenorrhoea, difficult or obstructed menstruation, is a term used\nfor menstruation accompanied by pain. This is a common menstrual\nderangement, and it may be neuralgic or inflammatory in origin, or it\nmay be caused by obstruction to the menstrual flow. There is another\nvariety of dysmenorrhoea, called membranous, in which the superficial\nlayer of the uterine lining is cast off partly or wholly.\n\nIn the neuralgic form the uterus and its appendages are normal in\nappearance, but the pain recurs monthly, and it may have degrees from\nmere discomfort to agony. This form is characterised by reflex\nheadache, sympathetic nausea or vomiting; and the pain may not be\nconfined to the uterus and its appendages. The irritation often brings\nout latent hysterical phenomena, spinal irritation, and neurasthenia.\nRheumatism and gout are predisposing causes, so are indolence, lack of\nphysical exercise, light clothing in cold weather, forced school work\nand similar depressing agents.\n\nIn the neurotic variety of dysmenorrhoea pain often persists after the\nmenstrual flow has set in, but in inflammatory dysmenorrhoea the flow\nrelieves the pain or removes it. Marriage commonly removes the\nneurotic form of dismenorrhoea.\n\nIn obstructive dysmenorrhoea the menstrual fluid is retained by narrow\nor tortuous outlets, flexions of the uterus, and similar causes. The\nprognosis is good in all forms of dysmenorrhoea, but frequently long\nand skilful treatment is required to cure such conditions, especially\nthe membranous form. Inflammatory, obstructive, and membranous\ndysmenorrhoea are commonly made worse by marriage.\n\nAt the end of the childbearing period menstruation gradually ceases.\nIn temperate climates this menopause occurs about the forty-fifth\nyear, but it may come earlier or considerably later. Work that keeps a\nwoman in a heated atmosphere, as cooking, washing, and baking,\ndisturbs menstruation and tends to advance the menopause. Workers in\nchemical factories, in badly ventilated rooms, or women that do heavy\nlabour in the open air, are apt to age prematurely, and have {243} an\nearly menopause or \"change of life.\" This premature climacteric is\nfound also in women that bear many children in rapid succession.\n\nAt the menopause there may be various physical or mental disturbances\nwhich are probably due more to the somewhat abrupt advent of old age,\nat the cessation of the childbearing part of life, rather than to the\nmenopause itself. It is a fact, however, that often profound\ndisturbances coincide with the climacteric, and we know no sufficient\ncause for them if the menopause itself may not be deemed such.\n\nThere are numerous disorders of the nervous system in women which are\ndependent directly or indirectly upon a derangement of the pelvic\norgans. Distant parts of the body are affected pathologically through\nsympathetic irritation when the primary disease is in the pelvic\norgans, and direct treatment of the pelvic trouble alone cures these\nreflex conditions. The very common disorders of pregnancy, the marked\nphysiological changes in women at the beginning of menstruation with\npuberty, and its cessation with the menopause, are among the first\nproofs of this assertion that occur. Menstruation may aggravate\ngoitre, uterine fibroid tumours, skin diseases, and affections of the\nblood vessels. Disordered menstruation causes sleeplessness,\nmelancholy, dementia, and mania, by affecting the brain; it may bring\non local paralysis; start up latent epilepsy; excite reflex cough and\ndifficulty in breathing; make the heart irritable; cause nausea,\nvomiting, dyspepsia, flatulence, diarrhoea, skin-inflammations, pain\nin the joints, and many other symptomatic phenomena.\n\nChorea (\"St. Vitus's Dance\") is caused by various irritatations, and\ndysmenorrhoea can be such a cause. If a person is disposed to hysteria\nby neurotic inheritance, idleness, sedentary habits, vicious\npractices, excessive development of the emotions, any affection of the\nuterus or its appendages will greatly aggravate the outbreaks. The\nsame is true in neurasthenia; and uterine disorders can directly cause\nneurasthenia, a condition described in another chapter. Migraine is an\nextremely severe form of headache which arises from various\nexcitations, and uterine disturbances are among the causes.\n\n{244}\n\nInsanity frequently appears in women at puberty, soon after marriage,\nduring pregnancy or lactation, and at the menopause; at these periods\ndisposed women are especially prone to outbreaks of insanity.\nIrritation and exhaustion from diseases of the pelvic organs are\npotent factors in bringing on insanity, although these conditions may\ncoexist independently of each other. Symptoms should not be mistaken\nfor causes, but pelvic diseases at least aggravate a tendency toward\nmental unbalance.\n\nIn an article like this it is not expedient to speak of treatment, but\nthe conditions are described in outline so that the spiritual adviser\nmay recognise the need of medical aid and suggest its employment. A\nwoman suffering from pelvic disorders should be relieved from a\nlabourious or responsible office until she has been cured of her\ndisease, in her own interest and especially in the interest of those\naffected by her condition.\n\nAUSTIN OMALLEY.\n\n\n{245}\n\nXXI\n\nCHRONIC DISEASE AND RESPONSIBILITY\n\nIt is often of great practical importance to bear in mind that a\nnumber of affections, commonly not serious in themselves at the\nbeginning, and sometimes giving very few external symptoms, may make\nthe mental condition of the individual suffering from them utterly\nincapable of meeting grave responsibilities. This is especially true\nwith regard to such positions as that occupied by the Superior of a\nreligious community who may, during the course of an ailment that has\na tendency to affect the mental condition, do things that involve the\ncommunity financially, or make life so uncomfortable for their\nsubjects as to cause them to abandon the religious life. Some of these\nailments are very insidious and may develop utterly apart from all\nanticipation in persons that were previously healthy. The weight of\nresponsibility itself may, by impairing the general health, bring on\nan aggravation of a previously mild chronic condition that will cause\ndistinct mental deterioration, yet without the absolute production of\nsuch disturbance of intellection as will be readily recognised by\nthose that are not brought intimately in contact with the individual.\n\nSuch cases are not uncommon in history. A distinguished specialist in\nmental diseases called attention, in the London _Lancet_ not long ago,\nto the case of Nicias, the Greek general who was in charge of the\nAthenian expedition against Syracuse. Nicias undoubtedly had a genius\nfor war and for politics when in normal health. Some of the mistakes\ncommitted by him, though, are of an order that indicate a lapse of\nmental control at certain times. Details given by a number of Greek\nhistorians point to the existence in Nicias of {246} symptoms of\nchronic nephritis, which at periods of great responsibility became\nexacerbated with consequent interference with normal intellection. The\nsame authority points to certain otherwise inexplicable political\nmistakes in the life of Napoleon III. as due to the existence in him\nof a low-grade nephritis, consequent upon the presence of stone in the\nkidney. After his abdication, during his life in England, he had to be\noperated upon for this condition, and the calculi found had manifestly\nbeen in existence for many years.\n\nEven more important for the sake of the individual himself than for\nthose he is in contact with is the recognition of his pathological\ncondition. Nothing is more likely to cause kidney disease to grow\nrapidly worse than responsibilities heavier than the individual is\naccustomed to. When, then, there are symptoms of nephritis it is\ninadvisable for the patient to be made Superior, and if the symptoms\ndevelop after his appointment or election he should be relieved of his\nresponsibilities, at least to a considerable degree. There are a\nnumber of cases on record in which failure to realise the necessity\nfor this mode of action has been a cause of great unhappiness in\nreligious communities, and not infrequently a shortening of a very\nprecious life that might otherwise have been spared for long years of\nusefulness in some less demanding position. It is not impossible that\nparesis should develop in the Superior of a religious community. The\ndisease is extremely rare among clergymen generally, and the\nstatistics of asylums show that it is rarest of all among Catholic\nclergymen. Should it occur, however, it must constitute a quite\nsufficient reason either for a change of Superiors, or for the\ninstitution of such other safeguards as may, according to the special\nreligious institute, be provided in order to prevent serious evil.\n\nIn the religious communities of women, particularly, it has seemed to\nus that the occurrence of Graves' disease (the affection is three\ntimes more frequent in women than in men) in a Superior should always\nbe the signal for relieving her of the responsible duties of her\nposition. This action is quite as necessary for the patient's own\nhealth as for the peace and happiness of the community. The disease\nmay exist in a {247} latent form and only develop strikingly after the\nassumption of the serious responsibilities of the position of\nSuperior. When, however, the eyes are prominent, the pulse rapid, and\nthe goitre, or swelling of the front of the throat, characteristic of\nthe disease, is present, there are practically always mental symptoms\nthat make it extremely inadvisable for her continuance in a position\nof serious responsibility. Professor Church of Chicago (Professor of\nNervous and Mental Diseases and of Medical Jurisprudence, in the\nNorthwestern University Medical School), in the last edition of his\nbook on _Nervous and Mental Diseases_,   [Footnote 5] has this to say\nwith regard to the mental disturbances of Graves' disease:\n\n  [Footnote 5: Nervous and Mental Diseases. Church and Peterson, 4th\n  edition. Saunders, Phila., Pa., 1903.]\n\n\"From the beginning, and often for a long period antecedent to the\nappearance of cardiac symptoms, the subjects of Graves' disease\npresent a considerable mental erethism. There is an indefinable and\ntormenting agitation, marked by mental and motor restlessness and an\nimperative and impulsive tendency to be doing. Their emotions are too\nreadily excited, and they are unusually impressionable and irritable,\nreacting in an exaggerated manner to all the incidents of daily life.\nIn more pronounced cases they become voluble and manifest the greatest\nmobility of ideas, but have no persistent concentration of logical\norder. Their affections are likely to undergo modifications, and they\nbecome irascible, fault-finding, inconsiderate, ungrateful, and hard\nto live with. In some instances this disturbance of mentation carries\nthem over the border into active mania, marked, perchance, by\ndelusions of fear, due to the cardiac symptoms of sensations of heat.\nInsomnia is often added and the fitful sleep is disturbed by\nhorrifying dreams that are likely to be projected into the waking\nmoments and woven into delusions which are usually unsystematised, and\nconstantly changing, furnishing the analogue of the motor\nrestlessness. Hallucinations of sight and hearing are not uncommon.\n\n\"The mental perturbance only rarely reaches the degree of actual\nmania, and then is, perhaps, equally dependent upon numerous other\ncauses acting in a neurotic individual. But {248} a condition of\nabnormal mental stimulation is characteristic of the malady, and is as\nimportant an index as any of the cardinal triad.\"   [Footnote 6]\n\n  [Footnote 6: Of physical symptoms, namely, the rapid heart, the\n  prominent eyes, and the enlargement of the thyroid gland in the\n  neck.]\n\nDr. Church considers, then, that the mental symptoms of the disease\nare as important a concomitant, and as little likely to be absent in\nany given case, as are any of the three or four well-known physical\nsymptoms characteristic of the disease. Under these circumstances the\nnecessity for the exercise of care in permitting such a patient to\ncontinue in the office of Superior must be manifest. It is a question\nnot for religious authorities to decide but for physicians, and they\nare to be experts in mental diseases. There are many physicians who\nhave had experience with cases in which Graves' disease has been a\nsource of unfortunate conditions in religious life, owing to the\nfailure to understand the relations of the physical affection to\nmental disturbances. At times unfortunate consequences follow that are\nirretrievable in the destruction of vocations and the impairment of\nthe religious spirit in communities.\n\nAs a rule it may be said that the development of serious disease is\nalmost sure to incapacitate a Superior from fulfilling the functions\nof office. This is true, however, not only for physical disease but\nfor the so-called neuroses. These are maladies which have their basis\nin some disturbance of the physical constitution, though this is not\nalways easy to find. We prefer to speak of them as neuroses rather\nthan neurasthenia, because this latter name has somehow come to have\nan unwelcome sound and to carry with it the idea of imaginary rather\nthan real ailments. A true neurasthenic, however, is supremely to be\npitied.\n\nIt has often been noticed that such individuals, while perfectly\ncapable of judging properly for others, are not able to form right\njudgments with regard to their own conditions. This principle,\nhowever, should not be taken as a rule, and it must not be forgotten\nthat neurasthenics are often the subjects of compulsory\nideas--so-called obsessions, in which they are not entirely\nresponsible for actions performed. At such {249} times they are prone\nto be irritated by very trivial faults, and what is worse, to\nexaggerate slight defects into serious infractions of rule or of\nobedience. With regard to such persons, therefore, constant care has\nto be exercised to control their statements by those of others and not\nto take them at their full value without due substantiation. In this\nmatter the subject is quite as likely to suffer as the Superior, and\ninformation obtained from them should not be acted upon without\nconsultation with others who know the details of the case.\n\nAs a rule neurasthenic individuals become, as is well known, worse as\nfar as the mental condition is concerned when they are asked to assume\nnew responsibilities. This physical side of the choice of Superiors,\nand of those to be elected by members of the community, should always\nreceive due attention, though sometimes it is entirely lost sight of.\nNot a few communities, however, have suffered in their usefulness and\nin the fulfilment of the design of their institute by the selection of\nSuperiors whose neurotic conditions sometimes seemed to proclaim a\nhigh degree of piety, which was, however, rather emotional than\npractical. The physician's view of some of these cases would add\nmaterially to the knowledge of the character of such individuals.\n\nIt should in general be very clear that the development of any serious\nnervous disease, which is not likely to be cured by ordinary remedies\nor which requires freedom from responsibility as the first requisite\nfor improvement, should be the signal for consideration as to a change\nof Superiors. Physicians see much more of the evil that may be worked\nin this way, and realise the true significance of what is often a sad\nstate of affairs, much better than those who have not the secret of\nthe cause of the unfortunate condition. It is almost needless to say\nthat the question of obedience to some one whose responsibility is not\ncomplete, but is influenced by neurotic disturbance, becomes an\nextremely difficult problem for the subject, and one in which there is\napt to be the feeling that it was not the original intention of his\nobligation of obedience to bind him under such circumstances.\n\nWith regard to women especially, it must be remembered that there is\nfor them a period between the ages of forty {250} and fifty, during\nwhich for several years they are extremely unsuited for the\nresponsibilities and exacting duties of a Superior. These years prove\neven to mothers of families, surrounded only by their own children and\nthe ordinary circumstances of home life, a time of worry and\nirritation that plays sad havoc even with the best of dispositions.\nMothers constantly complain to their physicians of an irritability of\ntemper which they can scarcely account for, and which makes them do\nand say things which they are extremely sorry for afterwards. It is\neasy to understand, then, that a Superior with still more insistent\nduties when brought in contact with a number of persons, some of whom\nare almost sure not to be entirely sympathetic, is likely to suffer\nfrom irritation that is not a sign of absence of a fitting religious\ndisposition, but only a physical manifestation of the physical strain\nthrough which she has to pass at this time of life. The years of the\nmenopause, to be very plain, should not be allowed to make a\nSuperior's life miserable and to add to the difficulties that a\nreligious community always has to face in its relations to its\nSuperior and to one another. Charcot, the distinguished French\nneurologist, used to say that women should never be asked to assume\nspecial responsibilities during the days of their monthly period, for\ntheir judgments are often warped by their physical condition. It is\ndoubtful whether, in the majority of normal women, this is quite true,\nthough the expression deserves to be remembered. There is no doubt,\nhowever, that the years of the change of life do bring on very serious\nmodifications of the character of the individual, and occasionally\nthese changes are lasting.\n\nJAMES J. WALSH.\n\n\n{251}\n\n\nXXII\n\nEPILEPSY AND RESPONSIBILITY\n\nFrom the very earliest times epilepsy has been looked upon as a\nmysterious and in many ways an inexplicable disease. The Romans spoke\nof it as the _malum comitiale_, the comitial disease, because if an\nattack of it occurred during the meeting of the Roman people known as\nthe _comitia_, in which municipal officers were elected and other city\nbusiness transacted, an adjournment was at once moved, and no further\nproceedings were considered valid. During more modern times,\nespecially during the middle ages, and almost down to our own time,\nthose affected by the disease frequently came to be looked upon as the\nsubjects of possession by the devil. Hysterical manifestations were\neven more frequently considered signs of possession (diabolical\nmanifestations) but even in our time it is not always easy to make the\ndistinction between certain forms of hysteria and epilepsy. Many of\nthese sufferers were considered as not responsible for their actions.\nIn this respect, at least, the advance of modern medical science has\nonly served to confirm the popular impression of less sophisticated\ntimes, and it has come to be recognised that quite a large number of\nthe sufferers from epilepsy must be deemed lacking in responsibility.\n\nThere are few nervous diseases that have been more studied than\nepilepsy, and yet, because the ailment involves so intimately the\nrelations of the nervous system and the bodily function, there are few\ndiseases of which less definite opinions can be given. This is\nespecially true as regards prognosis and the question of mental\ndeterioration in any given case. As a matter of fact the extension of\nour knowledge of epilepsy, far from making the question of the\nresponsibility of the {252} epileptic under trying circumstances more\neasy of solution, has rather served to show how difficult this problem\nmust ever remain.\n\nThere are many forms of the disease,--the frank epileptic convulsion\nin which patients fall down, are seized with certain convulsive\nmovements, become pale and lose consciousness for a time and then come\nto with an intense feeling of weariness which usually prompts them to\nsleep for some hours--too familiar to need further description. There\nare forms of epilepsy, however, quite different from these. In some\ncases, the attacks occur only at night, and unless the patient happens\nto be watched for some reason, there may be no trace of their\noccurrence, except perhaps a sore tongue where it has been bitten, or\nan intense feeling of weariness and depression in the morning. In\nstill other cases, the physical signs are lacking almost entirely.\nThere may be only a momentary loss of consciousness. A distinguished\nprofessor of medicine in this country used to have a momentary attack\nof confusion, during which he lost the thread of his discourse, and\nalways within a minute, with a somewhat flushed face, he was able to\ngo on, though he had to begin with another idea. The so-called psychic\nepilepsy, in which the symptoms are entirely mental and consist of\nsome marked change of disposition for a time, are now universally\nconceded as constituting well-marked phases of the disease. Curiously\nenough it is with regard to these obscure cases, uncomplicated by\nserious physical manifestations, that there is most mystery; and they\nseem to affect the mentality and to disturb volition and\nresponsibility more than the supposedly severer forms which cause\nconvulsive attacks and are so easy of recognition.\n\nCertain forms of masked or psychic epilepsy constitute the most\npuzzling problem that the expert in nervous and mental disease has to\ndeal with where criminal acts are performed, apparently without\nsufficient motive, and yet where the limits of responsibility must if\npossible be determined. It is easy to dismiss these cases and to\nconsider that because a certain amount of intelligence has been\ndisplayed in the performance of the act, and because the patient\nordinarily understands perfectly the distinction between good and\nevil. {253} that therefore the will must have been entirely free in\nthe accomplishment of the criminal action and the intellect must have\nunderstood what it was doing. As yet the general public refuses to\ntake the standpoint of the expert in mental diseases in many of these\ncases; and only when clergymen also shall come to a realisation of the\npathological elements undermining free will in these cases, that\njustice will be properly tempered, not by unworthy or misplaced\ncharity, but by the mercy which, knowing all, has learned duly to\nappreciate what is and what is not criminal.\n\nEpilepsy, in certain of its obscurer forms, is responsible for many\nconditions in which there is a sudden access of insane excitement of a\nviolent, often very impulsive, character, though sometimes of very\nshort duration. During this state the patient is practically\nirresponsible, and yet he may have sufficient control over his actions\nto enable him to work serious harm. Such a stage of excitement may\nlast not more than an hour or two; usually all trace of it passes off\nin a day or two; before and after it the patient may be in perfectly\nsound sense and in apparently good health. One of our best authorities\nhere in America, Berkley, in his treatise on _Mental Diseases_, gives\nthe following striking opinion on this subject.\n\n\"The subject of masked epilepsy and the consequent mania is replete\nwith interest to the physician and the jurist, since such patients are\nprone to impulsive acts of violence and automatic states in which the\nmost complicated, but entirely unconscious, actions and crimes may be\ncarried out without premeditation on the part of the sufferer, being\nalso out of all accord with his character during his intervals of\nmental health. Besides the irritability, impulsiveness is an equally\ncharacteristic feature. No form of insanity more frequently gives rise\nto assaults and murder than epilepsy, and in no form of alienation is\nthe physician so frequently called to the witness stand to determine\nthe responsibility of the criminal.\"\n\nOne of the most prominent features of all epilepsy is the well known\ntendency to irritability that characterises sufferers from the\ndisease. This of itself is an index of the fact that {254} their\nresponsibility is somewhat lessened, since they are unable to\nwithstand even the petty annoyances of life without exaggerated\nreaction. Friends of epileptics know very well that it is a\npreliminary symptom of the coming on of an attack of epilepsy for the\npatients to become even more irritable than usual. Just after the\ncomatose condition which follows an attack of epilepsy patients are\nalso prone to be very irritable. An attack of epilepsy is really an\nexplosion of nerve force, for no rational purpose, along motor nerves.\nThis same tendency to an unwarranted explosion of energy is liable to\noccur along other nerve tracts that rule the patient's disposition.\n\nThe main symptom of importance in the case, and the one on which\ndepends the recognition of the existence of the epileptic condition,\nis the actual occurrence of typical epileptic seizures. These do not\nalways occur. Sometimes the periodic attacks take the form of what are\ncalled epileptic equivalents, that is, certain anomalous states of\nconsciousness or disposition, which can be accounted for only on the\nsupposition that there is some more or less latent explosion of nerve\nforce in progress. At times even so simple a condition as migraine so\nnearly simulates epilepsy of the psychical type, because of its\ncomplications and sequelae and the regularity with which it occurs,\nthat it has been spoken of as an epileptic equivalent. There is no\ndoubt that, in successive generations, epilepsy and migraine may have\na relation to one another that is something more than merely a\ncoincidence.\n\nA very interesting feature of epilepsy for confessors and spiritual\ndirectors is the tendency to religious emotionalism which so often\naccompanies what is called idiopathic epilepsy. This means epilepsy\nthat develops without a direct cause, and which is evidently dependent\non some essential defect of the nervous system of the individual. In\nasylums epileptics that have become irrational are known for their\nreligious manifestations, and very often for perversion of their\nreligious tendencies. As has been well said, an epileptic may carry\nhis Bible under his arm, read passage after passage from the\nScriptures, sing psalms continuously, and yet be so {255} ungovernable\nas to be a nuisance, and so irritable towards his fellow patients and\nattendants as to be a constant source of worriment. He may read just\nthose passages which have reference to love and charity for one's\nneighbour and dwell on them until they become a bore by repetition,\nand yet in a moment of irritation implore to be allowed to get hold of\nsome deadly weapon in order to kill the usually inoffensive person who\nhas done him some imaginary injury.\n\nThis last is a marked feature of the disease, for epileptics are prone\nto foster fancied grudges, and to consider without due reason that\nthey have been ill treated. This is especially true with regard to\ntheir relatives or to those in attendance on them, and must be always\nborne in mind when the subjects of epilepsy bring tales of woe and\npersecution, which they pour out to anyone who will listen to them,\nand especially to anyone whom they think will set them right. These\nfancied wrongs are as real to the patients themselves as if they had\nsuffered from actual maltreatment. The idea of revenge may easily\nobtrude itself. It can be kept under control, as a rule, during\nordinary health, between attacks, but just preceding or after an\nattack it may very well become of the imperative character that sets\nan uncontrollable impulse at work.\n\nOn the other hand, no class of patients is apt to exhibit the low\ncunning of the insane in so marked a degree as the epileptic. Not only\nthis, but even during ordinary health between attacks they may, owing\nto their disposition, plan cunningly to simulate some of the symptoms\nof an attack and then accomplish a really malicious purpose with\ndeliberation. In a word, these patients present to the alienist the\nmost serious problem in the calculation of responsibility that can\npossibly be imagined. As an expert has declared, \"It is ofttimes\nimpossible to decide whether an assault has been committed with full\nconsciousness, or in a transient but blind epileptic fury.\"\n\nThere are a series of attacks that occur in which there are some\nalmost typical convulsive movements followed by loss of consciousness\nthat simulate epilepsy very closely, yet are not true epilepsy. These\nattacks are usually due to some {256} cerebral affection or perhaps to\nsome injury of the brain. Chronic intoxications, that is, the long\ncontinued presence in the body in noxious quantities of some poisonous\nsubstance, are especially liable to cause these attacks, which are\ncalled from their character epileptiform. Characteristic epileptiform\nconvulsions occur as the result of lead poisoning or from alcohol or\nsyphilis. Lead poisoning, for instance, may very well occur in others\nthan those engaged directly in the manufacture or handling of lead.\nCertain persons are extremely susceptible to the influence of lead. In\nthem such small amounts as are contained in a hair-dye, or even in\nwater that is being used by others without any bad effect, may cause\nparticularly the nervous symptoms of lead poisoning.\n\nChronic alcoholism is also a relative term in this regard. Some\npersons are able to stand very large amounts of alcohol without\nserious consequences, even though it is taken for long periods. Others\nsuccumb to its influence very rapidly; some especially susceptible\npeople are liable to suffer from epileptiform convulsions almost\nwhenever they take alcohol to excess. This masked epilepsy may take on\nan anomalous form. The story is told of a student of a Catholic\ncollege in the eastern part of this country, who, during one vacation,\nwas given as a joke by some friends a rather strong dose of liquor in\na glass of ginger ale. He was very thirsty at the time and did not\nnotice the presence of the alcohol until he had swallowed the whole\nglass. As he was well aware himself he was extremely susceptible to\nthe influence of alcohol. During the course of half an hour he became\nalmost wildly drunk, and going down the street with an open\npocket-knife he murdered the first person whom he met, who happened to\nbe an entire stranger to him. The occurrence took place in New Jersey,\nand, in spite of every influence that could be brought to bear--the\nincident took place some thirty years ago--Jersey justice would have\nits way and the young fellow of less than twenty was hanged.\n\nThe epileptiform attacks that occur in the midst of these\nintoxications are quite as likely to be accompanied by various forms\nof mental disturbance as are attacks of true {257} epilepsy. Only one\nfeature with regard to them is more favourable, and that is that the\nultimate prognosis is not bad. The neutralisation of existing poison\nin the system, and the prevention of further ingestion of the toxic\nmaterial, puts an end to the tendency to epileptiform convulsions, as\na rule, and also to the mental symptoms associated with them.\n\nEpilepsy remains, notwithstanding all the advance in modern nervous\npathology, quite as mysterious a disease as it has ever been. It\nmatters not what its cause, or how slight it may be, sooner or later\nit is almost sure to be followed by mental disturbance and\ndeterioration of intellectual and will power. At times there are\nperiodic attacks of mental perturbation that may become true insanity.\nEven the mild form of epilepsy known as Jacksonian epilepsy, and\nconsisting not of general convulsive movements, but of convulsive\nmovements in only one member or one side of the body, are, if allowed\nto continue, followed by some mental disturbance. It would seem as if\nthe explosion of nerve force in the brain centres,--which,\nphysiologically speaking, an attack of epilepsy evidently is,--causes\neventual deterioration of the physical basis of mind and will, so that\nmental operations can no longer be performed with their wonted\nexpertness or accuracy, nor decisions made as rationally as before.\n\nIn general, it is well understood that the more serious the epilepsy\nthe more liability there is of the development of permanent mental\ndisturbance. The earlier in life the epilepsy declares itself, too,\nthe more unfavourable is the prognosis as to the enduring retention of\ncomplete mental sanity. In people in whom the epilepsy commences late\nin life, the process of mental deterioration does not begin to be\nnoticeable so soon as when it occurs in younger years, and besides, it\npractically never runs a rapid course. Epilepsy, however, developing\nlate in life, unless for some special cause, as injury or the\ndevelopment of syphilitic tumours in the brain, is an extremely rare\naffection. Idiopathic epilepsy, that is, epilepsy for which no\ndefinite cause can be discovered, is usually dependent on hereditary\ninstability of the nervous system and is typically a disease of early\nyears, of childhood {258} and adolescence. According to the best\nauthorities, about one-fourth of the cases of epilepsy make their\nappearance before the age of 7 years. Over 50 per centum of all cases\ndevelop before puberty. About one-third of all the cases develop\nbetween 14 and 20. And even of the remaining, less than 20 per centum,\nover 12 per centum develop between 20 and 25, leaving scarcely more\nthan 5 per centum for all the remaining years of life.\n\nOf course, even in severer forms of epilepsy, mental disturbances do\nnot appear at once. It sometimes takes many years for the constantly\nrecurring manifestation of explosive nerve force to produce the\ndeterioration that gives rise to lowered rationality. Distinct mental\ndeterioration is eventually inevitable, though modern experience with\nepileptic colonies, in which patients are enabled to live a quiet\nlife, most of it in the open air and under conditions of nutrition and\nrestfulness especially favourable for their physical well-being, shows\nthat the development of insanity may be put off almost indefinitely.\n\nThere are many advertised cures for epilepsy. None of them is\nsuccessful, and all of them may do harm. The bromides have a distinct\neffect in lessening the number and frequency of seizures, but if taken\nto excess they have a serious depressing effect upon the patient.\nThere have been more cases of mental disturbance among epileptics, and\nintellectual degeneration sets in earlier, since the introduction of\nthe bromides, than before. It is the abuse of the drug, however, not\nits use, that does harm. More important than any drug is the care of\nthe patient's general health. The digestion must be kept without\nderangement; the bowels made regular; all sources of worry and\nemotional strain must be removed. Patients should as far as possible\nlive in the country, and farm life has been found especially suitable.\nRelatives are often a source of irritation rather than consolation to\nthese patients, and the life in epileptic colonies has been found\neminently helpful.\n\nJAMES J. WALSH.\n\n\n{259}\n\nXXIII\n\nPSYCHIC EPILEPSY AND SECONDARY PERSONALITY\n\n\nOne of the most interesting phases of epilepsy is the type of the\ndisease in which, without any significant motor symptoms, psychical\nmanifestations prevail very markedly. A special manifestation in this\naffection is the occurrence of a more or less complete assertion of\nwhat is called a secondary personality. Apparently the individual\nbecomes so divided in the use of the mental faculties that there are\ntwo states of consciousness. In one of these the patient knows and\nremembers all the ordinary acts of life, the other carries the record\nof only such actions as are done in a peculiarly morbid psychic or\nepileptic condition. It is rather easy to understand that this strange\nstate of affairs may readily give rise to even serious complications\nas regards the individual's relations to others, and may make the\nproblem of responsibility for apparently criminal acts that have been\nperformed very difficult of solution. Undoubtedly, however, this set\nof phenomena constitutes a form of mental alienation that must be\nreckoned with in many more cases than might be thought possible. The\ndifficulties that may have to be encountered in the proper\nappreciation of the actions of such individuals is best illustrated by\nsome cases.\n\nAt a recent meeting of the New York State Medical Association a case\nwas reported that shows how extremely difficult it may be to judge of\nresponsibility under these pathological circumstances. The patient, a\nyoung man of about twenty-two, was the son of parents themselves of\nmarked nervous heredity, signs of which appeared in other members of\nhis generation. While in attendance at a public academy he had been\nquite severely maltreated during the {260} course of an initiation\ninto a secret society of the students--the more or less familiar\nprocesses known as hazing being employed. As a result of this he had\nsuffered from an attack of unconsciousness that lasted for several\nhours. No other symptoms, however, or sequelae, appeared for nearly a\nyear. Then, while boarding with his sister, he became morose and\ndifficult to get along with. He quarrelled with his sister several\ntimes and generally their relations were rather strained. He came home\none evening very late to supper, and because things were not to suit\nhim on the table, he grew violently angry. He went upstairs to his\nroom in this morose state and, procuring a revolver, after a short\ntime came down and shot at his sister.\n\nFortunately he missed her. He at once left the house but was followed\nby his brother-in-law, and, after he began to run away, by others\nwhose attention had been attracted by the shot. He left the country\nroad and ran across the fields. He was found at the foot of a rather\nhigh stone wall in a state of unconsciousness. From this\nunconsciousness he did not recover until the next morning. In the\nmeantime he had been brought home and put to bed. The next morning he\nclaimed that he had absolutely no remembrance of anything that\nhappened after he became angry at the table because of his supper. The\nfamily made no further difficulty about the matter, and, as nothing\nserious had resulted, the boy went home to live with his father on a\nfarm and seemed to grow much more equable in temper.\n\nOne day, when very tired and out of sorts because things had not been\ngoing as he wanted them to, he was asked to clear a potato patch of\npotato bugs by spreading Paris green over it. Some hours later he was\nfound in the field suffering from severe pains in the stomach and with\nevident signs of having swallowed some of the poison. A doctor was\ncalled, an emetic was given and he purged, and after a time he\nrecovered from the symptoms of poisoning. He claimed that he had no\nrecollection of what he had done, nor did he know how he came to take\nthe poison. After this he begged the family to watch over him\ncarefully and not to let him be alone at times when they recognised\nthat he was somewhat {261} morose in temper. He was not melancholic in\nthe sense that he wanted to commit suicide, but something seemed to\ncome over him in spells, and while in a state of mind of which he had\nno recollection afterwards, he performed actions that seemed voluntary\nand yet were not.\n\nHe did not have very good health on the farm, and so he was advised to\ntry the effect of life at sea. A position as assistant steward was\nobtained for him on a coastwise vessel. In this position he gained\nrapidly in weight and seemed to have excellent health. All tendencies\nto moroseness of disposition disappeared. After a time he was promoted\nto a stewardship and later became the purser of a rather important\nvessel. He has given excellent satisfaction and feels in every way\nthat he is in a much more balanced condition than ever before.\n\nHe still insists that he remembers nothing of how the two almost fatal\nincidents in his life came about. All his family are convinced that it\nwas not a responsible state of mind that led him to attempt either of\nthe crimes. It seems not improbable that this is one of those\nfortunately rare cases in which an attack of psychic epilepsy\nsometimes obliterates for a moment the individuality of a patient. At\ntimes these attacks last much longer, and the change to a secondary\npersonality may represent a rather long interval. A number of cases of\nwhat are called ambulatory epilepsy have been brought to the attention\nof the general public of late years because of certain interesting\nfeatures of the cases that have been exploited in the daily press.\n\nPatients suffering from this form of nervous disease may wander from\ntheir homes, and while performing automatically a number of actions,\nsuch as buying tickets, travelling on cars and railroad trains, or\neven arranging the details of their journey for a long distance, may\nyet be in a state of mind that is not their ordinary consciousness.\nMen may leave home under the circumstances and find themselves after\nmonths in a strange town where they have established themselves in\nsome quite different occupation from that to which they were formerly\naccustomed, or for which their early training fitted them. There seems\nto be an absolute division between the {262} states of consciousness\nthat rule the individual during the intervals of ordinary and\nextraordinary personality. There are, of course, many reasons for\nthinking that at times such a change of personality might be feigned;\nbut many of the cases have been followed with too much care to allow\nthis thought to serve as an explanation for all of them.\n\nA case which serves to bring home very clearly the possibility of such\na state of mind giving rise to serious complications is the following:\nThe patient was a young man in attendance at the medical school of a\nuniversity in a foreign city. He had been very careless in money\nmatters, and had aroused family suspicion that even the money sent him\nfor tuition was being used extravagantly. A friend of the family came\nto see him unexpectedly in order to assure himself how the boy was\nactually getting along. The boy's accounts were in a very disordered\ncondition; he had not bought the books for which he pretended to want\nmoney; he had not paid his tuition. He realised that all this would\ncome out as soon as the university authorities were consulted. Very\nnaturally he was in an extremely perturbed state of mind.\n\nWhile on the way to the university with this friend they passed a\ncorner pharmacy, and the young man asked to be allowed to step in for\na moment for a remedy for headache. The friend waited on the sidewalk\nfor him, and when, after some minutes, the young man did not come out\nhe went in to inquire for him, and found that after purchasing a\nheadache powder the young man had gone out by a side door. For three\ndays nothing was heard from him. Then a telegram announced that he was\nin a hospital in a distant city and that he had been picked up on the\nstreet unconscious. When he came to in the hospital he had no idea\nwhere he was, and, according to his own story, no recollection of how\nhe got to the distant city.\n\nIt might be very easy to think, under such circumstances, that this\nwas all pretence. A number of these cases of ambulatory epilepsy have\nbeen under the observation of distinguished neurologists, however, and\nthere seems no good reason to doubt that some of them, at least, were\nentirely without any fictitious element. In any given case the {263}\npossibility of the occurrence of an attack of what is really the\nassumption of a secondary personality must be judged from the\ncircumstances, from the previous history of the individual, from the\nfamily traits, and from certain stigmata as narrowing of the field of\nvision and the like, which go to show the existence of a highly\nneurotic constitution. In this case the family history showed marked\nneurotic tendencies on both sides, and a brother had displayed a\ntendency to regularly spaced attacks of alcoholism about every six\nweeks, and finally became absolutely uncontrollable. There seemed good\nreason to think that the case was a real example of ambulatory\nepilepsy, and that the lapse of memory claimed by the patient really\nexisted.\n\nIn these cases it is usual for the so-called secondary personality to\nassert itself at moments of intense excitement, especially if they\nhave been preceded by days of worry and fatigue and nights of\ndisturbed rest. The secondary personality is not a complete\npersonality, but is a manifestation of the original ego with the\nmemory for past events as a _tabula rasa_. It is well known that the\nmemory is one of the intellectual faculties most dependent on physical\nconditions. It is the lowest in the scale of mental qualities and is\nshared to a very large degree by the animals. Injuries to the head not\ninfrequently produce lacunae in the memory. These lacunae often have\nvery striking limitations. It is not an unusual thing to find that old\npeople remember events of their very early childhood better than\nthings that have happened within a few years. Still more interesting\nis the fact that languages learned in youth may continue to be easily\nused, when those that were learned later in life, though perhaps known\nbetter than the previously studied languages, are forgotten.\n\nIt has often been noted that people who suffer from apoplexy may have\npeculiar affections of their memory. This may include such striking\npeculiarities as the forgetting of the uses of things, though their\nnames are retained, or more commonly, the forgetting of names while\nthe knowledge of uses remains. The one form of memory disturbance is\ncalled \"Word Amnesia;\" the other is called \"Apraxia.\" It is on {264}\nrecord that a person suffering from a hemorrhage in the brain has lost\ncompletely the use of a language acquired later in life, though the\nmemory of the native language, long since fallen into disuse, was\nperfectly retained. One apoplectic woman patient who had left Germany\nbefore she was ten years of age, and who had lived in America until\nshe was fifty, forgot absolutely the English she knew so well and had\nto set herself to work to learn it over again, though her German came\nback to her very naturally. These are wonderful peculiarities of\nmemory-pathology that show how much this faculty is dependent on the\nphysical basis of mind and upon the cellular constituents of the\nbrain.\n\nIt is not surprising, then, to find that lapses of memory may occur\nand that, as a consequence, so many of the facts that ordinarily\nenable us to identify ourselves as particular persons may be in\nabeyance. That apparently a secondary personality asserts\nitself,--though not in the sense that there is ever another ego\npresent, another mind or another will,--practically all experts in\npsychology and nervous diseases are now ready to concede. There are,\nhowever, involved in this question a number of important problems of\nresponsibility that have not as yet been entirely worked out, and with\nregard to which prudent persons are withholding their judgment. Each\ncase must be studied entirely on its own merits, with a leaning in\nfavour of the criminal or patient, in case there are evidences in past\nlife of serious disturbances of mentality, though only of very\ntemporary nature, or if there is a strong nervous or mental heredity.\n\nThe notion of the possibility of a secondary personality asserting\nitself is a much older idea than it is usually thought to be. When\nStevenson wrote _Dr. Jekyll and Mr. Hyde_, the immediate widespread\npopularity of the book was not due to recent psychological studies on\ndual personality and popular interest in a rare but striking mental\nphenomenon, but rather to the traditional feeling, long existent, of\nthe possibility of two personalities in almost any individual. The\nother law in his members, of which St. Paul speaks, is an expression\nof this feeling, and its recognition was not original with him since\nit is after all a phenomenon at least as old {265} as the existence of\nconscience. It is one of the basic ideas in religious feeling. Nearly\neveryone has something of the consciousness that there is in him\npossibilities for evil that somehow he escapes, and yet the escape is\nnot entirely due to his own will power. There is here the mystery of\ntemptation, of free will and of grace as the drama of conscience works\nitself out in every human being. At times the evil inclination seems\nto get beyond the power of the will and a period of irresponsibility\nsets in. Needless to say, the adjudication of how much may be due to\nthe habitual neglect of repression of lower instincts is extremely\ndifficult, and this constitutes the problem which the alienist must\ntry to solve. In the meantime there is need in many mysterious cases\nwhere secondary personality may play a role, of the exercise of a\nlarger Christian charity than that hitherto practised. Pretenders may\nsucceed in deceiving only too often, but in the past not a few\ninnocent individuals have been held to a responsibility for actions\nfor which they were not quite accountable.\n\nJAMES J. WALSH.\n\n\n{266}\n\nXXIV\n\nIMPULSE AND RESPONSIBILITY\n\nNot unlike that condition which develops as the result of so-called\npsychic epilepsy, in which patients perform apparently voluntary acts,\nwhile the mind is really clouded by an epileptic attack, are those\nstates in which, as the result of a more or less blind impulse, acts\nare performed for which the responsibility of the individual is at\nleast dubious. Modern experts in nervous and mental diseases have\nsometimes spoken of these states as obsessions. This term is adopted\nfrom the older writers on mysticism who used it to designate states of\nmind in which an individual was under the influence of some spirit,\nthough his intellectual and volitional state was not as completely\nunder the subjection of this spirit as in the condition of possession.\n\nIt seems clear to the modern student of these obscure conditions that\nthe old mystics and the modern alienists practically talk about the\nsame state of affairs when using this term. As the result of\nobsession, mystical writers would have conceded that responsibility is\nnot quite complete, though it is not entirely done away with. The\nmodern alienist is just as sure of the diminution of responsibility,\nthough he considers it due to the fact that for some physical reason\nthe will is not able to act or prevent action as it is under normal\nconditions. The will is sometimes spoken of by certain of these modern\npsychologists as mainly an inhibitory faculty, that is, a faculty\nwhich prevents certain reflex acts from taking place, though\npermitting one set of reflexes to have its way. Under the influence of\nan obsession or, as the French call it, _une idee obsedante_, this\ninhibition is not {267} exercised and as a result an action is\naccomplished which the agent may very shortly afterwards regret\nexceedingly.\n\nThere is no doubt that impulsions or impulsive ideas may push an\nindividual into the performance of an action which his reason\ncondemns. Uncontrollable anger is a well recognised example of this.\nImpulses of other kinds may exercise just as tyrannic a sway, though\nit is harder to recognise the elements that make up the mental\ncondition in other cases. Of course it may well be said that man must\ncontrol his impulses. It is, however, just such impulses as can not be\ncontrolled that lessen responsibility and sometimes seem entirely to\ndestroy it. It would, without doubt, be very easy to advance the\nuncontrollable impulse as an excuse for many criminal actions. In\nfact, the discussion of responsibility and its limitation by impulse\nwould seem to be open to so many abuses as to make it advisable, in\nthe present indefinite state of our knowledge, to put the subject\naside entirely. The argument, however, from the abuse of the thing,\ndoes not hold, and an effort must be made to get at the truth\nconcerning certain mental conditions which modify responsibility.\n\nIt is generally conceded that no two men are free in quite the same\nway with regard to the actions which they may or may not perform.\nAllurements that are almost compelling for some individuals, for\nothers have no influence at all. Some men are so under the influence\nof anger that irritation may easily lead them to the commission of\nacts for which they will be subsequently supremely sorry. This may\neven be the case to such an extent as to endanger their lives, yet\nthey are not able to control themselves. Many men suffering from\ndegeneration of the arteries of the heart have been warned, like John\nHunter more than a century ago, of the extreme danger of a fit of\nanger, yet, like John Hunter, have succumbed to bursts of anger,\nnotwithstanding the warning, because someone irritated them beyond\ntheir rather limited powers of endurance.\n\nIt is extremely difficult ever to come to any proper appreciation of\nthe responsibility of a given individual from a {268} single act.\nPreceding acts, however, may very well give evidence of the state of\nmind and the tendencies to disequilibrium which may make an apparently\nnormal individual irresponsible under trying circumstances. The only\nway to render this clear is to illustrate such conditions by a\nconcrete case.\n\nNot many years ago one of the large cities of this country was\nshocked, for one twenty-four hours at least, by the news that a\nbusiness man had shot his partners and himself, while at a\nconsultation in which the affairs of the partnership were being\nsettled up, after legal dissolution had taken place. The man in\nquestion had paid some debts of the firm with his own personal checks,\nand without taking proper legal recognisance for the moneys paid. When\nthe partnership had been dissolved his partners insisted that instead\nof obtaining credit for these payments he should, on the contrary, pay\nhis share of these debts once more as a partner. The state of the\nevidence was such that his lawyers told him it would be useless to\ntake the case before the court at all; there was nothing to do but pay\nthe unjust demands. He went to the meeting of his partners with a\ncertified check for the amount of their claims in his pocket. As he\ntook out his pocket-book to pass it over to them he seems to have\nrealised very poignantly the fact that he was paying money that he\nknew he did not owe, and that his partners knew he did not owe, and\nthat they were evidently taking advantage of a legal quibble in order\nto cheat him. Evidently it was an extremely trying situation. It was\ntoo much for his mental balance and he took a revolver from his\npocket, shot both his partners dead, and then shot himself.\n\nTaken by itself it is extremely difficult to say anything about the\nresponsibility of a man who commits an act like this. In ordinary life\nhe was known as a clever business man; to his friends he was known to\nbe rather irascible and impatient, but a fairly good fellow. He was\nknown to have what is called an awful temper; he had, however, never\ncommitted any violent act before. It is possible, of course, that a\nman should give way to a fit of anger for the beginning of which he is\nresponsible, and then do violence {269} much greater than he would\njustify himself for in calmer moments.\n\nThere was another occurrence in the man's life that seemed to throw\ninforming light on his mental condition. When he first came to live in\nthe large city in which he died he began paying attention to a young\nwoman, and the young woman was informed by a friend that he probably\nhad a wife living. The young woman investigated this by putting the\nquestion directly to him. He denied it at once, wanted to know the\nname of her informant, and finally laughed the whole matter out of her\nmind. Within a week after his marriage to her, while on their wedding\ntour, he was arrested, charged with bigamy at the instance of his\nfirst wife, and it became evident at once that the charge was well\nsubstantiated.\n\nHere is a man, then, who twice at least in life, when put in the\npresence of trying conditions, goes on to do the irretrievable, though\nthe act is eminently irrational.\n\nWith regard to the murder and suicide it is said that he had talked to\nfriends of shooting the scoundrels who were cheating him, but had been\npersuaded of the utter foolishness of any such idea. He had apparently\ngiven it up entirely. Notwithstanding this, he went to the last\nconference with his former partners with a loaded revolver, as well as\nthe certified check for the amount of their claim. In the case of his\nbigamous marriage, notwithstanding the warning that his second\nfiancee's questions must have been, he followed out his preconceived\nidea of marrying her, though he must have realised in saner moments\nthat discovery of his double dealing was inevitable. In a word, he was\na man who, becoming dominated by an idea, an obsession it may be\ncalled, to do something, could not get away from the sphere of its\ninfluence even though it might be made very clear to him it was\neminently irrational to follow out the idea.\n\nThere are many such individuals, and only the knowledge of their\nprevious career enables us to desume the responsibility for their acts\nunder trying conditions. That they are not responsible in the ordinary\nsense in which the logical, timorous mortal is who is at once repelled\nfrom such modes {270} of action seems very clear. Their lack of\nresponsibility is manifest, at least to a degree that makes it easy\nfor charity to find excuses for their crimes because of fatal flaws of\ncharacter, the result of physical defects and faulty training, which\nmake themselves felt especially at the moments that try men's souls.\n\nJAMES J. WALSH.\n\n\n{271}\n\nXXV\n\nCRIMINOLOGY AND THE HABITUAL CRIMINAL\n\nIn recent years no little attention has been devoted to the subject of\ncriminology, and a supposed science of the criminal has been evolved.\nIt has been the claim of a very well known Italian school of mental\ndiseases, whose leader is Professor Lombroso of Turin, that there is a\ncriminal type in humanity, that is, that there is a generic human\norganisation not difficult of differentiation, at least as a class,\nthe members of which almost necessarily develop criminal proclivities.\nEven when criminality has not actually occurred, this is thought to be\nbut an accident, and criminal acts may be looked for at any time from\nthese individuals. Lombroso's claims in this matter have met with\ndecided opposition in every country of Europe and also here in\nAmerica. This opposition has come especially from serious students of\nabnormal types who have devoted much time to the study of criminals\nand other supposedly degenerate individuals. Magnan, the very well and\nwidely known French authority on insane peculiarities, especially the\nso-called criminal monomaniacs, and whose opportunities for careful\ninvestigation of such cases in the Asile St. Anne in Paris have been\nvery extensive, utterly rejects the idea of a special physical\nconformation as characteristic of the criminal.\n\nHe is not the only one of the distinguished authorities in mental\ndiseases who is in opposition to Lombroso in this matter. Dr. Emile\nLaurent, the eminent criminologist of Paris, has shown that the same\nanomalies which are supposed to characterise criminals are to be found\namong those who have never committed any criminal act, and that these\nsupposed signs of degeneracy are not sufficient to indicate even {272}\nthat there are criminal tendencies. Manouvrier, the distinguished\nanthropological authority of the University of Paris, does not\nhesitate to advance the opinion that he can not find any distinctive\ndifference between criminals and normal men in the extensive studies\nof the comparative anatomy of the two classes. He admits, however,\nthat environment sometimes leads to the formation of habits which\nmodify the anatomy in certain ways, and that of course traces of hard\nwork, as well as of poor living, can be found in the anatomical\nconformation of many habitual criminals.\n\nDr. von Holder, a distinguished German authority on the subject, says\nthat it is impossible to draw any conclusion from cranial asymmetries\nas to psychical characteristics, and that physical signs of\ndegeneration indicate nothing further than the possible presence of a\ntendency to psychic degeneration. Dr. Wines, quoted by Draehms in his\nbook on _The Criminal, a Scientific Study_, says that in a strictly\nscientific sense, the existence of an anthropological criminal type\nhas not been proved, and it is doubtful whether it ever can be proved.\nDr. Arthur McDonald, the well known American specialist in criminology\nand degeneracy, some of whose work in connection with the National\nBureau of Education at Washington has attracted widespread attention,\nsays, in his _Abnormal Man:_ \"The study of the criminal can also be\nthe study of a normal man, for most criminals are so by occasion or\naccident, and differ in no essential respect from other men. Most\nhuman beings who are abnormal or defective in any way are much more\nlike than unlike normal individuals.\"\n\nHow much the subject of criminology has been overdone because of the\nmorbid popularity of the idea that many persons are, as it were,\nforced by their natures into the commission of crime, can best be\nappreciated from some recent publications with regard to left-handed\nindividuals. A number of supposed observers, much more anxious,\nevidently, to make out a case for a pet preconceived theory, than to\nmake observations that would add to the present store of truth, have\nrushed into print. As a result, left-handed persons have been said to\nbe criminals much more commonly than {273} those who habitually use\ntheir right hand, and have also been said to be defective in other\nways. They were spoken of as weaklings, degenerates, and the like.\nStatistics even were quoted to show a much larger proportion of\ncriminals than might be expected, according to the normal percentage,\nbetween right-handed and left-handed people, among those who use their\nleft hand by preference. As a matter of fact, left-handed people are\nfar from being the weaklings or degenerates they are thus proclaimed;\nbut on the contrary are often magnificent athletes and excellent\nspecimens of normal development. Left-handedness is due to\nright-brainedness and this is an accident dependent on a diversion of\nblood supply in an increased amount to this side of the brain in early\nembryonic life. This question of the criminal and the left-handed\nindividual and their mutual relations is only a good example, then, of\nhow far over zealous advocates of a theory have been led astray in\ntheir attempts to bolster it up.\n\nDraehms, whose opinion on the supposed born criminal is worth while\nquoting, as it is founded on his personal experiences and observations\nwhile a resident chaplain of the state prison at San Quentin,\nCalifornia, says:\n\n\"Crime is not, as Lombroso and his coadjutors would have us believe,\nwholly either a disease or a neurosis in the sense of a direct,\nabsolute, physiological, pathognomonic entity, though doubtless not\ninfrequently closely associated with physical, anatomical, and nerve\ndegeneration, as above conceded. To presuppose absolute and necessary\nbrain lesion or diseased nerve action, or anomalous, physiognomonical,\nor anatomical diathesis, as the inevitable precursor of any form of\nmental and moral deflection, is an assumption wholly unwarranted and\nis nowhere substantiated by facts, though its advocates have sought to\nlay their foundations deep and wide in the materialistic hypothesis.\nMost criminals present unusually sound physiological conditions, and\nthere is among them no unusual death rate, considering their habits\nand mode of life, as we shall hereafter see. Hence their moral\ninstability can not be associated with physiological instability in\nthe absolute sense. The physical defect must be either reversionary or\nincidental, rather than absolute.\"\n\n{274}\n\nThe impetus in the study of criminals, which came as a result of the\nrevolutionary teaching of the Italian school, has not been without a\ngood effect. Criminals all over the world have been studied more\nclosely and more sympathetically, in order to test the new ideas,\nuntil now it is possible to draw definite conclusions with regard to\ncertain features of the problem. After a time, Lombroso came to admit\nthat the so-called criminal type occurred in somewhat less than half\nthe criminal cases. Criminal anthropologists, however, have shown that\nthe physical conformation called by the name criminal, is really only\nthe result of a defective or degenerative physical constitution. It is\neasy to understand that persons born with a defective nervous system,\nor with serious degenerative lesions in other parts of the body, which\nprevent the proper nutrition and functional development of the nervous\nsystem, would perform many more materially criminal acts than the rest\nof the population. The idiot and certain forms of the degenerative\ninsane show this. Any defective development of the nervous system,\nmoreover, may lead to instability of moral character, because the free\naction of the soul may be hampered by the physical environment with\nwhich it is associated.\n\nCertain of the physical peculiarities most frequently seen in\ncriminals have an influence of this kind and merit discussion. A\nknowledge of them will furnish clergymen with reasons for a larger\ncharity to those unfortunates, and a greater tolerance for their\nrelapses, without allowing sentiment to play too important a role in\ndealing with them. There are all grades of defective human beings,\nfrom the idiot up to those little less than normal. Anatomical\npeculiarities prevent the proper functions of the nervous system, as\nit is not hard to understand. The will is hampered in its action by\nthe defect of the instrument through which it must work.\n\nIn persons properly to be considered as degenerates usually the head\nis small, though this may not be very noticeable because of\nover-development of the jaws. A heavy lower jaw particularly, because\nof the principle of bone-development that size depends on functional\naction and reaction, may lead to over-thickness of the skull at the\npoint of articulation. The {275} jaw articulates with the base of the\nskull, and as a consequence the cranial capacity of these individuals\nis distinctly less than normal. Besides this, there is commonly some\nabnormality in the shape of the head, or the cranium is distinctly\nasymmetrical. It has been noted that criminals have a large orbital\ncapacity, that is to say, the bony framework surrounding the eye is so\nlarge as to encroach much more than usual upon the space left within\nthe cranium for nervous tissue. The bones of the skull are likely to\nbe thicker and heavier than usual, thus also limiting the cranial\ncapacity. The superciliary ridges often project and give the beetling\nbrow that is sometimes so remarkable. The jaws are heavy, and\nespecially the lower jaw is apt to be large and prognathic, that is,\nprojecting. This may extend even to the existence of a so-called\nlemurian appendix of the jaw. The zygomatic process is apt to be\nprominent, in keeping with the heaviness of the upper jaw. The nose is\nusually somewhat flattened, and may be crooked. This peculiar\ndevelopment of the nose puts most of the internal parts of that\nimportant organ within the skull itself. This further encroaches upon\nthe cranial capacity. The ears are asymmetrical, often unevenly placed\nat the sides of the head, sometimes adherent at the lobule, sometimes\nvery prominent. The displacement of the soft tissues is due to the\nexistence of asymmetry of the skull. As may be seen, all of the\ncharacteristics of the criminal type, pointed out by Lombroso, may\npractically be summed up in the one expression, there is diminished\namount of intracranial space.\n\nWith regard to many cranial deformities, and especially various\nthickenings of the cranial bones, it must not be forgotten that they\nare not the expression of physical heredity, but are often\npathologically acquired. Certain diseases of children are accountable\nfor many of them. Various disorders of nutrition in the early years of\nlife express themselves in bony deformities, and the skull is not\nspared. Rickets, for instance, is well recognised as a cause of such\ndeformities. Owing to a wrong etymology of this word, by which it is\nsupposed to be derived from the Greek word [Greek text], meaning the\nspine, rickets is sometimes scientifically {276} called rachitis. The\nconnection, then, between the cranial deformity and some underlying\nnervous disturbance might be assumed. It does not exist, however.\nRickets is an English word, the derivation of which is unknown, but\nprobably it is _wricken_, twisted, deformed, and its use has crept in\nbecause the disease was first described in England, and is indeed\noften spoken of on the continent of Europe as an English disease. Not\nthat it is any more frequent in England, however, but was there first\nrecognised as a distinct pathological entity. As the result of this\naffection the children, usually of poor parents, suffer from\ngastro-intestinal disorders of various kinds, and develop symptoms of\nmalnutrition, affecting especially bone tissue. The ends of the long\nbones at the wrists and at the ankles, where the effects of the\ndisease can be noticed particularly, become more thickened and nodular\nthan usual. The ends of the ribs, where the bones join the cartilages,\nalso become nodular, so that a series of beads can be seen down each\nof the child's sides, a condition described as the rickety rosary. In\na similar way the bones of the skull become thickened, especially at\nthe edges of the fontanels, that is, the openings in the child's head\nbefore complete ossification of the skull has taken place. As a\nconsequence of this thickening these openings do not close as they\nshould, and the head becomes markedly deformed in some cases.\n\nIndeed, as has been shown by experts in children's diseases, many of\nthe peculiarities that have been pointed out by over enthusiastic\ncraniologists as indicating criminal degeneration, are really the\nresults of the rickety process on the skull. Needless to say, however,\nthis does not change the character of the individual, nor is there any\ngood reason why such deformities should have any special connection\nwith criminality. It happens that many of the criminal classes suffer\nfrom malnutrition in their early childhood, and as a consequence there\nis a faulty bony development of the skull. It is observations of this\nkind, particularly, that have served to discredit craniology as an\nindependent science.\n\nWith regard to habitual criminals, the question of criminality must be\ndiscussed from the standpoint, not of those who theorise, but of those\nwho know from actual {277} observation most about the criminal\nclasses. In an article in _The Nineteenth Century and After_ for\nDecember, 1901, Sir Robert Anderson discusses how to put an end to\nprofessional crime. Sir Robert has been Chairman of the Criminal\nInvestigation Committee of the English Parliament for many years. His\nopinion, then, is worth weighing well and is very strikingly different\nfrom those of the criminologists who would find a very large\nproportion of criminals among mankind. He says:\n\n\"I am not turning phrases about this matter, or dealing in rhetorical\nfireworks. I am speaking seriously and deliberately, and I appeal to\nall who have any confidence in my judgment and knowledge of the\nsubject, to accept my assurance that if not 70,000 but 70 known\ncriminals were put out of the way, the whole organisation of crime\nagainst property in England would be dislocated, and we should, not\nten years hence but immediately, enjoy an amount of immunity from\ncrimes of this kind that it might to-day seem Utopian to expect. The\ncriminal statistics cult blinds its votaries. It is the crime\ncommitted by professional criminals that keeps the community in a\nstate of siege. The professional criminals are few and I may add they\nare well known to the police. The theory that these men commit crimes\nunder the overpowering pressure of habit, or of impulse, is altogether\nmistaken. They pursue a career of crime because, as Sir Alfred Wills\nexpresses it, they calculate and accept its risks. And just in\nproportion as you increase the risks you will diminish the number of\nthose who will face them. True it is that the army of crime includes a\ncertain number of wretched creatures who have not sufficient moral\nstamina to resist the criminal impulse. I believe there are fewer of\nthis class in England than abroad, but I know that these are not the\nsort of criminals whose crimes perplex the police. The high-class\ncriminal is a different type of person altogether.\"\n\nSir Robert gives an extract from one of the morning papers of the day\non which he wrote these lines, in order to show how different is the\nstatus of every ordinary habitual criminal from that which the\nenthusiastic criminologist supposes it to be:\n\n{278}\n\n\"Hewson Patchett, 48, was sentenced yesterday for obtaining seven\npounds and a gold watch by false pretenses. He urged it was his first\noffence, but a London detective informed the court that there were\nabout two hundred cases against him for housebreaking.\"\n\nSir Robert adds: \"If Patchett is a cool-headed, deliberate criminal,\nthe whole proceeding is a farce. And if he be one of those miserable,\nweak creatures who can not abstain from crime, the sentence is\nbarbarous.\"\n\nSuch experiences as Sir Robert hints at as occurring frequently in\nEngland, are certainly by no means uncommon in this country. Within\nthe past year in at least four cases in New York City, in which a\nburglar, besides committing robbery, wounded or killed some one,\neither in the commission of the crime itself or in endeavouring to\navoid arrest afterwards, there were more than two convictions\nregistered against the criminal in his previous life. There can be no\ndoubt that criminality becomes for some men a sort of mania, and that\nsociety must protect itself against their actions quite as it does\nagainst those of the insane by confining them under surveillance. It\nseems very clear that while a man may, under stress of circumstances\nor because of some specially tempting opportunity, be induced to\ncommit burglary or some other crime by violence in order to obtain\nmoney, this will not happen a second time, except in the case of\ncertain individuals whose moral tone is so perverted that reformation\nis practically hopeless. If a second conviction for burglary,\ntherefore, is secured, a longer sentence than is now the custom should\nbe inflicted, and the individual should not be allowed to go from\nunder the surveillance of the authorities until he has demonstrated,\nfor at least five years, his willingness and capacity to earn an\nhonest living.\n\nThis may seem a drastic method. It may also appear to some that there\nwould be consequent upon this system of regulating criminals a very\nundesirable increase of our present rather extensive system for the\ncare of criminals. Here is where Sir Robert Anderson's experience is\nof value. The confirmed criminals are not near so many in number as is\nusually supposed, or as is even claimed by certain heedless {279}\nstatistical experts in criminology. There is no doubt, however, that\nthese men succeed in drawing others around them and in organising most\nof the crimes of violence that are committed. There is a certain\nglamour about the successful burglar that allures the young man and\nstarts him in the downward path of criminal tendencies from which he\nmay not be able later easily to withdraw.\n\nIf those who are most deeply interested in the reform of the criminal\nclasses would unite in an effort to secure legislation to the effect\nthat the habitual criminal should receive, not a definite sentence but\nan indeterminate sentence; that is to say, that on his second\nconviction for burglary, he should be sent to jail until such a time\nas, in the opinion of officers of the institution where he has been\nconfined, he shows signs of a disposition to become a worthy member of\nsociety, and that then he should be allowed to be at liberty only\nunder such circumstances as would permit of reports with regard to his\nconduct for a time equal at least to the years spent in prison, then\nthere would be much less need of the theoretical considerations with\nregard to the heredity of criminal traits, and the supposed all\npowerful influence of environment in fostering criminal tendencies.\nThere is in this matter a very worthy field for the development of\nphilanthropic qualities, and the student of the abnormal man will find\nmany opportunities for the exercise of a large-hearted charity, rather\nthan the facile condemnation which places all violations of law under\nthe head of criminality.\n\nThose who have made special studies with regard to criminals have, as\na rule, come to the conclusion that our modern method of treating\nthose convicted of crime is eminently irrational. It is a rare thing\nto pick up a newspaper without finding that a crime by violence has\nbeen committed by some one who has previously been in state's prison\nfor a similar crime. Most of the burglars have a police record.\nPickpockets and others continue to pursue their avocations,\nnotwithstanding a series of convictions. It is clear that a sentence\nof a year or two, or even more each time that a crime is committed,\ndoes not act as a deterrent. Such people are differently constituted\nfrom those who are influenced by {280} public conviction of crime and\nrestraint of liberty. There is something radically wrong with their\nmoral sense. It would seem that the proper way to treat them is after\nthe same fashion as the method used with those who are mentally\nimpaired.\n\nAfter a man has shown, by a second conviction of a crime by violence,\nthat he is one of those whose moral sense can not be restored by\npunishment to a realisation of his action, then an indeterminate\nsentence, somewhat as in the case of the mentally unstable, who are\nallowed to leave the asylum but are kept under observation, is the\nonly proper method.\n\nMen like Sir Robert Anderson are sure that this procedure could be\nadopted with regard to quite a liberal number of leading criminals\nwhose influence induces others to crime. There would be much less need\nfor all machinery of the criminal law than at the present time, and\nthe community would be better protected. This is certainly true as\nregards the large cities, where crimes against property are almost\nwithout exception committed by those who have been previously\nconvicted for such crimes, or who at least have been in intimate\nassociation with such convicted criminals.\n\nThis view of the criminal, as one against whom society must protect\nitself just as it does against the insane, is comparatively modern. It\nmust be borne in mind, however, that insane asylums are by no means an\nold institution, and that the present restraint of very large numbers\nof the insane is something unknown before in history. It seems not\nunlikely that if this newer aspect of criminology could be made\npopular great benefit would follow, not only to the peace of the\ncommunity and the freedom of its members from fear as to such crimes,\nbut also a number of the weaker individuals, who are now influenced\nand led astray by clever criminals, would be saved from commission of\ncrime and the necessity of punishment, with the degradation and\nlifelong stigma that this involves.\n\nThis is an aspect of criminology with which the Christian clergyman\ncan be in sympathy, and that does not smack of the utter materialism\nwhich was at the foundation of much of the discussion of the so-called\ncriminal type. The {281} recognition of moral perversion as a form of\ninsanity requiring treatment and then constant observation for many\nyears, just as in the case of mental disequilibration would be a\ndistinct advance over our present crude methods of dealing with\ncriminals.\n\nJAMES J. WALSH.\n\n\n{282}\n\nXXVI\n\nPARANOIA, A STUDY IN CRANKS\n\n\nOf late years the crank, in the various forms in which he or she may\noccur, has became a subject of great popular as well as scientific\ninterest. As a matter of fact, the queernesses of people are a more\nabsorbing study to the neurologists and psychologists than are any\nforms of insanity. It not infrequently happens that individuals of\npeculiar tendencies are prone to have special affinity for religious\nideas, and strange applications of Christian formulae of thought. Even\nwhen they do not become absolutely insane in their religiosity, they\nmay often go to extremes. It must be remembered, too, that some cranks\nare mentally affected in but mild form, and it may be difficult to\ndetermine whether their oddity is really the result of a certain\namount of mental torsion, or merely intellectual tension.\n\nSuch persons are more likely to be brought in close contact with their\npastors and other clergymen and with religious Superiors of various\nkinds than even normal individuals. They often put their confessors,\nparticularly, in serious quandaries in the matter of spiritual advice.\nA review, then, of the accepted ideas of experts with regard to such\npeople is likely to be of special service to those who would\nunderstand these cases as well as possible, though the present state\nof medical knowledge, here as elsewhere, leaves much to be desired.\n\nA distinguished authority in mental diseases once said, half in jest\nthough he meant it to be taken at least half in earnest, that a great\nmany more of us are cracked than are usually thought to be, only that\nmost of us succeed in concealing the crack quite well. The frequency\nof the crank adds to the {283} interest of his study, which is by no\nmeans a department of medical science of recent growth. While interest\nin this class of persons has become much more intense in recent years,\neccentric individuals have been an object of close observation and of\nserious study almost as far back as history goes. When Quintilian said\nthat genius was not far separated from insanity, he meant to record\nthe conclusion of his time, that men of genius are apt to seem\ninexplicable in their ways to those who come closely in contact with\nthem. Eccentric persons, however, are by no means always undesirable\nmembers of a generation. It has been noted by historians in all ages\nthat to the refusal of eccentric individuals,--often thought at the\nbeginning, particularly, to be little better than insane--to accept\nthe traditions of the past, we owe many of the privileges which we\nenjoy at the present time. Their refusal to think along old lines of\nthought often makes them valuable pioneers in progress.\n\nDefinite knowledge with regard to the pathological basis of crankism,\nor eccentricities, has not yet been obtained. What has been learned,\nhowever, has enabled the neurologist to distinguish various forms of\nmental perturbation, to recognise the probable influence of certain\nconditions and environments on the future action of eccentric\nindividuals, and to foretell the probable outcome of the cases. All of\nthis information is of very practical importance to religious\nSuperiors and others in positions of religious confidence, who are\nsure to be brought, even more than the rest of the community, in\ncontact with the eccentric class. It has seemed advisable, then, to\ncondense some of the recent knowledge on this subject into popular\nform for the use of confessors, spiritual directors, and those in\nreligious authority.\n\nHow recently medical knowledge on this important subject has developed\nalong strictly scientific lines may perhaps best be appreciated from\nthe fact that Professor Mendel of Berlin, to whom we owe the term\n_paranoia_, the recognised scientific designation for crankism, is yet\nalive and continuing his lectures on neurology at the great German\nuniversity. The term, from the Greek word [Greek text], meaning\nalongside of, and {284} [Greek text], mind, expresses the fact that\nthe mental faculties of individuals designated by it are beside\nthemselves, that is, the mental powers are not entirely under the\ncontrol of the individual, so that they only come near voluntary\nintellection in its highest sense. In a word, the term contains a\nseries of expressive innuendos by its etymological derivation.\n\nProfessor Berkley of Johns Hopkins University says that the word\nparanoia was first adapted by Mendel from the writings of Plato, to\nindicate an especial form of mental disease occurring in individuals\ncapable of considerable education, at times of brilliant acquirements,\nyet possessing a mental twist that makes them a class apart from the\ngreat mass of humanity.\n\nProfessor Peterson, the President of the New York State Commission of\nLunacy, gives a very good definition of the condition which, though\ncouched in somewhat technical terms, furnishes the most definite idea\nof the essential properties of paranoia. He says: \"Paranoia may be\ndefined as a progressive psychosis founded on a hereditary basis,\ncharacterised by an early hypochondriacal stage, followed by a stage\nof systematisation of delusions of persecution, which are later\ntransformed into systematised illusions of grandeur.\" He continues:\n\"Though hallucinations, especially of hearing, are often present, the\ncardinal symptom is the elabourate system of fixed delusion.\"\n\nIn a word, the paranoiac is a crank usually descended from more or\nless cranky ancestors, with an overweening interest in his health to\nbegin with, who later develops the idea that many people are trying to\ndo him harm, or at least to prevent his rise in the world, and who\nfinally becomes possessed of the notion that he is \"somebody,\" even\nthough those around him refuse to acknowledge it and pay very little\nattention to the claim. Such people not infrequently hear things that\nare not said. That is, not only do they hear the voices of the dead,\nof spirits good and evil, but also the voices of living persons, who\nare at a distance from them and sometimes even when those living\npersons are present, but have said absolutely nothing. These delusions\nof hearing, however, are not so important as the self-deception forced\nupon them by their {285} mental state with regard to their importance\nin the world and their relations to other people.\n\nThe most significant consideration with regard to paranoia is the fact\nthat it is practically always hereditary. Krafft-Ebing said that he\nnever saw a case of true and reasonably well developed paranoia\nwithout hereditary taint. This does not imply, of course, that the\nsame symptom of delusions exists in several generations, but some\nserious mental peculiarity is always found to exist in the preceding\ngeneration. Other authorities are not quite so sweeping in their\nassertion of heredity for these cases, though practically all are\nagreed that in over 80 per centum of the cases, some hereditary\nelement can be traced without overstretching the details of family\nhistory that are given.\n\nParanoia occurs a little more commonly in females than in males. As it\nis of hereditary origin, it is not surprising to find that the\npeculiarities are noticed very early in life, though they may not be\nsufficiently emphasised to attract the attention of any but acute\nobservers, who are brought closely in contact with the patients. Even\nin childhood, patients who subsequently develop serious forms of\nparanoia, usually have been shy, backward, inclined not to play\nreadily, irritable, peculiar, precocious, prone to spend much time in\nstudy at an age when they ought to be interested mainly in sports, and\nthey are generally old beyond their years. A typical example of this\nwas Friederich Nietzsche, the German philosopher, who died a few years\nago in an insane asylum.\n\nOlla Hanssen, Nietzsche's biographer, who carefully collected the\nfamily accounts of the philosopher's childhood, said that he did not\ntalk until much later in childhood than is usual. \"As a boy he was\nretiring and solitary in his habits. During his school days he was\nalways interested in books not in sports, in lonely walks not in young\ncompanions.\" A history of this kind will be found in the early career\nof many queer folk. Very often these old-fashioned traits are a source\nof pleasure to parents and sometimes even to teachers. During\nchildhood, however, the sports of childhood should satisfy the child,\nand abnormalities of interest in things outside of childhood's sphere\nare always suspicious. The growing {286} organism needs, first of all,\nmuscular exercise, and after that the freedom of mind that comes with\nspontaneous play. It may be said, in passing, that the walk of a city\nchild with its maid, when even the child's choice in the matter of\nwhere it shall walk is not consulted and the maid's will is constantly\nimposed, is the worst possible training for spontaneous action or\nvolition in later life.\n\nIn the cases that develop early in life it will practically always be\nfound that infantile cerebral disorders of some kind are a prominent\nfeature of the history. The mother's delivery was difficult perhaps,\nand the child was for some time after birth unconscious, or infantile\nconvulsions occurred. It may be remarked here that a history of\nconvulsions in childhood is now considered by physicians as of serious\nimport for the future nervous and mental life of the child. It has\nrecently been announced, for instance, that so-called idiopathic\nepilepsy,--that is, epilepsy without some directly immediate\ncause,--very seldom develops later in life in persons who have not had\nin childhood convulsive seizures as the result of some extreme\nirritation. This does not imply that every child that has convulsions\nwill suffer from some serious nervous or mental condition later; but\nevery child whose mental and nervous equilibrium is not stable,\nbecause of hereditary elements of weakness, will almost certainly\nsuffer. Injuries to the head in childhood are nearly of as great\nimportance as the actual occurrence of convulsions.\n\nThere are usually three stages of paranoia described by authorities in\nmental diseases. These have been called the prodromal or initial\nperiod, which is also, because of the set of symptoms usually most\nprominent in it, often called the hypochondriacal stage of the\ndisease. The patient occupies himself with his feelings and his\nsensations. He is concerned very much about the state of his health\nand is prone to think himself affected by diseases that he reads about\nor hears described. This set of symptoms, by itself alone, is not an\nindex of enduring mental disturbance, but may be only a manifestation\nof a passing mental perturbation in sympathy with some slight physical\nailment. This state may indeed be nothing more than the result of too\npersistent introspection. {287} Most medical students suffer from a\ncertain amount of hypochondria during their early acquisition of a\nknowledge of the symptoms of disease.\n\nIn the true hypochondriac, however, every bodily sensation, or as it\nis technically called, somaesthetic sensation, is translated to mean a\nsignificant symptom of serious disease. A slight feeling of fatigue\nbecomes to the patient's mind the \"tired feeling\" of a dangerous\nconstitutional disorder. Any peculiar feeling, such as that of the\nhand or foot going to sleep, is set down at once as a symptom of a\nserious nervous disease, or if the patient has heard that in old\npeople numbness of the extremities is a forerunner of apoplexy, he is\nsure to conclude that apoplexy is threatening in his own case.\nSubjective sensations of heat and cold set him to taking his\ntemperature and his pulse, and even slight variations in these are\nmagnified into important physical signs of disease.\n\nVery often such slight symptoms as passing lapses of memory are\nmagnified into approaching complete failure of memory, and lassitude\nbecomes a permanent loss of will power, evidently due to disease in\nthe patient's mind, and there begins the persuasion that nothing can\novercome it. Morbid introspection becomes, after a time, the favourite\noccupation, and every slightest sensation or feeling sets up trains of\nthought that lead to far-reaching conclusions with regard to physical\nweakness. The patient is apt to be greatly preoccupied with himself,\nto neglect his duty towards others, to be utterly selfish, to fail to\nrealise how much sympathy is being wasted on him.\n\nSome people never pass beyond this preliminary stage of the mental\ndisorder. Usually, however, after a time the patient misinterprets not\nonly his own sensations, but the actions of other people in his\nregard; he becomes suspicious and distrustful of everybody around him,\nsometimes even of his best friends. He is passing on to the second\nstage of the disease, in which he is sure to feel that he is the\nobject of persecution. Just as he misunderstood his physical symptoms,\nso he misconstrues the actions of his friends. He is sure that they\nlook at him curiously, that they smile {288} ironically. Sometimes he\nthinks that they wink at one another with regard to him, or make signs\nbehind his back that are meant to be derisive. Even harmless passing\nobservations may be morbidly perverted into severe and inimical\ncriticism of himself and his actions.\n\nThe paranoiac is now apt to enter fully upon the second or persecutory\nstage of his mental disorder. His distress and discomfort he\nattributes to those around him and he is sure that he is the subject\nof persecution. At first his persecutors are not very definitely\nrecognised. No particular person is picked out and even no particular\nset of persons. There is just a vague sense of persecution. A\ndistinguished neurologist once said that no sane person in this world,\noutside of a novel or a play, has time to make it his business to\npersecute anyone else. When people come, then, with stories of\npersecution, either they themselves are not in their right mind and\nare deluded as to the source of the persecution, or else their\npersecutor is not in his right mind and the case needs seeing to from\nthe other standpoint.\n\nAfter a time, longer or shorter in individual cases, the paranoiac\nbegins to recognise definitely who his persecutors are. As a rule, it\nis not some single individual, but a combination of individuals.\nAlready there is the beginning of the third state of the disease--the\ngrandiose stage of the disease, in which the patient feels an extreme\nsense of his own importance. It would be derogatory to his self\nconceit to consider himself the subject of persecution by an\nindividual, and so it is usually some society, or the government, or\nits officials, or some secret organisation that is persecuting him,\nand perhaps also persecuting those who are near and dear to him.\n\nSometimes it is the Odd Fellows, or perhaps the Masons, who are the\npersecutors. If the newspapers have recently had some account of the\ndisappearance of Morgan years ago, and this subject crops up\nperiodically in the papers, then the Masons become a favourite subject\nfor paranoiacs' delusions of persecutions. Just after the Cronin\nmurder in Chicago, the Clan-na-Gael became an extremely fearsome\nspectre for paranoiacs who thought themselves persecuted. It is of\nsome {289} importance to know, as a rule, what the usual reading\nmatter of a patient is, and what things are likely in his past history\nto have impressed him, in order to realise what the real source of his\ndelusions of persecutions are.\n\nIt is curious how rational these patients may be on all other subjects\nexcept the special topic of their delusion. During the past year a\nparanoiac has been under observation, who is considered a reasonably\nrational individual by those who know him well, who follows his daily\noccupation, that of clerk, without intermission and with business\nability, who is a faithful attendant at church, and who is very kind\nto his family, but who is sure that he is the subject of persecution\nby the Clan-na-Gael. He never belonged to the organisation. He is\nnot able to give any good reason why he should be persecuted, except\nperhaps the fact that, though an Irishman, he never did belong to\nthem. He is perfectly sure, however, that they are planning to poison\nhim and his family. He finds peculiar tastes in the tea and the coffee\nat times. He throws out these materials and insists on his wife\ngetting others at another grocery store. He sometimes brings groceries\nhome from a distance and yet finds that if he ever buys materials a\nsecond time in the same place, they are sure to have been tampered\nwith in the meantime by emissaries of this secret organisation. He\nfeels sure that he has seen these secret agents, but he is only able\nto give vague descriptions. Not a little of the prejudice against\nthese organisations is really founded on such morbid suspicions.\n\nAnother form that the idea of persecution sometimes takes, in this\nsecond stage, is the delusion that the patient is neglected by those\nwho should specially care for him or her. A woman insists that she is\nneglected by her husband. She may become intensely jealous of him and\nmake life extremely miserable for him without there being any good\nreason for her jealousy. These cases are not nearly so rare as might\nbe thought. On the other hand, men suspect their wives of\nunfaithfulness. This suspicion may go to very serious lengths in\npersecution at home, though the man all the time keeps his suspicions\nto himself, in order not to make a laughing stock of himself outside\nof the house. It is this curious mixture of {290} rationality and\ndelusion that is the characteristic feature of the disease. It is for\nthis reason that these conditions were sometimes called monomanias, as\nif patients were really disturbed only on one point. As a matter of\nfact, however, patients are mentally wrong on a number of points,\nthough there is some one mental aberration so much more prominent than\nother peculiarities that it overshadows the others.\n\nIt is not long after the persecutory stage sets in before patients are\napt to become themselves persecutors of others as a result of their\nbelief that they are being persecuted. The French have a suggestive\nexpression for this. It is _persecutes persecuteurs_, that is to say,\n\"persecuted persecutors,\"--patients who are trying to repay supposed\npersecutors by persecution on their own part. Such patients, of\ncourse, very easily become dangerous. They need to be carefully\nwatched. As a rule, the persons whom they are prone to select as the\npersecutors upon whom they must avenge themselves are absolutely\ninnocent parties. At times they are even dear and well meaning\nfriends.\n\nAfter the persecutory stage in paranoia, comes the third, or so-called\nexpansive period of the disease. It has been remarked that sometimes\nthis develops as a sort of logical sequence from the patient's ideas\nof persecution. If he has too many enemies and if important secret\norganisations are trying to be rid of him, he must be a person of some\nimportance. As a consequence he evolves for himself a royal or\naristocratic descent, or hints that he is the unacknowledged son of\ngreat personages. In a kingdom royalty is, of course, a dominant idea.\nIn a republic like our own, he may consider himself to be the\nPresident or the politician to whom the President owes his office.\n\n_Paranoia Religiosa_.--Not infrequently the first hint of their\nsupposed greatness comes to such patients suddenly in a dream or in a\nvision; when their expansiveness takes a religious turn, this is\nespecially apt to be the case. They may believe themselves to be\nespecially chosen by the Almighty, a new Messiah or even Christ\nHimself, come once more to earth. Such people may retain much of their\nrationality on most of the points relating to practical life, and yet\nhave this {291} hallucination as to their close relationship with the\ndivinity. Not only may they retain their mental equilibrium on other\npoints, but they may even give decided manifestations of great genius.\nThis is, I suppose, one of the most interesting features of this form\nof mental disease, but it is well illustrated in the lives of many\nmodern founders of religious sects, even in our own generation.\n\nSuch religious reformers as Mahomet and Swedenborg seem undoubtedly to\nhave been afflicted with this third stage of expansive paranoia. In\nour own day there is no doubt that many of the founders of new\nreligious sects, many of the heaven-sent apostles or reincarnations of\npatriarchs and prophets, the miraculous healers and the like, are\nafflicted in this same way. It is useless and entirely contrary to the\nknown facts to put such people aside as mere imposters. Imposters they\nare, but they have imposed on themselves as well as on their\nfollowers. They are sincere as far as they go, and the mental twist\nthat gives them their power has occurred in the midst of the\nmanifestation of the intellectual faculties of a highly practical\ncharacter and of executive ability, with wonderful capacity for the\ndirection of complex affairs. A prominent neurologist said, not long\nago, that the most interesting feature of Christian Science is to\ncontemplate in the study of the movement how near people may come to\ninsanity and yet retain their faculty to make and handle money and\neven accumulate fortunes.\n\n_Paranoia Erotica_.--After the _paranoia religiosa_, the most common\nform of the disease is the _paranoia erotica_. There are authorities\nin mental diseases who do not hesitate to say that an excess of\nreligiosity and of erotic sentimentality are more or less\ninterchangeable. This declaration represents, however, the unconscious\nexaggeration of a mind unsympathetic towards religious ideas. But it\nmust not be lost sight of that the two forms of excesses, erotic and\nreligious, are more nearly related than would be ordinarily supposed,\nand that erotic manifestations may be confidently looked for in\npatients who have been afflicted by a too highly wrought religious\nsentimentality. St. Theresa seems to have realised this very well and\nhas touched on the subject in one of her letters.\n\n{292}\n\nOrdinarily erotic paranoia manifests itself by the patient imagining\nhimself or herself to be beloved by some one of superior station. This\nlove is of rather a platonic character and the \"lover\" cranks are\nprone to pick out as the object of their attention and annoyance some\nyoung woman rather prominently in the public eye, but whose reputation\nis of the very highest. Mary Anderson was the subject of a good deal\nof this sort of persecution. At the present moment the well and\nfavourably known daughter of a great millionaire is the subject of\nmany such attentions.\n\nThese paranoiacs are apt to become dangerous if they are prevented\nfrom paying what they consider suitable attention to the object of\ntheir affection. In hospitals they have to be carefully watched, and\nmore than one accident has taken place as the result of relaxation of\nvigilance on the part of their attendants. If kept from the object of\nhis affection, delusions of persecution become prominent in the\namorous paranoiac, and he may become a persecutor in turn and thus a\ndangerous lunatic. He can not be made to understand that the sending\nof flowers and photographs and letters is entirely distasteful to the\nchosen one. Fortunately, after a time, in many of these cases, a state\nof dementia sets in, and then the patients become mild-mannered\nimbeciles whom it is not at all difficult to manage.\n\nAs a rule where the patient has passed through the various stages of\nparanoia, dementia, with symptoms of imbecility, closes the scene. The\nparanoia may not always follow the course mapped out for it. Stages\nmay be skipped, several forms of delusions may become prominent in the\nlife of the individual at about the same time. The main feature of the\ndisease is its progressive character, and its diagnosis depends on the\nqueerness exhibited all during the course of life, as well as on the\npresence of hereditary neurotic influences.\n\n_Special Forms of Paranoia_.--There are besides the two types\ndescribed a number of special forms of paranoia, some of which aroused\nattention first under the form of monomanias, that seem to merit brief\ntreatment by themselves. In their extreme forms they are easy of\nrecognition. Milder types, however, may easily escape classification\nunder the {293} head of paranoia, because they are considered to be\nindividual oddities and not due to any physical or mental incapacity.\nUndoubtedly, however, the study of these peculiar \"types,\" as the\nFrench call them, from the standard of the alienist or expert in\nmental diseases, will serve to make clearer the real significance of\nmany otherwise almost unaccountable actions. There is no doubt, that\nthe consideration of these eccentrics as paranoiacs makes the\ncharitable judgment of many of their acts much easier, and at the same\ntime is of service in managing them. They are likely to be of much\nless harm to the community and to their friends, when it is realised\nthat they are not to be taken too seriously, but that, on the\ncontrary, there is ample justification for a benevolent combination of\ninterests to keep them from injuring themselves and their friends.\n\n_Paranoia Querulans_.--One of the most important and familiar forms of\nthe special types of paranoia is what is known scientifically\n_paranoia querulans_, that is, the peculiarity of those who insist on\ngoing to law whenever there is the slightest pretext. It is pretty\ngenerally recognised that a goodly proportion of the civil suits that\ncrowd our law courts are due to the peculiarities of these people who\ninsist on having their rights, or what they think their rights,\nvindicated for them by a court of justice. There are very peculiar\ncharacters in this line, some of whom make themselves very much feared\nand detested by their neighbours. There are some individuals to whom\nthe slightest injury or show of injury means an immediate appeal to\nthe law.\n\nNot infrequently these patients, for such they are in the highest\nsense of that word, waste their own substance and even the means of\nsupport of wife and children, on their foolish law schemes. When their\nqueerness reaches a certain excessive degree its pathological\ncharacter is readily recognised. In a less degree _paranoia querulans_\nmay be a source of very serious discomfort to friends and neighbours\nwithout exciting a suspicion of its basis in mental abnormality. Not\ninfrequently such patients become more irrational at times when their\nphysical condition is lower than normal, and a return to their\nordinary health makes them {294} more amenable to reason and less\nprone to appeal to expensive litigation.\n\nIt is evident that the irrationality of frequent appeals to expensive\nand bothersome litigation should arouse suspicion. Such patients need\nto be cared for quite as effectually as those who have tendencies to\ngamble away their substance or to waste it in the midst of inebriety.\nUnfortunately it is extremely difficult to frame laws so as to meet\nsuch conditions. Severer forms of the affliction are readily\nrecognised and the sufferer is properly restrained. I remember once\nseeing a patient in Professor Flechsig's clinic in Leipzig, who had\nbeen sent to the asylum because of his tendency to go to law on the\nsmallest possible pretext. This patient's incarceration in the asylum\nwas due to a very striking manifestation of his _paranoia querulans_.\nHe answered an advertisement for a clerk, published by one of the\nlarge commercial houses. He found himself one of a row of applicants\nfor the position, and as the member of the firm whose duty it was to\nengage the clerk was at the moment busy, he had to wait several hours\nbefore his application was heard and refused. He tried to secure a\nwarrant for the firm in order to have them indemnify him for the time\nhe had spent while waiting for his application to be heard, at the\nrate of wages they would have been bound to pay him had he obtained\nthe vacant clerkship; only as they had spoiled a day he claimed a full\nday's wages.\n\nThis patient had been in the asylum several times before because of\nhis tendency to go to law. He always gained in weight while in the\nasylum, became much more tractable and less querulous as his physical\ncondition improved, and usually after some months could be allowed to\nleave the institution. He was, however, one of the inept. With the\nhelp of asylum influence he usually obtained some occupation more or\nless suitable, but was not able to retain it for long. When out of a\nsituation he worried about himself, usually did not take proper food,\nand then soon his litigious peculiarities began to manifest themselves\nonce more in such form that if he could get the money to retain an\nattorney, or if he could persuade one to take his case on a contingent\nfee, and he was very ingenious at this, he soon became a veritable\nnuisance to {295} those around him. When in poor health he was never\ncontented unless he had at least one lawsuit on his hands, and only\nreally happy when he had several.\n\n_The Gambler Paranoiac_.--A form of paranoia that inflicts almost more\nof human suffering on the friends of the patient than any other is\nthat in which the sufferer is possessed of the idea that he can, by\nluck or by ingenious combinations, succeed in winning money at\ngambling. Milder forms of this paranoia are so common that it is the\ncustom not to think of even the severer forms of the gambling mania as\na manifestation of irrational mentality. When a man thinks, however,\nthat he can beat a gambler at his own game, or when by long\nlucubration he comes to the conclusion that he has invented a system\nby which he can beat a roulette wheel, he is, on this subject at\nleast, as little responsible as the man who thinks that he has\ndiscovered perpetual motion.\n\nThis form of paranoia inflicts suffering mainly on the near relatives\nof the patient. There is no doubt that when extreme manifestation of\nthe gambling mania becomes evident, patients should be legally\nrestrained from further foolishness. One difficulty with regard to the\nproper appreciation of gambling has been an unfortunate tendency to\nclass gambling among the malicious actions. There are many people for\nwhom only two sins seem to have any special importance, drunkenness\nand gambling. As a rule, there is not the least spirit of malice in\nthe ordinary gambler; not meaning, of course, by this the sharpers,\nwho try to make money at the expense of others, but the man who\nbelieves that, somehow, chance and fate are going to conspire to\nenrich him at the expense of others, though it must be confessed that\nhe does not usually even think of this latter part of the proposition\nwhich he accepts so readily.\n\nWe have had in recent times so many manifestations of the practical\nuniversality of the gambling spirit, the belief by people that brokers\nand banking concerns are ready to make them rich quick, that we have\nin it perhaps the best illustration of the partial truth of the\nproposition that \"half the world is off, and the other half not quite\non.\"\n\n_The \"Phobias.\"_--Sometimes the special form of queerness {296} takes\non a very harmless aspect. Patients are worried because of the fact\nthat they can not keep themselves clean. They want to wash their hands\nevery time they touch any object that has been handled by others,\nwhether that object seems to be specially dirty or not. Such patients\nmay wear the skin off their hands washing them forty or fifty times a\nday. They almost absolutely refuse to touch a door-knob, because it is\nhandled by so many people. They will consent to take only perfectly\nnew bills. It is almost amusing to see the efforts they make to avoid\nshaking hands with people, without giving direct offense. When it\ncomes to shaking hands with their physician, they are apt candidly to\ndeclare that he must not ask them to do so, because they can not\novercome their feelings as to the possibility of contamination from\nhands that come in contact with so many patients. This fear of dirt\nhas received the name Misophobia.\n\nThere are a number of other \"phobias,\" and the patient's fears are\nmanifested at the most peculiar objects. Agoraphobia, for instance, is\nthe fear of crossing an open place. These patients begin to tremble as\nsoon as they get away from the line of buildings in a street, in their\nway across the square. This trembling becomes actual staggering, with\na sense of oppression over the heart that makes locomotion almost or\nquite impossible. Claustrophobia, the opposite of Agoraphobia, is the\nfear of narrow places, and prevents some people from going through a\nnarrow street with high buildings. Many of these \"phobias\" have a\nphysical basis in some organic or nervous heart affection.\n\n_The Tramp_.--One of the striking manifestations of paranoia in our\nmodern life is the tramp. Most people are inclined to consider that\nthe cause for the wandering life of these unfortunates is rather what\na distinguished physician euphemistically called by the scientific\nname, _pigritia indurata_, that is, chronic laziness, than any\npathological condition of mind. Most tramps, however, will be found,\non that close acquaintanceship which alone will justify judgment of\ntheir actions, to have many other peculiarities of mind besides the\nshiftlessness which prompts them to wander more or less aimlessly from\nplace to place. After all, it will hardly be denied that the calm\n{297} acceptance of the notion that it is more satisfactory to indulge\nin laziness and wander without home or fireside, suffering the many\nprivations and hardships, especially from the weather which these\ncreatures do, rather than work and be respected and comfortable among\ntheir fellows, is of itself irrational.\n\nMany of these tramps prove on close acquaintance to be interesting\npathological characters. Various stages of outspoken paranoia will be\nfound to exist among them. It is not unusual to find that certain\namong them have acquired the idea not so uncommon now among large\nclasses of humanity, that the world is so unjust in its treatment of\nthe labouring man, that work seems to them almost a persecution that\nmust be undergone for the sake of the pittance derived from it.\nSometimes there is the actual extrinsic idea of personal persecution\nfor some fancied wrong done to a large corporation during a strike, or\nlabour troubles, which they cherish as the reason for which they have\nhad to give up a fixed habitation, and resign the idea of supporting\nthemselves honestly and respectably. This persecution stage of\nparanoia easily turns to the second phase of this affection as already\ndescribed, that in which the fancied victim of persecution becomes in\nturn the persecutor. Tramps thus readily give way to even organised\nattempts at revenge upon social order, and are led to believe\nthemselves justified in attempts to burn and otherwise destroy\nproperty because of their enmity towards property holders and\nemployers generally. Not infrequently the third stage of paranoia, in\nwhich there are delusions of grandeur, may be observed.\n\nPersonally I have known two tramps who wandered about the country with\nthese grandiose ideas. One of them thought that he had in his\npossession immense wealth in the shape of large checks, signed\nsupposedly by various important capitalists, and even foreign rulers.\nThese checks were actually signed in the names of these personages, at\nthe tramp's own request, by any chance passer-by or acquaintance. This\npatient died in a country insane asylum in the demented stage of\nparanoia, having gone through all the usual phases of the disease.\nAnother tramp was confident that each recurring election he was to be\nelected to one of the highest offices in {298} the state, or even to\nbe made President of the United States. Not every one was taken into\nhis confidence in this matter, however. The simplest declaration after\nthe election from any chance acquaintance would assure him of his\nsuccess at the polls, and on more than one occasion he turned up at\nthe Capitol to claim exalted office, but was generally inoffensive in\nhis ways, and was rather readily persuaded that his term of office did\nnot begin for some time. It is easy to understand that a person might\ncome into the possession of the idea that the official holding office\nin his stead should be removed; the result might very well be one of\nthe sad tragedies supposedly due to anarchism, but really to paranoia.\n\nOf course as with criminals, so with tramps; not a few of them take up\nthis manner of life without any sufficient justification in their\nmental state to lessen our worst opinion of them. I do not think I\nshould hesitate to say, however, that the majority of these\nunfortunates present distinct signs of physical and mental\ndegeneration and are rather deserving of pity and care than of\ncondemnation. They need, as a rule, very special environment to enable\nthem to lead ordinary, respectable lives, because they were not\noriginally endowed with sufficient initiative and independence of\nspirit to enable them to carry on the struggle for life in the midst\nof the hurry and bustle of our modern civilisation. As the pressure of\nthe time becomes severer, more of these unfit come into evidence. They\narc examples of the lowered mental states, unable to stand the rivalry\nwith fellowmen, and ready to give up the struggle whenever the example\nof others who have already given it up is brought prominently to their\nnotice.\n\nIt is not a little surprising how many of these tramps belonged\noriginally to excellent, respectable families. Careful investigation\nof their personal history, however, will show that they have been, as\na rule, backward children at school, always a little awkward in the\nway they took hold of things early in life, unsuccessful in the\nrivalries of school competitions, and in their first efforts at labour\nafter school days were over. They always needed the encouragement of\nthose whom they loved and respected, to keep them at their\nunsatisfactorily fulfilled tasks. They were the predestined failures\n{299} in life, and have found out their uselessness early in their\ncareers. This is the view of tramp life that is coming to be realised\nas true by all those who have studied the question, not from the\nstandpoint of theory, but of practical experience with it.\n\n_So-called Monomania_. The old term for paranoia employed for a long\ntime was monomania, a word coined by Esquirol at the beginning of the\nnineteenth century. This word has dropped out of the terminology of\nmental diseases because there is no such thing as a patient suffering\nfrom a single symptom of mental disturbance, that is, being mentally\nperturbed on but one line of thought. There are always others, though\nthey may be hidden except from the careful investigator. When Esquirol\nintroduced the term he applied it to the most prominent symptom of the\npatient's mental alienation, but did not intend it to be taken as\nexcluding other symptoms by which the essential nature of the\npatient's insanity could be diagnosed. Careful study will always\ndisclose the fact that other symptoms are present. The word monomania\nhas been an unfortunate one for scientific psychiatry, because it has\nbeen abused to shield criminals. The plea is often heard that a person\nunder charge of crime is really subject to some mania that brought\nabout the commission of the crime.\n\nWe often hear of kleptomania as a defence for persons who have failed\nto recognise the distinction between _meum_ and _tuum_, and are haled\nbefore the court because of the detection of infringements of this\ndistinction. True kleptomaniacs there are, but there are always other\nsymptoms of their mental disturbance besides the tendency to steal.\nTheir queerness in other ways has usually been recognised by their\nfriends and by their family physician before the incident which calls\nattention to this special form of disequilibration occurs.\nKleptomaniacs, too, are usually prone to take things of little value,\nor not especially suited to their wants and for which they have\npractically no use.\n\nIt is true collectors, that is, those who have a hobby for gathering\ncuriosities of one kind or another to make a collection, may become so\ninterested in additions to their collection {300} as to be tempted to\nappropriate to themselves articles of which they can not otherwise\nobtain possession. Such actions may easily go beyond the bounds of\nreason. It must be remembered however, that the collection mania\nitself is often so pronounced as to be a little beyond the bounds of\nordinary rationality.\n\nOther so-called monomaniacs have the same characteristic and are\nassociated with related symptoms of mental disturbance. Pyromania is\nsometimes pleaded as a defense for arson. It is a legitimate defense,\nhowever, only when the careful tracing of the patient's history\nbeforehand shows the existence of other symptoms of mental unbalance.\nThe homicidal mania is of the same order. There have been cases where\nmen seem to have delighted in inflicting injuries or death upon fellow\ncreatures from pure malice. Such cases as that of Jack the Ripper, for\ninstance, are undoubtedly due to a special tendency to take life. In\nthese cases, however, associated symptoms are never lacking. It is not\nimprobable that in Jack the Ripper's case a sexual element was\npresent, because the victims were always of one low class, and that\nthe general character of the murderer would have revealed his\nirresponsibility. There are several stories of children--whose mothers\ndelighted in seeing their husbands, who were butchers, slaughter\nanimals--who seem to have had a veritable mania for seeing blood flow\nand to have exercised it in the murder of human beings.\n\nOnly the most careful examinations of the previous life of the\npatient, the investigation of childish tendencies and habits at\nschool, and the incidents of boyhood and youth will sometimes enable\nthe expert to recognise the constant existence of symptoms of mental\ndisequilibration, the decided manifestation of which leads to serious\nevents in after life. Monomania as a defense for crime has brought\nexpert evidence into great disrepute. In this matter the greatest care\nis undoubtedly needed, however, for it is easy to do great wrong and\npunish the irresponsible victim of an impulse over which he has no\nproper control. On the other hand, it must not be forgotten that no\nsuch thing is known to exist as the perversion of the will on a single\npoint. Moral insanity with regard to one special set of actions is a\ndelusion that the {301} increase of knowledge with regard to mental\ndiseases has erased from the text books on this subject.\n\n_Responsibility of Paranoiacs_.--From what has been said it is easy to\nunderstand how difficult is the determination of the responsibility of\nparanoiacs. Many classes of persons ordinarily considered to be quite\nresponsible for their actions are yet so circumstanced that they are\nled into the performance of actions usually not considered rational,\nthough not tempted thereto by any benefit directly accruing to\nthemselves. On the contrary, it not infrequently happens that the mode\nof life adopted by the paranoiacs is of such a kind as would of\nitself, because of the hardships involved or the mental trials, deter\nordinary people from following it. Paranoia, at least in its severer\nforms, completely justifies the plea of irresponsibility for actions\ncommitted. When it is remembered, however, that paranoiacs are often\ncunning enough to take advantage of their own supposed queerness\nvoluntarily to commit crimes they might otherwise be deterred from by\nfear of punishment, some idea of the difficulty of the decision in\nthese cases may be appreciated.\n\nIt is important, of course, that the physician should, as far as\npossible, avoid falling into the error of judging such people too\nharshly, since after all on him depends the attitude of society\ntowards them. It would seem to be quite as important that the\nclergyman should occupy an advanced position in this matter. It might\nseem that charity could easily be overdone; it must never be\nforgotten, however, that it is better that ninety-nine guilty should\nescape rather than that one innocent person should be punished.\n\nAs a matter of fact, prejudice is much more likely to be against the\nsupposed criminal than in his favour. While it is often declared that\ntoo many persons, who have done at least material wrong, are allowed\nto escape deserved punishment, as our knowledge of mental diseases\nincreases there is more and more of a tendency on the part of experts\nto recognise that for many apparently voluntary actions men have only\na modicum of responsibility. Responsibility is, after all, not the\nsame in all men, but modified very much by the character of the\nindividual, by his environment and by the {302} motives which have\ncome to be the well-springs of his actions. No two men are equal in\ntheir responsibility when there is question of certain temptations to\ndo wrong. Some men find it perfectly easy to resist allurements to\ndishonesty which others can not resist. Some men are perfectly free as\nregards their attitude towards indulgence in spirituous liquors.\nOthers find it almost impossible to resist their cravings in this\ndirection. One might go through the list of passionate actions and\nfind this true with regard to every one of them. If this must be\nadmitted with regard to men who are considered perfectly sane and\nresponsible, how much more so does it become true of those who are\nalready somewhat mentally unbalanced?\n\nUnfortunately, the tendency to judge harshly, rather than mercifully,\nstill continues to be one main reason for the infliction of punishment\nwhere often it is not deserved. Above all the clergyman must be a\nleader in this tendency to mercy, and his influence should be felt in\npopular education in this regard. It only too often happens that\nclergymen are found to be strenuous upholders of the opinion that\nright is simply right and wrong, wrong, and that a man who knows the\ndifference between right and wrong must be considered as responsible\nfor his actions, no matter what modifying circumstances or mental\nconditions may enter into the problem of the decision as to his\nresponsibility. If the clergyman would but realise how difficult in\nany individual case must be such a decision, and how much must be\nknown with regard to the previous character of the individual, then a\ngreat beginning for the modification of the present over-severe modes\nof thought will have been made.\n\nFrom a theoretic standpoint, it would not be easy to state all that\nthe physician considers necessary to enable him to make his decision\nas to individual responsibility. Perhaps, however, the consideration\nof a series of cases that have attracted widespread attention, and\nwhich have been most carefully investigated in all their\ncircumstances, may present the methods of responsible determination\nbetter than any set of rules. Three presidents of the United States\nhave been murdered within forty years. The murderers were native-born\n{303} Americans. In none of the three cases was there any adequate\nmotive for the commission of the crime. The assassin in President\nLincoln's case might, it is true, be presumed to have a sufficient\npolitical motive, but no entirely sane man could have thought for a\nmoment that any good would be accomplished at that time for the South\nby the removal of Lincoln. A man of known erratic tendency, with the\ncraving for theatrical effects deeply ingrained in his nature, with a\npersonal history not entirely free from even more serious\nmanifestations of mental disequilibration, and with a family history\nof more than suspicious character as regards the mental qualities of\nhis ancestors, committed the crime. He met his death at the hands of\npursuing soldiers. Such was the temper of the time, that had he been\ncaptured alive he would surely have suffered the formal legal death\npenalty. Even as it was, public sentiment clamoured for legal victims\nand unfortunately they were found.\n\nIt seems clear, beyond all doubt, that in this case complete\nresponsibility for his action was not present in the assassin himself.\nThe courts decided later that there had been a conspiracy, but there\nhas always been the feeling that justice was misled by over-zeal to\nfind scapegoats for injured public sentiment. There is no doubt that\nit is an extremely difficult matter to say what shall be done to the\nassassin in such a case. The unfortunate result is as much an accident\nas the fatal consequences of any other perverted natural force. An\nearthquake may kill its thousands and the inevitable must simply be\naccepted. Society may protect itself from the further manifestations\nof such perverse individuals by confining the unfortunate murderer for\nlife, but capital punishment, in the sense of a sanction for broken\nlaw, can scarcely be considered to have a place in the given\nconditions.\n\nWith regard to the murderer of our second assassinated President we\nhad the farce of a long-drawn-out public trial of a man who was\nevidently not in his right senses. Once more a victim had to be found\nto satisfy injured public feeling. Guiteau was condemned to death and\nsuffered the death penalty. Any one who reads the proceedings of the\ntrial and who realises the significance of the motive that Guiteau\n{304} himself gave for his act, will appreciate that the court had to\ndo with an irresponsible doer of a material but not a moral wrong.\nThere were many signs of mental disequilibration in Guiteau's previous\ncareer. It is on these eventually that the expert in mental diseases\nmust depend in order to enable him to obtain a proper estimate of the\nextent of the mental disturbance in any given individual. It may seem\nthat many real criminals can be defended on this same principle of\nfinding an inadequate motive for their crimes. There are, however,\ncertain signs of irrationality not difficult to detect if the previous\nlife of the individual be carefully scrutinised and these must form\nthe ultimate criterion as to criminal responsibility.\n\nWith regard to the third murderer of a President the case is clear. He\nwas an ignorant, somewhat conceited individual, but he presented none\nof the signs of true mental disequilibration that can ordinarily be\ndepended on to indicate such a disturbance of the physical basis of\nmind as impairs responsibility. He was not entirely without a motive,\nwhich in the mind of a brooding, conceited individual, might seem to\nbe adequate for the commission of the crime. His sentence of the death\npenalty was then in accord with the judgment of the best mental\nexperts. How society shall protect itself, and especially its high\nofficials, against such notoriety seekers is hard to say.\n\nThe consideration of these cases gives a clear idea of how a physician\nendeavours to fill up gaps in his knowledge of the character of the\nman, his heredity and environment, as well as his previous actions at\nvarious times in life when under the stress of emotion. It may be\nconsidered that such a weighing of circumstances will serve to excuse\nmany genuine criminals who eminently deserve to be punished. This is,\nhowever, the assumption of the older generation who considered that if\na man did a material wrong he must be punished for it. It is a\nheritage of the day, when even accidental killing was considered to\ndemand some punishment. At the present time the tendency is rather to\nconsider only the moral wrong, that is, to calculate responsibility\nonly for such actions as are committed with due {305} deliberation,\nintention, and the knowledge of right and wrong as well as the freedom\nto perform the action. The old English legal opinion which declared a\nman responsible if he knows that what he is doing is wrong has now\ngiven way in most judicial proceedings to the principle that the man\nmust not only know that he is doing wrong, but that he must also\nrealise that he is free not to do that which he knows to be wrong.\nThat is to say, if he feels himself compelled to the commission of\ncrime, there is surely an impairment of responsibility. Such impulses\nto do wrong without adequate motive occur not infrequently among those\nwhose mental condition is not perfectly normal, and this must always\nbe taken into consideration in the ultimate decision as to their\nresponsibility for their action.\n\nJAMES J. WALSH.\n\n\n{306}\n\n\nXXVII\n\nSUICIDES\n\nIt is a very difficult problem at times to explain just how a suicide\nis due to mental alienation in a person whose intellectual powers\nappeared previously unimpaired, yet in most of the cases a knowledge\nof all the circumstances and of the individual himself would lead\ninevitably to this more charitable view. Most suicides are persons\nthat have been recognised as paranoiacs and likely to do queer things\nfor a long time beforehand. Indeed, some of the melancholic qualities\non which the unfortunate impulse to self-murder depends are likely to\nhave exhibited themselves in former generations. Not long since it was\nargued that the regular occurrence of a certain number of suicides\nevery year--varying in various places, always on the increase, but\nevidently showing a definite relationship to certain local conditions\n--demonstrate that the human will is not free, since from a set of\nstatistics one can foretell about how many cases of suicide would take\nplace in a given city during the next year. As a matter of fact,\nsuicides are not in possession of free will as a rule, but are the\nvictims of circumstances and are unable to resist external influences.\n\nThe most important feature of suicide in recent years is the constant\nincrease in the number, the increase affecting disproportionately\nyoung adults. This increase in the number of suicides is no illusion;\nit is not due to more careful statistics. It is true that in recent\nyears, that is to say during the last quarter of a century\nparticularly, the unsparing investigation by the authorities of all\ncases of suspicious death, and their report by sensational newspapers,\nhas added somewhat to the apparent number of suicides. {307} Families\nwere accustomed to announce accidental death and have their story\nunquestioned, in a certain number of cases, where now there is no hope\nof concealment because of the unfortunate publicity that has crept\ninto life. This increase, however, would account for only a small\nadditional number of suicides, while the actual figures have more than\ntrebled in the last thirty years.\n\nThis increase has come especially in the large cities. According to\nthe report of the New York Board of Health, there were 1,308 suicides\nin New York City during the decade from 1870 to 1880. During the\ndecade from 1890 to 1900 there were 3,944 suicides. This increase is\nmuch more than the corresponding increase in population. During the\nfirst decade mentioned there were 124 suicides per million of\npopulation. During the last decade this had risen to 196 suicides per\nmillion. The increase is nearly 60 per centum. The increase is\nvariously distributed over the different ages. While every five years\nfrom twenty upwards shows a percentage of increase in the number of\nsuicides committed, somewhat less than the percentage of increase for\nall ages, the five years between fifteen and twenty shows an increase\nof 106 per centum. In a word the deaths of adolescents from suicide\nhave more than doubled in the last thirty years.\n\nTowards the end of the last decade of the nineteenth century there was\nfor a time a cessation of the continuous increase. This occurred\nduring the years 1898 and 1899. Apparently it was due to the fact that\nthe occupation of the country with other interests, the war and its\nproblems, and the fact that an era of prosperity made material\nconditions better, and thus gave less occasion for depression of\nspirits. During the years since 1900, however, the increase has not\nonly reasserted itself, but has more than made up for the period\nduring which suicides were less frequent. The increase during the last\nfour years is more than was noted during the six years from 1891 to\n1897.\n\nThe same increase has been noted in European cities. The higher the\nscale of civilisation in a city, or at least the greater the material\nprogress and the more strenuous the life, {308} the higher the death\nrate. In Dresden, for instance, the rate is 51 suicides per 100,000\nevery year. In Paris it is 42, in Berlin it is 36; while in Lisbon and\nMadrid it is lowest, being only respectively two and three per 100,000\nper year. While suicides are more common among men than women in all\ncountries, this is not true for certain ages. Between the ages of\nfifteen and twenty-five the suicides of women are more numerous than\nthose of men. The suicides of women are increasing faster than those\nof men. Fifty years ago the proportion was five to one. Twenty years\nago it had fallen from three to one. Now it is less than two and a\nhalf to one. The saddest feature of the suicide situation is the\nincreasing number of the children who commit suicide.\n\nAlmost needless to say, children's suicides are without any serious\nmotives and are usually due to an attack of pique because of a slight\nfrom a playmate, a reprimand at home, a rebuke from a teacher, envy of\nthe success of a companion, disappointment over a passing love affair,\nsometimes a peculiar attachment in the case of weak and morbid\nindividuals, the manifestations of which are resented by its object,\nor are forbidden by parents and guardians. These unfortunate accidents\nhave become so common now that special care must be taken with regard\nto children of neurotic heredity. When in previous generations there\nhave been the manifestations of lack of mental equilibrium, then\nchildren's mutterings with regard to possible recourse to suicide\nshould be the signal for the exercise of close surveillance. As far as\npossible such children should be kept from the strenuous competition\nat school in modern life.\n\nAs has been well pointed out there is no doubt that the power of\nsuggestion and example has much to do with the increase of suicide.\nDymond, an authority in the matter, says, \"The power of the example of\nthe suicide is much greater than has been thought. Every act of\nsuicide tacitly conveys the sanction of one more judgment in its\nfavour. Frequency of repetition diminishes the sensation of abhorrence\nand makes succeeding sufferers, even of less degree, resort to it with\nless reluctance.\"\n\n{309}\n\nOur modern newspapers, by supplying all the details of every suicide\nthat occurs, especially if it presents any criminally interesting\nfeatures or morbidly sentimental accessories, familiarise the mind,\nparticularly of the impressionable young, with the idea of suicide.\nWhen troubles come lack of experience in life makes the youthful mind\nforecast a future of hopeless suffering. Love episodes are responsible\nfor most of the suicides in the young, while sickness and physical\nills are the causes in the old. In a certain number of cases, however,\ndomestic quarrels, and especially the infliction of punishment on the\nyoung at an age when they are beginning to feel their independence and\ntheir right to be delivered from what they are prone to consider\nrestriction, are apt to be followed in the morbidly unstable by\nthoughts of suicide.\n\nThe important practical question is the prevention of the fulfilment\nof the morbid impulse during these impressionable years. Many a young\nperson has been saved from suicide at this time to realise the\nenormity of the act and to live without any further temptation to its\ncommission for a long lifetime. As a rule the motive for the act is so\ntrivial and often so insensate that it is not difficult to make\npatients (because patients they truly are) see the folly of their\nirrational impulse.\n\nIn order to forestall the putting into action of their impulse it is\nimportant that those who are close to the patient should have some\nrealisation of the possibility of its occurrence. There are usually\nsome signs beforehand of the possibility of the crime. Many of these\nearly suicides have distinct tendencies to and stigmata of hebephrenic\nmelancholia. The best known symptoms of this condition are those\ndescribed by Dr. Peterson, the present president of State Commission\nof Lunacy of New York in his book on mental diseases. The symptoms\nnoted are extraordinarily rapid and paradoxical changes of\ndisposition. Depressed ideas intrude themselves in the midst of\nboisterous gaiety, and untimely jocularity in the deepest depression,\nor at solemn moments. Then there is the paradoxical facial expression,\nthe so-called paramimia, that is, a look of joy and pleasure when\nreally mental depression is present, or a look of depression when\njoyful sentiments {310} are being expressed. The existence of such\nrather noticeable peculiarities may lead to the suspicion of mental\ndisequilibration in young people.\n\nThe most important warning may well be the occurrence of suicide in\nany other member of the family for several generations before. The\ntendency of suicide to repeat itself in families is now well known and\nrecognised. During the year 1901 in New York City, in one case other\nmembers of the immediate family had committed suicide in six\ninstances. The subject has taken on additional interest because of the\nsuicide of a well-known gambler who was the fourth of his family in\ntwo generations to take his own life. In another case, reported within\nthe last five years, the suicide was the last of a family of nine\nchildren, every one of whom had committed suicide. There is the record\nin the German army of four generations of a noble family, the eldest\nson of which committed suicide during the 5 years from 50 to 55.\n\nIn these cases the tendency to suicide is not directly inherited, but\nthere is a mental weakness that makes the individual incapable of\nwithstanding the sufferings life may entail. In the later members of\nthe family there is also a suggestibility that the frequent\ncontemplation of the idea of suicide finally leads to the putting off\nof the natural abhorrence at the thought of its commission. In such\nfamilies, therefore, it is particularly important to warn medical\nattendants and members of the family of the possibilities of\nunfortunate acts so as to prevent if possible the execution of any\nimpulse to self-murder.\n\nJAMES J. WALSH.\n\n\n{311}\n\nXXVIII\n\nVENEREAL DISEASES AND MARRIAGE\n\n\nSyphilis is a disease that is contagious, inoculable, and\ntransmissible by heredity. It may be acquired innocently, and it is so\nacquired in about 4 per centum of cases according to good authority,\nbut the other 96 per centum is venereal. The disease attacks any part\nof the body within and without from the soles of the feet to the hair\nand finger-nails. The first evidence, where the case is not\nhereditary, is a hardened sore called a chancre; next the lymphatic\nglands swell, and many forms of skin-eruption occur; then follows a\nchronic inflammation of the cellulo-vascular tissues and the bones,\nand small tumours, called gummata, may develop in almost any part of\nthe body. The disease may vary from a light attack to malignancy.\nThere are periods in the course of the disease.\n\n1. The period of primary incubation, or the time from infection to the\nappearance of the chancre. This is commonly three weeks.\n\n2. The primary stage: the chancre forms and the neighbouring glands\nare affected. This stage lasts from three to ten days.\n\n3. The secondary incubation, or the time between the appearance of the\nchancre and the development of what are called the secondary\nsymptoms,--usually about six months.\n\n4. The secondary stage. Here occur fever, anaemia, neuralgic pains,\nand the eruptions on the skin and the mucous membranes. This period\nlasts from twelve to eighteen months in the majority of cases.\n\n5. The intermediate period. During this time there may be no symptom,\nor slighter recurrence of the secondary {312} symptoms. This period\nlasts from two to four years. It may end in recovery of health or be\nfollowed by tertiary symptoms.\n\n6. The tertiary stage. In this period gummata form, or there may be\ndiffuse infiltration of various parts of the body, chronic\ninflammation and ulceration of the bones, skin and other tissues,\nnervous diseases, and so on. The tertiary stage commonly begins from\nthree to four years after the primary infection.\n\nThe three chief divisions, which are apt to blend one into the other,\nare the primary, secondary, and tertiary periods.\n\nThe affections of the secondary stage are often severe. There may be\nfever associated with weakness, headache, general malaise and pain,\nand this may be marked or rather light. In this stage iritis is liable\nto occur, and if it is not properly diagnosed and treated it will\nresult in blindness.\n\nThe lesions of the tertiary stage may cause great destruction of\ntissues and very grave consequences. Cerebral syphilis, if unchecked,\nwill inevitably cause paralysis or paresis. There may be loss of\nspeech, epilepsy, coma, paralyses, apoplectic hemiplegia, and so on.\nThe pain is harassing and often it amounts to great anguish. Whatever\npart of the brain substance is destroyed will not be restored.\n\nIn syphilitic affections of the spinal cord, if the inflammation is\nacute death ensues in a few days or weeks. _Tabes dorsalis_, or\nlocomotor ataxia, is caused in about 93 per centum of cases of this\ndisease by syphilis, and it is an incurable and dreadful malady.\n\nIf there is neuritis from the virus it becomes intense and causes\nmuscular contractions, paresis, and paralysis. The optic, auditory,\nand olfactory nerves may be attacked and destroyed. The nose also may\nbe destroyed and it commonly caves in. The bones of the face are\nfrequently attacked in the tertiary stage and they rot away. The tibia\nis diseased more frequently than the other long bones.\n\nThe heart is rarely injured, but when it is, the prognosis usually is\nbad. In a large number of cases death is sudden and unexpected. If the\narteries are involved the prognosis again is bad, because the symptoms\nhere do not show until {313} too late for effective treatment When the\nliver is the seat of gummata these may be cured in the early stage,\nbut in the later stage the prognosis is unfavourable. Some forms of\nrenal syphilis are remediable, but others are not, especially the\ninterstitial kind.\n\nSyphilis is transmitted to a child congenitally, not as a tendency or\npredisposition, but as an active contagion. It may come from the\nfather, the mother, from both parents, or by direct infection.\n\nThe transmission from the father is the most frequent. The spermatozoa\ncarry the infection to the maternal ovum. Down to the end of the\nsecondary stage, and half through the intermediate period between the\nsecondary and tertiary stages of syphilis, a father or mother may\nbeget a child that will be infected with hereditary syphilis, a\nshivering, blasted, rotten little wretch for whom a quick death is the\ngreatest imaginable blessing, and it usually gets this blessing. In\nthe acute stage of a virulent syphilis the disease is most likely to\nbe transmitted; but sometimes, though rarely, a father that has been\nfree from all symptoms of syphilis for many years may beget a child\nthat is born with a virulent hereditary form of the disease.\n\nInfection by the mother is more certain and more harmful than that\nfrom the father, because the intrauterine life of the child is\npoisoned throughout its course. Two-thirds of the cases of hereditary\nsyphilis die either by abortion, or if they live to term they die\nshortly after delivery. If the mother is infected during the first\neight months of pregnancy the child will nearly always be syphilitic,\nbut if she is infected after the eighth month the child may escape.\n\nIf at the moment of conception both parents have the disease the child\nwill almost certainly take it, and this infection will cause its\ndeath. In a series observed by Fournier, 28 per centum of the cases\ncaused by paternal infections died and 37 per centum showed the luetic\ntaint; in the cases caused by maternal infection 60 per centum died,\nand 84 per centum had syphilitic lesions; in the mixed heredity, that\nis when both the father and mother were luetic, 68.5 per centum died\nand 92 per centum were born syphilitic. When a child {314} is first\ninfected at delivery the case is not technically classed as hereditary\nsyphilis.\n\nDuring the first year after the father or mother has taken syphilis\nthe probability of infecting the child is the greatest. In the third\nyear the liability of infecting the child is lessened, but present. In\na series of 562 cases of hereditary syphilis observed by Fournier, 60\nchildren, over 10 per centum, were infected more than six years after\nthe primary parental infection. Carefully observed cases have been\nexceptionally found where infection of the child has occurred in the\nfifteenth and even the twentieth year after the original parental\nlesion. Fournier reports the case of one woman that had nineteen\nconsecutive stillbirths from syphilis.\n\nMild parental syphilis may transmit hereditarily the most malignant\ntype of the disease, and very virulent parental infection may result\nin a comparatively mild infection of the child, if any infection by\nsyphilis may be called mild. That the parent shows no symptoms from an\nold infection is no proof that he or she is cured, or that the child\nmay not be infected.\n\nWith proper treatment of the mother the infantile mortality in\nhereditary syphilis is reduced from 59 per centum to 3 per centum, and\nthe children that are born living are not unfrequently free from\nsyphilis. When a woman is infected at the conception of her child\nmiscarriage takes place before the child is viable, from the first to\nthe sixth month; later other miscarriages occur; later still, living\nbut syphilitic children are born, of whom one-fourth die within the\nfirst six months; finally she may have children that are not infected.\n\nIf a syphilitic man has been properly treated he may, after four\nyears, beget healthy children, and he commonly does, but he may be the\nfather of syphilitic children. Syphilitic women properly treated may,\nafter about six years from infection, bring forth healthy children,\nand they commonly do, but not always.\n\nThere is a wide diversity of opinion among the best authorities\nconcerning the curability of syphilis. Gowers (_Syphilis and the\nNervous System_. 1892) says: \"There is no evidence that the disease\never is or ever has been cured, the {315} word 'disease' being here\nused to designate that which causes the various manifestations of the\nmalady.\" He means there is no absolute proof that a person who has\nonce been infected is ever so fully cured that he may marry without\ndanger of transmitting the disease.\n\nFournier requires, as the minimum time, four years of methodical\ntreatment before he deems the patient safe, but even this arbitrary\nfixing of the number of years is not warranted by experience. Many\nphysicians hold that in the tertiary stage the disease is not\ntransmissible, but that statement is not true. Commonly it is,\nsometimes it is not. After all symptoms have disappeared the disease\nhas been transmitted.\n\nIn short, a person that wittingly marries any one who has had syphilis\nat any time is a fool; and if one of the contracting parties has had\nsyphilis within the four years preceding the marriage the marriage is\ncriminal, even if the syphilis has been carefully and skilfully\ntreated by a physician.\n\nGonorrhoea is always a dangerous disease. In the male, beside the\nacute lesions, it can cause chronic or fatal inflammations along the\nvarious parts of the genito-urinary tract or in different organs of\nthe body. When the disease becomes chronic it lasts indefinitely. It\nmay then cause cystitis, or so affect the kidneys as to bring about\nvery grave results; it may get into the circulation and induce\ngonorrhoeal rheumatism of the joints, especially of the knee joint,\nand result in a partly or completely stiffened joint. The heart may be\naffected and endocarditis ensue; there may be meningitis or\ninflammation of the cerebral membranes; the eye may be infected, and\nunless it is skilfully treated blindness will follow. Strictures of\nthe male urethra from chronic gonorrhoeal inflammation often require\nmajor surgical operations for relief.\n\nThe disease in women has most of these complications, and other grave\npeculiar phases. All prostitutes have acute or chronic gonorrhoea, and\n12 per centum, probably more, of reputable women are infected; and the\nsuffering caused is very great. The gonococcus remains virulent for\ntwo or three years at the least in a man's chronic gleet, and if he\nmarries he infects his wife. Should her womb be infected {316} she is\nseldom completely cured. If the Fallopian tubes are involved, and this\nhappens frequently, they suppurate, and often they must be removed by\ncoeliotomy. The woman suffers for a long time when the tubes are\nattacked by the disease, and she becomes sterile ordinarily.\n\nWhen a child is born to a woman that has gonorrhoea its eyes are\ninfected at delivery, and if it is not very skilfully treated it will\nsurely lose its sight. Because of this danger, in maternity hospitals\nthe eyes of all babies are treated at delivery as a precaution, and\nmany physicians observe the same precaution in private practice.\n\nWhen, therefore, a man has chronic gonorrhoea he should not marry\nuntil about four years after the last infection, and he should be\ncarefully treated in the meantime. There is a popular opinion that\ngonorrhoea is a trifling disease, but the contrary is the truth: it is\na grave disease, especially in women; and the person that carelessly\ninfects another is certainly guilty of crime for which a long term in\njail would be a light punishment.\n\nAUSTIN OMALLEY.\n\n\n{317}\n\nXXIX\n\nSOCIAL DISEASES\n\n\nThere are certain affections not at all uncommon and as a rule\nproducing rather serious effects upon the social body, of which,\nthough their existence is well known to all, very little is said. It\nis certain that what is considered the more severe of these venereal\ndiseases may be acquired quite innocently. Indeed, many thousands of\ncases of this affection, acquired innocently, have now been reported\nby medical men in this country alone. If the statistics of all the\nworld were gathered together, there would probably be a hundred\nthousand cases of this dreadful affection, which have been acquired\nwithout any blame on the part of the sufferer. It has become the\ncustom, especially in English speaking countries, to ignore the\npresence of these diseases, and this has led to a multiplication of\nopportunities for their spread to such a degree that now the condition\nof affairs, for those who know it best, is rather alarming. It is with\nthe intention that a few definite ideas, given absolutely without\nexaggeration and without any striving after effect, may enlist\nclergymen, as well as physicians, in a crusade against these diseases,\nthat the present chapter is written.\n\nIt has been said over and over again at medical society meetings that\nit is a very unfortunate thing that universities in these modern times\nare situated in large cities. The young man just freed from the\nrestraints of home life, or of the seclusion of a college, is at once\nwithout any preliminary training, exposed to all the dangers, moral\nand physical, of large city life. Not only is this true, but he is\neven not properly warned of the dangers that lie so close to his path.\nOur prudery has gone so far that the very names of these {318}\naffections are tabooed and above all must not be mentioned before the\nyoung. As to the awful evils that such diseases may cause, as to the\nlifelong suffering, even to mental degeneration and early death, that\nthey may involve, not even a hint is considered to be proper. The\nconsequence is that young men expose themselves not infrequently to\ndanger, absolutely unknowing the significance that such diseases have\nin recent years acquired in the minds of modern physicians, and it is\nusually not until a serious mistake has been made that the young man\nis brought in contact with the physician who may be frank in pointing\nout evils utterly unknown before.\n\nThis state of affairs has come to be considered as so irrational in\nmany foreign universities that now a special course of lectures is\ngiven every year on the significance of what may be called the social\ndiseases. The students are told very frankly what the possibilities of\ndanger for them in certain excesses may be, so that at least the young\nman can not say \"I knew nothing about it,\" when the risk becomes an\nactual reality of danger. At the University of Berlin the first course\nof such lectures was established, and the interest aroused and the\nresults obtained were such as to make other universities consider the\nadvisability of such lectures for their students. Even here in prim\nand prude America, one or two of the great universities have come to\nthe realisation that the physical well being of their students is\ncommitted to their care, as well as their intellectual development,\nand at least a beginning of that precious wisdom that comes from the\nfear of the physical evils of sin has been acquired because of\nopportunities provided by the faculty.\n\nIt is well admitted now by all that ignorance is not innocence and\nthat knowledge of the consequences of social diseases is likely to be\na very important factor in preventing young men from taking risks that\nwould otherwise be considered very slight, perhaps. As a matter of\nfact, nothing can be more helpful from the ethical standpoint than\nthis knowledge of how closely may follow the wages of sin, which is\ndeath. It is for this reason that clergymen would seem to owe it, as a\nduty to themselves and their position in social {319} life, to acquire\na certain knowledge of these affections. A very great change has come\nover the attitude of the medical profession towards the so-called\nvenereal diseases in recent years. A quarter of a century ago they\nwere considered to be not very serious after all, and indeed in some\ncases to be no more serious than a cold, a mere passing incident in\nlife. Now it is well recognised that almost never do they leave their\nvictim in the state of health in which he was before, and that\nunfortunately the deterioration of tissues which has taken place is\nlikely to be enduring. Even many years afterwards there may be serious\ncomplications involving health or even life.\n\nFor instance, it is now very generally conceded that paresis, or what\nis sometimes called general paralysis of the insane,--a progressive\nmental and nervous disease, which invariably ends fatally in from\nthree to seven years,--is always due to one of the so-called social or\nvenereal diseases. How important this affection has become in modern\nlife can be best appreciated from the fact that in Europe nearly one\nin four of those who die in the insane asylums are sufferers from\nparesis. In this country the disease is not so frequent, the\nproportion being less than one in five or even one in six. The disease\nis becoming more and more common, however, as large city life becomes\nmore prominent, and as the possibility of infection with social\ndiseases is more widespread.\n\nParesis is what is sometimes called softening of the brain, and it\nattacks by preference men under thirty-five. The first symptoms of it\nas a rule are not alarming. A young man's disposition changes, so that\nan individual heretofore rather stingy becomes extravagant, while\noccasionally a prodigal becomes very saving and considers that he has\nalready a large sum of money to his credit. The most prominent feature\nof the early stage of the disease is the occurrence of delusions of\ngrandeur, that is to say, the patients get the idea that they are\nimportant personages, or that they have fallen heirs to a large sum of\nmoney, or that they have been appointed to high salaried positions. As\na consequence of these delusions, they may make expensive presents to\ntheir friends. Occasionally there are other changes in disposition. A\nyoung {320} man, for instance, who has been of genial character\nbecomes morose and hard to live with. The opposite change to greater\nliveliness of disposition is not unknown, but is more infrequent.\nSometimes there are marked excesses, high living, luxurious habits,\nand the like, before the existence of disease is recognised.\n\nThe mental stigmata of the disease at the beginning are not alarming\nat all. There are slight lapses of memory. A man who has hitherto been\nknown as an accurate mathematician, makes frequent mistakes in adding\nor multiplying. The physical signs are even slighter. In using long\nwords, syllables are omitted from them. A favourite method of testing\nthe speech of a person suspected of beginning paresis is to ask for\nthe pronunciation of a word like Constantinople. Usually a syllable\nwill be elided, and the reply will be \"Constanople,\" or something\nsimilar. There is a slight tremulousness of the hands and usually a\nrather easily marked tremor of the lips, especially when the tongue is\nprotruded. Often in the very earliest stage of the disease, there are\nchanges in the pupils. They may be unequal, or may fail entirely to\nreact to light.\n\nWhen these signs are positive, that is, when there is a change in\ndisposition and then the physical stigmata that we have gone over\nappear, the diagnosis of the disease is almost certain. The physician\nis able to say, with considerable assurance, that the young, strong,\nhealthy-looking patient, who has often had to be tempted to come to\nsee the doctor by some specious reason, because he does not consider\nhimself that he has anything wrong with him, will have to be confined\nin an asylum within a year, or at most, two, and will die in a state\nof dementia within five years. This, of course, is an awful picture.\nThis is the course of the disease in nearly 20 per centum of the\ninmates of our asylums. Almost without exception there is a history of\nsyphilis in these cases, and the medical world is now persuaded that\nthis is the most important factor in the production of paresis.\n\nAnother nervous disease, corresponding in some of its features to\nparesis and indeed sometimes spoken of as a spinal form of paresis, is\nlocomotor ataxia. This affection {321} begins usually with loss of\nsensation in the soles of the feet so that the patient thinks that he\nis walking on carpet all the time. Before this there may have been\nsome disturbance of vision. The pupils may fail to react to light.\nOccasionally the first symptoms are motor, that is, the man notices\nthat he is not able to walk as readily as before. He staggers easily.\nIf he tries to turn round while walking he is apt to lose his balance.\nIf he tries to walk in the dark, he is almost sure to have so great a\nsense of insecurity that he dare not go far from the wall.\nOccasionally the first sign is a sinking of the limbs on the way down\nstairs. In certain very sad cases, the first and only symptom is a\nfailure of sight which goes on progressively, until the optic nerve is\ncompletely destroyed and sight forever rendered impossible.\n\nAll these symptoms are traceable directly to certain changes which\nhave been noted in the spinal cord. These changes are due to\ndisturbance of the blood and lymph supply of the nervous tissue. Once\nthe changes have taken place, there is no hope of the patient ever\nrecovering the normal use of his limbs. Not infrequently he becomes\nbedridden and can not walk at all because he is not able to steady\nhimself. He may not suffer in his general health, however, to any\nserious extent, and may live on for twenty years, though usually his\nresistive vitality is lowered and he is carried off by some\nintercurrent disease.\n\nAt times locomotor ataxia begins with very severe pain seizures, known\nas crises. These may occur in the legs or arms or in the stomach or\nsometimes in other organs. Occasionally they are the first symptoms of\nthe disease that are noticed, and they may continue for months or even\nyears before other symptoms manifest themselves. This sometimes makes\nit difficult to recognise the disease for what it really is. The pains\nare usually most excruciating, are tearing or boring in character, and\nare sometimes described by the patient as being similar to the\nsensation that would be felt if a red hot iron were forced into them,\nor if a knife were inserted and then twisted round. Hence the\ndescriptive name which has been applied to them of \"lightning pains\"\nwhich describes the suddenness of their onset and the intensity of\ntheir character. {322} Most of the ordinary anodyne or pain-killing\nmedicines fall to influence them, and the patient is one of the most\npitiable of objects while they last.\n\nIt is now conceded on all sides that at least 75 per centum of the\ncases of tabes are directly due to syphilis. Indeed this affection and\nparesis are sometimes spoken of as parasyphilitic affections.\nUnfortunately the ordinary treatment for syphilitic manifestations\ndoes not affect them in the least. So far as we know at the present\ntime, there is nothing that will hinder the course or prevent the\nprogress or alleviate the symptoms or have any curative action on\neither of these dreadful diseases. They are much more common in Europe\nthan they are in this country, but have been seen here with quite\nsufficient frequency in recent years to make physicians, at least,\nrealise the necessity for having young men appreciate the dangers they\ninvite in thoughtlessly yielding to the temptations of great city\nlife.\n\nThere are other affections which can be traced directly to the social\ndiseases. One of the most important of these consists of certain brain\ntumours which may even cause death if not properly treated. These\nsyphilitic brain tumours frequently cause paralysis and may lead to\npermanent changes in the nervous system with consequent loss of motor\npower. Whenever the symptoms of brain tumour occur, careful inquiry is\nmade as to the previous existence of syphilis in the case, in order to\ndetermine, if possible, if this is the morbid agent at work. If there\nis a history of syphilis it is usually said to be fortunate, for brain\ntumours due to syphilis may be made to disappear by the proper use of\nmercury and the iodides. If the treatment of the case is delayed,\nhowever, alterations in the nerve substance take place which can not\nbe improved.\n\nThis disease affects especially the blood vessels and, as a\nconsequence of the thickening of the coats of the arteries, blood may\nbe shut off from certain portions of the brain entirely. This will, of\ncourse, produce symptoms of paralysis. Indeed, whenever paralytic\nsymptoms manifest themselves under forty years of age, the physician's\nfirst thought is sure to be that there is syphilis in the case. This\nis not always {323} true, for by heredity and very hard work\noccasionally arteries become so degenerate that they rupture before a\npatient has reached many years beyond forty, but the case is always\nsuspicious. In this, as in the corresponding instance of brain tumour,\ntreatment, if applied sufficiently early, may not only give relief of\nall the symptoms, but produce a complete cure. That is, at least the\nsymptoms are relieved for the time, though there may be relapses.\nUsually these relapses are quite amenable to treatment, but sometimes\nthey get beyond the control of the physician and death ensues. It is\nalmost the rule where there have been serious nervous symptoms once,\nthat recurrences of them must be feared, and they will eventually\nshorten the patient's life.\n\nSyphilitic manifestations of serious character develop, however, not\nonly in the nervous system, but also in certain of the important\ninternal organs. The liver may become so much affected as to refuse to\ndo its work. Solid tumours may develop in the stomach, or along the\ncourse of the intestines, resembling cancer so much that occasionally\noperations are performed for their removal. As a rule, however, these\nyield quite promptly to proper antisyphilitic treatment. Whenever an\nobscure intraabdominal tumour is present, accordingly, it has become\nthe custom among physicians and surgeons not to make an absolute\ndiagnosis nor to perform any serious operation until antisyphilitic\ntreatment has been tried. The surprises of such treatment constitute a\nvery interesting chapter in obscure diseases in medicine.\n\nAs we said at the beginning, it is perfectly possible to have\ncontracted the disease innocently, and indeed, the first\nmanifestations may be so mild as to fail to attract the patient's\nattention. In these cases there will be no history of syphilis, yet\nthe test of antisyphilitic treatment will demonstrate that the disease\nhas been present. Not a few physicians have died from these serious\nmanifestations of syphilis after having contracted the disease through\na cut on the finger or the prick of an infected needle in the ordinary\ncourse of their professional work. Some of these cases in young men\nprove to be especially malignant and fail to react to treatment, so\nthat a fatal issue takes place within a few years.\n\n{324}\n\nOn the other hand, in general it may be said that the disease is\neminently curable, though it may require great care on the part of the\npatient and the avoidance of all excesses either of work or indulgence\nfor the rest of life. It has often been noted that people who live in\nthe midst of serious emotional strain are most likely to suffer from\nmanifestations of syphilis in their nervous system. Hence it is that\nparesis and locomotor ataxia are comparatively quite common among\nactors, brokers, and financiers. They are also quite common among sea\ncaptains and military men who are exposed to severe hardships and have\nto assume weighty responsibilities. In such men the previous attack of\nsyphilis has so weakened the nervous system that it degenerates under\nthe strain placed upon it by the subsequent responsibilities. These\ndiseases are very uncommon among clergymen and are less common in\nIreland than in any other country in the world, which would serve to\nconfirm the opinion that the venereal disease is a prominent factor in\ntheir causation.\n\nWe would not have the idea be assumed that syphilis is an incurable\ndisease and is bound to be followed in all cases by the awful\nmanifestations that we have described. There are many thousands of\ncases of syphilis that never have any of these serious manifestations\nat all. It is evident that some cases are completely cured and that no\ndeleterious influence remains. On the other hand, it must not be\nforgotten that the presence of this disease in the tissues of either\nparent during the first five years of its course are almost sure to\naffect offspring born at this time. The children may suffer from the\nskin lesions of syphilis in their early life, may suffer from serious\neye diseases a little later, and then eventually succumb to nervous\nand mental diseases resembling paresis and locomotor ataxia in early\nadult life. In fact it is this transmission of the disease that\nconstitutes one of its saddest pictures, and the sins of the parents\nare indeed visited on the children.\n\nBesides this severer type of social disease, there is what has been\ncalled sometimes a milder form. It consists only of a discharge with\nsome fever, which is considered to last not more than a few weeks. As\na matter of fact, however, the disease may continue to exist, though\nthe symptoms become latent {325} and the patient may infect others\nwhen he least suspects it. This form of disease gives rise to many sad\ncomplications in family life. Practically all the severe eye diseases\nof newly born children, the ophthalmia from which so many eyes are\nlost, is due to this disease. Special medical care is now taken of\nthese cases, and the serious consequences are not so often seen as\nused to be the case. Within a score of years, however, about one-half\nof the inmates of blind asylums owed their loss of sight to this\ndisease. At the present time there still remains a very notable\nproportion of persons blind from early childhood whose infirmity must\nbe attributed to the sad consequences of the social disease.\n\nMost of the sterility in families is due to the same cause. There is\nan unfortunate impression that usually the woman is responsible in\nthese cases, and not a little sympathy is wasted on the man, because\nof the absence of children in the family. Almost invariably, however,\nthe real cause of the family misfortune is to be traced to an\ninfectious disease in the man contracted perhaps many years before, of\nwhose presence he may be more or less unconscious, the symptoms have\nbecome so slight, but this has proved sufficient to infect the wife\nand bring about serious changes that preclude all possibility of the\nprocreation of children.\n\nThese statements may seem exaggerated. On the contrary, they are\nrather understatements of actualities. No one who knows the real state\nof the case will fail to realise this. Physicians themselves have only\ncome properly to appreciate the true state of affairs in the last\ntwenty years. We need a coordination of all the forces that make for\nsocial amelioration in modern life to correct present false\nimpressions.\n\nJAMES J. WALSH.\n\n\n{326}\n\nXXX\n\nDE IMPEDIMENTO MATRIMONII DIRIMENTE IMPOTENTIA\n\nHoc argumentum praecipue ad juris consultos ecclesiasticos et civiles\npertinet; et quamvis differentia sit inter jurisdictionem judicis\ncivilis et ecclesiastici tamen judicium utriusque quatenus necessario\npendet ab existentia conditionum physicalium in medici consilio situm\nest. Obscuritas doctrinae et quidem gravis de hoc impedimento, libris\nmoralistarum, medicorum et juris consultorum perlectis, invenitur; et\nquamvis, elapsis perpaucis annis, fere omnis liber tractans de\nscientia medicinali parva fide dignus, tamen multa ex editis\nphysiologorum veterum tanquam vera a moralistis praesertim\npromulgantur. Hae difficultates per ignorantiam anatomiae et\nphysiologiae genitalium non minuuntur. Ut auxilium, si quid sit, ad\ndifficultates solvendas feram, species et gradus Impotentiae hie\ncollegi tanquam medicus, eo modo ut conditio physica clarius\ncognoscatur.\n\nIn unoquoque Statuum Foederatorum Americae Septentrionalis impotentia\nratio sufficiens divortium obtenendi est, in plurimis autem\nmatrimonium irritum ab initio non reddit. Impotentia vel temporanea\ncausa divortii esse potest si impotens intra spatium temporis\nrationabile remedium medicinale recuset. Sub lege civili Americana\ncontrahens qui tempore matrimonii ineundi certior erat de impotentia\nconsortis jus divortii petendi propter abnormalitatem istam amittit.\nProcrastinatio longa et inexplicabilis divortii petendi, et etiam\ninscitia culpabilis impotentiae consortis divortium impossibile coram\njudice civili reddunt.\n\nConditio haec etiam impedimentum dirimens matrimonii sub lege canonica\nEcclesiae est. Si impotentia contractum matrimonii anteat et perpetua\nsit, matrimonii contractus {327} solvitur ipso facto, quandocumque\ndetegitur. Procrastinatio aut ignorantia culpabilis non excusant.\n\nJurgia oriuntur ex eo quod impotentia cum sterilitate saepius\nconfunditur. Juris consulti civiles infrequenter hoc modo offendunt,\nmedici autem et moralistae crebro in errore isto versantur. Juris\nconsulti Americani et medici de impotentia doctrinam accipiunt\nlibrorum praesertim _On Domestic Relations_, auctore Irving Browne\n(Boston. 1890), _A System of Legal Medicine_, auctore Allen MacLean\nHamilton (Neo-Eboraci, 1897), et _A Manual of Medical Jurisprudence_,\nauctore A. S. Taylor (Neo-Eboraci, 1897). Irving Browne (op. cit.)\nait: \"Ubi Impotentia adsit nullum habetur matrimonium validum.\nImpotentia autem incapacitatem prae se fert physiciam, non meram\nfrigitatem, declinationem seu repugnantiam, neque etiam recusationem\nabsolutam coitus sexualis. Neque sterilitas nec malformatio quae\ncopulam non impediant, neque infirmatio quaecumque sanabilis\nincapacitatem gignunt. Impotentiam tempore ineundi matrimonii\nexstitisse necesse est.\" Eadem est doctrina Schouleri et Baldwinii.\n\nWhite et Martin, medici, (_Genito-Urinary and Venereal Diseases_.\nPhiladelphiae. 1897.) impotentiam ita definiunt: \"Inabilitas actus\nsexualis perficiendi. Non necessario cum sterilitate consociatur,\nneque necesse est quod sterilis impotens sit.\" Et ita alii omnes.\n\nSignificatio vocis Impotentiae sub lege canonica deducitur, (1), ex\ndijudicationibus Pontificum Romanorum, aut (2), ex judiciis\nCongregationis Sancti Officii, tribunalis ad sententias hujus generis\npronuntiandas instituti, aut, (3), ex legis interpretatione a\nmoralistis scientia praeditis.\n\nSixtus V, Pontifex Romanus, (Const. _Cum frequenter_, anno 1587)\ndecrevit eunuchos impotentes esse sensu legis canonicae de Impotentia,\nnullum autem judicium papale totam questionem conficit. Congregatio\netiam Sancti Officii in perpaucis casibus particularibus dijudicavit\nsed legem nullomodo distincte definiebat. Norma igitur a nobis\nsequenda ex interpretatione moralistarum est depromenda.\n\n{328}\n\nLex non est decretum mere disciplinare: e natura ipsa contractus\nmatrimonialis desumitur. Ballerini (_Theol. Mor._, vol. 6, p. 658)\nscribit matrimonium consistere \"in mutua traditione potestatis ad\ncopulam conjugalem.\" S. Thomas (_Supplem. Sum, Theol._, q. 58, a. 3)\nait: \"In matrimonio est contractus quidam, quo unus alteri obligatur\nad debitum carnale solvendum: unde sicut in aliis contractibus non est\nconveniens obligatio si aliquis se obliget ad hoc quod non potest dare\nvel facere, ita non est conveniens matrimonii contractus, si fiat ab\naliquo qui debitum carnale solvere non possit; et hoc impedimentum\nvocatur _impotentia coeundi._\"\n\nAntequam explicationem a moralistis pleniorem vocum \"Impotentia\ncoeundi\" dabamus, attendendum accurate est ad definitionem matrimonii\nfinum a S. Alphonso Liguorio (_Theol. Mor._, lib. vi., n. 882) datam.\n\"_Fines_,\" inquit, \"intrinseci essentiales [sc. matrimonii] sunt duo:\ntraditio mutua cum obligatione reddendi debitum, et vinculum\nindissolubile. _Fines intrinseci accidentales_ pariter sunt duo:\nprocreatio prolis et remedium concupiscentiae. _Fines_ autem\n_accidentales extrinseci_ plurimi esse possunt, ut pax concilianda,\nvoluptas captanda, etc. His positis, certum est quod si quis\nexcluderet duos fines intrinsecos accidentales, non solum valide, sed\netiam licite posset quandoque contrahere; prout si esset senex et\nnuberet sine spe procreandi prolem, nec intenderet remedium\nconcupiscentiae; sufficit enim ut salventur fines substantiales, ut\nsupra.\"\n\nHaec sententia S. Alphonsi magni momenti est, et in ea solutio\nmultarum difficultatum inveniri potest. Dicit hic (1) fines\nintrinsecos essentiales matrimonii esse traditionem mutuam cum\nobligatione reddendi debitum, et vinculum indissolubile, atque illis\ndemptis nullum matrimonium; (2) procreationem autem prolis et remedium\nconcupiscentiae abesse posse, et tamen matrimonium esse validum si duo\nfines essentiales adsint.\n\nSanctus hoc loco infert, ut patet e contextu alibi (_e. g._, lib. vi.,\nn. 1095, res. 2), traditionem mutuam potestatis ad copulam carnalem\nnecessario potentiam coeundi supponere, potentiam autem generandi non\nesse necessariam nec remedium concupiscentiae. In libro vi., n. 1096,\nait: \"Impotentia est illa propter quam conjuges non possunt copulam\nhabere per se aptam ad generationem; unde sicut validum est\nmatrimonium {329} inter eos qui possunt copulari, esto per accidens\nnequeunt generare, puta quia steriles aut senes, vel quia femina semen\nnon retinet, ita nullum est matrimonium inter eos qui nequeunt\nconsummare eo actu, quo ex se esset possibilis generatio.\"\n\nDistinctio haec inter potentiam coeundi et potentiam generandi a\nmoralistis omnibus datur; illa autem data, plurimi distinctionem\nobliviscuntur et sterilitatem simplicem cum impotentia confundunt.\n\nA. Konings, C.SS.R., (_Theol. Mor._, ed. 7, vol. 2, p. 276) haec\nhabet: Impotentia est \"incapacitas ad copulam carnalem, per se aptam\nad generationem.\" In n. 1619, Sec. 5, ait: \"Non est confundenda\nimpotentia coeundi cum impotentia generandi. Hinc steriles et senes\nqui matrimonium consummare valent, valide contrahunt, item mulieres\nquae possunt semen excipere, etsi illud non retineant.\" Hanc doctrinam\nS. Alphonso refert (_Theol. Mor._, lib. 4, n. 1095, ed. Mech. 1845),\net paragraphum hoc modo complet: \"Non tamen carentes utero vel\nvagina.\" Hoc est, tenet mulierem utero et vagina carentem impotentem\nesse. Unusquisque carentiam vaginae impotentiam esse admittit; mulier\nautem sine utero semen excipiendi capax est, concupiscentiam quoque\nmaris satiare potest. Sterilis tantum est. Potentiam etiam habet\ncoeundi, semen excipere potest et retinere, concupiscentiam quoque\nsatiare potest, etiamsi uterus, ovaria et tubi Fallopiani absint.\nPraeterea, _illi duo fines intrinseci essentiales matrimonii\nexistunt_.\n\nAugustinus Lehmkuhl, S.J., (_Theol. Mor._), alius illustris discipulus\nS. Alphonsi est Impotentiam definit: \"Defectus propter quern conjuges\nnon possunt copulam habere per se aptam ad generationem.\" Alibi\n(_American Ecclesiastical Review_, vol. 28, n. 3), de impotentia\nexcisioneque ovariorum scribens, ait: \"Puto, questionem propositam,\nutrum excisio ovariorum vel uteri constituat impedimentum dirimens\nnecne, _theoretice_ nondum esse plane solutam.\" Existimat autem\nquestionem _practice_ solutam esse judiciis Congregationis S. Officii,\nd. 3 Februarii, 1887, et d. 30 Julii, 1890, editis, matrimonium\nmulieris ovariis carentis et mulieris utero et ovariis carentis,\npermittentibus. Etiamsi haec judicia non edarentur tanquam leges\nformaliter generales, Lehmkuhl opinatur in {330} casibus ejusdem\ngeneris aptari posse. Re quidem vera illa doctrina sequi potest\npractice et theoretice; nulla enim est quaestio seria de impotentia in\nmuliere carente ovariis.\n\nJoseph Antonelli tamen (_De Conceptu Impotentiae et Sterilitatis\nrelate ad Matrimonium_, Romae, 1900) tenet carentiam ovariorum esse\nimpotentiam sub lege; et Casacca (_Amer. Eccl. Rev._, vol. xxvii, n.\n6, et alibi) eamdem opinionem sequitur. E contra, Marc (_Inst. Mor.\nAlphon._) docet carentiam ovariorum uterique non esse impotentiam.\n\nJoseph Hild (_Amer. Ecc. Rev._ vol. xxviii., n. 6) optime vindicat\nopinionem, nempe, carentiam ovariorum non esse impotentiam, et in\ncorpore tractatus citat definitiones impotentiae a moralistis egregiis\nprolatas.\n\nSchmalzgrueber (_Theol. Mor._, lib. iv., tit 15, n. 31) dicit: \"Sola\nimpotentia ad copulam dirimit matrimonium, non vero impotentia ad\ngenerationem.\"\n\nConinck (_De Sacr._, vol. ii., d. 31, dub. 7, n. 86) ita habet:\n\"Steriles ... si aliter potentes sint ad usum matrimonii, valide\ncontrahunt; quia nec generatio nec potestas generandi est de essentia\nmatrimonii.\"\n\nMastrius (_Dis. de Matr._, q. v., n. 114) ait: \"Impotentia est\ninhabilitas perpetua ad consummandum matrimonium . . . non est ex eo\npraecise quod alteruter conjugum aut uterque sint steriles, quia\nimpotentia ad generandum seu ad prolificandum, dummodo adsit potentia\nad copulam carnalem et seminationem, non est impedimentum dirimens, ut\nomnes passim concedunt cum Scoto . . . et ubi est certa impossibilitas\nad bonum prolis, tunc matrimonium est ibi in remedium, non in\nofficium.\"\n\nVincentius de Justis (_De Dispens. Matr._ lib. ii, c. 17, nn. 1, 2, 3)\nscribit: \"Impotentia ad matrimonium est duplex. Prima, quae\n_sterilitas_ dicitur, efficit ut proles generari non possit, ex se\ntamen matrimonium nec impedit nec dirimit, ut docent Sanchez, Guttier,\nConinck. . . . Ratio est, quia nec generatio, nec generandi potestas\nsunt de essentia matrimonii.\"\n\nS. Thomas (_Supplem_, q. 58, a. 1) in articulo de Impotentia, quam\n_Frigiditatem_ et _Impotentiam Coeundi_ nuncupat, nihil de sterilitate\nscribit, nec de impotentia generandi tanquam quid impotentiae coeundi\noppositum.\n\n{331}\n\nIn omnibus hisce definitionibus verba _de se, ex se, per se,_ et alia\nsimilia, adhibentur de copula carnali _qua copula_. Amort (_De Matr_,\nq. 101) de his verbis loquens ait: \"Impotentia est inhabilitas\ncorporalis ad copulam carnalem _de se_ ad generationem prolis\nidoneam.--Dicitur: _de se;_ potest enim contingere _per accidens_, v.\ng., ob debilitatem spirituum seminalium in viro aut femina, vel ob\n_indispositionem matricis_ in muliere, quod copula carnalis, etiam\nperfecta, hoc est, _per effusionem seminis in vagina_ mulieris\ncompleta, non sit idonea ad generationem prolis.\" Loquuntur\nmoralistae, ut dixi, de copula carnali quatenus copula est sine\nrespectu ad possibilitatem generandi.\n\nHisce omnibus positis, rogamus:\n\n(1), Quid sit impotentia sub lege in muliere?\n\n(2), Estne mulier carens ovariis, utero vel tubis Fallopianis\nimpotens?\n\n(3), Quid sit impotentia sub hac lege in viro?\n\n(4), Estne vir aspermatosus impotens, et quid de viris semen sterile\nhabentibus?\n\nI. _Impotentia Mulieris._ Mulieres steriles frequentius quam viris,\nviri autem impotentes frequentius quam mulieres sunt. Impotentia\nabsoluta et perpetua raro in mulieribus, in viris crebro invenitur.\n\nIn fundo pelvis femineae septum est a latere in latus, rectum inter et\nvesicam urinariam, et in medio hujus partitionis uterus, qui\npiroformis est, quasi ad perpendiculum jacet et cervix sua in vaginam\nintrat.\n\nA cornibus uteri, i.e., ab angulis superioribus, tubi Fallopiani\nprocedunt ad libellam, et apud terminos tuborum ovarium est in utroque\nlatere. Tubi aperti sunt prope ovaria, et non substantiae ovariorum\ncontinui. Si unum ovarium et tubus oppositi lateris demantur, vel si\ntubus iste occludatur, ovum ex ovario manente migrare per partem\nexteriorem uteri et foecundari potest.\n\nGenitalia externa mulieris e labiis majoribus praecipue constant;\nintra et inter haec labia minora seu nymphae sunt. Intra labia minora\nad summum versus clitoris est; infra hanc est meatus urinarius; infra\nmeatum, orificium vaginae. Per imam partem orificii in virginibus\nextenditur pellicula tenuis quae hymen vocatur. Haec communiter in\ncoitu primo rumpitur.\n\n{332}\n\nTempore mensium praesertim ova egrediuntur ex ovariis in tubos\nFallopianos et inde in uterum. Si ova non foecundentur per vaginam\namittuntur. Foecundatio in tube Fallopiano fit.\n\nIn muliere impotentia temporanea aut perpetua oriri potest e causis\nsequentibus:\n\n(1), propter hymenem imperforabilem aut cribriformem, aut septatum aut\nannularem;\n\n(2), propter vaginam duplicem;\n\n(3), propter vaginismum aut dolorem;\n\n(4), propter uterum prolapsum aut productionem cervicis uteri;\n\n(5), propter atresiam vaginae aut labia adhaerentia;\n\n(6), propter orificium vaginae in loco abnormali;\n\n(7), propter arctationem vaginae;\n\n(8), propter tumores aut incrementum morbidum intra vel circa\ngenitalia;\n\n(9), propter Sadismum;\n\n(10), propter Masochismum;\n\n(11), propter Sodomiam gradus secundi seu defeminationem; Sodomiam\ngradus tertii; Sodomiam cum horrore; Urningismum; Androgyniam.\n\n1. Aliquando vice hymenis normalis invenitur membrana densa seu\ncartilaginosa, aut membrana continua, aut cribro similis, aut tanquam\nseptum, aut annularis, quae impediat intromissionem. Operatione\nsimplici chirurgica conditio removetur.\n\n2. Raro septum adest quod vaginam in duas partes dividit et\nimpotentiae causa est. Chirurgus septum removere potest.\n\n3. Vaginismus contractio spasmodica musculorum ad orificium vaginae\nest, et haec vaginam claudit. Frequenter inter neuroses ideopathicas\nincluditur, scrutinium autem diligens locum inflammationis detegit qui\norigo est spasmi reflexi. Insolenter conditio ex hyperaesthesia\nmurorum vaginalium inducitur.\n\nMedicatio vaginismi examen expertum supponit et quandoque scrutinium\nendoscopicum vesicae urinariae. Fissurae in ano, endometritis\nchronica, urethritis granosa circa cervicem vesicae urinariae, causae\nprincipales sunt vaginismi, et istae {333} causae sanabiles sunt.\nInflammatio acuta vulvae, vaginae, uteri, tuborum aut ovariorum,\ncarunculae urethrales, urethritis, fissurae cervicis vesicae\nurinariae, haemorrhoides, fissurae recti, coccygodinia, ulcera uteri\net amotio uteri vel ovariorum e loco debito, possunt tantum dolorem in\ncoitu infligere ut mulier practice impotens fiat. Morbi autem isti\nfere omnes medicabiles sunt, sed tamen aliqui omnino pervicaces sunt.\nIn vaginismo hysterico et in aliis casibus insanabilibus intromissio\nfieri potest ope chloroformi ad evitandum divortium.\n\n4. Quando uterus prolabitur vel cervix producitur ita ut copula\nimpossibilis sit, chirurgus mederi potest.\n\n5. Atresia vaginae est occlusio vaginae in longum perfecta vel\nimperfecta. Nullum orificium invenitur. Congenita esse potest, et tunc\nplerumque desunt omnia organa generativa. Atresia etiam consequitur\nvulnera et inflammationes morborum, ut diphtheritis et scarlatina.\n\nUbi atresia per totam vaginam extenditur nullum datur medicamentum, et\nimpotentia absoluta et perpetua adest. Labia adhaerentia separari\npossunt.\n\n6. Aliquando sed perraro vagina in rectum aperit. Possibilitas\nremovendi impotentiam e loco orificii vaginae pendet.\n\n7. Arctatio vaginae oritur ex causis atresiae, et remotio conditionis\nquum impotentia inducat impossibilis esse potest.\n\n8. Tumores pudendi, vaginae et recti, hypertrophia labiorum et\nclitoridis, et elephantiasis labiorum copulam impedire possunt. Alii\ntumores et hypertrophiae removeri possunt, alii autem insanabiles\nsunt.\n\n9. Dantur perversitates sexuales quae viros impotentes reddunt, et\nhaec aliquando in mulieribus inveniuntur. Tales sunt Sadismus,\nMasochismus, et gradus Sodomiae praeter primum. Isti morbi animi\ncausae sunt impotentiae in muliere propter aversionem ejus virorum\netiamsi physice potens sit. Vix in matrimonium iniit talis mulier, et\nigitur perversitates istae parvi momenti relate ad mulieres, relate\nautem ad viros magni momenti sunt. De his quid infra dicendum erit.\n\n10. Senectus nunquam reddit mulierem impotentem, virum autem reddit.\nEtiamsi nihil ad impotentiam pertineat, hic {334} juvat dicere in\nlocis temperatis terrae parturitionem maxima ex parte desinere anno a\nnatu quadragesimo-quinto. Cessare potest anno vicesimo-octavo, et\nperstare post annum quinquagesimum. J. Whitridge Williams\n(_Obstetrics._ Neo-Ebor. 1903), casum citat mulieris quae anno\nsexagesimo-tertio aetatis puerum vicesimum-secundum peperit et postea\nmenses aderant. Parturitio aliquando decem vel duodecim annos post\nultimos menses evenit.\n\nNunc, estne mulier ovariis carens impotens? Nullo modo: sterilis\ntantum est. Nam (1) Congregatio S. Officii in matrimonium duas\nmulieres ovariis orbatas inire permisit. (2) Talis mulier capax est\ncopulae carnalis aeque ac mulier habens ovaria, et moralistae omnes\nconcedunt nil amplius requirendum ut matrimonium validum fiat. (3) Si\ntalis mulier impotens sit omnis mulier insanabiliter sterilis impotens\nesset, et discrimen a moralistis prolatum impotentiam inter et\nsterilitatem nugatorium esset et puerile. Mulier in qua tubi\nFallopiani occludantur sterilis est perpetuo; idem dicendum de muliere\nhabente uterum infantilem, vel ovaria rudimentaria, vel ovaria\nmorbida, et ita porro. Nemo autem tales tanquam impotentes unquam\ntenet.\n\nAliquando mulier ovariis orbata sensationem sexualem possidet, vulgo\nautem non possidet. In utroque casu tamen remedium idem\nconcupiscentiae mari perstat, et hoc sufficit pro viro ut matrimonium\nvalidum sit. Huc accedit, relate tum ad mulierem tum ad virum, quod\nduo fines intrinseci essentiales matrimonii, et fines sufficientes\njuxta S. Alphonsum, adsint, scilicet, traditio mutua cum obligatione\net possibilitate reddendi debitum, et vinculum indissolubile.\n\nSi in tali muliere existat sensatio sexualis, pro ea remedium\nconcupiscentiae habetur, sin minus, dantur saltem duo fines\nessentiales intrinseci matrimonii. Re quidem vera mulier carens\novariis et eodem tempore expers sensationis sexualis differt a muliere\nquae parturit sed sine sensatione sexuali est; nihilominus semper\nmanent illi ovariis carenti duo fines essentiales intrinseci\nmatrimonii.\n\nVetula communiter nequit parire et expers sensationis sexualis est,\nsed licite matrimonium contrahit. Conditio vetulae est eadem ac\nconditio mulieris ovariis orbatae. Lehmkuhl {335} (_Amer. Ecc. Rev._\nvol. 28, n. 3), in hanc assertionem urget excisionem ovariorum esse\nquid \"positive actum contra primarium matrimonii finem,\" quum senectus\nconditio naturalis sit Chirurgus honestus aut inhonestus nunquam\nremovet ovaria ut conceptio evitetur; operatio enim nimis periculosa\nest. Removentur ovaria primario ad morbum gravem medendum, et\nsterilitas consequens intenditur tantum per accidens. Remotio\novariorum igitur est quid _per accidens_ actum contra \"primarium finem\nmatrimonii,\" (et iste non est finis essentialis intrinsecus) seu\ngenerationem prolis; et nihil refert etiamsi positive actum esset si\nnon sit in fraudem legis. In casu mulieris habentis ovaria\nrudimentaria et nullam sensationem sexualem (casus enim quandoque\ncontingit) quid sit \"positive actum contra primarium finem\nmatrimonii\"? Estne una lex pro ista a natura castrata et alia pro\nmuliere a chirurgo castrata et tertia pro vetula senectute castrata?\n\nInter ovaria et testiculos analogia est, etiamsi obstet D. Bossu,\nmedicus Gallicus, a Professore Hild (_Amer. Ecc. Rev._ vol. 28, n. 1)\net Eschbach citatus. Demptis ovariis sensatio sexualis destruitur haud\nsecus ac quum testiculi removeantur, sed analogia incompleta est et\nclaudit. Eunuchus insuper incapax est communiter intromissionis, et\nsemper inseminationis. Moralistae vulgo docent inseminationem\nessentialem esse copulae carnali. Utcumque de inseminationis\nnecessitate veritas sit (de qua infra) eunuchus nequit satisfacere\nprimo matrimonii fini essentiali intrinseco, mulier expers ovariis\nsatisdare potest.\n\nCarentia aut occlusio tuborum Fallopianorum sterilitatem insanabilem\nefficit, sed usque adhuc nemo tenet illam carentiam vel occlusionem\nesse impotentiam. Conditio quoad potentiam generandi eadem est ac in\ncarentia ovariorum, sensationem autem sexualem proprie carentia\ntuborum non efficit. Idem omnino dicendum est de carentia uteri. Si\nvagina remaneat capax talis mulier copulae carnalis est.\n\nMulier igitur impotens est sub lege ecclesiastica tantum in quinque\ncasibus:\n\n(1), ubi atresia vaginae aut adhaesio labiorum insanabiles sunt: haec\natresia et adhaesio raro inveniuntur;\n\n{336}\n\n(2), in casu rarissimo in quo vagina in rectum aperit insanabiliter;\n\n(3), ubi arctatio vaginae immedicabilis sit: haec rara est;\n\n(4), quando adsunt tumores maligni aut incrementa morbida quae\nnequeant removeri;\n\n(5), in casibus defeminationis aut Urningismi (de quibus infra).\nSadismus et Masochismus et aliae perversitates sexuales ita\ninfrequenter observantur, in gradu saltem in quo impotentiam creant,\nut negligi possint.\n\nII. _Impotentia Maris._ Tractus genitalis viri, a testiculis ad meatum\nurinarium seu orificium penis, ad centimetra 81 (uncias fere 32)\nextenditur. Ex testiculis chorda spermatica per inguen infra cutem\ntransit, murum abdominalem penetrat per annulum inguinalem, et sub\nvesica urinaria urethram juxta cervicem vesicae intrat. Semen non ex\nuno fonte provenit. Secretio ista fluida est et cinerea, partim ex\ntesticulis qui in scroto sunt oriens et partim ex vesiculis\nseminalibus, prostate, glandulis Cowperi, et folliculis cryptisque\nurethrae, quae omnia extra scrotum sunt. Elementum essentiale in\nsemine cellulae sunt quae spermatozoa vocantur, et haec ex testiculis\nproveniunt. Locomotionis potentiam habent spermatozoa et in\nfoecundatione ovum penetrant. Secretio glandularum quae spermatozoa\nfert alkalina est et removet aciditatem urinae; acidus enim\nspermatozoa destruit.\n\nErectio penis praecedit ejectionem seminis, et centra nervosa\nerectionis et ejectionis in chorda spinale apud lumbos sunt. Erectio\neffectus est dilatationis arteriarum penis et occlusionis venarum quae\ncongestionem sanguinis efficiunt; postea musculi perineales aliique\nmusculi erectionem perficiunt.\n\nImpotentia maris in tria genera dividi potest; videlicet: Impotentia\nPsychica, Impotentia Atonica, Impotentia Organica:\n\nI. Impotentia Psychica.\nSpecies:\n\n  (1), Impotentia Psychica absoluta aut relativa;\n  (2), Sadismus;\n  (3), Masochismus;\n  (4), Fetichismus;\n\n{337}\n\n  (5), Eviratio;\n  (6), Urningismus;\n  (7), Sodomia cum horrore;\n  (8), Gynandria;\n  (9), Metamorphosis Sexualis Paranoica;\n  (10), Anaesthesia Sexualis;\n\n\nII. Impotentia Atonica.\nSpecies:\n\n  (1), Impotentia Paralytica;\n  (2), Impotentia e venenis;\n  (3), Impotentia ex irritatione.\n\n\nIII. Impotentia Organica.\nSpecies:\n\n  (1), absentia penis;\n  (2), penis multiplex;\n  (3), hypertrophia aut magnitudo penis vel praeputii;\n  (4), penis rudimentarius;\n  (5), adhaesio penis scroto, ingueni vel abdomini;\n  (6), hypospadias et epispadias;\n  (7), distortiones penis ex podagra, lue, rheumatismo, gonorrhoea;\n  (8), aneurysma corporum cavernosorum et varix venae dorsalis penis;\n  (9), frenum nimis curtum;\n  (10), anchylosis articulamenti coxendicis et abdomen permagnum;\n  (11), tumores et incrementa morbida circa genitalia, sicut herniae,\n  hydrocele, haematocele, elephantiasis, lipoma, carcinoma, sarcoma,\n  cystoma, enchondroma et fibroma;\n  (12), phthisis testiculorum et varicocele;\n  (13), anorchismus et castratio;\n  (14), prostratitis chronica;\n  (15), senectus;\n  (16), aspermia.\n\nI. Impotentia Psychica.\n\n1. Impotentia psychica ea est quae ex coercitatione inhibente cerebri\nin centrum genito-spinale exercitata devenit. \"Impotentia ex\nmaleficio\" veterum moralistarum est. Timor, luctus, gaudium magnum, et\naversio hanc impotentiam psychicam efficiunt. Quandoque {338} nuper\nmaritus propter excitationem passionis ejectionem praecocem vel\nerectionem debilem vel nullam habet. In his casibus impotentia\ntemporanea est si medicus peritus prudensque sit. Haec impotentia\nrelativa esse potest.\n\n2. Sadismus. Haec paraesthesia sexualis et aliae perversitates ex\nexcessu venereo deveniunt et impotentiam gignunt. Sadismus nomen habet\na quodem libidinoso Gallico marchione de Sade, saeculo duodevicesimo\nvigente. Datur libido magna erga alium sexum sed cum crudelitate in\nobjectum uriginis, quae crudelitas usque ad homicidium cum mutilatione\nfrequenter extendit, vel saltem adesse debet humiliatio personae\namatae.\n\nSadistae erant Nero et Tiberius; et exemplum infame erat Giles de\nLaval, qui A.D. 1440, supplicium capitis affectus est, post\ntrucidationem Sadisticam fere 200 liberorum inter octo annos.\nOccisiones apud White Chapel Londini probabiliter Sadisticae fuerunt.\n\nSadista impotens est exceptis casibus in quibus crudelis vel saltem\ncontumeliosus simul esse potest. Haec crudelitas gradus habet a\nSadismo symbolico, in quo crudelitas simulatur, vel mere dramatica\nest, per contumeliam veram usque ad homicidium et anthropophagiam.\nFormae etiam bestiales et sodomiticae inveniuntur. Sadista nullo modo\ntanquam semper insanus considerari debet, species autem suae pessimae\nparanoicae sunt, et degeneratio neurotica frequens est in familiis\nSadistarum.\n\nSadismus maris frequens est, sed Kraft-Ebing (_Psycopathia Sexualis_,\nPhiladelphiae, 1893) tantum duos casus inter mulieres invenit.\nFictiones antiquae de Lamiis et Marmolycibus ex actibus mulierum\nSadisticarum ortae sunt.\n\nNecrophilia, seu libido erga cadavera cum propensione ad mutilationem,\nspecies est Sadismi quae vulgo paranoica est.\n\n3. Masochismus. Haec degeneratio nomen habet a fabularum scriptore\nSacher-Masoch. Conditio est Sadismo contraria. Masochista uriginem\nhabet magnam uti Sadista, et nulla datur potentia sexualis sine\ncrudelitate vel humiliatione; crudelitas autem vel humiliatio in\nMasochistam ipsum vertenda est. Hic homicidium non intrat.\nMasochismus, natura sua passiva, vitium feminarum esse debet, sed\nsolummodo {339} casus unus in muliere inventus est a Kraft-Ebing.\nValde communis est inter mares.\n\nMasochismus Larvatus est species hujus degenerationis in qua sordes\nphysicae sordibus adduntur moralibus.\n\n4. Masochismus Symbolicus seu Fetichismus. Fetichista potens est\ntantum praesente parte vestium, e. g., calccus mulieris, vel aliud\nobjectum seu \"Fetich,\" quodcumque sit. Aliquando mera imaginatio\nsufficit. Tonsores furtivi capillorum puellarum quandoque Fetichistae\nsunt, et in capillis longis virorum attractio sexualis quandoque est\nmulieribus. Virtus musicorum saepe in capillis Samsoniis est plus quam\narte. Westermarck (_History of Human Marriage._ Neo-Eboraci. 1891)\ndescribit seditionem gravem mulierum in Madagascar quum Rex Radama\ncapillos longos militum tonderi jusserit. Relatio etiam est odores\ninter et passionem sexualem. Si nervi olfactorii catelli scindantur\ncatellus nunquam canem femineam recognoscit. Meretrices gaudent\nodoramentis pungentibus, e.g., moscho.\n\n5. Eviratio. Haec degeneratio gradus est Sodomiae. In gradu primo\nSodomiae impotentia non necesse adest, in gradu autem secundo semper\nadest. In hoc secundo gradu homo Sodomiticus meretrix masculina evadit\ncum maribus, atque transformatio profunda et stabilis animi\nsupervenit, ita ut mas se feminam esse in actu sexuali sentit. Hic est\neffeminatio usque ad statum criminalem pregrediens. Gradus initialis\nhujus status est amicitia inordinata inter duos pueros aut duas\npuellas.\n\nIn casibus firmatis evirationis, Sodomista agit tanquam pellex\nmasculina aliis Sodomistis, aut in vestibus femineis ut uxor se gerit.\nColoniae sunt Sodomistarum hujus generis in fere omne urbe magna; se\ninvicem cognoscunt, societates, choreas publicas, et dialectum\ncompletam habent, praesertim Berolini, Lutetiae-Parisiorum, Neapolis\net Washingtonii. Impotentes sunt ad copulam carnalem naturalem.\n\nSodomia cum effeminatione seu viraginitate frequens est inter\nmulieres. Hie degenerata marem mente evenit. Impotens vix dici potest,\nnisi propter aversionem sexualem a maribus.\n\n6. Urningismus. _Urning_ est vox Germanica ab Ulrichs inventa.\nUrningismus idem est in re ac Sodomia primi et {340} secundi gradus,\nsed additur mollitia scriptionis poesis, ambulationum imminente luna,\net aliorum hujusmodi.\n\n7. Sodomia cum horrore est similis evirationi et defeminationi, sed\nvice frigiditatis adest horror alterius sexus.\n\n8. Gynandria et Androgynia. In istis degenerationibus transformatio\nita profunda est ut Sodomista masculinus circa pectus et in modo se\ngerendi feminae similis sit physice, et virago virum evadat aspectu.\nExempla sunt _bote et mujerado_ inter Sioux et Pueblos Indos\nAmericanos.\n\n9. Metamorphosis Sexualis Paranoica species insaniae est in qua\npatiens imaginat sexum suum mutatum esse. Insanabilis est.\n\nDegenerationes istae fere omnes cum masturbatione incipiunt. Medicatio\nmoralis esse debet, sed Kraft-Ebing et von Schrenk-Notzing sanationem\nobtinuerunt ope hypnosis.\n\n10. Anaesthesia Sexualis status est in quo vir aut mulier omnino caret\nsensatione sexuali. Illi secus habent corpora normalia. Conditio valde\ninfrequens est. Kraft-Ebing enumerat decem casus congenitos in\nmaribus, et duos in feminis. Anaesthesia sexualis acquisita etiam\ninvenitur.\n\n\n\nII. Impotentia Atonica.\n\n1. Impotentia Paralytica. Centra nervosa sexualia in chorda spinale\napud lumbos atonica esse possunt propter morbum generalem, aut venena,\naut paralysem. Impotentia atonica frequens est in anaemia, diabete\nmellito, uraemia, cholaemia, lepra, rheumatismo, ataxia lumbali, lue\nchordae spinalis, myelitide, parese, et haemorrhagia cerebrali.\n\nAliqui tumores cerebrales impotentiam gignunt, paralysis diphtheritica\ncausa est impotentiae temporaneae, et conditio invenitur in cachexia\nalicujus morbi tabescentis. Phthisicus autem saepe potens est usque ad\nfinem vitae. Utrum impotentia perpetua sit necne ex natura morbi\ndependet.\n\n2. Impotentia ex venenis. Potentia sexualis minuitur vel destruitur\nabusu venenorum vel absorbendo eadem, uti opium, morphina, chloral,\npotassii bromidum et iodidum, cannabis Indica, carbonei sulphidum,\narsenium, antimonium, plumbum et iodum. Fabri, ut pictores\n(house-painters) et typographi, qui plumbo utuntur hoc modo patiuntur.\nAlcohol frequenter origo est impotentiae, et quandoque tabacum eumdem\n{341} affectum habet sine alio indicio physico. Impotentia pervicax\nesse potest ex utraque causa.\n\n3. Impotentia ex irritatione. Irritatio chronica urethrae prostaticae\ne libidine, gonorrhoea, masturbatione, urina acida aut neurosibus\ngenito-urinariis impotentiam inducit. Neuroses centrorum sexualium\nsensibiles aut motoriae esse possunt, et neuroses motoriae quandoque\nimpotentiam creant. Prognosis hujusmodi impotentiae fausta est nisi\nadsint spermatorrhoea et genitalium atrophia. Prostatorrhoea quoque\nimpotentiae causa esse potest, et hic prognosis melior quam in\nspermatorrhoea est. Athletae, ut pugil, cursor, et alii ejusdem\nclassis temporaliter impotentes esse possunt\n\nIII. Impotentia Organica. Mas impotens esse potest propter\nmalformationes congenitas aut acquisitas, morbos et defectus\ngenitalium.\n\n1. Absentia congenita aut postnatalis penis impotentiam insanabilem\ncreat.\n\n2. Penis rudimentarius causa impotentiae est, sed casus\namplificationis post matrimonium habentur.\n\n3. Penis multiplex rarissime impotentiam creat.\n\n4. Hypertrophia penis aut praeputii, et magnitudo relativa penis\nrarissime efficiunt hominem impotentem.\n\n5. Adhaesio penis scroto, ingueni vel abdomini reddit hominem\nimpotentem; sanabilis autem est conditio.\n\n6. Impotentiam quandoque creat hypospadias, seu absentia partis\ninferioris urethrae, et epispadias, seu absentia partis dorsalis\nurethrae; sed conditiones a chirurgo sanari plerumque possunt,\nquandoque autem nequeunt.\n\n7. Distortiones penis e podagra, lue, rheuraatismo, et gonorrhoea\nimpotentem faciunt virum quandoque immedicabiliter.\n\n8. Aneurysma corporum cavernosorum et varix venae dorsalis penis\nimpotentiae a chirurgo sanabilis causae sunt.\n\n9. Frenum glandulae penis curtum nimis incurvat penem, et ita vir\nimpotens est. Conditio facile a chirurgo removeri potest.\n\n10. Rarissime anchylosis articulamenti coxendicis et venter\npinguedineus impotentem virum reddit. Anchylosis insanabilis est.\n\n11. Tumores et incrementa morbida circa genitalia, ut {342} herniae,\nhydrocele, haematocele, elephantiasis, lipoma, carcinoma, sarcoma,\ncystoma, enchondroma, et fibroma causae sunt impotentiae. Herniae,\nlipoma, hydrocele, haematocele, et quandoque elephantiasis scroti\nsanari possunt; tumores benigni et maligni aliquando removentur sed\nvulgo amputatione penis aut testiculorum.\n\n12. Testiculi marcescunt in varicocele et impotentia sequitur.\nVaricocele amoveri potest, et si mature operetur chirurgus impotentia\nevitatur. Lues testiculorum destrui potest substantiam testiculorum\nnisi morbus mature sanetur, et impotentia potest esse absoluta.\nTuberculosis testiculorum destruit organum.\n\n13. Anorchismus seu absentia testiculorum bilateralis et congenita,\nidem efficit ac castratio. Conditio rara est Cryptorchismus, seu\nretentio testiculorum in abdomine, plerumque sterilitatem gignit non\nnecessario impotentiam.\n\nCastratio completa, morbo vel secus, impotentiae causa est, sed non\nnecessario statim post castrationem. Gross (_A Practical Treatise on\nImpotence_, Philadelphiae. 1890) citat quattuor casus in quibus\nerectio permanebat, in uno homine usque ad decennium. Kruegelstein\n(_Henke's Zeitschrift._ 1842. vol. I, p. 348) dicit virum quemdam post\namissionem testiculorum uxorem foecundavit. Si casus revera\ncontigerit, spermatazoa in vesciculis seminalibus permanserant.\n\n14. Prostatitis chronica causa est impotentiae et plerumque\ninsanabilis est.\n\n15. Nulla regula firma dari potest de impotentia physiologica\nsenectutis in maribus. Viri sexto et octogesimo anno non solum\npotentes inventi sunt sed etiam liberos generaverunt. Potentia\ngenerandi in maribus vulgo circa annum sexagesimum-secundum cessat,\nexceptiones autem multae inveniuntur. Potentia coeundi permanere\npotest longe post annum sexagesimum-secundum. Ecclesia igitur senes\ncujuscumque aetatis ad matrimonium admittit; et confessarius nihil\nrogat de potentia nisi ab ipso sene interrogatur. Si confessarius\nsciat senem revera impotentem esse, non permittere debet matrimonium\nejus.\n\n16. Opinio videtur esse moralistarum ad habendam copulam carnalem\nnecessariam esse non solum erectionem et {343} intromissionem sed\nettam inseminationem plus minusve perfectam.\n\nLaymann (_De Imped. Matr.,_ cap. 11) ait: \"Impotentia perpetua ad\ncopulam perfectam dirimit matrimonium subsequens.\" Et addit: \"Dixi\n_perfectam,_ id est, quae fit cum effusione veri seminis in vas\nmuliebre.\" Mastrius (loco jam citato) tenet inseminationem esse\nnecessariam.\n\nLehmkuhl (_Theol. Mor._) in definitione impotentiae absolutae dicit\ntalem esse impotentiam quae \"aliquem ad quamlibet copulam consummatam\ninhabilem reddit.\" Hic utitur vocibtis, _copula consummata,_ in qua\nBallerini requirit inseminationem quasi perfectam (_op, cit._, vol. 6,\np. 178), et Sanchez (_De Matr.,_ lib. 2, disp. 21, n. 5)\ninseminationem imperfectam. Petrus de Ledesma quoque (apud Eschbach.\n_Disputationes Physico-Theologiae._ Disp. 200) de senibus loquens ait:\n\"Si enim senes ita senio confecti et exhausti, quod nullo modo semine\nvaleant, quamvis possint erigere membrum et penetrare vas, non possunt\ncontrahere, et si contrahunt, matrimonium est invalidum.\"\n\nQui steriles sunt ita sunt ex tribus causis: (1) Aspermia, seu\nabsentia absoluta seminis; (2) Azoospermia, seu absentia spermatozoon\nin semine; (3) Oligospermia, seu carentia alicujus partis seminis.\n\nAspermia vulgo efficitur occlusione urethrae vel obliteratione partis\nejusdem. Defectus isti congeniti esse possunt vel ex morbo aut\nvulnere. Tumores tractus generativi claudere possunt aditum inter\ntesticulos meatumque urinarium et ita aspermia efficitur. Spadones,\netiamsi raro potentiam habeant intromissionis, aspermia afflictantur\nquoad partem seminis ex testiculis provenientem (in qua spermatozoa\nsunt), sed humor ex parte anteriori tractus generativi adesse aliquo\nmodo potest.\n\nAzoospermia fere eodem modo oritur, obstructio autem vel destructio\nprope testiculos est, et ita secretio aliarum partium tractus\ngenerativi exire potest, sed sine spermatozois.\n\nIn Oligospermia spermatozoa adesse possunt, sed quia aliud elementum\nseminis deest spermatozoa inertia sunt.\n\nCasus inveniuntur in quibus propter malformationem semen perfectum in\nvesicam urinariam ejactatur.\n\n{344}\n\nOmnes istae conditiones insanabiles esse possunt, raro sanari possunt.\n\nEstne vir aspermatosus, seu carens semine, impotens?\n\n(1). Affirmant multi moralistae qui inseminationem requirant talem\nimpotentem.\n\n(2). Ejectio seminis confectio est actus sexualis viro, et alia in\nactu ejectioni mere conducunt.\n\nIn Azoospermia copula carnalis qua copula eadem est ac in coitu\nnormali: microscopium solum aut sterilitas absentiam spermatozoon\ndetegunt. In Oligospermia coitus quoque normalis esse paret.\n\nOpinor virum aspermatosum impotentem sub lege esse quia nequit copulam\nsexualem perficere; e contra, virum oligo-spermatosum aut\nazoospermatosum steriles tantum esse.\n\nImpotentia igitur definiri potest, in viro: Impotens est quum (1) vel\nabsolute et perpetua, vel relative et perpetua, incapax sit\nintromissionis et quasi inseminationis; aut (2) quum spado sit, et ita\nsub decreto Sixti V veniat.\n\nImpotentia in muliere definiri potest: quum nullam vaginam vel vaginam\nperpetuo impenetrabilem habeat; vel cum pathologice recuset marem.\n\nImpotentia coeundi potest esse (1) aut antecedens aut consequens;\nprout matrimonii contractum anteit aut illi supervenit; (2) perpetua\nseu insanabilis, aut temporanea; (3) absoluta aut relativa, in quantum\n\"aliquem ad quemlibet copulam consummatam inhabilem reddit, aut\ntantummodo usum matrimonii inter duas certas personas impossibilem\nfacit\" (Lehmkuhl).\n\nUt impotentia tanquam impedimentum matrimonii dirimens habeatur, debet\nesse: (1) impotentia coeundi; (2) insanabilis; (3) antecedens; (4) aut\nabsoluta aut relativa.\n\nAUGUSTINUS OMALLEY.\n\n\n{345}\n\nAPPENDIX\n\n{346}\n\n{347}\n\nAPPENDIX\n\nBLOODY SWEAT\n\n\nThe bloody sweat of our Lord mentioned in Saint Luke's Gospel (xxii.,\n44), has given rise to not a little discussion. The Greek text is:\n[Greek text]. The Vulgate has this text thus: \"Et factus est sudor\nejus sicut guttae sanguinis decurrentis in terram.\" The Douay version\nis: \"And his sweat became as drops of blood trickling down upon the\nground.\" The King James translation has it: \"And his sweat was as it\nwere great drops of blood falling down to the ground.\" The Greek text\nand the Vulgate and Douay versions are the same, but in the King James\ntranslation the words, \"as it were great\" differ somewhat from the\nstatement in Greek.\n\nThe belief in the Catholic Church is that our Lord literally sweat\nblood through His unbroken skin, and this sweat is commonly deemed\nmiraculous. Those that deny the sweat was really blood have no ground\nwhatever for their assertion, because apart from all miracle bloody\nsweat can be a purely natural occurrence.\n\nDr. J. H. Pooley, in _The Popular Science Monthly_ (vol. 26, p. 357),\nhas an article on this subject in which he reported 47 cases of bloody\nsweat through unbroken skin. He, however, is of the opinion that our\nLord's sweat had no real blood in it. Whatever his reason may be for\nthis assertion he carefully conceals it.\n\nHemorrhage through the unbroken skin is a rare occurrence; but, as has\nbeen said, Dr. Pooley found 47 cases reported, and there are probably\nmany others. The discharge may be pure blood which coagulates in\ncrusts, or it may be blood mixed with sweat; it may be present over\nthe whole surface of the body or only in those parts where the {348}\nskin is thin and delicate. Commonly, bloody sweat is an oozing, but\nHebra, is his _Diseases of the Skin,_ tells of a young man that he\nhimself observed, from whose legs and hand blood ran, sometimes in\nminute jets one-twelfth of an inch in height. The skin was sound, and\nthe bloody sweat was not caused by any emotion.\n\nThe flow may be intermittent, appearing at intervals from a few hours\nto months. Sometimes the discharge is connected with skin diseases,\nbut often the skin is unaffected. Examples have been found at every\nage and in both sexes, but this sweat is commoner in women. Du Gard\nreports an instance in a child only three months old, and Spolinus\ntells of such a sweat in a child twelve years of age.\n\nBloody sweat may occur in malaria; it may be connected with\nneurasthenic conditions, and it has been caused frequently by\noverwhelming emotion, as terror and anguish.\n\nDe Thou tells of a French officer who was in command at Monte Maro in\nPiedmont in 1552, who sweated blood after he had been threatened with\nan ignominious execution if he did not surrender the town. The same\nwriter mentions a young Florentine, put to death in Rome during the\npontificate of Sixtus V, who sweated blood before execution.\n\nThe Society of Arts at Haarlem reported the case of a Danish sailor\nwho sweated blood through terror in a storm. This man was observed\ncarefully by a physician on the ship. The physician at first thought\nthe man had been wounded by a fall, but after wiping away the blood he\ndiscovered that the oozing came through uninjured skin. When the storm\nhad ceased the sailor at once regained a healthy condition.\n\nIn the _French Transactions medicales,_ for November, 1830, is\nnarrated the case of a young woman who had turned from Protestantism\nto Catholicism, and after this conversion she grew hysterical because\nof persecution by her family. During the hysterical attacks she sweat\nblood from the surface of her cheeks and belly.\n\nBefore the Christian era bloody sweat was observed by Aristotle,\nGalen, Diodorus Siculus, and Lucan also mention such occurrences.\n\nThe stigmata of some saints are authenticated cases of bleeding\nthrough the sound skin of the hands, feet, and side during\nextraordinary sympathy with our Lord in His Passion, and deep mental\nconcentration upon that Passion,--the stigmata of Saint Francis of\nAssisi, for example. Such bleeding is regarded in the Church as\nmiraculous. Apart from any question of faith, there is no reason why\nthey may not be {349} miraculous, especially if the supernatural\nquality is supported by other facts; but, again, such stigmata can be\nnatural. To prove, in general, that stigmata are miraculous requires\ncommonly heroic sanctity as a background, and even then in all cases\nthe proof is not necessarily absolute.\n\nFocachon, a chemist at Charmes, applied postage stamps to the left\nshoulder of a hypnotised subject, and kept them in place with ordinary\nsticking plaster and a bandage. He suggested to the patient that he\nhad applied a blister. The subject was watched, and after twenty-four\nhours the bandage, which had been untouched, was removed. The skin\nunder the postage stamps was thickened, necrotic, of a yellowish-white\ncolour, puffy with the serum of the blood and leucocytes, and\nsurrounded by an intensely red zone of inflammation. Several\nphysicians, including Beaunis, confirmed this observation; and Beaunis\nmade photographs of the blister, which he showed to the Society of\nPhysiological Psychology, June 29, 1885. (_Animal Magnetism._ Binet\nand Fere. New York, 1889.)\n\nIn Ricard's _Journal de magnetisme animal,_ 2d year, 1840, pp. 18,\n151, is a similar case. Prejalmini, in November, 1840, raised a\nblister on the healthy skin of a somnambulist by a piece of ordinary\nwriting paper on which he had written a prescription for a blister.\n\nAt the meeting of the _Societe de biologie,_ on July 11, 1885, Bourru\nand Burot, professors of the Rochefort school, published records of\nepistaxis and of bloody sweat, produced by suggestion on a male\nhysteric. On one occasion, after the patient had been hypnotised, his\nname was traced with the end of a blunt probe on both the patient's\nforearms. There was, of course, no mark of any kind left on the arms.\nThen the patient was told: \"This afternoon, at four o'clock, you will\ngo to sleep, and blood will then issue from your arms on the lines\nwhich I have now traced.\" The man was paralytic and anaesthetic on the\nleft side. He fell asleep at four o'clock, and while he was asleep the\nname appeared on the sound left arm, raised in a red wheal, and there\nwere minute drops of complete blood (serum and corpuscles) in several\nplaces. There was no change on the paralysed right forearm. Later the\npatient himself commanded the arm to bleed and it did so. This second\noccurrence was observed by Mabille. (Binet and Fere. Op. cit., p.\n199.) Charcot and his pupils at the Salpetriere have often produced by\nsuggestion alone the effects of burns upon the skin of hypnotised\npatients. The blisters in these cases did not appear at once {350} but\nafter some hours had elapsed. The blisters, of course, contained\nblood.\n\nThe weekly bleeding, through the unbroken skin, of the hands and feet\nof Louise Lateau is an example of stigmata in our own day, which may\nhave been supernatural or natural. Physicians would call it natural,\nan effect of autohypnosis, but there is no reason why it may not have\nbeen just as miraculous as the stigmata of the saints. Professor\nLefevre of the University of Louvain, a physician, said her stigmata\nwere miraculous. Theodore Schwann, the discoverer of the cell\ndoctrine, deemed her condition natural.\n\nIn the Letters of the Rt. Rev. Casper Borgess, Bishop of Detroit,\nMichigan, is an account of a visit to Louise Lateau made in July,\n1877. He says, \"I first seated myself on the only chair in the room,\nwhich I had placed at the right side, near the head of the bed.\nLouise's two hands rested on several thicknesses of folded linen,\nspread over the bed-cover, and were covered with a folded linen cloth.\nThis I removed. The hands were both heavily covered with blood; in\nsome places it had congealed, and looked very dark; but in the centre,\nbetween the fore and little fingers, on the upper part of the hand,\nthe blood was quite fresh and flowed freely. Not knowing at the time\nthat the wiping of the hands causes her intense pain, I proceeded to\nwipe off the hands, for a more perfect inspection of the wound on each\nhand. The wound, or stigma, on the right hand seemed more than one\ninch in length, about half an inch at its greatest width, and was of\noval shape. Turning the hand, I saw a wound of the same form in the\npalm of the hand, and opposite the wound on the back of the same. The\nblood seemed to rise in bubbles, forming in rapid succession, flowing\nin a spread stream down to the wrist. Examining the wound itself, I\nwas well convinced that the skin of the hand was not broken nor in any\nway injured; and there was no sign of a wound made by any material\ninstrument, sharp or dull. And, withal, the blood oozing out of the\nwound appeared a reality, and complete in form.\"\n\nThe bishop evidently uses the term \"wound\" in a figurative sense,\nbecause he draws attention to the fact that the skin was intact,\ncontinuous. She bled from the dorsal and palmar surfaces of the hands\nin areas shaped like the wounds represented by painters on the hands\nof our Lord. While the bishop was examining her hands Louise went into\nan ecstatic condition.\n\nIf the Church defines that a bloody sweat or the stigmata of a saint\nare supernatural, that definition, of course, ends the matter for\nCatholics as far as the particular case is concerned; {351} but until\nsuch a decision has been made these conditions are all to be regarded\nas effects of natural causes working in a natural manner.\n\nIn many conditions where the nervous system can have influence a\nmiracle is very difficult of proof from the context. There can, of\ncourse, be evident miracles in the cure of some nervous disorders,\nsupposing the diagnosis to be certain. The sudden cure of advanced\nparesis would be as much a miracle as the sudden replacing of a lost\nfemur. Commonly, however, in neuroses if there is an apparently\nmiraculous healing or similar effect, the supernatural quality can not\nbe established. Suppose Bernadette reported that she had seen the\nBlessed Virgin at Lourdes: the only safe thing to do in such a case is\nto deny the apparition until it has been proved. Suppose, secondly,\nthat a patient who has been confined to bed for years by an hysterical\nparalysis, believed in the reality of the vision, had himself carried\nto Lourdes, and while at prayer there he suddenly stood up cured. That\neffect would prove neither the reality of the vision nor the\nsupernatural quality of the cure; nor would it disprove either. We\nsimply can not judge the case, because exactly the same effect has\nhappened hundreds of times from purely natural impressions. If that\nsame paralytic were lying in his bed at home and you set the house\nafire he would jump up and run.\n\nIf the patient, however, had been bedridden with a paralysis caused by\ncertain degeneration of nervous tissue, and he were cured in the\nmanner described, that effect would be supernatural, miraculous;\nalways provided there is no error in the medical diagnosis.\n\nThere is a genuine diabetes and a pseudodiabetes. The latter condition\nmay be diagnosed as true diabetes by a number of physicians, but it is\nonly a symptom of hysteria. If the pseudodiabetes is suddenly cured,\nthis cure may or may not be miraculous, but no one can say which is\nthe truth; the probability is a hundred to one that the cure is\naltogether natural. There was a flourishing Christian Science\ncongregation established in the west recently upon \"miraculous\" cure\nof a case of pseudodiabetes, which some ignorant physicians had called\ntrue diabetes, notwithstanding the fact that Christian Science does\nnot believe in either diabetes or false diabetes.\n\nWe must not, then, call every strange event miraculous; nor, what is\nworse, are we rashly to make the supernatural a matter to be explained\naway loftily by the impudence of half science. A Belgian priest named\nHahn wrote a monograph {352} to the effect that the ecstatic\nconditions observed in the life of Saint Teresa were autohypnotic, and\nhe succeeded in drawing upon himself the undivided attention of the\nCongregation of the Index and a serious disturbance of his peace of\nmind. He became a martyr to science. We all like to be \"liberal,\"\nimpartial; but from the religious Mugwump _libera nos, Domine!_\nAutohypnosis is always a mark of degeneracy in the natural order, and\nto call the ecstacy of a saint autohypnosis not only takes all worth\nfrom the manifestation, but the assertion is also untrue. There is a\nvast difference between the intense intellectual contemplation of a\ngreat saint in ecstacy, which leaves the person unconscious of the\nbody and its surroundings, and the cataleptic trance of a neurotic\npatient who may mimic the saint.\n\nHypnotic or autohypnotic stigmata, and by stigmata here is meant\nbleeding from the hands, feet, and side, would be degeneracy of the\nmind and body in the natural order. Moreover, no clearly established\ncases are known, because conditions like those of Louise Lateau are by\nno means certainly physical from all points of view, as they would be\nif they occurred in an ordinary hysteric. In hypnosis or autohypnosis\nthe subject's mind and body are degenerate; in sanctity, where at\ntimes may be displayed certain effects that resemble autohypnosis,\nthere is always a sound mind. A saint may have an unsound, neurotic\nbody, but a crazy \"saint\" or an hysterical \"saint\" is no better than\nany other lunatic or hysteric, and certainly anything but a saint. If\na saint has stigmata, these external marks might come (1)\nmiraculously, as a gratuitous sign of divine favour; (2) as an effect\nof natural, intense contemplation of the Passion of our Lord,\nproducing these bleedings in a sound body; or (3) as an effect of a\nrational, intense contemplation of the same Passion, acting, more\neasily, on a neurotic body.\n\nScientific theorising on this matter is necessarily sterile, because\nsuch an investigation is only half material for science,--physical\nscience. Science is not a bad thing in itself, especially when it\nminds its own business and keeps its place below stairs; but it never\nsympathises with sanctity, and there is no deep knowledge without\nsympathy. Fact-grinding made Darwin \"nauseate Shakspere.\" Science can\nnot see in the dark as genius and sanctity see, and if it does see in\nthe dark it is no longer science but genius working on a scientific\nobject. As Professor William James said: \"Science taken in its essence\nshould stand only for a method, and not for any special beliefs, yet,\nas habitually taken by its {353} votaries, Science has come to be\nidentified with a certain fixed general belief, the belief that the\ndeeper order of Nature is mechanical exclusively, and that\nnon-mechanical categories are irrational ways of conceiving and\nexplaining even such a thing as human life.\" Science should recognise\nits own limitations and not meddle in attempted explanations of the\ninexplicable. Therefore, what of the stigmata of the saints from a\nscientific point of view? There is no scientific point of view.\n\nAUSTIN OMALLEY.\n\n\n{354}\n\n{355}\n\nINDEX\n\n{356}\n\n{357}\n\nINDEX\n\nA\n\nAbdominal pregnancy, 5.\nAbortion, 22, 48;\n  causes of, 48, 49, 51, 52, 53;\n  in puerperal pneumonia, 151;\n  tubal, 6.\n\n_Abortus_, 19, 20, 49.\nAcephalus, 75.\nActinomyces, visits in, 183.\nAcute indigestion in the aged, 154.\nAddison's disease, death in, 155;\n  symptoms of, 156.\nAdipocere, 7.\nAertnys on ectopic gestation, 26, 27.\nAggressor, 18, 19.\nAgoraphobia, 296.\nAir-space, 204.\nAlcohol,\n  effects on the mind, 109;\n  in proprietary medicines, 93;\n  in snake-poisoning, 118;\n  in typhoid fever, 118.\n\nAlcoholic amnesia, 110;\n  climacteric, 108;\n  delusions, 109, 110;\n  insanity, 107, 105, 109;\n  liquors, 108;\n  poisoning, 107, 109, 110;\n  pseudo-paranoia, 109.\n\nAlcoholism, 105;\n  and cirrhosis of the liver, 156;\n  and coma, 138;\n  and conjugal infidelity, 109;\n  and epilepsy, 256;\n  and idiocy, 113;\n  and imbecility, 112, 114;\n  and marriage, 111, 126;\n  and pneumonia, 151;\n  and surgical operations, 163;\n  and the will, 111;\n  causes of, 108;\n  children in, 112;\n  complicating disease, 162;\n  temperance societies, 112.\n\nAmateur medical advice, 89.\nAmbulatory epilepsy, 261.\nAmenorrhoea, 241.\nAmnesia and epilepsy, 263.\nAmpullar pregnancy, 5.\nAmputations, uterine, 65.\nAnaesthesia in mania, 227.\n_Anatomia genitalium mulieris_, 331.\nAndrogynia, 340.\nAneurism,\n  causes of, 155;\n  death in, 155.\n\nAngina pectoris, death in, 142.\nAnointing in smallpox, 177.\nAnopheles mosquito, 186.\nAnthrax, visits in, 184.\nAntitoxin, 171, 195.\nAortic valvular disease, death in, 140.\nApoplexy, 143;\n  and fainting, 145;\n  hard arteries and, 144;\n  short neck and, 146;\n  symptoms of, 144;\n  the third stroke in, 146;\n  treatment in, 145;\n  vertigo and, 144.\n\nAppendicitis,\n  peritonitis in, 153;\n  prognosis in, 153.\n\nApraxia, 263.\nAristotle, his determinants of morality, 14.\nArteries in apoplexy, 146.\nArteriosclerosis and apoplexy, 144.\nAspects of intoxication, 105.\nAspermia, 343.\nAsomata, 75.\nAssassins of presidents, 302.\n_Atresia vaginae et impotentia_, 333.\nAutohypnosis, 130.\nAutositic monsters, 75.\nAzoospermia, 343.\n\nB\n\nBacteria, 168;\n  kinds of, 169;\n  specific causes of disease, 169.\n\nBaptism in ectopic gestation, 83;\n  of monsters, 87.\n\nBarber's itch, contagiousness, 198.\nBarkers, 237.\nBeer, percentage of alcohol in, 108.\nBeriberi, visits in, 184.\nBibliography of hypnotism, 117.\nBichloride of mercury, a disinfectant, 191.\nBlack death, 184;\n  mortality of, 184.\n\nBlack fevers, 160.\nBleeders, 124.\nBlood brought out by suggestion, 349.\nBloody sweat, 347;\n  and hypnosis, 349;\n  cases of, 348.\n\nBooks and infection, 195;\n  disinfection of, 190.\nBorgess on the Lateau case, 350.\nBrain tumours, 148;\n  and syphilis, 322;\n  symptoms of, 148.\n\nBreeding places of mosquitoes, 186.\nBreuss' ovum, 73.\n                                                               {356}\nBrick in buildings, 203.\nBroad ligament, 3.\nBroad-ligament pregnancy, 5.\nBromides and epilepsy, 98.\nBubonic plague,\n  mortality in, 185;\n  transmission of, 185;\n  visits in, 184.\n\nBuilding materials, 203.\nBuilding sites, 202.\nBurns, death in, 156.\n\nC\n\nCaesarean section, 41, 42, 51, 55;\n  and sepsis, 56, 57;\n  indications for, 55;\n  statistics of, 55.\n\nCancer complicating pregnancy, 44;\n  death in, 158.\n\nCanonical law on impotence, 326.\nCarbonic add in the air, 206.\nCardiac massage, 165.\n_Carentia ovariorum_, 334.\nCarpets, disinfection of, 194.\nCases of ectopic gestation, 22.\n_Castratio et impotentia,_ 342.\nCatarrh and proprietary drugs, 100\nCathartics, 100.\n_Causae impotentiae mulieris,_ 332.\nCats and diphtheria, 195.\nCells, 69.\nCellular activity and death, 164.\nCentrosome, 70.\nCerebrospinal meningitis, 148, 182.\nCerebral neurasthenia, 230.\nChickenpox, 197.\nChildren of drunkards, 112;\n  suicide of, 308.\n\nChorea, 51;\n  and menstrual disorders, 243.\n\nChromatin, 70.\nChromosomes, 70, 71.\nCircular insanity, 228.\nCircumstances m morality, 12.\nCirrhosis of the liver,\n  causes of, 156;\n  death in, 156.\n\nClassrooms, 204.\nClaustrophobia, 296.\nClothes, disinfection of, 191.\nCocaine, insanity from, 116;\n  intoxication, 115, 116, 117.\n\nCoeliotomy, 4.\nColelithiasis, death in, 160.\nComa and alcoholism, 138;\n  and kidney disease, 138.\n\nComposite monsters, 77.\nCompulsory vaccination, 175.\nConfluent smallpox, 172.\nCongenital syphilis, 313;\n  statistics of, 313.\n\nConjugata vera, 55, 56, 57.\nConjunctivitis, infectiousness of, 199.\nConinck on impotence, 330.\nConsanguinity and monsters, 76.\nConscience, 15.\nConstipation, 100.\nContagion, 168.\n_Copula carnalis_, 331.\nCornish jumpers, 237.\nCough, physiology of, 91.\n_Convulsionnaires_, 237.\nCranial asymmetry and crime, 272, 275.\nCraniopagus, 84.\nCraniotomy, 22, 28, 42, 55, 56, 58, 59;\n  indications for, 58;\n  mortality in, 59.\n\nCranks, 282.\nCrile's method of resuscitation, 166.\nCrime, suppression of, 278.\nCriminal types not a scientific fact, 271.\nCriminals, indeterminate sentence for, 279.\nCriminology and the habitual criminal, 271.\nCross immunisation, 172.\nCyclops, 75.\nCysts complicating pregnancy, 40, 41.\nCytoplasm, 70.\n\nD\n\nDancing plague, 236.\nDeath\n  from alcohol, 162;\n  from varicose veins, 159;\n  in acute indigestion, 154;\n  in Addison's disease, 155;\n  in aneurism, 155;\n  in appendicitis, 153;\n  in burns, 156;\n  in cancer, 158;\n  in cirrhosis of the liver, 156;\n  in colelithiasis, 160;\n  in delirium tremens, 162;\n  in dysentery, 155;\n  in ear disease, 159;\n  in gastric ulcer, 161;\n  in hydrophobia, 161;\n  in kidney diseases, 137;\n  in the lymphatic diathesis, 157;\n  in mania, 227;\n  in pancreatitis, 160;\n  in rheumatism, 153;\n  in tetanus, 161;\n  in tuberculosis, 158;\n  moment of, 164;\n  prognosis of, 136;\n  resuscitation after apparent, 164;\n  unexpected, 135.\n\nDegeneration and criminals, 271.\nDegeneracy, symptoms of, 274.\n_De impedimento impotentia,_ 326.\nDejecta, disinfection of, 192.\nDe Lugo, on homicide, 18.\nDelirium tremens, 109;\n  death in, 162.\n\nDelusions in melancholia, 221.\nDementia, 228.\nDengue, visits in, 181.\nDermoid cysts, 86.\nDesks in schools, 207.\nDesquamation after disease, 197.\nDestruction of infected articles, 194.\nDicephali, examples of, 80, 81.\nDicephalus, species of, 79, 80.\n                                                      {359}\nDiphtheria\n  and domestic animals, 195;\n  antitoxin, 103, 195;\n  bacillus, persistence of, 192;\n  cause of, 187;\n  communication of, 187, 190;\n  disinfection in, 190, 193;\n  error in diagnosis of, 187;\n  immunity against, 188;\n  in a school, 196;\n  precautions against, 190;\n  visits in, 181.\n\nDiprosopi, species of, 79.\nDipsomania, 110;\n  cured by hypnotism, 117.\n\nDipygi, 83.\nDiseases\n  caused by bacteria, 169;\n  caused by plasmodia, 169.\n\nDisinfection\n  by formalin, 193;\n  by steam, 193;\n  in diphtheria, 190;\n  of carpets, 194;\n  of clothing, 191;\n  of dejecta, 192;\n  of eating utensils, 192;\n  of money, 194;\n  of rooms, 193;\n  of the body, 193.\n\nDivorce and impotence, 326.\nDomestic animals and diphtheria, 195.\nDormitories, 204.\nDouble autositic monsters, 79.\nDraehms on the criminal, 272.\nDrainage,\n  defects of, 203;\n  of buildings, 203.\n\nDrinking cups and infection, 195.\nDrunkenness, accountability in, 106.\nDysmenorrhoea, 242;\n  varieties of, 242.\n\nDysentery, death in, 155.\n\nE\n\nEar disease and death, 159.\nEclampsia, 52.\nEcstacy of saints and hysterics, 352.\nEctoderm, 73.\nEctopic gestation, 1;\n  baptism in, 11;\n  children saved in, 30;\n  difficult to diagnose, 8;\n  location of, 1;\n  medical treatment of, 10;\n  opinions of physicians, 8, 9;\n  statistics of, 33, 34;\n  surgical operation for, 23.\n\nEffect of actions, 14, 15.\nEmbryo, 4;\n  development of, 73, 74.\n\nEmbryotomy, 58.\nEmmet on ectopic gestation, 8.\nEnd in morality, 13.\nEndoderm, 73.\nEpiblast, 73.\nEpidemic hysteria, 236, 237.\nEpilepsy,\n  ambulatory form of, 261;\n  and alcoholism, 256;\n  and homicide, 253;\n  and insanity, 253;\n  and lapse of memory, 262;\n  and religiosity, 254;\n  and responsibility, 251;\n  age at development, 258;\n  examples of cases of, 259, 262;\n  idiopathic form of, 257;\n  irritability in, 253;\n  masked or psychic, 252;\n  notions of persecution in, 255;\n  prognosis in, 257;\n  symptoms of, 252;\n  treatment of, 99, 258.\n\nEpileptics and bromides, 98.\nEpileptiform convulsions, 256.\nErlich's theory of immunity, 171.\nErysipelas, visits in, 183.\nEunuchs and impotence, 327.\nEviratio, 339.\nEvisceration, 58.\nExophthalmic goitre, 247.\nExtreme unction in smallpox, 177.\nExtrauterine pregnancy, 1, 154.\nEye,\n  diphtheria in the, 200;\n  gonococci in the, 200;\n  infections of the, 199.\n\nEyesight and schools, 208.\n\nF\n\nFainting and apoplexy, 145.\nFallopian tubes, 1, 2;\n  rupture of, 5.\n\nFalse angina pectoris, 142.\nFavus, contagiousness of, 198.\nFecundation, 3.\nFibroid tumours in pregnancy, 41.\nFimbria ovarica, 2.\nFission fungi, 168.\nFission theory for composite monsters, 77, 78.\nFlat pelves, 56.\nFoetal blood, 67.\nFoetal death,\n  causes of, 8;\n  in ectopic gestation, 6.\n\nFoetus, 4;\n  anideus, 75;\n  in utero, 67;\n  when viable, 4.\n\nFood in schools, 208.\nFormalin disinfection, 190, 193.\nFractures of the skull, 147.\nFrigidity, 330.\nFusion theory for monsters, 77.\n\nG\n\nGall stones, 160.\nGambling mania, 295.\nGambler's paranoia, 295.\nGarfield's assassination, 303.\nGastric ulcer, death in, 161.\nGastritis, death in, 154.\nGastrula, 73.\nGenicot on ectopic gestation, 21.\n_Genitalia maris_, 336.\n_Genitalia mulieris_, 331.\nGerminal vesicle, 72.\nGestation,\n  duration of, 3;\n  ectopic, 1;\n  term of, 4.\n\nGlanders, visits in, 181.\nGlottis, oedema of the, 139.\nGonorrhoea, 324;\n  and ectopic gestation, 36;\n  effects of, 315;\n  and marriage, 315;\n  and sterility, 325.\n\nGoodell on ectopic gestation, 9.\nGrandeur, delusions of, 290.\nGranular eyelids, 200.\nGraves' disease, responsibility in, 246.\nGrief and melancholia, 215.\nGrippe, visits in, 181.\nGuiteau's insanity, 303.\nGynandria, 340.\n\n                                                       {360}\nH\n\nHabitual criminals, 271.\nHaematocele, 6.\nHaematosalpynx, 6.\nHarelip, 123.\n\nHeart disease\n  and mania, 226;\n  death in, 140;\n  in pregnancy, 49;\n  in typhoid fever, 152;\n  pulse signification in, 141.\n\nHeating of schools, 206.\nHebephrenic melancholia, 309.\nHebra's case of bloody sweat, 348.\nHecker on the plague, 185.\nHemiterata, 74.\nHemophilia, 123.\nHeredity, 120;\n  and acquired characteristics, 122;\n  and melancholia, 216;\n  circular insanity and, 228;\n  in insanity, 224, 225;\n  mania and, 224.\n\nHermaphrodites, 74.\nHeterotaxic monsters, 74.\nHirst on ectopic gestation, 8.\nHolaind\n  on ectopic gestation, 8;\n  on self-defence, 18, 19.\n\nHoly Office on abortion, 20, 49, 50, 51.\nHomesickness, melancholia and, 217.\nHomicide, 17, 18;\n  direct, 17;\n  indirect, 18, 43;\n  morality of, 17, 18.\n\nHomicidal mania, 300.\nHumoral pathology, 88.\nHuntingdon's chorea, 122.\nHydramnios, 53.\nHydrophobia, death in, 161.\nHygiene in schools, 202.\nHymen imperforabilis, 332.\nHypnosis\n  and bloody sweat, 345;\n  and crime, 131, 132;\n  and responsibility, 131;\n  danger in, 130, 131;\n  utility of, 130.\n\nHypnotism, 129;\n  bibliography of, 117;\n  in dipsomania, 117;\n  in morphinism, 117.\n\nHypoblast, 73.\nHypochondriacs, 287.\nHysterectomy, 42.\nHysteria, 235;\n  and marriage, 239;\n  causes of, 235;\n  imitative form of, 236;\n  in males, 235;\n  major form of, 237;\n  manifestations of, 235;\n  minor forms of, 238;\n  symptoms of, 238;\n  treatment of, 239.\n\nI\n\n_Idee obsedante,_ 266.\nIdiocy\n  and alcoholism, 113;\n  and maternal impressions, 64.\n\nIdiopathic insanity, 212\nImbecility\n  and alcoholism, 112, 114;\n  grades of, 114.\n\nImitative hysteria, 236, 237.\nImmunity to disease, 170, 171.\nImpetigo, contagiousness, 199.\nImpotence,\n  American authorities on, 327;\n  and American law, 326;\n  canon law on, 326;\n  definition, 327;\n  definition by moralists, 329, 330;\n  St. Alphonsus's definition, 328.\n\n_Impotentia_\n  _atonica_, 340;\n  _e morbis penis_, 341;\n  _e vaginismo_, 332;\n  _e venenis_, 340;\n  _et aspermia_, 344;\n  _et castratio_, 342;\n  _et inseminatio_, 343;\n  _et prolapsus_, 333;\n  _et senectus_, 333;\n  _et varicocele_, 342;\n  _ex irritatione_, 341;\n  _ex maleficio_, 337;\n  _maris_, 336;\n  _mulieris_, 331;\n  _organica_, 341;\n  _paralytica_, 340;\n  _propter atresiam_, 333;\n  _pychica_, 336, 337;\n  _impotentiae definitio_, 344;\n  _multeris causae_, 332.\n\nImpregnation, 240.\nImpulse and responsibility, 266.\nIndeterminate sentence tor criminals, 279, 280.\nInfected patient, release of, 192.\nInfection, 168.\nInfectious diseases, 168;\n  and mania, 226;\n  in schools, 187.\n\nInfluenza, visits in, 181.\nInsanity, 212;\n  alcoholic, 107;\n  and crime, 274;\n  and epilepsy, 253;\n  and heredity, 224;\n  and menstrual diseases, 243, 244;\n  and religious vocations, 226;\n  and sexuality, 226;\n  diagnosis of, 106;\n  from cocaine, 116;\n  marriage and, 225;\n  recurrence of, 213.\n\n_Inseminatio_, 341.\nInterstitial tubal pregnancy, 5.\nIntoxicants, 105.\nIntrauterine hemorrhage, 53.\nIodide of potassium and sarsaparilla, 96.\nIschiopagi, 82.\nIsthmic ectopic pregnancy, 5.\nItalian school of criminology, 271.\nItch, 198.\n\nJ\n\nJacksonian epilepsy, 257.\nJews and the plague, 185.\n\nK\n\nKelly on ectopic gestation, 5, 8.\nKidney diseases\n  and oedema, 139;\n  coma in, 138;\n  effect of heat and cold in, 138;\n  fatality of, 137.\n\nKleptomania, 299.\nKonings on impotence, 329.\n\nL\n\nLaurent on criminals, 271.\nLaw, St. Thomas's definition of, 16.\nLeft-handedness and crime, 272.\nLehmkuhl\n  on abortion, 19;\n  on ectopic gestation, 25;\n  on impotence, 329.\n\nLeprosy,\n  contagiousness of, 183;\n  visits in, 182.\n\nLice, 198.\nLighting of schools, 205.\nLincoln's assassination, 303.\nLife, beginning of, 3.\n\n                                                      {361}\n\nLithopoedion, 7.\nLockjaw, 161.\nLocomotor ataxia, 312, 320;\n  symptoms of, 321.\n\nLombroso's theory on criminals, 271.\nLouise Lateau, 350.\nLungs, oedema of, 139.\nLusk on ectopic gestation, 9.\nLymphatic diathesis, 157.\n\nM\n\nMacDonald on criminals, 272.\nMcKinley's assassination, 304.\nMagnan on criminal monomanias, 271.\nMahomet a paranoiac, 291.\nMajor hysteria, 237.\nMalaria, 186.\nMalta fever, 185.\n_Malum comitiale_, 251.\nMammalian ovum, 69.\nMania, 222;\n  anaesthesia in, 227;\n  after infectious diseases, 226;\n  a potu, 109;\n  causes of, 224;\n  death in, 227;\n  prognosis in, 227;\n  symptoms of, 223.\n\nManouvrier on criminals, 272.\nMarriage,\n  ends of, 328;\n  and hysteria, 239;\n  and insanity, 225;\n  and venereal diseases, 311;\n  Liguorian definition, 328.\n\n_Maris impotentia_, 336.\nMasked epilepsy, 252.\nMassachusetts report on alcoholic tonics, 93.\nMastrius on impotence, 330.\n_Masochismus_, 338;\n  _symbolicus_, 339.\n\nMaternal impressions, 60;\n  and idiocy, 64.\n\nMaterially unjust aggressor, 19, 26.\nMeans in morality, 14.\nMeasles, disinfection after, 197.\nMediaeval plagues, 185\nMelancholia, 214;\n  and grief, 215;\n  autointoxication in, 217;\n  causes of, 215;\n  childbearing and, 217;\n  delusions in, 221;\n  heredity and, 216;\n  in women, 217;\n  predisposition to, 216;\n  prognosis m, 220;\n  recurrence of, 214;\n  starving in, 222;\n  suicide in, 218, 219;\n  symptoms of, 218.\n\nMembranous croup, 187.\nMemory and alcoholism, 110.\nMemory in epilepsy, 263.\nMendel and heredity, 120, 128.\nMeningitis, 148.\nMenopause, 240, 242;\n  and responsibility, 249.\n\nMenorrhagia, 241.\nMenstrual diseases, 240;\n  and insanity, 243.\n\nMenstruation, 3, 240;\n  beginning of, 240;\n  derangements of, 241;\n  process of, 240.\n\nMental defects and pregnancy, 63.\nMental diseases and spiritual direction, 211.\nMesoblast, 73.\nMesoderm, 73.\nMetamorphosis sexualis, 340.\nMetrorrhagia, 241.\nMiddle ear disease, 159.\nMinor hysteria, 238.\nMiracles and the nervous diseases, 351.\nMiracles, physical proof of, 351.\nMiscarriage, 48.\nMisophobia, 296.\nMitotic division of cells, 70.\nMoment of death, 164.\nMoney, disinfection of, 194.\nMonomanias, 292, 299.\nMonsters, 69;\n  aetiology of, 76;\n  composite, 77;\n  double autositic, 79;\n  produced artificially, 76.\n\nMorality,\n  circumstances in, 12;\n  determinants of, 12, 13, 105;\n  end in, 13, 15;\n  general laws in, 15;\n  means in, 14;\n  object in, 12, 15;\n  will in, 13.\n\nMorphinism, 115;\n  causes of, 115;\n  effects of, 115.\n\nMorula, 73.\nMosquitoes as disease-carriers, 186.\n_Mulieris impotentia_, 331.\nMumps, 199.\n\nN\n\nNarrow pelves, 55.\nNephritis, responsibility in, 246.\nNervous school-children, 208.\nNervous strain and syphilis, 324.\nNeuralgic dysmenorrhoea, 242.\nNeurasthenia, 230;\n  causes of, 233;\n  and responsibility, 248;\n  sexual form of, 232;\n  spinal form of, 232;\n  symptoms of, 230;\n  traumatic form of, 233;\n  treatment of, 233;\n  types of, 231.\n\nNeurotic dysmenorrhoea, 242.\nNeurotic superiors, 248.\nNewspapers and suicide, 132, 133.\nNietzsche, 285.\n\nO\n\nObject in morality, 12.\nObsession, 266.\nObstructive dysmenorrhoea, 242.\nOedema\n  in kidney diseases, 139;\n  of the glottis, 139.\n\nOil-stocks in smallpox visits, 177.\nOligospermia, 343.\nOmphalopagus, 84.\nOmphalositic monsters, 75.\nOmphalosites, origin of, 76.\nOperation in ectopic gestation, 23.\nOphthalmia, 200;\n  neonatorum, 200.\n\nOpisthotonos, 237.\nOvarian pregnancy, 5.\n_Ovariorum carentia_, 334.\n\n                                                 {362}\n\nOvary, anatomy of, 2.\nOvulation, 3, 240.\nOvum, 2, 3, 69, 72;\n  arrest of, in tube, 4;\n  segmentation-nucleus of, 3.\n\nP\n\nPancreatitis, death in, 160.\nParacephalus, 75.\nParalysis from syphilis, 322.\nParamimia, 309.\nParanoia, 220, 282;\n  and suicide, 306;\n  erotica, 291;\n  occurrence of, 285;\n  of tramps, 297;\n  persecution and, 288;\n  querulans, 293;\n  religiosa, 290;\n  responsibility in, 301;\n  signification of, 283, 284;\n  special forms of, 292;\n  stages of, 286;\n  symptoms of, 284, 285, 286.\n\nParasitic monsters, 85.\nParesis and syphilis, 319;\n  symptoms of, 319.\n\nPathological micro-organisms, 168.\nPelvic tumours in pregnancy, 40.\nPerforation of the intestines, 152.\nPeritonitis in typhoid fever, 152.\nPernicious vomiting, 53.\n_Persecuteurs persecutes_, 290.\nPersecution and paranoia, 288.\nPeterson on paranoia, 284.\nPeters' ovum, 73.\nPhobias, 295.\nPhysical exercise in schools, 209.\n_Pigritia indurata_, 296.\nPlacenta, 6, 23, 24, 67;\n  praevia, 53.\n\nPlague, 185.\nPneumococcic meningitis, 148.\nPneumonia,\n  alcoholism and, 151;\n  in pregnancy, 150;\n  prognosis in, 150;\n  visits in, 182;\n  walking cases of, 151.\n\nPooley on bloody sweat, 347.\nPorrigo, 199.\nPorro operation, 50.\nPregnancy,\n  ampullar, 5;\n  extrauterine, 1;\n  in broad ligament, 5;\n  interstitial, 5;\n  isthmic, 5;\n  pneumonia in, 150;\n  term of, 3;\n  tubo-abdominal,5;\n  tubo-ovarian, 5.\n\nPremature labour, 48.\nPrepotency, 71.\nPrice on ectopic gestation, 9.\nPriest in infectious diseases, 168.\nPrimitive trace, 74.\nProbabilism, 15;\n  and law, 16;\n  constituents of, 16.\n\nProfessional criminals, suppression of, 277.\nPromulgation of law, 16.\nProprietary drugs\n  and alcohol, 93;\n  evils of, 91.\n\nProsopothoracopagus, 84.\nProtozoa, 165.\nPseudo-angina pectoris, 142.\nPsychic epilepsy, 259;\n  and secondary personality, 259.\n\nPyelonephritis, 51.\nPygopagi, 83.\nPyromania, 300.\n\nQ\n\nQuarantine, needless of, 188.\n\nR\n\nRabies, 161, 180;\n  symptoms of, 162.\nRachipagus, 84.\nRelapsing fever, 179.\nReligious perversions in epilepsy, 254.\nResponsibility\n  and epilepsy, 252;\n  and impulse, 266;\n  Graves' disease and, 246;\n  in paranoia, 301;\n  judgment of, 268;\n  nephritis and, 246.\n\nResuscitation, cases of, 165.\nRheumatism\n  and proprietary drugs, 101,\n  fatal cases of, 153.\n\nRickets\n  and cranial deformity, 275;\n  and degeneration, 276.\n\nRingworm, contagiousness of, 198.\nRituale Romanum on monsters, 87.\nRupture in ectopic gestation, 29.\n\nS\n\nSabetti on ectopic gestation, 24.\nSacraments\n in apoplexy, 147;\n in apparent death, 167;\n  in smallpox, 176;\n  in typhus, 179.\n\nSadismus, 338.\nScabies, 198.\nScarlet fever,\n  disinfection after, 197;\n  visits in, 170.\n\nSchmaltzgreuber on impotence, 330.\nSchool desks, rules for, 207.\nSchools,\n  disinfection of, 196;\n  food in, 208;\n  heating of, 206;\n  hygiene, 202;\n  infection in, 187;\n  lighting of, 205;\n  sites for, 202;\n  stairways, 200;\n  ventilation of, 206;\n  water-closets in, 207;\n  windows in, 205.\n\nScrupulosity, 208, 231.\nSecondary personality, 259.\nSelf-defence, 18.\n_Senectus et impotentia_, 333.\nSerum therapy, 172.\nSexuality and insanity, 226.\nSexual perverts, 233.\nSewer gas, 203.\nSkull-formation of criminals, 275.\nSkull, fractures of, 147.\nSiamese twins, 84.\nSingle monsters, 75.\nSiren, 75.\nSir Robert Anderson on criminals, 277.\nSites for schools, 202.\nSixtus V, decree on eunuchs, 327.\nSmallpox, 172;\n  contagiousness, 170, 172;\n  mortality in, 174;\n  precautions in visiting, 176;\n  sacraments in, 176.\n\n                                                  {363}\n\nSnake-bite and alcohol, 118.\nSocial diseases, 317;\n  and youth, 318.\n\nSocial medicine, 88.\nSoftening of the brain, 319.\nSoil under school buildings, 202.\nSoothing syrups, evils of, 99.\nSoul,\n  entrance of, 3;\n  when it leaves the body, 164.\n\n_Spaltungstheorie_, 77.\nSpermatozoon, 3, 70, 72, 73.\n_Spes phthisica_, 158.\nSpiritual direction and mental disease, 211.\nSports in plants, 127.\nStairways in schools, 206.\nStegomyia mosquito, 186.\nStigmata, 348;\n  and science, 352.\n\nStole in smallpox visits, 177.\nSuicide, 306;\n  and newspapers, 132, 309;\n  and paranoia, 306;\n  European statistics of, 308;\n  heredity in, 132;\n  increase of, 306;\n  in families, 310;\n  melancholia and, 218;\n  of children, 308;\n  statistics of, 307.\n\nSulphur as a disinfectant, 190, 196.\nSuperfoetation, 82.\nSuperimpregnation, 82.\nSuperiors, chronic disease in, 245, 249.\nSurgery and alcoholism, 163.\nSusceptibility to disease, 170.\nSymphyseotomy, 56, 57;\n  mortality in, 57.\n\nSyncephalus, 84.\nSyphilis, 311;\n  accidental infection with, 323;\n  and marriage, 315;\n  and nervous strain, 324;\n  cause of paresis, 319;\n  cause of tabes, 312, 322;\n  classes affected, 324;\n  congenital form of, 313;\n  maternal form of, 313;\n  prognosis in, 314, 324;\n  stages in, 311;\n  statistics of congenital form of, 314;\n  symptoms of, 311 312, 313;\n  transmission of, 313.\n\nSyphilitic affection\n  of the trunk organs, 323;\n  arterial disease, 323;\n  brain tumours, 322;\n  paralysis, 322.\n\nT\n\nTabes dorsalis, 312, 320.\nTait on tubal pregnancy, 5, 6.\nTarantism, 236.\nTerata, 69;\n  anadidyma, 79, 83;\n  anakatadidyma, 79, 84;\n  classification of, 74;\n  katadidyma, 70.\n\nTetanus,\n  death in, 161;\n  visits in, 183.\n\nThomas on ectopic gestation, 9.\nThoracopagus, 84.\nTinea favosa, 197.\nTobacco,\n  not a disinfectant, 173;\n  use of by boys, 209.\n\nTrachoma, 200.\nTramps, 296.\nTriple monsters, 86.\nTubal\n  abortion, 6;\n  pregnancy, 5.\n\nTuberculosis, 89, 90;\n  and proprietary drugs, 91;\n  curability of, 90;\n  death in, 158;\n  in schools, 198;\n  prophylaxis, 90;\n  visits in, 182.\n\nTubo-abdominal pregnancy, 5.\nTubo-ovarian pregnancy, 5.\nTumours of the brain, 148\nTyphoid fever, 152;\n  peritonitis in, 152;\n  prognosis of, 152;\n  walking cases of, 152.\n\nTyphus, 179.\nTwins, 78.\n\nU\n\nUnexpected death, 135, 150.\nUnjust aggressor, 18.\nUrningismus, 339.\nUterine amputations, 65.\nUterus,\n  abnormal, 7;\n  anatomy of, 1.\n\nV\n\nVaccination, 173;\n  compulsory, 175;\n  symptoms of, 176.\n\n_Vaginismus et impotentia_, 332.\n_Varicocele et impotentia_, 342.\nVaricose veins, 159.\nVenereal diseases and marriage, 311.\nVentilation, 206.\nVertigo and apoplexy, 144.\n_Verwachsungstheorie_, 77\nViaticum in smallpox, 178.\nVincentius de Justis on impotence, 330.\nVital tripod, 136.\nVitelline membrane, 72.\nVitellus, 72.\nVon Holder on criminals, 272.\n\nW\n\nWall-paper, disinfection of, 194.\nWalls of buildings, 203.\nWater-closets in schools, 207.\nWhiskey, percentage of alcohol in, 108.\nWhooping cough, danger in, 199.\nWill in morality, 13.\nWindows in schools, 205.\nWines, percentage of alcohol in, 108.\n_Witzelsucht_, 224.\nWorking hours for children, 204.\n\nY\n\nYellow fever, aetiology of, 185.\nYouth and social diseases, 318.\n\nZ\n\nZona pellucida, 72.","title":"Essays In Pastoral Medicine","tradition":"scripture-revelation","translated_text":null,"word_count":126094}