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+The Project Gutenberg EBook of Essays In Pastoral Medicine, by
+Austin OMalley and James J. Walsh
+
+This eBook is for the use of anyone anywhere at no cost and with
+almost no restrictions whatsoever.  You may copy it, give it away or
+re-use it under the terms of the Project Gutenberg License included
+with this eBook or online at www.gutenberg.org
+
+
+Title: Essays In Pastoral Medicine
+
+Author: Austin OMalley
+        James J. Walsh
+
+Release Date: March 3, 2012 [EBook #39036]
+
+Language: English
+
+Character set encoding: ASCII
+
+*** START OF THIS PROJECT GUTENBERG EBOOK ESSAYS IN PASTORAL MEDICINE ***
+
+
+
+
+Produced by Don Kostuch
+
+
+
+
+[Transcriber's notes]
+  This is derived from the Internet Archive:
+   http://www.archive.org/details/essaysinpastora00walsgoog
+
+  Page numbers in this book are indicated by numbers enclosed in curly
+  braces, e.g. {99}. They have been located where page breaks occurred
+  in the original book.
+
+  Obvious spelling errors have been corrected but "inventive" and
+  inconsistent spelling is left unchanged.
+
+[End Transcriber's notes]
+
+
+{iii}
+
+
+ESSAYS IN PASTORAL MEDICINE
+
+
+BY
+
+
+AUSTIN OMALLEY, M.D., Ph.D., LL.D,
+
+PATHOLOGIST AND OPHTHALMOLOGIST
+TO SAINT AGNES'S HOSPITAL
+PHILADELPHIA
+
+and
+
+JAMES J. WALSH, M.D., Ph.D., LL.D.
+
+ADJUNCT PROFESSOR OF MEDICINE AT THE NEW YORK POLYCLINIC SCHOOL
+FOR GRADUATES IN MEDICINE; PROFESSOR OF NERVOUS
+DISEASES AND OF THE HISTORY OF MEDICINE
+FORDHAM UNIVERSITY, NEW YORK
+
+
+
+LONGMANS, GREEN, AND CO.
+
+91 AND 93 FIFTH AVENUE, NEW YORK
+
+LONDON AND BOMBAY
+
+1906
+
+{iv}
+
+_Copyright, 1906_
+
+By Longmans, Green, and Co.
+
+_All rights reserved._
+
+
+
+THE UNIVERSITY PRESS, CAMBRIDGE, U. S. A.
+
+
+
+
+
+
+{v}
+
+PREFACE
+
+The term Pastoral Medicine is somewhat difficult to define because it
+comprises unrelated material ranging from disinfection to foeticide.
+It presents that part of medicine which is of import to a pastor in
+his cure, and those divisions of ethics and moral theology which
+concern a physician in his practice. It sets forth facts and
+principles whereby the physician himself or his pastor may direct the
+operator's conscience whenever medicine takes on a moral quality, and
+it also explains to the pastor, who must often minister to a mind
+diseased, certain medical truths which will soften harsh judgments,
+and other facts, which may be indifferent morally but which assist him
+in the proper conduct of his work, especially as an educator. Pastoral
+medicine is not to be confused with the code of rules commonly called
+medical ethics.
+
+The material of pastoral medicine requires constantly renewed
+discussion, because medicine in general is progressive enough
+frequently to devise better methods of diagnosis and treatment, and
+thus the postulates of the moral questions involved are changed. This
+discussion, however, is not easily made. The facts upon which the
+ethical part of pastoral medicine rests are furnished by the physician
+for the consideration and judgment of the moralist--the physician
+educated after modern methods knows little or nothing of ethics and
+can not himself make accurate moral decisions. The moralist, on the
+other hand, is commonly a poor counsellor to the physician, because
+long training in medicine is needed before the physical data of the
+moral decisions is comprehended. The physician, therefore, is at a
+loss to determine what he may or may not do in {vi} cases that involve
+the greatest moral responsibility, and the priest is a hesitating
+guide because the moral theologies do not convincingly present the
+doctrine in these cases.
+
+Now and then such subjects have been proposed for discussion to a
+group of physicians and moralists, but usually no practical conclusion
+has been reached because one side did not understand the other. In
+1898 there was a series of articles on ectopic gestation in the
+_American Ecclesiastical Review_, in which moralists like Lehmkuhl,
+Sabetti, Aertnys, and Holaind, and some of the leading gynaecologists
+of America considered the questions but arrived at no decision. The
+physicians did not understand certain questions, other questions were
+on obsolete medical practice, essential questions were omitted, and
+from the data the moralists came to opposed conclusions.
+
+We find also in moral theologies deductions drawn from false medical
+sources. Reasons are given, for example, to justify the use of a large
+quantity of alcoholic liquor at a dose in cases of great pain, typhoid
+fever, snake-poisoning, and other diseases, in the supposition that
+such doses will benefit or cure the patient, whereas the physician
+that would follow that treatment would be guilty of malpractice. There
+was recently in America a discussion on the relation of oeophorectomy
+to the _impedimentum impotentiae_. One side held that a lack of
+ovaries constitutes impotence; the other side, that it does not. The
+discussion was useful because it incidentally gathered the full
+doctrine of the moralists on this subject, but from the medical point
+of view there is no connection whatever between these conditions.
+
+A small number of books on pastoral medicine have been written by
+clergymen that were not physicians, and a few German books by
+physicians that were also moralists. Those by the physicians draw
+conclusions from antiquated medical practice, or they are mere popular
+treatises on hygiene; those by the clergymen have some value on the
+ethical side, but they are incomplete because the authors had not the
+necessary medical knowledge. The essays offered in this book by no
+{vii} means cover the entire field of pastoral medicine, but as far as
+they go we have endeavoured to offer the medical doctrine of the
+present day on the questions considered, and that as completely as is
+necessary to draw the moral inferences.
+
+Since, then, so many of the questions of pastoral medicine are not
+defined, physicians are likely to follow the doctrine of the standard
+medical books, which without exception advise them to take the life of
+a dangerous foetus almost as unconcernedly as they might prescribe an
+active drug, or in any case to put utility before justice. There is,
+therefore, an urgent necessity that competent men fix that shifting
+part of ethics and moral theology called pastoral medicine, and these
+essays are presented as a temporary bridge to serve in crossing a
+corner of the bog until better engineers lay down a permanent
+causeway.
+
+Some may think that the authors are inclined toward an exaggerated
+charity in suggesting the measure of responsibility for many human
+actions, but the physician that is brought much in contact with those
+suffering from mental defects of various kinds soon learns how easily
+complete responsibility becomes marred. Responsibility is dependent
+entirely upon free will; and while the great principle of free will
+remains solid in truth, no two men are free in exactly the same
+manner. Physical conditions have not a little to do with modifications
+of freedom of the will. To point out this fact to the clergyman and
+the physician has been our intention, for a proper appreciation of it
+will widen the bounds of charity and save many that are more sinned
+against than sinning from the injury of grievous misjudgment. It is
+better to run the risk of exculpating a few individuals whose
+responsibility is not entirely clear when the application of the same
+principles lifts many others above the rash judgment of those that can
+be of most help to them.
+
+{viii}
+
+{ix}
+
+CONTENTS
+
+_The Authorship of the respective Essays is indicated by the signature
+at the end of each Essay_.
+
+Chapter               Page
+
+I. Ectopic Gestation 1
+
+II. Pelvic Tumours in Pregnancy 40
+
+III. Abortion, Miscarriage, and Premature Labour   48
+
+IV. The Caesarean Section and Craniotomy   55
+
+V. Maternal Impressions 60
+
+VI. Human Terata and the Sacraments 69
+
+VII. Social Medicine 88
+
+VIII. Some Aspects of Intoxication 105
+
+IX. Heredity, Physical Disease, and Moral Weakness 120
+
+X. Hypnotism, Suggestion, and Crime 129
+
+XI. Unexpected Death 135
+
+XII. Unexpected Death in Special Diseases   150
+
+XIII. The Moment of Death 164
+
+XIV. The Priest in Infectious Diseases 168
+
+XV. Infectious Diseases in Schools 187
+
+XVI. School Hygiene 202
+
+XVII. Mental Diseases and Spiritual Direction   211
+
+XVIII. Neurasthenia 230
+
+XIX. Hysteria 235
+
+XX. Menstrual Diseases 240
+
+XXI. Chronic Disease and Responsibility 245
+
+{x}
+
+XXII. Epilepsy and Responsibility 251
+
+XXIII. Psychic Epilepsy and Secondary Personality  259
+
+XXIV. Impulse and Responsibility 266
+
+XXV. Criminology and the Habitual Criminal  271
+
+XXVI. Paranoia, a Study in Cranks 282
+
+XXVII. Suicides 306
+
+XXVIII. Venereal Diseases and Marriage 311
+
+XXIX. Social Diseases 317
+
+XXX. De Impedimento Matrimonii Dirimente Impotentia 326
+
+APPENDIX. Bloody Sweat 347
+
+INDEX 357
+
+{1}
+
+ESSAYS IN PASTORAL MEDICINE
+
+
+I
+
+ECTOPIC GESTATION
+
+
+Ectopic gestation is gestation in the uterine adnexa, the peritoneal
+cavity, or the horn of an abnormal or rudimentary uterus. It is
+opposed to natural uterine gestation, and, since it includes pregnancy
+in an abnormal uterus, it is a more comprehensive term than
+extrauterine pregnancy.
+
+In this article the morality involved in the surgical treatment of
+ectopic gestation is considered; and to have the data requisite for
+judgment it is necessary to describe in outline the anatomy of the
+uterine adnexa and the growth of the foetus; to explain the varieties,
+effects, diagnosis, and treatment of ectopic gestation; to present the
+cases of this condition, or rather this disease, as they occur in
+medical practice; to set forth some of the moral principles or laws
+that govern medical practice, especially where there is question of
+life and death; and finally to apply these principles to the cases
+offered for investigation.
+
+The uterus is in the pelvic cavity, between the bladder and the rectum
+and above the vagina, into which it opens. It is a hollow,
+pear-shaped, muscular organ, somewhat flattened, and about three
+inches long, two inches broad, and one inch thick. The base or fundus
+is upward, and the neck is downward. Passing out horizontally from the
+corners or horns of the uterus, which are at its base, are the two
+Fallopian Tubes, one on either side. These are about five inches in
+length and somewhat convoluted. They are true tubes, opening into the
+uterus, and they are about one-sixteenth of an inch in diameter along
+the greater part of their extent The ends farthest {2} from the uterus
+are fringed and funnel-shaped; and this funnel-end, called the
+Infundibulum or the Fimbriated Extremity, opens into the abdominal or
+peritoneal cavity. Near the Fimbriated Extremity of each tube is an
+Ovary,--an oval body about one and a half inches long by
+three-quarters of an inch in width.
+
+
+  [Illustration]
+  The Uterus and its Adnexa
+
+  _F U_, Fundus or Base of the Uterus. _F T, P T_, Fallopian Tubes. On
+  the left of the reader the Fimbriated Extremity of the tube is
+  lifted up to show it. _O, O_, Ovaries. _B L, B L_, Broad Ligament.
+  _R_, Rectum. _B_, Bladder.
+
+
+For convenience in description, each tube is divided into four parts:
+(1) the Uterine Portion, which is that part included in the wall of
+the uterus itself; it extends from the outer end of the horn into the
+upper angle of the uterine cavity, and its lumen is so small it will
+admit only a very fine probe; (2) the Isthmus, or the narrow part of
+the tube which lies nearest the uterus; it gradually opens into the
+wider part called (3) the Ampulla; (4) the Infundibulum, or the
+funnel-shaped end of the Ampulla. This part is fimbriated, as has been
+said, and one of the fimbriae--the Fimbria Ovarica--which is longer
+than the others, forms a shallow gutter which extends to the ovary.
+
+{3}
+
+The uterus, tubes, and ovaries lie in a septum which reaches across
+the pelvis from hip to hip. This septum is called the Broad Ligament.
+If a man's soft felt hat, of the kind called a "Fedora" hat, is held
+crown downward with one hand at the front and the other at the back of
+the rim, it will represent the pelvic cavity, and the fold along the
+crown of the hat coming up into this cavity is very like the Broad
+Ligament. As the crown is held downward, the uterus would be in the
+middle, its fundus upward, and, of course, altogether outside the hat,
+but in the crown fold. The tubes and ovaries would also be outside the
+hat and in the crown fold, and the fimbriated extremities would open
+by holes into the hat's interior.
+
+The ovum breaks through the surface of the ovary, passes, probably on
+a capillary layer of fluid, into the fimbriated extremity of the tube,
+and then is moved along slowly through the tube into the uterus.
+Ovulation and menstruation occur about the same time, but often one
+antedates the other a few days. In exceptional cases they may occur
+independently.
+
+If the ovum produced is not fecundated, it gradually shrivels up, and
+passes off through the uterus and the vagina. Fecundation of the ovum
+rarely occurs in the uterus, but ordinarily in the Fallopian tube,
+according to the general opinion of physiologists. After fecundation
+the ovum is pushed on into the uterus in from five to seven days,
+where it fastens to the wall and develops. Hyrtl (_Kollmann's Lehrbuch
+der Entwickelungsgeschichte des Menschen_, Jena, 1898) speaks of a
+case in which the ovum appeared to reach the uterus in three days. If
+the fecundated ovum is blocked or held in the Fallopian tube, the
+embryo grows where the ovum stops, and we have a case of Ectopic
+Gestation.
+
+The average time of normal human gestation is ten lunar months or
+forty weeks. At the moment the pronucleus of the spermatozoon fuses
+with the pronucleus of the ovum in the Fallopian tube and makes the
+segmentation nucleus, in my opinion, the soul of the child enters, and
+personality exists as absolutely as it does in a child after birth. It
+is as much a murder, as such, to unjustly destroy this microscopic
+fecundated ovum as it is to kill the child after birth. This is the
+opinion of every embryologist I have consulted on the {4} subject,
+with the exception of one who said he did not know when the soul
+enters.
+
+Technically the product of conception is called the Ovum for the first
+two weeks of pregnancy; during the third and fourth weeks it is called
+the Embryo, and after the fifth week the Foetus. During the fourth
+week the embryo begins to draw nourishment from the maternal blood
+through its umbilical vessels, but before that time it obtains
+nourishment by osmosis.
+
+The foetus at the end of the eighth week is about one inch in length;
+at the end of the fourth lunar month it is from four to six inches
+long, and its sex may be distinguished. At the end of twenty-four
+weeks, if the normal foetus is born it will attempt to breathe and to
+move its limbs, but it dies in a short time. At the end of
+twenty-eight weeks of gestation if it is born it moves its limbs
+freely and cries weakly. It is nearly fifteen inches in length and
+weighs about three pounds. Such an infant might be deemed viable, but
+its chances for life are extremely precarious, even in most expert
+hands and with the help of an incubator. At the end of thirty-two
+weeks of gestation a foetus if born may be raised with skilful care,
+but the chances are not promising. It is viable. At the end of forty
+weeks the child is at term.
+
+In 1876 Parry collected 500 cases of extrauterine pregnancy from
+medical literature, but when Tait in 1883 first operated on a case of
+ruptured tubal pregnancy attention was called to the subject. It was
+better understood as coeliotomies (opening the abdomen) became common,
+and in 1892 Schrenck collected 610 cases that had been reported during
+the preceding five years. Kuestner alone has operated on 105 cases in
+five years.
+
+There has been much discussion among physicians as to the causes that
+arrest the fertilized ovum in the tube, but whatever these causes may
+be they do not affect the moral questions which come up in this
+article. There may be mechanical obstruction from peritoneal
+adhesions, or abnormal conditions resulting from inflammatory diseases
+of the tubes, ovaries, and the pelvic peritoneum, but no general cause
+that will explain all cases can be ascribed.
+
+{5}
+
+Tait denied the possibility of Ovarian Pregnancy, or a pregnancy where
+the ovum fastened to the ovary itself and developed there, but five
+fully established cases of this kind have been reported. Dr. J.
+Whitridge Williams, professor of Obstetrics at the Johns Hopkins
+University, in his textbook on Obstetrics (New York, 1903), collects
+twenty-five cases of ovarian pregnancy, where five cases are certain
+diagnoses, thirteen highly probable, and seven fairly probable. In
+these twenty-five cases ten foetuses reached full term, but four of
+the five certain cases ruptured at early periods.
+
+It was formerly thought that primary abdominal pregnancy is quite
+common; that is, that the ovum is implanted on some organ within the
+abdomen itself, apart from the uterine adnexa. This is now looked upon
+as very doubtful, and such cases are probably secondary; that is,
+secondary to a pre-existing tubal pregnancy which has ruptured without
+great maternal hemorrhage and let the foetus grow within the
+peritoneal cavity.
+
+The common form of extrauterine pregnancy is the Tubal Pregnancy. The
+ovum may be stopped in any one of the three parts of the tube, and we
+find Interstitial, Isthmic, or Ampullar Pregnancy. From these primary
+types, by rupture, secondary forms sometimes arise,--Tubo-abdominal,
+Tubo-ovarian, and Broad-ligament Pregnancy.
+
+The interstitial form, that is, where the ovum is arrested in that
+part of the tube which passes through the wall of the uterus itself,
+is the rarest of the tubal pregnancies. Rosenthal (_Ein Fall
+intranturaler Schwangerschaft. Centralbl. f. Gyn._ 1297-1305) found it
+in only three per centum of 1324 cases of tubal pregnancy. Some deem
+the Isthmic variety the commonest. Dr. Howard Kelly (_Operative
+Gynaecology_) says he never met a case of Interstitial or Ovarian
+pregnancy in his practice. The interstitial form is especially liable
+to rupture with suddenly fatal hemorrhage.
+
+About one-fourth of the cases of tubal pregnancy end within the first
+twelve weeks by rupture of the Fallopian tube. If the embryo is
+implanted in the interstitial end of the tube, the rupture (into the
+uterus, or into the abdominal cavity, or into the broad ligament)
+takes place later,--about the fourth month, or even considerably after
+that time. The reason for {6} the delay here is that the uterus grows
+with the foetus. If the foetus breaks into the uterus (a very rare
+occurrence), it is either expelled through the vagina almost
+immediately or it goes on like a normal pregnancy.
+
+Tait was of the opinion that every case of tubal pregnancy results in
+a rupture of the tube not later than the twelfth week, but this
+opinion is no longer held. Very rarely a tubal pregnancy goes on
+without rupture to full term, as in the cases reported by Williams,
+Saxtorph, Spiegelberg, Chiari, and a few others.
+
+Three-fourths, about seventy-eight per centum, of the cases of tubal
+pregnancy result in what is technically called "tubal abortion"
+instead of rupture. In tubal abortion the connection between the
+embryo and the tube-wall is broken by effusion of blood. If the
+separation is complete the effused blood pushes the embryo out through
+the fimbriated end of the tube into the abdominal cavity, and then the
+hemorrhage of the mother commonly ceases. Such an extrusion of the
+foetus is called a complete tubal abortion. If the connection between
+the foetus and the tube-wall is only partly severed, the ovum remains
+in the tube, and the maternal hemorrhage goes on. This is called
+incomplete tubal abortion.
+
+In incomplete tubal abortion the maternal blood may slowly trickle
+from the fimbriated extremity of the tube into the abdominal cavity,
+become encapsulated, and thus form an haematocele. If the fimbriated
+extremity of the tube is blocked, the blood accumulates in the tube
+and makes an haematosalpynx.
+
+In complete tubal abortion the foetus dies; in incomplete tubal
+abortion the viability might depend on the injury done the placenta,
+but in almost every case of even incomplete tubal abortion the foetus
+dies as a result of its separation from the tubal wall, or from
+compression after the bleeding.
+
+In cases of rupture of the tube in extrauterine pregnancy, if the
+foetus with its attachments is expelled from the tube into the
+peritoneal cavity or into the broad ligament, the embryo dies.
+
+If the foetus or embryo itself alone is expelled into the abdominal
+cavity and the placenta remains attached to the wall of the tube and
+communicates with the foetus by the umbilical cord which runs through
+the tear in the tube, the foetus may {7} possibly live, provided the
+mother does not die from hemorrhage. If the foetus goes on growing in
+this case, we have an abdominal pregnancy. One such case is reported
+by Both where a fully developed foetus was found in the abdominal
+cavity even lacking all its membranes, which had been left in the
+tube, but a foetus will not live apart from its membranes within the
+maternal body.
+
+When an embryo or foetus ruptures the tube and goes into the broad
+ligament, it may live or die according to the injury done its
+attachments to the tubal wall, but it ordinarily dies. Sometimes such
+a broad-ligament pregnancy ruptures again into the abdominal cavity.
+Because the bleeding is more likely to be confined within the folds of
+the broad ligament, the immediate danger of maternal death from
+hemorrhage is less in this than in other forms of rupture.
+
+Concerning tubo-abdominal pregnancy the only remark to be made is
+that, owing to adhesions, it is often surgically difficult to remove
+such a growth.
+
+If the foetus is expelled after rupture into the peritoneal cavity it
+dies, and if the hemorrhage does not kill the mother the dead foetus
+if small is absorbed; if large it becomes mummified, or it hardens
+into a lithopoedion, or it turns into a yellowish greasy mass called
+adipocere, or it putrefies. A lithopoedion may be carried for years.
+There are more than thirty cases reported which were carried from
+twenty to thirty years in the abdomen, and one case where a
+lithopoedion was carried for fifty years.
+
+If the foetus putrefies it causes fatal septicaemia in the mother, or
+a perforating abscess, unless it is successfully removed.
+
+There are various abnormalities of the uterus, and in these pregnancy
+resembles in effect extrauterine pregnancy. An abnormal uterus may be
+unicornis, didelphys, pseudodidelphys, bicornis duplex, bicornis
+septus, bicornis subseptus, bicornis unicollis, or bicornis unicollis
+with a rudimentary horn. The impregnated ovum may fasten in the
+rudimentary horn and be blocked there; then the usual result is
+rupture within the first four months, with fatal hemorrhage unless the
+bleeding is immediately checked by coeliotomy and ligation.
+
+{8}
+
+As to diagnosis in Ectopic Gestation, Williams (_op. cit._), one of
+the authorities at present on the subject, says: "A positive diagnosis
+is occasionally made before rupture, but in the vast majority of cases
+the condition escapes recognition until symptoms of collapse point to
+the probability of rupture or abortion. In advanced cases careful
+examination will usually disclose the real condition of affairs, and
+when full term has been passed the history is so characteristic that
+mistakes should hardly occur."
+
+In the _American Ecclesiastical Review_ for January, 1898 (vol. ix.,
+n. i), Father Rene I. Holaind, S. J., published the answers of many
+physicians to six questions concerning extrauterine pregnancy. Among
+these physicians were Thomas Addis Emmet, Barton Cooke Hirst, Howard
+A. Kelly, W. T. Lusk, T. Galliard Thomas, Mordecai Price and his
+brother Joseph Price, William Goodell, and Lawson Tait,--all eminent
+authorities on this subject. The second question submitted was:
+"During pregnancy, at what time and by what means can a differential
+diagnosis be made between _intra_ and _extra-uterine_ pregnancy, and
+between abnormal gestation and pelvic or other tumour?"
+
+In answer to this question Dr. Emmet said: "There can be no absolute
+certainty as to the existence of pregnancy in any case until the
+pulsation of the foetal heart can be detected. [After the eighteenth
+or twentieth week of gestation.] . . . A diagnosis is difficult in all
+cases of abnormal pregnancy, but an expert can, within a reasonable
+degree of certainty, arrive at a knowledge of the existing conditions
+between the second and third month."
+
+Dr. Hirst said: "In almost all cases of advanced gestation the
+differential diagnosis can be made. In early cases it is not always
+possible unless conditions be favourable."
+
+Dr. Howard A. Kelly said: "The differential diagnosis between intra
+and extrauterine pregnancy can usually be made from the sixth week up
+to the end of pregnancy. It is more easily made from the tenth to the
+twelfth week on." Writing in the _American Text Book of Obstetrics_
+(Philadelphia, 1896), he says: "In the atypical cases, on the
+contrary, a positive diagnosis is often difficult or even impossible.
+. . . {9} The diagnosis of ectopic gestation after the death of the
+foetus is largely dependent upon the clinical history; if this be
+deficient, the diagnosis is frequently impossible."
+
+Dr. Lusk said: ".... The frequent discovery of the dead ovum in a tube
+when there has been no suspicion of pregnancy shows the difficulty of
+a diagnosis." In his text-book (_The Science and Art of Midwifery_,
+New York, 1890) is this remark: "Sometimes the diagnosis can only be
+decided by the introduction of the sound or a finger into the uterus,
+the physician assuming the risk of premature labour, should he find
+his supposition of extrauterine pregnancy an error." This means that
+sometimes the diagnosis is impossible without running the risk of
+causing abortion of a normal uterine pregnancy.
+
+Dr. Thomas said, "After the second month the diagnosis is perfectly
+possible." This was also the opinion of Dr. Mordecai Price; and Dr.
+Joseph Price holds that the diagnosis can be made "after the third
+month, by exclusion." Dr. John F. Roderer, quoting Lawson Tait, says
+that "the diagnosis between intra and extrauterine pregnancy can not
+be made with certainty before rupture, nor can it be determined
+exactly whether an enlargement of the tube is either an ectopic
+pregnancy or some form of tumour."
+
+Dr. Goodell's opinion was, "A differential diagnosis can rarely be
+made positively at any stage of extrauterine pregnancy."
+
+The diagnosis, then, is difficult; and for the ordinary practitioner,
+the average physician, who does perhaps ninety-five per centum of the
+medical work of the world, the diagnosis is often impossible. There is
+no greater expert than Dr. Thomas Addis Emmet, and he says the
+diagnosis is difficult. Others hold that the diagnosis can be clearly
+made, and they speak truly as regards themselves, but ordinary skill
+finds the diagnosis almost impossible in many cases. Mordecai Price
+(_The Pennsylvania Medical Journal_, vol. viii. p. 223) in one year
+saw four cases which he and other physicians diagnosed as ectopic
+pregnancies with rupture of the tube. When the abdomen had been
+opened, uterine pregnancy was discovered with a ruptured tube in each
+case, and all the women died.
+
+{10}
+
+The first positive diagnosis of unruptured tubal pregnancy was made by
+Veit in 1883, and the first one made in America was by Janvrin in
+1886, eight years before Father Holaind's article was written. Before
+1883, only eleven years in advance of the same article, when Lawson
+Tait performed the first coeliotomy for the purpose of checking
+hemorrhage from a ruptured tubal gestation, extrauterine pregnancy was
+as mysterious as the old "inflammation of the bowels," which turned
+out afterward to be appendicitis. Hence common skill in the difficult
+diagnosis of ectopic gestation can not be looked for.
+
+The doctrine given in all the leading medical works at present
+concerning the treatment of extrauterine pregnancy is this:
+
+  1. As soon as an extrauterine pregnancy is discovered remove the
+  foetus through an opening made in the mother's abdominal wall. Do
+  not use electricity or the injection of poisons into the foetal sac,
+  or the incandescent knife. Emmet and a few others approved of the
+  use of electricity at times, but this is against the teaching of the
+  great majority of writers at present. The reason for removing the
+  foetus at once is that it is apt at any moment to cause rupture and
+  fatal hemorrhage before surgical aid can be effective.
+
+  2. In a case of rupture with free hemorrhage and collapse the only
+  operation advised is an immediate coeliotomy to stop the bleeding by
+  ligatures. The rupture should not be approached through the vaginal
+  wall according to the common doctrine, but through the abdominal
+  wall.
+
+  3. If there is a rupture in which the bleeding is confined and there
+  is no collapse, do not operate at once unless the haematocele
+  increases steadily or shows signs of suppuration. Sometimes
+  evacuation of the haematocele through the vaginal wall is possible.
+
+  4. In the later months of an extrauterine pregnancy, whether the
+  case is intraligamentous or abdominal, perform coeliotomy as soon as
+  the diagnosis has been made, and remove the foetus, because there is
+  always danger of sudden and fatal hemorrhage before the surgeon can
+  reach the source of the bleeding. What is to be done in a case where
+  the surgeon is certain before operating that the foetus is {11}
+  dead, has interest only for the physician, and it involves no moral
+  question.
+
+Operating for extrauterine pregnancy maybe a simple coeliotomy, if any
+coeliotomy is really simple, but it commonly is the most dangerous
+operation for the mother that the gynaecologist is called upon to
+perform.
+
+The discussion of the moral questions that arise in cases of ectopic
+gestation which began in volume ix. of the _American Ecclesiastical
+Review_ was very valuable, but as the moralists had not full data to
+work on their decision as a whole is not satisfactory. The original
+cases presented are in part obsolete in the medical practice of
+to-day, and important physical conditions were not disclosed in some
+of the other parts of the cases. Father Holaind tentatively agreed
+with Father Lehmkuhl in one decision, Fathers Eschbach and Sabetti
+directly attacked Father Lehmkuhl's reasons, and Father Aertnys
+indirectly opposed Father Sabetti's chief argument. These men are all
+eminent authorities, but as each, except Father Holaind, was
+dissatisfied with the arguments advanced by the others, and as their
+data were incomplete, we can not rest the case on their decision.
+
+In Father Holaind's fifth question, if I understand it correctly, he
+seemed to think it possible to baptize a foetus through the opening in
+the mother's abdominal wall while it lies in the abdominal cavity
+before surgical removal. He mentions antiseptic precautions in the
+baptism, which would have no meaning if the foetus were out of the
+abdomen.
+
+Baptism would not be possible in that case: the priest could not get
+at the foetus, he ordinarily could not even see it, and certainly no
+surgeon would permit the attempt. There would be no time for the
+attempt in a rupture case, even if the foetus could be seen; and there
+would be no advantage gained by baptizing the foetus in the abdominal
+cavity where the conditions gave time to do so. If it is alive it will
+live long enough for baptism after removal from the abdomen, provided,
+of course, it is baptized immediately in the operating room. That it
+does not breathe is no proof of immediate death. It is not unusual for
+a full-term child not to breathe for even an hour or longer after
+birth.
+
+{12}
+
+If Father Holaind had not in view baptism within the abdominal cavity,
+the question has this meaning: What is the most effective method after
+the foetus has been removed from the abdomen to open its enveloping
+membranes so as to give it a chance for a life lasting long enough to
+allow baptism?
+
+The best method is to slit the membranes with a scalpel or scissors as
+quickly as possible. The envelopes, cord, and placenta are essential
+parts of the foetus itself, and they grow from itself, not from the
+mother. They take the place of the lungs and the alimentary tract,
+which do not come into action until after normal birth. It would be
+worth discussing whether a baptism on the intact foetal envelopes is
+valid, were it not that we may not apply probabilism in such a case.
+The remaining matter brought out in Father Holaind's questions will be
+considered in the course of this article.
+
+Before presenting the cases of ectopic gestation that occur in medical
+practice, the fundamental ethical principles that are to be applied in
+judging the morality of the surgeon's interference should be given.
+
+The morality of any action is determined, (1) by the object of the
+action; (2) by the circumstances that accompany the action; (3) by the
+end the agent had in view.
+
+  1. The term _object_ has various meanings, but here it means the deed
+  performed in the action, the thing which the will chooses. That deed
+  by its very nature may be good, or it may be bad, or it may be
+  indifferent morally. In themselves to help the afflicted is a good
+  action, to blaspheme is a bad action, to walk is an indifferent
+  action. Some bad actions are absolutely bad, they never can become
+  good or indifferent (blasphemy or adultery, for example); others, as
+  stealing, are evil because of a lack of right in the agent: these
+  may become good by acquiring the missing right. Others are evil
+  because of the danger necessarily connected with their
+  performance,--the danger of sin connected with them, or the
+  unnecessary peril to life. An action to have the moral quality must
+  be voluntary, deliberate; and mere repugnance in doing an act does
+  not in itself make the act involuntary.
+
+  2. Circumstances sometimes, though not always, can add a {13} new
+  element of good or evil to an action. The circumstances of an action
+  are the agent, the object, the place in which the action is done,
+  the means used, the end in view, the method observed in using the
+  means, the time in which the deed is done. If a judge in his
+  official position tells a sheriff to hang a criminal, and a private
+  citizen gives the same command, the actions are very different
+  morally because of the circumstances of the agent giving the
+  command. The object--it changes the morality of the deed if a man
+  steals a cent or a thousand dollars. The place--what might be merely
+  a filthy action in a house might be a sacrilege in a church. The
+  means--to support a family by labour or by thievery. The end in
+  view--to give alms in obedience to divine command or to give them
+  to buy votes. The method observed in using means--kindly, say, or
+  cruelly. The time--to do manual labour on Sunday or on Monday. Some
+  circumstances aggravate the evil in a deed, some extenuate it.
+  Others may so colour a deed that they specify the deed, make the
+  action some special virtue or vice. The circumstance that a murderer
+  is the son of the man he kills specifies the deed as parricide.
+
+The end also determines the morality of an action (see St Thomas,
+_Sum. Theol_. I. 2., q. xviii., a. 4 and 7). Since the end is the
+first thing in the intention of the agent, he passes from the object
+wished for in the end to choosing the means for obtaining it. Without
+the end the means can not exist as such. There are occasions when an
+end is only a circumstance: for example, if it is a concomitant end.
+When an end is a, _finis extrinsecus operantis_, when it is in keeping
+with right reason or discordant thereto, it may become a determinant
+of morality.
+
+In every voluntary, or human, act there is an interior and an exterior
+act of the will, and each of these acts has its own object. The end is
+the proper object of the interior act of the will; the exterior object
+acted upon is the object of the exterior act of the will; and as this
+exterior act specifies the morality, so does the interior
+object--which is the end--specify it, and even more importantly than
+the exterior object does.
+
+The will uses the body as an instrument on the external {14} object,
+and the action of the body is connected with morality only through the
+will. We judge the morality of a blow, not by the physical stroke, but
+from the intention of the striker. The exterior object of the will is,
+in a way, the matter of the morality, and the interior object of the
+will, or the end, is the form. Aristotle (_Ethics_, lib. v., cap. 2)
+says: "He that steals that he may commit adultery, is, absolutely
+speaking, more an adulterer than a thief." The thievery is a means to
+the principal end, and it is this principal end that chiefly specifies
+or informs the action.
+
+The means used to obtain an end are very important in a consideration
+of the morality of an act. There are four classes of means,--the good,
+the bad, the indifferent, and the excusable.
+
+Good means may be absolutely good, but commonly they are liable to
+become vitiated by circumstances,--almsgiving is an example. Some
+means are bad always and inexcusable,--lying, for example. The
+excusable means are those which are bad, but justifiable through
+circumstances. To save a man's life by cutting off his leg is an
+excusable means.
+
+The existence of excusable means whereby some good actions are
+effected does not establish the assertion that the end justifies the
+means. The end sometimes may incriminate or sanctify indifferent
+means, but it does not in itself justify all means. The means, like
+other circumstances, are accidents of an action, but they are in an
+action just as much as colour is in a man. Colour is not of a man's
+essence, but you can not have a man without colour.
+
+The effect of an action, the result or product of an effective cause
+or agency, may in itself be an end or an object or a circumstance, and
+it has influence in the determination of morality. Sometimes an act
+has two effects, one good and the other bad; and that such an action
+be lawful it is necessary (1) that the action itself be good or
+indifferent; (2) that the good effect be intended and the evil effect
+be not intended (chosen) but only reluctantly permitted; (3) that the
+evil effect be not a means to secure the good effect; (4) that there
+be present a motive sufficiently grave to excuse or counterbalance the
+bad effect. {15} St. Thomas (_Sum. Theol_. 2. 2. q. 64, a. 7) Speaking
+of killing a man in self-defence, says: "Nihil prohibet unius actus
+esse duos effectus, quorum alter solum sit in intentione, alius vero
+sit praeter intentionem. Morales autem actus recipiunt speciem
+secundum id quod intenditur, non autem ab eo quod est praeter
+intentionem, cum sit per accidens."
+
+That an act, therefore, be morally good, or justifiable, (a) the whole
+train of the tendency of the will must be good; that is, (1) the
+object, (2) the end, (3) and the circumstances must be good; or (b)
+the intention should be good, and the remaining elements in the train
+of will-tendency are to be indifferent. That an act be morally bad it
+is enough that the object, the end, or the circumstances be
+inexcusably bad.
+
+There may be honest doubt as to the existence of evil in the
+circumstances or the end, and here enters the matter of probability;
+but apart from this, some general rules of morality that govern all
+cases may be formulated:
+
+  1. An intention or end which is gravely evil always makes the entire
+  action evil and unjustifiable.
+
+  2. An intention or end which is slightly evil, if it is the entire
+  end of an action, makes the whole action evil but not gravely
+  evil--makes it, say, a venial sin and not a mortal sin.
+
+  3. If an intention or end which is venially evil accompanies
+  secondarily a good intention or end, and is rather a motive than the
+  real effective agent in attracting the will, this venial evil does
+  not vitiate the whole goodness or righteousness of the main action.
+  Compare the remarks made above in discussing an action that has a
+  double effect, partly good and partly bad.
+
+  4. Circumstances that are gravely evil practically vitiate the
+  entire action, but circumstances which are venially evil do not
+  always vitiate the entire action.
+
+Much might be said here concerning conscience as a judge of the
+morality in an act, but this discussion is not necessary for our
+present purpose. Like other men, physicians often confuse conscience
+with inclination, or at best with unfounded opinion. When conscience
+is to be a rule of action it must {16} have at the least moral
+certitude; or, what is different but practically the same thing, the
+opinion of conscience must be at the least genuinely probable. The
+term "probable" is used here in a technical sense, and it will be so
+used throughout the remainder of this article.
+
+The doctrine of Probabilism is connected with the promulgation of law.
+A law, according to St. Thomas (_op. cit._ I. 2., q. 90, a. 4) is:
+"Ordinatio rationis ad bonum commune ab eo qui curam habet
+communitatis promulgata." Sometimes it is not evident whether or not a
+law binds in a particular case, and in such a condition, that is, in
+which there is question solely of the existence, interpretation, or
+application of a law, we may follow a probable opinion which assures
+us the act is licit, although the opinion which says the act is
+illicit may be just as probable or even more probable. This is the
+fundamental proposition of Probabilism, which is the doctrine
+especially of St. Alphonsus Liguori, but it was held centuries before
+his time. As the church has never condemned this doctrine, but rather
+tacitly approved of it, Catholics may safely follow it, and those that
+are not Catholics will find it very reasonable.
+
+A law which is doubtful after honest and capable investigation has not
+been sufficiently promulgated, and therefore it can not impose a
+certain obligation because it lacks an essential element of a law.
+When we have used such moral diligence of inquiry as the gravity of a
+matter calls for, but still the applicability of the law is doubtful
+in the action in view, the law does not bind; and what a law does not
+forbid it leaves open.
+
+Probabilism is not permissible when there is question of the worth of
+an action as compared with another, or of issues like the physical
+consequences of an act. If a physician knows a remedy for a disease
+that is certainly efficacious and another that is probably
+efficacious, he may not choose the probable cure, at the least in a
+grave illness. Probabilism has to do with the existence,
+interpretation, or applicability of a law, as I said, not with the
+differentiation of actions.
+
+The term probable means provable, not guessed at, or jumped at without
+reason. There must be sound reason {17} adduced to constitute
+probability. The doubt must be founded on a positive opinion against
+the existence, interpretation, or application of the law. It must be
+more than mere negative doubt, more than ignorance, more than vague
+suspicion, especially must it be more than a sentimental impression.
+There is a mental condition, which easily passes over into disease,
+wherein a man habitually can not make up his mind. This flabbiness has
+nothing to do with Probabilism. The opinion against a law to
+constitute Probabilism must be solid. It must rest upon an intrinsic
+reason from the nature of the case, or an extrinsic reason from
+authority,--always supposing the authority cited is really an
+authority. Many men sitting upon the supreme bench in the Court of
+Science and called authorities by friends and newspapers, are only
+fools in good company.
+
+The probability must also be comparative. What seems to be a very good
+reason when standing alone may be very weak when compared with a
+reason on the other side. When we have weighed the arguments on both
+sides, and we still have good reason left for standing by our opinion,
+our opinion is probable. The probability is, moreover, to be
+practical. It must have considered all the circumstances of the case.
+
+The principles presented here have been arranged, as we said, with a
+view toward application in judging the morality of actions that may
+occur in cases of ectopic gestation, and we shall apply the doctrine
+of probabilism in the question, does the commandment "Thou shalt not
+kill" bind in certain cases of ectopic pregnancy? It is also necessary
+to add the principles underlying our duty to preserve human life.
+
+  1. It is never lawful directly or indirectly to kill an innocent
+  man. "Insontem et justum non occides" (Exod. xxiii. 7). An
+  _innocent_ man is one that has not by any human act done harm to
+  another man or to society commensurate with the loss of his life.
+  _Directly_ means to kill either as an end, say, for revenge, or as a
+  means toward an end.
+
+  A man is a person, an intelligent being, therefore free, and
+  autocentric; he belongs to no one except to God, who made {18} him;
+  he is by that very fact distinguished from brutes or things which
+  may belong to another. Now, if you kill a man, you destroy his human
+  nature by separating his soul and body, you subordinate and
+  sacrifice him wholly to yourself, make him entirely yours, which is
+  unjust. Even the state has no right to kill an innocent man. A
+  foetus in the womb, only a few hours old, is as much a human being
+  as a man fifty years of age, and this natural law holds for the
+  foetus as for the man.
+
+  2. It is, however, lawful _indirectly_ to kill a man provided this
+  man is an unjust aggressor. Cardinal de Lugo (_De Just. et Jure_,
+  10, 149) and others hold you may even _directly_ kill an unjust
+  aggressor. _Indirectly_ here means incidentally. An effect happens
+  indirectly when it is neither intended as an end nor a means, but
+  happens as a circumstance unavoidably attached to the end or means
+  intended.
+
+We may not, however, kill an innocent man even indirectly, because no
+end is proportionate to the sacrifice of an innocent man's life, but
+the case of an unjust aggressor differs from that of an innocent man.
+By an unjust aggressor is meant some one that outside the due course
+of law threatens your life or the equivalent of your life, or the life
+of some one you should or may protect. You may stop such an aggressor,
+and if you happen to kill him while trying to stop him, there is no
+moral wrong involved. This aggressor may be formally or only
+materially unjust: he may be a normal man with a formal intention to
+kill you or your ward, or a murderous lunatic that tries to kill you
+or your ward, but he must be _unjust_ either formally or materially.
+
+It is natural for every being to maintain itself in existence, to
+resist destruction. This is a primary law of nature. As Father Holaind
+well said (_Amer. Eccl. Rev._, January, 1894): "The ethical foundation
+of self-defence is this: Justice requires a sort of moral equation,
+and if a right prevails it must be superior to the right which it
+holds in abeyance. At the outset both the aggressor and his intended
+victim have equal rights to life, but the fact of the former using his
+own life for the destruction of a fellow man places him in a condition
+of juridic inferiority with regard to the latter. If we may be {19}
+allowed so to express it, the moral power of the aggressor is equal to
+his inborn right to life, less the unrighteous use which he makes of
+it, whilst the moral power of the intended victim remains in its
+integrity and has consequently a higher juridic value. When the person
+assailed cannot defend himself, his right _can_ and sometimes _must_
+be exercised by those who are bound in justice or charity to protect
+the innocent. At the dawn of human life the physician or surgeon
+stands as the natural protector both of the mother and of the child;
+he is beholden to both.
+
+"The right of self-defence is not annulled by the fact that the
+aggressor is irresponsible. The absence of knowledge saves him from
+moral guilt, but it does not alter the character of the act,
+considered objectively and in itself; it is yet an unjust aggression,
+and in the conflict, the life assailed has yet a superior juridic
+value. The right of killing in self-defence is not based on the ill
+will of the aggressor but on the illegitimate character of the
+aggression. Now, an aggressor is _at least materially unjust_ whenever
+he perpetrates an act destructive of the right of another."
+
+Mark the words "right of another," at the end of the quotation. In a
+case of pregnancy at term in a woman with a contracted pelvis the
+foetus would be a contributing instrument of death to the mother,
+supposing there were no artificial means of delivering her, but such a
+child is not an aggressor even materially unjust. The child itself is
+normal, it has a natural right to be where it is, it did not put
+itself where it is; the mother's contracting uterus crushing the child
+against her narrow pelvic arch is the direct agency that kills the
+woman, and the child is only an inert instrument used by the
+contracting uterus. In such a case the mother might be considered an
+aggressor materially unjust against the life of the child rather than
+that the child is the aggressor.
+
+Lehmkuhl (_Compendium Theologiae Moralis_, 1891, p. 238) says:
+"Medicus graviter peccat ... si media abortus procurat: nisi quando ad
+salvandam matrem ex probabili opinione liceat." On page 188 he says:
+"Ex consulto abortum inducere, etiam liceri videtur in praesenti vitae
+{20} maternae discrimine, quod per solam foetus immaturi ejectionem
+avert! possit . . . Idque videtur applicari posse ad matrem quae tarn
+arcta est ut tempus praematuri partus exspectare non possit."
+
+By _foetus immaturus_ here he means an unviable foetus, as is evident
+from the context. If this probabilism of Father Lehmkuhl's stands (but
+it does not), a decision in most of the cases that occur in ectopic
+gestation would be easily made, but even he himself would not take
+responsibility in the matter, and that before the decision of the Holy
+Office which defined abortion. Since this decision, made July 24,
+1895, Lehmkuhl has entirely withdrawn his opinion.
+
+On May 4, 1898, the Holy Office published the following decree, which
+was approved by the Pope:
+
+  BEATISSIME PATER,--Episcopus Sinaloen. ad pedes S. V. provolutus,
+  humiliter petit resolutionem insequentium dubiorum:
+
+  I. Eritne licita partus acceleratio quoties ex mulieris arctitudine
+  impossibilis evaderet foetus egressio suo naturali tempore?
+
+  II. Et si mulieris arctitudo talis sit, ut neque partus prematurus
+  possibilis censeatur, licebitne abortum provocare aut caesariam suo
+  tempore perficere operationem?
+
+  III. Estne licita laparotomia quando agitur de pregnatione
+  extra-uterina, seu de ectopicis conceptibus?
+
+  Feria iv, die 4 Mali, 1898.
+
+  In Congregatione habita, etc . . . EE. ac RR. Patres rescribendum
+  censuerunt:
+
+  Ad I. Partus accelerationem per se illicitam non esse, duromodo
+  perficiatur justis de causis et eo tempore ac modis, quibus ex
+  ordinariis contingentibus matris et foetus vitae consulatur.
+
+  Ad II. Quoad primam partem, _negative_, juxta decretum, Feria iv.,
+  24 Julii, 1895, de abortus illiceitate.--Ad secundam vero quod
+  spectat: nihil obstare quominus mulier de qua agitur caesareae
+  operationi suo tempore subjiciatur.
+
+  Ad III. Necessitate cogente, licitam esse laparotomiam ad
+  extra-hendos e sinu matris ectopicos conceptos, dummodo et foetus et
+  matris vitae, quantum fieri potest, serio et opportune provideatur.
+
+  In sequenti Feria vi., die 6 ejusdem mensis et anni . . . SSmus
+  responsiones EE. ac RR. Patrum approbavit.
+
+{21}
+
+The third question proposed by the bishop is:
+
+"Is laparotomy licit when performed for extrauterine pregnancy or
+ectopic gestation?"
+
+The approved answer of the Holy Office to this question is:
+
+"In a case of necessity, laparotomy for the purpose of removing an
+ectopic foetus (_conceptus_) from the abdomen of the mother is licit,
+provided the lives of both the foetus and the mother, as far as is
+possible, are carefully and fitly guarded."
+
+The expression, "dummodo et foetus et matris vitae, quantum fieri
+potest, serio et opportune provideatur," is capable of various
+translations and interpretations.
+
+The words might have this meaning: "In a case of necessity you may do
+laparotomy and remove an ectopic gestation, provided you do not kill
+either the mother or the foetus." If that is the interpretation, the
+decree means that we may never remove an unviable ectopic foetus when
+we know that the foetus is alive, because removal will kill it.
+
+The sentence can also be translated in this sense: "In a case of
+necessity, you may do laparotomy and remove an ectopic foetus from the
+mother, provided you take full care to save mother and child if that
+is possible."
+
+If that is the signification, it is evidently very different from the
+first interpretation. It would mean: do the laparotomy, remove the
+foetus, and if you possibly can save both mother and foetus do so, but
+if you can not, take the best means you can to save one or the other.
+
+If the decree refers only to cases in which the foetus is viable, it
+would appear to be unnecessary--we need no decree of the Holy Office
+to let us do a laparotomy to remove a viable foetus. If it does not
+refer to a viable foetus, it refers to an unviable foetus, but to
+remove an unviable foetus is to either kill it or to hasten its death.
+
+Genicot (_Institutiones Theologiae Moralis_, Louvain, 1902, vol. i. p.
+358) has this interpretation of the decree:
+
+"In conceptione extra-uterina licebit sane recurrere ad laparotomiam
+similemve operationem, quando aliqua etiam tenuissima spes affulget
+salvandi infantem, simul ac mater fere certo liberabitur. . . . Ubi
+vero nulla spes hujusmodi {22} affulget, neque in hoc casu licebit
+abortum directe inducere, etiamsi foetus certo moriturus sit antequam
+in lucem edatur, et baptismum recipere nequeat. Etenim S. Inqu., dum
+provocat ad responsum 19 August, 1888, satis indicat abortus
+inductionem a se haberi tamquam operationem directe occisivam foetus
+ideoque semper illicitam."
+
+There is no question of an _abortion_ in a laparotomy for extrauterine
+gestation; abortion is altogether a different operation in method and
+nature. Secondly, the other decree of the Holy Office to which he
+refers speaks of a direct killing of the foetus, but there is no
+direct killing of the foetus in the operation for ectopic gestation,
+nor is the indirect hastening of the foetus's death a means to an end.
+The decree on abortion is so clear it leaves no room for doubt.
+
+Cardinal Monaco, in the _Epistola ad Archiepiscopum Camarcensem_,
+August 19, 1889, says the Holy Office decreed that "In scholis
+catholicis tuto doceri non posse licitam esse operationem chirurgicam
+quam _craniotomiam_ appellant, sicut declaratum fuit die 28 Maii,
+1884, et quamcumque chirurgicam operationem directe occisivam foetus
+vel matris gestantis."
+
+Note the words "_directe_ occisivam." Craniotomy is a direct killing,
+and a direct killing used as a means to an end; moreover it is an
+altogether unnecessary killing. Artificial abortion in the case of an
+unviable foetus is also a direct killing as a means to save the
+mother's life, but the removal of an unviable ectopic foetus is
+neither a direct killing, nor is it a means toward any end.
+
+Since the meaning of the decree concerning laparotomy in extrauterine
+pregnancy is by no means clear, we may discuss the question until the
+law has been fully promulgated, ready to conform to the real meaning
+of the decree whenever it is explained. In that spirit we may now
+consider the cases that occur in ectopic gestation.
+
+Case I. A surgeon is called in to treat a woman and he finds her in a
+state of collapse. He makes a diagnosis of tubal pregnancy, which has
+gone on to rupture with hemorrhage, and the bleeding will evidently be
+fatal to the mother unless it is checked. Practically the only chance
+of saving the {23} mother's life is coeliotomy and the ligation of her
+open arteries. Dr. Howard Kelly (_Operative Gynaecology_, vol. ii. p.
+437) says: "When the hemorrhage is sudden and excessive the patient
+falls in collapse; but, in spite of these alarming symptoms, she may
+survive a succession of similar attacks and the foetus and sac may
+continue to develop." This exception complicates the case slightly. If
+the surgeon were absolutely certain that the only possible chance to
+save the woman's life is coeliotomy and haemostasis, the case would be
+somewhat different from one in which there is some chance of escape by
+spontaneous haemostasis. That chance, however, is so slight, and so
+far beyond any means we have for forecasting, that it is mere luck,
+and it is to be neglected. The surgeon may safely consider the patient
+in the gravest actual danger.
+
+(a) Before he opens the abdomen he can not tell whether the foetus is
+alive or not; but the stronger probability is that it is not, and the
+certainty is that it has no chance at all to remain alive more than a
+few minutes or hours, unless the surgeon is willing to trust to sheer
+luck in the expectation that he may happen to have one of Dr. Kelly's
+exceptions before him.
+
+(b) The operation to save the mother is this: as quickly as possible
+he makes a vertical slit from four to six inches long through the
+woman's belly-wall. Then commonly the free blood begins to run out, or
+it may even spurt out some feet into the air. The surgeon can see
+nothing for the blood and the presence of the entrails. If the blood
+is not freshly welling up he bails it out with his hands or a ladle;
+if it is spurting he at once thrusts in his hand, feels for the foetal
+sac, lifts it up, and puts on clamps near the uterus on one side and
+near the pelvic brim on the other. This stops the hemorrhage, and he
+can then work more leisurely, but unfortunately this also stops the
+flow of blood to the foetus. He can not first examine the foetus and
+then stop the hemorrhage. He can not back out even if he finds a live
+foetus without letting the mother die on the table.
+
+(c) If the placenta is already loose from the Fallopian tube the child
+is dead or it will die in a few seconds or minutes. If it was not
+loose the lifting out may tear it loose, and this {24} tearing loose
+will hasten the death of the foetus a few minutes (but give a chance
+for baptising it).
+
+(d) If the lifting out does not tear loose the supposedly fixed
+placenta, the foetus either will die anyhow if the mother dies, or it
+will die if the mother lives, because to save her the surgeon must put
+ligatures just where the flow of blood will be shut off from the
+foetus. Commonly there is no time to even look for the foetus until
+after the maternal arteries have been closed.
+
+(e) The same conditions could exist in the rupture of a pregnancy in a
+rudimentary uterine horn as in a rupture in tubal gestation.
+
+What is the surgeon to do in a case like this? Fathers Holaind (_Amer.
+Eccl. Rev._, January, 1894, in a note on p. 39), Lehmkuhl and Sabetti
+say: do coeliotomy, ligate the mother's arteries, remove and baptise
+the foetus.
+
+The analysis of the case is this: (i) The _action_ is the stopping of
+a fatal hemorrhage in a woman, and possibly, though not certainly, an
+indirect incidental hastening of a foetus's inevitable death.
+
+(2) The _object of the action_ is the haemostasis, which is good, and
+the possible indirect hastening of the foetus's death, which is evil,
+but, as we shall see, excusable evil.
+
+(3) The _end of the action_ is to save the mother's life--a good end.
+
+(4) The _circumstances are_: (a) that possibly, through mere luck, the
+woman's condition is not necessarily hopeless: a few women have
+escaped in this seemingly imminent peril--but that chance of escape is
+not soundly probable; the stronger probability by far is on the side
+of a fatal issue; therefore the chance for escape may be neglected,
+and the woman's case may be regarded as hopeless if operation is
+foregone.
+
+(b) The quickest possible work on the surgeon's part is necessary, and
+there is no time or chance to examine the foetus's condition before
+tying the maternal arteries. Before he opens the mother's abdomen he
+can tell nothing whatever of the foetus's condition, but the
+probability is all in favour of the fact that the foetus is already
+dead or moribund.
+
+(c) The _means_ are coeliotomy, and the ligation of the {25} uterine
+and ovarian arteries to stop the mother's bleeding. This ligation, in
+the contingency that the foetus is still attached to the Fallopian
+tube, will also shut off the blood from the foetus, yet the uncertain
+shutting off of the foetal blood-supply is not intended by the surgeon
+as a means toward his end in any degree direct or indirect, but it is
+an evil circumstance associated with the action which may hasten the
+foetal death--even here the hastening is uncertain.
+
+(5) The _action has two effects_,--one, the saving of the mother, is
+directly intended and evidently good; the other, the possible indirect
+hastening of the foetus's death, may or may not be evil. The moral
+centre of the whole case is this possible hastening of the foetus's
+death. If that possible hastening is licit the whole action is licit;
+if it is not permissible it will vitiate the entire action.
+
+Suppose that there is no doubt that the ligation of the maternal
+arteries in this case really hastens the foetus's death some minutes:
+it would still be an indirect volition. Father Lehmkuhl also calls it
+indirect and licit. Father Sabetti denied that it is indirect, but he
+held that it is licit for another reason. Sabetti said (_Aner. Eccl.
+Rev_., August, 1894): "It is evidently false to say that a means which
+is _directly_ adopted for obtaining an end is only _indirectly_
+contained in the intention of the agent who so adopts it." That is
+true, but the minor proposition in a syllogism drawn from that
+statement is to be emphatically denied. The cutting off of the foetal
+blood is a fact associated with the means, not a means direct or
+indirect toward the end, which is to save the mother--the means to
+save the mother is the stopping of her bleeding.
+
+This is not hair-splitting in the opprobrious sense of that term. The
+bases of all sins are absolutely abstract principles, and because
+abstract principles can not be pinched or weighed, they have often
+little meaning for the opposition in an argument. There is only the
+width of a hair between Heaven and Hell at many places along the
+frontier, and there is only the difference between a direct or an
+indirect volition separating murder and a good deed. The best ethics
+frequently consists in delicate hair-splitting; and despite the
+protests of sentimentalists, one of the most valuable benefits of
+Moral Science is {26} to show us how to handle moral poisons for good
+purposes, as a physician uses the material poisons, opium and aconite.
+
+If the foetus in this case of rupture in ectopic gestation were a
+materially unjust aggressor on the mother's life, the indirect
+hastening of its death would be justifiable according to all
+moralists, and the direct hastening would be licit according to
+Cardinal de Lugo, who was, in the opinion of St. Alphonsus, "post D.
+Thomam inter alios theologos facile princeps"
+(_Th. Mor._, lib. 4. n. 552).
+
+Sabetti held that the foetus is a materially unjust aggressor. His
+reason for this opinion is that the extrauterine foetus is not in a
+position in which it has a right to be. If it were in the uterus, its
+natural position, it would have a right to its position. Ectopic
+gestation is a disease, not a physiological condition.
+
+Father Aertnys (_Amer. Eccl,_ Rev., July, 1893) denies that the foetus
+is an aggressor materially unjust. He says: "Nequaquam enim mortem
+intentat matri, sed actione, quam non ipse sed corpus matris producit,
+conatur ad lucem pervenire, et iste conatus non nisi ex naturali
+concursu rerum fit matri causa mortis. Infans ergo non est _aggressor_
+et multo minus est _aggressor injustus_. Hinc nego paritatem cum
+homine mente capto, qui delirans alteri mortem intentat; hic enim agit
+motus a sua voluntate, licet absque culpa, et ponit actiones in se
+injustas, utpote ad necandum directe intentas."
+
+In the same periodical (January, 1894) while repeating this statement
+he says: "Sive in utero existat sive alibi reconditus sit [sc.
+foetus], nequaquam mortem intentat matri, siquidem non ipse actione
+propria conatur egredi, sed corpus matris infantem expellit et haec
+expulsio a matre emanans fit matri causa mortis."
+
+What Father Aertnys says in these two passages is true of an
+intrauterine foetus, but it is altogether erroneous when applied to an
+extrauterine foetus, of which alone there is question here. In
+extrauterine pregnancy the uterus or any other part of the maternal
+body does not "try to expel" the foetus; the uterus has nothing at all
+to do with the case--the very name of the condition is _extra_-uterine
+pregnancy. If an ectopic gestation {27} goes on to term (a very rare
+happening), there will be false labour and uterine contractions, and
+these cease after a time without effect one way or the other; but in
+all cases of rupture and the like the uterus is outside the question
+and the mother is passive. There is no attempt by the mother in
+extrauterine pregnancy at expulsion either before rupture or at any
+other time unless the dead foetus putrefies, and the maternal tissues
+"try to expel" it as a foreign body by breaking down into an abscess.
+The foetus simply grows, and its bulk bursts the tube. If it were in
+the uterus, the uterus would enlarge synchronously with the foetus and
+there would be no rupture, but the tube will not give beyond a certain
+point, therefore it bursts.
+
+In normal uterine pregnancy at term the uterus and other maternal
+muscles are the active factors in expelling the foetus--the foetus is
+passive. In ectopic gestation the foetus is active, the mother is
+passive, and there is no attempt at expulsion from either side. In
+this case the foetus in the tube through the action of its own vital
+principle draws nourishment from the mother and grows gradually larger
+till it bursts the tube (it may even move its arms and legs if
+advanced), and this rupture tears open arteries wherethrough the
+mother bleeds, commonly to death. This is evidently material
+aggression.
+
+Father Aertnys says the foetus differs from the murderous lunatic in
+this, that the madman is moved by his will, although blamelessly, in
+doing unjust actions directly intended as homicidal. The fact that the
+lunatic uses his will has no weight whatever in permitting me to
+defend my life against him, it is an accidental thing outside the
+question; but Father Aertnys in mentioning the madman's will means
+solely, if I understand him, that the madman is really an active
+aggressor. The foetus, however, is also an active aggressor without
+using its will. I might fall from a height toward a man and certainly
+endanger his life while I was not using my will at all, not conscious
+of the man's presence under me, or even while I was using all the
+power of my will against the result. In any of these cases I should be
+a materially unjust aggressor; and if in trying to prevent my body
+from killing him the man killed me, he would be blameless.
+
+{28}
+
+Now, in the first place, the tubal foetus is an aggressor; and since,
+secondly, its position is unnatural, monstrous, a disease, a thing not
+intended by nature, it has no right to its position, and it is
+therefore a materially unjust aggressor. Since it is an aggressor on
+the very life of the mother in a place where it should not be, the
+surgeon therefore may at the least stop the fatal bleeding it causes.
+If the foetus dies as an unwished for, though permitted, consequence
+of this haemostasis, the surgeon may lament this result, but he is
+blameless.
+
+The foetus was blocked in its unnatural position through a defect in
+the mother, nevertheless it remains a materially unjust aggressor. If
+I by an accidental blow had made a man insane, and later this lunatic
+tried to kill me, I, or my legitimate protector, might lawfully kill
+the lunatic in defence of my life. This is an exact parallel to the
+case of the mother and the extrauterine foetus.
+
+The extrauterine foetus is not like a foetus in a craniotomy case.
+Where there might be question of craniotomy the foetus is not an
+unjust aggressor even materially, as has been said: first, because it
+is not an aggressor in any manner, it is altogether passive; secondly,
+it has a perfectly natural right to be where it is. In ectopic
+gestation with fatal rupture the foetus is, first, an active
+aggressor; secondly, it has no right to be where it is. In craniotomy
+the foetus is killed as a direct means toward the end that its head
+may be reduced and extracted and the mother saved; in extrauterine
+gestation with fatal rupture the foetus is incidentally killed as a
+consequence of the haemostasis, and not as a means in any sense of the
+term. In craniotomy the child is wantonly killed since there are other
+means of saving the mother; in extrauterine pregnancy with fatal
+rupture the hastening of the death of the child is unfortunately
+associated with the only possible means we have to save the mother.
+
+In Case I., therefore, we have an action that has an object partly
+good and partly, very probably, not evil; the end intended is good;
+the circumstances are justifiable or indifferent; consequently in Case
+I. the surgeon may do coeliotomy, tie the uterine and ovarian
+arteries, and if the foetus {29} happens to be alive he may
+reluctantly and indirectly permit the hastening of its death after
+attempting to baptise it.
+
+Case II. The conditions presented in Case I. are the ordinary and most
+common that the surgeon meets with in treating ectopic gestation, but
+other conditions may be found.
+
+Suppose the surgeon, before operation, diagnoses a case of ectopic
+gestation, but that he can not tell whether or not the foetus is
+alive. The probability leans toward the side that the foetus is alive,
+because there is no indubitable history, as physicians say, of
+maternal symptoms that indicate rupture.
+
+Medical authorities tell him to do coeliotomy at once, ligate the
+uterine and ovarian arteries, and remove the foetus. Would he
+certainly or probably be justified in following out this medical
+doctrine?
+
+The mother is in actual, _very probable_ danger of death, but not in
+actual, _certain_ danger of death. She may possibly escape if
+operation is deferred; she has a negligible chance of escape if no
+operation is performed after the death of the foetus; coeliotomy and
+ligation of the uterine and ovarian arteries give her by far the
+surest chance of escape, so sure an opportunity for escape when
+performed early that it can scarcely be called a mere chance.
+
+If operation is deferred the chances for rupture are about 22 per
+centum, say, one and a half in five chances, and all ruptures are not
+necessarily fatal. The chances of the mother's death, however, are
+much higher than that, because death can come in ectopic pregnancy
+from causes other than rupture. From 63.1 to 68.8 per centum (say,
+66.3 per centum) of ectopic gestations treated by the expectant method
+result in death to the mother--just two-thirds of the women die. A.
+Martin in a series of 265 cases of ectopic gestation where the
+expectant treatment was employed found a maternal mortality of 63.1
+per centum; Parry in 500 similar cases found a mortality of 67.2 per
+centum; and Schauta in 241 cases a mortality of 68.8 per centum.
+
+In the 87 years between 1809 and 1896, 77 cases of coeliotomy for the
+delivery of _viable_ ectopic foetuses were reported {30} in all
+medical literature with a maternal mortality of about 58.3 per centum.
+Between 1809 and 1888 there were 37 coeliotomies with a maternal
+mortality of 86.5 per centum. Between 1889 and 1896 there were 40 such
+operations, with a maternal mortality reduced to 32.5 per centum by
+modern surgical methods.
+
+The results as regards the children were almost the same in the two
+series, and perhaps a little better in the latter series. In the first
+series the 37 children were alive at delivery: the length of time in
+which three of these children lived is not given; three more were
+alive but they did not breathe; the others lived from a few seconds to
+days, weeks, months or years. One was well at six months, another at
+one year, another at seven and a half years, another in its fourteenth
+year, another in its fifteenth year. In the second series the results
+as regards the children were, as has been said, almost the same. The
+40 cases that were reported from 1889 to 1896 are the standard for
+this phase of ectopic gestation, because they come under the diagnosis
+and treatment of the present day. They represent closely all such
+cases that occurred in the entire world between 1889 and 1896, because
+physicians report these operations to medical societies, and active
+physicians are almost without exception members of such
+societies--outside the civilised world these operations do not take
+place. In the seven years there were annually less than six cases of
+coeliotomy for ectopic gestation at term in the world, therefore
+operations at term may be neglected in discussing Case II., and the
+argument may be confined to the ordinary cases of expectant treatment.
+Schrenck in 1892 collected 610 cases of ectopic gestation which had
+been reported between 1887 and 1892; during the same time there were
+23 cases (less than 4 per centum) of operations for the delivery of
+viable foetuses.
+
+If the physician that has made the diagnosis in this Case II. leaves
+the patient, she may have a fatal hemorrhage at any moment. Dr. Howard
+Kelly reports (_Operative Gynaecology_, vol. ii. p. 438) a fatal
+hemorrhage in two days from rupture where the foetus was only as large
+as a Lima bean. The hemorrhage may be so suddenly fatal that the woman
+drops {31} to the floor unconscious just as if she had been shot. Dr.
+Harris (_International Cyclop. of Surgery_, vol. vi. p. 784) tells of
+a case where three of the best obstetricians in Philadelphia met in
+consultation daily for 16 days expectantly watching development, but
+the woman died from hemorrhage in thirty minutes before any of these
+physicians could be called to her aid. Death may be brought about by
+anaemia after repeated hemorrhages. Some hemorrhages can be mistaken
+for colic by the physician, and this error will defer until too late
+the treatment for hemorrhage.
+
+If the woman is living in a hospital where there is a resident surgeon
+with instruments ready, she has a better chance than if she is in her
+own house. Even if she has a surgeon within call the outcome of the
+case for her will depend largely on his skill, his presence of mind,
+the preparedness of his instruments, the general condition of the
+patient, and many other circumstances.
+
+The instruments, ligatures, gauzes, solutions, dressing, etc., for
+coeliotomy are multitudinous, and all must be sterile, or the woman
+will be killed by septicaemia even if the hemorrhage is stopped. It is
+almost impossible to keep a set of instruments and the other things
+used in a coeliotomy always sterile and ready for instant use.
+
+The skin surface of the patient's abdomen must be sterilised, or pus
+infection will get into the peritoneum through the wound. In all
+ordinary coeliotomies this surface is carefully sterilised by a long
+process the night before the operation, a protective dressing is put
+on, and the sterilisation is repeated the next day just before the
+operation. This is so important that its voluntary omission is
+malpractice. In the hurried operation for tubal rupture there would be
+no time for sterilisation of the abdominal skin surface, and probably
+no time to sterilise the instruments and other things used, especially
+the surgeon's hands.
+
+The surgeon to do any coeliotomy needs assistant physicians--one to
+anaesthetise the patient, and at the least one other to work with him
+in the operation. He should have three or four physicians and one or
+two nurses. He can not do a coeliotomy alone. Hence the patient in a
+ruptured {32} extrauterine pregnancy must have at the very least two
+physicians within call.
+
+The woman, then, in Case II. before operation has one chance in three
+of life if no operation is done until the child is viable, and if she
+remains alive till the child is viable (when she must be operated
+upon) her chances for life will be no better, judging from modern
+statistics.
+
+At any moment, therefore, she is in actual peril of death by two
+chances in three, and probably more if all special circumstances are
+considered. The foetus is a materially unjust aggressor in this case
+before rupture or other similar mishap, as it was in Case I., but not
+to the same extent. In Case II. it is a materially unjust aggressor as
+two is to three; in Case I. it is a materially unjust aggressor as
+three is to three.
+
+If a lunatic is just about to fire three cartridges at me, I may know
+the chances are only two in three, or even only one in three, that he
+will hit me fatally, nevertheless I may licitly kill him to stop the
+firing and save my life. The mother in Case II. is in exactly similar
+danger of life.
+
+The objection that the danger to my life from the action of the
+lunatic exists _hic et nunc_ and that the danger to the mother's life
+does not threaten _hic et nunc_, is not of any weight. She is in
+actual danger _hic et nunc_, even while the surgeon is in the room
+examining her. Moreover, the matter of time here is accidental. If you
+give a man a poison that may kill him in ten hours, or one that may
+kill him in ten days, the action is essentially the same.
+
+I am of the opinion that if this second case were proposed to moral
+theologians many of them would decide that the surgeon should explain
+the case fully to the patient or her family, and if immediate
+operation were insisted upon he should withdraw from the case.
+Nevertheless, as far as I can see, he has sound probabilism on the
+side that operation is justifiable.
+
+But, it may be objected, in Case I. the surgeon ligated the uterine
+and ovarian arteries to stop an actual hemorrhage, and he permitted
+the death of the foetus; in Case II. there is no hemorrhage yet, there
+may possibly be none at all. I answer {33} that in Case II. if he
+operates he ties the two arteries to forestall an imminent hemorrhage
+which might begin within the next hour if it were not securely shut
+off, and to forestall sepsis by leisurely and proper precautions, and
+exactly as in the first case he permits the death of the foetus, he
+indirectly kills an unjust aggressor. If the lunatic is aiming at me I
+do not have to wait until he begins firing to licitly shoot at him.
+The sooner I shoot, _servato moderamine inculpatae tutelae_, the more
+prudent my action.
+
+To put it in another form--in Case II. the surgeon is standing before
+a dam (the stretched Fallopian tube) that is threatening to break at
+any moment and cause death to a woman below it, because there is a
+lunatic (the foetus) behind it tearing away the masonry. If the
+surgeon shunts off the water just above the dam (the ligation of the
+arteries), he will suddenly let the lunatic who is tearing away the
+masonry fall down to the rocks at the bottom of the dam and be killed.
+May he let the lunatic fall? Certainly he may. But perhaps the lunatic
+will not succeed in tearing away the masonry. He is well provided with
+tools to do so; the chances are even two in three that he will
+succeed. Is he or the woman to be given the benefit of the doubt? The
+woman, by all means; she has a doubt worth in juridic value at the
+least twice as much as that which the lunatic has.
+
+In any case of ectopic gestation the foetus has a very faint chance
+indeed of even living long enough for baptism if the expectant
+treatment is employed. We have seen that between November 1809 and
+November 1896 there were reported 77 cases of operation for the
+delivery of viable foetuses. Eleven of these children survived, 67
+died within a few months, and many of these died just after delivery.
+Still, probably all might have been baptised. Judging, however, from
+the geographical distribution of the cases (see Kelly's _Operative
+Gynaecology_, vol. ii. p. 458) and the names of the operators, only
+about 14 of these children received baptism.
+
+Now, since Schrenck found 610 ectopic gestations reported in five
+years, this indicates that the average number of cases of ectopic
+gestation which occur in the civilised world is at the least 122 a
+year, for many more (twice as many, at the lowest {34} estimate) are
+not diagnosed or not reported when diagnosed. In the 80 years, then,
+between 1809 and 1896 there were at the least 9760 cases of ectopic
+gestation in the civilised world; in the uncivilised countries there
+were certainly as many more with not a child saved, or even brought
+out of the pelvic cavity. To be sure, by rejecting perhaps a third of
+the cases through bad diagnoses and neglect of reports, there were
+20,000 cases; and in all these hardly 20 children baptised--one in a
+thousand.
+
+Modern surgical methods and improved diagnosis will do little to
+better the condition, from the nature of the disease. Between 1893 and
+1896 there were 21 cases of operation for the delivery of viable
+foetuses reported, and this list is approximately correct, because the
+surgeons that operate on such material are men that as a rule report
+their work even when it is to their discredit. In these 21 cases, 6
+mothers, 28 per centum died, 72 per centum recovered. Even if modern
+surgery should save all the mothers who had escaped until the foetus
+was viable, and should bring all the children to baptism, there would
+not be more than about 7 such cases in the world annually. Increased
+skill in diagnosis would raise the number of children brought to
+baptism, but it would more than proportionately raise the whole number
+of ectopic gestations discovered. If 10 foetuses were brought from the
+pelvic cavity alive in the 130 cases of ectopic gestation of the year,
+the chances for an extrauterine foetus to only reach baptism at a
+viable age (not to live after baptism) are only 7 in 100 at a most
+liberal estimate. Statistics are unreliable, of course, but I am
+giving odds of two to one. The foetus has a much better chance for
+baptism if the coeliotomy is done as early in the pregnancy as
+possible, but it has a negligible chance of life in any case. Since
+the creation of man there have been less than 15 extrauterine children
+saved, and of these 15 four were less than a year old when reported,
+and three under five years of age: the oldest was fifteen years of
+age, and all were weaklings.
+
+The practical rule, then, is that the ectopic foetus will die anyhow,
+and operation only _indirectly_ (mark the word) accelerates the
+inevitable death of a materially unjust aggressor, {35} while it gives
+the mother the best chance for her life, which is in very grave peril.
+
+Case III. The surgeon before operation diagnoses with the help of
+consultors extrauterine pregnancy, but he or they can not tell whether
+the foetus is alive or not. What should he do?
+
+In my opinion he may operate with much more solid probability than
+that which exists in Case II. If the argument is more for the death of
+the foetus than for its life, this, of course, strengthens the
+permissibility of the operation.
+
+(1) The danger to the mother is exactly the same,_caeteris paribus_,
+as in Case II.; (2) the foetus is only probably alive. An actual
+danger to life is opposed to the probable life of a materially unjust
+aggressor; therefore the surgeon may probably operate at once.
+Probable here is used in the technical sense of the term.
+
+Case IV. The following case is given because a similar one was
+proposed in the articles in the _American Ecclesiastical Review_, but
+it is not a practical case.
+
+The surgeon, after consultation, does not know whether the growth in a
+woman's pelvis is a malignant tumour or a sac containing an
+extrauterine foetus. If the growth is a malignant tumour, the woman is
+in actual and certain danger of life, her death is a mere matter of
+time if a malignant tumour is not removed, and the sooner the tumour
+is removed the better. If operation is deferred, metastases of the
+tumour will have occurred, and operation will be too late. The
+indication when we find a malignant tumour is, if it is not already
+too late to operate, to take it out at once.
+
+If the surgeon thinks that the growth may possibly be a foetus, and he
+puts off the operation until a time when certain signs of pregnancy
+should be present to establish a diagnosis of gestation, or their lack
+to establish a diagnosis of tumour, it would almost surely be too late
+to operate in the event the growth turned out to be a malignant
+tumour.
+
+As has been said, the case is not practical, because malignant tumours
+of the tube are so very rare that they are not to be looked for,--only
+one or two have been observed. {36} Malignant tumours about the tube
+should be diagnosed. Supposing, however, the case to stand, it offers
+in favour of operation a probabilism stronger than that in any case
+except Case I., because the mother's danger is graver, and the
+argument concerning the foetus is the same as that in Case III.
+
+Case V. Suppose a doubtful case like Case III. or Case IV., but after
+the surgeon has opened the abdomen he finds a foetus evidently alive.
+This is an improbable but a possible case. Case V. then becomes like
+Case II. with the addition of another grave danger to the lives of
+both the mother and the foetus, which is the coeliotomy already
+performed. The suggestion that the surgeon can leave the woman, back
+out of the case, is absurd. If he closes the abdomen, the coeliotomy
+may cause tubal abortion, the wound might have to be opened again in a
+few hours or a few days, and the mother would be left in much greater
+peril than she was in Case II. For the reasons already given, he
+should go on with the operation.
+
+Case VI. Suppose a case like Case V. in every particular except that
+when the surgeon finds the foetus he can not tell whether it is alive
+or not. He should,_ a fortiori_, finish the operation.
+
+Case VII. A case of ectopic gestation is diagnosed, the conditions are
+explained to the woman, and she refuses to be operated upon. Is she
+justified? The probability is one to two that she will escape death if
+she waits, and much less than one to two if she finally refuses
+operation. The moralists would tell her she may refuse operation.
+
+Case VIII. Let us suppose a case where a Fallopian tube either has its
+lumen so narrowed by a gonorrhoeal inflammation that although the
+spermatozoa may pass through and fecundate the ovum this fecundated
+ovum can not get out to the uterus; or, secondly, that the gonorrhoeal
+infection has completely shut the tube, yet migratory fecundation has
+occurred through the route of the other tube and the passage along the
+fundus of the uterus to the ovary of the infected side. In either case
+an ectopic gestation begins.
+
+The first case is improbable from a medical point of view, {37} and
+the second is barely possible. Gonorrhoeal infection of the tubes is
+common enough, but when it occurs it usually shuts the tube up
+permanently. In chronic salpingitis at times the ovarian end of the
+tube is not wholly closed at once, and since the body of the ovary is
+very rarely affected by gonorrhoea, there is a possibility worth
+considering of a tubal pregnancy through migration to occur.
+
+In such a condition the woman might have been infected with
+gonorrhoea, first, before her marriage through fornication or
+accident; second, after her marriage through adultery or accident;
+third, after the marriage by her husband.
+
+If she had been infected through fornication or adultery, she is
+accountable for the foreseen consequences of her sin, and she has put
+an impediment for which she is responsible before the embryo. Suppose
+the physician knows these facts. Then the excuse for indirectly
+hastening the death of the foetus does not, at first sight, seem to
+exist, because the foetus is apparently not a materially unjust
+aggressor. It could easily happen that a surgeon's refusal to operate
+in a case like this would cause the death of the mother and foetus.
+Should he let both perish? Is he to let the mother die for the sake of
+staving off for a half-hour the certain death of a useless embryo the
+size of a pigeon's egg? It is not a useless embryo the size of a
+pigeon's egg, but a human being, the most important thing on earth,
+and a human being shut off from life and baptism as a direct
+consequence of that woman's brutal sensuality. But the woman may be
+the mother of other helpless children. What is to be done? Let us
+recur to the example of the homicidal maniac.
+
+If I accidently by a blow make a man insane and that insane man
+afterward tries to kill me, I or my protector may permit his death to
+save my life. If I maliciously make a man insane and he afterward
+tries to kill me, may I or my protector kill him in my defence? Some
+may say that I may not because I have lost all juridic superiority
+over the madman as a consequence of my sin against him. That position,
+however, does not seem to be correct.
+
+If it is correct, parity makes the assertion true that the foetus in
+the case supposed above may not be indirectly {38} killed to save the
+mother. If it is not true, the foetus may be indirectly destroyed.
+Does my sin against the insane man give him a right to kill me? By no
+means. Nothing but defence of life or its equivalent gives any private
+individual the right to kill another. The man might kill me before
+this aggression of mine, in defence of his sanity, but after the fact
+such a killing would be mere revenge, or an _actus hominis_, not a
+right.
+
+The woman, we suppose, has maliciously put the foetus in its position
+of material aggressor, but has the foetus the right to kill her? No;
+the foetus is an individual not acting in self-defence, it is merely
+growing. Has the woman or the surgeon, her protector, the right to
+permit the death of the foetus to defend the woman's life? I think
+they have, because the foetus here also is, from its unnatural
+position, a materially unjust aggressor.
+
+But, you say, this is a vicious circle. You justify the permitted
+death of the foetus in Case I. because it is a materially unjust
+aggressor, and it is a materially unjust aggressor because it is in an
+unnatural position where it has no right to be; but in the present
+case the mother put it in the unnatural position, and it therefore has
+a right to be where it is. No: the consequence does not follow. The
+fact that the mother put the foetus in its unnatural position does not
+give the foetus a _right_ to be in that position, although it
+constitutes a ground for her punishment by proper authority. You
+object again, if this woman has a right to permit the death of the
+foetus to save her own life, how may she be punished for that death?
+She will not be punished for the actual coeliotomy which indirectly
+caused the death of the foetus, but she will be punished for the sin
+of putting that child in a position in which it had to be killed. This
+seems to be a distinction without a difference. As far as the mother
+is concerned, _transeat _; but it is a real distinction as far as the
+surgeon is concerned.
+
+If the woman's condition is a result of accidental infection before or
+after marriage, the case goes into the class of those discussed above,
+and operation is justifiable.
+
+If her infection comes after her marriage adulterously, her {39} sin
+is the greater, but the operation is justifiable for the reasons which
+were given in the case of culpable infection before marriage.
+
+If she had been infected by her husband, the operation is
+justifiable--the father is accountable for the foetus's death.
+
+Fortunately the entire case is so nearly hypothetical that it is
+little more than mere words.
+
+AUSTIN OMALLEY.
+
+
+{40}
+
+II
+
+PELVIC TUMOURS IN PREGNANCY
+
+
+Tumours of the uterus and its adnexa at times, though rarely,
+complicate pregnancy, and they may involve certain moral questions
+that have been little discussed. The tumours that cause difficulty are
+ovarian and uterine.
+
+Cystic ovarian tumours commonly do not prevent impregnation, if there
+has been an absence of inflammation. When these cysts are small they
+may not disturb pregnancy or delivery; large cysts can, however,
+become a source of danger. They may sink into the pelvis and block the
+channel of delivery needed by the child at term; they may have their
+pedicles twisted, and thus become gangrenous and septic. Big cysts of
+the ovary may during the growth of the pregnant uterus press upon the
+portal vein, or the diaphragm, or they may burst or cause sepsis.
+Litzman, in 56 cases of ovarian tumours complicating pregnancy, had
+only 10 normal deliveries; and Remy held that 23 per centum of these
+cases, when left untouched, result in death to the mothers. Stratz
+says the mortality is 32 per centum, and it has gone as high as 40 per
+centum. Some physicians teach that any ovarian cyst found complicating
+pregnancy should be removed surgically. Other authorities hold that
+they should all be treated expectantly: if they threaten the life of
+the mother, they should be tapped by a trocar through the belly-wall
+or the vagina, and removed only after labour. This second operation is
+safe, and I think it should prevail.
+
+Such cysts have often been removed during pregnancy. Orgler reported
+146 ovariotomies (removal of the ovaries) performed during gestation
+with only four maternal deaths--2.7 per centum. If the operation had
+not been performed {41} about 32 per centum of these women would have
+died. The chance against saving the child in such an operation is the
+crux. If there is no operation 17 per centum of the cases result in
+abortion and the loss of the child, as Remy found from a consideration
+of 321 cases. In Orgler's series of 146 ovariotomies, where he lost
+only 2.7 per centum of the mothers, and saved about 30 per centum that
+would have died (97 per centum in all); he lost 32 children through
+abortion caused by the ovariotomies, or 22.5 per centum; whereas by
+the expectant method (without tapping) only 17 per centum of the
+children were lost.
+
+Bovee of Washington, however, reported 38 cases of removal of the
+ovaries during pregnancy with one maternal death and only four
+abortions, or 12.6 per centum. That is considerably less than the loss
+by the expectant method without tapping. As Bovee succeeded, other men
+now do, but it would be far better to attempt tapping first. The
+earlier in the pregnancy either tapping or removal is done the better.
+
+Fibroid tumours of the uterus, complicating pregnancy, occur in about
+0.6 per centum of pregnancies, and they usually go on without causing
+trouble; but again these tumours may block the pelvic outlet, they may
+dangerously press upon abdominal viscera and the diaphragm; some
+writers hold they may become inflamed and degenerate with sloughing
+and gangrene, and thus bring about sepsis and death to the mother and
+child. That they become gangrenous must very rarely happen; the
+increased blood supply should prevent gangrene, but cause an increase
+in the size of the fibroma.
+
+A group of gynaecologists maintain that when fibromata cause dangerous
+symptoms in pregnancy the uterus should be taken out in part or wholly
+if the tumour is so deeply involved in the uterine wall that it can
+not be separated. This operation, of course, kills the foetus. At
+times the child is viable, and a precedent caesarean section will save
+it. Surgeons do not remove fibromata merely as a precaution, as they
+sometimes do in the case of ovarian cysts. Other surgeons say it is
+safe to wait. If the channel of delivery is blocked, these men wait
+till term and then do caesarean {42} section; in other cases the
+tumour will often be lifted up out of the way during the later stages
+of gestation or labour.
+
+In those very rare cases where it is necessary to remove the uterus
+wholly or in part before the child is viable, and thereby also to kill
+the foetus, the operation at first glance seems in no wise to differ
+in nature from a craniotomy upon a living child. The condition,
+however, is commonly worse than one in which a craniotomy is
+indicated, because in the latter condition we have a viable child, and
+the caesarean section to solve the difficulty, but in the former we
+have a child not viable, and therefore the caesarean section would be
+useless, except for the opportunity it might give for baptism of the
+child. In such a case must the surgeon let the mother die lest he
+hasten the death of a non-viable child?
+
+The action reduces to this, that the surgeon by operating would permit
+a hastening of the inevitable death of the foetus while saving the
+mother's life, but the child is not an unjust aggressor, not even a
+materially unjust aggressor. It has a right to be where it is. The
+only excuse for hastening its death is to save the mother's
+life,--there is no question of self-defence; but deliberately to
+hasten the death of a human being a second of time, except it be done
+by an individual in self-defence against an unjust aggressor, or by
+the state for legitimate cause, is murder. It seems probable, however,
+that there is something to be said in favour of the unavoidable
+hysterectomy (removal of the womb) in a pregnancy complicated with
+uterine fibromata that undoubtedly endanger life.
+
+Such cases differ from craniotomy, or the direct killing of a foetus
+(which were formally forbidden by the Holy Office on May 28, 1884, and
+August 19, 1888, and always forbidden by the natural law) in several
+factors: first, in craniotomy the child is _directly_ killed, although
+it is not an aggressor, in the hysterectomy it is permitted to die, it
+is _indirectly_ killed; secondly, in craniotomy there is a viable
+child, in the hysterectomy, an unviable child; thirdly, in craniotomy
+there is a killing that is a means toward the end of saving the
+mother's life, in the hysterectomy there is a permitted hastening of
+the foetus's death, and this is only a circumstance inseparably joined
+to the act; fourthly, in craniotomy the killing is utterly {43}
+uncalled for, because the caesarean section, or symphyseotomy (a
+temporary dividing of the pubic joint to get more room) will do
+instead, in the hysterectomy, because the child is not viable, there
+is no alternate way out of the difficulty; fifthly, formal judgment
+has been pronounced by the Holy Office in craniotomy, no formal
+judgment has been made as regards this hysterectomy.
+
+Suppose A and B are on a boat hoisting a weighty object to a ship; the
+tackle breaks, the falling weight mortally hurts B, and wedges him
+fast to the wrecked boat. The boat is about to sink and drown both
+men, but if A tips off the weight, and with it unavoidably the
+entangled B, A can float to safety. A will indirectly hasten the
+inevitable death of B by throwing off the weight which will drag him
+down. May A do so? Very probably he may.
+
+Two swimmers, A and B, are trying to save C, who dies in the water,
+and as he dies he grips A and B so tightly they can not shake the
+corpse off. A is weak, and he will soon sink and drown owing to the
+weight of the corpse; B also will later go down with A and C. A,
+however, cuts his clothing loose from the grip of the corpse (or some
+one in a boat does so who can do no more) and A is saved; but thus
+immediately B is drowned, owing to the fact that the full weight of
+the corpse is upon him. Is A, or the man in the boat, justified?
+Probably they are. A is the mother, B the foetus, C the diseased
+uterus, the man in the boat is the surgeon. The mother has herself cut
+away from the uterus and the foetus's death is hastened.
+
+Again, take an example used by Father Ricaby in his _Moral
+Philosophy_, p. 205 (London, 1901). He supposes a visitor to a quarry
+to be standing on a ledge of rock which a quarryman had occasion to
+blast, and the quarry man saw that "unless that piece of rock where
+the visitor stood were blown up instantly, a catastrophe would happen
+elsewhere, which would be the death of many men, and if there were no
+time to warn the visitor to clear off who could blame him if he
+applied the explosive? The means of averting the catastrophe would be,
+not that visitor's death, but the blowing up of the rock. The presence
+or absence of the visitor, his death {44} or escape, is all one to the
+end intended: it has no bearing thereon at all."
+
+If these examples of indirect killing are allowable, why may not the
+surgeon in the rare example presented here remove the uterus and
+indirectly permit the hastening of the foetus's death? That hastening
+of death is not an end, nor a means toward an end, but a circumstance
+only reluctantly and indirectly willed. The end is to save the
+mother's life, and the means is the removal of a septic or impacted
+uterus.
+
+It may be objected that an artificial abortion wherein the womb is
+emptied of an unviable foetus to save the mother's life is only an
+indirect hastening of this foetus's death, but there is a difference:
+in abortion the removal of the foetus is the means whereby the end is
+attained, in the hysterectomy the removal of the _tumour_ is the means
+whereby the end is attained. This argument is advanced only
+tentatively and with diffidence, that the matter may be discussed and
+settled by authority.
+
+Sometimes carcinoma (a cancer) complicates pregnancy--once in 2000
+cases is above the average. A carcinoma is a malignant tumour, and the
+malignancy is made much worse by the stimulus of pregnancy with its
+increased blood supply. The maternal deaths from carcinoma of the
+uterus during pregnancy is, according to the latest and most
+favourable statistics, 30 per centum. The mortality of the children is
+from 50 to 63 per centum.
+
+Now, first, if an artificial abortion is induced while the foetus is
+unviable, the foetus is lost and the mother's condition is not
+materially improved.
+
+Secondly, if curettement (a scraping away with a sharp spoonlike
+instrument), cauterization, or amputation of the uterine cervix are
+performed, the mother is helped very little, if at all, and consequent
+abortion is frequent.
+
+Thirdly, if caesarean section is done at term the child has a good
+chance (Sanger saved 16 of 18 children thus in one series: over 88 per
+centum), but this operation nearly always kills the mother when cancer
+is present, unless the entire uterus can be removed, and often it can
+not be removed; that {45} is, the case is inoperable and removal is
+useless owing to extension of the cancer into the surrounding tissues.
+
+Fourthly, if the mother's condition is hopeless, a caesarean section
+gives the child a chance for life, but the operation will hasten the
+mother's death in nearly every case.
+
+The first and second cases here are not practical. If the surgeon can
+remove the uterus at term after a caesarean section, that is the most
+reasonable operation for the mother and child, and it offers no moral
+difficulty.
+
+If the mother's condition is so bad that the uterus may not be
+removed, the chances are that her death will be hastened by caesarean
+section, but if caesarean section is not done, from 50 to 63 per
+centum is the ratio against the saving of the child. I do not think a
+general rule can be given as regards the certainty of hastening the
+maternal death: the reckoning is to be made to meet the particular
+condition. It seems, however, probable that in every case of
+inoperable carcinoma of the uterus complicating pregnancy a caesarean
+section would hasten the maternal death. She will die anyhow from the
+cancer, but in certain cases she may live longer if the section is not
+done.
+
+If, again, a carcinoma of the uterus is inoperable at term, the
+delivery of the child may be impossible without caesarean section,
+from uterine inertia, or the opposition of the dense inflamed tissues,
+or the friability of these tissues. In such a case without the section
+she would die, and die probably sooner than with it. The operation
+would possibly slightly prolong her life, by, say, a few hours or
+days, and it certainly would give the child a very good chance for its
+life. She may, of course, die upon the operating table, but she would
+die in childbed without the section.
+
+The case is different from the ordinary caesarean section done because
+of a narrow pelvic bony girdle. In the latter condition the chances
+that the mother will live are very high if the surgeon is competent,
+but in the carcinoma case she will die no matter who the surgeon may
+be, and very probably, or almost certainly, her death will be hastened
+by the operation in the majority of cases.
+
+If the condition is such that the woman can not be delivered {46}
+without the section, I see no difficulty against operation, because
+the surgeon can not, as far as I know, say positively whether he will
+hasten the maternal death or not, and in the circumstances he may take
+advantage of the doubt.
+
+If the woman with an inoperable carcinoma uteri may be delivered
+_without_ section, should such a delivery be chosen although it raises
+the chances of mortality as regards the child from about 12 per centum
+to at the least 50 per centum? It is a matter of a very probable
+hastening of the mother's death as weighed against the safety of the
+child--the child has about one chance in two of life without the
+section, and, say, seven chances in eight with the section. The
+operation is far preferable as regards the child alone, but not
+preferable as regards the mother alone. Is it then allowable?
+
+In the hysterectomy for fibroma already considered, the mother is
+saved and the child's inevitable death is certainly hastened; in the
+caesarean section the child is most probably saved, and the mother's
+inevitable death is most probably hastened; we might say, in some
+cases, that her death is undoubtedly hastened. If in the carcinoma
+case here the child had no chance whatever for delivery except by the
+caesarean section, while the mother's death would be probably or
+certainly hastened, she might legitimately consent to the operation or
+she might legitimately refuse the operation.
+
+The child, however, has, as we said, one chance of delivery in two
+without the section, while the mother's death will very probably be
+hastened. If the mother's death would certainly be hastened by the
+section, her death, although it would be a circumstance and indirect,
+not an end nor a means, would not have counterbalanced against it
+necessarily the saving of the child's life, because the child has one
+chance in two in any event. In such an hypothesis the operation seems
+to be unjustifiable.
+
+If, however, the hastening of the mother's death is only probable and
+not certain, may we oppose that probability to the advantage that must
+accrue to the child through the section? If the doubt that her death
+will be hastened is soundly probable, the woman may consent to the
+operation. She risks through charity the hastening of her own death
+for a great {47} advantage to the child, but she may risk legitimately
+immediate death in major surgical operations for an advantage less
+than the saving of life itself. She may have her skull opened for the
+removal of a depressed bone that is causing paralysis, she may have
+her knee-joint opened for the wiring of a patella to prevent lameness,
+but both these operations always immediately endanger life. She may go
+into a burning house, jump into a river, and so on, to save her child
+from possible injury.
+
+AUSTIN OMALLEY.
+
+{48}
+
+III
+
+ABORTION, MISCARRIAGE AND PREMATURE LABOUR
+
+If pregnancy ends in the emptying of the uterus before the sixteenth
+week of gestation, the condition is called an abortion; if this
+happens between the sixteenth and the twenty-eighth weeks, it is
+miscarriage; if the child is born after the twenty-eighth week but
+before full term, the birth is premature. The term "abortion" in the
+popular mind carries with it the notion of criminal interference, and
+the word "miscarriage" is used for both abortion and miscarriage by
+the laity; physicians, on the other hand, commonly use the term
+"abortion" for both abortion and miscarriage. These conditions may
+occur spontaneously or they may be induced artificially.
+
+Spontaneous abortions are very frequent; perhaps one in every five or
+six pregnancies is the proportion: the writer has known a single
+physician, not a specialist in obstetrics, to be called to three in
+one day and that in private practice. From 150 to 200 children in
+every 1000 that are conceived never get a chance for baptism. In the
+early months of pregnancy the foetus is usually dead before expulsion
+takes place. Twisting of the cord, hydramnios, syphilis, an acute
+infectious disease in the mother, poisonings of the mother by metals
+and the like substances, maternal cardiac and renal diseases, chronic
+inflammations and displacements of the womb, and violent emotions are
+some of the causes of abortion. In certain women a slight exertion, a
+misstep, a fall, a ride over a rough road, the _debitum conjugale_,
+and similar causes bring on abortion; in other women almost no shock
+is enough to make them miscarry. Inflammations and displacements of
+{49} the womb cause most of the abortions in the first four months,
+and after that time syphilis and Bright's disease are the chief forces
+at work.
+
+If a woman in early pregnancy begins to lose blood from the uterus,
+and has pain in her back and lower abdomen, abortion is threatened; if
+this hemorrhage is marked, and the cervix is dilated, the abortion
+will very probably occur; and the escape of the _liquor amnii_ renders
+the abortion unavoidable. In this latter case the vagina and the
+cervical canal are packed with sterile gauze to check the hemorrhage,
+and after twenty-four hours it is removed. Then commonly the entire
+ovum comes away with the gauze, or what remains of it is taken out
+with a curette.
+
+Valvular lesions of the heart in pregnancy make a maternal mortality
+of about 28 per centum, according to Guerard, and when compensation is
+lost the mortality may run from 48 to even 100 per centum with
+different physicians and different cases. The prognosis is good as
+long as compensation is retained, but very bad if this fails. In the
+latter condition premature labour is indicated, or the early removal
+of the viable child. Catholic physicians may not induce artificial
+abortion of an unviable foetus. The decree of the Holy Office
+concerning this matter is as follows:
+
+  Beatissime Pater,--Stephanus . . . Archiepiscopus Cameracensis . . .
+  Quae sequuntur humiliter exponit:
+
+  Titus medicus, cum ad praegnantem graviter decumbentem vocabatur,
+  passim animadvertebat lethalis morbi causam aliam non subesse
+  praeter ipsam praegnationem, hoc est, foetus in utero praesentia,
+  una igitur, ut matrem a certa atque imminenti morte salvaret,
+  praesto ipsi erat via, procurandi scilicet abortum seu foetus et
+  ejectionem. Viam hanc consueto ipse inibat, adhibitis tamen mediis
+  et operationibus, per se atque immediate non quidem ad id
+  tendentibus, ut in materno sinu foetum occiderent, sed solummodo ut
+  vivus, si fieri posset, ad lucem ederetur, quamvis proxime
+  moriturus, utpote qui immaturus omnino adhuc esset.
+
+  Jamvero lectis quae die 19 Augusti, 1888, Sancta Sedes ad
+  Cameracenses Archiepiscopos rescripsit: _tuto doceri non posse_
+  licitam esse quamcumque operationem directe occisivam foetus, etiam
+  si hoc necessarium foret ad matrem salvandam: dubiis haeret Titius
+  circa {50} liceitatem operationum chirurgicarum, quibus non raro
+  ipse abortum hucusque procurabat, ut praegnantes graviter
+  aegrotantes salvaret.
+
+  Quare ut conscientiae suae consulat supplex Titius petit: utrum
+  enuntiatas operationes in repetitis dictis circumstantiis instaurare
+  tuto possit.
+
+  Feria iv, die 24 Julii, 1895.
+
+  In Congregatione generali S. Romanae et Universalis Inquisitionis .
+  . . Emi ac Rmi Domini Cardinales . . . respondendum decreverunt:
+  _Negative_, juxta alias decreta, diei scilicet 28 Maii, 1884, et 19
+  Augusti, 1888.
+
+  . . . Sanctissimus Dominus noster . . . approbavit.
+
+Other documents referring to the same matter are the following:
+
+  Epistola ad Archiepiscopum Cameracensem. . . . Anno 1886,
+  Amplitudinis tuae Praedecessor dubia nonnulla hinc supremae
+  Congregationi proposuit circa liceitatem quarumdem operationum
+  chirurgicarum craniotomiae affinium. Quibus sedulo perpensis,
+  Eminentissimi ac Reverendissimi Patres Cardinales una mecum
+  Inquisitores Generales, feria iv, die 14 currentis mensis,
+  respondendum mandaverunt:
+
+  In scholis catholicis tuto doceri non posse licitam esse operationem
+  chirurgicam quam craniotomiam appellant, sicut declaratum fuit die
+  28 Maii, 1884, et quamcumque chirurgicam operationem directe
+  occisivam foetus vel matris gestantis.
+
+  Idque notum facio Amplitudini tuae, ut significes professoribus
+  facultatis medicae Universitatis catholicae Insulensis. . . .
+
+  Romae, die 19 Augusti, 1889. . . .
+
+  R. CARD. MONACO.
+
+The date of this response here is 1889, but in the preceding decree it
+is given as 1888. In the _Acta Sanctae Sedis_ the date is 1889.
+
+Another letter from Cardinal Monaco is this:
+
+  Eme et Rme Dne,--Emi PP. mecum Inquisitores generales in
+  Congregatione habita feria iv, die 28 labentis Maii, ad examen
+  revocarunt dubium ab Eminentia tua propositum--An tuto doceri possit
+  in scholis catholicis licitam esse operationem chirurgicam, quam
+  Craniotomiam appellant, quando scilicet, ea omissa, mater et infans
+  perituri sint, ea e contra admissa, salvanda sit mater, infante
+  pereunte?
+
+{51}
+
+  --Ac omnibus diu et mature perpensis, habita quoque ratione eorum
+  quae hac in re a peritis catholicis viris conscripta ac ab Eminentia
+  tua hinc Congregationi transmissa sunt, respondendum esse duxerunt:
+  _Tuto doceri non posse_.
+
+  Quam responsionem cum SSmus D. N. in audientia ejusdem feriae ac
+  diei plene confirmaverit, Eminentiae tuae communico. . . .
+
+  R. CARD. MONACO.
+  Romae, 31 Mail, 1884.
+
+  Emo Archiepiscopo Lugdunensi.
+
+Another decree concerning abortion is in part as follows:
+
+  Beatissime Pater,--Episcopus Sinaloen. ad pedes S.V. provolutus,
+  humiliter petit resolutionem insequentium dubiorum:
+
+  I. Eritne licita partus acceleratio quoties ex mulieris arctitudine
+  impossibilis evaderet foetus egressio suo naturali tempore?
+
+  II. Et si mulieris arctitudo talis sit, ut neque partus praematurus
+  possibilis censeatur, licibitne abortum provocare aut caesaream suo
+  tempore perficere operationem? . . .
+
+  Feria iv, die 4 Mail, 1898.
+
+  In Congregatione habita, etc. . . . EE. ac RR. Patres rescribendum
+  censuerunt:
+
+  Ad I. Partus accelerationem per se illicitam non esse, dummodo
+  perficiatur justis de causis et eo tempore ac modis, quibus ex
+  ordinariis contingentibus matris et foetus vitae consulatur.
+
+  Ad II. Quoad primam partem, _negative_, juxta decretum Feria iv, 24
+  Julii, 1895, de abortus illiceitate. Ad secundum vero quod spectat;
+  nihil obstare quominus mulier de qua agitur caesareae operationi suo
+  tempore subjiciatur. . . .
+
+  In sequenti Feria vi, die 6 ejusdem mensis et anni . . . SSmus
+  responsiones EE. ac RR. Patrum approbavit.
+
+Pyelonephritis (an inflammation of the kidney where pus is present),
+from the pressure of the pregnant uterus, is a condition which
+sometimes obliges the physician to bring about premature labour to
+save the mother. The symptoms usually appear in the latter half of
+gestation.
+
+Chorea ("St. Vitus' Dance"), when it develops during pregnancy, has a
+maternal mortality of from 17 to 22 per centum. It may cause death
+before the child is viable, and to empty {52} the uterus will stop the
+symptoms. Here the decrees of the Holy Office will occasionally
+prevent the Catholic physician from interfering.
+
+If a grave surgical operation is imperatively indicated during
+pregnancy, and may not be put off until after delivery, it should be
+undertaken in many cases, because modern technique commonly does not
+bring about an abortion; but, in general, no rule can be given--each
+case must be judged separately.
+
+If a pregnant woman has at the same time considerable albumen in her
+urine and a low excretion of urea, her condition is very dangerous. To
+empty her uterus will, in most cases, relieve the renal trouble, but
+in any case premature labour is not to be induced rashly: many women
+escape, when by all the rules they should die.
+
+Eclampsia is a very grave complication of pregnancy, and it was
+formerly supposed to be uraemia. The disease is characterized by
+convulsions, loss of consciousness, and coma. It occurs, commonly, in
+the second half of gestation, but it has been observed as early as the
+third month. About 70 to 80 per centum of the cases are in primiparous
+women. The convulsions may come on altogether unexpectedly, but
+commonly the attack begins with symptoms of toxaemia. Eclampsia may
+occur before, during, or after parturition. When it comes before term
+it usually ends in spontaneous or artificial abortion, but at times
+the woman dies undelivered. Now and then she may recover and be
+delivered at term.
+
+The kidneys are usually affected, even in those cases in which
+albuminous urine is not found. There is also a hemorrhagic
+inflammation of the liver; and oedema and congestion of the brain,
+with or without apoplexy, are other symptoms of the disease. There are
+other lesions, but the chief are in the kidneys, liver, and brain.
+
+The aetiology of the disease is not yet known, and there are very many
+theories offered to explain it. The prognosis is always serious, and
+the condition is one of the most dangerous found in pregnancy. The
+mortality varies, but it is about from 20 to 25 per centum in the
+women, and from 33 to 50 per centum in the children. It is impossible
+to determine {53} the prognosis in particular cases, but a large
+number of quickly recurring convulsive seizures, with a weak, thready
+pulse, and a high temperature usually indicate a fatal ending.
+Apoplexy, oedema of the lungs, and paralysis also, as a rule, end in
+death.
+
+If the uterus is emptied during the convulsions, these cease either
+immediately or soon after delivery, in from 66 to 93 per centum of the
+cases, and the maternal mortality then is about 11 per centum. With
+the expectant treatment, in convulsive cases, about 28 per centum of
+the women die, although a use of aconite in these cases may better the
+prognosis.
+
+Pernicious vomiting (hyperemesis gravidarum) is another complication
+of pregnancy, which sometimes results fatally if the uterus is not
+emptied. There are cases, especially those with high fever, which end
+in death despite all treatment. Here, again, the aetiology of the
+disease is not known. There is commonly an element of hysteria in the
+condition, and in such a case moral suggestion often has a curative
+effect Any bodily irritation is to be removed. Eye-strain alone is
+enough to cause persistent vomiting. It is very difficult to decide
+when premature labour is absolutely indicated, because some very bad
+cases recover spontaneously when all hope is lost.
+
+Hydramnios, or an excessive quantity of _liquor amnii,_ may so distend
+the uterus as to cause grave danger to maternal life, and if the child
+is viable the uterus should be emptied.
+
+Intrauterine hemorrhage brought on by a premature separation of the
+placenta is a very dangerous condition: 32 to 50 per centum of the
+mothers die, and 85 to 94 per centum of the children. In a marked
+hemorrhage the only way to save the mother is to empty the uterus, so
+that it may contract and thus close the patulous vessels.
+
+Placenta praevia is a placenta implanted in the neighbourhood of the
+internal os of the uterine neck. This is a very perilous condition,
+calling for the induction of premature labour. The medical treatment
+is artificial abortion as soon as the condition is diagnosed in any
+stage of gestation; but this is, of course, in conflict with the
+decrees of the Holy Office. Under expectant treatment about 40 per
+centum of {54} the mothers die, and 66 per centum of the children.
+Those children that are born alive commonly die within ten days after
+delivery. The great foetal mortality is due to premature birth and
+asphyxiation. Skilful obstetricians get much better results, but
+skilful obstetricians are unfortunately rare.
+
+When the grave complications enumerated above occur in the early
+months of pregnancy, before the foetus is viable, the Catholic
+physician, since by the natural law and the decisions of the Holy
+Office he is forbidden to induce artificial abortion, must withdraw
+from the case. If there is no other physician to attend to the woman,
+he must let her die. He can not withdraw without explanation, and in
+many cases the explanation of the condition will promptly result in
+the calling in of a physician who has no scruple in inducing this
+abortion, no matter how reputable he may be. The universal medical
+doctrine is to induce abortion in cases where abortion will save the
+mother's life and the foetus is "too young to amount to anything."
+This is looked upon as legitimate abortion by the very best men that
+do not recognise the authority of the Holy Office: they deem the
+position of the Catholic physician in these cases as altogether
+erroneous, or even criminal.
+
+The position of the Catholic moralists on craniotomy has turned the
+attention of many non-Catholic physicians to the immorality of the
+act, which formerly was deemed entirely permissible. Probably the same
+good result will be effected in the matter of abortion.
+
+AUSTIN OMALLEY.
+
+{55}
+
+THE CAESAREAN SECTION AND CRANIOTOMY
+
+In the caesarean section the infant is delivered through an incision
+in the abdominal or uterine walls. The operation, according to one
+opinion, takes its name from Caius Julius Caesar, who, it is said, was
+brought into the world in this manner, _"a caeso matris utero"_; this,
+however, is a myth.
+
+Up to 1876 the maternal mortality from the operation was about 52 per
+centum. Between 1787 and 1876 in the city of Paris there was not one
+successful caesarean section as far as the mothers were concerned. At
+present on an average less than 10 per centum of the women are lost,
+and expert surgeons have better results. Up to about 1902 Zweifel had
+made 76 such sections with only one death, and Reynolds, 23 with no
+death. Leopold has performed the operation four times on the same
+woman, and Ahlfeld and Birnbaum have reported instances where the same
+woman has had five caesarean sections performed upon her. The
+operation is, of course, capital, and always most serious, even in
+city hospitals.
+
+The indication for the operation is chiefly a narrow pelvis, which
+blocks the delivery of the child. There are no reliable statistics as
+to the frequency of narrow pelves in the United States; but Dr.
+Williams, of the Johns Hopkins University Hospital, in a series of
+2133 cases found 6.9 per centum in white women and 18.82 in negroes.
+Normally the average female pelvis, at its narrowest diameter, is 11
+centimetres wide. This part is called the conjugata vera, and it is
+the diameter from the promontory of the sacrum behind to a point on
+the inner surface of the symphysis pubis in front.
+
+In delivery much depends upon the size of the child, and in each case
+the obstetrician waits until he sees that delivery {56} is impossible
+by natural means before he resorts to the caesarean section or other
+operative interference. Of two women with pelves of the same
+contraction one may require the section and the other may have a
+normal labour. A bisischial diameter at the outlet of the parturient
+canal of 7 centimetres or less is an indication for section; so are
+certain tumours that block the delivery of the child.
+
+When the conjugata vera is less than 7 centimetres in flat pelves, or
+7.5 centimetres in generally contracted pelves, the treatment varies
+in the customary medical practice according as the child is alive or
+dead, and it varies as the condition of the mother. The common medical
+doctrine will first be given here before the moral questions that may
+be involved are mentioned.
+
+If the deformity is diagnosed during pregnancy, the woman is sent to a
+hospital, the caesarean section is performed, and thus all the
+children, and nearly all the mothers, are saved. When the narrowness
+of the pelvis is discovered only during labour, the treatment varies
+with the condition. If the woman is not septic, and has not been
+repeatedly examined by the vagina, and if the surroundings are
+favourable, caesarean section is done; if she is septic, the
+indications are for the section, or symphyseotomy or craniotomy. Where
+the conjugata vera is below 5 centimetres in length, the caesarean
+section is the only method to get the child out, dead or alive, and
+after the child has been delivered, the uterus, if septic, is removed.
+If the conjugata vera is at the least 7 centimetres long,
+symphyseotomy may be done; if the conjugata vera is above 5
+centimetres, the mother septic, and the child dead or dying,
+craniotomy is indicated. Even if the child is not dying, some
+obstetricians will do craniotomy.
+
+In cases where the conjugata vera is above 7 centimetres in flat
+pelves and 7.5 centimetres in generally contracted pelves, the
+treatment can not be reduced to general rules. Delivery without
+operation occurs in many of these cases, but commonly the condition is
+obscure to the physician for some time. We can measure the pelves, but
+the size of the child's head is not satisfactorily measurable.
+
+If the conjugata vera is from 10 to 9 centimetres, or from {57} 9.5 to
+8.5 centimetres, labour without operation is the rule, and the child
+can usually be delivered by forceps. Should the child die during
+labour in these cases, it is best delivered by craniotomy, unless the
+longer diameter of its head has already passed the narrowest part of
+the pelvis.
+
+When the conjugata vera is from 8.9 to 7.5 centimetres, about 50 per
+centum of the women will be delivered with forceps, but the other half
+will not. After about two hours of the second stage of labour delivery
+by forceps is tried, but prolonged traction is not applied.
+Occasionally delivery will come when least expected, but often it will
+not. If the head sticks, caesarean section is done in favourable
+circumstances, and craniotomy in unfavourable circumstances. If there
+is ground for supposing that septic infection of the mother has begun,
+the conditions are explained, and if she wishes to have the caesarean
+section done the risk is left to her. When the breech or face of the
+child presents in contracted pelves, the condition is especially
+unfavourable for the child.
+
+There are very many varieties of deformed pelves, but the same rules
+apply to them as to those already mentioned, except that the caesarean
+section is oftener indicated. Difficulty also not seldom occurs in
+women with normal pelves from an excessive size in the child through
+prolonged pregnancy, bigness of one or both parents, or the advanced
+age or multiparity of the mother. The child's head alone may be of
+excessive size. Some monsters offer difficulty in delivery from size
+or shape, but, of course, they are human beings, and are to be
+considered as such in delivery. The technique of the caesarean section
+has only a medical signification, and it need not be described here.
+
+Symphyseotomy is an operation in which the joint of the pelvis at the
+symphysis pubis is cut, and the pelvis is allowed to gape so as to let
+out the child. The operation has fallen into disrepute. The mortality
+as regards the mother is about the same as in the caesarean section,
+but the mortality of the children is higher. In symphyseotomy the
+infantile mortality is about 9 per centum, while in the caesarean
+section it is practically nothing. If in symphyseotomy an error is
+made in estimating the size of the pelvis or the child's head--and
+{58} such an error is often possible--the child will be killed, but in
+the caesarean section these errors make no difference. After the
+caesarean section the woman recovers promptly; after the symphyseotomy
+she recovers very slowly, and she may receive permanent injury.
+
+Craniotomy is an operation wherein the head of the child is reduced in
+size to render delivery possible. The skull is perforated and the
+brain is broken up and removed or crushed out. Embryotomy is a similar
+operation wherein the viscera of the child are removed through an
+incision made in its thorax or belly (evisceration), or the head of
+the child is cut off (decapitation). There are numerous instruments
+and methods for performing craniotomy and embryotomy, but they all
+open the skull or belly, remove the brain or viscera, and then extract
+the child's body.
+
+If the infant is hydrocephalic and is alive, the advocates of the
+operation warn us to be careful after opening the head to push the
+perforator into the base of the skull and stir it around well, so as
+to be sure the child will not be born alive. Pernice has recently
+reported a case of hydrocephalus which was delivered by craniotomy,
+but the operator did not work his perforator efficiently, and the
+child recovered, and grew up an idiot. A similar case occurred in
+Baltimore.
+
+The indications for craniotomy among those that advocate its
+occasional use (and they are many) is in those cases in which the
+woman is so infected that caesarean section is dangerous, or where a
+child is hydrocephalic, or where an after-coming head is jammed (in
+this case even a caesarean section will not effect delivery), or in
+the case of a narrow pelvis and a moribund child, or finally in the
+practice of a country physician, who can not in an emergency get an
+assistant to do a caesarean section. One man can do craniotomy, but it
+requires three to perform the caesarean section. If the woman's narrow
+pelvis has a conjugata vera of five or more centimetres, craniotomy,
+if properly done, is not dangerous to the mother. With a conjugata
+vera less than 5 centimetres it is more fatal than the caesarean
+section. If the women are septic, the mortality in {59} craniotomy is
+from 10 to 15 per centum; in caesarean section about 25 per centum.
+
+As to the morality of craniotomy on the living or moribund child, it
+is not permissible under any possible circumstances: a consideration
+of the ethical principles set forth in the article on Ectopic
+Gestation will make this assertion clear.
+
+The Congregation of the Holy Office on August 19, 1888, decreed that
+"In scholis catholicis tuto doceri non posse licitam esse operationem
+chirurgicam quam Craniotomiam appellunt." They gave a similar decision
+May 28, 1884, and they repeated the prohibition, with the papal
+approbation, on July 24, 1895. The text of these decrees may be found
+in the article on abortion, miscarriage, and premature labour.
+
+The Porro operation consists essentially in a removal of the uterus
+after caesarean section to prevent further conceptions. As a means to
+prevent conception it is altogether unjustifiable, because repeated
+caesarean sections in the same woman, if the surgeon is at all
+competent, are practically no more dangerous than normal labour.
+
+AUSTIN OMALLEY.
+
+
+{60}
+
+V
+
+MATERNAL IMPRESSIONS
+
+
+There is a wide-spread persuasion that a child, while carried in the
+womb of its mother, may be marked as the result of incidents that
+produce violent impressions upon her nervous system. This is so old a
+conviction in the human race and would seem to be substantiated by so
+much evidence that it is extremely difficult to convince people that
+there is no scientific basis for it. As a matter of fact, however,
+there is something mysterious about the way in which certain things
+that happen to the mother seem to affect the child _in utero_. As the
+result of the common belief in the truth of maternal impressions,
+mothers sometimes are prone to blame themselves for not having been
+sufficiently circumspect during the time of their pregnancy, and
+accordingly they may seek advice and consolation in the matter from
+clergymen. Women sometimes become very much depressed as a consequence
+of an unfortunate event of this kind, and as the simple truth is the
+best possible source of consolation, it would seem that a special
+chapter should be given to the subject in a work of this kind.
+
+The evidence for the truth of the theory of maternal impression is
+almost entirely due to peculiar coincidences. James I. of England, the
+son of Mary Queen of Scots, could never stand, according to Sir Walter
+Scott, the sight of a drawn sword with equanimity, and it is said even
+that he nearly fainted at his coronation because of an unexpected
+glimpse of some naked blades in the hands of courtiers. This
+peculiarity was attributed to the fact that his mother, while carrying
+him _in utero,_ had witnessed the violent death of her secretary, the
+unfortunate David Rizzio. There have been, however, any {61} number of
+men who paled at the sight of a drawn sword before and since James I.,
+with regard to whom no such circumstantial story could be told to
+account for it. There have been any number of women that have
+witnessed bloody murders under circumstances quite as heartrending as
+those surrounding Mary Queen of Scots and her secretary, and yet their
+offspring, though at the time _in utero_, have not been disturbed at
+the sight of drawn swords, nor of blood or any other circumstance
+connected with the deep impression that must have been produced on
+their mothers.
+
+There is, of course, a striking instance related in the Old Testament,
+which seems to make it very clear that a belief in maternal
+impressions existed from the very earliest times among the Israelites.
+The story of Jacob is well known: "Jacob took him rods of green poplar
+and of the hazel and chestnut tree and pilled white streaks in them
+and made the white appear which was in the rods, and he set the rods
+which he had pilled before the flocks in the watering troughs when the
+flocks came to drink, and the flocks conceived before the rods and
+brought forth cattle, ring-streaked, speckled and spotted." In this
+case it seems evident that Jacob was not looking for a miracle, but
+was expecting that a law of nature would be fulfilled in the matter,
+the influence of the unusual sight upon the animal mothers proving
+sufficient to have a definite effect upon their unborn offspring. The
+most ardent advocates of the power of maternal impressions would
+scarcely concede the existence of as much influence as this of the
+mother's mind over the child unborn, otherwise there would surely be a
+very absurd collection of anomalous births in the race.
+
+On the other hand, it is generally conceded that the mother's habitual
+temper of mind and the thoughts with which she occupies herself may
+influence her unborn offspring to a most marked degree. The story is
+told of a child-murderer who delighted in fiendish deeds of cruelty
+and had murdered many people in cold blood, that his mother, the wife
+of a butcher, had delighted in watching the operation of slaughtering
+during the course of her pregnancy. There are any number of women,
+however, who have, by the necessities {62} of their occupation, had to
+witness the shedding of animal blood under such circumstances and yet
+without any special effect being noticeable in their offspring. It has
+been said that the opposite is also true, and that if a woman occupies
+herself with high and lofty thoughts, with noble deeds and unselfish
+devotion to others and if she occupies her mind and senses with the
+great works of art, a correspondingly beneficial effect will be noted
+upon the character of the foetus. These are, however, abstruse
+speculations leading to conclusions not founded upon actual
+observation, but upon theorising over the supposed fitness of things.
+
+Coincidence plays such a large part in the matter of supposed maternal
+impressions that it is impossible to decide how much there is of fact
+and of consequence in the many stories that are told. Most women are a
+little afraid, as the time of their labour approaches, lest something
+or other--usually of an indefinite nature--that has happened during
+their pregnancy, may cause the marking of their child. When they find
+that the child is perfectly normal, they breathe a sigh of relief and
+forget all about it. If any anomaly is noted, however, then they are
+sure to connect it with some incident during pregnancy, and
+imagination is apt to lend details that confirm the supposed
+connection. On the other hand, there are not a few cases in which such
+anomalies have occurred, and good, sensible mothers have been unable
+to recall anything that might possibly serve to account for the
+peculiarity noticed in the child, though corresponding peculiarities
+in other children were supposed to be readily traceable to maternal
+impression. Even where there has been no foreboding of evil results,
+something or other that has occurred during the pregnancy will often
+be magnified enough by memory to account for the supposed maternal
+impression.
+
+Doctors are very familiar with this tendency to make up stories to
+account for various deformities. It used to be considered that
+hip-joint disease and Pott's disease were the result of injuries in
+early life. They are now known to be due to tuberculous processes not
+necessarily and indeed only very seldom connected with injuries of any
+kind. Mothers are {63} nearly always able to account in some way,
+however, for the beginnings of the disease in some accident that has
+happened. Young children are apt to have so many falls that some one
+of them is picked out as the probable cause of the disease that
+subsequently manifests itself in the joints. It is just this state of
+affairs that occurs with regard to supposed maternal impression. Some
+incident that would be otherwise unthought of is magnified into an
+accident that caused a serious nervous shock, and consequently led to
+the marking of the child.
+
+In general it may be said for the clergyman's direction, that if women
+have, as is sometimes the case, a morbid sense of their guiltiness
+with regard to some maternal impression that has set a mark upon their
+child, such a state of feeling may very well be rendered less poignant
+by a frank statement of the present attitude of mind of most
+physicians with regard to the possible effects of maternal
+impressions. Scepticism is much more the rule than it used to be, and
+as time goes on fewer and fewer of the cases that used to be
+considered so inexplicable in the direct relationship that seemed to
+exist between maternal impression and deformity in the child are
+reported. Fifty years ago nearly all the authorities on this subject
+were agreed in considering that maternal impressions did play some
+part, though they could not explain just how, in the production of
+certain deformities. Now we venture to say that most of the thinking
+physicians who have occupied themselves with this subject would
+scarcely hesitate to say that they were utterly incredulous of any
+such effects being produced. The lack of any direct nervous or blood
+connection between mother and child is the basis for such disbelief,
+and is of itself the best argument against the old tradition.
+
+With regard to mental defects, as a rule, not so much is said as for
+bodily defects. Bodily deformities are noted at once after birth, and
+then the mother recalls some incident of the pregnancy to account for
+them. Mental defects are, however, noticed much later, and are not so
+likely to be considered as connected with incidents of the puerperal
+period. There is no doubt that if the mother has had to pass through a
+series of emotional strains, or has suffered from severe {64} shocks,
+children are likely to be born with diminished mental capacity. This
+is, however, not difficult to understand, since such incidents produce
+disturbances of the nervous system of the mother, and consequently
+also of her nutrition, and this is prone to be reflected in the
+child's condition, especially in that most delicate part of the
+child's organism, the brain. Hence it is that children born during the
+siege of Paris, or shortly after, were defective to such a marked
+degree that they were spoken of as "children of the siege," and this
+was considered to be quite sufficient explanation of nervous
+peculiarities later in life.
+
+Baron Larrey, the distinguished French surgeon, made a report with
+regard to the children born after the siege of Landau in 1793. Of 92
+children, 16 died at birth, 33 died within ten months, 8 showed marked
+signs of mental defects, most of them to the extent of idiocy, and two
+were born with several broken bones. In this case, however, it is well
+known that besides the shock of the danger consequent to the siege and
+the fear and distress of the women with regard to their husbands and
+relatives, there were added many privations and physical sufferings.
+The nutrition of the mothers was seriously disturbed by these, and it
+might well be expected that the children should suffer severely. The
+statistics of such events are not available in general, and when an
+effort is made to establish a cause for idiocy under other
+circumstances, none is usually found. Out of nearly five hundred cases
+of idiots whose histories were carefully traced in Scotland, in only
+six was there any question of maternal impressions having been the
+cause of the condition.
+
+Of course there are many very wonderful coincidences that seem to
+confirm the idea that impressions made upon the mother's mind are
+sometimes communicated to the child in her womb. That they are not
+more than coincidences, however, is rather easy to demonstrate in most
+cases, since, as a matter of fact, at the time when the incident
+occurred which is supposed to have caused the deformity in the foetus,
+the stage of development of the intrauterine child has passed long
+beyond the period when formative defects could occur. For instance, it
+sometimes happens that the child-bearing woman {65} sees an accident
+especially to the father of the child involving the loss of a limb.
+If, by chance the child should be born with a missing member, as
+sometimes happens, then there would seem almost to be no doubt of a
+direct connection between the accident witnessed, the effect produced
+upon the mother's mind, and the consequent deformity.
+
+We know now that the formation of the limbs of the foetus is complete
+by the end of the third month. At this time the woman is scarcely more
+than conscious of the fact that she is pregnant, and it is not during
+this early period, as a rule, but during a much later period, that
+maternal impressions are supposed to have their influence. It is only
+such maternal impressions as occur very early in pregnancy, before the
+tenth week as a rule, that could possibly have any effect in the
+production of such deformities. It is by no means infrequent, however,
+to have children born lacking one or both limbs. Sometimes nothing but
+the stumps of limbs remain. In such cases it is now well known that
+intrauterine amputation has taken place. Some of the membranes that
+surround the child, especially the amnion, become separated into bands
+which surround tightly the growing members of the foetus and by
+shutting off the blood supply through constant pressure, lead to the
+dropping off of all that portion of the member lying below the band.
+
+Not infrequently it happens that when a child is born thus deformed,
+the mother, by carefully searching her memory, can find some dreadful
+story that she has read, some accident that she has seen or heard of,
+and that has produced a seriously depressing effect upon her at the
+time, to which she now attributes the deformity that has occurred.
+Until the unfortunate appearance of her child was reported to her, she
+had no idea of any possible connection between the story and the
+bodily state of her intrauterine child. In not a few cases, however,
+the most faithful searching of the memory fails to show anything which
+could, by any possible connection, be made accountable for the
+deformity; and these cases, we may say at once, are in a majority.
+
+Not a little of a popular notion with regard to the influence of
+maternal impression is due to the repetition of certain {66} village
+gossip which by no means loses its point or effectiveness passing from
+mouth to mouth. On the other hand, maternal impressions have been
+exploited by novelists, who have found that the morbid curiosity of
+women particularly with regard to this subject may make their stories
+more widely read. Lucas Malet, who, in spite of the apparently
+masculine pseudonym, is really the late Rev. Charles Kingsley's
+daughter, has recently called renewed attention to this subject by her
+novel "Sir Richard Calmady." In this the hero is born with both his
+lower limbs missing from just below the knees. The author has been
+careful, however, with regard to the details of the supposed maternal
+impression to which this deformity is attributed. A young married
+woman in the early part of her first pregnancy has her husband, whom
+she loves very dearly, brought back to her with both his limbs taken
+off by a shocking accident which resulted fatally. It is not
+impossible, some physicians might think, to consider that so severe a
+shock could produce a very deleterious effect upon the foetus. That
+the result should so exactly copy the scene which was brought under
+the eyes of the young mother is, however, beyond credence.
+Occasionally such stories, supposedly on medical authority, find their
+way into the newspapers, usually from distant parts of the country.
+Certain parts of Texas particularly seem to be a fruitful source of
+such stories for newspaper correspondents when there is a dearth of
+other news. Farmers in thinly settled parts of the country lose a foot
+in a reaping machine or a hand in the hay-cutting machine when there
+is no one near to help them but their wives, with the result that the
+shock to their wives proves the occasion of a similar deformity in an
+as yet unborn child. Careful investigation of such cases, however, has
+invariably shown that either they were completely false or that the
+details showed that whatever had happened was at most a coincidence
+and never a direct causative factor in the subsequent deformity.
+
+The greatest difficulty in the mind of the medical man, with regard to
+the possibility of maternal impression being communicated in any way
+to the foetus, is, as we have said, his knowledge of the anatomy of
+mother and foetus. While it is {67} generally supposed that the mother
+is very intimately connected with her child _in utero,_ the actual
+connection is by no means so direct as might be expected from the
+popular impression. It is usually considered that the mother's blood
+flows in the child's veins; but this is absolutely false. The child's
+blood is formed independently of the mother's blood quite as is that
+of the chick in the egg. At all times the blood of the child remains
+quite different in constitution to that of its mother. It contains
+many more red cells than does her blood and differs in other very
+easily recognisable ways. Mother and child are connected by means of
+an organ known as the placenta, which is attached very closely to the
+uterine wall and from which through the cord the blood of the foetus
+circulates. This placenta constitutes the so-called afterbirth. The
+mother's blood flows in one portion of it, that of the child in
+another, and they always remain distinct and separate from each other.
+The gases necessary for the child's life diffuse through the membrane
+which separates the two different bloods, and the salts and soluble
+proteids necessary for the child's nutrition, as well as the water
+necessary for its vital processes, all pass through this membrane, but
+at no time is there any direct blood connection between mother and
+child. Indeed, for a large part of the formative period of the foetus
+life, that is, during the first two months of its existence, the ovum
+is not very closely attached to the uterus at all, but grows by means
+of the vital power which it has within itself.
+
+Nor is there any direct nervous connection between mother and child;
+indeed, there are no nerves at all in the placenta, and none in the
+cord through which all communications between mother and child must
+pass. It seems impossible to explain, then, how maternal impressions
+can so effectively pass from mother to child; and indeed, the whole
+subject, when looked at in this way, is apt to be considered
+legendary, and the facts adduced in support of the theory of maternal
+impressions are practically sure to be thought mere coincidences. A
+little knowledge here might seem to justify many things that more
+complete knowledge fails to be able to find any reasons for.
+
+{68}
+
+There is no doubt, however, that the mother's environment during
+pregnancy is in general very important for the perfect development of
+the intrauterine child. Many more deformed births are reported after
+times of stress and trial, as, for example, after the sieges of great
+cities, notably the siege of Paris in 1871, and such scenes of
+desolation as occurred during the thirty years' war in Germany. These
+are, however, not direct, but indirect effects of maternal
+impressions. The development of the human being _in utero_ is an
+extremely complicated process. Any disturbance of it, however slight,
+is sure to be followed by serious consequences. Disturbances of
+nutrition, such as are consequent upon the deprivation that has to be
+endured in times of war or during sieges, is of itself sufficient
+seriously to disturb even the uterine life of the child. In these
+cases, however, there will be no traceable connection between the form
+of the maternal impression and the type of deformity that occurs. This
+is, however, the essence of the old theory of the direct effect of
+maternal impressions, and consequently that theory must fall to the
+ground.
+
+From all that has been said, however, it becomes very clear that as
+far as possible women should be shielded from the effect of various
+nervous shocks during their pregnancy, and that they owe it to
+themselves and their offspring to be careful with regard to any morbid
+manifestations of feeling that they may detect in themselves.
+
+JAMES J. WALSH.
+
+{69}
+
+VI
+
+HUMAN TERATA AND THE SACRAMENTS
+
+Teratology ([Greek text], a monster) is a part of biology that treats
+of deviation from a normal development in man and the lower animals.
+The name was adopted in 1822 by the elder Saint-Hilaire, who then
+attempted to separate the results of modern exact methods of research
+from the myths and loose descriptions of monsters found in the
+writings of old authors. Cicero (_De Divinatione_) derives the term
+monster from the proper preternatural signification looked for in the
+occurrence of these abnormal beings: "Monstra, ostenta, portenta,
+prodigia appellantur, quoniam monstrant, ostendunt, portendunt et
+predicunt."
+
+At the end of the seventeenth century Malpighi and Grew discovered
+that plant tissue is entirely made up of microscopic spaces enclosing
+fluid; they called these spaces _cells_. Different investigators found
+that animal tissue is also composed of cells; and between 1835 and
+1839 Schwann and Schleiden formulated the law that every metazoic
+organism is made of cells, and starts from a cell.
+
+In 1672 de Graaf discovered the mammalian ovum, in 1675 Ludwig Ham
+found spermatozoa, in 1827 von Baer recognised the human ovum, but not
+until 1875 was the important fact established that fertilisation is
+effected by the fusion of the male and female pronuclei. This was
+demonstrated by Oscar Hertwig from observation of the ova of
+starfishes.
+
+Mammalian ova, owing to an almost complete lack of yolk, are all
+small. The egg of a whale is about the size of a fern-seed, but the
+yolked eggs of birds are large--that of the great auk was 7.5 inches
+long. In man the ovum is from 0.18 to 0.2 mm. in diameter, scarcely
+visible to the {70} naked eye, and the spermatozoon is extremely
+minute. The human spermatozoon is only fifty-four thousandths of a
+millimetre in length, and from forty-one to fifty-three thousandths of
+a millimetre are taken up by its flagellum. The essential part is from
+four to six thousandths of a millimetre in length (Dr. L. N. Boston,
+_Journ, of Applied Microscopy_, vol. iv. p. 1360). A line of 18 human
+spermatozoa would reach only across the head of an ordinary pin. These
+spermatozoa have the power of locomotion in alkaline fluid. Henle
+found they can travel one centimetre in three minutes.
+
+  The human ovum and spermatozoon are single cells, and the principal
+  parts of a typical cell are the cytoplasm (called also the
+  protoplasm), and, within this, the nucleus and centrosome. The
+  centrosome is efficient in the process of cell-division. A few cells
+  have also an outer envelope or membrane, and this part is well
+  developed in the ovum.
+
+  The nucleus is the centre of activity in a cell. In the resting
+  state it is surrounded by a membrane, and within the membrane is an
+  intra-nuclear network made up of chromatin and linin--the chromatin
+  is an important element. The meshes of this network are probably
+  filled with fluid.
+
+  During the stages preparatory to the mitotic, or indirect, division
+  of a cell into two cells (one of the methods of reproduction) the
+  chromatin segregates in typical cases into two groups of loops, and
+  each group has equal portions of the chromatin. When the chromatin
+  is in this shape, a loop is called a chromosome.
+
+  The chromosomes are very important. They occur in constant definite
+  numbers in the somatic cells of the various species of many animals
+  and plants, and it is probable that each species of plant and animal
+  has its own characteristic number of chromosomes. Wilson (_The Cell
+  in Development and Inheritance,_ New York, 1890) gives a list of 72
+  species in which the number has been determined. Man has probably 16
+  chromosomes in the somatic cell, and the mature male and female germ
+  cells in man contribute eight chromosomes each to the nucleus of the
+  impregnated ovum.
+
+The chromosomes transmit the physical bases of heredity from one
+generation to the next, and the heritages from the two parents are
+equal except in cases of prepotency. Every cell {71} in the human body
+is derived from the father and the mother equally. The fact that the
+woman carries a child for months in her womb means only that she
+employs a peculiar method of feeding and protecting it. After its
+birth she feeds it from her breasts, before birth through its
+umbilical vessels, but she originally gives only the eight chromosomes
+as the father does, and the child's vital principle builds up the body
+from this foundation. The popular notion that the foetus in the womb
+is formed through some process of literal abstraction from the
+maternal tissues is no more true than that the infant is so built up
+while it is suckling; both processes are merely different methods of
+feeding.
+
+All the chromosomes from the fathers of at least 200 men could fit
+simultaneously on the head of one pin, yet virtually, not merely
+potentially, half the bodily substance of that multitude, and all the
+physical characteristics derived from the 200 fathers, are indubitably
+contained in those chromosomes and nowhere else, unless by a special
+creation they are infused with the new soul, which seems to be an
+altogether unreasonable alternative. This statement concerning the
+minuteness of the chromosomes is not speculation--they can readily be
+seen and measured with the aid of the microscope.
+
+A human being, then, obtains eight microscopic chromosomes from his
+father and eight from his mother, positively nothing more except food;
+yet he develops into a man with a body made up of countless millions
+of cells which expand into more than 200 bones in the skeleton and
+over 200 muscles,--into the fascias, ligaments, tendons, the great and
+small glands, the lymph and blood systems, the respiratory and
+alimentary tracts, the skin and its appendages, and a nervous system,
+which alone furnishes material for years of study if we would learn
+its anatomy fully. Not only all this, but the man commonly closely
+resembles his father or his mother, or some other ancestor, in
+personal appearance, in certain physical tendencies, in graces or
+blemishes; and furthermore, he shows inherited racial characteristics.
+
+If a father is prepotent, he may have a greater effect in producing
+the formed child than the mother has, and _vice versa,_ as when a son
+closely resembles his father or his mother. {72} Prepotency, moreover,
+may extend down through generations and centuries. In the streets of
+Palermo to-day typical Normans may be seen, despite the intermarriages
+of centuries, who are the descendants of those male Normans that went
+down to Sicily with Tancred. There are Romans there, too, and
+Saracens. When the Belgae--a race of tall, red-bearded men, with
+elliptical skulls--went from the continent of Europe to Ireland,
+probably six centuries before our era, they conquered the aborigines,
+a gentle, brune race of lower stature. These Belgae became the
+ancestors of the chieftain class, and their physical type persists
+until to-day; so does that of the Pictish aborigines. Daniel O'Connell
+had a typical Belgic body. Other big, blond Irishmen are Norse or
+Danish in remote origin.
+
+  How is the extremely complex human body with its various physical
+  characteristics built up from the nucleus of a fecundated cell, the
+  ovum? The endeavour to answer this question has brought out most
+  ingenious speculation from nearly all the great biologists of modern
+  times. The question is the foundation of the theories of heredity,
+  and it is also fundamental in the theories of evolution.
+
+  The human ovum is a flattened spherical cell, made up of a very
+  delicate cell-wall, called the vitelline membrane; outside this is a
+  comparatively thick membrane, the zona pellucida, which is properly
+  not a part of the cell. Within the vitelline membrane is a granular
+  cytoplasm, the vitellus (yolk), and in this lies the nucleus, which
+  in the old text-books was called the germinal vesicle. This nucleus
+  contains a nucleolus.
+
+  The human spermatozoon consists of a flattened head which has a thin
+  protoplasmic cap extending down two-thirds of its length. In the
+  head is the nucleus with the chromatin. Beyond the head is the neck,
+  which contains the anterior and posterior centrosomes. Behind the
+  neck is the tail, or flagellum, in three parts,--the middle piece,
+  the principal part, and the end piece. From the neck to the end of
+  the tail centrally runs a bundle of fibrils, the axial filament. In
+  the middle piece these fibrils are wrapped within a single spiral
+  filament which winds from the neck down to the annulus at the
+  beginning of the principal part, and lies in a clear fluid. Without
+  the spiral filament, along the middle piece, is the mitochondria, a
+  finely granular protoplasmic layer. The principal part of the tail
+  consists of the axial {73} filament enclosed in an involucrum, and
+  the end piece is made up of this filament without the involucrum.
+
+  The head and neck of the spermatozoon, which contain the nucleus and
+  centrosomes, are the essential parts, and the middle piece and the
+  remainder of the tail appear to be used solely for locomotion and
+  penetration. When the head penetrates the ovum, the tail is detached
+  and rejected.
+
+  Our knowledge of the initial stages in the development of a human
+  embryo is derived indirectly from the observation of other mammals.
+  There are nine early human embryos reported, and the average
+  probable age of these is twelve days. Breuss' specimen was probably
+  ten days old (_Wiener med. Wochenblatt,_ 1877). Peters (_Einbettung
+  des mensch. Eies,_ 1899) found a smaller embryo than this. The
+  Breuss ovum was 5 mm. in length; Peters' was 3 by 1.5 by 1.5 mm.,
+  but the probable age was not given. There have been numerous embryos
+  more than twelve days old observed, and since the process after the
+  twelfth day is identical in man and the higher mammals, there is no
+  doubt that the first stages are also the same.
+
+  The segmentation that makes new cells is complicated, and the
+  outcome of the division is a ball of cells. In eggs which have a
+  large yolk, like those of birds, the cells form a round body resting
+  on the surface of the yolk, but in mammalian ova a hollow ball of
+  cells, or a _Morula,_ results, which lines the internal surface of
+  the cellular envelope. The ovum absorbs moisture by osmosis and
+  enlarges, and about the twelfth day after the germ-nuclei have begun
+  to divide, the Morula, or hollow ball of cells, called also the
+  _Blastodermic Vesicle,_ is formed.
+
+  The next stage in development is the establishment of two primary
+  germinal layers, called together the _Gastrula_, The outer layer is
+  the _Ectoderm_ or the _Epiblast,_ and the inner layer is the
+  _Endoderm_ or _Hypoblast_. In a Morula the smaller cells, which
+  contain less yolk-material, gradually grow around the larger
+  yolk-containing cells to form the Gastrula.
+
+ Between the Ectoderm and the Endoderm a layer of cells called the
+ _Mesoderm_ or _Mesoblast_ is next formed, and from these three layers
+ all the parts of the embryo are built up. From the outer Ectoderm and
+ the inner Endoderm those organs arise which are in the body, outer
+ and inner,--as the nervous system and the outer skin from the
+ Ectoderm, the inner entrails, the lungs and liver, from the Endoderm.
+ From the Mesoderm come the inner skin, the bones and muscles.
+
+  By this time the embryo is a minute longitudinal streak at the {74}
+  surface of one pole of the ovum. The "Primitive Trace" is like a
+  long inverted letter U, the legs of which are in apposition. The
+  Primitive Trace becomes a circular flattened disc; and it grows into
+  a cylindrical body by the juncture of the free margins which fold
+  downward and inward and meet in the median line, and this closes in
+  the pelvic, abdominal, thoracic, pharyngeal, and oral cavities. The
+  legs and arms bud from this cylinder later. While the ventral
+  cylinder is growing, another longitudinal cylinder is formed along
+  the upper surface of the embryo, which will contain the brain and
+  the spinal column. The subsequent development of the embryo and
+  foetus need not be known for an understanding of the material
+  considered in treating here of terata.
+
+Human terata occur in certain rather definite, types of erroneous
+development, and the classification of Hirst and Piersol (_Human
+Monstrosities_, Philadelphia, 1891), which is a combination and change
+of the classifications of Geoffrey Saint-Hilaire, Klebs, and Foerster,
+is the most satisfactory. There are four great groups of abnormally
+developed human beings: (1) Hemiteratic; (2) Heterotaxic; (3)
+Hermaphroditic; (4) Monstrous.
+
+Hemiterata are giants, dwarfs, persons showing anomalies in shape, in
+colour, in closure of embryonic clefts, in absence or excess of
+digits, or having other defects. This group does not come under
+discussion here, but attention should be called to the fact that women
+who are dwarfs are to be warned before marriage that they cannot be
+delivered normally,--that the caesarean section or symphyseotomy will
+be necessary, or that certain physicians will practise craniotomy in
+delivering them.
+
+The Heterotaxic group comprises persons whose left or right visceral
+organs are reversed in position through abnormal embryonic
+development; the liver is on the left side, the heart points to the
+right, and so on.
+
+Of the next group, the Hermaphroditic, it may be said that a true
+hermaphrodite, in the full sense of the term, has not been found; but
+there have been several examples of individuals who had an ovary and a
+testicle, and other rudimentary sexual organs that belonged to both
+male and female. Forms of apparent doubling are common, and in case of
+doubt as to sex the probability leans toward the {75} masculine side.
+As to marriage in such cases, questions may arise that are to be
+settled by the anatomist. In dealing with double monsters it is
+sometimes difficult or impossible to determine whether we have to do
+with one or two individuals, and this difficulty has serious weight,
+especially in the administration of baptism. It is improbable that
+there is a doubling of personality in hermaphrodites. A striking
+characteristic of compound terata is that the individuals are always
+of the same sex; moreover, the embryonal development of reproductive
+organs in general is such as almost to preclude a question of duality
+of personality.
+
+Terata, more properly so called, are divided into single, double, and
+triple monsters. Single monsters may be autositic, or independent of
+another embryo or foetus; or they may be omphalositic, that is,
+dependent upon another embryo or foetus, which is commonly well
+developed, and which supplies blood for both through the umbilical
+vessels. When an omphalosite exists, the other foetus is called, in
+this case also, the autosite.
+
+The first order of autositic single monsters contains four genera with
+eight species, and under these species are thirty-four varieties. They
+may have imperfect limbs, no limbs, one eye in the middle of the
+forehead (_cyclops_), fused lower limbs (_siren_), and so on. Some of
+these monsters show a strong resemblance to lower animals, but there
+is no record that is in any degree scientific of a hybrid between a
+human being and a lower animal.
+
+There are two genera of the omphalositic single monsters, with four
+species. One of the twins, the autosite, is commonly a normal child;
+the other, the omphalosite, may be as small as a child's fist, and be
+very much deformed. Of these omphalosites the _paracephalus_ has an
+imperfect head, commonly no heart, and the lungs are absent or
+rudimentary. The _acephalus_ has no head, and commonly no arms; the
+_asomata_ is a head more or less developed, with a sac below
+containing rudiments of the trunk organs. The Acephalus is very
+rare--the rarest of all monsters except the Tricephalus. There is a
+fourth kind--the _foetus anideus_. This is a shapeless mass of flesh
+covered with skin. There may be a {76} slight prominence with a tuft
+of hair on it at one end of the mass to indicate the head. In this
+monster there are more traces of bodily organs than might be expected.
+These four kinds of omphalosites are either dead when born, or they
+die as soon as the placental circulation is cut off. If there is any
+probability of life, the physician should give them baptism before the
+placental circulation is stopped.
+
+  Nothing satisfactory is known concerning the etiology of single
+  monsters. Landau, and other authorities as great as he is, reject
+  the theory that maternal impressions from fright or exposure to the
+  sight of hideous deformity are the cause of terata. I think the
+  father is accountable for terata as often as the mother is. Barnes,
+  an English physician, and others claim they find that terata are
+  frequent in consanguineous marriages, but I have not been able to
+  verify the assertion.
+
+  It seems a theory may be offered to explain the single terata. In
+  1888 Roux of Breslau by puncturing one blastomere of a frog's egg in
+  the two-cell stage killed the punctured blastomere without affecting
+  the other. The punctured blastomere remained inactive, but the other
+  developed into a complete _half_ embryo.
+
+  Crampton by separating and isolating the blastomeres in the two-cell
+  stage obtained a half embryo; and Zoja by isolating blastomeres of
+  the medusae, Clytia and Laodice, got _dwarfed_ larvae.
+
+  Wilson succeeded by the separation through shaking of the
+  blastomeres in the two-cell and four-cell stages in developing
+  Amphioxus larvae, which were half the natural size for the two-cell
+  blastomeres, and commonly half the normal size from the four-cell
+  blastomeres, yet in the latter some of the larvae were of the normal
+  size but imperfect From the eight-cell stage he got only _imperfect_.
+  larvae. Similar results were obtained by other operators with
+  various eggs.
+
+  Driesch and Morgan by removing part of the cytoplasm from a
+  fertilized egg of the ctenophore, Beroe, produced imperfect larvae
+  showing certain defects which represent the parts removed.
+
+  In these cases of injured and isolated blastomeres we have, it seems
+  to me, a plausible theory for the etiology of single terata. The
+  blastomeres in the human ovum may perhaps be injured in part by
+  toxins from the mother, or they may be defective through disease in
+  the ovum or the spermatozoon. They also may possibly be displaced
+  traumatically, but this seems to be doubtful.
+
+  There are three theories concerning the origin of omphalositic {77}
+  terata. Ahlfeld (_Missbildungen des Menschen_, Leipsic, 1882) holds
+  that the autosite is stronger than the omphalosite, and as a
+  consequence the foetal circulation in the omphalosite is reversed,
+  and development is thus checked. Dareste (_Production artificielle
+  des monstruosites_, Paris, 1876), Panum (_Beitrag zur Kenntniss der
+  physiol. Bedeut. der angeboren Missbildungen, Virchow's Archiv.,_
+  1878), Perls (_Lehrbuch der allgem. Pathologie_) and Breus (_Wiener
+  med. Jahrbuch_, 1882) maintain there is an inherent original defect
+  in the omphalositic child which prevents development of the
+  blood-vessels, and that Ahlfeld's theory of an indirect umbilical
+  connection of the omphalosite to the placenta is not probable; if it
+  were, omphalosites would be very common, because one of twins is
+  nearly always stronger than the other. Hirst and Piersol (_op. cit_)
+  combine these theories. This kind of monster is certainly an
+  imperfectly developed human individual, and even the Foetus Anideus
+  should receive at the least conditional baptism.
+
+The next group comprises the composite monsters. Normal twins may
+arise from the fertilisation of one ovum and of two distinct ova. In
+506 cases examined by Ahlfeld he found that 66 twin births came from
+single ova. Twins from a single ovum are always of the same sex, and
+they are not easily distinguished one from the other. Triplets may
+arise from one, two, or three ova. The elder Saint-Hilaire thought
+that composite monsters arise from the fusion of two impregnated ova,
+but this opinion is now generally rejected. Composite terata in every
+instance arise from a single ovum.
+
+  There is a divergence of opinion, however, as to the origin of a
+  composite monster in the single ovum. Some authorities maintain that
+  these monsters arise from the union of two originally separate
+  primitive traces. This supposes primitive duality followed by fusion
+  (_Verwachsungstheorie_). Other writers hold that there is originally
+  one primitive trace, and that composite terata are the product of a
+  more or less extensive cleavage of this single blastoderm. This
+  supposes primitive unity followed by fission (_Spaltungstheorie_).
+  Here, as in the case of normal development, the argument is founded
+  on analogy. The earliest stage in the development of a human double
+  monster observed was at the fourth week after
+  fertilisation--Ahlfeld's case.
+
+  B. Schultze (_U. anomale Duplicitaet der Axenorgane, Virchow's
+  Archiv._) and Panum and Dareste (_op. cit._) hold the fusion
+  theory-- {78} the fusion of two separate blastoderms in one ovum.
+  Panum and Dareste have seen two separate normal blastoderms on one
+  ovum. Allen Thompson in 1844 (_London and Edinburgh Monthly Journal
+  of Medical Science_), Wolff, von Baer, and Reichert also observed
+  two embryos in one ovum. Dareste is of the opinion that the fusion
+  of two separate ova is impossible. The fission theory--the fission
+  of a single blastoderm to make a composite monster--is supported by
+  Wolff, J. F. Meckel, von Baer, J. Mueller, Valentine, Bischoff, and
+  others, especially by Ahlfeld. Ahlfeld says that this single
+  blastoderm is split by pressure.
+
+  Gerlach also (_Die Entstehungsweise der Doppelmissbildungen, etc.,_
+  Stuttgart, 1882) admits fission, but he contends that it is not so
+  simple a process as Ahlfeld thinks it is. It is not a passive
+  cleavage, but a result of a force in the cell-mass existing before
+  differentiation. Gerlach calls fission at the anterior or head-end
+  of the single blastoderm, _bifurcation_; and he has actually
+  observed such bifurcation in a chick embryo of sixteen hours (_U. d.
+  Entstehungsweise der vorderen Verdoppelung. Deutsche Archiv. f.
+  klin, Med.,_ 1887). In this case the first change noticed was a
+  broadening of the anterior end of the primitive streak; next a
+  forked divergence appeared, and this became more pronounced; until
+  by the twenty-sixth hour the bifurcation was half as long as the
+  undivided posterior part. From each anterior end of the diverging
+  branches a distinct head-process extended. Allen Thompson (_loc.
+  cit._) in 1844 saw a goose-egg, which had been incubated for five
+  days, in which was a double monster divided to the neck.
+
+  Beyond this observation by Gerlach we have the fact, which seems to
+  make for the fission theory, that no matter how unequally nourished
+  or how variable in extent, the union between the halves of double
+  monsters is always symmetric--exactly the same parts of each twin
+  are joined. This seems to exclude a fortuitous growing together of
+  dissimilar areas or cell-masses, for non-parasitic double terata at
+  the least. Born ( _U. d. Furchung des Eies bei Doppelbildungen,
+  Breslauer Aerztl. Zeitschr._, 1887), in a study of fish ova, found
+  that ova which produce double monsters begin with a segmentation
+  like that of the single normal ovum.
+
+  If fission is complete homogeneous twins are the result; these twins
+  are of the same sex and very similar in appearance. Incomplete
+  fission, as has been said, gives rise to double or triple terata. If
+  one of the teratic twin embryos is stronger than the other, the
+  various combinations of enclosure and parasitism may result,
+  although the origin of parasitic double terata is not convincingly
+  clear. A triple {79} monster, according to the fission theory,
+  arises from a double incomplete cleavage of the primitive trace. Dr.
+  Ephraim Cutter has observed teratic composite spermatozoa which, he
+  thinks, probably have influence in producing composite monsters.
+
+There are three orders of the double autositic monsters: _Terata
+Katadidyma,_ in which the embryonal fission was at the cerebral end;
+the _Terata Anadidyma_, divided below; the _Terata Anakatadidyma_,
+divided above and below, but joined at the middle of the body. There
+are four genera of the Terata Katadidyma with many species. The first
+genus is the _Diprosopus,_ the double-faced. The doubling varies from
+the finding of two complete faces to a slight trace of duplex
+formation in one head. Foerster in 500 human monsters observed 29 cases
+of diprosopi.
+
+There are six species of diprosopi: 1. _D. Diophthalmus,_ which has
+only two eyes, but there is a doubling of the nose. 2. _D. Distomus_,
+which has two mouths, two lower jaws, two tongues, one pharynx, and
+one oesophagus. 3. _D. Triophthalmus_, which has three eyes, and the
+doubling of the face is more complete. There are only two ears. 4. _D.
+Tetrophthalmus_, which has four eyes and two well-separated faces. 5.
+_D. Triotus_ is like the last, but it has three ears. 6. _D. Tetrotus_
+has four ears, four eyes, and there is some doubling at the pharynx.
+Two oesophaguses enter one stomach in this species commonly. D.
+Tetrotus is rare--only one example in man is known. In all diprosopi
+there is only one trunk, one pair of arms, and one pair of legs. Sir
+James Paget had a photograph, made in 1856, of a living diprosopus,
+the second face of which had a mouth, nose, eye, part of an ear, and a
+brain (?) of its own. The two faces acted simultaneously, suckled,
+sneezed, yawned together.
+
+Are diprosopi twins? An answer to this question will be clearer after
+a description of other composite terata.
+
+The second genus of the Terata Katadidyma is the _Dicephalus_. This
+genus comprises five species, which have in each case two heads, with
+separate necks commonly. There are two vertebral columns, which
+usually are separate down to the sacrum, and they converge at the
+lower end. {80} In the interior organs doubling will be found
+corresponding to the degree of separation of the trunks. In all the
+species of this genus there are one umbilicus and one cord.
+
+The first species of the Dicephalus is the _Dicephalus Dibrachius_--a
+two-armed, double-headed monster. In this species most of the viscera
+are single, but the right and left halves of each viscus are supplied
+by the respective foetuses, and the entrail does not become
+indistinguishably single until near the lower end of the ileum. There
+may be two ordinary kidneys and a third smaller one, two pancreatic
+glands, and two gall-bladders. Such a monster may be monauchenous or
+diauchenous.
+
+The next species is the _Dicephalus Tribrachius Dipus_--two heads,
+three arms, and two legs. There is also a _Dicephalus Tribrachius
+Tripus_ (three arms and three legs), _D. Tetrabrachius Dipus_ (four
+arms and two legs), and _D. Tetrabrachius Tripus_ (four arms and three
+legs). In all these cases there is no doubt of the presence of twins,
+unless there might be some doubt as to dual personality in the
+Dicephalus Dibrachius. In the Dicephalus Tetrabrachius Dipus and the
+Dicephalus Tetrabrachius Tripus there is almost complete duplication
+of the internal organs, and the halves of the composite body belong
+evidently to individuals distinct in thought, volition, and character.
+Each brain controls only its own half of the body. There are four
+lungs, two hearts (sometimes in one pericardium), two stomachs, two
+intestinal canals down to the colon or lower, two livers (sometimes
+joined), four kidneys (or three, one of which is small), two bladders,
+emptied at different times through a common urethra.
+
+Dicephali are somewhat common. Foerster found 140 among 500 specimens
+of monsters. They are rarely born alive. The best known cases of
+dicephali that lived for any length of time are:
+
+1. Peter and Paul, of Florence, born in 1316, lived thirty days.
+
+2. The Scotch Brothers, born in 1490, lived twenty-eight years. They
+were at the court of James III. Above the point of union the twins
+were independent in sensation and action, but below the point all
+sensation and action were {81} common. One died before the other, and
+the second "succumbed to infection from putrefaction" a few days
+later.
+
+3. The Wuertemberg Sisters, born in 1498.
+
+4. The twins, Justina and Dorothea, born in 1627, lived six weeks.
+
+5. Boy twins at Padua, born in 1691, lived to be baptised.
+
+6. Rita-Cristina, born at Sassari in Sardinia in 1829. They lived
+eight months. These children had a common trunk below the breast, one
+pelvis, and one pair of legs. Rita was feeble and quiet, Cristina
+vigorous and lively. They suckled at different times; and sensation in
+the heads and arms was individual, but below the junction it was
+common. Rita died of bronchitis, and during Rita's final illness
+Cristina was healthy; but when Rita died, Cristina, who was suckling
+at the time, suddenly expired. They had two hearts in one pericardium,
+the digestive tracts did not fuse until the lowest third of the ileum
+was reached. The livers were fused, the vertebral columns were
+distinct throughout. These twins were baptised separately.
+
+7. Marie-Rose Drouin, born in Montreal in 1878. They lived seven
+months. Marie died of cholera infantum; and Rose then died, although
+she had not been directly affected by the disease. These twins were
+like Rita-Cristina anatomically except that they had no legs. The
+respirations and heart-pulsations differed, and one child slept while
+the other child cried.
+
+8. The Tocci boys, born in Turin in 1877. In 1882 they were strong and
+healthy, and they may be living still. They resembled Rita-Cristina
+anatomically in every respect. Each boy had control of the leg on his
+own side, but not of the other leg, consequently they could not walk.
+Their sensations above the juncture were distinct, and their thoughts
+and emotions differed.
+
+In the Paris _L'union medicale_ there is an account of a bicephalic
+still-born monster, born at Alexandria in 1848, which, according to
+the report, had on one side a typical negro head and on the other side
+a typical Egyptian fellah head. This report is probably not authentic;
+but if it is, it would be difficult to reconcile it with the fission
+theory. {82} Supposing the report true, the case would have to be one
+(1) of superimpregnation wherein (2) a spermatozoon from each source
+penetrated the same ovum, (3) a bicephalic monster resulted, with (4)
+distinct racial characteristics. All this is extremely improbable.
+
+Superimpregnation has happened. There are cases where negresses have
+given birth to twins, one of which was a negro and the other a
+mulatto. Instances are cited in books on Legal Medicine like those of
+Tidy and Beck. In Flint's Physiology a case is recorded in which a
+mulatto woman in Kent County, Virginia, married to a negro, gave birth
+to twins, in 1867, one of which was a negro much blacker than the
+mother, and the other a white child, with long, light, silky hair, and
+a "brilliant complexion." The white child's nose was shaped like the
+mother's, but there was no other resemblance. Even supposing this to
+be a case of superimpregnation, that does not fully explain the
+extreme whiteness of one child and the extreme blackness of the other.
+
+Superfoetation is also possible. Tidy (_Legal Medicine_) gives a case:
+"Mary Anne Bigaud, at thirty-seven, on April 30th, 1748, gave birth to
+a full-term mature boy, which survived its birth two and a half
+months, and to a second mature child (girl) on September 16th, 1748,
+which lived for one year." The second child was born four and a half
+months after the first, and both were "nine-months" children. It was
+proved after death in this case that the mother had not a double
+uterus, and the report is vouched for by Professor Eisenman, and by
+Leriche, surgeon-major of the Strasburg Military Hospital. Several
+other cases of superfoetation are given by Bonnar (_Edin. Med.
+Journ.,_ January, 1865).
+
+The third genus of Terata Katadidyma is the _Ischiopagus_. These twins
+are divided so much from above downward that the heads are at almost
+opposite ends of the double body. They are joined at the coccyges and
+sacra, and the spinal columns have nearly the same axis. The trunk
+organs are complete and separate, except that they are commonly fused
+in the pelvis. There may be two, three, or four legs, given off at
+right angles to the pelvis. This kind of monster is not rare. Foerster
+collected twenty cases, and nine new examples {83} were reported in
+the _Index Medicus_ between 1879 and 1893. Ischiopagic twins were born
+in County Roscommon, Ireland, in 1827, and baptised separately. The
+Jones Twins, born in Typhon County, Indiana, in 1889, lived for about
+two years; they were ischiopagi, and they had the very unusual
+quality, it is said, that they differed in complexion and the colour
+of eyes and hair. A case was reported in _American Medicine_,
+September, 1903.
+
+Classed with the Katadidyma is the genus _Pygopagus_, although it has
+four legs. This form is very rare. The twins are joined only by the
+latero-posterior aspects of the sacra and coccyges, so that the two
+individuals are placed almost back to back. The trunk organs are
+independent, except for some fusion near the point of juncture.
+Examples of this class are the Hungarian Sisters, born at Szony in
+1701, who lived to womanhood; the negresses Millie-Christine, born in
+1851, and who were recently living in North Carolina; and the Blazek
+Sisters of Bohemia. The negresses had common sensation in the legs,
+but Millie could not localise what part of Christine's legs was
+touched, and _vice versa_.
+
+The second group of the double autositic monsters are _Terata
+Anadidyma_--terata divided from below upward. The first genus is the
+_Dipygus_. This has a single body above, but a double pelvis with
+double lower extremities in the typical cases. There is an exact
+description of a double monster of this kind in the Gaelic _Annals of
+the Four Masters_ as early as the year 727 of this era. The chronicler
+says in that year on Dalkey Island near Dublin, "There was a cow seen
+which had one head and one body as far as her shoulders, two bodies
+from her shoulders hindward, and two tails. She had eight legs, and
+she was milked three times a day."
+
+A perfect human Dipygus with two equally developed pairs of legs is
+unknown. Catherine Kaufmann, who was born in 1876, and who died in
+1878, had a double pelvis with double pelvic organs in part, but she
+had only one pair of legs. There is a similar anomaly said to be
+living in Philadelphia at present. Blanche Dumas, born in 1860, had a
+double pelvis, double pelvic organs, and three legs. Mrs. B., born in
+1868, {84} had four legs--the two inner ones were smaller than the
+outer pair. Her spinal column was divided up to the third lumbar
+vertebra. Her double pelvic organs acted independently. There are
+living male examples of this form of monster.
+
+The next genus is the _Syncephalus_, called also _Janus_ and
+_Janiceps_. Its lower body is double up to the umbilicus, the trunk
+single above that point; the head shows signs of doubling, and there
+are four legs and four arms; the bodies grow front to front. The head
+usually is large, therefore this monster is born dead.
+
+Another genus is the _Craniopagus_--twins joined only by the skull or
+scalp. There are three species, named from the place of
+union--_Craniopagus Frontalis, C. Parietalis_, and _C. Occipitalis_.
+
+A third group of double autositic monsters are the _Terata
+Anakatadidyma_, which are divided above and below, but joined from the
+navel to the head. There are three genera. The first, the
+_Prosopothoracopagus_, is joined at the upper abdomen, the chest, and
+the faces; the spinal columns are separate. The faces are imperfect,
+the jaws are united; there is a broad neck with one oesophagus, and
+there is one stomach and one duodenum. This is a rare form, and it can
+not exist out of the uterus.
+
+A second genus, the _Thoracopagus_, has a thorax in common, and the
+inner legs may be united. It is, as a rule, still-born.
+
+The next genus is the _Omphalopagus_, in which the twins are joined
+from the navel to the bottom of the chest. This double monster has the
+slightest union of all, and it is very rare. The Siamese Twins were
+omphalopagi. They quarrelled; one became a drunkard and the other
+remained temperate. They married two women, and Chang had ten
+children, and Eng twelve. Chang died while Eng was asleep, and the
+latter died two hours after he had waked and learned of his brother's
+death.
+
+There is a genus, the _Rachipagus_, the examples of which are joined
+behind like the class Terata Anakatadidyma that are joined in front.
+
+{85}
+
+Four known attempts have been made to separate double monsters
+surgically, but all failed owing to crude surgery; modern methods
+might be successful in some cases.
+
+The second order of double monsters comprises the parasitic class.
+There are three genera of these terata, with five species and
+seventeen varieties. The chief of these only will be mentioned. The
+_Heterotypus_ is a parasitic child which hangs from the abdominal wall
+of the principal subject. Varieties of this species are the
+_Heteropagus_, which is a parasite with head and arms; the
+_Heterodelphus_, which has no head; the _Heterodymus_, which has a
+head, neck, and thorax. The _Heteralitis_ is a second species, in
+which the parasite is inserted at a distance from the navel of the
+autosite. The _Epicomus_ is the only example, and it consists of a
+parasitic supernumerary head. The _Polypnathus_ is a parasite attached
+to the jaw of the autosite. When fastened to the upper jaw, it is an
+_Epignathus_; at the lower jaw it is an _Hypognathns_. Another group
+is made up of terata having parasitic legs which are attached to
+different parts of the autosite,--to the pelvis, the head, the
+abdomen, and so on. Finally, there is the _Endocyma_, which is a
+parasite enclosed within the body of an autosite.
+
+Parasites are nourished through the blood supply of the autosite, and
+the parasites usually are incapable of motion. The autosite can feel
+when the parasite is touched, and in some cases the autosite can
+localise the touch. In India, in 1783, a child was born which had a
+supernumerary head attached to the autositic head, crown to crown; it
+lived four years. The parasite's eyes were always partly open, but
+they appeared to be incapable of intelligent vision. They contracted
+under strong light, and when the autosite was suddenly awakened both
+sets of eyes moved.
+
+Gould and Pyle (_Anomalies and Curiosities of Medicine_) give an
+account of an Italian boy, aged eight years, who had a small parasitic
+head protruding from near the left third rib. Sensibility was common.
+Each of the heads received baptism (one was called John and the other
+Matthew), and there was question as to whether extreme unction should
+be administered to the parasitic head. A similar case occurred in {86}
+England in 1880 (_British Med. Journal_), and the parasitic head could
+be pinched without attracting the attention of the autosite.
+
+Teratologists now exclude Dermoid Cysts from the lists of terata. The
+hair, teeth, and particles of bone found in these cysts are looked
+upon as the development of abnormal ectodermic and endodermic cells,
+rather than as evidence of a separate personality.
+
+There is only one well-authenticated case of a triple monster, and
+this happened in Italy in 1831. The monster had a single broad body
+with three distinct heads and two necks. It was killed in delivery.
+
+In Katadidyma (terata divided from above downward), when we have
+dicephali, ischiopagi, or pygopagi, there are evidently two
+individuals present. Is the Diprosopus, however, the two-faced
+monster, possessed of one or two souls? The cases vary, as we said,
+from examples with two distinct faces and four ears to cases that have
+merely two noses. What portion of a human body is required to contain
+a new soul? That is an interesting question for the psychologist and a
+very practical one for the moralist, and no moralist has yet attempted
+to solve it. The presence of a brain is not essential, because
+acephalous monsters develop without brain, and they are born alive;
+they have a vital principle which is identical with the soul.
+
+Among the Terata Anadidyma (divided from below upward) the Syncephalus
+and the Craniopagus are unquestionably two persons. Is the Dipygus
+(single down to the navel, double below) one or two persons? Mrs. B.,
+the example already given, was as double below the navel as any
+Dicephalus is above that point. She had features so well ordered in
+unity that she was a pretty woman, but that unity ceased at her waist.
+Was her husband unknowingly a bigamist? I think he was. After a
+consideration of the fission of terata, and the non-essential quality
+of the brain, why should fission that started at the feet differ from
+fission that started at the head?
+
+In the _Rituale Romanum Pauli V._ (tit. ii. cap. i. nn. 18, 19, 20,
+21), the following directions for the baptising of terata are given:
+
+{87}
+
+  18. In monstris vero baptizandis, si casus eveniat, magna cautio
+  adhibenda est, de quo si opus fuerit, Ordinarius loci; vel alii
+  periti consulantur, nisi mortis periculum immineat.
+
+  19. Monstrum, quod humanam speciem non praeseferat, baptizari non
+  debet; de quo si dubium fuerit, baptizetur sub hac conditione: _Si
+  tu es homo, ego te baptizo,_ etc.
+
+  20. lllud vero, de quo dubium est, una ne, aut plures sint personae,
+  non baptizetur, donec id discernatur: discerni autem potest, si
+  habeat unum vel plura capita, unum vel plura pectora; tunc enim
+  totidem erunt corda et animae, hominesque distincti, et eo casu
+  singuli seorsum sunt baptizandi, unicuique dicendo: _Ego te
+  baptizo_, etc Si vero periculum mortis immineat, tempusque non
+  suppetat, ut singuli separatim baptizentur, potent minister
+  singulorum capitibus aquam infundens omnes simul baptizari, dicendo:
+  _Ego vos baptizo_, in nomine Patris, et Filii, et Spiritus sancti.
+  Quam tamen formam in iis solum, et in aliis similibus mortis
+  periculis, ad plures simul baptizandos, et ubi tempus non patitur,
+  ut singuli separatim baptizentur, alias numquam, licet adhibere.
+
+  21. Quando vero non est certum in monstro esse duas personas, ut
+  quia duo capita et duo pectora non habet distincta; tunc debet
+  primum unus absolute baptizari, et postea alter sub conditione, hoc
+  modo: _Si non es baptizatus, ego te baptizo in nomine Patris, et
+  Filii, et Spiritus sancti._
+
+   AUSTIN OMALLEY.
+
+
+{88}
+
+VII
+
+SOCIAL MEDICINE
+
+
+The influence of the clergyman or the charitable visitor in matters of
+health and sanitation can scarcely be overestimated. The removal of
+prejudices with regard to sanitary regulations for the prevention of
+disease and modern advances in the treatment of disease is an
+important social duty. There is no doubt that if this influence be
+properly directed, sanitary measures of various kinds will be much
+more readily enforced and the precautions necessary to prevent the
+spread of serious infectious ailments more faithfully observed. As
+this amelioration of sanitary conditions will affect mainly the poor,
+lessening their suffering and adding to their possibilities of
+happiness, its accomplishment becomes a great Christian duty,
+obligatory on all those who are interested in the uplifting of the
+poorer classes.
+
+Professor Virchow, the distinguished German pathologist, used to say
+that popular medicine was in all ages at least fifty years behind
+scientific medicine. He had himself discovered the principles of
+cellular pathology nearly half a century before his death, yet he
+declared that the popular mind still believed in the old doctrines of
+humoral pathology,--that is, that the conditions of health and
+disease depended on the constitution of the fluids of the body (the
+blood, the bile, the mucus, and so forth), and had not generally
+accepted modern advances in medical knowledge of the underlying basis
+of disease in the solid tissues. There is no doubt that many
+old-fashioned notions long since discredited by physicians are still
+very generally accepted by the popular mind, and even the intelligent
+classes sometimes harbour convictions with regard to the good or evil
+effects of habits {89} of life, diet, and the operation of drugs of
+various kinds that are entirely contrary to present-day medical
+knowledge.
+
+It is extremely important, then, that the clergyman or charitable
+visitor, in giving views on medical matters, which are sure to have
+much more weight than he perhaps attributes to them himself, should be
+careful not to make statements for which he has not good authority in
+modern medical science. It is very easy, in a matter of this kind, to
+state principles that are not the result of education, properly so
+called, but are gleaned from early false impressions obtained one
+knows not how or where, entirely without definite consciousness as to
+their real origin. The physician himself finds that he is compelled to
+be careful of this same tendency to put too much stress on traditions
+with regard to health which he imbibed before he began to study
+medicine. It is perhaps not so surprising, then, to hear physicians
+complain often that clergymen instead of being a help are sometimes a
+hindrance to the enforcement of modern hygienic rules, because they
+still cling to old-fogy notions of hygiene and sanitation retained
+from a defective early training. Owing to the influence that the
+clergyman is sure to exert, this becomes an extremely important
+matter. Great harm may be done and the  physician discredited, almost
+without a realisation, on the part of the clergyman, that he is
+interfering in another's department. Sympathetic coordination of
+clerical and medical efforts would accomplish much good that is now
+unfortunately left undone.
+
+There is no doubt that for the important crusade against tuberculosis,
+for instance, the aid of the clergyman will accomplish much for the
+reduction of the death rate from this disease. What is needed at the
+present moment is a universal conviction that tuberculosis is not an
+hereditary but a communicable disease. This does not mean that it is
+virulently contagious and that as a result sufferers from tuberculosis
+must at once be segregated from other members of the family and from
+the community generally; but it does mean that careful precautions
+must be taken with regard to the disposal of sputum, with the
+enforcement of the most exacting cleanliness on the part of
+consumptives themselves. {90} It also means that the person suffering
+from the disease should not sleep with those as yet unaffected, nor be
+allowed to live in very close contact, especially with children or
+susceptible individuals.
+
+The persuasion that tuberculosis is not hereditary will do much to
+encourage patients suffering from the disease to feel that they are
+not hopelessly doomed. At the present time it is not unusual to find
+patients so discouraged, when told that they have tuberculosis, that
+it is almost impossible to secure a favourable reaction to any mode of
+treatment. They have seen members of families die one after another,
+or they have heard stories of the inevitable way in which consumption
+wiped families out of existence, and they give up hope and become
+quite cast down. Needless to say, while in this condition any
+treatment is practically hopeless. On the other hand, the conviction
+that tuberculosis is only an infectious disease, quite curable in the
+majority of cases if taken in time, is of itself a most important aid
+in the treatment of the disease, since courage and faith are the
+principal requirements for successfully combating the affection.
+
+We have had any number of newly invented remedies for consumption in
+the last twenty-five years. Scarcely a year has passed in which some
+new form of treatment, often eventually proved to be the resuggestion
+of an old therapeutic method, has not been heralded as a positive cure
+for consumption. In every case the first patients treated by the
+discoverer of the new remedy have rapidly improved under his care. In
+the hands of others, however, such results have not been obtained, or
+only for a very short time at the beginning of the treatment. After a
+time the new remedy failed in its inventor's hands. The true reason
+for the improvement was then seen to be, not the remedy suggested, but
+the favourable influence on the mind of consumptives produced by the
+faith of the inventor in his remedy, and their reaction to this
+powerful suggestion when they were put under proper conditions of an
+abundance of fresh air and a plentiful diet.
+
+This shows, too, the reasonableness of the modern treatment of
+consumption, which consists not in the giving of {91} drugs, but in
+securing for the patient a plenty of fresh air for many hours a day
+and the encouragement to consume a liberal amount of nutritious food.
+Most of the much advertised remedies for consumption are really
+harmful rather than beneficent. Many of them are ordinary cough
+mixtures containing considerable opium, which lessens the cough, it is
+true, but also lessens the appetite and locks up the bowels. Besides,
+the cough is nature's method of removing material from the lungs which
+has become disintegrated, and if allowed to remain will certainly
+bring about the spread of the infection in the pulmonary tissues.
+Cough is a natural protective reaction to be encouraged, and is not in
+itself a source of evil needing to be suppressed. If cough is
+bothering the patient so much at night as to cause loss of sleep, then
+it is necessary to make a choice between two evils and somewhat to
+suppress the cough, even though it involves certain other
+inconvenience to the patient. All these so-called consumption cures
+contain materials that are almost sure to disturb the appetite and
+upset the stomach. The fate of a consumptive patient absolutely
+depends on his stomach; just as little, then, of medicine must be
+employed as possible. This will indicate the necessity for clergymen
+rather advising against than in favour of these proprietary medicines
+which have been definitely known to do so much harm in recent years.
+Many a patient delays an appeal to medical aid so long, as the result
+of trusting to such medicines, that a curable case of consumption
+becomes incurable, or else develops to such a condition as to require
+years of treatment on the fresh-air, abundant-food plan, where months
+would have sufficed before.
+
+A very interesting phase of social medicine is the ease and confidence
+displayed by people, often of more than ordinary intelligence, in
+recommending various proprietary medicines of which they know nothing
+except the fact that someone says he, or more often she, was cured of
+something or other by their use. A chance remark like this to a
+sufferer becomes a high recommendation. The hardest problem the doctor
+has before him is to find out what is really the matter with his
+patients. Not infrequently people having apparently the same set of
+symptoms are suffering from quite different {92} ailments. A symptom
+like a sore throat, for instance, may very well be due to any one of
+at least a half-dozen of causes, most of which require their own
+peculiar treatment. When the affection under consideration is as
+indefinite as a tired feeling, or indigestion, or some one of the many
+ailments included under the term biliousness or kidney trouble, from
+which people are supposed to suffer, then the diagnosis problem
+becomes by far the most serious question in the case, and is often
+very difficult. The trained physician prudently hesitates, but the
+inexpert in medicine steps in and quite volubly announces what the
+ailment is in his opinion, and what will probably do it good. A little
+knowledge is indeed a dangerous thing in medical matters. If it be
+remembered that there is a very general impression among medical men
+now, as the result of recent acquisitions of scientific information
+with regard to the origin, pathological basis, and course of disease,
+that very probably more harm than good has been done by the
+administration of medicines in the past, not only the futility of lay
+(or clerical) prescribing will be manifest, but also somewhat of the
+amount of harm that may be done.
+
+It is often a matter for painful surprise, then, to find that
+clergymen and members of religious communities allow their names to be
+used in the recommendation of remedies of whose composition they know
+nothing, for a disease of which they know less, if possible. This evil
+becomes especially poignant when the columns of our reputable
+religious press are allowed to be used for the purpose of exploiting
+the public in these matters. The remedies most often recommended are
+the so-called tonics. These are best represented by the sarsaparillas,
+and by various cures for catarrh, indigestion, and kindred indefinite
+ills, of which there are a great many on the market. These are not
+secret remedies, since their composition is well known by those of the
+medical profession who care to secure the information. Some six years
+ago an analysis of most of them was made by the Massachusetts State
+Board of Health.   [Footnote 1]
+
+  [Footnote 1: 28th Annual Report Mass. Board of Health; food and drug
+  inspection, 1897.]
+
+The principal active agent in all of these   remedies was {93} found
+to be alcohol. In most of them it exists in a proportion about equal
+to that in which it is supposed to occur in ordinary whiskey. Some of
+them are even stronger in alcoholic contents than the whiskey usually
+sold in our large cities. This matter has seemed so important that we
+give the official figures of the Board of Health.
+
+
+TABLE
+
+From the Report of the Massachusetts Board of Health
+
+_Tonics and Bitters_
+
+The following were examined for the purpose of ascertaining the
+percentage of alcohol in each. Some of them have been recommended as
+temperance drinks!
+
+       Per cent, of Alcohol (by volume).
+
+  "Best" Tonic    7.6
+  Carter's Physical Extract    22.0
+  Hooker's Wigwam Tonic   20.7
+  Hoofland's German Tonic   29.3
+  Hop Tonic   7.0
+  Howe's Arabian Tonic, "not a rum drink"   13.2
+  Jackson's Golden Seal Tonic   19.6
+  Liebig Company's Coca Beef Tonic   23.2
+  Mensman's Peptonized Beef Tonic   16.5
+  Parker's Tonic, "purely vegetable," "recommended for inebriates"   41.6
+  Schenck's Sea Weed Tonic, "entirely harmless"   19.5
+  Atwood's Quinine Tonic Bitters     29.2
+  L. T. Atwood's Jaundice Bitters   22.3
+  Moses Atwood's Jaundice Bitters   17. 1
+  Baxter's Mandrake Bitters   16.5
+  Boker's Stomach Bitters   42.6
+  Brown's Iron Bitters   19.7
+  Burdock Blood Bitters   25.2
+  Carter's Scotch Bitters   17.6
+  Colton's Bitters   27.1
+  Copp's White Mountain Bitters, "not an alcoholic beverage" 6.0
+  Drake's Plantation Bitters   33.2
+  Flint's Quaker Bitters   21.4
+  Goodhue's Bitters 16.1
+  Greene's Nervura   17.2
+{94}
+  Hartshorn's Bitters   22.2
+  Hoofland's German Bitters, "entirely vegetable and free from
+          alcoholic stimulant"   25.6
+
+  Hop Bitters 12.0
+  Hostetter's Stomach Bitters   44.3
+  Kaufmann's Sulphur Bitters, "contains no alcohol." As
+      a matter of fact, it contains 20.5 per cent, of alcohol
+      and no sulphur   20.5
+
+  Kingsley's Iron Tonic 14.9
+  Langley's Bitters   18.1
+  Liverpool's Mexican Tonic Bitters   22.4
+  Paine's Celery Compound   21.0
+  Pierce's Indian Restorative Bitters   6.1
+  Puritana   22.0
+  Porter's Stomach Bitters   27.9
+  Pulmonine   16.0
+  Rush's Bitters   35.0
+  Richardson's Concentrated Sherry Wine Bitters   47.5
+  Secor's Cinchona Bitters   13.1
+  Shonyo's German Bitters   21.5
+  Job Sweet's Strengthening Bitters   29.0
+  Thurston's Old Continental Bitters   11.4
+  Walker's Vinegar Bitters, "contains no spirit"   6.1
+  Warner's Safe Tonic Bitters   35.7
+  Warren's Bilious Bitters   21.5
+  Wheeler's Tonic Sherry Wine Bitters   18.8
+  Wheat Bitters   13.6
+  Faith Whitcomb's Nerve Bitters   20.3
+  Dr. Williams' Vegetable Jaundice Bitters   18.5
+  Whiskol, "a non-intoxicating stimulant, whiskey without its sting"   28.2
+  Colden's Liquid Beef Tonic,
+      "recommended for treatment of the alcoholic habit"   26.5
+
+  Ayer's Sarsaparilla   26.2
+  Thayer's Compound Extract of Sarsaparilla   21.5
+  Hood's Sarsaparilla   18.8
+  Allen's Sarsaparilla   13.5
+  Dana's Sarsaparilla   13.5
+  Brown's Sarsaparilla   13.5
+  Corbett's Shaker Sarsaparilla   8.8
+  Radway's Resolvent   7.9
+
+  The dose recommended upon the labels of the foregoing preparations
+  varies from a teaspoonful to a wineglassful, and the frequency also
+  varies from one to four times a day, "increased as needed."
+
+  Many so-called tonics not on this list are also known to contain
+  alcohol, {95} though not as yet officially analysed so as to give
+  exact figures. Most of the cure-alls for women's ills contain
+  alcohol in noteworthy amounts, this being in fact usually the only
+  active ingredient in them.
+
+As the analyst of the State Board of Health of Massachusetts is a
+thoroughly competent chemist, and as these figures have now been
+before the public for over five years without any contradiction on the
+part of the manufacturers of these remedies, though it is evident how
+undesirable the truth of the matter is from an advertising standpoint,
+there can no longer be any question as to the authoritativeness of the
+proportions of the alcohol in the remedies as given.
+
+It is rather sad to think of mothers giving these remedies to their
+children, hopeful of the good they may accomplish, when, as a matter
+of fact, it would be so much simpler and just the same in the end, to
+give them, instead of a tablespoonful of the favourite sarsaparilla,
+whatever it might be, a tablespoonful of dilute whiskey. As was noted
+in the volumes on the _Physiological Aspects of the Liquor Problem_
+published recently by a sub-committee of the Committee of Fifty for
+the investigation of the liquor problem, not a few prominent total
+abstinence advocates have put themselves on record as recommending
+these remedies, though there can be no possible doubt of the great
+harm likely to arise from their use. There are many physicians who
+feel sure that some of the alcoholic habits in women, whose origin it
+has been hard to account for, were really contracted during this
+secret "tippling" process under the form of a tonic remedy. Everyone
+knows that any tonic, in order to be effective, has to be gradually
+increased, so it is not surprising that in many cases physicians have
+heard of patients taking six to ten tablespoonfuls of some tonic
+remedy every day. This would be the equivalent, in some cases, of from
+three to five ounces of whiskey--a rather liberal allowance even for a
+confirmed whiskey drinker.
+
+As noted by the Massachusetts Board of Health, the dose recommended
+upon the labels varies considerably, but practically all agree in
+suggesting that the amount of the remedy taken shall be increased as
+needed. A simple presentation of this subject will surely be
+sufficient to arouse clergymen {96} to a proper sense of their duty in
+this matter. Senators, judges of Supreme Courts, Congressmen, and even
+university professors and teachers may be so benefited by dilute
+whiskey, taken early and often, as to be tempted to furnish
+testimonials for them (for a due consideration usually), but clergymen
+should at least know something of the consequences of their act before
+committing themselves.
+
+An almost precisely similar state of affairs obtains with regard to
+another class of favourite popular remedies. A number of so-called
+blood-purifying remedies have been recommended at various times, and
+here, as in other things, it is surprising to find how many
+intelligent people lend themselves to the exploitation of the public
+in the interests of the proprietary vender, who cares only to sell,
+and cares very little what effect his remedies may produce. Most of
+the sarsaparillas are said to be blood purifiers. It is surprising
+what vogue this word "sarsaparilla" has obtained. A little more than
+half a century ago a German chemist and pharmacist announced that the
+sarsaparilla plant contained certain principles that could be
+extracted by boiling, and that form excellent remedies for atonic and
+anaemic conditions. This announcement was received by the medical
+profession very kindly, and immediate tests as to the efficacy of the
+new remedy were made. As a result of these tests, within a few years
+the inefficacy of sarsaparilla became very clear. It is almost
+entirely without effect upon the human system. In the meantime,
+however, the word "sarsaparilla" was one to conjure with for the
+popular mind, and the sarsaparilla remedies began to be manufactured.
+Millions have been made on them and out of the public. The only active
+agent as regards tonic qualities which they contain is, as we have
+said, alcohol. Most of them however, contain at least one other
+well-known drug likely to be at least as harmful as alcohol. This is
+iodide of potash. Very few of the so-called sarsaparillas are without
+a notable proportion of this strong mineral salt, as the Massachusetts
+Board of Health said.
+
+"With but few exceptions they contain a considerable percentage of a
+very active and powerful remedy, the iodide of potassium. The sale of
+such an article in unlimited {97} quantities by druggists, grocers,
+and others is censurable. More than this, the method of its sale is
+dishonest, since the unwary purchaser is led to believe that he is
+purchasing a harmless vegetable remedy, namely, sarsaparilla.
+
+"It may be seriously questioned whether the blood of persons who take
+iodide of potassium continuously is not decidedly impoverished,
+instead of being purified, as is claimed by the manufacturers. It is
+not uncommon to find persons who have used continuously six, eight, or
+ten pint bottles of one of these preparations.
+
+"Unlike sarsaparilla, the iodide of potassium is classed among poisons
+by nearly every writer upon toxicology."
+
+Practically all the proprietary remedies have their most potent
+principle in the supposed mystery of their composition. As a matter of
+fact, all are simple prescriptions, well known to physicians, and
+owing their successful treatment of many ills much more to the
+printer's ink used to secure their sale than to any pharmaceutical
+ingredient which they contain. No important remedy has ever been put
+on the market by advertising methods. Exposure of the charlatanry of
+such methods will not, however, cause an interruption of their sale.
+Long ago Barnum said that people wish to be humbugged, and there is no
+doubt that they have been, are, and will be humbugged just to the
+extent to which they lay themselves open to the alluring methods of
+the advertiser. It does seem too bad, however, that the influence of
+the clergymen and of religious as well as charitable visitors--an
+influence acquired because of the confidential position they occupy
+and the feeling of good faith their mode of life inspires--should be
+abused for the encouragement and extension of what is manifestly a
+great evil.
+
+Alcohol and iodide of potash are not the only drugs likely to do harm
+that are incorporated in proprietary medicines. Great complaints have
+recently been made with regard to the spread of the cocaine habit in
+this country. Not a few of the remedies that are supposed to give
+immediate relief to colds in the head contain cocaine in dangerous
+amounts; and there seems no doubt that in many cases the drug habit
+for this substance has been acquired innocently and {98} unconsciously
+at first by the use of such preparations. These are only the more
+notable evils likely to result from the indiscriminate employment of
+medicines of whose composition there is complete ignorance, and of
+whose effect there can be only the judgment dependent upon the
+subjective feelings of the patient. It must not be forgotten that the
+patient's feelings are for the moment often favourably influenced by
+some substance that may do no good to the ailment, though making the
+patient less sensitive to any symptoms from which he was suffering;
+but in the end doing positive harm, because of the contraction of the
+alcohol or some drug habit, or because the suppression of symptoms may
+be the very worst thing for the patients, since it allows the
+underlying ailment to progress to a serious stage without forcing them
+to have it treated _in radice_.
+
+These are only a few examples that show very well the inadvisability
+of recommending in any way medicines of which one does not know the
+exact contents. The present writer has had one example of how utterly
+disingenuous, though one feels much more like calling it rascally, the
+manufacturers of so-called patent medicines or proprietary remedies
+may be. One of the remedies widely advertised for the cure of
+epilepsy, or fits, is announced always as containing no harmful drugs,
+no bromide of potash. The manufacturer of the remedy was asked how he
+could say any such thing, since it was very evident even to the taste
+that the remedy contained bromides. "Oh," he said, "yes, it contains
+sodium bromide, but not bromide of potash." Almost needless to say,
+sodium bromide is at least as harmful as potassium bromide, and the
+advertisement is entirely for purposes of deception.
+
+The poor epileptics have been a source of revenue for quacks and
+charlatans as long as history runs. At the present time one not
+infrequently finds testimonials from convents, asylums, reformatories,
+and the like, asserting the value of some particularly advertised
+remedy for this disease. All these remedies contain bromides. The
+treatment of epilepsy is now better understood by physicians and it is
+generally recognised that the two things that epileptic {99} patients
+need are outdoor air and as far as possible all freedom from
+responsibility. Bromides will, for a time, control the number and
+frequency of the attacks, but if used indiscriminately, and especially
+if employed without any proper realisation of their possibilities for
+harm, these salts are almost sure to make the condition of the patient
+much worse than before, to bring on a state in which mental symptoms
+predominate over physical, and in which the patient may go into
+dementia, or some form of mental alienation. Especially is this true
+with regard to epileptic children. Continuous dosing with drugs of any
+kind is sure to do them harm rather than good. Care for their diet and
+rest and the removal of all sources of disturbance of their digestive
+tract is more important than any other method of treatment.
+
+The poor children have to suffer many things from many people. People
+hesitate, as a rule, to accept recommendations with regard to the
+administration of drugs to their animals when the person who gives the
+recommendation is known not to be an expert in the matter. Almost any
+suggestion, however, with regard to the dosing of their children is
+likely to be followed by loving but indiscreet mothers. It is well
+known now, and in many cases is admitted, that the so-called soothing
+syrups so often given to children contain opium in quite appreciable
+quantities. Needless to say, nothing much worse than this could
+possibly be given to children. The child soon becomes accustomed to
+its daily dose of opium and craves the repetition of it. It will not
+sleep without it, and as this adds to the sales of the remedy, this
+special ingredient continues to put money in the pockets of the
+manufacturers, but at the expense of the nervous stability of the
+child, and lack of resisting power later in life. It would be hard to
+say how many of the nervous wrecks so commonly met with in young
+adults now are to be attributed to this unfortunate state of affairs
+early in life; but undoubtedly this evil has had much to do with the
+noticeable increase in the nervousness of our people. The more nervous
+the heredity of the child, the more it must be guarded against such
+mistaken methods of inducing sleep, or the result is sure to be
+serious.
+
+{100}
+
+Scarcely too much can be said in condemnation of most of the
+proprietary remedies for constipation, though it is in this department
+of medication that the non-medical are freest with their advice.
+First, the cheapest possible drugs are selected by the manufacturers
+of such remedies. Secondly, those drugs especially are employed which,
+while producing the desired immediate effect, are always followed by a
+reaction which requires further use of the medicine. One finds
+testimonials, however, from all classes of the community, even from
+clergymen, with regard to such remedies, though at the last
+international medical congress it was confidently asserted, by three
+of the most prominent specialists in digestive diseases in the world,
+that the modern problems in digestive disturbances are so much more
+intricate than they used to be, and the affections which develop are
+so much more difficult of treatment, because of the use of these
+unsuitable remedies, and the consequent habituation to drugs, which
+has been acquired during the prolonged period of their employment.
+
+In recent years catarrh has become the word that is supposed to
+attract popular attention most, and accordingly is the watchword of
+the proprietary medicine manufacturer. A long time ago, that is, about
+half a century ago, catarrh was supposed really to mean something in
+medicine. Those were the days of humoral pathology, when disturbances
+of secretion were supposed to be the basis of all disease.
+Accordingly, whenever there was an excessive discharge from the nose,
+a patient was said to be suffering from catarrh, and as the nasal
+secretion was supposed to be connected in some way with the brain, it
+is easy to understand how significant such a pathological condition
+might well be thought. In more recent years, the word "catarrh" has
+still been employed by physicians who thoughtlessly employ terms that
+they think will be better understood by the laity, owing to their
+familiarity with them, though they have been outlived in medicine.
+From representing an affection of the nose, catarrh, as a consequence,
+has come to be employed for an excess of secretion from any mucous
+membrane. Accordingly we hear of catarrh of the stomach, catarrh of
+the bladder, or catarrh of the {101} bile-ducts, and there has come to
+the general public a notion that catarrh is an all-pervading affection
+whose ravages must be prevented, at all hazards, and whose beginning
+must be the signal for prompt medical treatment.
+
+As a matter of fact, catarrh, when it means anything, means only that
+stage of inflammation in which there is an increased secretion and
+which represents an inflammatory condition so mild as often to be
+described as only hyperaemic, that is, due to an increase of blood in
+the part. It is rather easy to understand that if more blood flows
+through a mucous membrane, there will be greater secretion from it
+than would normally be the case. This is what happens in the
+production of catarrh. As a rule, it is only a passing congestion
+without any lasting changes in the tissue. Catarrh may, however,
+continue to be present if the irritation, which originally caused the
+congestion, be allowed to continue. It is this irritation, however,
+which needs to be treated, and not the catarrhal inflammation, which
+is only a symptom of it. The three most used words in popular
+medicine,--catarrh, rheumatism, and gout,--when traced to their
+etymological signification, mean the same thing. Catarrh means a
+flowing down, rheumatism a state of flowing, both being formed from
+the Greek verb [Greek text], to flow, while gout is derived from the
+Latin word _gutta_, a drop, which hints at the excess of fluid that is
+supposed to be the basis of the disease.
+
+For these three diseases, however, the most varied remedies have been
+proposed, and practically entirely without success, when tested, in a
+large number of cases. As a matter of fact, under the two words
+catarrh and rheumatism, there is grouped a series of affections very
+different from one another, and requiring very different treatment.
+The important thing is not so much the suggestion of a remedy as the
+recognition of the particular cause which in one case is producing an
+excess of secretion and in the other is giving rise to the so-called
+rheumatic pain. When the exact cause can be found, it is usually not
+so difficult to succeed in preventing the recurrence of the
+troublesome symptoms. It is with regard to these two diseases,
+however, that in non-medical circles even intelligent men are ready to
+give advice. They constitute {102} the most puzzling problem that the
+physician has to deal with, but the non-medical mind waives the
+difficulty and suggests the remedy. In this matter one is forcibly
+reminded of a famous expression of Josh Billings, who used to say, "It
+is not so much the ignorance of mankind that makes them ridiculous as
+the knowing so many things that are not so."
+
+Clergymen, lawyers, members of Congress, and of various state
+legislatures, all permit their portraits to appear, advertising the
+merits of some trumped-up cure for catarrh or rheumatism. It is
+interesting to realise, then, that in most cases, according to expert
+testimony, the remedy they recommend so highly consists of nothing
+more than diluted alcohol flavoured so as to taste like medicine. The
+only real effect is the alcoholic exhilaration which follows its
+ingestion and gives the sense of well being, because of which the
+testimonials are provided. As one of the medical journals said
+recently, it would be very interesting to make a list of the men and
+women throughout the country who, by permitting their portraits and
+recommendations to be used in the advertisements of various patent
+medicines, have practically confessed that they like to take their
+whiskey rather dilute but mixed with a little bitters. The whole
+question illustrates the tendency of the proprietary medicine man to
+exploit some phase of medicine long after it has ceased to be of
+interest to the medical profession.
+
+With regard to all of these things clergymen may do a great
+humanitarian work by protecting the poor from the efforts of
+advertising remedy-makers to get their hard-earned money. It is
+sometimes said that long years have been spent in the preparation of a
+remedy. This not only is never true, but never has been true in the
+history of proprietary medicines. Some one who has an eye to business
+gets hold of a prescription of which he knows nothing, but of which
+his advertising agents are able to say much, and the result is
+sometimes a fortune for the advertiser. There is always a pretence of
+philanthropy, but it is the mask of heartless hypocrisy. Unfortunately
+many of our religious journals are tempted by the promptly paid bills
+of such manufacturing concerns to print their advertisements. They are
+aiding in a {103} deliberate swindle, and if this were better
+understood there would be much less suffering and fewer vain hopes.
+The best-managed newspapers and magazines in the country are now
+absolutely refusing all medical advertisements. This is the only
+proper attitude in the matter, for there is a place to advertise
+medicines, if they are worthy, and that place is the medical journals.
+If the popular advertising could be reduced, we should soon have much
+less of the proprietary medicine evil.
+
+There are many ways in which clergymen by their example, their advice,
+and their influence can be of great assistance to practitioners of
+medicine. It is very sad, then, to find that some of them, having
+elabourated theories of their own on certain subjects, or having taken
+up with peculiar notions, are in opposition to the accepted medical
+teaching of the world. Occasionally they are found among the ranks of
+the anti-vaccinationists, though if there is anything that has been
+demonstrated to a certainty, it is that vaccination has practically
+eradicated smallpox, considering the frequency of the disease a
+century ago, and that it would absolutely eradicate it, if the
+practice could be made universal. Statistics are at hand to
+demonstrate this beyond all possibility of doubt. There are a certain
+number of people, however, who apparently, out of a desire for
+singularity as much as anything else, refuse to accept the evidence.
+It is very unfortunate to find clergymen among them, for it tends to
+bring the clerical judgment into disrepute.
+
+Nearly the same thing might be said of antitoxin for diphtheria.
+Clergymen seem to consider it necessary for them to have their minds
+made up as to whether the use of diphtheria antitoxin is advisable or
+not. If they have once committed themselves to the expression of the
+opinion that antitoxin is of no value, then no amount of evidence will
+succeed in changing their opinion. Under these circumstances it
+becomes extremely difficult at times for physicians to succeed in
+having families permit them to treat their patients after the manner
+in which they are convinced the treatment should be carried on. If
+such clergymen would only realise that the clergyman has, as a rule,
+much less right to express {104} opinions on medical subjects than has
+the physician to air views with regard to theological principles,
+there would be much less friction, and it would be better for patients
+in the end.
+
+There are certain sanitary regulations that clergymen should not only
+not oppose, but endeavour, by every means in their power, to have
+those who respect their opinions follow out as carefully as possible.
+Such sanitary regulations have in the past twenty-five years
+practically cut down the death rate of our large cities a half. There
+is no greater source of alleviation for the physical evils, at least
+those which afflict the lower classes, than the due enforcement of
+modern sanitation. There are prejudices, however, that must be
+overcome, and the clergyman should be found beside the doctor, helping
+him rather than opposing him, as is sometimes the case.
+
+JAMES J. WALSH.
+
+
+{105}
+
+VIII
+
+SOME ASPECTS OF INTOXICATION
+
+There are various drugs that, through acute or chronic poisoning from
+their use, cause mental disturbance,--alcohol, chloral, cannabis
+indica, somnal, sulphonal, paraldehyde, ether, chloroform, antipyrin,
+phenacetin, trional, chloralamid, iodoform, atropine, hyoscyamus,
+salicylic acid, quinine, lead, arsenic, mercury, opium and morphine,
+the bromides, cocaine, and others. Of these intoxicants alcohol always
+has been most commonly used by western nations, but the moral aspects
+of alcoholism have not been shown with sufficient insistence. There
+are many sots in human society much less reprehensible than to the
+unskilled observer they appear to be; others are more blameworthy.
+
+Morality, as far as the agent is concerned, apart from the nature and
+circumstances of the deed, supposes, first, voluntary acts, or acts
+that proceed from the will with a knowledge of the end toward which
+the acts tend; and, secondly, free acts, or acts that under given
+conditions may or may not be willed. If by unavoidable chance one
+stumbles against a man standing at the edge of a wharf, knocks him
+into the water, and drowns him, the act has no element of morality in
+it, because it is not voluntary and free. If a mind is diseased, and,
+impelled by a mad notion of persecution, it brings about a like
+killing, there is no question of morality, because the agent is not
+free, and when fully analysed his action is not voluntary.
+
+An act is more or less voluntary and free, and therefore more or less
+moral, as the agent is affected by ignorance, passionate desire, fear,
+or disease. Ignorance, fear, and disease may be such as to remove all
+quality of morality from an act. {106} Certain diseases or
+pathological conditions, especially of the nervous system, can take
+out of an act the elements of voluntariness and freedom that are
+necessary to make the act moral or immoral, provided, however, these
+pathological conditions are not brought on through the fault of the
+subject in which they exist. If a man voluntarily becomes drunk with
+alcohol, or some other drug, he is, of course, accountable for the
+evil he may unconsciously do while under the influence of that drug,
+and if he begets an idiot or a criminal imbecile in his drunkenness,
+he must atone somewhere for the blinded soul of his child. Here,
+again, there are certain extenuating circumstances, because very few
+drunkards are fully conscious of the extent of the evil in alcoholism.
+
+Apart from the other requirements that go to make an act moral, the
+agent must be sane; that the act be immoral, he must be sane or
+insane, either temporarily or permanently, through his own fault; that
+it be devoid of morality an act must be a mere _actus hominis_, or it
+must be the act of a person blamelessly insane. If a man knows that an
+alcoholic is liable to beget a criminal imbecile solely because of the
+alcoholism,--and most men are aware of that fact,--this father or
+grandfather is more or less accountable for every larceny, rape, and
+murder done by the imbecile. The law, therefore, should put the
+imbecile into safe keeping, then seek out the father and hang him.
+
+Insanity is a common condition, but it has not been satisfactorily
+defined. It supposes an appreciable unsoundness of the will, memory,
+and understanding, or of one or two of these faculties, but no
+alienist has given a short differentiation of that unsoundness. Where
+shall we draw the line between the weak but responsible will and the
+insane will? What degree of opacity between intellect and the world
+separates the ignorant man from the lunatic? The extremes of sanity
+and insanity are readily recognisable, but the intermediate degrees
+are not clear. There is no test to apply to all cases; each must be
+diagnosed from its peculiar symptoms, but the will of an insane man is
+always weak. It can not deny or defer the gratification of a desire,
+nor can it keep up an effort. Even in its lightest forms insanity is
+selfish and {107} impolite, because it lacks the force of will
+necessary to take trouble. It foregoes great future benefit for slight
+present gratification. The insane man is idle, or busy only in work
+that he likes, in pleasurable activity. A marked quality of sanity is
+the capacity for sustained work, and the man that shirks work merely
+because he does not like it is gratifying himself dangerously.
+
+These defects are found commonly in sane persons, but the lunatic can
+not rise from them, and he adds to the defects of will a warped
+intellect. He can not adjust himself to his surroundings, and the
+fault is in himself, not in the circumstances. His intellect may be
+brilliant, but it sooner or later shows a taint. The insane man is not
+a free, rational agent.
+
+Alcoholism readily passes over into unmistakable insanity, and it
+almost always is the cause of nervous degeneration in the children
+born within its influence. This, is a phase of the evil not
+sufficiently insisted upon by those that plead for total abstinence.
+
+Chronic poisoning by alcohol induces hardening and calcification in
+the walls of the arteries, degeneration of the nerve cells and
+dendrites, wasting or overgrowth of the heart muscle, and fatty
+degeneration of the liver and kidneys. The nerve centres that control
+the circulation of the blood are paralysed by it, and, as a sequence,
+the arteries and capillaries are diminished in calibre. This state in
+turn obstructs the flow of the blood, and the body is not nourished,
+nor are the waste and poisonous results of metabolism carried off as
+they should be. Alcohol prevents the haemoglobin of the blood from
+doing its office, which is to supply oxygen and remove carbon dioxid.
+It absorbs the necessary water from the tissues, and thus it acts as a
+corroding poison. It is also a functional toxin, because it depresses
+the activity of organs by injuring the innervation. The poison affects
+the brain, and as the cerebral gray matter, especially its pyramidal
+cells, are the physical instruments of thought, will, and memory, or
+the means of communication between the soul and the outer world, the
+exercise of these spiritual functions is checked or inhibited by it.
+
+A tendency to excess in the use of alcohol commonly {108} manifests
+itself before the thirtieth year, and in some cases it may be removed
+at the alcoholic climacteric, which is from the fortieth to the
+sixty-fifth year. Those that become drunkards are usually of a
+neuropathic constitution, through inheritance or abuse. Severe
+diseases, like influenza, syphilis, typhoid; injuries to the head,
+sunstroke, shock, worry; the disturbance that may accompany puberty,
+pregnancy, lactation, and so on,--cause a nervous depression which is
+soothed by alcohol, and thus a habit is fixed. The reckless
+prescription of alcohol by some physicians is another cause of the
+habit, and the use of proprietary medicines is a still more prolific
+source of drunkenness and the consequent misfortune.
+
+Cider, beer, ale, and porter contain from 4 to 6 per centum of real
+alcohol; light wines, red and white, and natural sherry, 10 to 12 per
+centum; strong sherry and port, 16 to 18 per centum; brandy, 39 to 47
+per centum by weight, or 46 to 55 per centum by volume; and whiskey,
+44 to 50 per centum by weight, or 50 to 58 per centum by volume. The
+effect of these liquors on the body is due primarily to alcohol, and
+secondarily to ethereal derivatives of alcohol. Some owe a part of
+their effect to non-volatile substances,--beer from which all alcohol
+has been boiled can still affect the body in a marked degree.
+
+The chemist of the Massachusetts State Board of Health (Document No.
+34) gives the percentage of alcohol in the common proprietary
+medicines, and these percentages will be found in the article on
+_Social Medicine_.
+
+The weakest of these compounds are twice as strong in alcohol as beer,
+and they treacherously bring about the habit of drunkenness in
+disposed persons who may be very desirous to avoid such a calamity.
+
+Some men and women are quickly destroyed by alcohol; others resist it
+more or less successfully for a lifetime, as far as mere existence is
+concerned. Alcoholism is one of the commonest causes of insanity, but
+it is often an effect of insanity. It may be an early symptom of
+paresis, or a part of the maniacal stage of circular insanity. In
+poisoning by alcohol the higher nerve centres are first affected and
+the {109} lowest last. The sense of human dignity and of morality, the
+exercise of the intellect, are more or less inhibited before the
+motive muscles are affected.
+
+The usual effect of alcoholic poisoning is boisterous exaltation of
+mind, but there is a depressed type of drunkenness which weeps. Some
+patients at once are subjected by hallucinations and delusions, others
+are so depressed that they have a suicidal tendency, others may have a
+maniacal frenzy that is destructive or homicidal. In these neuropathic
+conditions muscular co-ordination is commonly well preserved--the
+patient is "drunk in the head and sober in the legs."
+
+In alcoholism the mental changes are gradual and progressive. The
+intellect is blunted, the judgment becomes foolish, the moral sense is
+dulled. The drunkard is always a liar. Delusions not infrequently
+occur, and it is one of the common symptoms of alcoholic insanity to
+suspect a wife or husband of conjugal infidelity. If a man that is a
+drunkard accuses his wife of infidelity, the chances are fifty to one
+that she is innocent and that he is in the first stages of insanity.
+This symptom is characteristic also of cocaine intoxication.
+
+Another mental disturbance of acute alcoholism is _delirium tremens_,
+which is inexactly called _mania a potu_ by some writers. _Delirium
+tremens_ is not a form of mania, but an acute hallucinatory confusion,
+in which the consciousness is much more impaired than it is in a
+mania. _Mania a potu_ is a real mania, and it is transient commonly,
+although it may leave permanent mental weakness with delusions.
+
+In chronic alcoholism a paranoid condition may occur, and this often
+is incurable. This psychosis may come on suddenly or gradually. In
+true paranoia the delusions are systematised, but in this alcoholic
+pseudoparanoia the enfeebled intellect can not build up coherently
+even a delusion. The alcoholic hallucinations are visual and auditory,
+and we find delusions of persecution, especially of a sexual nature.
+The patient hears all kinds of insulting remarks made by "voices."
+These voices often come from his own belly. His enemies send poisonous
+or foul odours into his room at night, and the groundless suspicions
+of his wife's infidelity take most outrageous forms of expression. He
+will swear {110} he has _seen_ her misdeeds. Often the baseless
+suspicions of his wife begin before any other noticeable impairment of
+intellect, and are not recognised as delusions. The first step a
+priest should take in investigating accusations of conjugal infidelity
+is to find out whether the accuser is a tippler or not.
+
+The delusions of persecution lead to attacks on the supposed enemies
+which often are homicidal. Occasionally alcoholic insanity takes on a
+paretic form, or it may be epileptic. Ten per centum of alcoholics are
+epileptic. When the children of alcoholics are epileptic, the
+convulsions begin in these children about four years earlier than in
+children that are epileptics from other causes. If epilepsy is latent,
+alcoholism will start it into action.
+
+Alcoholism sometimes produces a condition of waking trance followed by
+amnesia (lack of memory). In such a state the drunkard may transfer
+property, carry out complicated professional actions, commit crime,
+take long journeys, travel for days, and so act that no one notices
+his disordered mental condition. Then suddenly he awakens and he has
+no recollection whatever of what has happened during this trance. He
+appears to be conscious, but to have no memory of his consciousness.
+There is another alcoholic amnesia, found especially in those that
+drink much during the morning hours, where there is instantaneous
+forgetfulness. If you ask one of these men to shut a door, for
+example, he will forget between his chair and the door what he started
+to do. This condition is difficult to cure even after the use of
+alcohol has been relinquished.
+
+Dipsomania is a form of impulsive degenerative insanity, and it is
+probably epileptic in origin. After a few days of insomnia and loss of
+appetite for food, there is an irresistible impulse to drink alcoholic
+liquor and to indulge in other excess. The patient drinks until all
+means of getting alcohol are exhausted. He will take crude alcohol,
+bay rum, cologne, the alcohol that is about pathologic specimens in a
+hospital museum. The attack lasts from one to two weeks, and is
+followed by depression and a feeling of remorse. The onsets are
+irregular in occurrence, and between them the patient may {111} be
+temperate or have even an extreme distaste for alcohol. This form of
+disease is not infrequent among professional men and clergymen, and it
+is impossible to find out just how far the patient is responsible for
+his condition. If bishops would investigate the alcoholic tendencies
+of the _families_ of candidates for seminaries, and reject all that
+have this taint, there would be much less scandal. It is a serious
+error of judgment to ordain a seminarian that has even once been under
+the influence of alcohol, and those seminarians that cover up the
+tippling of a companion, because he is a good fellow, are guilty of
+far-reaching crime. The fact is worth investigation whether or not a
+liquor dealer who never drinks alcohol, but who lives for years in the
+presence of volatilised alcohol, has much of the alcoholic degeneracy
+and a tendency to beget neurotic children. Certainly the fumes of wood
+alcohol have killed workmen that went down only once into a vat
+containing these fumes, and other alcohols in the form of vapour
+should have deleterious effects. Fere produced monsters in chickens by
+exposing eggs to the vapour of alcohol.
+
+In judging a drunkard, it must be remembered that in many forms of
+alcoholism, after the condition is well established, the patient has
+little more freedom of will than a brute has. If he is accountable for
+the habit, he is blamable for the crime that follows. If he is not
+accountable, and it is often very difficult to prove that he is, he is
+to be treated as a blamelessly insane man. In proper surroundings, and
+with skilful direction, a child born with a tendency, or more exactly
+a temptation, to dipsomania or other alcoholic neurosis can be saved,
+but commonly the circumstances of such a child's life are the worst
+imaginable. These children must never take alcohol, even as a
+medicine, and they must not be pushed in school to nervous exhaustion.
+A tendency to unchastity can "run in families," like a disposition
+toward alcoholism, but the disgrace in yielding to this vicious bias
+keeps many such unfortunates clean. It is to be regretted that public
+opinion can not give the same aid in alcoholic predisposition.
+
+A confirmed alcoholic should be prevented, if possible, from marriage,
+because his sins will be visited upon his posterity. {112} The first
+children of an alcoholic may be mentally sound, the younger children
+are more or less mentally weak, the youngest are not uncommonly
+imbeciles, or idiots, or under shock they grow insane. Fortunately
+many of the children of alcoholics die at an early age, and the family
+of a drunkard very seldom lasts beyond four generations. In the first
+generation moral depravity and alcoholic excess are found; in the
+second, chronic drunkenness and mania; in the third, melancholia,
+hypochondria, impulsive and homicidal ideas; in the fourth, idiocy,
+imbecility, and extinction of the family. The lower the social caste
+of the drunkard, the greater the liability of meeting these blights.
+
+Priests should take a deep interest in societies established for the
+promotion of temperance, and the only temperance for most persons is
+total abstinence. No man knows what latent tendency to alcoholism he
+may have, especially in America, where great grandfathers are unknown
+and the climate and life are trying on the nervous system. The
+adulterated liquors sold everywhere at present make the danger greater
+than it ever was. Whatever may be the truth as regards heredity, there
+is no doubt concerning the strong influence of environment; therefore
+get into the temperance societies the children of alcoholic parents,
+of parents that are shiftless, hysterical, irritable. If a man has a
+violent temper or if he is unchaste, get him and his children into the
+society to check the downward drift. A bad temper is a neurotic taint,
+and it commonly is a first step toward alcoholism. Do not forget to
+warn the people against patent medicines that contain alcohol.
+
+If you go over the list of the families in a parish, it is startling
+to find how few there are without one or more "black sheep." The human
+black sheep, in a good environment, is always physically imperfect,
+and never so black as the gossips paint him. He may be a powerful
+football player, but there is something wrong with his gray matter. He
+is morally deaf, he was born so, and he is to be excused if he can not
+always hear the still, small voice. This may sound like lax doctrine,
+but it is true, nevertheless.
+
+We must recognise that moral weakness is very often, {113} partly at
+least, a physical defect, and there is no such state as "moral
+insanity" where the intellect is normal. Now, I do not wish to be
+quoted as holding that all moral depravity has a physical basis; most
+of it is the unalloyed stuff; the Lombroso criminal is not a
+scientific fact; but there is a moral condition very frequently met
+with which is largely physical in origin. Given so many grains of
+cocaine or morphine or so many ounces of alcohol, and you can make a
+liar of a man once on the way toward sanctity. Given an attack of
+hysteria in a holy nun, and she at once becomes a liar, an altogether
+blameless liar, but no influence that does not remove the physical
+cause will cure the lying.
+
+The morally weak do not at present obtain enough religious
+instruction. Their religion is more a matter of inheritance and habit
+than of positive energy. It is "in the bones," sometimes in the fists,
+rather than in the soul. They prefer the Sunday newspaper to the
+Sunday sermon. The remedy here seems to be in making the Sunday school
+solidly interesting and its teaching impressive.
+
+Alcoholism in the parents, especially drunkenness at the moment of
+conception, is one of the chief causes of idiocy in children. Fere, as
+was said before, by injecting a few drops of alcohol beneath the shell
+of hens' eggs, or by exposing the eggs to the vapour of alcohol, could
+produce monsters almost invariably. In 1000 cases of idiocy at the
+Bicetre, Bourneville found a history of alcoholism in 620, or 62 per
+centum: in the fathers of 471, in the mothers of 84, in both parents
+of 65; and in one-half of the remaining 38 per centum no history was
+obtainable--probably most of these also had the alcoholic taint. The
+administration of alcohol to infants, of gin and whiskey, of essences
+of peppermint and anise, to relieve colic or induce sleep, and the
+dosing with opiates like paregoric, are also well-established causes
+of idiocy.
+
+The idiot is practically dead, except for the trouble he gives in
+caring for him; but another unfortunate, the imbecile, most commonly
+the offspring of alcoholics, is often capable of great mischief. The
+higher grades of imbeciles, those nearest the normal, are almost
+invariably criminals. Not all criminals, of course, are imbeciles, but
+a vast number of petty and brutal {114} criminals are imbeciles. We
+keep these unfortunates most of their lives in jail, while we fine
+their drunken fathers, the cause of the imbecility, "five dollars and
+costs."
+
+Imbecility has grades,--from marked lack of intellectual power, a
+stage little beyond idiocy, up to the presence of a mind capable of
+fair education,--but in all cases there is real defect, either of
+intellect or of will. Sometimes, where the will is so weak that the
+patient becomes a criminal in spite of all training, the intellect is
+practically normal to the superficial observer.
+
+The grades of imbecility can not be clearly marked off from one
+another, but, roughly speaking, there are three. The lowest grade of
+imbeciles understands simple commands, and has a slight manual
+dexterity. They express themselves by signs and in monosyllables. They
+can not concentrate attention upon anything, nor can they be taught to
+read or write. Careful training can advance them so far that they may
+do rough, menial work, and they are industrious when directed by a
+present superior. They are inclined to masturbation. If they are not
+teased, they are quiet; if annoyed, they may become dangerous.
+
+Imbeciles of the middle grade can converse in a narrow vocabulary, and
+they commonly stammer. They may be taught to read monosyllables; they
+can not do even the simplest sum in addition, yet they show a certain
+shrewdness. They are irritable and quarrelsome, inclined to lying and
+stealing, and they have no sense of shame. They will not do any
+regular work, but change from one occupation to another. They may have
+sexual instincts and cause trouble on that account. They are slow to
+understand, their memories are defective, and they are always very
+vain. Their belly and what they shall wear are the chief things in
+their lives. They are less criminal than the highest grade of
+imbeciles.
+
+The third class, the high-grade imbecile, is the most important,
+because he is commonly a criminal. His intellect is below the average,
+and his will is very flabby. He learns little at school, and what he
+does learn is acquired slowly. He reads and writes badly and he may be
+able to add simple {115} columns of numbers, but he can not multiply
+or divide. Sometimes such an imbecile has a remarkable facility in
+getting a speaking knowledge of two or three languages, and he may
+learn a trade. There is a high-grade imbecile that is cunning and
+shrewd, but he has no will, and he is a criminal. As imbeciles
+approach the normal in intellect they recede from it in abnormality of
+will.
+
+Autopsies on imbeciles show an infantile development of the forebrain.
+Imprisonment does no good in these cases. They are not taught anything
+in prison, not even a trade, because the labour organisations and the
+protected industries will not permit prison labour. They should be
+confined so that they will not pervert youth and propagate their kind.
+It is impossible to say how far a given imbecile is morally
+accountable for what he does, but the accountability is not full in
+the best cases. A neurasthenic, however, is not to be mistaken for an
+imbecile. A neurasthenic person may have a tender conscience, an
+imbecile has no conscience. In imbecility the fault is in the will,
+rather than in the intellect, in the middle and highest grades. Many
+women, especially, that are hopeless fools intellectually have strong
+wills, but an imbecile never has a strong will except in the sense
+that stubbornness is strength. Stubbornness is perverted strength.
+
+_Morphine and Cocaine Intoxication_,--Morphine, an alkaloid of opium,
+is used very extensively as an intoxicant. Since 1890 the importation
+of opium into the United States has increased fourfold, although
+physicians are now using less opium than they formerly did.
+
+The insomnia, worry, moral distress, which bring on the alcoholic
+habit in some persons, lead to morphinism in others. Some physicians,
+by carelessly prescribing morphine for neuralgia, migraine,
+dysmenorrhoea, or any pain, make their patients slaves of this drug.
+
+The degenerative effects of morphine are not so great nor so rapid as
+those of alcohol. It does not shorten life so much as alcohol does,
+nor are the children of a person addicted to the use of the drug so
+liable to idiocy and imbecility. The mind is enfeebled--slowly in some
+cases, rapidly in others. The patient will resort to almost any means
+to obtain the {116} drug, if he is deprived of it. Authorities hold
+that he will lie without reason, merely for the perverse pleasure in
+deceiving, that he is uncertain and treacherous, with a dull
+conscience and morbid impulses. There are exceptions to this in cases
+where the drug is easily obtained by the patients. Opium and morphine
+diminish the sexual appetite in males, even to impotence. The bodily
+changes are slow but profound.
+
+When a user of morphine has been deprived of the drug for from ten to
+fifteen hours, he becomes so weak he can not stand; he gets diarrhoea
+with cramps; he sweats, trembles, and collapses. Later, mental
+disturbance comes on. He grows delirious, sees insects and small
+animals, as the delirium tremens patient does, and his suffering is
+very great. It is extremely difficult, and commonly impossible, to
+cure the morphine disease after it has been firmly established, and a
+deliberate acceptance of the habit is evidently a grave vice. Where a
+patient has become addicted to the use of the drug, through the fault
+of a physician, or through ignorance, the treatment from the social
+point of view of such a patient is commonly cruel.
+
+Cocaine intoxication is much worse than morphinism. It is a new
+excess, which was unknown before 1886. Many users of morphine can
+carry on business, but the cocaine _habitue_ can not do so. He is
+always extremely busy doing nothing. He writes long letters which are
+never finished. He changes from work to work, and even his
+conversation wanders. His bodily weight decreases rapidly, even
+one-third of his whole weight may be lost within a few weeks. The skin
+hangs in folds and is of a dirty yellow colour, the facial appearance
+is that of extreme distress, and the muscles are feeble. Fainting,
+irregular cardiac action, sweating, and insomnia are other symptoms.
+
+Insanity is an occasional sequence, with hallucinations, especially of
+hearing. Such a patient hears roaring noises and voices; his secret
+thoughts are shouted out, he thinks, to crowds; loud screams, shrieks
+of murder, and similar noises appall him. Again, he sees swarms of
+flies, ants, roaches, which cover him and crawl into his mouth,
+nostrils, {117} and ears. He feels bugs crawling under his skin, and
+he has a multitude of similar interesting experiences.
+
+Such patients grow homicidal. Like alcoholics, they are jealous and
+suspicious of their wives, but, unlike the alcoholic, the cocaine user
+is commonly reticent; he is not willing to talk of his troubles.
+
+The prognosis is always bad, even in the best cases. This drug can be
+withdrawn from a patient more rapidly than is possible in chronic
+poisoning from morphine, but a relapse is to be expected.
+
+In dipsomania, morphinomania, and other drug habits, and in the cases
+of vicious and degenerate children, many encouragingly good results
+have been reported from the use of hypnotism. Forel, Voisin, Ladame,
+Tatzel, Hirt, Nielson, de Jong, Liebeault, Bernheim, van Eeden, van
+Renterghem, Hamilton Osgood, Wetterstrand, Schrenck-Notzing,
+Kraft-Ebbing, Francis Cruise, Lloyd Tuckey, Kingsbury, Woods, and
+others have undoubtedly cured dipsomania by hypnosis.
+
+Wetterstrand alone cured 37 of 51 cases of morphinism by hypnosis. One
+of these patients had been using morphine for fourteen years and
+morphine with cocaine for an additional four years. All his cases
+except one were treated at home--they were not obliged to go to a
+hospital or sanitarium.
+
+As to vicious children: Liebeault in 1887 recorded 77 cases, 45 of
+whom were boys and 32 girls. By hypnosis 56 of these were cured, 9
+improved, 12 were not affected.
+
+As to the so-called dangers of hypnotism in the hands of skilled
+physicians, there are none. Forel said: "Liebeault, Bernheim,
+Wetterstrand, van Eeden, de Jong, I myself, and the other followers of
+the Nancy school, declare absolutely that, although we have seen many
+thousands of hypnotised persons, we have never observed a single case
+of mental or physical harm caused by hypnosis." Travelling mountebanks
+that hypnotise in public can do harm, and they should be prevented
+from so doing. On the continent of Europe only physicians are
+permitted to use hypnosis.
+
+For a bibliography of hypnosis as a curative agent, see _Allbutt's
+System of Medicine_, vol. viii. p. 428 (The Macmillan Co.).
+
+{118}
+
+In Genicot's _Theologiae Moralis Institutiones_, vol. i. p. 162
+(Louvain, 1902), is the following passage: "Videtur licitum ebrietatem
+inducere ad morbum depellendum, si quando practicum est, ex gr. ad
+typhum depellendum, vel ad coercendam vim veneni quod e serpentis
+morsu haustum sit (Sabetti. N. 149). Similiter, per se licebit sensus
+sopire ope ebrietatis ad magnos dolores levandos: nullum enim
+discrimen morale videtur inter hoc medium et alia, ex gr.
+chloroformium, quae adhiberi solent."
+
+That is, Father Genicot permitted alcoholic intoxication to cure
+typhus or typhoid (typhoid is called typhus abdominalis in Europe) and
+snake bite, or to quiet great pain, as chloroform is used, in his
+opinion. This doctrine would be correct morally if from a medical
+point of view alcoholic intoxication cured typhus, typhoid, or snake
+bite, but it does not. Alcoholic liquors are necessary in some stages
+or forms of typhus and typhoid, and they must be administered
+skilfully; but to induce alcoholic intoxication in any pathological
+condition is always to add a grave poison to the disease already at
+work. The very name of the condition is _intoxication_, poisoning. You
+can end a toothache by removing a man's jaw, but the practice is not
+to be encouraged.
+
+In America, when a person is bitten by a rattlesnake or copperhead,
+the first aid to the injured is commonly a pint of whiskey. You might
+better rub milk on the patient's bootheels, because the milk is
+harmless, but the pint of whiskey is anything but harmless; and one is
+as good as the other as far as curing the snake bite is concerned.
+Whiskey is popularly supposed to be a good medicine in all the ills of
+humanity. It is a good medicine in certain cases and a very bad
+medicine in others. A snake bite is a startling evil, and while far
+from a physician the early settlers gave the patient the only medicine
+they had, whiskey, and if a little is good a great deal is better. As
+the "bite" of the North American snakes is frequently not fatal, some
+early victims grew well in spite of the snake venom and the added
+whiskey poisoning; therefore a pint of whiskey cured them, _post hoc
+ergo propter hoc_. Thus the "cure" became fixed in the popular
+ignorance, and some moral theologians, without investigating the {119}
+matter, fixed it deeper. The venom of the East Indian cobra and of
+other tropical and subtropical snakes would not be affected in the
+slightest degree by all the whiskey in Kentucky. The only hope in such
+cases, is in Calmette's antitoxin, administered within an hour or two
+after the poisoning.
+
+Snake venom paralyses the muscles of respiration, and the patient
+ceases to breathe. A little whiskey may do good--whiskey pushed to
+intoxication is very injurious. Artificial respiration, if needed, as
+in a case of attempted resuscitation after partial drowning, with
+skilful stimulation by a physician, and the use of an antitoxin, are
+the main parts of the treatment in snake poisoning; but to pour a pint
+of whiskey into the victim is cruel ignorance. Patients often come
+into dispensaries showing bitten wounds which are stuffed with hair
+from the dog that did the biting; whiskey causes a man to see snakes,
+therefore use "hair from the dog that bit you." This may be good
+homoeopathy, but it is not medicine.
+
+The making a man drunk with alcohol "to remove great pain" is a
+treatment not used by reputable physicians: there are many correct
+medical methods of removing pain, but a big draught of whiskey is not
+one of them. Even in a case where a physician can not be found, it is
+usually questionable whether the effect of alcoholic intoxication
+would not be worse than the irritation of the pain; and if it were
+not, where is the line to be drawn? Some male and female old ladies
+can work up "great pain" from a colic. The bigger and stronger a man
+is, especially if he has never been ill before, the greater his
+"agony" when he is having a tooth filled.
+
+AUSTIN OMALLEY.
+
+
+{120}
+
+IX
+
+HEREDITY, PHYSICAL DISEASE, AND MORAL WEAKNESS
+
+
+Heredity is a very vexed question, with regard to which most varied
+opinions are held even by those apparently justified in having
+opinions, so that it is evident we are as yet only crossing the
+threshold of definite knowledge and are not near anything like the
+clear view that many people have imagined. The most striking proof of
+this inchoateness of scientific knowledge of heredity is the fact that
+within five years the work of a monk in Austria, done about forty
+years ago, which has lain utterly unrecognised ever since, has come to
+be accepted as the most striking bit of progress made--almost the only
+real scientific knowledge with regard to heredity that was acquired
+during the whole nineteenth century. Father Gregor Mendel's work
+[Footnote 2] was done with regard to the pea plants in his monastery
+garden, and it revolutionised all the supposedly scientific thinking
+with regard to heredity that has been current in biology for half a
+century.
+
+  [Footnote 2: _See American Ecclesiastical Review_, Jan. 1904; Walsh,
+  _A New Outlook in Heredity_. ]
+
+This serves very well to show how far in advance of observed facts
+theories of heredity have gone. There is undoubtedly a very
+significant influence exerted over life and its functions by the
+special powers that are transmitted by heredity. How far this
+influence extends, however, and how much it may be said to rule
+details of existence, of action and in human beings, that complex of
+elements we call character, is entirely a matter of conjecture, and
+the {121} belief in its extent, or limitation, depends absolutely on
+the tendency of the individual mind to accept or discredit certain
+theories in heredity which have had great vogue.
+
+Until within a very few years it was considered a matter of common
+experience and observation that under some circumstances, at least,
+acquired characteristics were transmitted by heredity. That is to say,
+it has been definitely asserted as probable, and by many even
+intelligent people considered absolutely certain, that modifications
+of a living being undergone during the course of its existence might
+influence the progeny of that being in various but very definite ways.
+It was not, of course, thought that if a man lost an arm and
+subsequently begot a child, the child would be born without an arm,
+but slighter modifications of the organism were somehow supposed to be
+transmissible; and, on the other hand, modifications which affect
+important organic structures of the body were somehow thought to have
+a definite effect, by transmission, upon corresponding portions of the
+progeny.
+
+When this theory is stated thus baldly, very few people confess their
+belief in it, yet how many there are who find ample justification for
+such expressions as, "His father suffered from rheumatism and it is
+not surprising then that he should have it"; "Her mother had heart
+trouble and we've always been afraid she would suffer in the same
+way." We are only just beginning to get beyond the period in which
+consumption was thought to be directly and almost inevitably
+inherited. With regard to mental ailments this was frankly conceded by
+nearly every one. If the direct ancestry suffered from mental disease
+of some kind, then it is not considered surprising that the immediate
+descendants should be mentally affected in some way. Physicians are
+quite as prone as those without medical training to make loose
+statements of this kind.
+
+Of course there is a reason for the confusion that exists in this
+matter. Oliver Wendell Holmes once said that he could cure any patient
+that came to him for treatment, if he but applied to him in time. For
+proper success, however, he considered that many of his patients would
+have had to come to him in the persons of their great grandfathers. As
+{122} a matter of fact, many of the supposed hereditary influences
+that are traced only to a father or a mother are family conditions
+that have existed many generations, and that were probably originally
+acquired, but the moment of whose acquisition cannot be definitely
+determined. We know that the Hapsburg lip has been a distinguishing
+feature, a persistently recurring peculiarity, in some of the members
+of the Austrian ruling family in nearly every generation for seven
+centuries. How much farther back than that it goes we have no way of
+determining. It is a family affair, a characteristic which became a
+matter of heredity perhaps ten centuries ago, but the mode of its
+original acquisition is a mystery.
+
+There is no really great scientist in biology at the present moment
+who teaches the hereditary transmission of acquired characteristics.
+Modifications of the organism that become matter for heredity have
+existed for many generations and we cannot tell just how they began.
+There is no doubt that there is some hereditary influence, for
+insanity in the same family is likely to keep recurring in successive
+generations. More than this, affections of certain less important
+organs are evidently a common trait in certain family strains. There
+is no doubt that in some families stomach affections are the rule in
+successive generations. It is very hard to say, however, just when
+such defective organisation became a family trait. The tendency to
+nervous affections is undoubtedly a similar family affair. Certain
+affections have been hereditary traits for many generations. An
+excellent example of this is the so-called Huntingdon's chorea, which
+several generations of American doctors, of the name of Huntingdon, by
+following carefully the history of certain families on Long Island,
+succeeded in tracing through four generations.
+
+The habits of life of a father or a grandfather may so weaken the
+physical constitution of his descendants as to make them less capable
+of resisting infections in the physical order, or in the moral order
+of withstanding trials and temptations, and the allurement to abuse of
+nervous excitement to which they may be subjected. That some acquired
+pathological condition, however, as stomach trouble, or heart {123}
+trouble, or affection of the liver or of the brain, should be directly
+transmitted, is quite as nonsensical as that the loss of an arm should
+be a subject for hereditary transmission. On investigation it will be
+found that the pathological conditions of immediate ancestors are
+themselves only a manifestation of family traits that have existed for
+many generations. The possibility of inheritance must therefore always
+be borne in mind. We are utterly unable as yet to understand how such
+family traits are originally developed, since, in ordinary experience,
+at least, acquired characteristics are not the subject of inheritance
+or transmission, and consequently it becomes difficult to understand
+how they ever became impressed upon the family constitution.
+
+Notwithstanding this general principle with regard to heredity, there
+are a number of striking observations which show that even unimportant
+peculiarities may occur from generation to generation, though it is
+not always easy to decide where the peculiarity originated. The
+well-known example of the occurrence of six toes has already been
+mentioned, and is an oft-quoted bit of evidence as regards hereditary
+transmission. An extra finger on the hand, or some portion of an extra
+finger, at least, comes in the same category. Not long since it was
+pointed out that harelip is another of these peculiarities that
+readily lends itself to hereditary transmission. Recently there was
+the report of a family into which there were born four girls with
+harelip and cleft palate, and three boys not showing any trace of
+these deformities.
+
+Often when in such cases there is no definite history of harelip, it
+is found that in either one of the parents there is a very high arched
+palate and a thin upper lip, showing that the normal occlusion of the
+cleft which exists here during foetal development is not quite
+perfect, and this peculiarity may be traced for several generations
+back, with an occasional occurrence of harelip as an exaggerated
+example of the faulty tendency not to produce sufficient tissue in
+this neighbourhood for the proper closure of the embryonic cleft.
+
+An even more striking manifestation of a physical anomaly, as a family
+trait, is the condition known as hemophilia. This {124} tendency to
+bleed easily, so that a slight scratch, or the pulling of a tooth, may
+give rise to fatal hemorrhage, occurs, as a rule, only in males, but
+is transmitted through the female line. It is in the mother's male
+relatives that the history of its previous occurrence is found, and
+the tendency usually can be traced through several generations, until
+it is lost in vague tradition. It is no wonder, with such examples
+before them as six-toedness, harelip, and hemophilia, that physicians
+have been ready to accept heredity of qualities in the moral order,
+traits of character and disposition, and pathological tendencies to
+crime or passion or indulgence.
+
+One of the most frequently discussed conditions of supposed
+pathological inheritance of this order is dipsomania. Everyone has
+heard it said, "Poor fellow, how can he help it; his father was a
+drunkard before him." As we have already said, in such direct cases
+inheritance is absolutely unproven. An alcoholic father may transmit a
+very weak physical constitution to his children, and this may prove
+inadequate to enable them to withstand the emotional strain and worry
+of modern great city life, and, as a consequence, they may take to
+alcohol for consolation until the habit is formed, and then the
+craving for stimulants supplies the place of any hereditary influence
+that may be supposed to be needed.
+
+Of course there are cases of the drink habit in which, after a number
+of generations of family history of alcoholism, an individual seems to
+have the craving for stimulants born in him. In such cases it is not
+unusual to find that the patient, for such he must be considered, is
+able to avoid indulgence in liquor entirely, except at certain times.
+Every physician of any large experience has had under his care
+dipsomaniacs who had no difficulty in keeping away from liquor for
+weeks, or even months, but who had regularly recurring periods,
+sometimes as far apart as every three months, when they had an
+irresistible craving for stimulants come over them. The regularity of
+the interval in these cases is often very remarkable. Here, of course,
+we may be in the presence of some as yet not well-understood
+periodical law of cell life, with consequent depression, and then the
+irresistible craving for stimulation. {125} As a rule, however, it
+would seem that in most of these cases suggestion has great influence.
+As we have said elsewhere, with regard to suicide, when a man has
+constantly before his mind's eye the fact that a father, perhaps a
+grandfather, or other members of the family, have committed suicide,
+he is likely to be much more easily led to the thought of this way of
+escaping hard conditions in life than are other individuals. The man
+who knows that the fact that his father indulged too freely in
+stimulants will be looked upon by many as an excuse for his deviations
+in this matter is likely to be more easily led to take an occasional
+drink at moments of depression, or for friendship's sake, though he
+realises that it so weakens his will power over himself that he is
+likely to take too much before he stops.
+
+The passage in _Julius Caesar_ (Act. I. sc. 2) in which Cassius says:
+
+  "The fault, dear Brutus, is not in our stars, but in ourselves,"
+
+illustrates one phase of the subject. There are, of course, many other
+things besides the drink habit, with regard to which men are prone to
+find excuses in heredity, and to consider that somehow their ancestral
+tendencies make them not quite responsible for actions commonly
+considered the result of malice or passion, rather than hereditary
+influence, and our great English poet, knowing men so well, has stated
+the truth forcibly.
+
+In _King Lear_ there is an often quoted passage which properly
+stigmatises the opinion in this matter held by those who would find
+excuses for wrong-doing in hereditary qualities:
+
+  "This is the excellent foppery of the world, that, when we are sick
+  in fortune,--often the surfeit of our own behaviour,--we make guilty
+  of our disasters the sun, the moon, and the stars; as if we were
+  villains by necessity; fools by heavenly compulsion; knaves,
+  thieves, and treachers by spherical predominance; drunkards, liars,
+  and adulterers by an enforced obedience of planetary influence; and
+  all that we are evil in, by a divine thrusting on; an admirable
+  evasion of whore-master man, to lay his goatish disposition to the
+  charge of a star!"
+
+{126}
+
+One phase of the question of hereditary tendencies to inebriety is
+extremely interesting from a physiological and sociological point of
+view. As the result of carefully gathered statistics, there seems to
+be no doubt now that when children are conceived while the parents, or
+either of them, is in a state of drunkenness, the offspring is very
+likely to be of low-grade physical constitution and often of very
+neurotic tendencies. In France, particularly in the case of a number
+of insane children and idiots, histories of this nature have been
+obtained in confirmation of this unfortunate factor as an element in
+degeneracy. In general it may be said that about one-third of the
+admissions to homes for children of low intelligence, as well as to
+insane asylums, are due to this cause.
+
+There is in this, of course, an added motive for temperance, and it
+would seem that parents should be warned of the danger to which they
+are subjecting their offspring by excessive indulgence in alcohol,
+when it may be followed by such serious and lasting results to the
+beings on whom their love and affection will be expended in the
+future. This phase of alcoholic excess has never been taught as
+insistently as its importance would demand, perhaps because of the
+delicacy of the subjects which it involves; but it is too significant
+a factor in making or marring progress in the development of the race
+to allow any pusillanimous motives to prevent the spread of precious
+knowledge.  [Footnote 3]
+
+  [Footnote 3: The present conditions that obtain with regard to the
+  celebration of marriages are very prone to have a certain amount of
+  intoxication as their result. Perhaps, then, it is a fortunate
+  thing, as has often been said, that the first child is not born
+  until some considerable time after it might normally be expected. It
+  has been said more than once, however, that first children are a
+  little more likely to have certain degenerative defects than are
+  others, and a connection has been found between certain abuses of
+  stimulants and incidental exhaustion to account for this. One of the
+  most amusing things to Li Hung Chang, on his travels through our
+  country, was the curious publicity we give to everything connected
+  with marriage, while presumably our Christian ideas should rather
+  counsel a veiling of the mysteries, religious and physical,
+  connected with it. Certain it is that the present tendency towards
+  farewell dinners at clubs, and other festivities of various kinds,
+  are not at all likely to result in benefit to the presumably
+  hoped-for offspring.]
+
+The only real light that has been thrown on the puzzling details of
+heredity has come from work in the same field in which Mendel made his
+ground-breaking observations. {127} De Vries, the professor of botany
+at the University of Amsterdam, has succeeded in showing that new
+species of plants may be made to arise by careful attention to certain
+anomalous plants which occur from generation to generation. These
+plants breed true, that is, maintain their own peculiarities. To begin
+with, they are quite different from the parent plants, and the
+difference is perpetuated by inbreeding.
+
+So far the problem of the origin of species has been supposed to
+depend upon the normal variation that is noticed in plants and
+animals. All living things differ from one another, even though they
+may belong to the same species, and differ sometimes in remarkable
+degrees. This continuous variation was supposed to account for the
+origin of new species when it became excessive. It has become well
+recognised now, however, that such differences gradually disappear in
+the course of the normal multiplication of plants and animals. The
+tendency is much more towards the disappearance than the maintenance
+of peculiarities.
+
+There are certain discontinuous variations, however--sports, as they
+are called--in plants which differ very markedly in some quality from
+others, and these have the tendency to perpetuate themselves. Just why
+these sports occur is not known, nor how. They occur in a certain
+small percentage of all normal plants, but may die out, though it
+takes but little encouragement to succeed in helping them to maintain
+themselves. It is this that De Vries has done, and thus has succeeded
+in raising what would be called new species of plants.
+
+This same thing would seem to occur in human beings. Some definite
+variation occurs as a consequence of a peculiar embryologic process.
+This becomes stamped upon the genital material and appears in the
+subsequent generations. It does not occur as a consequence of
+pathological changes nor of mere embryonic faults; it is almost as if
+it were something introduced from without. Once having found an
+entrance, however, it affects the germinal material and thus
+perpetuates itself.
+
+With regard to plants, it has been suggested that the only explanation
+available for the occurrence of sports is that there is a purposeful
+introduction of them as the result of the laws of nature, and that it
+is thus that evolution is intentionally {128} brought about. This is,
+of course, a scientific reversion to teleology once more, but the
+question of teleological influences has been discussed more seriously
+in the last few years in biological circles than ever before.
+Unfortunately for the coincident evolution argument involved in human
+beings, the peculiarities introduced, which become the subject of
+inheritance, do not make for the development, but rather for the
+degeneracy, of the race. Even such peculiarities as six toes can
+scarcely be said to add any special feature of advantage to man in his
+struggle against his environment.
+
+It is agreed by many of our best authorities in biology, zoology, and
+botany, by such men as Professor Wilson of Columbia University,
+Professor Thomas Hunt Morgan of Bryn Mawr, Professor Castle of Harvard
+University, Professor Bailly of Cornell University, Professor Michael
+Guyer of the University of Cincinnati, Professor Spillmann, who is the
+Agrostologtst of the United States Government, and Professor Bateson
+of the University of Cambridge, England, that these principles of
+heredity enunciated by Father Mendel will undoubtedly revolutionise
+the modern knowledge of the subject. In the meantime, however, all the
+old theories are in abeyance. Darwin's work and Weissmann's brilliant
+theories and observations must give way, while the application of
+these new laws is being worked out to their fullest extent. While the
+influence of heredity can not be denied, there is undoubtedly a
+tendency to overestimate the influence on the physical being of the
+power of hereditary transmission, and, on the other hand, to
+underestimate the influence of this same force as regards disposition
+and character. There is no doubt now that the physical basis
+influences the exercise of the will, and that consequently
+responsibility is not infrequently modified by the hampering influence
+of unfortunate physical qualities. This truth makes for that larger
+charity in the judgment of the actions of others which enables
+physicians to realise how much men are to be pitied, while its failure
+of recognition by the "unco guid" not only causes suffering, but in
+the end adds to the amount of evil.
+
+JAMES J. WALSH.
+
+
+{129}
+
+X
+
+HYPNOTISM, SUGGESTION, AND CRIME
+
+
+In recent years a quasi-unconscious state, induced by suggestion and
+called the hypnotic trance, has come to occupy a very important place
+in the popular mind. Hypnotism, as the general consideration of this
+state is known, has attracted not a little attention, as well from
+physicians as from those interested in psychology. The hypnotic
+(Greek, [Greek text], sleep) trance is a condition in which voluntary
+brain activity is almost completely in abeyance, though the mind is
+able passively to receive many impressions from the external world.
+There are very curious limitations in the effect of the hypnotic state
+upon the various senses. While visual sensations, and, as a rule also,
+impressions from the tactile sense, lose their significance, or are
+translated according to the will of the person active in producing the
+hypnotic state, or of some person present making suggestions, auditory
+sensations are quite normally perceived. The patient has all the
+appearance of being asleep, though motions, and even locomotion, are
+often possible, and are performed as if the patient were walking in
+sleep.
+
+The hypnotic state is a partial sleep, then, of the motor side of the
+nervous system and of portions of the sensory nervous system. Certain
+of the higher intellectual powers, however, are entirely awake, and
+capable of being impressed through the hearing, and thus hypnotic
+suggestion has a place. For a time, under the influence of Charcot and
+his disciples, there was a very generally accepted opinion that the
+hypnotic trance was a pathological condition, somewhat allied to the
+cataleptic phase of major hysteria. It is well known that persons
+suffering from severe attacks of hysteria {130} may, while apparently
+unconscious, yet receive suggestions through the hearing. On the other
+hand, the production of cataleptic and other strained attitudes, in
+the maintenance of which fatigue seems to play no part, is possible by
+means of hypnotic suggestion in susceptible individuals.
+
+Further investigation, however, seems to have shown that the hypnotic
+state is rather to be considered as a quasi-physiological condition,
+somewhat related to sleep, all the mystery of which is not as yet
+understood. This is not surprising when we realise that such a normal
+and absolutely physiological condition as healthy sleep is yet without
+a satisfactory explanation on the part of physiologists. Hypnotism is
+recognised now as having a certain limited power for good, though the
+benefit derived from it is apt to be temporary, and the operator loses
+his power after a time,--not so much failing to produce the hypnotic
+condition, as failing to have his suggestions favourably accepted by
+the subject While the Nancy school of hypnotism insisted that most
+people were susceptible to the hypnotic trance, it is now generally
+considered that something less than 40 per centum of ordinary
+individuals can be brought under its influence.
+
+Much has been said of the dangers of hypnotism. There seems no doubt
+that very nervous persons are likely to be hurt by repeated recourse
+to the hypnotic condition. After a time they are likely to live most
+of their lives in a half-dreamy condition, in which initiative and
+spontaneous activity becomes more difficult than before. Where persons
+have been hypnotised by means of the flash of a bright object, or by
+some other special means, it sometimes happens that accidentally some
+similar object may send them into hypnotic trance. After a time, too,
+auto-hypnotism becomes possible, and much of the individual's waking
+time is occupied with efforts to keep himself from going into the
+hypnotic trance. These are, however, very extreme cases, likely to
+occur only in those who are not of strong mentality in the beginning.
+Unfortunately these are the individuals who are most likely to be made
+the subjects of repeated and prolonged hypnotic experimentation on the
+part of unscrupulous charlatans.
+
+For the great majority of those that are susceptible to the {131}
+hypnotic condition, there is very little danger. We now have on record
+the experiences of men who have seriously devoted many years to the
+study of hypnotic phenomena. There is entire agreement among these men
+that the possible dangers of hypnotism have been exaggerated. Indeed,
+it may be as well to say at once that most of what has been written
+with regard to the dangers of hypnotism has come from those who have
+least practical experience with the condition. Dr. Milne Bramwell,
+who, for a quarter of a century, has had a very extensive experience
+with hypnotism in its many phases, in his recent book on hypnotism,
+deliberately speaks of the "so-called dangers" of hypnotism. He has
+never seen any evil effects, though he has been practising hypnotism
+very freely on all kinds of patients for over twenty years.
+
+It is on the experience of such serious, disinterested observers that
+we must rely for our ultimate conclusions as to hypnotism, rather than
+on the claims of pseudo-experts who like to magnify their own powers,
+or on popular magazine articles, or still less the Sunday newspapers,
+the writers for which are mainly interested in producing a sensation.
+It seems probable that in the next few years hypnotism will occupy a
+less prominent place in popular interest than it has in the recent
+past. Interest in hypnotism runs in cycles, reaching a maximum about
+once a generation, and we are on the downward swing of the last wave
+of popular attention to this subject.
+
+A subject that has attracted much attention, whenever hypnotism has
+been under discussion, has been the possibility of crime being
+committed under the influence of hypnotic suggestion. The best
+authorities in hypnotism seem to be agreed that subjects can not be
+brought by hypnotic influence to perform actions that are directly
+contrary to their own feeling of right and wrong. The supposed
+exceptions to this rule are rather newspaper sensations than real
+compelled crimes. There is no doubt, however, that a tendency to the
+performance of certain wrong actions, so that the normal
+disinclination to their performance becomes much less than before, may
+be cultivated by a series of hypnotic as well as by waking
+suggestions. Where the individual influenced is {132} already
+characterised by weakness of will in certain directions, the added
+weight of the motives furnished by hypnotic suggestion may prove
+sufficient to turn the scale of responsibility. It is probably because
+of such influence that a recent case in France has attracted
+world-wide attention.
+
+In general, however, it may be said that normal individuals can not be
+brought to the commission of crime by hypnotic suggestion, and the
+plea of irresponsibility, for this reason, is not worthy of
+consideration. There are phases of this important problem, however,
+which require further careful study. Undoubtedly some of the so-called
+inherited tendencies to the commission of crime are really instances
+of the influence of auto-suggestion that has kept the possibility of
+some criminal act constantly before the mind. Some of the cases of
+hereditary dipsomania are almost surely of this character. Persons
+whose parents have been the subject of inebriety lose something of
+their own will power to keep away from intoxicating drink by the
+reflection that it is hopeless for them to struggle against an
+inherited tendency.
+
+A series of cases have been reported in which suicide has occurred in
+successive generations in the same family at about the same time of
+life. There seems no doubt that suggestion must have great influence
+in such cases. In one well-authenticated report, mentioned in the
+chapter on suicides, the members of the family were officers in the
+German army, and the eldest son, the family representative, committed
+suicide within the same five years of life, in four successive
+generations. The last member of the family had refused to marry,
+because of this doom hanging over the house, and had often referred to
+the possibility of suicide in his own case. In his early years he
+seemed to have the idea that he might escape the family fate, but
+after middle life he settled down irretrievably to the persuasion that
+he would inevitably go like the others.
+
+Here, in America, a rather striking example of this has recently been
+the subject of sensational newspaper reports. A notorious gambler,
+whose career had seen many ups and downs, finally found himself in a
+condition where, strange as it may seem, legal restriction made it
+impossible for him to {133} continue his usually lucrative profession.
+Three members of his immediate family, two brothers and his mother,
+had committed suicide. To friends he had sometimes spoken of this sad
+history of family self-murder, but always with a calm rationality
+which seemed to indicate that he hoped to avoid any such fate. When
+well on in years, however, with his means of livelihood taken from
+him, he, too, took the family path out of difficulties and shot
+himself at the door of the man who had been most instrumental in
+taking away from him his occupation. It seems not unlikely, from the
+circumstances of the case, that a double crime, homicide, as well as
+suicide would have been reported, only for the fortuitous circumstance
+that the other man was not in at a time when usually he was to be
+found at his office.
+
+In such cases as these it seems reasonably clear that long-continued
+familiarity with a given idea produces an auto-suggestion which
+finally overcomes the natural abhorrence even of suicide. Something
+can be done for such unfortunates by suggestion in the opposite
+direction, and by taking care that as far as possible they are not
+allowed to brood over the fate they consider impending. At times of
+stress and emotional strain, relatives and friends must be
+particularly careful in their watch over them. It is never advisable
+that they should take up such professions as those of broker or
+politician, or speculator, since the emotional states connected with
+such occupations are likely to prove too much for their mental
+equilibrium.
+
+Practically all physicians that have given any attention to the
+subject are convinced that not a few of the suicides, which are now so
+alarmingly on the increase in this country, are due to the frequent
+reading in newspapers of the accounts of suicides. As we have said
+elsewhere, brooding over the details of these is very likely to lessen
+the natural abhorrence of self-murder in persons that are predisposed,
+by melancholic dispositions, to such an act. The publication of cases
+of suicide can do no possible good, while it undoubtedly does, in this
+way, work incalculable harm. This is especially true with regard to
+suicides among young people, that is, individuals under twenty-five
+years of age. The saddest feature of recent {134} statistics with
+regard to suicide is that this crime has become proportionately much
+more frequent among young men and young girls, and even children, than
+it was two or three decades ago. It has been noted, too, in many cases
+that a previous suicide in the family seems to have familiarised the
+young mind with the idea of self-destruction and thus suggested its
+commission.
+
+On the other hand, among young people especially, it has been noted
+that there is frequently an imitative element in suicides. Three or
+four suicides, practically with the same details, will occur, within a
+few days of each other. Suicides at all ages are especially likely to
+occur in groups, and are often cited to exemplify the truth of the old
+axiom that evils never come singly. It is especially among young
+people, however, that this relationship to previous suicides can be
+traced, and there is no doubt that it is the unfortunate publicity
+given to suicide, with the consequent suggestive influence, which
+constitutes the most important factor in these cases. All the
+influence that clergymen can exert, then, must be wielded to suppress
+this, as well as the many other evils which flow from sensational
+journalism.
+
+JAMES J. WALSH.
+
+
+{135}
+
+XI
+
+UNEXPECTED DEATH
+
+Unexpected death and its problems constitute the principal reason why
+there should be a pastoral medicine, and why the clergyman must keep
+himself in close touch with advances in medicine. To have an ailing
+member of a congregation die unexpectedly, that is, without the rites
+of the Church, when perhaps there has been some warning as to the
+possibility of such an accident, can not but be a source of the
+gravest concern in pastoral work. Sudden death can be anticipated in
+many diseases that are acute, while in chronic forms of disease the
+sufferer can be prepared for its possibility by the administration of
+the sacraments at regular intervals. There is, however, an old proverb
+which says that death always comes unexpectedly; and even with all the
+modern advance in medicine, this still contains a modicum of truth. As
+an unprepared death is an occasion of the most poignant regret to the
+friends of the deceased and to the attending clergyman, it is with the
+idea of furnishing some data by which the occurrence of death without
+due anticipation may be rendered more infrequent, that the following
+medical points on the possibilities of a fatal termination in certain
+diseases have been brought together. Unfortunately, even with all our
+progress in modern medicine, they must be far from adequate for all
+cases.
+
+Needless to say, the only rational standpoint in this matter must be
+that it is better to be sure than to be sorry. The impression is very
+prevalent now that at least the sacraments of Penance and the Holy
+Eucharist should be administered to the sick whenever there is even
+the possibility of a fatal termination of the illness. Extreme Unction
+is more usually delayed until there is some positive sign of {136}
+approaching dissolution. Delay in its administration, however, not
+infrequently leads to this sacrament being given when the patient is
+unable to appreciate its significance. This would seem to be very far
+from the intention of the Church. The idea has been constantly kept in
+mind, then, so to advise the clergyman with regard to the liability of
+a fatal termination as to secure, if possible, the administration of
+Extreme Unction while the patient is still in the full possession of
+his senses.
+
+Assured prognosis, that is, positive foresight as to the course of any
+disease, is the most difficult problem in medicine. Nearly 2400 years
+ago, when Hippocrates wrote his chapter on the progress of diseases,
+he stated that the hardest question to answer in the practice of
+medicine is, will the patient live? That special chapter of his book
+remains, according to our best authorities, down even to our own day,
+a valuable document in medical literature. It can be read by young or
+old in medical practice with profit. While our knowledge of the course
+of disease has advanced very much, the wise old Greek physician
+anticipated most of the principles on which our present knowledge of
+prognosis is founded. This fact in itself will serve to show how
+unsatisfactory must be any absolute conclusion as to the termination
+of any given disease. Our forecasts are founded on empirical
+data,--that is, they are the result of a series of observations,--and
+the underlying basis of all the phenomena is the individual human
+being, whose constitution it is impossible to know adequately, and
+whose reaction to disease it is impossible, therefore, to state with
+absolute certainty.
+
+With this warning as to the element of doubt that exists in all
+prognosis, we may proceed to the consideration of certain organic
+affections which make sudden death frequent.
+
+At the beginning of the present century, Bichat, a distinguished
+French physician who revolutionised medical practice, said that health
+and the favourable or unfavourable termination of disease depends on
+the condition of three sets of organs--the brain, the heart, and the
+lungs. This was what he called the vital tripod. It was not until
+nearly thirty years after Bichat's death that Bright, an English {137}
+physician, taught the medical profession to recognise kidney disease.
+Since his time we have learned that even more important than Bichat's
+vital tripod, as regards health and the termination of disease, is the
+condition of the kidneys. We shall consider affections of these four
+organs, and their influence on the human system and intercurrent
+disease, in the order of their importance.
+
+When kidney disease exists the individual's resistive vitality is much
+lowered. The kidneys are the organs which serve to excrete poisons
+that find their way into the circulation. When the kidneys fail to
+act, these poisons are retained. As a result other important organs,
+notably the nervous system and the heart, suffer severely because of
+the irritating effect of the retained poison. A patient with kidney
+disease runs a very serious risk in any infectious fever, no matter
+how mild, and such patients should always be completely prepared for a
+fatal termination when they acquire any of these diseases.
+
+Nephritic patients bear operations very badly. The shock to the
+nervous system incident upon operation always throws a certain amount
+more than usual of excrementitious material into the circulation.
+Diseased kidneys do not fulfil their function of removing this at
+once, and the result is an irritated and fatigued nervous system.
+Anaesthetics, that is, chloroform and ether, are not well tolerated
+when nephritis exists, and this adds to the danger of operation in
+such patients. No matter how simple or short the operation that is to
+be performed on a person suffering from kidney disease, if an
+anaesthetic is to be administered it would be well to prepare the
+patient for an untoward event that may occur.
+
+Kidney disease is often extremely insidious. It may develop absolutely
+without the patient's knowledge, even though he might be deemed to be
+in a position to have at least some suspicion of its existence. The
+story is told of more than one professor of medicine who has presented
+his own urine to his class for examination in order that they might
+have the opportunity of studying normal urine, only to find to his
+painful surprise that albumen was present and that he was the subject
+of latent Bright's disease. In these cases it is {138} impossible to
+foresee results. They constitute a large number of the cases in which
+patients, seemingly in good health, succumb rather easily and
+unexpectedly to some simple disease, like grippe or dysentery. It is
+well to take the precaution, then, to ask the attending physician what
+the condition of the kidneys is in such cases. If there are anomalous
+symptoms, this precaution becomes doubly necessary. Even such simple
+infectious diseases as mumps or chicken-pox may cause a fatal issue
+where the kidneys are not in a condition to do their normal work of
+excretion.
+
+An important class of cases for the clergyman are those which are
+picked up on the street. As a rule, these patients are comatose
+because of the presence of kidney disease. A certain proportion of
+them are unconscious because of apoplexy. Very often the patients have
+had some preliminary symptoms of their approaching collapse, though
+these were not sufficient to make them think that any serious danger
+threatened. As a consequence, they will not infrequently have had
+recourse to some stimulant. It seems unfortunately to be almost a
+rule, when such cases are picked up, if there is the odour of alcohol
+on their breath, to consider that the condition is due to alcoholism.
+Every year, in our large cities, some deaths are reported in the cells
+of the station houses because a serious illness was mistaken for
+alcoholism as a result of the odour of the breath. Needless to say,
+then, the odour of alcohol on the breath of a person in coma should
+not deter a clergyman from waiting for a time to be sure his
+ministrations may not be needed for something much more serious than
+alcoholism.
+
+Patients suffering from kidney disease bear extremes of cold and heat
+very badly. In cold weather the fact that the blood is driven from the
+surface of the body lessens the excretory function of the skin, and
+this throws the work of this important organ, so helpful an auxiliary
+in excretion, back upon the kidneys. Besides, congestions of internal
+organs are not infrequent during cold, damp seasons, and these bring
+on exacerbations of previously existing ailments that may make fatal
+complications. In summer intense heat leads to many more changes in
+the tissues, and so provides more material to {139} be excreted than
+in temperate weather. Patients picked up on the street, then, at such
+time, will usually be found to be suffering from kidney disease.
+Though in profound coma, such patients seldom die without recovering
+consciousness. Not infrequently, after the primary stroke of the coma,
+there is, in an hour or two, a period in which the patient becomes
+almost completely rational. This period of consciousness does not last
+long, in many cases, and should be taken immediate advantage of, yet
+without unduly disturbing the patient.
+
+There is a well-known tendency in kidney disease to the production of
+oedema, that is, to the outflow of the watery constituents of the
+blood into certain loose tissues of the body. This is easily
+recognised, and constitutes a valuable sign of kidney disease in the
+swelling of the eyelids and of the feet, that occurs so often in
+patients suffering from kidney trouble. The usual rule is, if the
+oedema begins in the face, it is due to the kidneys; if in the feet,
+to the heart. The cause in the latter case is the sluggish circulation
+due to the weakness of the heart muscle, which delays the blood so
+long in the extremities that its watery elements find their way out
+into the tissues. In kidney disease this tendency to oedema
+constitutes a distinct danger that may involve sudden death in certain
+affections. In patients suffering from kidney disease any acute sore
+throat involving the larynx and causing hoarseness may be followed by
+what is called oedema of the glottis. This is often fatal in a very
+short time. The glottis is the opening between the vocal cords through
+which respiration is carried on. This opening is but small, and
+swelling of the surrounding tissues readily encroaches upon it, and
+soon causes difficulty of breathing. If the swelling is not relieved
+without delay, death takes place from asphyxiation. This was probably
+the cause of death in George Washington. In almost the same way any
+acute affection of the lungs that occurs in a patient suffering from
+kidney disease may be followed by oedema of the lungs. The outflow of
+serum from the blood vessels into the loose tissues of the lungs so
+encroaches upon the space available for breathing, and at the same
+time so reduces the elasticity of lung tissue, that {140} respiration
+becomes impossible, and death takes place in a few hours. This is
+often the cause of unexpected death after operations. The kidney
+affection in the patient is so slight as to have been unsuspected, or
+to have been considered of not sufficient importance to render the
+operation especially dangerous.
+
+After kidney disease the most important factor in the production of
+unexpected death is heart disease. In about 60 per centum of the
+patients who die suddenly, in the midst of seemingly good-health,
+death is due to heart disease. All forms of heart disease may be
+considered under two heads--the congenital and the acquired. The
+congenital form of heart disease usually causes death in early years.
+If such patients survive the fourth or fifth year, they are usually
+carried off by some slight intercurrent disease shortly after puberty.
+A few cases of congenital heart disease, however, live on to a good
+old age and seem not to be seriously inconvenienced by their heart
+trouble. Most of the acquired heart disease, that is, at least 65 per
+centum of it, is due to rheumatism. All of the infectious fevers,
+however, may cause heart disease, and scarlet fever especially is
+prone to do so; heart complications occurring in about one out of
+every ten cases. The probabilities of sudden death in a case of heart
+disease depend on what valve is affected and what the condition of the
+heart muscle is. Most of the cases of sudden death occur in disease of
+the aortic valves, that is, of the valves that prevent the blood from
+flowing back from the heart after it has been pumped out. Diseases of
+the other side of the heart, the mitral valve, cause lingering illness
+until the heart muscle becomes diseased, when sudden death usually
+closes the scene.
+
+Diseases of the aortic valves of the heart cause visible pulsations of
+the arteries, especially of those in the neck. This readily attracts
+attention if one is on the lookout for it. Deaths in heart disease,
+whether sudden or in the midst of apparent health, or as the terminal
+stage after confinement to bed because of weak heart, are apt to occur
+particularly during continued cold or hot spells. Each of the
+blizzards that we have had in recent years has been the occasion for a
+{141} markedly increased mortality in all forms of heart disease. The
+cold itself is exhaustive, and the heavy fall of snow, by delaying
+cars and modes of conveyance generally, is very apt to give occasion
+for considerably more exertion than usual. Besides, cold closes up the
+peripheral capillaries and makes the pumping work of the heart much
+harder than before. At times of continued cold, in our large cities
+particularly, the ordinary arrangements for heating the house fail to
+keep it at a constant temperature, and this proves a source of
+exhaustion to cardiac patients.
+
+Heated spells, if prolonged, always cause an increased mortality in
+such patients, because heat is relaxant and this leads to exhaustion.
+Patients who have been nursed faithfully through a severe winter will
+sometimes succumb to the first few successive days of hot weather that
+are likely to come at the end of May or the beginning of June. The
+deaths that occur during the hot spells of July and August are more
+looked for and accordingly prove not so unexpected.
+
+The warning symptom in heart disease that the patient is giving out is
+the development of irregularity and rapidity of the pulse. On the
+other hand, when a pulse has been running rapidly for weeks and then
+drops to below the regular rate, to 50 or 60, a fatal termination may
+be looked for at almost any time, though, of course, the patient may
+rally. The prognosis of heart cases is extremely difficult. Confined
+to bed and evidently seriously ill, they may continue in reasonably
+good condition for months, and then some indiscretion in diet, which
+causes a dilation of the stomach with gas, pushes the diaphragm up
+against the heart, adds a mechanical impediment to the physical
+difficulties the organ is already labouring under, and a sudden
+termination may ensue. As a rule, lingering heart cases terminate
+suddenly and often with little warning of the approach of death.
+
+An interesting set of heart symptoms, for the physician as well as the
+clergyman, are those which occur in what is called angina pectoris,
+heart pang, or heart anguish. Serious angina pectoris occurs in
+elderly people whose arteries are degenerate. Its main symptom is a
+feeling of discomfort which develops in the praecordia,--the region
+over the heart. {142} This discomfort may often increase to positive
+cutting pain. The pain is often referred to the shoulder, and runs
+down the left arm. This set of symptoms is accompanied by an intense
+sense of impending death. When the patient's arteries are degenerated,
+this train of symptoms must always be considered of ominous
+significance. A readily visible sign of arterial degeneration can
+sometimes be noted in the tortuous prominent temporal artery just
+above the temple.
+
+Heberden, an English physician, a little over a century ago, pointed
+out that there existed in cases of true angina pectoris a degeneration
+of the coronary arteries. These are the arteries which supply the
+heart itself with blood. As might naturally be expected, their
+degeneration seriously impairs the function of the heart muscle. The
+first patient in whom the condition was diagnosed during life was the
+distinguished anatomist, John Hunter. Hunter was of a rather irascible
+temperament, and after he had had several of these attacks, and a
+consultation with Heberden convinced him of their significance, he is
+said to have remarked, "I am at the mercy of any villain who rouses my
+temper." Sure enough. Hunter died in a sudden fit of anger within the
+year after making the remark. Charcot, the distinguished neurologist,
+suffered from attacks of angina pectoris, and was asked by his family
+to consult a distinguished heart specialist for them. He said: "Either
+I have degenerated heart arteries, or I have not. I believe that I
+have not, and that my attacks are due to a nervous condition of my
+heart. If I should consult the physician you mention, and he were to
+tell me that my attacks are due to degeneration of the heart, he would
+advise my giving up work. That I am not ready to do, and so I prefer
+to take my own assurance in the matter." A few years later he was
+found one morning dead in bed. In many of the cases of death in bed,
+especially where some complaint of pain has been heard during the
+night, death is due to that condition of the heart arteries which
+causes angina pectoris, though it may be the first attack which proves
+fatal.
+
+There is a condition similar to angina pectoris, sometimes called
+pseudo-angina, or false heart pang, which occurs in individuals from
+fifteen to thirty years of age. It is often a {143} source of great
+worry. It occurs in young persons of a nervous temperament who have
+been overworked or overworried and have run down in weight. There are
+always accompanying signs of gastric disturbance. The casual factor of
+the symptoms seems to be a more or less sudden dilation of the stomach
+with gas. As the stomach lies just below the heart, only separated
+from it by the comparatively thin layer of diaphragm, the heart is
+pushed up and its action interfered with. In healthy individuals this
+causes no more than a passing sense of discomfort and some heart
+palpitation. That it is which sends so many young patients to
+physicians with the persuasion that they have heart disease, when they
+have nothing more than indigestion. In nervous individuals, however,
+this interference with the heart action disturbs the nervous mechanism
+of the heart, which is very intricate and delicate, and gives rise to
+the symptoms of false "heart pang." One of these symptoms is always,
+as in true angina pectoris, an impending sense of death. This can not
+be shaken off, and is not merely an imagination of the patient.
+Pseudo-angina is, however, not a dangerous affection. Patients can
+usually be assured that there is no danger of death. This assurance is
+not absolute, however. For some of these cases have congenital defects
+in their coronary arteries, and the nervous system of the heart
+itself, which make them liable to sudden death. It is sometimes
+impossible to differentiate such cases of organic heart defects from
+the ordinary functional heart disturbance due to indigestion, which
+causes simple curable pseudo-angina. Young patients may usually be
+disabused of their nervousness in the matter, but absolute assurance
+can not be given until the case has been under observation for some
+time.
+
+After the heart, the head is the most important factor in sudden
+death. The most frequent form of death from intra-cranial causes is
+apoplexy. Apoplexy, as the name indicates--a breaking out--is due to
+a rupture of one of the arteries of the brain, and a consequent
+flowing out of blood into the brain tissue. The presence of the exuded
+blood causes pressure upon important nerve tracts, and so gives rise
+to unconsciousness, to paralysis, and to the other symptoms which are
+{144} noted in apoplexy. There are a number of symptoms that act as
+warnings of the approach of apoplexy. First, it occurs only in those
+beyond middle life, that is, in individuals over forty-five, and in
+these only where there is marked degeneration of arteries. The
+degeneration of the arteries can be easily noted, as a rule, in other
+parts of the body. The condition known as arterio-sclerosis, that is,
+arterial hardening, can be detected by the finger at the wrist, or by
+the eye in the branch of the temporal artery, which can so frequently
+be seen to take its sinuous course on the forehead behind and above
+the eye. At the wrist the thickened artery is felt as a cord that can
+be rolled under the finger. It is not straight as in health, but is
+tortuous, because the overgrowth in the walls, which makes it thick,
+has also made it longer than normal, thus producing tortuosity.
+
+Besides these objective signs, as they are called, there are certain
+subjective signs, that is, signs easily recognised by the patient
+himself, which should put him on his guard, and at the same time serve
+as a warning to the clergyman, should he hear of their presence. These
+signs are recurring dizziness, or vertigo, not clearly associated with
+gastric disturbance; tendency of the limbs, and especially the fingers
+and toes, to go to sleep easily, and when there is no external cause
+for this condition; tendency to faintness and to dizziness when the
+patient rises in the morning, especially if he assumes the erect
+position suddenly; tendency to vertigo when the patient stoops, as to
+tie a shoe, or pick up something from the floor, and the like;
+finally, certain changes in the patient's disposition, with a loss of
+memory for things that are recent, though the memory may be retained
+for the happenings of years before. When several of these symptoms
+occur, patients who are well on in years should take warning of the
+fact that they are liable at any time to have a stroke. Needless to
+say, this has no reference to the cases of young nervous persons who
+may readily imagine that they have some or all of these symptoms.
+Apoplexy is typically the disease of those over fifty years of age.
+
+There may even occasionally be slight losses of power in the hand or
+foot that point to the occurrence of small hemorrhages in the brain,
+that is, slight preliminary "strokes."
+
+{145}
+
+Patients that have had these symptoms should not, as a rule, be
+allowed to leave home unattended. If the apoplexy occurs in the street
+they are liable to be mishandled by those ignorant of their true
+condition. The clergyman is usually summoned at once in these cases
+and may reach the stricken individual before the physician. Some
+words, then, with regard to the general management of such patients
+will not be out of place. As a rule, when a patient is taken with some
+sudden illness which causes him to fall down unconscious, the first
+thing done is to dash water in his face, force a stimulant down his
+throat, put his head low down, and loosen the clothing around his
+neck. Most of these proceedings are the very worst things that could
+be done for a patient suffering from apoplexy. The rough handling,
+particularly, and the administration of a stimulant, will surely do
+harm. The water on the face will certainly do no good.
+
+Apoplectic patients can be recognised from those who are merely in a
+fainting fit, first, by the fact that they are usually old, while the
+fainters are young; and secondly, by the manner of the breathing. In a
+faint the breathing is shallow and faint, not easily seen. In apoplexy
+it is apt to be deep and long. It may be irregular, and it is always
+accompanied by a blowing outward and inward of the cheeks, and
+especially of the side of the face which is paralysed, as a
+consequence of a hemorrhage into the brain.
+
+The lips are forced outward and drawn inward during the respiration.
+In such cases the patient should be moved as little as possible;
+stimulants should be avoided, and the head should be placed higher
+than the rest of the body, so as to make the hemorrhage into the brain
+as small as possible, by calling in the assistance of gravity to keep
+the heart from sending too much blood into the head. Besides this
+placing the head high, there is only one other helpful measure that
+even the physician can practise, except in rare cases, that is, to put
+an ice-bag on the head. For this a cloth dipped in cool water may be
+used in an emergency. Of course, as soon as the doctor arrives, the
+patient should be left entirely to his care.
+
+The artery that ruptures in the brain, in cases of apoplexy, {146} is
+practically always the same. Its scientific name is the
+lenticulo-striate artery, but it is oftener called by the name given
+it by Charcot--the artery of cerebral hemorrhage. The reason why
+arteries in the brain rupture rather than arteries in other organs is
+that in the brain, in order to avoid the demoralising effect of too
+sudden changes of blood pressure upon the nervous substance, the
+cerebral arteries are terminal, are not connected directly with a
+network of finer arteries as in the rest of the body, but gradually
+become smaller and smaller, and end in the capillary network which is
+the beginning of the venous vascular system. This special artery
+ruptures, because it is almost on a direct line from the heart, and so
+blood pressure is higher in it than in other brain arteries.
+
+The tradition that people with short necks are a little more liable to
+apoplexy than are those of longer cervical development has a certain
+amount of truth in it, though not near so much as is often claimed for
+it. Another predisposing element to apoplexy is undoubtedly heredity.
+Families have been traced in which, for five successive generations,
+there have been attacks of apoplexy between fifty-five and sixty years
+of age. Short-necked people, with any history of apoplexy in the
+family, should especially be careful, if they have any of the
+symptoms--dizziness, sleepy fingers, etc.--that we have already
+noted.
+
+There is a tradition that the third stroke of apoplexy is always
+fatal. This is without foundation in experience, though of course the
+liability of death increases with each stroke, and few patients
+survive the third attack. I remember seeing in Mendel's clinic, in
+Berlin, a man who was suffering from his seventh stroke and promised
+to recover to have another. Each successive stroke is much more
+dangerous to life than the preceding one, however. In general, the
+prognosis of an apoplexy, that is to say what the ultimate result will
+be, is impossible. The patient may come to in an hour or two, and may
+not come out of the coma at all. There is no way of deciding how large
+the artery is that is ruptured, nor how much blood has been effused
+into the brain, nor how much damage has been done to important nerve
+centres. Nor is there any {147} effective way of stopping the
+effusion, though certain things seem to be of some benefit in this
+matter. We can only wait, assured that, in most of the cases, the
+patient will have a return of consciousness, at least for a time.
+
+Next to apoplexy, injuries of the head are most important. The
+symptoms presented by the patient will often be nearly the same as
+those of apoplexy. If the skull is fractured, and the depressed bone
+is exerting pressure upon the brain substance, there is a similar
+state of affairs to that which exists in apoplexy. Any return to
+consciousness must be taken advantage of for the administration of the
+Sacraments. As a rule, it is impossible to tell the extent of the
+injury or to forecast the ultimate result.
+
+A very characteristic set of symptoms develops sometimes after
+injuries in the temporal region or just above it. For a short time up
+to an hour or two after the injury, the patient is unconscious. Then
+he comes to for a while, but relapses into unconsciousness, from which
+he will usually not recover except after an operation. The explanation
+of this succession of symptoms is that the primary unconsciousness is
+due to shock--concussion or shaking up of the brain. The injury has,
+however, also caused a rupture of an important artery which occurs in
+one of the membranes of the brain in this region, the middle meningeal
+artery. During the state of shock blood pressure is low and hemorrhage
+is not severe. When consciousness is regained, blood pressure goes up
+and the laceration of the middle meningeal artery, already spoken of,
+provides an opening for the exit of considerable blood, which clots in
+this region and presses upon the brain, causing the subsequent
+unconsciousness. As a rule, the patient's only hope is in operation
+with ligature of the torn artery. The condition is always very
+serious, and complete precautions as to the possibility of fatal
+termination should be taken, as soon as consciousness is regained
+after the blow, in any case where the head injury has been severe
+enough to cause more than a momentary loss of self-possession. No one
+can tell whether there may be further change or not, and if this
+happens it will be in the form of an unconsciousness gradually
+deepening until relieved by operation or ended by death.
+
+{148}
+
+Tumours of the brain often produce death, but usually give abundant
+warning of their presence. The symptoms by which the physician
+diagnoses the presence of a brain tumour are vertigo, headache,
+vomiting, usually some eye trouble, and frequently some interference
+with the motion of some part of the body, because of pressure exerted
+upon the nerve centres which preside over its motions. Brain tumours
+are especially liable to develop in two classes of cases--in patients
+who are suffering from tuberculosis in its terminal stages or from
+syphilis. Where patients are known to have either of these diseases
+and present any two of the symptoms of brain tumour that I have
+mentioned, it is well to suggest at least the preliminary preparation
+for a fatal termination. Sometimes states of intense persistent pain,
+or of mental disturbance, develop in these cases and make the
+administration of the Sacraments unsatisfactory.
+
+Meningitis is a fatal affection which sometimes causes sudden death,
+but more frequently produces unconsciousness without very much
+warning, and the unconsciousness lasts until the death of the patient.
+Meningitis is seen much more frequently in children than in the adult.
+Ordinarily it is due to tuberculosis. Sometimes, however, there are
+epidemics of cerebrospinal meningitis--spotted fever, as it used to be
+called. In about one-half the cases this affection is fatal.
+Unfortunately this disease gives very little warning of its approach
+in many cases before unconsciousness sets in. We have had renewed
+epidemics of the disease in the eastern part of the United States in
+recent years, and the affection is likely to occur more frequently for
+some time to come. The first hint of the onset of the disease during
+an epidemic should be the signal for the administration of all the
+rites of the Church.
+
+Of late years we have learned that the pneumococcus, that is, the
+bacterium which causes pneumonia, may produce a fatal form of
+meningitis. The first symptom of meningitis is usually a stiffness of
+the muscles at the back of the neck. If this stiffness becomes very
+marked in a patient suffering from tuberculosis, or who has, or has
+recently had, pneumonia, or at a time when there is any reason to
+suspect that epidemic cerebrospinal meningitis exists in a
+neighbourhood, the {149} prognosis of the case is always very serious.
+Every precaution should be taken to prepare the patient for the worst.
+Unconsciousness may ensue at any moment and no opportunity for
+satisfactory administration of the consolations of religion be
+afterwards afforded.
+
+While Bichat put the lungs down as one of the vital tripod on which
+the continuance of life depends, affections of these organs very
+seldom lead to sudden or unexpected death. Pulmonary affections
+usually run a very chronic course. Acute bronchitis, however,
+occurring in a patient with kidney trouble, may lead to the
+development of oedema of the lungs, and death will usually ensue in a
+few hours. It may be well to note here that individuals who have what
+are called clubbed fingers, or as the Germans picturesquely put it,
+drumstick fingers, that is, fingers with bulbous ends, the finger
+beyond the last joint being larger than the preceding part, nearly
+always have some chronic affection within the thorax. This means that
+there is some organic affection of the heart or lungs which has lasted
+for many years. The existence of such condition makes them distinctly
+more vulnerable to any serious intercurrent disease, and this sign
+alone may be enough to put the attending physician on his guard as to
+the possibility of fatal complications in the case.
+
+JAMES J. WALSH.
+
+
+{150}
+
+XII
+
+UNEXPECTED DEATH IN SPECIAL DISEASES
+
+
+Besides the general systemic conditions in which sudden death may
+occur without anticipation, there are certain specific diseases of
+which unexpected death is sometimes a feature. For the clergyman to
+know the condition in which the sudden fatal termination is liable to
+occur is to be forearmed against the possibility of death without the
+Sacraments, or their enforced administration in haste, when the
+recipient is in a very unsatisfactory condition of mind and body. It
+has been said that if a normally healthy individual reaches the age of
+twenty-five he is reasonably sure to live to a good old age, provided
+he does not meet with an accident or catch typhoid fever or pneumonia.
+
+Pneumonia is an extremely important affection as regards its
+prognosis. From 15 to 20 per centum of sufferers from the disease die;
+that is to say, about one in six of those attacked by the disease will
+not recover. It is a little more fatal in women than in men. It is
+especially serious for the very young and the old.
+
+Healthy adults in middle life very rarely die from the disease. The
+prognosis of any individual case, it has been well said, depends on
+what the patient takes with him into the pneumonia. Serious affections
+of important organs nearly always cause fatal complications. If the
+heart is affected before the pneumonia is acquired, then the prognosis
+is very unfavourable, and a fatal termination is almost inevitable. If
+the kidneys are seriously diseased beforehand, death is almost the
+rule. Pneumonia developing during the course of pregnancy is fatal in
+more than one-half of the cases. At one time it was suggested that
+premature delivery of pregnant {151} pneumonia patients might save at
+least the mother's life. Experience in Germany, however, has shown
+that, far from making the prognosis more favourable, the induction of
+premature labour makes the outlook a little worse for the patient.
+Previous affections of the lungs, emphysema, or tuberculosis, are
+prone to make the prognosis of pneumonia much more unfavourable than
+under ordinary circumstances.
+
+Deteriorated conditions of the blood, anaemia, chlorosis--such as
+occurs so commonly in young women--is prone to make the outlook in
+pneumonia more serious. Pneumonia of the upper lobes of the lungs is
+more apt to be followed by complications, and is therefore more
+serious than pneumonia of the lower lobes. Secondary pneumonia--that
+is, inflammation of the lungs which develops as a complication of some
+other disease--is much more unfavourable than primary pneumonia which
+develops in the midst of health. The amount of lung involved is of
+course a serious factor in the prognosis. If the whole of one lung is
+consolidated, or if considerable portions of both lungs are thus
+affected, the prognosis becomes extremely unfavourable.
+
+In persons of alcoholic habits the result of pneumonia is always to be
+dreaded. The more liberal has been the consumption of alcohol, as a
+rule, the less hope is there of a prompt, uncomplicated recovery.
+Stimulants are of the greatest importance in pneumonia, and the less
+the patient has taken of them before the development of his pulmonary
+affection the more effective are they when the crisis of the disease
+comes. The less the alcohol that has been taken habitually before the
+development of pneumonia, the more surely will it do the work expected
+of it during the course of the pneumonia. It must be borne in mind
+that cases of pneumonia that occur in institutions, asylums,
+hospitals, and the like, and in crowded quarters in tenement houses or
+lodging houses, have a distinctly worse prognosis than those treated
+in private houses, and the priest must accordingly be more on his
+guard and give the Sacraments early.
+
+In pneumonia, as in typhoid fever, so-called walking cases always have
+a serious prognosis. They occur in very strong patients who resist,
+not the invasion of the disease, but its {152} weakening influence,
+and keep on their feet for several days, despite the presence of
+symptoms that require them to be in bed. When a patient walks into a
+doctor's office in the third or fourth day of a pneumonia with most of
+one lung consolidated, exhaustion of the heart and of the nervous
+system, under these unfavourable conditions, will usually have made
+his resistive vitality very low. Such cases should be given the
+Sacraments early, while in the full possession of their senses.
+Conditions sometimes develop rather unexpectedly in which the
+administration of the Sacraments becomes unsatisfactory, because of
+the collapsed state of the patient.
+
+This same advice holds with regard to walking cases of typhoid fever.
+Where strong patients suffering from the disease have insisted on
+being around on their feet for from six to ten days at the beginning
+of the affection, the prognosis becomes very unfavourable.
+Complications, such as hemorrhage or perforation of the intestine,
+occur about the beginning of the third week, and often prove fatal.
+All typhoid fever patients should receive at least the Sacraments
+necessary to give a sense of security to the priest and their friends
+during the course of the second week, even though they may seemingly
+be in excellent condition. When typhoid fever is fatal the
+complications occur suddenly, often without much warning; and if
+intestinal perforation, for instance, takes place, the peritonitis
+which develops makes the patient's condition very unsuitable for the
+reception of the Sacraments in a proper state of mind.
+
+Typhoid fever patients sometimes die suddenly in collapse when they
+are convalescent. The toxine of the typhoid bacillus often affects the
+heart, and causes what is called cloudy swelling of its muscular
+fibres. This decreases very notably their functional ability. Any
+sudden exertion, even sitting up in bed, may cause the heart to stop
+under such circumstances. The modern custom in hospitals is not to
+allow typhoid patients to sit up in convalescence until the head of
+the bed has been raised gradually for several days so as to accustom
+the heart to pumping blood up the hill to the brain. Priests must be
+careful, then, when they call to see convalescent typhoid patients,
+not to permit them to sit up {153} to greet them. The doctor's
+directions in this matter should be followed very carefully.
+
+This sudden fatal collapse may occur after any of the infectious
+diseases. It is seen not infrequently after diphtheria. It occurs more
+rarely after scarlet fever, and even after some of the milder
+children's diseases. In rheumatism, especially where a heart
+complication has occurred, this rule with regard to sudden movements
+is extremely important Rheumatism is itself not a fatal disease, yet
+there are certain cases in which very high temperature sets in, causes
+delirium, and death ensues at times before the patient recovers
+consciousness. Where rheumatic patients show a tendency to run high
+temperatures, that is, 104 deg. or higher, it is well to be prepared for
+this emergency.
+
+Appendicitis is very much talked about in our day; but the fatal
+affection represented by the new word is no more frequent than it was
+half a century ago, or, for that matter, twenty-five centuries ago.
+People died of inflammation of the bowels and peritonitis then; and as
+the appendix was not known as the origin of the trouble, the fateful
+name was not the spectre that it is now. Practically all abdominal
+colic--and this means 90 per centum of all the acute pain which
+follows gastro-intestinal disturbance in young or middle-aged
+adults--is due to appendicitis. It comes on, as a rule, in the midst
+of good health. It is very treacherous, and when the patient is
+apparently but slightly ill, a sudden turn for the worse may assert
+itself, and an intensely painful and prostrating condition develop.
+Where symptoms of appendicitis are present, it is the part of safety
+to have the patient receive at least the Sacraments of Penance and the
+Holy Eucharist. When peritonitis develops, vomiting is the rule. Hence
+the advisability of prompt administration of Holy Communion. Extreme
+Unction can be given with some satisfaction, even during the disturbed
+period which follows a beginning peritonitis. For the peritonitis that
+sometimes results from appendicitis there is no hope of recovery
+except by operation. Operation, to be successful, must follow the
+perforation of the appendix not later than by a few hours.
+
+{154}
+
+Early pregnancy, that is, the first eight to ten weeks of gestation,
+is sometimes complicated by a set of symptoms the most prominent of
+which are sudden very acute pains in the lower part of the abdomen,
+followed by intense prostration, and then by the symptoms of internal
+bleeding,--namely, a soft pulse, pallor with cold extremities, sighing
+respiration, and marked tendency to faintness. When symptoms like
+these occur during the first three months of pregnancy, they signify,
+almost without exception, rupture of an extrauterine gestation-sac.
+Except where operation can be performed at once, these cases are
+almost invariably fatal. Extrauterine pregnancy occurs with greatest
+frequency in women who, having had one or more children, then have a
+period of five or more years without children, followed by pregnancy.
+Undoubtedly, extrauterine pregnancy, the knowledge of which is the
+result of medical advance in very recent years, and appendicitis,
+which is the growth of the last twelve years, were prominent factors
+in the production of many inexplicable deaths in history. These were
+not infrequently set down as due to poison.
+
+Acute indigestion in elderly people is sometimes followed by sudden
+death. Observations in this matter have somehow become much more
+frequent of late years, and many of the so-called cases of heart
+failure belong to this group. The important nerve trunk that carries
+nervous fibres to the heart bears fibres to the digestive tract, the
+oesophagus, the stomach, the intestines, the liver as well, and also
+to the larynx and lungs. There is a certain intercommunication between
+the impulses which pass along these various nerve fibres. Intense
+irritation of the nerve endings in any one of these organs may be
+reflected back upon the heart. Curiously enough the nerve fibres to
+the heart that run in this trunk are many of them inhibitory; that is
+to say, they lessen the function of the heart or cause it to stop
+beating entirely. If an intense nervous irritation is set up in the
+stomach, reflex nervous impulses may cause the heart to stop
+completely and never resume its work.
+
+Typical cases of this kind often occur during the first cold days of
+the winter time. Elderly people come to their meals cold and chilly,
+yet with appetite increased by the bracing air. They sit down at once,
+take a larger meal than usual, and then develop severe gastritis
+during the night. This is {155} relieved by purging and vomiting, and
+the pain yields to the administration of morphine. Their condition
+improves and all danger seems past, when, on sitting up suddenly the
+next day, or, if left alone, getting up to get something for
+themselves, they collapse and are dead before help can come to them.
+Deaths like this sometimes occur in dysentery also, the reason being
+the intense nervous reflex from the irritated intestinal nerve endings
+which exerts its influence upon the heart nerves.
+
+Certain diseases practically always end in sudden death and must be
+taken special care of by the priest for this reason. Aneurism, for
+instance, is one of these. An aneurism is a widening or dilatation at
+some point of an artery. The most important aneurisms occur in the
+arch of the aorta, that is, in the large curved artery which comes
+directly from the heart itself and of which all the other arteries are
+branches. Aneurisms develop, according to the expression of a
+distinguished American physician, in the special votaries of three
+heathen divinities, Vulcan, Bacchus, and Venus,--that is, in those who
+have worked too hard, in those who have drunk too hard, and in those
+who have devoted themselves too much to the pleasures of the flesh.
+The most important factor of all is, however, the contraction of
+venereal disease, especially of that form known as syphilis.
+
+The termination of aneurism cases is usually by rupture with profuse
+hemorrhage. Death takes place in a moment or two. Aneurisms often
+cause intense pain, which is sometimes thought to be rheumatic in
+origin. If the aneurism, in its enlargement, meets with bony
+structure, it produces absorption of the bone by pressure upon it and
+so finds a way even through the bone to the overlying skin. This
+process is always intensely painful, and shortly after the aneurism
+appears at the surface the pressure upon the skin causes it to become
+thin and the aneurism may rupture externally.
+
+Addison's Disease always ends suddenly. This is a rare affection,
+described by Addison, an English physician, some fifty years ago,
+which develops in individuals whose suprarenal capsules are
+degenerated. The suprarenal capsules are little bodies of half-moon
+shape which lie above the kidneys. {156} Their degeneration produces a
+great lowering of blood pressure. The patient becomes intensely weak,
+muscular movement becomes impossible, intellectual processes cause
+great fatigue, and finally blood pressure becomes so low that fatal
+collapse ensues from lack of blood in the brain. The external symptoms
+of these cases is a pigmentation, that is, a very dark discolouration
+of the skin, which develops rather early in the disease. The tongue
+especially becomes a very dark brown. Areas of pigmentation also occur
+where the skin is irritated,--at the wrists from the irritation of the
+coat sleeves, at the edge of the hair from the irritation of the hat.
+Dr. S. Weir Mitchell, in his _Autobiography of a Quack_, has described
+one of these cases very strikingly. The hero of the tale is found dead
+one morning by the nurse in the hospital, after he has been feeling
+quite as well as usual for some time.
+
+It must not be forgotten that patients who are burned extensively very
+frequently die shortly after the accident. A burn that involves more
+than one-half of the body, no matter how superficial the burning may
+be, will always have a fatal termination. Deep burns in one part,
+unless it is some very vital part, are not so serious as extensive
+superficial burns. Patients with extensive burns frequently remain in
+encouragingly good condition for several days, and then have a sudden
+change for the worse. Sometimes death takes place in coma. Sometimes
+it takes place as the result of a perforation of the duodenum. These
+perforations of duodenal ulcers may take place as late as a week to
+ten days after the burn. They are always followed by symptoms of
+peritonitis and the condition of intense prostration which this brings
+on. Such cases need to be prepared for the worst after the first acute
+symptoms of the burn have subsided, when a certain amount of peace of
+mind is restored.
+
+Cirrhosis of the liver not infrequently causes sudden death. Cirrhosis
+is an affection in which a large part of the liver substance proper
+degenerates, and its place is taken by connective tissue. It is
+typically a disease of people of alcoholic habit. It occurs in those
+who are engaged in the sale of spirits, though the alcoholic
+absorption does not take place {157} through the skin, but in a much
+more direct way. It is most frequent in people who take strong spirits
+on an empty stomach. Those who are much exposed to changes of
+temperature are especially liable to form such habits. It is found
+most frequently in the drivers of wagons and cars, in policemen, and
+in sea-captains, sailors, and the like. When cirrhosis causes sudden
+death, it is nearly always by hemorrhage. The hemorrhage takes place
+from the oesophagus, some of the large veins of which have become
+dilated until the thin walls are unable to retain the blood. The
+dilatation is due to interference with the venous circulation in the
+liver.
+
+Of late years pathologists and medical men, especially those who are
+interested in children's diseases, have devoted considerable time to
+the study of certain cases of sudden death, which have long been very
+mysterious. Infants often die while in apparent good health without
+any adequate reason that can be found, even on the most careful
+autopsy. Children of an older growth sometimes die suddenly as the
+result of some slight shock or fright, or they die after the
+administration of a few whiffs of chloroform, given to help in the
+performance of some simple surgical operation, or they die at the
+beginning of some infectious fever which they ought to be able to
+withstand without any difficulty. A distinguished pathologist at
+Vienna, Professor Paltauf, who was the coroner's physician of the city
+and had a large number of these sudden deaths to investigate, found
+that in most of the cases one abnormal condition was constantly
+present. This consisted in an enlargement of the lymph glands all over
+the body. The lymph glands in the neck were involved, also the tonsils
+and lymphoid tissue at the back of the throat, the series of lymph
+glands in the groin, and, finally, there was a hypertrophy of the
+lymphoid tissue that occurs all along the intestinal tract. This
+condition of hypertrophy of lymphoid tissue has come to be known as
+the lymphatic diathesis or constitution. It is nearly always
+accompanied by a distinct hypertrophy of the thymus gland. The thymus
+gland is an organ which occurs in the upper part of the thorax of the
+child, but which atrophies and practically disappears after the age of
+two years. In these cases it is from twice to three {158} times its
+normal size in the infant, and in older children it is
+persistent--that is, retains its primary size, though in the ordinary
+course of nature it should atrophy. This lymphatic diathesis
+undoubtedly has considerable to do with the sudden deaths which occur
+in these patients. What the exact connection is we do not as yet
+definitely know. Unfortunately, moreover, this lymphatic constitution
+gives no sure sign of its existence before the occurrence of the fatal
+termination. Enlargement of the glands of the neck and of the groin,
+with some enlargement of the tonsils, occurs in delicate children
+without necessarily being symptoms of the lymphatic diathesis. The
+enlargement or persistence of the thymus can be better recognised, and
+doctors now seldom fail to notice it. Where any suspicion of such a
+condition exists in children of from eight to sixteen or seventeen
+years of age, proper precautions must be taken to prevent sudden fatal
+termination of any even mild disease without due preparation.
+Undoubtedly many of the cases of sudden death under chloroform and
+ether in children and young persons are due to the existence of this
+lymphatic diathesis.
+
+Diseases, like tuberculosis and cancer, that run a long but assuredly
+fatal course, usually terminate unexpectedly. The tuberculous patient
+particularly will almost surely be planning for next year the day
+before he dies. This condition of euphoria, that is, of sense of well
+being, was recognised as associated with tuberculosis as far back as
+we have any history of the disease. Hippocrates pointed out as one of
+the symptoms of consumption the _spes phthisical_ or consumptive hope.
+If the patient has been very much run down, death may take place from
+thrombosis of some of the arteries. If the thrombosis takes place in
+the brain, consciousness will be lost, and the patient will often die
+without recovering it. Patients often develop tubercles in their brain
+as the result of a spread of the disease beyond the lungs, and then,
+as a rule, death will take place in the midst of a paralysis, which
+may be accompanied by loss of consciousness that lasts for several
+days or a week or more.
+
+Cancer patients also die suddenly, or at least unexpectedly, at the
+end. Very often in them, as in tuberculosis, {159} thrombosis plays an
+important role in the fatal termination. In cancer of the stomach,
+peritonitis from perforation of the stomach may close the scene. The
+fatal termination in cancer of the uterus is often brought about by
+the development of uraemic symptoms. The new growth in the pelvis
+involves the ureters, prevents the free egress of urine, and so causes
+the retention in the system of poisonous substances that should be
+excreted. Cancer in other parts of the body often causes death by
+metastatic cancers, that is, offshoots of the original cancer which
+occur in other organs. Usually these are in the liver, but sometimes
+they are in the brain, and sometimes in the bones that surround the
+spinal cord. In the course of their growth they cause pressure
+symptoms upon the nervous system, and this leads to death. If patients
+become very much weakened, as is not infrequently the case, thrombosis
+occurs, and portions of the clots may be shot into the pulmonary
+veins, and cause death in this way.
+
+Two affections which are quite common, one of them usually involving
+no danger at all, sometimes cause sudden death. They are varicose
+veins and a discharging ear. Varicose veins are the enlarged veins
+which occur on the limbs of a great many elderly people. If these
+people become run down in health and then exhaust themselves by
+overwork, the circulation through these enlarged veins is sometimes so
+impeded that clotting--thrombosis, as it is called--occurs. If a
+portion of the clot becomes detached, and is carried off into the
+circulation, a so-called embolus, this may cause sudden death, either
+by its effect upon the heart, or more usually upon the lungs.
+
+Middle-ear disease causes death, either by producing an abscess of the
+brain, or by causing thrombosis of some of the large veins within the
+skull. The dangers involved in a discharge from the ear are now well
+recognised. Insurance companies refuse to take risks on the lives of
+persons affected by chronic otitis media, as it is called
+scientifically. Such persons may run along in perfect good health for
+years without accident, but a sudden stoppage of the flow may be the
+signal for the formation of the brain abscess, with almost inevitable
+death.
+
+{160}
+
+Certain severe forms of the infectious fevers are very often fatal.
+These forms are popularly known as black fevers, that is, black
+measles, black scarlet fever, etc. These fulminant forms occur
+especially in camps, barracks, orphan asylums, jails, and the like,
+where the hygienic conditions of the patients have been very poor, and
+where the resistive vitality has, as a consequence, become greatly
+lowered. The black spots that occur on such patients are really due to
+small hemorrhages into the skin. The hemorrhages are caused by a lack
+of resistance in the blood-vessels and by a change in the constitution
+of the blood that allows it to escape easily from the vessels. Where
+such cases occur, patients should be fully prepared for the worst As a
+rule, the mortality is from 40 to 70 per centum.
+
+Acute pancreatitis is a uniformly fatal disease, though fortunately it
+is rare. It occurs much more frequently, however, than used to be
+thought. It occurs in persons over thirty who have been for some years
+addicted to the use of alcohol. The symptoms of the disease are severe
+pain in the upper left zone of the abdomen, that is, above and to the
+left of the umbilicus. This is accompanied by nausea and vomiting.
+Collapse ensues and death takes place on the second to the fourth day
+of the affection. This disease may have important medico-legal
+bearings. Some slight injury in the abdomen, as from a blow or a kick,
+may precipitate an attack in predisposed individuals. Accusation of
+murder may result. The mental attitude of the physician and the
+clergyman with regard to such cases must be very conservative. No
+opinion as to possible culpability should be ventured.
+
+Cholelithiasis, that is, stone in the bile duct, may not only cause
+severe pain, but may lead to rupture of the duct and a rapidly fatal
+termination. Owing to the practice of wearing corsets, gall-stones
+occur much more commonly in women than in men. Twenty-five per centum
+of all women over 60 years of age are found to have gall-stones. While
+these cases suffer from intense pain they are very seldom fatal. But
+it must not be forgotten that a fatal issue can take place either from
+collapse and stoppage of the heart, because of the intensity of the
+pain, or from perforative peritonitis.
+
+{161}
+
+The perforation of a gastric ulcer may cause symptoms which rapidly
+place the patient in a condition in which the administration of the
+Sacraments is very unsatisfactory. Gastric ulcers occur especially in
+young women, usually in those who follow some indoor occupation. Its
+favourite victims are cooks, though laundresses, seamstresses, and
+even clerks in stores, suffer from it much more than those engaged in
+other occupations. It occurs by preference in anaemic or chlorotic
+women. Sometimes, however, as in the case of cooks, the patients may
+seem to be in good health. Acute pain in the stomach region, followed
+by symptoms of collapse, should in such persons be a signal for the
+administration of all the Sacraments. Fatal peritonitis soon brings on
+a state of painful uneasiness ill adapted to the proper dispositions
+for the Sacraments.
+
+Two diseases that are fortunately very rare, but which are almost
+uniformly fatal, deserve to be mentioned here. In both of them the
+symptoms of the disease are manifested through the nervous system.
+They are tetanus and hydrophobia. Tetanus occurs as a consequence
+especially of a wound which has been contaminated by the street dirt
+of a large city, or the refuse of a farm. It follows deep wounds such
+as are made by a hayrake or a pitchfork; or seared wounds, such as are
+made by a toy pistol. A serum for the treatment of the disease has
+been discovered, but unfortunately the first symptom of tetanus is not
+the first symptom of the disease, but the preliminary symptom of the
+terminal stage of the disease, the affection of the nervous system.
+Practically all cases of acute tetanus terminate fatally. As soon as a
+patient exhibits the characteristic symptoms, the lockjaw, the stiff
+neck, and the rigid muscles, all the Sacraments should be
+administered. In tetanus, as a rule, consciousness is preserved until
+very late in the disease. In severe cases, however, a convulsive state
+of intense irritability develops in which the slightest sound or
+effort brings on a series of spasmodic seizures. Patients must be
+prepared, then, early in the disease, if possible.
+
+Rabies or hydrophobia is a disease which claims a certain number of
+victims every year in our large cities. {162} Its symptoms are the
+occurrence of fever and disquietude, with spasmodic convulsions of the
+muscles of the throat whenever an attempt is made to swallow. These
+symptoms come on from three to fifteen days after the bite of a mad
+dog. Unless the Pasteur treatment has been taken shortly after the
+bite of the animal was inflicted, no treatment that present-day
+medicine possesses is able to affect the course of the disease, and
+patients nearly always die. Their preparation, then, is a matter of
+necessity as soon as the first assured symptoms of the disease show
+themselves.  [Footnote 4]
+
+  [Footnote 4: One cannot help but add a word here as to the cause of
+  the disease, because clergymen can by their advice do something to
+  remedy the evil which lies at the root of the infliction.
+  Hydrophobia is due to stray dogs. In practically every case the
+  fatal bite is inflicted by some animal that no one in the
+  neighbourhood claims. Bites by pet dogs are rarely fatal. If
+  clergymen would use their influence to suppress the dog nuisance we
+  would soon have an end of hydrophobia.]
+
+Alcoholic subjects are very liable to unexpected death from a good
+many causes. Patients suffering from delirium tremens, for instance,
+may die suddenly in the midst of a paroxysm of excitement. Such a
+termination is not frequent, but it has occurred often enough to make
+it the custom, at asylums for inebriates, to warn friends who bring
+patients of the liability of such an accident. It is not so apt to
+happen during a first attack of delirium tremens as during subsequent
+attacks. It is most frequent among those whose addiction to alcohol
+for years has caused repeated paroxysms of delirium tremens. The cause
+of the sudden death is usually heart failure. This term means nothing
+in itself, but it expresses the fact that a degenerated heart finally
+refuses to act. Alcoholic poison in the circulation has led to fibroid
+degeneration of the muscular elements of the heart and made them
+incapable of proper function, or at least has greatly hampered their
+action, and the heart ceases to beat.
+
+It must be borne in mind that chronic alcoholism makes a number of
+serious organic diseases run a latent course. The patient is apt to
+attribute his symptoms to the after effects of the abuse of alcohol.
+Unless the doctor who is called in makes a very careful examination,
+serious kidney disease or even advanced pneumonia may not be
+discovered. Alcoholic subjects bear pneumonia very badly, and the
+preliminary {163} symptoms of the disease are often completely
+concealed by the symptoms due to the patient's alcoholism. Other
+infectious diseases, as typhoid fever, tuberculosis, and even various
+forms of meningitis, may run a very insidious course and give but very
+slight warning of their presence. The result is that these diseases
+are very frequently fatal in alcoholic subjects.
+
+Old inebriates bear operations badly, and the mortality after any
+operation in such subjects is distinctly higher than in normal
+individuals. One reason for this is that considerably more ether or
+chloroform is required to produce narcosis in alcoholic subjects than
+in ordinary individuals. Ether and chloroform are very irritant to the
+kidneys. The kidneys are prone to be affected more or less in old
+alcoholic subjects. Death from oedema of the lungs or from some form
+of pneumonia is not infrequent in these post-operative cases, and
+gives as a rule but little warning of its approach.
+
+It is clear, then, that alcoholic subjects must be prepared with
+special care whenever disease is actually present or an operation is
+to be performed. Too great care can scarcely be exercised in their
+regard. What would seem overcaution will save many a heartburn to
+friends and priest, for it is in alcoholic subjects especially that
+some of the saddest cases of unexpected death without preparation
+occur.
+
+JAMES J. WALSH.
+
+
+{164}
+
+XIII
+
+THE MOMENT OF DEATH
+
+It not infrequently happens that a priest reaches a patient who has
+just died. Conditional absolution, baptism, or other spiritual
+ministration might have been offered if there were signs of life, but
+the heart and lungs are still, "the patient is dead," and the priest
+leaves the place without doing anything. Yet the patient may not
+really be dead.
+
+Our knowledge of the precise time the soul leaves the body is very
+imperfect. There is, we are aware, a close connection between the
+vital functions of the body, taken together or singly, and cellular
+activity. If the cells are not destroyed, a vital function sometimes
+may be restored after its cessation, but if the cells are destroyed up
+to a certain extent, the vital function is not recoverable. For
+example, if the various bodily cells of a patient dead from diphtheria
+are examined microscopically, it will be found that the diphtheria
+toxin has disintegrated the nuclei of these cells. What number of
+cells proportionate to the whole in, say, the heart should be
+destroyed before the vitality of that organ is lost, is not clearly
+known. Where the cells are intact, or nearly so, mere absence of
+respiration, or of even the heart movement, are not absolute proof of
+death. Numerous cases are found in medical records of persons that had
+been lying under water for many minutes, up to even an hour, but who
+were restored to life by patient and skilful efforts; and of late
+remarkable restorations after what was practically death, under
+anaesthesia and otherwise, have been reported. The technique consists
+chiefly in rhythmical compression of the heart, commonly after
+surgical exposure of that organ, with artificial respiration, and, in
+Crile's method, peripheral resistance is {165} employed to raise the
+blood pressure. Ludwig in 1842, experimented in cardiac massage, and
+Professor Schiff at Florence was the first to apply the method to
+human subjects. Kemp and Gardner, in the _New York Medical Journal_,
+May 7, 1904, described various methods used in attempting
+resuscitation.
+
+Professor W. W. Keen of Philadelphia has collected the records of the
+chief cases of resuscitation after apparent death (see _The
+Therapeutic Gazette_, April, 1904), and some of these are the
+following: Dr. Christian Igelstrud of Tromsoe, Norway, in 1901, was
+operating upon a woman, 43 years of age, for cancer. During the
+operation, which was a coeliotomy, she collapsed and her heart ceased
+beating. After the usual means for resuscitation had been
+ineffectively tried, her heart was laid bare. Igelstrud took hold of
+the heart with his hand and made rhythmic pressure upon it. In about
+one minute the heart began to pulsate. The patient was discharged from
+the hospital five weeks afterward.
+
+Tuffier (_Bull, et mem. soc. de chir._, 1898, p. 937) in 1898 had a
+patient whose heart stopped after an operation for appendicitis. The
+surgeon had left the operating room, but he returned, laid bare the
+heart, pressed it rhythmically, and after two minutes it began to move
+again. The patient breathed regularly, his eyes opened, the dilated
+pupils contracted, and he turned his head. After the opening over the
+heart had been closed, however, he died.
+
+Prus (_Wiener klin. Woch._, no. 21, 1900, p. 486) by the same method
+started contractions of the heart after 15 minutes in a man that had
+hanged himself. The effort at resuscitation was made two hours after
+the suicide had been discovered, but the recovery did not go beyond
+imperfect movements of the heart, which gradually ceased.
+
+Maag (_Centralbl. f. Chir._, 1901, p. 20) reports the case of a man
+who under chloroform anaesthesia ceased breathing and whose heart
+stopped. After 10 minutes the patient was pulseless, without
+respiration, cyanotic, and cold. The heart was exposed and compressed
+rhythmically; it was restored to action, and he began to breathe. He
+remained alive for 12 hours, seemingly asleep; then he died.
+
+{166}
+
+Starling and Lane (_Lancet_, Nov. 22, 1902, p. 1397) were operating
+upon a man 65 years of age. The heart and respiration ceased. Lane put
+his hand into the abdominal incision and squeezed the heart through
+the diaphragm. After twelve minutes of artificial respiration the
+lungs and heart began to act. The patient afterward was discharged
+from the hospital cured.
+
+Sick (_Centralblatt f. Chirurgie_, Sept. 5, 1903, p. 981) reports a
+very remarkable case. A boy of 15 years of age died upon the operating
+table. _Three quarters of an hour_ after the heart had ceased to beat
+it was laid bare. The flaps did not bleed, the pericardium was
+bloodless, the heart was motionless, relaxed, and cold. After a
+quarter of an hour, during which the heart was compressed, and
+artificial respiration was kept up, that is, one hour after what any
+physician would call death, the heart was beating and respiration was
+restored. Two hours later the boy became conscious and complained of
+great thirst and dyspnoea. He remained in this condition for
+twenty-seven hours, and during that time his speech was indistinct but
+intelligible. He then died.
+
+Dr. George W. Crile, of Cleveland, Ohio, reports the case of a woman
+whose heart movement and respiration had ceased for six minutes. She
+was restored completely, even without exposing the heart. Dr. Crile
+uses an inflated rubber suit on the patient to raise the blood
+pressure by peripheral resistance--he does not expose the heart. He
+had another case, a man 38 years of age, who "died during operation,
+was resuscitated, and died again two hours later."
+
+Two Hungarian labourers, whose skulls had been crushed in the same
+accident, were brought into Dr. Crile's clinic in a dying condition.
+The heart of one of these men ceased beating as he was brought into
+the operating room. After nine minutes the surgeons began to work upon
+him to resuscitate him. They succeeded, but he lived for only 28
+minutes.
+
+They then examined the other man and found him dead. Just 45 minutes
+after this second patient had been brought into the operating room the
+effort to resuscitate him began. As he had not been observed while the
+physicians had been engaged with the first man, they do not know when
+his heart {167} had ceased to beat, but he certainly was dead in the
+opinion of skilled observers. They resuscitated him so well that he
+moved his head away from the operator who was relieving the depression
+of the skull, but he died again in 34 minutes.
+
+These cases are not what is commonly called conditions of suspended
+animation. All the patients would have been pronounced dead by any
+physician, and if they had been left untouched, they surely never
+would have been revived.
+
+There have been about thirty attempts made by surgeons to restore
+patients who were dead in the full acceptance of the term as used at
+present. Four of these attempts resulted in complete success, others
+in a partial recovery, and many were without positive result. The
+number of complete and partial resuscitations, however, are enough to
+justify a priest in giving conditional absolution or baptism within an
+hour, or even two hours, after a patient has to all appearance died,
+especially in accident cases. We do not know when the soul enters the
+body, and there is the same doubt as to the moment when the soul
+leaves the body. In these latter cases we should give the patient the
+benefit of the doubt.
+
+AUSTIN OMALLEY.
+
+
+{168}
+
+XIV
+
+THE PRIEST IN INFECTIOUS DISEASES
+
+The subject of infection is complicated, and the medical doctrine
+concerning it is far from certainty despite the multitude of facts
+presented by bacteriologists, chemists, pathologists, and clinicians.
+Before the days of bacteriology the term _Infectious_ commonly was
+applied to diseases produced by no known or definable influence of any
+person on another, but wherein common climatic or other widespread
+conditions were thought to be chiefly instrumental in the diffusion.
+The contagious disease was one transmitted by contact with the
+patient, either directly by touch, or indirectly through the use of
+the same articles.
+
+Now we know that many diseases called infectious are caused by
+micro-organisms, and we group others under this class because we hold
+theoretically that they have their origin in microbes not yet
+isolated. Hence we define an infectious disease as one which is caused
+by a living pathogenic micro-organism, which enters the tissues from
+without, and is capable of multiplying therein. These micro-organisms
+have a time of incubation during which a poison is made in the
+tissues, and this brings about the intoxication we call the disease.
+
+Infection is a general term that includes contagion; and contagious
+diseases are infective diseases that may be transmitted directly or
+indirectly from patient to patient.
+
+The pathological micro-organisms with which we shall deal in this
+article are (1) the Schizomycetes or Fission-Fungi, which are
+microscopical organisms that multiply by fission, and are commonly
+known as Bacteria; and (2) a few Protozoa, which are animal
+micro-organisms.
+
+The bacteria are classed with plants because, like plants, {169} they
+derive nourishment from both organic and inorganic material. They have
+no seeds or flowers, but many of them are reproduced by spores. They
+consist of cells, single or grouped, which when spherical are called
+_cocci_, when rod-shaped, _bacilli_, when spiral, _spirilla_. There
+are various subdivisions of these groups. We do not know whether
+bacterial cells have nuclei or not.
+
+A micro-organism is a _parasite_ when it can live in animal tissues.
+It is a _saphrophyte_ when it can exist outside animal tissues. If a
+parasite cannot exist outside animal tissues, it is an _obligatory
+parasite_; if it can, it is a _facultative saphrophyte_. Similarly the
+saphrophytes are classed as obligatory saphrophytes and facultative
+parasites. Pathological micro-organisms have very complicated products
+which are in large part poisonous.
+
+Bacteriologists require seven conditions to prove a micro-organism the
+_specific_ cause of a given disease, and all these conditions have been
+fulfilled for anthrax, diphtheria, and tetanus. The specificity has
+been satisfactorily settled for glanders, malaria, tuberculosis,
+actinomycosis, gonorrhoea, and malignant oedema. It has been
+practically settled for typhoid, influenza, the Madura disease, and
+the bubonic plague; and incompletely defined for leprosy, relapsing
+fever, and Malta fever.
+
+There are certain diseases which are not called specific, because they
+may be produced by various micro-organisms. These are pneumonia,
+osteomyelitis, septicaemia, pymaeia, endocarditis, meningitis,
+erysipelas, angina Ludovici, broncho-pneumonia, and similar maladies.
+Cholera and dysentery also might be grouped with these, as cholera
+appears to be produced by various vibrios and dysentery by different
+amoebae.
+
+There are other infective diseases, in which we have not yet found the
+causative micro-organism, but we presume its existence. These are:
+rabies, syphilis, yellow fever, dengue, typhus, mumps, whooping-cough,
+smallpox, measles, scarlet fever, and others among the exanthemata.
+
+Malaria and similar diseases are caused by plasmodia, which are
+protozoa and not bacteria.
+
+{170}
+
+The priest is almost as frequently exposed to the danger arising from
+contagion as the physician is, and a priest that often ministers to
+the sick is liable to grow imprudently indifferent to danger. For one
+priest that is too much afraid of disease we find a hundred that have
+not sufficient dread.
+
+No matter what medical science may say to the contrary, many priests
+hold that they have often left smallpox cases, for example, without
+disinfecting themselves, and that they have not spread the disease.
+This is a very rash assertion. It is absolutely certain that smallpox
+has been communicated to susceptible persons by those coming from
+patients ill with that disease merely passing the susceptible man on
+the street. The number of persons that will not take smallpox when
+exposed to it is very large. In Washington in 1895, during an epidemic
+of smallpox, 187 persons, to my personal knowledge, were exposed to
+one group of 39 smallpox patients without taking the disease. The
+unharmed had been present in sick-rooms or had even nursed the
+patients, not knowing that the disease was smallpox. In this epidemic
+eight persons lived in the same rooms with, or visited frequently, two
+patients that afterward died of virulent smallpox, and none of the
+eight took the disease. One of these eight, however, went into a
+dramshop, had one glass of beer and left immediately, and in fourteen
+days afterward (the average time of incubation) we took the barkeeper
+to the smallpox hospital. This barkeeper had not been exposed to
+smallpox except by contact with the man mentioned here. There were
+about 60 cases of smallpox in that epidemic, and we traced every one
+to direct or indirect contact with one initial case.
+
+If we were infected by every exposure to contagious disease the world
+would be depopulated. It is true that you cannot give some persons
+diphtheria if you actually put the Klebs-Loeffler bacillus into their
+mouths, and nurses and physicians in consumptive wards have the
+tubercle bacillus in their nostrils without ill effect. So for many
+diseases; but it unfortunately remains true that there are susceptible
+persons everywhere who will at once take a disease when they are
+exposed to it.
+
+{171}
+
+Immunity changes in the same person. Starvation, fatigue, loss of
+blood, unsuitable diet, exposure to heat, cold, and moisture, and
+other influences lessen the power of resistance to infection. Men vary
+almost as do the lower animals as regards infection. The quantity of
+tetanus toxin that will kill 400 horses will not bother a hen;
+Algerian sheep and the white rat are not affected by anthrax, but
+other sheep and the brown rat are very susceptible; a hog will not
+take glanders, man and a horse will; men, cattle, and monkeys have
+tuberculosis, dogs and goats do not; white men with few exceptions are
+susceptible to yellow fever and malaria, negroes are practically
+immune; negroes readily succumb to the fatal sleeping sickness, white
+men are almost immune; and similar differences are observable in the
+same race or family.
+
+The question of immunity to infectious disease is very difficult to
+make clear because it is so technical, and it is only a theory at
+best. The poison of an infectious disease kills by splitting and
+destroying the nuclei of the body's cells. The toxic products of the
+micro-organisms seem to become chemically united with certain
+molecules of the body cells and to inhibit the normal function of
+these molecules. According to Erlich's theory there are other
+molecules in cells which neutralise toxic molecules, and when the
+neutralising molecules appear in excess the patient recovers. These
+neutralising bodies are called antitoxins.
+
+Some antitoxins are always present in cells, and where the normal
+quantity of these is used up in neutralising toxins, other antitoxic
+bodies are formed, until finally the excess of these is thrown off
+into the blood serum. After they are called into being by the
+excitation of some toxic products, like those of the typhoid bacillus
+for example, the antitoxins remain in the blood for years, ready to
+neutralise at once any influx of fresh infection. In other diseases,
+like diphtheria and pneumonia, they are soon lost,--hence the
+recurrence of such diseases. The acquired antitoxin lasts after
+smallpox, vaccinia, yellow fever, scarlet fever, measles, typhoid,
+mumps, and whooping-cough; it is very transient after pneumonia,
+influenza, diphtheria, erysipelas, and cholera.
+
+{172}
+
+In serum therapy antitoxins are artificially excited into being in the
+blood of beasts. This artificially prepared antitoxin is injected into
+the blood of, say, a diphtheria patient, and the poison is at once
+neutralised, instead of leaving the patient to make his own antitoxin
+and letting him perhaps fail in the effort.
+
+The antitoxin produced in the contest of the body cells against some
+diseases will not only neutralise the toxin of a particular disease,
+but it will also neutralise the toxin of a second disease. By
+vaccinating a person we inoculate him with vaccinia or cowpox. His
+body cells make an antitoxin which neutralises the toxin or virus of
+cowpox, he recovers from this light disease, and the antitoxin now
+remaining in his body prevents for years another successful
+inoculation with cowpox. It does more: in 90 per centum of cases it
+will prevent successful infection with smallpox.
+
+Smallpox (the pocks, pokes or pockets of matter,--opposed to the great
+pox or syphilis) has been known from very early times--probably even
+from 1200 B.C. The name "small pokkes" was first used in England in
+1518. The disease was brought to America in 1507.
+
+It may be communicated from the sick to the healthy (1) by persons
+suffering with the disease; (2) by bodies of persons that have died of
+smallpox; (3) by infected articles; (4) by healthy third persons; (5)
+by the air, to persons living even at some distance; (6) by
+inoculation. The poison enters the body by the mucous membrane of the
+nose, mouth, or respiratory tract, and probably through the mucous
+membrane of the stomach and through the broken skin.
+
+Patients can communicate the disease probably during the period of
+incubation (from 5 to 20 days after exposure to the disease--commonly
+about 14 days); and certainly from the initial stage until no trace is
+left of the final skin-desquamation. The infection is most active
+during the formation and duration of the pocks. The mildest smallpox
+in one person can cause malignant smallpox in another, and _vice
+versa_. The mortality in the unvaccinated is between 40 and 50 per
+centum.
+
+A typical case of confluent smallpox at its height is the {173}
+ugliest disease in appearance and stench and almost in substance,
+known to medicine. Anyone liable to infection by it, or likely to
+carry it to others, who says he is "not afraid of it," has either
+never seen it and he is talking childish nonsense, or he has seen it
+and he is a fool.
+
+The face is a bloated mass of corruption; the eyes are swollen shut;
+the nose, cheeks, lips, and neck are puffed out enormously; the mouth
+is a large sore, ulcerous, and spittle trickles from it ceaselessly.
+The fever is up to 103 or 105 degrees; there is an unquenchable
+thirst, a vile stench, sleeplessness; often delirium is the only
+relief, and there is one chance in two of a disfigured recovery.
+Tobacco, alcoholic liquor and a walk in the fresh air will not
+disinfect the visitor to such a disease. Years ago I investigated in
+the laboratory the popular notion that tobacco is a disinfectant. I
+found that bacteria, the diphtheria bacillus and swarms of others more
+delicate, will grow as well in the presence of a large piece of "Navy
+Plug," as when tobacco is absent. Chewing tobacco, whiskey, a walk in
+the fresh air as disinfectants, the Sioux medicine-man's powwow, the
+hind leg of a rabbit as a charm, are all in the same category.
+
+The first and chief protection against smallpox is vaccination.
+Vaccination does not always prevent infection by smallpox, but it does
+prevent it in more than 90 per centum of exposures to the disease.
+Welch reported in 1894 that the death-rate in one series of 5,000
+cases of smallpox was 58 per centum in the unvaccinated, and 16 per
+centum in the vaccinated, but the vaccinated took the disease in less
+than 10 per centum of the exposures. During the Franco-German War in
+1870-1871, the Germans who had a million vaccinated men lost 458
+soldiers from smallpox while a great epidemic of smallpox was existing
+in Germany; the French, who were indifferent to vaccination, during
+the same time lost 23,400 men from this disease alone. In the United
+States, where there is no compulsory vaccination except such attempts
+as school boards make, there were between July and December, 1903,
+13,739 cases of smallpox; in Germany, where there is a compulsory
+{174} vaccination law, there was no smallpox at all, during the same
+time, except 14 cases in two seaports, Bremen and Kiel, whither the
+infection had been brought from without.
+
+Before 1874 there had been no compulsory vaccination law in Germany
+except for the army. In 1871, 143,000 Germans died of smallpox. Since
+the law went into effect in 1874 the disease has been stamped out,
+until there was between July and December, 1903, only one death from
+smallpox in Germany.
+
+The chart on page 175 will show very graphically the effect of
+vaccination upon smallpox.
+
+In October, 1898, smallpox was endemic in Puerto Rico; in December,
+1898, it was epidemic; in January, 1899, it was all over the island
+and spreading rapidly. In February, 1899, compulsory vaccination was
+begun and carried out for only four months, when 860,000 vaccinations
+had been made in a population of about 960,000 people. The death-rate
+from smallpox dropped from 621 a year to 2.
+
+During the century preceding Jenner's discovery of vaccination,
+according to Neimeyer's calculation 400,000 people died of smallpox
+each year in Europe. Bernouilli, a trustworthy statistician, says that
+during that same century, "Fully two-thirds of all children born in
+Europe were, sooner or later, attacked by smallpox, and on an average
+one-twelfth of all children born succumbed to the disease."
+
+Early in the sixteenth century 3,500,000 people in Mexico had smallpox
+(Prescott's _Conquest of Mexico_). In 1707, in Iceland, 18,000 of the
+population of 50,000 died of smallpox; and in 1891, 25,000 persons in
+Guatemala died of this disease. In 1875 there were anti-vaccination
+riots in Montreal, and as a consequence most of the younger
+inhabitants of that city were not vaccinated. In 1885, smallpox was
+brought in from Chicago; 3,164 persons died of the disease; of these
+2,717 were children under ten years of age, and thousands had the
+disease.
+
+{175}
+
+[Illustration: ]
+
+PRUSSIA.--With compulsory vaccination and
+compulsory revaccination at the age of 12.
+
+HOLLAND--With compulsory vaccination of children before entering a school.
+
+AUSTRIA.--Without compulsory vaccination.
+
+
+{176}
+
+Vaccination may render one immune to smallpox for many years, but if
+the disease is epidemic it is well to renew the vaccination after
+about eight years. In normal vaccination, where the lymph has been
+derived from a reliable source, on the third or fourth day pale red
+papules develop at the point of inoculation, and about the tenth day
+these have become pustules. The vesicles dry gradually, and between
+the fourteenth and twentieth days the scab falls off, leaving a pitted
+scar. About the fifth day an aureola of inflammation forms around the
+pocks, from a quarter of an inch to two inches in extent, and the
+inflamed area may be somewhat sore. A shield should be kept over the
+vaccination spot for two days, and this is then to be replaced by a
+piece of sterile gauze held in place by narrow strips of
+sticking-plaster above and below the inflamed area. Sometimes hives
+and other rashes occur in vaccination, but they are unimportant.
+
+Where there is a very sore arm or other trouble, the cause may be a
+pre-existing unhealthy condition, like scrofula for example, or the
+patient has scratched the pocks, or infected them from his clothing,
+or the vaccine lymph was unsterile. A careless and dirty vaccinator
+might infect an arm with pus organisms. If good glycerinated lymph,
+not too fresh or too old, is used, there is seldom any trouble; but in
+any case all the annoyance that may come from vaccination is
+infinitesimal when compared with the smallpox it averts.
+
+We may take a smallpox case as a typical contagious disease in which
+the priest is to give the last Sacraments; and the disinfection and
+other precautions observed in such a visit will serve for any other
+very contagious disease. For only typhus and one or two other maladies
+are the precautions so elaborate as those needed in smallpox.
+
+There is a dress, called "Dr. Hawes' Antiseptic Suit," and in time of
+epidemics a priest should have one of these suits, or one made after
+it as a pattern--they can be obtained in the shops for two or three
+dollars. They cover the entire person, even the shoes, and they make
+unnecessary the changing of clothing and the disinfection of the
+exposed parts of the body. The hands of the priest may be left bare
+after fastening the sleeves of the suit about the wrists, or he may
+wear surgeon's thin rubber gloves. In visiting a patient that has any
+of the contagious diseases mentioned in this chapter, the priest
+should never touch {177} his own face with his hands after he has
+entered the sick-room until he has washed them in a bichloride of
+mercury solution.
+
+A ritual should not be taken into a smallpox room, because a book
+cannot be disinfected without rendering it useless. The priest should
+memorise the prayers and ceremonial, or write them out on paper which
+can be burned in the hospital or the patient's house.
+
+The priest may be obliged to administer baptism, to hear confession,
+to give the Viaticum and Extreme Unction. Before going to visit a
+smallpox patient let him find out from the physician in attendance
+whether the patient can receive the Viaticum, whether he can swallow
+it or not, whether he can open his mouth enough to take it. Ask also
+about the possibility of vomiting. Only a very small particle is to be
+brought in the pyx.
+
+The leather cover for the pyx should not be taken into a smallpox
+room. Set the pyx inside a corporal, wrap the corporal in paper, and
+put this package into the pocket of the Hawes suit before entering the
+room.
+
+As to the use of a stole,--the moralists say "graviter peccatur ab eo
+qui sine urgente necessitate sine ulla sacra veste unctionem
+administrat." There is a grave necessity here for doing away with the
+stole because of the difficulty in disinfecting it, unless you have
+one made that can be put into boiling water for ten minutes before you
+leave the patient's house.
+
+The oil-stocks should contain only as much oil as is necessary for the
+single occasion, because what remains, with the cotton, should be
+burned in the patient's house.
+
+Do not remain in the room longer than you must unless you have had
+smallpox. If there is any prayer or ceremonial that can be omitted, by
+all means leave it out. Lehmkuhl says that the penitential psalms and
+the litanies may be omitted. Baptise by the short form.
+
+St. Alphonsus Liguori (_Theol. Mor._, lib. 5, tr. 5, n. 710) tells us
+there is no obligation to anoint both eyes and both ears, "si adsit
+periculum infectionis," but danger of infection is not materially
+increased by anointing both sides. {178} Lehmkuhl adds, "excepta
+dispensatione Sedis Apostolicae addatur unctio pedum." When the feet
+are to be anointed do not touch the bed-clothing,--tell the nurse to
+uncover the feet.
+
+St. Alphonsus (_loc. cit.,_ n. 729) speaking of extreme unction has
+these words: "Pastor ratione officii tenetur sub mortali dare lis qui
+petunt, nisi justa causa excuset: etiam tempore pestis, modo possit
+absque periculo vitae; cum eo non teneri docent _Tann. Dian._," etc.
+If you have not had smallpox you certainly risk your life by going
+into the room of a smallpox patient, and the danger of infection is
+greater in typhus; but suppose a pastor were inclined to take
+advantage of the excuse, he would be obliged at any risk to go into
+such a room to hear confession or to baptise, and if he hears
+confession he may as well stay for the anointing.
+
+If you anoint a patient that has confluent smallpox you probably can
+not wipe away the oil, because the skin will be pustular. Wipe the
+oil-stock carefully; then all cotton used should be wrapped in paper
+and burned in the paper before you leave the house. After anointing,
+you had better wash your hands carefully in water in which a
+bichloride of mercury tablet has been dissolved--do not use soap and
+do not put the bichloride in a metal vessel. Wash your hands thus
+before you leave the sick-room.
+
+If the patient can receive the Viaticum let him lie on his back, and
+you should drop the Host into his mouth without touching him with your
+hand. St. Alphonsus says: "non licet tempore pestis porrigere
+Eucharistiam medio aliquo instrumento . . . sed manu danda est" There
+is no need of an instrument. If there are any crumbs left in the pyx
+make the patient take them. St. Alphonsus says this may be done, and
+it would be almost certain infection to take them yourself if you have
+not had smallpox recently. Let as little ablution water as possible be
+given to the patient.
+
+When you leave the room, put the pyx, oil-stocks, corporal, and stole
+in a pan of water and boil them for ten minutes. This will disinfect
+them thoroughly and will not injure them in any way. Then take off the
+Hawes suit as near the street-door as possible and wet it with
+bichloride {179} solution. Wash your hands again in the bichloride
+solution and rinse off the bichloride; take the pyx, oil-stocks,
+corporal, and stole and leave immediately. Do not touch the door-knob
+when going out--let some one open the door for you--and do not shake
+hands with any one.
+
+Typhus fever is now rare in America, but there was an outbreak in New
+York City in 1881. This was the fever that killed multitudes of Irish
+emigrants about the middle of the nineteenth century. It is called
+also spotted fever, camp, jail, ship, and hospital fever, and it has
+many other names. The name typhus is from [Greek text], a smoke or
+fog, and it indicates the befogged, stuporous condition of the
+patient. Typhoid fever is so called because it has some resemblance to
+typhus.
+
+The specific cause of typhus is unknown, but the contagion develops
+and reproduces itself in the body of the patient. It is thought that
+the contagion exists in the secretions and excretions of the body and
+in the exhalations from the lungs and skin. The infection can
+certainly be carried by clothing, dust, furniture, conveyances of all
+kinds, and dead bodies, and it remains active for months. It may be
+transmitted through the air for short distances, not nearly so far as
+the air will carry the contagion of smallpox. In well-ventilated rooms
+there is less danger of infection, and a typhus patient should have at
+least 1,500 cubic feet of air space. The contagion may be transmitted
+in all stages of the disease and during convalescence.
+
+Physical weakness, anxiety and worry, improper food, and poverty, are
+disposing conditions for infection by typhus. The mortality is about
+10 per centum--much less than that of smallpox.
+
+In giving the last Sacraments to a typhus patient exactly the same
+method should be followed as that observed for a smallpox patient.
+Keep as far from the patient as possible. After you touch him in
+anointing or in giving other Sacraments step away from him to say the
+necessary words. Do not stand between him and an open fireplace,
+window, door, or ventilator.
+
+Relapsing fever, or famine fever, caused by Obermeier's {180}
+spirillum, is sometimes associated with typhus. It has a mortality
+that can go up to 14 per centum in unfavourable circumstances, but the
+disease is not more contagious than typhoid under hygienic
+surroundings. Wash the hands in bichloride solution after visiting a
+case, and do not touch the door-knob or things in the room.
+
+Rabies (called also hydrophobia in man) is a rare disease. It is
+communicable by inoculation, but it is very doubtful that the disease
+has been communicated from man to man. The saliva from a person
+suffering with rabies if injected into a warm-blooded animal will
+cause rabies, and on that account it is prudent to use care in
+touching such a patient in administering the last Sacraments. The
+virus might enter through an abrasion on the priest's hand.
+
+There is a false hydrophobia observed in excitable persons that have
+been bitten by a dog thought to be mad. The dog that has genuine
+rabies grows sullen, it hides in comers, and it snaps at everything
+presented to it A sticky, frothy mucus drivels from its mouth and its
+eyes become red. It will run straight ahead, snapping at anything it
+meets; it swallows small stones, chips, and similar objects; it does
+not avoid water. It howls, grows lean, and its hind legs and lower jaw
+become paralysed.
+
+In man there is a premonitory stage; a furious stage, which lasts from
+about a day to three days; then a final paralytic stage. It is well to
+wait for the paralytic stage before anointing the patient, because in
+the other stages the slightest touch causes violent spasms. Confessors
+should note that the virus of rabies excites the sexual centres.
+
+Scarlatina or scarlet fever first appeared in North America in
+Massachusetts in 1735. It is especially an April disease here. One
+attack commonly makes the person immune for life. It is a disease of
+children, but it attacks adults, and it is fatal among children old
+enough to receive the last Sacraments. Some epidemics are very
+malignant; and in such times all the precautions mentioned in speaking
+of the visitation of smallpox patients should be observed. The
+contagion is spread just as that of smallpox is spread, except that it
+is not carried through the air so far.
+
+{181}
+
+Diphtheria is a disease of children, but it also can be fatal to
+adults and to children old enough to receive the last Sacraments. It
+is caused by the Klebs-Loeffler bacillus, and it most frequently
+attacks the throat and nostrils. It can start in a cut in the skin, or
+on any mucous surface, as the inside of the eyelid. The contagion is
+not in the breath, but it can be coughed out. It is in the saliva of
+the patient and it gets on his hands and on what he and the nurse
+touch. It is not nearly so infectious as smallpox and scarlet fever.
+
+In visiting such a patient the priest should be careful not to touch
+anything in the room, and he should wash his hands in the bichloride
+solution after a visit. He must also wet the soles of his shoes with
+the solution. He should be very careful lest a child suddenly cough
+fine sputum containing the bacillus into his eyes. Diphtheria in the
+eyes would destroy sight, and I have seen a pair of spectacles save a
+man in a case like that. A detailed description of the disinfection in
+diphtheria is given in the chapter on Infectious Diseases in Schools.
+
+Glanders is sometimes transmitted from beasts to man, and it is almost
+always fatal in the human subject. The disease is caused by the
+glanders bacillus. Horses, asses, dogs, cats, goats, and sheep are
+susceptible to the disease; pigs are somewhat susceptible; cattle and
+birds are immune. The infection is in the discharge from the nose of
+the patient and on the skin eruptions. The same precautions are to be
+taken as are needed in a diphtheria case.
+
+Influenza, called popularly the grippe, is caused by the bacillus
+influenzae, which was isolated by Pfeiffer in 1891. The bacillus is
+found in the nasal secretions and in sputum; it dies in from twelve to
+twenty-four hours when dried. The disease is contagious, and it is
+often fatal in alcoholics, the overworked and harassed, and in those
+that have chronic diseases. In any case it is a serious malady.
+Disinfect the hands after visiting a case.
+
+Dengue becomes epidemic at times, especially in the Southern States.
+The disease is very severe, painful, and depressant, but the mortality
+is quite low except in complication with other maladies. Its cause is
+not known. It is {182} very contagious and has symptoms which belong
+to the class of disease in which are scarlatina and measles. The
+priest should act as in a case of scarlatina.
+
+There is a form of pneumonia which spreads so widely and rapidly that
+it is called epidemic pneumonia. In visiting patients afflicted with
+this disease the priest should act as in a diphtheria case.
+
+Epidemic cerebrospinal meningitis is a very fatal disease at times in
+America. Even those patients that survive are frequently made blind or
+deaf, or are left injured otherwise. The malignant type is nearly
+always fatal. In some epidemics the mortality is as high as 75 per
+centum. The visiting priest should act as in a case of diphtheria,
+although the danger of direct infection is not great.
+
+Tuberculosis is a chronic febrile disease, caused by the bacillus
+tuberculosis, a parasitic micro-organism discovered by Koch in 1882.
+One-seventh of mankind die by this disease. The bacillus remains
+virulent a long time after it leaves the human body, but it is soon
+killed by sunlight.
+
+Tuberculosis of the lungs is spread especially through sputum. In the
+room occupied by the patient, the clothes, furniture, walls, doors,
+and floor are infected by the bacilli coughed out, even when the
+consumptive is careful to disinfect the sputum, and, by the way, he
+rarely is careful. When the priest visits a consumptive's room he
+should disinfect his hands with bichloride.
+
+Leprosy is caused by the lepra bacillus, discovered by Hansen in 1871.
+It is present in many parts of the body, especially in the glands and
+nervous tissues, and it is found in the mucosa of the mouth and in the
+nasal secretions. It is very profusely distributed in the corium of
+the skin. The name comes from [Greek text], scaly.
+
+Leprosy is present here and there along the Mississippi valley from
+Minnesota and Wisconsin to Louisiana. It is found also in California,
+Florida, and the Dakotas, in the Philippines, the West Indies, and the
+worst infected part of the world is the Hawaiian Islands.
+
+The bacillus has not been found in rooms used by lepers, nor in the
+soil of their graves. Inoculation by leprous {183} material has failed
+so far undoubtedly to cause leprosy. There is much dispute concerning
+the contagiousness of this disease. The Dominican Sisters nursing in
+the Trinidad asylum have been in constant contact with the lepers for
+about thirty years but none of them has yet contracted the disease.
+Zambaco Pasha tells of a family which has lived in the leper asylum at
+Constantinople for three generations and no one in the family has been
+infected. Father Damien, however, in Molokai, and Father Boglioli, in
+New Orleans, did contract the disease. There have been cases of
+infection from man to man, but ordinarily it seems that some unknown
+factor must be present to insure infection.
+
+A priest need have no more fear in visiting a case of leprosy than he
+should have in visiting a case of tuberculosis--not so much. He may
+wash his hands in bichloride solution after anointing a leper, but it
+is scarcely necessary to do even that.
+
+Actinomycosis ([Greek text], ray-fungus) is a disease caused by
+actinomyces, a micro-organism that partly resembles a bacterium and
+partly a fungus. The disease can be fatal. It is very improbable that
+it ever passes from man to man, but as a matter of prudence the priest
+should wash his hands in bichloride after anointing such a patient.
+
+Septicaemia, or blood-poisoning, can be brought about by different
+pyogenetic bacteria,--the varieties of the staphylococci (irregularly
+grouped cocci), streptococci (chain-cocci), pneumococci, and others.
+The danger of infection is so slight that it may be neglected.
+
+Erysipelas can be fatal, especially in alcoholics, the aged, and in
+chronic diseases. Erysipelas is contagious, especially if the bacteria
+get into an abrasion in the skin. Patients having this disease
+sometimes grow delirious and violent, and the priest should be careful
+how he handles them. Disinfect the hands after anointing such a
+patient.
+
+Tetanus, or lockjaw, is not communicable except by inoculation. The
+bacillus, which was isolated by Kitasato, the Japanese bacteriologist,
+in 1889, is found everywhere in soil, hay dust, floors, on old nails,
+especially on the floors of old wooden slaughter-houses. It grows best
+in deep wounds {184} where it is shut off from the oxygen of the air.
+Hence the danger of treading upon a nail that has been lying near the
+ground.
+
+Beriberi, a disease observed especially among seamen, appears at times
+in our coast towns. It is always a very serious malady and sometimes
+it is rapidly fatal. The infective agent, which is not known, is not
+undoubtedly communicable from man to man, but it is carried from place
+to place, and it clings to ships and buildings; it thrives in hot,
+moist, crowded places. The priest should disinfect his hands after
+visiting a case.
+
+Anthrax, called also wool-sorter's disease and splenic fever, is a
+very fatal disease, and the bacillus is communicable to any one
+through an abrasion of the skin, through the intestines by swallowing
+it, or through the lungs by breathing it in in dust. Disinfect the
+hands and the shoes after visiting a patient. Be careful not to touch
+anything in his room.
+
+The bacteria that cause typhoid fever, Asiatic cholera (which has been
+epidemic in America) and epidemic dysentery must get on the hands, or
+on food, or in water, and thus reach the mouth and be swallowed before
+they produce these diseases. Act in cholera as in anthrax, and
+disinfect the hands after visiting a case of typhoid.
+
+The bubonic plague, the most fatal of all epidemic diseases, has
+already appeared in California and Mexico. It is caused by a specific
+bacillus isolated by Kitasato and Yersin in 1894. The disease is
+communicated by contact and it is seemingly also miasmatic.
+
+The terrible plague of the Black Death that swept over Europe from
+1347 to 1350 was a malignant form of the bubonic plague. Over
+1,200,000 people died in Germany, and Italy suffered much more. In
+Vienna for some time about 1000 people a day died and were buried in
+great trenches. Venice lost 100,000 inhabitants, and London lost more
+than that. In both Padua and Florence only one-third of the
+inhabitants were left alive; at Avignon the Rhone was consecrated so
+that bodies might be thrown into it for burial; and ships drifted
+about the coasts of Europe {185} with dead crews. Hecker, in his study
+of this plague, says that nearly one-fourth of the population of
+Europe died in that visitation. Civilisation was wellnigh overthrown
+in the panic. In Germany, Italy, and France the Jews were accused of
+poisoning the wells and thus causing the plague, and they were
+slaughtered by thousands. At Strasburg 2000 Jews were burned to death
+in one holocaust; at other places, as at Eslingen, in despair the Jews
+set fire to their synagogues and destroyed themselves. The Great
+Plague of London in 1665, in which 70,000 persons died, was also the
+bubonic plague.
+
+The mortality is about 90 per centum in some epidemics. The bacillus
+leaves the body in the faeces, flies carry it to food, it thus gets to
+rats and mice, and it is carried from place to place. Rats, however,
+are commonly infected as if by a miasm before the disease appears in
+man. There is dispute as to the communicability of the plague from man
+to man by contact with fomites, but it is practically certain the
+disease can be thus transmitted. Kitasato once succeeded in producing
+the disease in animals by inoculation with dust taken in an infected
+house. Merely touching a patient does not apparently convey infection,
+yet some authorities hold that in time of epidemic the contagion is
+transmitted even through the air, especially on the ground floor of
+houses. Perhaps mosquitoes are the medium of infection, as they are
+inclined to fly low.
+
+In visiting a case of bubonic plague the priest should be as cautious
+as if he were attending a smallpox patient. After death by smallpox,
+plague, typhus, cholera, scarlatina, diphtheria, and measles the
+funerals should be private and the bodies should not be taken to the
+church.
+
+Malta Fever, or bilious remittent fever, is found in some of the
+islands taken from Spain. It has a low mortality and is not
+contagious. Bruce in 1887 isolated the bacterium that causes it.
+
+We do not know the cause of yellow fever despite the claims of
+Sanarelli that he has isolated the specific micro-organism. Recently
+American physicians discovered that it is transmitted from man to man
+by mosquitoes that belong {186} to the genus Stegomyia, the Stegomyia
+Fasciata especially. If a yellow fever patient is put into a room in
+which the mosquitoes have been killed and the doors and windows are
+screened, he is as harmless, as far as contagion is concerned, as a
+man with a broken leg. The disease is not spread by fomites.
+
+Malaria is caused by plasmodia, which are protozoa, not bacteria, and
+it is carried from case to case by mosquitoes of the genus Anopheles.
+So certain are we that this is the mode of infection that the
+expression "no anopheles, no malaria" has almost become a medical
+axiom. A bite from an anopheles mosquito does not cause malaria unless
+the particular mosquito has previously bitten a malaria patient.
+
+The stegomyia flies and bites in the early afternoon and again at
+night, the anopheles flies and bites after sunset. In visiting a case
+of pernicious malaria or one of yellow fever avoid the bites of
+mosquitoes by gloves and a piece of netting, and there is no danger
+whatever.
+
+The stegomyia mosquitoes are tropical and subtropical, but they can
+live as far north as Philadelphia and even farther. The anopheles is
+especially a northern insect. The ordinary culex mosquito, when it
+alights upon a wall, stands with its body parallel to the wall, as a
+house-fly stands; the anopheles mosquito stands with its tail raised
+from the wall at an angle. A mosquito lays its eggs in any pool of
+still water, and the "wrigglers" seen in an open rain-barrel are the
+larvae from these eggs. The larvae come to the surface of the water to
+get air, and they may be smothered with petroleum; but the only
+effective way to get rid of malaria and yellow fever is to drain or
+fill pools of water and marshes. Mosquitoes will breed also in the
+small still bights along the edges of running streams; in old tomato
+cans that contain rain water; in any still water, fresh or salt.
+
+AUSTIN OMALLEY.
+
+
+{187}
+
+XV
+
+INFECTIOUS DISEASES IN SCHOOLS
+
+Cases of diphtheria, scarlet fever, measles, and even smallpox are not
+seldom found in schoolrooms, and much anxiety can be averted and the
+spread of infection can be wholly or in great part averted by a
+knowledge of disinfection.
+
+The laity will often follow the advice of a priest in matters of
+hygiene when they are inclined to rebel against the regulations of
+health departments and the suggestions of physicians, therefore a
+preliminary explanation of methods for the prevention of infection in
+the family will be advantageous; prevention in the family is also
+intimately connected with prevention in the school. Methods useful in
+the family are useful also in convents and boarding-schools.
+
+As regards diphtheria, the chief causes of the spread of this disease
+are mistaken diagnosis, imperfect isolation, incomplete disinfection,
+and, paradoxical though it may seem, a lack of susceptibility to the
+disease in a large number of children.
+
+Many physicians are still under the grave error that diphtheria can
+always be recognised without the aid of the microscope, and that
+membranous croup commonly kills. All scientific writers upon
+diphtheria agree that it is caused by the Klebs-Loeffler bacillus.
+They also hold that there is a disease called membranous croup, as
+distinct from diphtheria as typhoid is, but that membranous croup is a
+comparatively harmless and non-contagious disease. Two per centum is a
+liberal mortality in membranous croup, yet a certain class of
+physicians are constantly reporting deaths from this disease. In a
+series of 286 cases (not deaths) diagnosed as membranous croup by
+physicians of New York {188} City a few years ago, Park found the
+diphtheria bacillus in 229, or 80 per centum. I have never examined
+the throat of a child dead from so-called membranous croup in which I
+did not find the diphtheria bacillus. This is the experience of almost
+every bacteriologist who has had to do with diphtheria. Some men
+report deaths from diphtheria as thrush! These deaths might just as
+truthfully be attributed to the wearing of linen collars.
+
+On the other hand, according to Baginsky of Berlin, Martin of Paris,
+Park of New York, and Morse of Boston, from 20 to 50 per centum of the
+cases admitted even to diphtheria hospitals have not diphtheria at
+all. Bacteriologists find that about 35 per centum of the cases
+reported by physicians to be diphtheria are really nothing but
+tonsilitis or pharyngitis, with now and then a case of membranous
+croup. Without a bacteriological diagnosis, therefore, 35 families in
+each 100 quarantined (where quarantine laws exist) are unjustly
+quarantined and subjected to the trouble and expense of useless
+disinfection. The suffering this can cause to a poor family, whose
+small business is often ruined by quarantine, is a matter for very
+serious consideration. Again, no matter what experience a physician
+may have had, he can not in many cases differentiate diphtheria in its
+early stages, or in children of good resisting power, from
+comparatively harmless throat affections. The extraordinary resisting
+power against diphtheria shown by some children and adults has been
+described by Wassermann (_Zeitschrift f. Hyg._, 19 B., 3 H.). He found
+one series of 17 children, from one and a half to eleven years of age,
+and 34 adults, in which 11 children and 28 adults were not only immune
+to diphtheria, but some of them had enough antitoxin in their blood to
+neutralise a tenfold fatal dose of diphtheria toxin. This explains
+many mysterious outbreaks of diphtheria: such immune persons are
+infected and they carry about the disease unconsciously because they
+are not ill themselves. I have seen a mother kiss a child dying of
+malignant diphtheria and the woman did not get even a sore throat, but
+I know of another case exactly like this in which the mother died from
+the infection.
+
+{189}
+
+There are bad cases of diphtheria which the experienced physician can
+diagnose as soon as he enters the patient's room without even looking
+at the throat, but the lighter cases that are dangerous are not easily
+recognised. I have seen two children of a family in Washington
+attacked with a slight throat soreness after one child had died of
+diphtheria in the house. The cases of these two children would never
+even suggest diphtheria if that first child had not had the disease.
+Both these patients died within ten days of syncope without the
+formation of any membrane, but the diphtheria bacillus was present
+microscopically. To the moment of death there was nothing in the
+symptoms of these two children to show diphtheria to the naked eye.
+From a personal experience with more than 800 cases of diphtheria in
+hospitals and as a medical inspector, I feel certain that light
+attacks of diphtheria can not be diagnosed without the aid of the
+microscope.
+
+The immunity mentioned above explains the fact that the Klebs-Loeffler
+bacillus is sometimes found in healthy throats, and the person that
+has such a throat is really more dangerous than a patient that is ill
+with diphtheria, because we cannot guard ourselves against him.
+School-children at times have what appears to be mere sore throat but
+which is really diphtheria in the naturally immune.
+
+All cases of sore throat in school-children should be examined
+bacteriologically, but unfortunately the bacteriological examination
+for diphtheria is a complicated process which requires an expert
+bacteriologist and a laboratory. The cost of a laboratory fitted for
+this diagnosis alone is not great, but it is not easy to persuade
+small city governments that they need such plants.
+
+The only resource, then, is to treat every suspicious case of sore
+throat as if the disease were really diphtheria, until a diagnosis is
+established as near the truth as possible. Children that are afflicted
+with throat inflammations should be kept from school. The people
+should be taught the necessity of isolation and disinfection; they
+should be warned against patent disinfectants, and told to ask
+competent physicians to advise them in disinfection.
+
+{190}
+
+Diphtheria is not directly caused by unhygienic surroundings. A
+disregard for hygiene disposes a child for infection if the child is
+exposed to the bacillus. The specific germ must be introduced into the
+patient's mouth or nostrils. When a child is infected with diphtheria
+the breath is not a medium of contagion. The sputum, spat out or
+coughed out, is a means whereby the disease is spread. The bacillus is
+in the patient's mouth and nostrils; it gets upon his hands by
+contact, upon eating utensils, upon whatever touches the mouth of the
+sick person. The bacillus does not float in the air of even the
+sick-room, except in those cases where dried sputum is stirred up by
+sweeping or attrition of other kinds.
+
+In a boarding-school or family when a diphtheria patient is found,
+select a room set off as far as possible from the rooms commonly used,
+and before putting the patient into this room remove all curtains,
+upholstered furniture and carpets from it that are not so cheap or so
+worn that they may be destroyed after the patient's convalescence, or
+which are of such texture that they will not be destroyed by water or
+disinfection by heat. In any case the less there is in the room the
+easier the disinfection will be.
+
+Use the mattress upon which the patient had slept before you
+discovered the nature of the disease. Books should be removed, because
+an infected book can not be disinfected except upon the outside. The
+room is not to be swept while the patient is in it,--dust may be wiped
+up with a damp cloth. The cloth is to be disinfected before it is sent
+out of the room.
+
+The popular notions regarding sulphur as a disinfectant after
+diphtheria are erroneous. Sulphur fumes in certain definite quantities
+will disinfect after smallpox, scarlet fever, measles, and some other
+diseases; these fumes will also kill the diphtheria bacillus, if the
+bacillus is wet and exposed directly; but if it is buried in sputum or
+in clothing the fumes will have no effect whatever upon it. The
+disinfectants to use are acid bichloride of mercury and heat.
+Formaldehyde does not penetrate well enough to be reliable in
+diphtheria.
+
+{191}
+
+When the patient is taken to the room prepared, let a mixture of one
+ounce of bichloride of mercury in the powdered form, in two ounces of
+common hydrochloric acid (not the dilute hydrochloric acid used in
+medicine), be obtained. This is a violent poison, and it must be kept
+out of the reach of children and careless persons. Two teaspoonfuls of
+this solution in an ordinary wooden bucket filled with water to within
+two inches of the rim makes the disinfecting mixture. A wooden washtub
+nearly filled with this disinfectant, mixed in the bucket as directed,
+should be kept near the door of the room, and all towels, sheets, and
+soiled linen must be soaked in this tub for twenty-four hours. After
+that any one may handle these articles with perfect safety. The
+articles that have been soaked for twenty-four hours should be rinsed
+in ordinary water to remove the acid, and they may then be washed. The
+nurse should not touch the outside of the tub with infected articles
+while putting these in the disinfectant. Do not make the disinfectant
+stronger than directed here, or it will destroy the articles soaked in
+it, and for the same reason do not leave them in it longer than
+twenty-four hours.
+
+If the attendant can be kept isolated with the patient there will be
+less liability of carrying the infection through the house. In a
+majority of cases in families, however, the mother is obliged to care
+for the patient and to attend also to her household duties. In the
+last case, let her keep near the door of the room a cotton wrapper
+which can be put on over her dress whenever she enters the room. She
+had better tie a towel over her hair. In the room a china-stone basin
+should be kept, containing a gallon of water, in which there is a
+teaspoonful of the acid bichloride. Every time the attendant touches
+the patient let her wash her hands in this mixture, using no soap. She
+should remove her finger rings or they will be blackened. The patient
+should not be handled except when absolutely necessary, to avoid
+needless exposure to infection; it is also injurious to a child ill
+with diphtheria to lift it up. The nurse's covering wrapper should be
+soaked in the tub as often as possible. Some ignorant persons give as
+an excuse for a lack of care in {192} handling patients having
+contagious diseases like diphtheria, that they are not afraid of the
+infection. Fear has nothing to do with the matter.
+
+Food is to be taken to the door of the sick-room by some one other
+than the attendant. The tray should not be carried into the room.
+After the meal, take to the door a pan containing water, and let the
+attendant set the dishes, knives and forks, and the food handled by
+the child, under the water without touching the rim or sides of the
+dish-pan. Then any one may carry the pan to the kitchen, where it is
+to be set upon the stove, and the water holding the dishes and the
+rejected food is boiled for an hour. After that process the contents
+of the pan are safe, and they may be handled for washing. Cloths used
+in wiping the mouth of the patient are to be wrapped in paper and
+burned. Dejecta should be covered with fresh chlorinated lime, one
+part to two of water.
+
+After the patient begins to convalesce the danger of infection grows
+greater. When the membrane has disappeared, and the child is able to
+run about the room, the attendant ceases commonly to use the
+throat-spray because the process is troublesome. In such cases the
+diphtheria bacillus remains in the patient's mouth for some time--from
+a few days to weeks. During the most of this time the child is as
+dangerous to others as it was while it was ill. In one case in my own
+experience, the bacillus remained present for eleven weeks from the
+date of diagnosis, and I then lost sight of the child. In the tenth
+week the bacillus present when in pure culture killed a guinea-pig in
+thirty-six hours. This is, of course, an exceptional occurrence; but
+the routine practice is to keep the patient isolated for three weeks
+after the membrane has disappeared, unless a bacteriological
+examination shows that the bacillus is absent. The bacillus remains
+after the use of antitoxin just as if antitoxin had not been used.
+
+When a child is to be released from the sick-room, bathe it carefully
+with soaped warm water, washing out the hair and under the
+finger-nails carefully. Then wet a towel with the disinfectant (the
+acid bichloride of mercury,--a {193} teaspoonful to a gallon of water)
+and go over the body with it; afterward rinse with ordinary water. Do
+not let the disinfectant enter the child's mouth or eyes. Next,
+without allowing the child to touch anything in the room, especially
+avoiding the door-knob, send it to another room and dress it in
+clothing that has not been near the sick-room. If, after this process,
+other children are infected, the explanation is that the child had
+been released too soon--before the bacillus had disappeared.
+
+It commonly happens that a child has been going about the house for
+some days before a physician has been called in. In that event you
+have the house to disinfect. You must then wet with bichloride
+everything the child has touched, and boil all eating utensils.
+
+As to the disinfection of the room and its contents: the irritation of
+diphtheria causes a large quantity of saliva to flow from the
+patient's mouth; this infected saliva runs down upon the pillows and
+soaks into them. It may also soak into the mattress. If a town has a
+steam disinfecting plant, there is no trouble in dealing with bedding
+and carpets after diphtheria and other contagious diseases; such a
+plant, however, costs at the least $6000. It is safer, in the absence
+of steam disinfection, to destroy pillows by fire; but if these are
+opened and the filling put into tubs or barrels containing two
+teaspoonfuls of the acid bichloride of mercury to each gallon of water
+and soaked for about two days they will be safe. The ticking in this
+case should be boiled in a wash-boiler, and the filling is to be
+rinsed before drying. The mattress is less liable to infection but it
+may be infected. If a piece of oil-cloth or rubber sheeting is spread
+beneath the bed-clothes under the patient and the mattress is kept
+well covered during the course of the disease, the filling of the tick
+will most probably be not infected. The loss of a good feather or hair
+mattress is considerable in the house of a poor man, and these often
+may be saved. To disinfect the surface of a mattress place it on
+chairs in a small room or in a closet and pour upon a cloth under it
+500 cc. of formalin for each 1000 cubic feet of air-space in the room
+or closet--multiply the length by the height by {194} the width of the
+room or closet to get the cubic feet of air-space. Leave the room or
+closet shut tightly for twenty-four hours. The Trenner-Lee
+formaldehyde disinfector is a good apparatus for disinfecting. The
+smaller size costs twenty-five dollars.
+
+If anything is to be sent out of a room to be burned, spread a piece
+of old carpet, bagging, or similar useless cloth outside the room
+door, set on this the articles to be destroyed, wrap them carefully in
+the fabric, tying all with cords; then take the bundle outside the
+town in a covered wagon, pour kerosene oil on the package without
+opening it, and set it afire. Afterward wash the wagon with the acid
+bichloride.
+
+Wet the furniture and floors of the room with the acid bichloride. Do
+not merely sprinkle the solution about, flood everything with it,
+because the germ is killed only by direct contact; and remember that a
+diphtheria bacillus magnified 800 times is not larger than the eye of
+a needle. The bichloride will spoil gilt picture-frames, therefore use
+a 10 per centum solution of pure carbolic acid on these and all other
+metallic surfaces. Coins should be boiled, and paper money should be
+dipped in the 10 per centum carbolic acid solution and dried at a
+stove. Money is frequently found in smallpox rooms under the patient's
+pillow.
+
+Formalin is the best disinfectant for wall-paper unless the child has
+spat upon it--then use the bichloride. Sometimes the bichloride will
+not injure the wall-paper, but if there are gilt figures upon it these
+will be blackened. Sulphur fumes are no better than formalin--not so
+good, and they injure and blacken tinted and gilded wall-paper, silks,
+satins, and other fabrics. If you determine to have the room
+repapered, wet it with bichloride before you bring in the workmen.
+
+It is difficult to disinfect a carpet except by steam, and on this
+account the carpet should be removed from the room before the patient
+is brought into it. If it has been kept in the room, wet it thoroughly
+with the bichloride, when you are disinfecting, if you can not have it
+disinfected by hot steam. The wetting commonly spoils the carpet,
+consequently it may be necessary to bum it.
+
+{195}
+
+Keep cats, dogs, and especially kittens, out of a diphtheria room.
+Kittens will take the disease easily, and cats and dogs will carry
+about the contagion. If a valuable dog should get into the room,
+disinfect its hair thoroughly with the acid bichloride and then rinse
+the hair. Be careful to disinfect its feet.
+
+While using the bichloride do not forget the window-panes, the
+door-knobs, and that part of the chair-legs which touches the floor.
+After you have used the bichloride expose the room to the gas from
+formalin. Hang up sheets wet with 500 c.c. of formalin for each 1000
+cubic feet of air-space, and close all keyholes and cracks; then leave
+the room shut for twenty-four hours.
+
+As to the use of antitoxin as a preventive and cure for diphtheria,
+too much praise cannot be given to that wonderful discovery. Reliable
+diphtheria antitoxin, used in proper quantity and early enough, is
+almost an absolute cure. Where it fails it has been used too late or
+not in the proper dose. In any case its only evil effect may be an
+attack of nettle-rash or hives. The few deaths that have occurred in
+its use were caused by an ignorant use of the syringe. If you find a
+physician opposed to the use of antitoxin this simply means that he is
+a quack. One serious disadvantage in the use of antitoxin is that it
+leaves the dangerous bacillus in the throat of the patient about as
+long as an unaided convalescence would leave it. The membrane often
+will disappear in twenty-four hours where antitoxin has been used, and
+the child will be playing about the floor. Then the mother will say
+the child never had diphtheria; she will not disinfect, and she will
+let the child run about the house.
+
+The free book system that prevails in some schools is a prolific
+source of infection. Books are infected at home or by children from
+infected houses, and mixed with other books in the school. The
+diphtheria bacillus will cling to a book for at least a year. If books
+are given to the children, give them outright; do not let the books be
+mixed in the schoolroom.
+
+Drinking-cups used in common are another source of {196} infection.
+Let each child have its own tin cup. The clothes-rack in a school also
+spreads infection. Room enough should be given to each hook to keep
+the hat and coat of one child from touching those of another, and a
+wooden partition standing out from the wall about eight inches should
+separate hook from hook. The janitor should wash the clothes-racks
+with the acid bichloride solution every time he sweeps.
+
+Suppose a child having diphtheria is found in school, or one is
+discovered as coming from a house where he was in contact with
+diphtheria. The discovery is made commonly after the child has been
+spreading infection for some days. Do not frighten the youngster, but
+find out from him what parts of the school-building he has been
+visiting. Then send him and the other children home. Rooms in which
+the child has not been are not infected, and only that which he has
+touched is infected in any case. Wet everything in the building and
+outhouses with which he possibly could have come in contact with the
+acid bichloride. Burn his books and papers, or, if this action may
+cause difficulty with parents, let him take his books home and inform
+the health officer of that fact. When he returns to school be sure of
+the history of his books. Use formalin or sulphur in the infected
+rooms, and classes may be begun again the next day. If within the week
+any child shows signs of sore throat send it home immediately.
+
+Sulphur must be burned when used as a disinfectant, and to be
+effectual four pounds should be burned for every 1000 cubic feet of
+air-space in the room. A teaspoonful of sulphur when burned will fill
+a house with choking, dangerous fumes, but two pounds of sulphur
+burned in an ordinary bedroom will have no effect whatever on the
+diphtheria bacillus and very little on any other disease. Sprinkling
+disinfectants about a house, and setting saucers containing
+disinfectants in rooms is nonsense--the quantity must be sufficient
+and be in actual contact with the contagion. A deodorant does not
+disinfect because it removes a stench.
+
+To burn sulphur set a coal-hod or an old tin pan on two bricks in the
+middle of the room, but see that there are no {197} holes in the
+bottom of the hod or pan through which burning sulphur could drip to
+the floor. For a like reason see that the pan is not too narrow nor
+too shallow. It is safer to set the bricks in a tub filled with water
+up to the top of the bricks. Use powdered sulphur in preference to the
+cakes sold by the druggists, and fire this sulphur with a red coal.
+The room should be moist with steam when the sulphur is set afire so
+that the fumes will act effectually. Leave it shut tightly for
+twenty-four hours.
+
+In the Northern States diphtheria is most prevalent in October,
+November, and December; scarlet fever is an April disease, but it may
+occur at any time. It is easier to spread the infection of scarlet
+fever and measles than that of diphtheria, but it is not so difficult
+to disinfect after scarlet fever and measles as after diphtheria. The
+contagion of scarlet fever does not resist the fumes of sulphur or
+formalin. Disinfect a room after scarlet fever as for diphtheria but
+be sure to use also either sulphur or formalin because the contagion
+can float about a room. Eruptive contagious diseases like scarlet
+fever, smallpox, and measles so affect the skin that during
+convalescence the cuticle scales off. In severe cases of smallpox and
+scarlet fever the entire outer skin of the hand may peel off like a
+glove. The contagion is always found in the scaling skin. As the
+patient grows stronger the scales become finer, until at last they lie
+as mere mealy dust in the hollows of the elbows or other parts of the
+body. Down to the very last these scales are infectious, and they will
+retain the infection for months, probably for a year or more. The
+scales float in the air of a sick-room, fall on the clothing of
+visitors, are carried away by the shoes of those that leave the room.
+The scaling may continue for three weeks--it commonly does. These
+three diseases are infectious before the scaling begins, sometimes
+before the rash is well out. A very light attack of any of these
+diseases in one child may infect another fatally. Insist upon keeping
+a scarlet fever or measles patient out of school until all scaling has
+ceased.
+
+Chickenpox is almost a harmless disease, but it is more infectious
+than even measles. Be cautious with it because {198} nearly every
+epidemic of smallpox begins through some one mistaking smallpox for
+chickenpox, although there is little or no similarity between the
+diseases.
+
+A child with tuberculosis of the lungs or a child infected with acute
+syphilis should not be permitted to go to school under any
+circumstance.
+
+In the chapter on The Priest in Infectious Diseases will be found an
+account of the necessity of vaccination as a precaution against
+smallpox.
+
+Tinea Favosa, or favus, is a contagious and a very stubborn disease of
+the skin, caused by the fungus _Achorion Schoenleinii_. It produces
+yellowish crusts about the hairs of the scalp and other parts of the
+body, and it destroys the hair. It attacks also the finger-nails and
+the skin that is without hair. In the later stages of the disease
+there is a foul odour. It is one of the most difficult of the
+scalp-diseases to cure; months and sometimes years are required to get
+rid of it.
+
+A child with tinea should be kept away from school; and his desk and
+what he touches should be washed with the bichloride of mercury
+solution. Burn his books and papers.
+
+Ringworm is a kind of tinea, and it is caused by various mould fungi.
+Tinea Tonsurans is ringworm of the scalp; Tinea Circinata is ringworm
+of the body; Barber's Itch is another form; there is also a ringworm
+of the finger-nails; and Pityriasis Versicolor is still another form.
+All are contagious, and some are difficult to cure because the
+parasite gets down between the skin and the hair-follicles and an
+antiseptic can not reach it. Children affected with these diseases
+should be kept away from school until they have been cured.
+
+The presence of lice and of the Acarus Scabiei can bring about acute
+and severe skin eruptions. The Acarus Scabiei causes itch, but
+fortunately it is rare in America. These parasites go from person to
+person, hence a child having either should be kept from school until
+he is clean. A thorough washing will remove lice if they have not yet
+inflamed the skin, but itch requires a more vigorous {199} treatment.
+The desks of such patients should be disinfected and their clothing
+should be baked. They will probably be reinfected at home if the
+treatment is not applied to other members of the family.
+
+Contagious Impetigo, or porrigo, as it was formerly called, is a skin
+disease common among children, and it may affect adults. It appears to
+be of parasitic origin, but the specific organism that causes it has
+not been isolated. The lesions in this disease are commonly
+discrete--separate one from another--but they may be crowded together.
+They are vesico-pustular and they are sunken at the top in the typical
+form. If they are not broken by scratching, they dry into a yellowish
+crust. The disease affects only the skin, but as it is contagious a
+child affected with it should be kept from school until cured. The
+desk and articles used by the child should be disinfected, and his
+books are to be burned.
+
+Whooping-cough is very infectious, and, contrary to the popular
+opinion, it is frequently a fatal disease. There is a period of
+incubation for from seven to ten days, then a catarrhal stage follows
+in which the child has the symptoms of an ordinary "cold." In about
+another week the dry cough becomes paroxysmal with the characteristic
+"whoop" when the air is drawn in after the fit of coughing. When there
+is an epidemic of whooping-cough, children with "colds" should be sent
+home from school. The objects used by a child that has whooping-cough
+should be disinfected, and its books and papers are to be burnt.
+
+Mumps can be a serious and a very painful disease and it is infectious
+to a marked degree. The specific organism is not known. Boys are more
+liable to this disease than girls are, and recurrence is rare. After a
+period of incubation, which lasts from two to three weeks, there is
+fever, pain under one ear, and the parotid gland swells. The disease
+is commonly mild, but it may affect a child seriously. The patient is
+to be quarantined, what it has touched should be disinfected, and its
+books are to be burnt.
+
+There are a number of infectious eye diseases that occur among
+school-children. Acute Contagious Conjunctivitis, {200} or "pink eye,"
+is one of the most important. One form of acute Contagious
+Conjunctivitis is caused by the Koch-Weeks Bacillus; it is "pink eye,"
+properly so called, and it is very infectious. Objects handled by the
+patient can infect others and spread the disease. The attack is
+severe, but the prognosis for full recovery is good. The child should
+be strictly quarantined until all secretion from the eyes has ceased,
+and whatever he has touched is to be carefully disinfected.
+
+Another form of Acute Infectious Conjunctivitis, less contagious than
+that caused by the Koch-Weeks bacillus, is brought about by the
+introduction into the eye of the bacteria that give rise to pneumonia.
+Commonly the pneumonia bacteria do not cause conjunctivitis unless the
+patient is susceptible in a special manner. As it is difficult to
+differentiate this second form from the first, the same precaution
+should be used.
+
+Trachoma, called also granular conjunctivitis, Egyptian ophthalmia,
+and military ophthalmia, is a very serious inflammatory disease of the
+external eye which has of late years become prevalent in American
+cities, whither it has been brought by immigrants from eastern and
+southeastern Europe. Persons that have this disease on landing in the
+United States are deported, but despite this precaution it has crept
+in and is now endemic. It is contagious, and when well established it
+is extremely difficult to cure. If untreated it lasts for years and it
+may destroy the cornea and consequently the sight. A trachomatous
+child should be kept from school until it has been cured, and that
+cure will take a very long time.
+
+The Gonococcus can be carried into the eye by handling objects like
+soap, towels, wash-basins, which have been used by persons afflicted
+with gonorrhoea. The infection of the eye is very severe and
+dangerous, and the usual quarantine is to be observed. The ophthalmia
+of the new-born is gonorrhoeal.
+
+The Diphtheria Bacillus also may get into the eye, and set up a
+primary infection there. A membranous conjunctivitis, too, is at times
+induced by pus organisms. {201} Xerosis Epithelialis, tuberculosis,
+leprosy, and syphilis may affect the eye primarily, and additional
+forms of eye-diseases are found that are infectious. The general rule,
+then, is that children with any inflammation of the eyes are to be
+kept out of school until a physician pronounces them harmless.
+
+AUSTIN OMALLEY.
+
+{202}
+
+XVI
+
+SCHOOL HYGIENE
+
+
+Priests have to put up buildings for parochial schools, colleges,
+seminaries, orphan asylums, convents, and the like, but in such work
+sanitation is commonly given only a passing thought in connection with
+sewer-traps and these are left to the wisdom of a plumber. The
+physical welfare of youth is almost as important as its mental
+training, and there are many factors beside sewer-traps involved in
+the effort to sustain it.
+
+If there is freedom of choice as regards the site of a schoolhouse or
+similar building, the top of a small elevation is to be selected. Such
+a position affords the best natural drainage, removes dampness, avoids
+inundations, gives full sunlight and the purer air. The top of a high
+hill may be too exposed to the wind.
+
+Next to the top of a knoll, the southerly slope of a hill is to be
+chosen. The building should not be overshadowed by a hill, especially
+on the western side. Trees are not to be planted close to a building
+in which children live, and ivy and similar plants should not be
+permitted to cover the walls.
+
+If a building is set in a hollow it will be surrounded with chill air
+and mists in the cold seasons, even if a costly drainage system keeps
+the cellar and basement dry.
+
+A gravelly or sandy soil beneath a building is the best, provided this
+soil is not already saturated with organic matter, or is not close
+above a dense layer of clay or rock. Clay, marl, peat, and made soils
+should be avoided if possible, because they are full of organic
+matter; they are cold, and they infect the ground air. Rock does not
+make a good building site--its seams carry water.
+
+{203}
+
+The subsoil should be drained four or six feet below the cellar floor,
+and this floor is to be laid in concrete and cement. At the level of
+the ground there should be a course of hollow vitrified brick to
+exclude dampness and to give ventilation.
+
+Limestone walls conduct more heat in and out than an equal thickness
+of glass, bricks, plastering, and wainscoting. The porosity of the
+building material determines the interchange of the air through the
+walls, and it affects the temperature of the rooms. If there is water
+in the pores of the walls heat is conducted rapidly, but air is not
+permitted to pass. Brick as a building material has many
+disadvantages, but on the whole it is best for schools, and it resists
+fire better than most stones. The harder the brick the better it
+is--vitrified brick is the best. Hard-pressed brick of a light colour
+makes an excellent outer wall-surface.
+
+It is very doubtful that sewer gas escaping into a house will directly
+carry the micro-organisms of diseases like typhoid and diphtheria, but
+such gas is poisonous, depressant, and it renders the inmates of a
+house liable to disease; lessens their power of resistance. The
+typhoid bacillus and other bacteria can, of course, be carried into a
+cellar by the seeping in of drainage water. Infants kept in the upper
+story of a house in hot weather are more liable to intestinal diseases
+than are those that live on the lower floors, but here the weakening
+agent is heat. Tuberculosis, scrofula, rheumatism, neuralgias,
+bronchial, and kidney affections are made worse in damp houses.
+
+The chief defects in plumbing and drainage are the following: (1)
+Earthen pipe drains become broken or their joints leak, and they
+saturate the ground under a house with sewage. (2) Tree roots break
+and clog drain pipes. (3) The pipes sometimes have not fall enough.
+(4) Drains without running traps admit sewer gas. (5) Rats burrow
+along a drain pipe from the sewer into the house and admit sewer gas.
+(6) When the soil pipe from a water-closet is exposed in cold weather
+it may freeze up or be clogged by urinary deposits. (7) Rats gnaw
+through lead pipes and joints. (8) Two or more closets or sinks with
+unventilated {204} traps on the same pipe will siphon back sewage. (9)
+Overflow pipes sometimes have no traps and they let in gas. (10) Ash
+pits near a house carry moisture to walls, (11) Cesspools leak through
+the soil.
+
+In planning a school-building the classrooms and the study-halls are
+the first things to be considered. The classrooms should be oblong,
+with the aisles running lengthwise. Each child should have at the
+least 15 square feet of floor space and 200 cubic feet of air space. A
+room 30 by 25 feet with a ceiling 13 feet from the floor will serve
+for 48 pupils and no more. This is the best size for a room when
+blackboards and maps are used in teaching, because a larger room sets
+the children in the back seats too far away to see without eye-strain.
+
+Dormitories should have at the least 300 cubic feet of air space for
+each child, and great care is to be taken in the ventilation. Children
+about 10 years of age require 11 hours of sleep; under 13 years,
+10-1/2 hours; under 15 years, 10 hours; under 17 years, 9-1/2 hours;
+under 19 years, 9 hours. Do not make children get out of bed before
+seven o'clock in the morning; do not let them study before breakfast,
+and do not force them to work after half-past eight or nine o'clock at
+night until they are at the least 17 years of age. The hours for work
+should be:
+
+Ages       Hours of work a week
+
+From
+5 to 6         6
+6 to 7        9
+7 to 8      12
+8 to 10    15
+10 to 12   20
+12 to 14   25
+14 to 15   30
+15 to 16   35
+16 to 17   40
+17 to 18   45
+18 to 19   50
+
+Work given for punishment must be included in these hours. No one,
+even an adult, should study for more than two hours at a time without
+an intermission for a few {205} minutes. In a boarding-school no one
+under any pretext, even on rainy days, should be permitted to study
+during recreation hours, and the deprivation of recreation to make up
+lessons is a relic of barbarism. If a teacher can not get class work
+done except by shutting up children during recreation hours, remove
+the teacher or expel the pupil.
+
+The amount of glazed window surface admitting light to a classroom or
+study-hall should be from one-sixth to one-fourth the floor space of
+the room, and this must be increased if the light is obstructed by
+neighbouring houses or trees. The light is to be admitted on the left
+side of the pupils,--all other windows should be counted as
+ventilators only. Windows facing the children or the teacher are to be
+avoided. In rooms fourteen feet high a desk twenty-four feet from a
+window is insufficiently lighted. The larger the panes of glass the
+better, and the external appearance of windows is to be sacrificed to
+good lighting. If screens are used to protect the glass from
+stone-throwing, allowance is to be made for the light the screens cut
+off.
+
+If a room can not have enough light from the left side alone, put the
+additional windows on the right so that their lower sills will be
+eight feet from the floor; and be careful in this case that the light
+from the right is not brighter than that from the left.
+
+Windows should have as little space as possible between them to avoid
+alternate bands of shadow and light. Set them up as near the ceiling
+as possible, since the higher they are the better the illumination;
+and they should not be arched at the top. The lower window sills may
+be about four feet from the floor. When window shades are used to cut
+off direct sunlight, they should be somewhat darker in colour than the
+walls.
+
+If artificial light is used in boarding-schools in the study-halls,
+the best light is one that is as near in colour as possible to the
+white light of the sun, and ample, but not glaring. It should be
+steady, and it should not give out great heat nor injurious products
+of combustion. Hence the electric light is the best; after that, gas
+through Welsbach {206} or Siemens burners. Well refined kerosene oil
+gives a good light, but it is always dangerous. Acetylene gas is now
+used in a safe apparatus, and it also is an excellent light.
+
+No colour that absorbs light should be used on the walls. Pale
+greenish gray, nearly white, is the most satisfactory colour. There
+should be no wall paper, curtains, or hangings of any kind in a school
+or college building. The wall decorations should be as plain as
+possible, with no roughened places to catch dust.
+
+Stairways are to be well lighted; they should be at the least five
+feet wide, and have landings half-way between each story. Diagonal or
+spiral stairways are dangerous. Steps with six-inch risers and
+eleven-inch treads are the easiest for children, but
+six-and-a-half-inch risers may be used in high schools and colleges.
+
+Carbonic acid in the air of a classroom is an index of impurity.
+External air has about three parts of carbonic acid in 10,000 parts of
+air, and above seven parts in 10,000 is injurious. Each person exhales
+about fourteen cubic feet of carbonic acid gas in an hour. There is no
+easy method of determining the quantity of carbonic acid gas present
+in a room, and we must therefore arrange the ventilation so that about
+3000 cubic feet of fresh air an hour will be supplied to each person
+in the house.
+
+Beside carbonic acid there are other impurities in house air, as dust,
+micro-organisms of disease, exhalations from bodies, sewer gas, and
+the like, which accumulate and do injury when the ventilation is
+defective.
+
+If every person in a house has 1000 cubic feet of air space, natural
+ventilation will suffice ordinarily, but artificial ventilation is
+needed in schoolrooms and dormitories. The subject of ventilation can
+not be satisfactorily discussed in a short article, and those that are
+interested in school building should leave the matter to a competent
+architect, or study books and articles like J. S. Billings'
+_Ventilation and Heating_, Pettenkofer's _Ueber Luft in den Schulen_,
+and Kober's article on House Sanitation in the _Reference Handbook of
+the Medical Sciences_.
+
+{207}
+
+The proper heating of a schoolroom is a matter so generally understood
+that there is no need for special remark here, except this, that
+provision for proper humidity in the heated air is commonly neglected.
+
+Cheap water-closets do not save money--they get out of order too
+easily. The pan, valve, and plunger hoppers are not to be tolerated.
+The only kind to use are short-hopper closets with a trap that opens
+into the soil-pipe above the floor. These may have valve-lifters
+attached to the seats, because children forget to flush the hoppers.
+The ventilation of the water-closets should be separate from that of
+the main building. In country places where vaults are used, there
+should be a supply of dry loam kept, and enough of this to cover the
+fresh contents should be thrown into the vaults every evening.
+
+Children are seemingly always thirsty, and they should be allowed to
+have all the drinking water they want if the source is free from
+typhoid germs and infection by organic matter. Common cups are an
+abomination, and a prolific cause of contagious diseases. Each child
+should have its own cup.
+
+The rules for desks and seats for children are these:
+
+1. The height of the seat should be about two-sevenths of that of the
+body.
+
+2. The width of the seat should be about one-fifth of the length of
+the body, or three-fourths the length of the thigh. Do not keep
+unfortunate little children's feet dangling all through their school
+years to save a few pennies on school furniture.
+
+3. The seat should slope downward a little toward the back, be
+slightly concave, and have rounded edges in front.
+
+4. There must be a back-rest.
+
+5. The child, when sitting erect, should be able to place both
+forearms on the desk without raising or lowering the shoulders. This
+is a very important rule.
+
+6. The seat must be correctly placed as regards the distance of its
+front edge from the corresponding edge of the desk.
+
+7. The desk slope should be 15 degrees.
+
+{208}
+
+Badly constructed desks cause eye-strain and marked distortions of the
+spine. Desks should be adjustable in height, especially for growing
+children. School-children grow most rapidly between the ages of twelve
+and sixteen years--nearly two inches a year--and the desks and seats
+should be adjusted twice a year at the least. If a child is moved to
+another desk an adjustment is to be made at once.
+
+To counteract the bad effect of long sitting, even at properly
+adjusted desks, children should be frequently sent to blackboards, and
+at regular intervals a few minutes are to be given to "setting up"
+exercises.
+
+Great attention should be paid to the eyesight of children. Those that
+complain of headache should have their eyes examined. The lines in
+school books should be not more than four inches in length, and they
+are to be printed in clear, well-leaded type. Slates are dirty and
+unsanitary: let the children write on paper that has a dull finish.
+
+Teachers should prevent lounging positions at desks, especially
+stooping. They are not, however, to try to make children under fifteen
+years of age sit still. The youngsters can not remain immovable, and
+the effort to make them do so is irritating to no purpose.
+
+Nervous children need outdoor exercise more than anything else. When
+nervousness takes the form of religious scrupulosity in
+school-children and novices do not immediately apply a moral theology
+to them--call in a physician that has common-sense, because there is a
+nervous scrupulosity which is much more frequently met with than the
+purely spiritual form. Aridity in prayer, a loss of sensible devotion,
+and similar troubles have to do with advance in the spiritual life,
+but they more commonly have to do with the liver in persons that are
+not nearly so important spiritually as they fancy they are; and in
+these cases the cook is the particular devil at fault, if they have
+exercise enough.
+
+One of the chief sanitary evils in our boarding-schools, convents, and
+similar institutions, is the stupid sameness in the food which may be
+otherwise unobjectionable. The meat, for example, may be good, but the
+college and seminary cook sends it into the refectory chilled and
+clammy, or hot and overdone. In any case it is everlastingly the {209}
+same. Children can predict a dinner's ingredients a month in advance.
+
+Give children meat twice a day; white flour in their bread, because it
+is digested better than whole flour; all the sugar they want at meals;
+milk rather than tea, and tea rather than coffee; but let it be tea,
+not a dose of tannic acid.
+
+The physical education of girls is neglected. Their general education
+is effeminate rather than feminine. If a convent faculty grows bold
+and "modern" it hires a teacher of gymnastics, puts an "extra" on the
+bill of expense, and ten or twelve wealthy girls play at gymnastics if
+they are not too lazy. Even if the whole school is obliged to attend
+the club-swinging and posturing and the other nonsense, little good is
+done. Girls should be kept out of doors for their exercise, and fresh
+air is much cheaper than a gymnastic teacher. If school-girls were
+forced into the open air more, they would not have time for munching
+caramels over the erotic spasms of Araminta and Reginald in the
+popular novel, and there would be advantage in the change. The absence
+of daily, regular, and sufficient exercise renders girls listless,
+anaemic, sallow, foul-breathed, melancholy, stooped, irritable.
+
+Do not permit boys under eighteen years of age to go into regular
+training for college track-teams. Their hearts are not strong enough
+for the strain.
+
+Boys should not use tobacco in any form, but it is useless to try to
+make them believe this statement. Tobacco stunts a boy, causes
+dyspepsia, and renders his mind dull. The measurements made for years
+at Yale, Amherst, and other colleges, by physical directors, show
+remarkable reduction in the height and chest expansion in tobacco
+users as compared with boys that do not smoke. Cigarette smoking would
+not be different from other smoking if it did not so readily tend to
+excess. Cigarette smoke is inhaled more than the smoke from cigars and
+pipes, and thus more of the injurious ingredients of tobacco are
+absorbed.
+
+{210}
+
+If a boy will smoke let him use a good long-cut tobacco which has
+little or no Perique tobacco in it, in a "Remington," "Edison," or
+similar wooden pipe. These are pipes with stems of large calibre, and
+in the stem there is a roll of absorbent paper or pith which keeps the
+pipe clean. Cigars, no matter how costly they may be, are too strong
+for a boy and for most men. A poor cigar irritates the throat aside
+from the regular effect of the tobacco, especially if there is much
+nitre in the wrapper. Meerschaum pipes are dirty and too strong. The
+tongue is irritated by a pipe that has a small bore in the mouthpiece:
+use a mouthpiece that has as large a bore as possible. Cigar smokers
+should, after cutting off the end of a cigar, blow the dust out of it
+from the lighting end to avoid inhaling this irritating dust.
+
+AUSTIN OMALLEY.
+
+
+{211}
+
+XVII
+
+MENTAL DISEASES AND SPIRITUAL DIRECTION
+
+
+It is a well-recognised fact that persons suffering from many forms of
+beginning mental disease are likely to be affected by an exaggeration
+of religious sentiment. An unaccountable increase in piety is
+sometimes the first warning of approaching mental deterioration. It is
+not hard to understand why this should be, since religious feelings
+occupy so prominent a place in the minds of the majority of people,
+and the removal of proper control over mental operations of all kinds
+leads to an exaggeration, especially of those that have meant most for
+the individual before. Supposed religious vocations, especially when
+of sudden development, are sometimes no more than an index of
+disturbed mentality. Every confessor of lengthy experience has had
+some examples of this. This makes it important that clergymen should
+have a knowledge of at least the first principles on which the
+diagnosis of mental diseases is made. Superiors of religious
+communities, and especially those that have to decide as to the
+suitability of those applying for entrance to, or already in probation
+for, the religious life, need even more than others a definite
+knowledge of the beginning symptoms of the various mental diseases,
+and of the types of individuals that are most prone to suffer from
+them.
+
+Besides, confessors and religious friends and advisers often gain the
+confidence of the mentally diseased much more fully than any one else.
+It is to them especially that the earliest symptoms of beginning
+mental disturbance are liable to be first manifested. After all, a
+pastor's and a {212} confessor's duty is bound up with the welfare of
+his spiritual children in every sense; and it would be supremely
+serviceable to the patients themselves and to their friends, if these
+earliest symptoms could be recognised and properly appreciated, and
+due warning thus given of the approach of further mental
+deterioration.
+
+The mental diseases that are of special interest in this respect are
+the so-called idiopathic insanities. Idiopathic is a word we medical
+men use to conceal our ignorance of the cause of disease. Idiopathic
+diseases are those that have come of themselves, that is, without
+ascertainable cause. As a matter of fact, the most important group of
+mental diseases develop without presenting any alteration of the brain
+substance, so far as can be detected by our present-day methods of
+examination. The initial symptoms of these diseases, then, are of
+great importance, and not readily recognisable unless looked for
+especially. There is no physical change to attract attention, and the
+change of disposition and mental condition is often insidious and only
+to be recognised by some one who is in the confidence of the patient.
+It is in these idiopathic insanities, then, that the careful
+observation of the clergyman is of special significance. Needless to
+say, powers of observation to be of service must be trained.
+
+While there are no known changes in the brain tissues in these
+diseases, it seems not improbable that the development of our
+knowledge of brain anatomy, which is especially active at the present
+time, will very soon demonstrate the minute lesions that are the basis
+of these mental disturbances. It seems not unlikely that the
+underlying cause of so-called idiopathic insanity is usually some
+change within the brain cells. Hints of the truth of this conjecture
+are already at hand. Meantime the actual observation of this class of
+patients in asylums and institutions, private and public, and the
+collation of the observations of authorities in psychiatry from all
+over the world, have thrown a great deal of light on these forms of
+mental disease. We know much more of the initial symptoms and of
+incipient conditions that threaten the development of mental {213}
+disequilibration than we did twenty-five years ago. With regard to
+prognosis especially, recent publications have added considerably to
+our knowledge, although it must be confessed that they have rendered
+our judgment of such cases much less hopeful.
+
+The ordinary forms of mental diseases have sometimes been considered
+as passing incidents in the lives of patients suffering from such
+disorders. While it was generally understood that severe cases were
+apt to have recurrences, and that after persistence of mental symptoms
+for a certain length of time the outlook as regards eventual absolute
+cure is rather dubious, yet the general prognosis of such simple
+states as melancholia or simple mania was not considered to be
+distinctly unfavourable. Patients might very well recover their mental
+sensibility after even a severe attack, and never have a relapse.
+
+It was something of an unpleasant surprise to the medical world, a few
+years ago, when one of the most distinguished authorities in Europe on
+the subject of mental diseases, Professor Kraepelin, of the University
+of Heidelberg, stated in his text-book of psychiatry, that among a
+thousand cases of acute mania he has observed only one in which the
+symptoms did not recur. Professor Berkley, of Johns Hopkins
+University, Baltimore, a conservative American authority, in
+discussing this subject of relapses after single occurrences of mania,
+is evidently of the opinion that Professor Kraepelin's opinion in the
+matter presents the inevitable conclusion that must be drawn from
+recent advances in the clinical knowledge of maniacal conditions.
+"Simple mania," he says, "is, according to the statistics now at hand,
+an exceedingly rare form of mental disease, and the physician should
+therefore be cautious in making a prognosis of final recovery.
+Relapses after a number of years, when stability is apparently
+assured, are frequent, as every one interested in mental medicine
+knows only too well."
+
+The more experience the specialist in mental diseases has, the less
+liable he is to give an opinion that will assure friends of the
+patient that relapses may not occur after any form of disturbed
+mentality. While this is true in mania, {214} it is almost more
+generally admitted with regard to melancholia. Most patients who have
+one attack of severe depression of spirits will surely have others if
+they are placed in circumstances that encourage the development of
+melancholic ideas. Any severe emotional strain will be followed by at
+least some symptoms of greater depression than would be expected from
+the normal person under the same conditions.
+
+Professor Kraepelin has pointed out that in about one out of six cases
+the patients who came to him supposedly for the treatment of primary
+attacks of melancholia proved to be really suffering from a relapse of
+severe mental depression. The careful investigation of the history of
+these cases showed that they had suffered from previous attacks of
+depression, though sometimes these were so slight as not to have
+attracted any special attention from the medical attendant,--if
+indeed one had been called in the case--and at times even failed to
+occasion more than a passing remark on the part of friends with whom
+the patient was living.
+
+The most frequent form of idiopathic insanity is melancholia. The
+disease is characterised by depression of spirits. Professor Berkley's
+definition, besides being scientifically exact, is popularly
+intelligible. According to him, "Melancholia is a simple, affective
+insanity in persons not necessarily burdened by neuropathic heredity,
+characterised by mental pain which is excessive, out of all adequate
+proportion to its cause, and accompanied by a more or less
+well-defined inhibition of the mental faculties." This latter part of
+the definition is extremely important. In extreme cases patients are
+able to accomplish no other mental acts beyond those which concern the
+supposed cause of their depression. Their lack of attention to other
+things is the measure of the mental disturbance. Their minds
+constantly revolve about one source of discouragement. They become
+absolutely introspective and their surroundings fail utterly, in
+pronounced cases, to produce any reaction in them. In milder cases
+this involves an increasing neglect of whatever occupation the patient
+may have, solely for the purpose of giving up time to the
+contemplation of the cause of his depression.
+
+It is not easy always to recognise the limits between a {215}
+depression of spirits that is not entirely abnormal and a
+corresponding state of mind that is manifestly due to insanity. When
+misfortunes occur, individuals will be mentally depressed. Sorrow has
+in it necessarily no element of mental alienation. It is only when it
+becomes excessive that observers realise that there is disturbance of
+the mental faculties, causing the undue persistence and the
+exaggeration of the grief.
+
+For example, a mother loses an only son in the prime of manhood and at
+the height of his career. It will not be surprising if, for a
+considerable period, she is unable to take up once more the thread of
+life where it was so rudely interrupted. For weeks she may react very
+little to her surroundings and may prove to be so moody as to arouse
+suspicion of her mental condition. After a time, however, she begins
+to have some of her old interest in affairs around her. Her depression
+of spirits may not entirely disappear for long years, perhaps never;
+but her affective state does not go beyond a simple sorrow. On the
+other hand, under the same circumstances, a mother may give way to
+transports of grief that after a while settle down into a persistent
+state of dejection. Every thought, every word, every motive, has a
+sorrowful aspect to her. After a time she may begin to think and even
+to state that the misfortune of the loss of her son has come because
+of her own exceeding wickedness. She may consider it a punishment from
+on high and think that she has committed the unpardonable sin and
+absolutely refuse any consolation in the matter. This state of mind is
+distinctly abnormal, and if it persists for some time must lead to the
+patient's being kept under careful surveillance.
+
+The immediate cause of the development of such a melancholic state is
+always some unfortunate event in the course of life. Worry and sorrow
+are important causative factors. Mostly, however, these causes are
+only capable of producing their serious effects upon the mental state
+of predisposed individuals, or at times when the health of the subject
+is decidedly below the normal. Emotional disturbances are not liable
+to have such serious effects, except when anaemia, or continued
+dyspepsia, or some serious nutritive drain upon {216} the system, like
+frequently continued hemorrhages, persistent dysenteric conditions, or
+too prolonged lactation, have brought the system into a condition of
+lowered vital resistance. Unfortunately, in ordinary life these
+run-down physical conditions are prone to be associated with the worry
+and overwork that precede disaster.
+
+The effect of grief as a cause of melancholia may best be realised
+from the fact that in something over one-half of all the cases of
+melancholia the death of a near relative, father or mother, or even
+more frequently husband or wife, or child, is found in the clinical
+history of the patient shortly before the development of the mental
+disturbance. Serious business troubles, however, loss of property,
+actual want of proper nourishment, failure to succeed in some project
+on which the mind has been set, and similar conditions, so common in
+our modern hurried life, are also capable of producing the mental
+depression that assumes an insane character in certain individuals.
+
+For the development of melancholia a predisposition seems to be
+necessary. Most people can suffer the reverses of fortune, the
+accidents of life, and the griefs of loss of friends and relatives,
+without mental disequilibration. Certain predisposing factors are well
+known. Heredity, for instance, is extremely important. Melancholic
+conditions are frequently found in successive generations of the same
+family. While heredity is not as prominent a feature in melancholia as
+in other forms of insanity, the direct descent of a special form of
+melancholic mental disturbance from one generation to another is noted
+more frequently than in any other form of insanity.
+
+Women are more often the subjects of melancholia than are men. This is
+especially true in the earlier and in the later periods of life. In
+the years between twenty and thirty-five the proportion of cases in
+each sex is more nearly equal. The two conditions, the establishment
+of the sexual functions, that is, the important systemic changes
+incident to puberty, and the obliteration of the sexual function at
+the menopause, with its consequent physical disturbances, are
+especially important in predisposing to the occurrence of {217}
+melancholia in women. Their mental functions are less stable
+naturally, and are subject to greater physical strains and stresses.
+Childbirth and lactation are also important factors in the causation
+of the condition. Long-continued lactation--that is, beyond the
+physiological limit of about nine months--is especially a frequent
+cause. The development of the mental disturbance in this case is
+always preceded by a state of intense anaemia, in which the skin
+assumes a pasty paleness, and other physical signs give warning of the
+danger. Lactation is sometimes prolonged for no better reason than the
+hope to avoid pregnancy. Usually we may say this method fails of its
+purpose and pregnancy and lactation together work serious harm.
+
+In young people particularly, homesickness is a not uncommon cause of
+melancholia. It is especially liable to produce the condition if young
+people at a distance from home are subjected to serious mental and
+physical strain at a time when the food provided for them is either
+insufficient or unsuitable, or when disturbances of their digestive
+systems make it impossible for them properly to assimilate it. A
+number of instructive examples of this condition have occurred in the
+last few years among our young soldiers in the Philippines. To the
+physical strain necessarily incident to campaigning, especially in
+young men unaccustomed to the life of the soldier, there was added the
+serious trial of the tropical climate and the unusual and not
+over-abundant or varied diet provided by the army rations.
+
+Autointoxication is said to play a prominent role in the causation of
+melancholia. This supposes that there is a manufacture of poisonous
+materials within the system, whose transference to the nervous tissues
+causes functional disturbance of these delicate organs. Such poisons
+are especially liable to be manufactured when digestive disturbances
+have existed for long periods of time, or when chronic alcoholism is a
+feature of the case. The ordinary depressed condition so familiar in
+our dyspeptic friends and that develops so commonly as the result of
+indigestion, is an example of the depressing effect of toxic
+substances upon nervous tissues and mental states.
+
+{218}
+
+Melancholia does not develop as a rule without some warning of what
+may be looked for. Nutritive disturbances are nearly always prominent
+features in the case for some time before any mental peculiarities are
+noticed. Professor Berkley remarks that a feeling of woe and of
+uneasiness seems to be the way by which the brain expresses its sense
+of the lack of proper nourishment. Usually there has been distinct
+digestive disturbance for some months. There is apt to be loss of
+appetite. There may be some slight yellowness in the whites of the
+eyes. Commonly there has been an increasing disregard for the
+patient's usual habits, especially in the matter of exercise and
+friendly intercourse. There is a disposition to sit apart and brood by
+the hour, and a well-marked tendency to avoid friends and even members
+of the family, with an utter disinclination to meet strangers.
+
+One of the marked features of the disease in women is a tendency to
+untidiness. Women lose all regard for their personal appearance and
+fail to arrange their clothes properly. Men who have been specially
+neat in their personal appearance take on slouchy, careless habits,
+allow their clothes to become soiled and dirty, and have evidently
+forgotten all their old customs in this matter.
+
+The symptoms are not always continuous. There is often a rhythmic
+alteration of intensity of symptoms that corresponds more or less to
+the physiological rhythm of life. In ordinary circumstances human
+temperature is highest in the afternoon and vital processes are most
+active at this time. The lowest temperatures occur in the morning,
+especially in the early hours; and it is at this time that vital
+processes are least active and the general condition is most
+depressed. It is not surprising, then, to find that melancholic
+patients are liable to suffer from deeper mental depression during the
+morning hours. In suicidal cases it is especially in the morning hours
+that patients need the closest surveillance.
+
+In a certain number of cases of melancholia, instead of the quiet,
+often absolute immobility of the patients, there is a form of the
+disease characterised by the presence of incessant movement and an
+agitated state of countenance, {219} that disclose their disturbed
+mental conditions. In melancholia, as a rule, sleep is very much
+disturbed, and at times patients do not sleep at all. In the agitated
+form of melancholia, the patient is often quiet only when under the
+influence of a sleeping-potion. Patients may tear their hair,
+disarrange their clothing, strike themselves, hit their heads against
+the wall, sigh and sob, and repeat some phrase that indicates their
+deep depression. They are apt to reiterate such expressions as "I am
+lost," "I am damned."
+
+This is a much more serious form of melancholia than the quiet kind.
+The mental faculties are much more completely unbalanced, and the
+prognosis of the case is more unfavourable. There may be recovery
+within a very short time, and this recovery may be more or less
+complete. Usually, however, the condition becomes chronic and runs for
+many years. Such patients may sometimes be distracted sufficiently
+from their state of depression to smile and manifest pleasure in other
+ways. Usually, however, this diversion is only temporary and they
+recur to their darker moods until some new and specially striking
+notion distracts their thoughts once more.
+
+With regard to melancholia the most important feature is the tendency
+to suicide. This is apt to be present in any case, however mild, and
+may assert itself unexpectedly at any moment. Where there is suspicion
+of the existence of melancholia, patients must be under constant
+surveillance; and, as a rule, they should be under the supervision of
+some one accustomed to the difficulties that such cases may present.
+Patients are often extremely ingenious in the methods by which they
+obtain the opportunities necessary for the commission of suicide. For
+instance, a man who has been calm in his depression and has shown no
+special suicidal tendencies may make his preparations apparently to
+shave and then use his razor with fatal success. In a recent case in
+New York City, a woman under the surveillance of a new, though trained
+nurse, asked the nurse to step from the room for a moment. When the
+nurse came back three minutes later, the woman was crushed to death on
+the sidewalk seven stories below. A male patient asks an attendant
+{220} to step from the room for a moment for reasons of delicacy, and
+takes the opportunity to possess himself of some sharp instrument or
+of some poison. At times, during the night, patients rise up while
+attendants doze for a few minutes, and find the means to hang
+themselves without the production of the slightest noise.
+
+These unfortunate suicides are happening every day. They are the
+saddest possible blow to a family. Only the most careful watchfulness
+will prevent their occurrence. Clergymen should add the weight of
+their authority to that of the medical attendant in insisting, when
+such patients are kept at home, that they shall be guarded every
+moment. As a rule melancholic patients should be treated in an
+institution. Their chances of ultimate complete recovery, and, more
+important still, of speedier recovery than at home are much better
+under the routine of institution life and the care of trained
+attendants.
+
+Nearly three-fourths of the patients who suffer from melancholia will
+recover from a first attack under proper care. Subsequent attacks make
+the prognosis much more unfavourable. Not more than one-half will
+recover from a second attack, and, although melancholia is often
+spoken of as a mild form of intellectual disturbance, recurring
+attacks give a proportionately worse and worse outlook for the
+patient.
+
+If the general condition of the patient, that is, the physical health,
+is very much run down when the mental disturbance commences, then the
+outlook is much better than if the mental disturbance should occur
+when the patient is enjoying ordinarily good health. Thin, anaemic
+patients, contrary to what might be expected, usually recover and
+often their recovery is permanent. The first favourable sign in the
+case is an improvement in physical health. This is very shortly
+followed by an almost corresponding improvement in the mental
+condition. When the patient has reached the normal physical condition,
+the mental disturbance has usually disappeared.
+
+It is an extremely unfavourable sign, however, to have run-down
+patients gradually improve in physical health {221} without
+commensurate improvement in their mental condition. This is nearly
+always a positive index that the mental disturbance will continue for
+a long while, may not be recovered from completely, or may degenerate
+into a condition of dementia with more or less complete loss of mental
+faculties.
+
+The severe forms of melancholia are apt to be associated with
+delusions. Fear becomes a prominent factor, and the patient is afraid
+of every one who approaches, or concentrates his timidity with regard
+to certain persons or things. Delusions of persecution are not
+unusual, and this sometimes leads to homicidal tendencies. After
+enduring supposed persecution for as long as he considers it possible,
+the melancholic turns on his persecutors and inflicts bodily harm. The
+simplest actions, even efforts to benefit the patient by enforcement
+of the regulations of the physician, may be misconstrued into serious
+attempts at personal injury, for which the patient may execute summary
+vengeance. At times the hallucinations take on the character of the
+supposition that attempts to poison them are being made. The patient
+may conceal his supposed knowledge of these attempts until a
+favourable opportunity presents itself for revenging them. On the
+other hand, it is not an unusual thing to have melancholic patients
+commit homicide with the idea of putting friends out of a wicked
+world. The stories so common in the newspapers of husbands who kill
+wives and children, of mothers who murder their children, are often
+founded on some such delusion as this. A mother argues with herself,
+that her own unworthiness is to be visited on her children, and that
+they are to be still more unhappy than she is. Out of maternal
+solicitude, then, but in an acute excess of melancholia, she puts them
+out of existence and ends her own life at the same time.
+
+When the melancholia is founded on supposed incurable ills in the
+body, patients are sometimes known to mutilate themselves, or to have
+recourse to alcohol, or some narcotic drug, in order to relieve them
+of their pain, which is mostly imaginary, and make life somewhat more
+livable during its continuance. Alcoholic excesses are especially
+common in {222} cases of recurrent or periodical melancholia. Many of
+the cases of so-called periodical dipsomania are really due to
+recurring attacks of severe depression of spirits, in which men take
+to alcohol as some relief for their intense feelings of inward pain
+and discouragement.
+
+One of the most characteristic symptoms of melancholia is the refusal
+to take food. Sometimes this refusal is the consequence of an
+expressed or concealed desire to commit suicide. In many cases the
+refusal of food is associated with the patient's melancholic
+delusions. If the patient is hypochondriac, food is not taken because
+the stomach is supposed not to be able to digest it, or because it
+would never pass through the system. At times the delusions are in the
+moral sphere and the patient is too wicked to eat, or must fast for a
+long period or perhaps for the rest of life, with the idea of doing
+penance. As a matter of fact the refusal to eat is associated with the
+lowered state of function all through the system, which is the basis
+of the melancholic condition. This causes loss of appetite and
+lowering of the digestive function with a certain amount of nausea
+even at the thought of food, so that it is scarcely any wonder that
+patients refuse to take food. Needless to say, they must be made to
+eat. This often requires the insertion of a stomach tube and forced
+feeding. And as it must be done regularly, it is accomplished much
+more easily at an institution than at home.
+
+The other most common type of functional mental disease is mania. This
+is a form of insanity characterised by exaltation of spirits with a
+rapid flow of ideas and a distinct tendency to muscular agitation. It
+is almost exactly the opposite of melancholia in every symptom.
+Originally, of course, mania meant any form of madness. Then it became
+gradually limited to those forms of insanity which differed from
+melancholia. Now it has come to have a meaning as an acute attack of
+mental exaltation. It is necessary to remember this development of
+signification in reading the older literature on the subject of mental
+disturbance.
+
+Professor Berkley calls attention to the fact that Shakespeare's
+statement, "Melancholy is the nurse of frenzy," may have been founded
+upon the observation that there are {223} few cases of mental
+exaltation without a forerunning stage of depression. It is
+characteristic of the acuity of observation of the poet whose works
+have created so much discussion as to his early training, that this
+association of mental states, which became an accepted scientific
+truth only during the last century, should have been anticipated in a
+passing remark in the development of a dramatic character. Melancholia
+precedes mania so constantly that it is not an unusual mistake in
+diagnosis to consider a patient melancholic when an outbreak of mania
+is really preparing.
+
+Mania is sometimes said to break out suddenly. As a matter of fact
+there are always preliminary symptoms; though these are of such a
+general nature that they may have escaped observation. The patient's
+history generally shows that there has been loss of appetite and
+consequent loss in weight, commonly accompanied by constipation and
+headache with increasing inability to sleep. Usually these symptoms
+have been present at least for some weeks or a month or more. Then the
+patient brightens up. Instead of the brooding so common before, there
+is a tendency to talkativeness; the eye is bright; the expression
+lively; in the midst of his loquacity the patient becomes facetious
+and jocular. The backward before become enterprising. Undertakings are
+attempted that are evidently far beyond the power, pecuniary or
+mental, of the individual. Active employment is sought, and, where
+this fails, restless to and fro movement becomes the habit.
+
+Friends notice this change in disposition, and also note a certain
+lack of connection in the ideas. There is apt to be a distinct change
+of disposition. A man who has been very loath to make friends before,
+now becomes easy in his manner toward strangers and takes many people
+into his confidence. In the severer forms motion becomes constant; the
+arms are thrown around; to and fro movement at least is kept up; the
+voice becomes loud and is constantly used. Patients can not be kept
+quiet, and, as a consequence of their constant movement, their
+temperature rises and loss of sleep makes them weaker and weaker until
+perhaps physical exhaustion ensues.
+
+{224}
+
+The causes of mania are not always so distinctly traceable as those of
+melancholia. Heredity is an important factor. This is, however, not so
+much a question of actual direct inheritance of mental disturbance
+from the preceding generation, as a family trait of mental weakness
+that can be traced through many generations. Direct inheritance of
+acquired peculiarities no scientific thinker now admits. Family
+peculiarities, however, are traceable through many generations. So
+striking a peculiarity as the possession of six fingers or six toes
+has been traced through a majority of the members of as many as five
+generations in a single family. And as has been said other family
+traits can be traced back in the same way.
+
+It would not be entirely surprising, then, if mental peculiarities and
+a predisposition to mental disturbance should be also a matter of
+inheritance. It is well known now that the physical condition of the
+brain substance may have much to do with the intellectual functions.
+Injuries to certain parts of the brain may cause special changes even
+of personal disposition. In the famous crowbar case, in which an iron
+drill over four feet in length was driven through one side of the
+head, it was noted that the man, who had been somewhat morose before,
+was inclined to be more amiable afterwards, but also had a tendency to
+be bibulous in his habits.
+
+German clinicians have recently pointed out that the existence of an
+excess of pressure on the frontal lobes of the brain, such as is
+produced by the presence of a tumour, may cause a tendency to make
+little jokes. This symptom is known as "Witzelsucht." It is considered
+of distinct significance and value in localising tumours of the brain.
+The question of the type of the witticisms and particularly a tendency
+to obscenity are noted as a special diagnostic aid in the recognition
+of the character of these tumours by at least three prominent German
+medical observers.
+
+If modifications of the brain substance can produce changes of
+disposition and temperament, it is easy to understand how temperament
+and disposition may be a matter of inheritance. If we inherit a
+father's nose and a mother's eyes, {225} the minutest conformations of
+brain substance may also be inherited. It is on these, to a certain
+extent at least, that the general outlines of the disposition depend.
+It would not be surprising to find, then, a disposition to mental
+unsteadiness as the result of the transmission of brain peculiarities.
+Here, as in everything else, there is question, not merely of parental
+influence, but of the inheritance of the family traits, some of which
+are skipped in certain generations.
+
+When melancholia and mania are said to be due to heredity as one of
+the principal causes, the meaning intended is that in certain families
+the brain tissues are liable to be transmitted in somewhat impaired
+condition, and that through these brain tissues the mind will either
+not act properly, or under the stress of violent emotion, the loss of
+friends by death, or the loss of fortune, or serious disappointments
+in life, or a love affair, the already tottering mental condition will
+be overturned. In a word, it is not the direct transmission of
+insanity, but of a predisposition to the development of insanity under
+stresses and strains that is a matter of family inheritance. This is
+considered true now not only of mental but of all diseases. Not
+consumption, but the predisposition to it is inherited.
+
+These considerations make clear how important this matter of heredity
+is. Physicians and students of anthropology are so much concerned
+about the increase of insanity as the result of the intermarriage of
+defectives that we are constantly reading in the newspapers of
+attempts at the legal regulations of marriage, so as to prevent
+further racial degeneration. Under present circumstances, any such
+legal regulation is probably impossible; but it seems perfectly clear
+that clerical influence should be brought to bear to discourage, as
+far as possible, intermarriage among those of even slightly disturbed
+mental heredity. Especially must any such idea as the possible
+beneficial influence of matrimony (for there are popular traditions to
+this effect) be unhesitatingly rejected and it must not be allowed to
+tempt those interested to look on such intermarriage with
+indifference.
+
+{226}
+
+Another and more serious question for the clergyman is that of the
+vocation in life of those who are weak mentally. By vocation is meant
+not only religious calling, but the occupation in life generally.
+Young people of unstable mentality and especially those of insane
+heredity should be advised against taking up such professions as that
+of actor or actress, or broker, or other life duties that entail
+excitement and mental strain. As far as possible they should be
+discouraged from taking up city life, and should be advised to live
+quietly in the country.
+
+Mania is apt to follow certain severe infectious diseases in delicate
+individuals. Pneumonia, for instance, or typhoid fever or chorea, and
+sometimes consumption or rheumatism, may be followed by a period of
+maniacal excitement. Severe injury to the brain or the pressure due to
+the presence of a brain tumour, may also be a cause of mania. A
+certain number of good authorities in mental diseases have called
+attention to the fact that mania is a little more liable to occur in
+patients who are suffering from heart disease. By this is meant in
+persons who have some organic lesion of the valvular mechanism of the
+heart. This leads to disturbance of the circulation and interferes
+with cerebral nutrition, thus predisposing to functional brain
+disturbance.
+
+While melancholia occurs very frequently in older people, mania is
+almost essentially a mental disease of the young. The vast majority of
+cases occur between the twelfth and thirty-fifth year. The subjects of
+the disease are usually those who possess what is called the sanguine
+temperament, that is, hopeful, enthusiastic people, easily excited and
+aroused, easily cast down. Mania is much more common in females than
+in males.
+
+One of the important characteristics of mania is the super-excitation
+of the sexual faculty. In many individuals the first sign of their
+mental disequilibration noticed by friends is a tendency to sexual
+excess. This is true of women as well as of men, and the extent to
+which this may manifest itself is almost unlimited. At the beginning
+of the disease this symptom is often a source of serious
+misunderstanding, and may be the cause of family disruption. Usually,
+before {227} there are any open insane manifestations, there are
+definite symptoms that would point to a pathological excitement in the
+sexual sphere.
+
+One of the most striking characteristics of maniacal patients is the
+anaesthesia that often develops and is maintained in spite of the most
+serious injury. Because of this, maniacal patients should be guarded
+with quite as much care as those suffering from melancholia. I have
+seen a patient who, during an attack of acute mania, had put her hand
+over a lighted gas jet, holding it there until the tissues were
+completely charred. The burner was behind an iron grating, but she
+succeeded in reaching it. Neither from this dreadful burning itself,
+nor during the after dressings, did she complain of the slightest
+pain. Because of this anaesthetic condition and the consequent lack of
+complaint, maniacal patients often suffer from severe internal trouble
+without the medical attendant having any suspicion of its existence.
+There are few conditions that are more painful, for instance, than
+peritonitis, yet maniacal patients have been known to suffer and die
+from peritonitis, due to intestinal or gastric perforation, without a
+single complaint.
+
+Unexpected death frequently occurs in mania because of the failure to
+recognise the existence of serious pathological conditions. Pneumonia
+may develop, for instance, without the slightest complaint on the part
+of the patient and go rapidly on to a fatal termination during the
+exhaustion incident to the constant movement, it being utterly
+impossible to confine the patient to bed. Meningitis may develop in
+the same way and proceed to a fatal issue without the patient's making
+any complaint or any sign that will call attention to its existence.
+In the meantime, the patient may be constantly in the wildest motion
+and so add to the exhausting effect of the organic disease.
+
+The prognosis of acute mania is not unfavourable. Patients suffering
+from a first attack will recover completely in eight cases out of ten.
+Notwithstanding complete recovery, relapses are prone to occur
+whenever the patient undergoes a severe emotional strain. As a rule
+not nearly so much mental disturbance is required to produce a second
+attack {228} as the first one, so that patients require great care. In
+a certain number of cases recovery is incomplete; persistent delusions
+remain, and there may even be some weakness of intelligence. Paranoia,
+as it is called, mild delusional insanity, may assert itself and then
+may persist for the rest of life. Notwithstanding this, patients may
+get along in life reasonably well, though their mental condition is
+decidedly below the normal.
+
+In a certain number of cases, after the period of excitement
+disappears, a certain amount of dementia is noticed. This consists of
+a distinct lowering of the intelligence, though without the presence
+of any special delusion. This dementia progresses until finally there
+is a state of almost complete obliteration of the mental faculties.
+The prognosis as to life in cases of mania is very good. Very few
+patients die during an attack of acute mania. At times there is a
+development of tuberculosis that proves fatal, because of the
+restlessness of the individual. Pneumonia or typhoid fever may also
+prove fatal.
+
+Besides mania or melancholia, there is a third form of functional
+mental disease, which is a combination of these two forms. It is
+usually spoken of as circular insanity. The patient has usually first
+an attack of melancholia, then an attack of mania, and then after an
+interval melancholia and mania once more. We have said that most cases
+of mania develop after a distinct stage of depression of spirits, so
+that successive attacks of mania take partly the character of circular
+insanity. This latter disease, however, is an index of a much more
+degenerated mental state of the individual than is either mania or
+melancholia alone. When it occurs, the prognosis as to future sanity
+for any lengthy interval is unfavourable. A series of attacks
+alternately of depression and excitement finally make it necessary to
+confine the patient to an institution.
+
+As might be expected in this severer form of mental disturbance,
+heredity plays an especially important part in circular insanity. At
+least 70 per centum of the patients affected show a family history of
+insanity in some forms. In this disease direct inheritance of this
+particular form of {229} mental disturbance is noticeably frequent.
+The patients who develop this form of insanity usually show marked
+signs of degeneration, even before any attack of absolute mental
+disturbance has occurred. Wounds of the head, alcoholism, and epilepsy
+are prominent factors in the production of circular insanity. This
+only means that the predisposition to mental disequilibration is so
+strong that but very little is required to disturb the intellectual
+equilibrium.
+
+Fortunately, circular insanity is rare. In 40,000 cases of insanity in
+New York State, only 96 cases of this form were noted. Mild types of
+the disease are not, however, very rare. Many otherwise sane people
+have alternating periods of hopeful excitement and of discouraging
+depression, not momentary but enduring for weeks at a time, which are
+really due to the same functional disturbances that in people of less
+stable mentality produce absolute insanity. These cases are of special
+interest to the clergyman and to directors of consciences.
+
+JAMES J. WALSH.
+
+
+{230}
+
+XVIII
+
+NEURASTHENIA
+
+Neurasthenia, or nerve-weakness, "the vapours" of the old novelists
+and dramatists, is a very common malady, and it gives the clergyman
+trouble by the turmoil it causes in families, religious communities,
+in themselves, and elsewhere. Whether the condition is a distinct
+disease or not, and that question has been voluminously discussed, is
+not altogether an important matter, but that there is such a group of
+symptoms is unfortunately a weighty fact. It takes so many forms that
+it is bewildering, and therefore not readily reduced to unity.
+
+The cerebral form often exists independently. There is such a thing as
+"brain fag," although many complainants may have very little material
+for the fag to work on. Often such a patient is robust, even an
+athlete, and his assertions meet with ridicule or abuse instead of
+treatment. If the patient is a woman she is not seldom called
+"hysterical." She is not hysterical. Hysteria, by the way, is as
+distinct a trouble as a broken leg, and far more serious, and not a
+synonym for perverseness, as the term is popularly used.
+
+In the cerebral form, business, reading, study "go into one ear and
+out the other." The patient's memory fails him temporarily just when
+he may need it most, say, in a speech or sermon; a fly buzzing on a
+pane is a calamity and a source of profanity; a flat note in the
+choir-singing is ample reason for doubting the divine origin of the
+church, and every petty trouble that whisks its harmless tail across
+his floor makes him seek the table-top. I have known a whole convent
+of nuns, who were closely shut in, with bad ventilation and a worse
+cook, until all were more or less neurasthenic, almost {231}
+disintegrated by the presence of a lamb sent in as a pet; not because
+of the bleating or any ordinary reason, but solely because of the
+hideous incongruity and indecency in the fact that the lamb was a
+male.
+
+The cerebral neurasthenic makes rash, impetuous changes in his mode of
+life. He leaves a religious order because the coffee is weak, he
+resigns an important post in a bank because the president uses snuff,
+he abandons medicine for trade because the curate meddled in the
+treatment of two of his patients. He takes on anxiety, locks up the
+house six times over the same night; meals are eaten in awed silence
+by his trembling children; altogether he is an unmitigated nuisance.
+
+He may get religious scruples. If he is a priest he takes an hour to
+an hour and a half to say a low mass, and most of that time is spent
+in searching the corporal for imaginary particles or in drying the dry
+chalice. He rereads his breviary until he is exhausted. Because moral
+theologians say that certain scruples are from the devil, he is
+convinced that the devil takes a particular interest in his case. The
+devil did probably take a special interest in his father's or
+grandfather's lack of scrupulosity, for his condition is commonly a
+result of alcoholism in an ancestor.
+
+There are three chief types of neurasthenics: in one class is the
+person that appears robust, and is really so except in his nervous
+system, which lacks a governor. Such patients have little more than a
+troubled appearance to draw the attention of a chance observer to
+their condition.
+
+A second class is made up of eloquent narrators of their troubles.
+They try all the physicians in turn, then the homoeopaths and
+osteopaths and similar quacks, and they add patent medicines
+prescribed by themselves. They are petulant, capricious, and despite
+their apparent energy they accomplish nothing.
+
+The third class are silent, limp, clammy-handed; they are brought
+against their will to see the physician; they are sulky; bitter and
+unreasoning haters; inclined to melancholy. They may have a tendency
+even to suicide, but this is somewhat rare. Neurasthenics are not so
+liable to insanity as is popularly supposed, but such an outcome is
+possible in certain {232} cases. If their vague fears go on into a
+more or less fixed delusion there is cause for anxiety lest insanity
+result, but care should be taken here to be sure the delusion is
+really irremovable.
+
+Some neurasthenics are afraid to cross an open square or a wide
+street, others dread any closed apartment. Vertigo is common; so is
+insomnia. Insomnia is almost a constant symptom. The patient may have
+naps or he may have uninterrupted vigils. Sometimes there is a heavy
+but unrefreshing sleep. Sleepless patients are thrown into distracting
+rage by the barking of a neighbour's dog, the howling of cats, or the
+cackling of a successful hen, and they haunt the magistrates' courts
+in efforts to suppress such noises. They put cotton in their ears,
+wear heavy nightcaps, stop clocks, board up windows in search of
+sleep, which is not found.
+
+These patients commonly have an enduring feeling of weight or
+constriction in the head, especially at the occiput,--a headache that
+is not actual pain. They also have vertigo, which is independent of
+any aural disease, and this is transient, showing itself on abrupt
+changes of position.
+
+Another phase of neurasthenia is spinal. These cases have pain in the
+back and their legs give out. The back-pain is a diffuse ache, or it
+manifests itself on pressure at certain spots along the spine. There
+may be severe pain at the coccyx, especially in women. The walking may
+simulate paralytic forms if hysteria is mixed with the neurasthenia.
+Cardiac symptoms are often prominent, especially palpitation, but
+there is a nervous excitation of the heart rather than any definite
+lesion.
+
+The gastro-intestinal symptoms are often important. Pain referred to
+the stomach and acidity are common, the tongue is coated, the faeces
+scybalous. Digestion is torpid. Sometimes there is nervous diarrhoea.
+A list of the belly symptoms described by some neurasthenics is
+interminable.
+
+We often find a sexual form, which is the worst of all and the hardest
+to cure. It is commonly connected with masturbation. Such
+neurasthenics are shameless in the description of their nastiness. It
+is better to keep them from marriage unless they are cured, and they
+are not to be foisted off on {233} any one as husband or wife to
+effect a cure. Allbutt says of them: "I fear that some of our
+'criminal psychologists' are encouraging many sorts of prurient
+debauchees by dignifying the tales of their vice with the name of
+science, a course of conduct which is in the worst interests both of
+these persons themselves and of our own profession. It were a curious
+inquiry how it comes that sexual perversions are so 'scientific' a
+study, while the brutalities of the thieves' kitchen or the wiles of
+other pests of society lie in comparative neglect."
+
+Physical, intellectual, or emotional strain can cause neurasthenia
+suddenly or gradually. Where it comes on without obvious cause there
+is commonly a bad family history of nervousness or alcoholism. Anaemia
+makes it worse; eye-strain, too, is a provoking factor. In some cases
+a renal congestion is the cause. In many cases a lack of restraint,
+bad education, uncontrolled passion, are a marked influence in fixing
+the neurasthenic habit. A sedulous parent nags at a neurasthenic child
+that is too weak for exertion until the child's susceptibility to
+correction is blunted. Instead of treatment and help the child
+receives cuffs and abuse, and hell-fire is held up before him until he
+deems all religious talk dust and ashes. Encouragement will sometimes
+do more good than all the threats in the _via purgativa_. Nagging
+never cured anything except a tendency toward virtue, and it always
+deepens neurasthenia. Be careful in the selection of a confessor for a
+neurasthenic child. Get one that does not believe in kicking a soul
+into paradise.
+
+The treatment of neurasthenia is difficult. Traveling about in search
+of health is not advisable. The Weir Mitchell Rest Cure is very
+effective in many bad cases, but it is costly, and if not correctly
+applied it is useless. It is the only cure for some patients. Sea air
+helps a certain class of neurasthenics, but it makes others worse--it
+is bad for the dyspeptic neurasthenic. A chronic rhinitis, a
+refractive error of the eyes, a displacement of the uterus, a
+congested kidney, a floating kidney, a tight prepuce, and similar
+teasing disorders must be cured before the neurasthenia can be
+removed; often the neurasthenia disappears with this cure.
+
+Traumatic neurasthenia is like simple neurasthenia in {234} most
+details. It is called also nerve shock, spinal irritation, railway
+spine. There is always a causative shock or injury, which is followed
+at once or after an interval by the symptoms of neurasthenia. In acute
+traumatic neurasthenia there may be, in addition to the symptoms
+observed in simple neurasthenia, high fever, and such a fever has been
+observed to go as high as 113 degrees Fahrenheit.
+
+AUSTIN OMALLEY.
+
+
+{235}
+
+XIX
+
+HYSTERIA
+
+The term Hysteria ([Greek text] uterus) has been handed down from the
+days when physicians thought there was a connection between
+womb-disorders and the set of nervous symptoms grouped under the title
+hysteria. It is now etymologically meaningless,--men also grow
+hysterical. Briquet found 11 male to 204 female hysterics, and later
+statistics increase the number of males.
+
+The disease is not readily definable. The patient is usually a young
+emotional woman, oftenest between 15 and 20 years of age. She commonly
+has anaesthetic spots on her body, concentric limitations of the field
+of vision, and hystero-genetic zones, or tender points, which, when
+pressed, appear to inhibit the hysterical fit. The symptoms enumerated
+here are not, however, found in every case of hysteria, and it is
+difficult at times to diagnose the disease.
+
+The various manifestations of hysteria are (1) apt to come and go
+suddenly. A severe paralysis that suddenly disappears for a time is
+hysterical; (2) even if they last for years they may be suddenly
+cured; (3) they are dominated more by mental and moral influences than
+are the symptoms of any other disease; (4) we find no organic lesion
+with which we can connect the symptoms.
+
+The conditions that bring about hysteria are hysteria in a parent, or
+insanity, alcoholism, or some similar neurotic taint in an ancestor.
+There is no direct connection between hysteria and the disorders of
+the sexual organs.
+
+Immediate causes are acute depressive emotions, shocks from danger,
+sudden grief, severe revulsions of feeling, as from disappointment in
+love; and, secondly, cumulative {236} emotional disturbance, as from
+worry, poverty, ill treatment, unhappy marriage, or religious
+revivals. Certain diseased conditions, as anaemia, chronic
+intoxications, pelvic trouble, cause hysteria, or, more exactly, start
+it into activity where it is latent. It is also communicated by
+imitation and it may become epidemic.
+
+After the great plague, the Black Death, in the fourteenth century,
+there were very remarkable epidemics of imitative hysteria in Germany
+and elsewhere. In 1374, at Aix-la-Chapelle, crowds of men and women
+danced together in the streets until they fell exhausted in a
+cataleptic state. These dances spread over Holland and Belgium and
+went to Cologne and Metz. It is said that in Metz there were 1100 of
+the dancers seen at the same time.
+
+The "Dancing Plague" broke out again in 1418 at Strasburg, in Belgium,
+and along the Lower Rhine.
+
+  "Viel hundert fingen zu Strassburg an
+  Zu tanzen und springen Frau und Mann,
+  Am offnen Markt, Gassen und Strassen;
+  Tag und Nacht ihrer viel nicht assen,
+  Bis ihn das Wuethen wieder gelag.
+  St. Vits Tanz ward genannt die Plag."
+
+Beckmann (_Historia des Fuerstenthums Anhalt_. Zerbst. 1710) tells of a
+similar outbreak in 1237, wherein nearly a hundred children were
+seized by the disease at Erfurt, and they went along the road to
+Arnstadt, dancing and jumping hysterically. A number of these children
+died of exhaustion. The same infection is often at work in the fury of
+a mob, the panic of a beaten army, and it probably was an element in
+the Children's Crusade.
+
+The Tarantism so common in Italy from the fifteenth to the eighteenth
+century is another example of epidemic hysteria. The Bubonic Plague
+ravaged Italy sixteen times between 1119 and 1340, and smallpox was at
+work when the black death could find no fresh victims. As a
+consequence of economic disturbance and fear the people were generally
+neurasthenic, and a slight shock was enough at times to set whole
+villages into hysterical convulsions.
+
+{237}
+
+In 1787, at Hodden Bridge in Lancashire, England, a girl in a cotton
+mill threw a mouse upon another girl that had a great dread of this
+animal. The frightened girl was thrown into a hysterical convulsion
+which lasted for hours. The next day three girls that had watched her
+were in convulsions, the following day six more, and two days later
+fourteen more girls and a man were in fits. American white and negro
+camp-meetings result in similar outbreaks, and the French
+_Convulsionnaires_, who did outrageous things from 1731 to 1790, were
+also afflicted with imitative hysteria. The Cornish Jumpers, founded
+in 1760 by Harris Rowland and William Williams, and the American
+Barkers were also hysterical. The Barkers in the meetings would run
+about on all fours growling, "to show the degeneration of their human
+nature," and they would end in almost general fits of imitative
+hysteria.
+
+There was an epidemic of hysteria in Tennessee, Kentucky, and a part
+of Virginia, which began in 1800 and lasted for a number of years. It
+started at revivals. The majority of the cases were in persons from 15
+to 25 years of age, although it was observed in every age from 6 years
+to 60. The muscles affected were those of the neck, trunk, and arms.
+The contractions were so violent that the patients were thrown to the
+ground, and their motions there exactly resembled those of a live fish
+thrown out of the water upon the land.
+
+There are numerous theories formulated to explain hysteria; some are
+ingenious, especially that of Janet, but none is convincing.
+Convulsions, tremors, paralyses of various forms and degrees are
+common in hysteria. In major hysteria the patient falls into a
+convulsion gently. There is checked breathing, up to apparent danger
+of suffocation. Then follows a furious convulsion, even with bloody
+froth at the mouth, but there is a trace of wilfulness or purpose in
+the movements. Next may come a stage of opisthotonos, where the body
+is bent back in a rigid arch till the patient rests on her heels and
+head only, and this is followed by relaxation and recurrence of the
+contortions. An ecstatic phase succeeds this, at times in the
+so-called crucifix position, with outbursts of various emotions, and a
+final regaining of a {238} normal state. Any of these stages, however,
+may constitute the whole fit.
+
+In minor hysteria there is commonly a sensation of a rising ball in
+the throat (the _globus hystericus_). There may be uncontrollable
+laughter or weeping. Muscular rigidity is frequently found. The
+patient, especially if she is a child, may mimic dogs and other
+animals. The snarling, biting, and barking of false hydrophobia are
+hysterical; these symptoms do not occur in real hydrophobia.
+
+There are almost innumerable physical symptoms of the disease, which
+are chiefly of medical interest, but the mental phases are such as to
+involve questions of morality. The hysterical character is marked by
+an overmastering desire to be an object of general sympathy,
+admiration, or interest, rather than by a tendency to baser
+indulgence. The will is weak, the emotions explosive, the patient is
+impulsive and lacking in self-control. She is a "giggler," who goes
+from absurd laughter into floods of tears. The desire for sympathy and
+attention makes the patient exaggerate her symptoms or simulate
+diseases and conditions that do not exist in her case. Hysterics will
+swallow pins or stick them into their flesh to force attention.
+Sometimes the simulation of disease is not willed. If there are a
+number of hysterical girls in a hospital ward and one develops, say, a
+peculiar paralysis, within two or three hours every hysterical woman
+in the room will have the same paralysis,--not pretended, but real,
+although temporary. It must be remembered that the disease, with all
+its perversity, is as much a fact as pneumonia, and the element of
+sham is only one of its symptoms. Some authorities go so far as to
+hold that a woman who will not lie is not hysterical. They invent most
+extraordinary slanders against even their own immediate family, and it
+is never prudent to believe an accusation made by an hysterical
+patient, no matter how plausible the story.
+
+Acquired hysteria in many cases may be cured, but the congenital
+condition is practically hopeless, yet the latter kind may be kept
+from violent outbreaks.
+
+We can not prevent drunkards, epileptics, and lunatics from
+propagating their kind, and therefore we shall still have the {239}
+hysteric with us. The child that has a bad ancestry and shows
+hysterical tendencies should be carefully reared. If it has an
+hysterical father or mother it should, if possible, be removed from
+this evil influence. Keep it from long hours of mechanical work that
+leaves opportunity for dreaming. Shut out novels and "art for art's
+sake," especially music. Give it a practical education. Teach it
+obedience, self-control, and truthfulness. Harden its will by exercise
+at things it does not like, and do not coddle it. Do not marry off an
+hysterical girl to cure her. Do not inflict her presence upon some
+unfortunate young man because he is a good citizen. Marriage will not
+cure hysteria,--the worst cases are married women, and they beget
+other hysterics in spreading succession.
+
+When the disease shows itself offer no sympathy,--do not try to put
+out a fire with oil. When a "good, pious girl" grows hysterical, the
+chief obstacles to her cure are untactful and sympathetic visits from
+friends, lay and clerical. A visit from the pastor, because of his
+importance, is always harmful, and if the bishop drives up in his
+carriage so that the neighbours may see him, all the physicians in the
+city can not help her. If you wish to keep an hysterical girl in her
+vapours, get her a physician that will grow excited over her, take the
+dear child out of school and weep above her couch, let the family and
+its friends assure the unfortunate attending physician in her presence
+that he is heartless, and she will stay hysterical to her soul's
+content.
+
+If you wish to control the attack, or even remove the disease under
+certain conditions, call in an experienced physician, leave the
+treatment to him, and pay no attention to her. Do not make light of
+the disease, do not speak of it at all. There are attacks that may be
+cured by the razor-strop or a bucket of cold water, but these are
+exceptional. They are new cases or old professional offenders. Rough
+treatment is not so good as patient tact, but at times roughness is
+the only cure.
+
+AUSTIN OMALLEY.
+
+
+{240}
+
+XX
+
+MENSTRUAL DISEASES
+
+Menstruation is a periodic discharge of blood from the uterus and the
+Fallopian tubes. It occurs every twenty-eight or thirty days, and it
+lasts from puberty to the menopause, or the cessation of the
+menses,--about the forty-fifth year of age.
+
+There is a connection between menstruation and the production of the
+human ovum. During the first stage of menstruation the mucous membrane
+lining the uterus swells to twice or thrice its normal thickness, and
+this growth is a preparation for the reception of the ovum, which, as
+a rule, is given off by one of the ovaries at this time and passes out
+into the uterus. Menstruation and ovulation ordinarily occur
+simultaneously, but they may be independent and take place at
+different times. If, during this stage, the ovum is impregnated,
+pregnancy begins, and menstruation ceases until some time after
+childbirth. In married women conception is more likely to be effected
+during the first stage of menstruation than during the interval of
+quiescence; the contrary is almost the exception. Impregnation,
+however, is likely to occur in the spring more than at other seasons,
+and this fact coincides with the advent of spring in various
+latitudes.
+
+If the ovum is not impregnated, the material that made the uterine
+mucous membrane thick during the first week of menstruation
+degenerates and passes off, constituting the menstrual flow. This
+stage lasts about five days. A reparative period of about four days
+follows, and then a period of quiescence until the next menstruation
+commences.
+
+Menstruation is first observed about the fourteenth year, but it may
+start earlier or later. In general, it comes on {241} earlier in warm
+climates, and later in the extreme north. The menstruation, too, is
+likely to show sooner in the labouring classes than in girls who do
+not work.
+
+Even in normal menstruation there is often a marked physiological
+excitation which affects the entire person. Very commonly a nervous
+disturbance and sensitiveness are observed, and in women that are not
+robust there may be mental depression and irritability. The
+temperature will rise a half degree, and drop to the normal height on
+the day preceding the flow.
+
+There are derangements of menstruation which are symptoms of various
+diseases. Amenorrhoea is an absence of menstruation in conditions
+other than pregnancy or lactation. Absolute amenorrhoea is a complete
+absence of menstruation for several months; relative amenorrhoea is
+delayed, scant menstruation.
+
+Amenorrhoea is common during convalescence from acute diseases; it is
+also a result of chronic diseases of the liver, stomach, intestines,
+kidneys, and especially of the lungs; it complicates anaemia, malaria,
+rheumatism, and other general pathological conditions. Fright, grief,
+great anxiety, mental shock cause amenorrhoea; so do homesickness and
+many forms of insanity.
+
+There are also local causes of this condition: imperfect development
+of the uterus or the organs connected therewith, and inflammations of
+these organs or of the pelvic wall.
+
+Opposed to amenorrhoea is menorrhagia, or an excessive menstrual flow.
+Metrorrhagia, or hemorrhage from the uterus at any time, is a term
+confounded with menorrhagia, which is an inordinate menstrual loss of
+uterine blood, but the distinction is not important. Menorrhagia and
+metrorrhagia commonly have an identical cause and they frequently
+coexist. They are found in chronic diseases of the heart, lungs,
+liver, and other organs; they are an outcome of prolonged lactation,
+and of local affections of the uterus and its appendages. Any
+condition also that deranges the blood may cause menorrhagia or
+metrorrhagia; so do malignant tumours of the uterus, uterine
+displacements, lacerations that {242} occur in childbirth, and
+psychical influences, as fright, anxiety, and other strong emotions.
+
+Dysmenorrhoea, difficult or obstructed menstruation, is a term used
+for menstruation accompanied by pain. This is a common menstrual
+derangement, and it may be neuralgic or inflammatory in origin, or it
+may be caused by obstruction to the menstrual flow. There is another
+variety of dysmenorrhoea, called membranous, in which the superficial
+layer of the uterine lining is cast off partly or wholly.
+
+In the neuralgic form the uterus and its appendages are normal in
+appearance, but the pain recurs monthly, and it may have degrees from
+mere discomfort to agony. This form is characterised by reflex
+headache, sympathetic nausea or vomiting; and the pain may not be
+confined to the uterus and its appendages. The irritation often brings
+out latent hysterical phenomena, spinal irritation, and neurasthenia.
+Rheumatism and gout are predisposing causes, so are indolence, lack of
+physical exercise, light clothing in cold weather, forced school work
+and similar depressing agents.
+
+In the neurotic variety of dysmenorrhoea pain often persists after the
+menstrual flow has set in, but in inflammatory dysmenorrhoea the flow
+relieves the pain or removes it. Marriage commonly removes the
+neurotic form of dismenorrhoea.
+
+In obstructive dysmenorrhoea the menstrual fluid is retained by narrow
+or tortuous outlets, flexions of the uterus, and similar causes. The
+prognosis is good in all forms of dysmenorrhoea, but frequently long
+and skilful treatment is required to cure such conditions, especially
+the membranous form. Inflammatory, obstructive, and membranous
+dysmenorrhoea are commonly made worse by marriage.
+
+At the end of the childbearing period menstruation gradually ceases.
+In temperate climates this menopause occurs about the forty-fifth
+year, but it may come earlier or considerably later. Work that keeps a
+woman in a heated atmosphere, as cooking, washing, and baking,
+disturbs menstruation and tends to advance the menopause. Workers in
+chemical factories, in badly ventilated rooms, or women that do heavy
+labour in the open air, are apt to age prematurely, and have {243} an
+early menopause or "change of life." This premature climacteric is
+found also in women that bear many children in rapid succession.
+
+At the menopause there may be various physical or mental disturbances
+which are probably due more to the somewhat abrupt advent of old age,
+at the cessation of the childbearing part of life, rather than to the
+menopause itself. It is a fact, however, that often profound
+disturbances coincide with the climacteric, and we know no sufficient
+cause for them if the menopause itself may not be deemed such.
+
+There are numerous disorders of the nervous system in women which are
+dependent directly or indirectly upon a derangement of the pelvic
+organs. Distant parts of the body are affected pathologically through
+sympathetic irritation when the primary disease is in the pelvic
+organs, and direct treatment of the pelvic trouble alone cures these
+reflex conditions. The very common disorders of pregnancy, the marked
+physiological changes in women at the beginning of menstruation with
+puberty, and its cessation with the menopause, are among the first
+proofs of this assertion that occur. Menstruation may aggravate
+goitre, uterine fibroid tumours, skin diseases, and affections of the
+blood vessels. Disordered menstruation causes sleeplessness,
+melancholy, dementia, and mania, by affecting the brain; it may bring
+on local paralysis; start up latent epilepsy; excite reflex cough and
+difficulty in breathing; make the heart irritable; cause nausea,
+vomiting, dyspepsia, flatulence, diarrhoea, skin-inflammations, pain
+in the joints, and many other symptomatic phenomena.
+
+Chorea ("St. Vitus's Dance") is caused by various irritatations, and
+dysmenorrhoea can be such a cause. If a person is disposed to hysteria
+by neurotic inheritance, idleness, sedentary habits, vicious
+practices, excessive development of the emotions, any affection of the
+uterus or its appendages will greatly aggravate the outbreaks. The
+same is true in neurasthenia; and uterine disorders can directly cause
+neurasthenia, a condition described in another chapter. Migraine is an
+extremely severe form of headache which arises from various
+excitations, and uterine disturbances are among the causes.
+
+{244}
+
+Insanity frequently appears in women at puberty, soon after marriage,
+during pregnancy or lactation, and at the menopause; at these periods
+disposed women are especially prone to outbreaks of insanity.
+Irritation and exhaustion from diseases of the pelvic organs are
+potent factors in bringing on insanity, although these conditions may
+coexist independently of each other. Symptoms should not be mistaken
+for causes, but pelvic diseases at least aggravate a tendency toward
+mental unbalance.
+
+In an article like this it is not expedient to speak of treatment, but
+the conditions are described in outline so that the spiritual adviser
+may recognise the need of medical aid and suggest its employment. A
+woman suffering from pelvic disorders should be relieved from a
+labourious or responsible office until she has been cured of her
+disease, in her own interest and especially in the interest of those
+affected by her condition.
+
+AUSTIN OMALLEY.
+
+
+{245}
+
+XXI
+
+CHRONIC DISEASE AND RESPONSIBILITY
+
+It is often of great practical importance to bear in mind that a
+number of affections, commonly not serious in themselves at the
+beginning, and sometimes giving very few external symptoms, may make
+the mental condition of the individual suffering from them utterly
+incapable of meeting grave responsibilities. This is especially true
+with regard to such positions as that occupied by the Superior of a
+religious community who may, during the course of an ailment that has
+a tendency to affect the mental condition, do things that involve the
+community financially, or make life so uncomfortable for their
+subjects as to cause them to abandon the religious life. Some of these
+ailments are very insidious and may develop utterly apart from all
+anticipation in persons that were previously healthy. The weight of
+responsibility itself may, by impairing the general health, bring on
+an aggravation of a previously mild chronic condition that will cause
+distinct mental deterioration, yet without the absolute production of
+such disturbance of intellection as will be readily recognised by
+those that are not brought intimately in contact with the individual.
+
+Such cases are not uncommon in history. A distinguished specialist in
+mental diseases called attention, in the London _Lancet_ not long ago,
+to the case of Nicias, the Greek general who was in charge of the
+Athenian expedition against Syracuse. Nicias undoubtedly had a genius
+for war and for politics when in normal health. Some of the mistakes
+committed by him, though, are of an order that indicate a lapse of
+mental control at certain times. Details given by a number of Greek
+historians point to the existence in Nicias of {246} symptoms of
+chronic nephritis, which at periods of great responsibility became
+exacerbated with consequent interference with normal intellection. The
+same authority points to certain otherwise inexplicable political
+mistakes in the life of Napoleon III. as due to the existence in him
+of a low-grade nephritis, consequent upon the presence of stone in the
+kidney. After his abdication, during his life in England, he had to be
+operated upon for this condition, and the calculi found had manifestly
+been in existence for many years.
+
+Even more important for the sake of the individual himself than for
+those he is in contact with is the recognition of his pathological
+condition. Nothing is more likely to cause kidney disease to grow
+rapidly worse than responsibilities heavier than the individual is
+accustomed to. When, then, there are symptoms of nephritis it is
+inadvisable for the patient to be made Superior, and if the symptoms
+develop after his appointment or election he should be relieved of his
+responsibilities, at least to a considerable degree. There are a
+number of cases on record in which failure to realise the necessity
+for this mode of action has been a cause of great unhappiness in
+religious communities, and not infrequently a shortening of a very
+precious life that might otherwise have been spared for long years of
+usefulness in some less demanding position. It is not impossible that
+paresis should develop in the Superior of a religious community. The
+disease is extremely rare among clergymen generally, and the
+statistics of asylums show that it is rarest of all among Catholic
+clergymen. Should it occur, however, it must constitute a quite
+sufficient reason either for a change of Superiors, or for the
+institution of such other safeguards as may, according to the special
+religious institute, be provided in order to prevent serious evil.
+
+In the religious communities of women, particularly, it has seemed to
+us that the occurrence of Graves' disease (the affection is three
+times more frequent in women than in men) in a Superior should always
+be the signal for relieving her of the responsible duties of her
+position. This action is quite as necessary for the patient's own
+health as for the peace and happiness of the community. The disease
+may exist in a {247} latent form and only develop strikingly after the
+assumption of the serious responsibilities of the position of
+Superior. When, however, the eyes are prominent, the pulse rapid, and
+the goitre, or swelling of the front of the throat, characteristic of
+the disease, is present, there are practically always mental symptoms
+that make it extremely inadvisable for her continuance in a position
+of serious responsibility. Professor Church of Chicago (Professor of
+Nervous and Mental Diseases and of Medical Jurisprudence, in the
+Northwestern University Medical School), in the last edition of his
+book on _Nervous and Mental Diseases_,   [Footnote 5] has this to say
+with regard to the mental disturbances of Graves' disease:
+
+  [Footnote 5: Nervous and Mental Diseases. Church and Peterson, 4th
+  edition. Saunders, Phila., Pa., 1903.]
+
+"From the beginning, and often for a long period antecedent to the
+appearance of cardiac symptoms, the subjects of Graves' disease
+present a considerable mental erethism. There is an indefinable and
+tormenting agitation, marked by mental and motor restlessness and an
+imperative and impulsive tendency to be doing. Their emotions are too
+readily excited, and they are unusually impressionable and irritable,
+reacting in an exaggerated manner to all the incidents of daily life.
+In more pronounced cases they become voluble and manifest the greatest
+mobility of ideas, but have no persistent concentration of logical
+order. Their affections are likely to undergo modifications, and they
+become irascible, fault-finding, inconsiderate, ungrateful, and hard
+to live with. In some instances this disturbance of mentation carries
+them over the border into active mania, marked, perchance, by
+delusions of fear, due to the cardiac symptoms of sensations of heat.
+Insomnia is often added and the fitful sleep is disturbed by
+horrifying dreams that are likely to be projected into the waking
+moments and woven into delusions which are usually unsystematised, and
+constantly changing, furnishing the analogue of the motor
+restlessness. Hallucinations of sight and hearing are not uncommon.
+
+"The mental perturbance only rarely reaches the degree of actual
+mania, and then is, perhaps, equally dependent upon numerous other
+causes acting in a neurotic individual. But {248} a condition of
+abnormal mental stimulation is characteristic of the malady, and is as
+important an index as any of the cardinal triad."   [Footnote 6]
+
+  [Footnote 6: Of physical symptoms, namely, the rapid heart, the
+  prominent eyes, and the enlargement of the thyroid gland in the
+  neck.]
+
+Dr. Church considers, then, that the mental symptoms of the disease
+are as important a concomitant, and as little likely to be absent in
+any given case, as are any of the three or four well-known physical
+symptoms characteristic of the disease. Under these circumstances the
+necessity for the exercise of care in permitting such a patient to
+continue in the office of Superior must be manifest. It is a question
+not for religious authorities to decide but for physicians, and they
+are to be experts in mental diseases. There are many physicians who
+have had experience with cases in which Graves' disease has been a
+source of unfortunate conditions in religious life, owing to the
+failure to understand the relations of the physical affection to
+mental disturbances. At times unfortunate consequences follow that are
+irretrievable in the destruction of vocations and the impairment of
+the religious spirit in communities.
+
+As a rule it may be said that the development of serious disease is
+almost sure to incapacitate a Superior from fulfilling the functions
+of office. This is true, however, not only for physical disease but
+for the so-called neuroses. These are maladies which have their basis
+in some disturbance of the physical constitution, though this is not
+always easy to find. We prefer to speak of them as neuroses rather
+than neurasthenia, because this latter name has somehow come to have
+an unwelcome sound and to carry with it the idea of imaginary rather
+than real ailments. A true neurasthenic, however, is supremely to be
+pitied.
+
+It has often been noticed that such individuals, while perfectly
+capable of judging properly for others, are not able to form right
+judgments with regard to their own conditions. This principle,
+however, should not be taken as a rule, and it must not be forgotten
+that neurasthenics are often the subjects of compulsory
+ideas--so-called obsessions, in which they are not entirely
+responsible for actions performed. At such {249} times they are prone
+to be irritated by very trivial faults, and what is worse, to
+exaggerate slight defects into serious infractions of rule or of
+obedience. With regard to such persons, therefore, constant care has
+to be exercised to control their statements by those of others and not
+to take them at their full value without due substantiation. In this
+matter the subject is quite as likely to suffer as the Superior, and
+information obtained from them should not be acted upon without
+consultation with others who know the details of the case.
+
+As a rule neurasthenic individuals become, as is well known, worse as
+far as the mental condition is concerned when they are asked to assume
+new responsibilities. This physical side of the choice of Superiors,
+and of those to be elected by members of the community, should always
+receive due attention, though sometimes it is entirely lost sight of.
+Not a few communities, however, have suffered in their usefulness and
+in the fulfilment of the design of their institute by the selection of
+Superiors whose neurotic conditions sometimes seemed to proclaim a
+high degree of piety, which was, however, rather emotional than
+practical. The physician's view of some of these cases would add
+materially to the knowledge of the character of such individuals.
+
+It should in general be very clear that the development of any serious
+nervous disease, which is not likely to be cured by ordinary remedies
+or which requires freedom from responsibility as the first requisite
+for improvement, should be the signal for consideration as to a change
+of Superiors. Physicians see much more of the evil that may be worked
+in this way, and realise the true significance of what is often a sad
+state of affairs, much better than those who have not the secret of
+the cause of the unfortunate condition. It is almost needless to say
+that the question of obedience to some one whose responsibility is not
+complete, but is influenced by neurotic disturbance, becomes an
+extremely difficult problem for the subject, and one in which there is
+apt to be the feeling that it was not the original intention of his
+obligation of obedience to bind him under such circumstances.
+
+With regard to women especially, it must be remembered that there is
+for them a period between the ages of forty {250} and fifty, during
+which for several years they are extremely unsuited for the
+responsibilities and exacting duties of a Superior. These years prove
+even to mothers of families, surrounded only by their own children and
+the ordinary circumstances of home life, a time of worry and
+irritation that plays sad havoc even with the best of dispositions.
+Mothers constantly complain to their physicians of an irritability of
+temper which they can scarcely account for, and which makes them do
+and say things which they are extremely sorry for afterwards. It is
+easy to understand, then, that a Superior with still more insistent
+duties when brought in contact with a number of persons, some of whom
+are almost sure not to be entirely sympathetic, is likely to suffer
+from irritation that is not a sign of absence of a fitting religious
+disposition, but only a physical manifestation of the physical strain
+through which she has to pass at this time of life. The years of the
+menopause, to be very plain, should not be allowed to make a
+Superior's life miserable and to add to the difficulties that a
+religious community always has to face in its relations to its
+Superior and to one another. Charcot, the distinguished French
+neurologist, used to say that women should never be asked to assume
+special responsibilities during the days of their monthly period, for
+their judgments are often warped by their physical condition. It is
+doubtful whether, in the majority of normal women, this is quite true,
+though the expression deserves to be remembered. There is no doubt,
+however, that the years of the change of life do bring on very serious
+modifications of the character of the individual, and occasionally
+these changes are lasting.
+
+JAMES J. WALSH.
+
+
+{251}
+
+
+XXII
+
+EPILEPSY AND RESPONSIBILITY
+
+From the very earliest times epilepsy has been looked upon as a
+mysterious and in many ways an inexplicable disease. The Romans spoke
+of it as the _malum comitiale_, the comitial disease, because if an
+attack of it occurred during the meeting of the Roman people known as
+the _comitia_, in which municipal officers were elected and other city
+business transacted, an adjournment was at once moved, and no further
+proceedings were considered valid. During more modern times,
+especially during the middle ages, and almost down to our own time,
+those affected by the disease frequently came to be looked upon as the
+subjects of possession by the devil. Hysterical manifestations were
+even more frequently considered signs of possession (diabolical
+manifestations) but even in our time it is not always easy to make the
+distinction between certain forms of hysteria and epilepsy. Many of
+these sufferers were considered as not responsible for their actions.
+In this respect, at least, the advance of modern medical science has
+only served to confirm the popular impression of less sophisticated
+times, and it has come to be recognised that quite a large number of
+the sufferers from epilepsy must be deemed lacking in responsibility.
+
+There are few nervous diseases that have been more studied than
+epilepsy, and yet, because the ailment involves so intimately the
+relations of the nervous system and the bodily function, there are few
+diseases of which less definite opinions can be given. This is
+especially true as regards prognosis and the question of mental
+deterioration in any given case. As a matter of fact the extension of
+our knowledge of epilepsy, far from making the question of the
+responsibility of the {252} epileptic under trying circumstances more
+easy of solution, has rather served to show how difficult this problem
+must ever remain.
+
+There are many forms of the disease,--the frank epileptic convulsion
+in which patients fall down, are seized with certain convulsive
+movements, become pale and lose consciousness for a time and then come
+to with an intense feeling of weariness which usually prompts them to
+sleep for some hours--too familiar to need further description. There
+are forms of epilepsy, however, quite different from these. In some
+cases, the attacks occur only at night, and unless the patient happens
+to be watched for some reason, there may be no trace of their
+occurrence, except perhaps a sore tongue where it has been bitten, or
+an intense feeling of weariness and depression in the morning. In
+still other cases, the physical signs are lacking almost entirely.
+There may be only a momentary loss of consciousness. A distinguished
+professor of medicine in this country used to have a momentary attack
+of confusion, during which he lost the thread of his discourse, and
+always within a minute, with a somewhat flushed face, he was able to
+go on, though he had to begin with another idea. The so-called psychic
+epilepsy, in which the symptoms are entirely mental and consist of
+some marked change of disposition for a time, are now universally
+conceded as constituting well-marked phases of the disease. Curiously
+enough it is with regard to these obscure cases, uncomplicated by
+serious physical manifestations, that there is most mystery; and they
+seem to affect the mentality and to disturb volition and
+responsibility more than the supposedly severer forms which cause
+convulsive attacks and are so easy of recognition.
+
+Certain forms of masked or psychic epilepsy constitute the most
+puzzling problem that the expert in nervous and mental disease has to
+deal with where criminal acts are performed, apparently without
+sufficient motive, and yet where the limits of responsibility must if
+possible be determined. It is easy to dismiss these cases and to
+consider that because a certain amount of intelligence has been
+displayed in the performance of the act, and because the patient
+ordinarily understands perfectly the distinction between good and
+evil. {253} that therefore the will must have been entirely free in
+the accomplishment of the criminal action and the intellect must have
+understood what it was doing. As yet the general public refuses to
+take the standpoint of the expert in mental diseases in many of these
+cases; and only when clergymen also shall come to a realisation of the
+pathological elements undermining free will in these cases, that
+justice will be properly tempered, not by unworthy or misplaced
+charity, but by the mercy which, knowing all, has learned duly to
+appreciate what is and what is not criminal.
+
+Epilepsy, in certain of its obscurer forms, is responsible for many
+conditions in which there is a sudden access of insane excitement of a
+violent, often very impulsive, character, though sometimes of very
+short duration. During this state the patient is practically
+irresponsible, and yet he may have sufficient control over his actions
+to enable him to work serious harm. Such a stage of excitement may
+last not more than an hour or two; usually all trace of it passes off
+in a day or two; before and after it the patient may be in perfectly
+sound sense and in apparently good health. One of our best authorities
+here in America, Berkley, in his treatise on _Mental Diseases_, gives
+the following striking opinion on this subject.
+
+"The subject of masked epilepsy and the consequent mania is replete
+with interest to the physician and the jurist, since such patients are
+prone to impulsive acts of violence and automatic states in which the
+most complicated, but entirely unconscious, actions and crimes may be
+carried out without premeditation on the part of the sufferer, being
+also out of all accord with his character during his intervals of
+mental health. Besides the irritability, impulsiveness is an equally
+characteristic feature. No form of insanity more frequently gives rise
+to assaults and murder than epilepsy, and in no form of alienation is
+the physician so frequently called to the witness stand to determine
+the responsibility of the criminal."
+
+One of the most prominent features of all epilepsy is the well known
+tendency to irritability that characterises sufferers from the
+disease. This of itself is an index of the fact that {254} their
+responsibility is somewhat lessened, since they are unable to
+withstand even the petty annoyances of life without exaggerated
+reaction. Friends of epileptics know very well that it is a
+preliminary symptom of the coming on of an attack of epilepsy for the
+patients to become even more irritable than usual. Just after the
+comatose condition which follows an attack of epilepsy patients are
+also prone to be very irritable. An attack of epilepsy is really an
+explosion of nerve force, for no rational purpose, along motor nerves.
+This same tendency to an unwarranted explosion of energy is liable to
+occur along other nerve tracts that rule the patient's disposition.
+
+The main symptom of importance in the case, and the one on which
+depends the recognition of the existence of the epileptic condition,
+is the actual occurrence of typical epileptic seizures. These do not
+always occur. Sometimes the periodic attacks take the form of what are
+called epileptic equivalents, that is, certain anomalous states of
+consciousness or disposition, which can be accounted for only on the
+supposition that there is some more or less latent explosion of nerve
+force in progress. At times even so simple a condition as migraine so
+nearly simulates epilepsy of the psychical type, because of its
+complications and sequelae and the regularity with which it occurs,
+that it has been spoken of as an epileptic equivalent. There is no
+doubt that, in successive generations, epilepsy and migraine may have
+a relation to one another that is something more than merely a
+coincidence.
+
+A very interesting feature of epilepsy for confessors and spiritual
+directors is the tendency to religious emotionalism which so often
+accompanies what is called idiopathic epilepsy. This means epilepsy
+that develops without a direct cause, and which is evidently dependent
+on some essential defect of the nervous system of the individual. In
+asylums epileptics that have become irrational are known for their
+religious manifestations, and very often for perversion of their
+religious tendencies. As has been well said, an epileptic may carry
+his Bible under his arm, read passage after passage from the
+Scriptures, sing psalms continuously, and yet be so {255} ungovernable
+as to be a nuisance, and so irritable towards his fellow patients and
+attendants as to be a constant source of worriment. He may read just
+those passages which have reference to love and charity for one's
+neighbour and dwell on them until they become a bore by repetition,
+and yet in a moment of irritation implore to be allowed to get hold of
+some deadly weapon in order to kill the usually inoffensive person who
+has done him some imaginary injury.
+
+This last is a marked feature of the disease, for epileptics are prone
+to foster fancied grudges, and to consider without due reason that
+they have been ill treated. This is especially true with regard to
+their relatives or to those in attendance on them, and must be always
+borne in mind when the subjects of epilepsy bring tales of woe and
+persecution, which they pour out to anyone who will listen to them,
+and especially to anyone whom they think will set them right. These
+fancied wrongs are as real to the patients themselves as if they had
+suffered from actual maltreatment. The idea of revenge may easily
+obtrude itself. It can be kept under control, as a rule, during
+ordinary health, between attacks, but just preceding or after an
+attack it may very well become of the imperative character that sets
+an uncontrollable impulse at work.
+
+On the other hand, no class of patients is apt to exhibit the low
+cunning of the insane in so marked a degree as the epileptic. Not only
+this, but even during ordinary health between attacks they may, owing
+to their disposition, plan cunningly to simulate some of the symptoms
+of an attack and then accomplish a really malicious purpose with
+deliberation. In a word, these patients present to the alienist the
+most serious problem in the calculation of responsibility that can
+possibly be imagined. As an expert has declared, "It is ofttimes
+impossible to decide whether an assault has been committed with full
+consciousness, or in a transient but blind epileptic fury."
+
+There are a series of attacks that occur in which there are some
+almost typical convulsive movements followed by loss of consciousness
+that simulate epilepsy very closely, yet are not true epilepsy. These
+attacks are usually due to some {256} cerebral affection or perhaps to
+some injury of the brain. Chronic intoxications, that is, the long
+continued presence in the body in noxious quantities of some poisonous
+substance, are especially liable to cause these attacks, which are
+called from their character epileptiform. Characteristic epileptiform
+convulsions occur as the result of lead poisoning or from alcohol or
+syphilis. Lead poisoning, for instance, may very well occur in others
+than those engaged directly in the manufacture or handling of lead.
+Certain persons are extremely susceptible to the influence of lead. In
+them such small amounts as are contained in a hair-dye, or even in
+water that is being used by others without any bad effect, may cause
+particularly the nervous symptoms of lead poisoning.
+
+Chronic alcoholism is also a relative term in this regard. Some
+persons are able to stand very large amounts of alcohol without
+serious consequences, even though it is taken for long periods. Others
+succumb to its influence very rapidly; some especially susceptible
+people are liable to suffer from epileptiform convulsions almost
+whenever they take alcohol to excess. This masked epilepsy may take on
+an anomalous form. The story is told of a student of a Catholic
+college in the eastern part of this country, who, during one vacation,
+was given as a joke by some friends a rather strong dose of liquor in
+a glass of ginger ale. He was very thirsty at the time and did not
+notice the presence of the alcohol until he had swallowed the whole
+glass. As he was well aware himself he was extremely susceptible to
+the influence of alcohol. During the course of half an hour he became
+almost wildly drunk, and going down the street with an open
+pocket-knife he murdered the first person whom he met, who happened to
+be an entire stranger to him. The occurrence took place in New Jersey,
+and, in spite of every influence that could be brought to bear--the
+incident took place some thirty years ago--Jersey justice would have
+its way and the young fellow of less than twenty was hanged.
+
+The epileptiform attacks that occur in the midst of these
+intoxications are quite as likely to be accompanied by various forms
+of mental disturbance as are attacks of true {257} epilepsy. Only one
+feature with regard to them is more favourable, and that is that the
+ultimate prognosis is not bad. The neutralisation of existing poison
+in the system, and the prevention of further ingestion of the toxic
+material, puts an end to the tendency to epileptiform convulsions, as
+a rule, and also to the mental symptoms associated with them.
+
+Epilepsy remains, notwithstanding all the advance in modern nervous
+pathology, quite as mysterious a disease as it has ever been. It
+matters not what its cause, or how slight it may be, sooner or later
+it is almost sure to be followed by mental disturbance and
+deterioration of intellectual and will power. At times there are
+periodic attacks of mental perturbation that may become true insanity.
+Even the mild form of epilepsy known as Jacksonian epilepsy, and
+consisting not of general convulsive movements, but of convulsive
+movements in only one member or one side of the body, are, if allowed
+to continue, followed by some mental disturbance. It would seem as if
+the explosion of nerve force in the brain centres,--which,
+physiologically speaking, an attack of epilepsy evidently is,--causes
+eventual deterioration of the physical basis of mind and will, so that
+mental operations can no longer be performed with their wonted
+expertness or accuracy, nor decisions made as rationally as before.
+
+In general, it is well understood that the more serious the epilepsy
+the more liability there is of the development of permanent mental
+disturbance. The earlier in life the epilepsy declares itself, too,
+the more unfavourable is the prognosis as to the enduring retention of
+complete mental sanity. In people in whom the epilepsy commences late
+in life, the process of mental deterioration does not begin to be
+noticeable so soon as when it occurs in younger years, and besides, it
+practically never runs a rapid course. Epilepsy, however, developing
+late in life, unless for some special cause, as injury or the
+development of syphilitic tumours in the brain, is an extremely rare
+affection. Idiopathic epilepsy, that is, epilepsy for which no
+definite cause can be discovered, is usually dependent on hereditary
+instability of the nervous system and is typically a disease of early
+years, of childhood {258} and adolescence. According to the best
+authorities, about one-fourth of the cases of epilepsy make their
+appearance before the age of 7 years. Over 50 per centum of all cases
+develop before puberty. About one-third of all the cases develop
+between 14 and 20. And even of the remaining, less than 20 per centum,
+over 12 per centum develop between 20 and 25, leaving scarcely more
+than 5 per centum for all the remaining years of life.
+
+Of course, even in severer forms of epilepsy, mental disturbances do
+not appear at once. It sometimes takes many years for the constantly
+recurring manifestation of explosive nerve force to produce the
+deterioration that gives rise to lowered rationality. Distinct mental
+deterioration is eventually inevitable, though modern experience with
+epileptic colonies, in which patients are enabled to live a quiet
+life, most of it in the open air and under conditions of nutrition and
+restfulness especially favourable for their physical well-being, shows
+that the development of insanity may be put off almost indefinitely.
+
+There are many advertised cures for epilepsy. None of them is
+successful, and all of them may do harm. The bromides have a distinct
+effect in lessening the number and frequency of seizures, but if taken
+to excess they have a serious depressing effect upon the patient.
+There have been more cases of mental disturbance among epileptics, and
+intellectual degeneration sets in earlier, since the introduction of
+the bromides, than before. It is the abuse of the drug, however, not
+its use, that does harm. More important than any drug is the care of
+the patient's general health. The digestion must be kept without
+derangement; the bowels made regular; all sources of worry and
+emotional strain must be removed. Patients should as far as possible
+live in the country, and farm life has been found especially suitable.
+Relatives are often a source of irritation rather than consolation to
+these patients, and the life in epileptic colonies has been found
+eminently helpful.
+
+JAMES J. WALSH.
+
+
+{259}
+
+XXIII
+
+PSYCHIC EPILEPSY AND SECONDARY PERSONALITY
+
+
+One of the most interesting phases of epilepsy is the type of the
+disease in which, without any significant motor symptoms, psychical
+manifestations prevail very markedly. A special manifestation in this
+affection is the occurrence of a more or less complete assertion of
+what is called a secondary personality. Apparently the individual
+becomes so divided in the use of the mental faculties that there are
+two states of consciousness. In one of these the patient knows and
+remembers all the ordinary acts of life, the other carries the record
+of only such actions as are done in a peculiarly morbid psychic or
+epileptic condition. It is rather easy to understand that this strange
+state of affairs may readily give rise to even serious complications
+as regards the individual's relations to others, and may make the
+problem of responsibility for apparently criminal acts that have been
+performed very difficult of solution. Undoubtedly, however, this set
+of phenomena constitutes a form of mental alienation that must be
+reckoned with in many more cases than might be thought possible. The
+difficulties that may have to be encountered in the proper
+appreciation of the actions of such individuals is best illustrated by
+some cases.
+
+At a recent meeting of the New York State Medical Association a case
+was reported that shows how extremely difficult it may be to judge of
+responsibility under these pathological circumstances. The patient, a
+young man of about twenty-two, was the son of parents themselves of
+marked nervous heredity, signs of which appeared in other members of
+his generation. While in attendance at a public academy he had been
+quite severely maltreated during the {260} course of an initiation
+into a secret society of the students--the more or less familiar
+processes known as hazing being employed. As a result of this he had
+suffered from an attack of unconsciousness that lasted for several
+hours. No other symptoms, however, or sequelae, appeared for nearly a
+year. Then, while boarding with his sister, he became morose and
+difficult to get along with. He quarrelled with his sister several
+times and generally their relations were rather strained. He came home
+one evening very late to supper, and because things were not to suit
+him on the table, he grew violently angry. He went upstairs to his
+room in this morose state and, procuring a revolver, after a short
+time came down and shot at his sister.
+
+Fortunately he missed her. He at once left the house but was followed
+by his brother-in-law, and, after he began to run away, by others
+whose attention had been attracted by the shot. He left the country
+road and ran across the fields. He was found at the foot of a rather
+high stone wall in a state of unconsciousness. From this
+unconsciousness he did not recover until the next morning. In the
+meantime he had been brought home and put to bed. The next morning he
+claimed that he had absolutely no remembrance of anything that
+happened after he became angry at the table because of his supper. The
+family made no further difficulty about the matter, and, as nothing
+serious had resulted, the boy went home to live with his father on a
+farm and seemed to grow much more equable in temper.
+
+One day, when very tired and out of sorts because things had not been
+going as he wanted them to, he was asked to clear a potato patch of
+potato bugs by spreading Paris green over it. Some hours later he was
+found in the field suffering from severe pains in the stomach and with
+evident signs of having swallowed some of the poison. A doctor was
+called, an emetic was given and he purged, and after a time he
+recovered from the symptoms of poisoning. He claimed that he had no
+recollection of what he had done, nor did he know how he came to take
+the poison. After this he begged the family to watch over him
+carefully and not to let him be alone at times when they recognised
+that he was somewhat {261} morose in temper. He was not melancholic in
+the sense that he wanted to commit suicide, but something seemed to
+come over him in spells, and while in a state of mind of which he had
+no recollection afterwards, he performed actions that seemed voluntary
+and yet were not.
+
+He did not have very good health on the farm, and so he was advised to
+try the effect of life at sea. A position as assistant steward was
+obtained for him on a coastwise vessel. In this position he gained
+rapidly in weight and seemed to have excellent health. All tendencies
+to moroseness of disposition disappeared. After a time he was promoted
+to a stewardship and later became the purser of a rather important
+vessel. He has given excellent satisfaction and feels in every way
+that he is in a much more balanced condition than ever before.
+
+He still insists that he remembers nothing of how the two almost fatal
+incidents in his life came about. All his family are convinced that it
+was not a responsible state of mind that led him to attempt either of
+the crimes. It seems not improbable that this is one of those
+fortunately rare cases in which an attack of psychic epilepsy
+sometimes obliterates for a moment the individuality of a patient. At
+times these attacks last much longer, and the change to a secondary
+personality may represent a rather long interval. A number of cases of
+what are called ambulatory epilepsy have been brought to the attention
+of the general public of late years because of certain interesting
+features of the cases that have been exploited in the daily press.
+
+Patients suffering from this form of nervous disease may wander from
+their homes, and while performing automatically a number of actions,
+such as buying tickets, travelling on cars and railroad trains, or
+even arranging the details of their journey for a long distance, may
+yet be in a state of mind that is not their ordinary consciousness.
+Men may leave home under the circumstances and find themselves after
+months in a strange town where they have established themselves in
+some quite different occupation from that to which they were formerly
+accustomed, or for which their early training fitted them. There seems
+to be an absolute division between the {262} states of consciousness
+that rule the individual during the intervals of ordinary and
+extraordinary personality. There are, of course, many reasons for
+thinking that at times such a change of personality might be feigned;
+but many of the cases have been followed with too much care to allow
+this thought to serve as an explanation for all of them.
+
+A case which serves to bring home very clearly the possibility of such
+a state of mind giving rise to serious complications is the following:
+The patient was a young man in attendance at the medical school of a
+university in a foreign city. He had been very careless in money
+matters, and had aroused family suspicion that even the money sent him
+for tuition was being used extravagantly. A friend of the family came
+to see him unexpectedly in order to assure himself how the boy was
+actually getting along. The boy's accounts were in a very disordered
+condition; he had not bought the books for which he pretended to want
+money; he had not paid his tuition. He realised that all this would
+come out as soon as the university authorities were consulted. Very
+naturally he was in an extremely perturbed state of mind.
+
+While on the way to the university with this friend they passed a
+corner pharmacy, and the young man asked to be allowed to step in for
+a moment for a remedy for headache. The friend waited on the sidewalk
+for him, and when, after some minutes, the young man did not come out
+he went in to inquire for him, and found that after purchasing a
+headache powder the young man had gone out by a side door. For three
+days nothing was heard from him. Then a telegram announced that he was
+in a hospital in a distant city and that he had been picked up on the
+street unconscious. When he came to in the hospital he had no idea
+where he was, and, according to his own story, no recollection of how
+he got to the distant city.
+
+It might be very easy to think, under such circumstances, that this
+was all pretence. A number of these cases of ambulatory epilepsy have
+been under the observation of distinguished neurologists, however, and
+there seems no good reason to doubt that some of them, at least, were
+entirely without any fictitious element. In any given case the {263}
+possibility of the occurrence of an attack of what is really the
+assumption of a secondary personality must be judged from the
+circumstances, from the previous history of the individual, from the
+family traits, and from certain stigmata as narrowing of the field of
+vision and the like, which go to show the existence of a highly
+neurotic constitution. In this case the family history showed marked
+neurotic tendencies on both sides, and a brother had displayed a
+tendency to regularly spaced attacks of alcoholism about every six
+weeks, and finally became absolutely uncontrollable. There seemed good
+reason to think that the case was a real example of ambulatory
+epilepsy, and that the lapse of memory claimed by the patient really
+existed.
+
+In these cases it is usual for the so-called secondary personality to
+assert itself at moments of intense excitement, especially if they
+have been preceded by days of worry and fatigue and nights of
+disturbed rest. The secondary personality is not a complete
+personality, but is a manifestation of the original ego with the
+memory for past events as a _tabula rasa_. It is well known that the
+memory is one of the intellectual faculties most dependent on physical
+conditions. It is the lowest in the scale of mental qualities and is
+shared to a very large degree by the animals. Injuries to the head not
+infrequently produce lacunae in the memory. These lacunae often have
+very striking limitations. It is not an unusual thing to find that old
+people remember events of their very early childhood better than
+things that have happened within a few years. Still more interesting
+is the fact that languages learned in youth may continue to be easily
+used, when those that were learned later in life, though perhaps known
+better than the previously studied languages, are forgotten.
+
+It has often been noted that people who suffer from apoplexy may have
+peculiar affections of their memory. This may include such striking
+peculiarities as the forgetting of the uses of things, though their
+names are retained, or more commonly, the forgetting of names while
+the knowledge of uses remains. The one form of memory disturbance is
+called "Word Amnesia;" the other is called "Apraxia." It is on {264}
+record that a person suffering from a hemorrhage in the brain has lost
+completely the use of a language acquired later in life, though the
+memory of the native language, long since fallen into disuse, was
+perfectly retained. One apoplectic woman patient who had left Germany
+before she was ten years of age, and who had lived in America until
+she was fifty, forgot absolutely the English she knew so well and had
+to set herself to work to learn it over again, though her German came
+back to her very naturally. These are wonderful peculiarities of
+memory-pathology that show how much this faculty is dependent on the
+physical basis of mind and upon the cellular constituents of the
+brain.
+
+It is not surprising, then, to find that lapses of memory may occur
+and that, as a consequence, so many of the facts that ordinarily
+enable us to identify ourselves as particular persons may be in
+abeyance. That apparently a secondary personality asserts
+itself,--though not in the sense that there is ever another ego
+present, another mind or another will,--practically all experts in
+psychology and nervous diseases are now ready to concede. There are,
+however, involved in this question a number of important problems of
+responsibility that have not as yet been entirely worked out, and with
+regard to which prudent persons are withholding their judgment. Each
+case must be studied entirely on its own merits, with a leaning in
+favour of the criminal or patient, in case there are evidences in past
+life of serious disturbances of mentality, though only of very
+temporary nature, or if there is a strong nervous or mental heredity.
+
+The notion of the possibility of a secondary personality asserting
+itself is a much older idea than it is usually thought to be. When
+Stevenson wrote _Dr. Jekyll and Mr. Hyde_, the immediate widespread
+popularity of the book was not due to recent psychological studies on
+dual personality and popular interest in a rare but striking mental
+phenomenon, but rather to the traditional feeling, long existent, of
+the possibility of two personalities in almost any individual. The
+other law in his members, of which St. Paul speaks, is an expression
+of this feeling, and its recognition was not original with him since
+it is after all a phenomenon at least as old {265} as the existence of
+conscience. It is one of the basic ideas in religious feeling. Nearly
+everyone has something of the consciousness that there is in him
+possibilities for evil that somehow he escapes, and yet the escape is
+not entirely due to his own will power. There is here the mystery of
+temptation, of free will and of grace as the drama of conscience works
+itself out in every human being. At times the evil inclination seems
+to get beyond the power of the will and a period of irresponsibility
+sets in. Needless to say, the adjudication of how much may be due to
+the habitual neglect of repression of lower instincts is extremely
+difficult, and this constitutes the problem which the alienist must
+try to solve. In the meantime there is need in many mysterious cases
+where secondary personality may play a role, of the exercise of a
+larger Christian charity than that hitherto practised. Pretenders may
+succeed in deceiving only too often, but in the past not a few
+innocent individuals have been held to a responsibility for actions
+for which they were not quite accountable.
+
+JAMES J. WALSH.
+
+
+{266}
+
+XXIV
+
+IMPULSE AND RESPONSIBILITY
+
+Not unlike that condition which develops as the result of so-called
+psychic epilepsy, in which patients perform apparently voluntary acts,
+while the mind is really clouded by an epileptic attack, are those
+states in which, as the result of a more or less blind impulse, acts
+are performed for which the responsibility of the individual is at
+least dubious. Modern experts in nervous and mental diseases have
+sometimes spoken of these states as obsessions. This term is adopted
+from the older writers on mysticism who used it to designate states of
+mind in which an individual was under the influence of some spirit,
+though his intellectual and volitional state was not as completely
+under the subjection of this spirit as in the condition of possession.
+
+It seems clear to the modern student of these obscure conditions that
+the old mystics and the modern alienists practically talk about the
+same state of affairs when using this term. As the result of
+obsession, mystical writers would have conceded that responsibility is
+not quite complete, though it is not entirely done away with. The
+modern alienist is just as sure of the diminution of responsibility,
+though he considers it due to the fact that for some physical reason
+the will is not able to act or prevent action as it is under normal
+conditions. The will is sometimes spoken of by certain of these modern
+psychologists as mainly an inhibitory faculty, that is, a faculty
+which prevents certain reflex acts from taking place, though
+permitting one set of reflexes to have its way. Under the influence of
+an obsession or, as the French call it, _une idee obsedante_, this
+inhibition is not {267} exercised and as a result an action is
+accomplished which the agent may very shortly afterwards regret
+exceedingly.
+
+There is no doubt that impulsions or impulsive ideas may push an
+individual into the performance of an action which his reason
+condemns. Uncontrollable anger is a well recognised example of this.
+Impulses of other kinds may exercise just as tyrannic a sway, though
+it is harder to recognise the elements that make up the mental
+condition in other cases. Of course it may well be said that man must
+control his impulses. It is, however, just such impulses as can not be
+controlled that lessen responsibility and sometimes seem entirely to
+destroy it. It would, without doubt, be very easy to advance the
+uncontrollable impulse as an excuse for many criminal actions. In
+fact, the discussion of responsibility and its limitation by impulse
+would seem to be open to so many abuses as to make it advisable, in
+the present indefinite state of our knowledge, to put the subject
+aside entirely. The argument, however, from the abuse of the thing,
+does not hold, and an effort must be made to get at the truth
+concerning certain mental conditions which modify responsibility.
+
+It is generally conceded that no two men are free in quite the same
+way with regard to the actions which they may or may not perform.
+Allurements that are almost compelling for some individuals, for
+others have no influence at all. Some men are so under the influence
+of anger that irritation may easily lead them to the commission of
+acts for which they will be subsequently supremely sorry. This may
+even be the case to such an extent as to endanger their lives, yet
+they are not able to control themselves. Many men suffering from
+degeneration of the arteries of the heart have been warned, like John
+Hunter more than a century ago, of the extreme danger of a fit of
+anger, yet, like John Hunter, have succumbed to bursts of anger,
+notwithstanding the warning, because someone irritated them beyond
+their rather limited powers of endurance.
+
+It is extremely difficult ever to come to any proper appreciation of
+the responsibility of a given individual from a {268} single act.
+Preceding acts, however, may very well give evidence of the state of
+mind and the tendencies to disequilibrium which may make an apparently
+normal individual irresponsible under trying circumstances. The only
+way to render this clear is to illustrate such conditions by a
+concrete case.
+
+Not many years ago one of the large cities of this country was
+shocked, for one twenty-four hours at least, by the news that a
+business man had shot his partners and himself, while at a
+consultation in which the affairs of the partnership were being
+settled up, after legal dissolution had taken place. The man in
+question had paid some debts of the firm with his own personal checks,
+and without taking proper legal recognisance for the moneys paid. When
+the partnership had been dissolved his partners insisted that instead
+of obtaining credit for these payments he should, on the contrary, pay
+his share of these debts once more as a partner. The state of the
+evidence was such that his lawyers told him it would be useless to
+take the case before the court at all; there was nothing to do but pay
+the unjust demands. He went to the meeting of his partners with a
+certified check for the amount of their claims in his pocket. As he
+took out his pocket-book to pass it over to them he seems to have
+realised very poignantly the fact that he was paying money that he
+knew he did not owe, and that his partners knew he did not owe, and
+that they were evidently taking advantage of a legal quibble in order
+to cheat him. Evidently it was an extremely trying situation. It was
+too much for his mental balance and he took a revolver from his
+pocket, shot both his partners dead, and then shot himself.
+
+Taken by itself it is extremely difficult to say anything about the
+responsibility of a man who commits an act like this. In ordinary life
+he was known as a clever business man; to his friends he was known to
+be rather irascible and impatient, but a fairly good fellow. He was
+known to have what is called an awful temper; he had, however, never
+committed any violent act before. It is possible, of course, that a
+man should give way to a fit of anger for the beginning of which he is
+responsible, and then do violence {269} much greater than he would
+justify himself for in calmer moments.
+
+There was another occurrence in the man's life that seemed to throw
+informing light on his mental condition. When he first came to live in
+the large city in which he died he began paying attention to a young
+woman, and the young woman was informed by a friend that he probably
+had a wife living. The young woman investigated this by putting the
+question directly to him. He denied it at once, wanted to know the
+name of her informant, and finally laughed the whole matter out of her
+mind. Within a week after his marriage to her, while on their wedding
+tour, he was arrested, charged with bigamy at the instance of his
+first wife, and it became evident at once that the charge was well
+substantiated.
+
+Here is a man, then, who twice at least in life, when put in the
+presence of trying conditions, goes on to do the irretrievable, though
+the act is eminently irrational.
+
+With regard to the murder and suicide it is said that he had talked to
+friends of shooting the scoundrels who were cheating him, but had been
+persuaded of the utter foolishness of any such idea. He had apparently
+given it up entirely. Notwithstanding this, he went to the last
+conference with his former partners with a loaded revolver, as well as
+the certified check for the amount of their claim. In the case of his
+bigamous marriage, notwithstanding the warning that his second
+fiancee's questions must have been, he followed out his preconceived
+idea of marrying her, though he must have realised in saner moments
+that discovery of his double dealing was inevitable. In a word, he was
+a man who, becoming dominated by an idea, an obsession it may be
+called, to do something, could not get away from the sphere of its
+influence even though it might be made very clear to him it was
+eminently irrational to follow out the idea.
+
+There are many such individuals, and only the knowledge of their
+previous career enables us to desume the responsibility for their acts
+under trying conditions. That they are not responsible in the ordinary
+sense in which the logical, timorous mortal is who is at once repelled
+from such modes {270} of action seems very clear. Their lack of
+responsibility is manifest, at least to a degree that makes it easy
+for charity to find excuses for their crimes because of fatal flaws of
+character, the result of physical defects and faulty training, which
+make themselves felt especially at the moments that try men's souls.
+
+JAMES J. WALSH.
+
+
+{271}
+
+XXV
+
+CRIMINOLOGY AND THE HABITUAL CRIMINAL
+
+In recent years no little attention has been devoted to the subject of
+criminology, and a supposed science of the criminal has been evolved.
+It has been the claim of a very well known Italian school of mental
+diseases, whose leader is Professor Lombroso of Turin, that there is a
+criminal type in humanity, that is, that there is a generic human
+organisation not difficult of differentiation, at least as a class,
+the members of which almost necessarily develop criminal proclivities.
+Even when criminality has not actually occurred, this is thought to be
+but an accident, and criminal acts may be looked for at any time from
+these individuals. Lombroso's claims in this matter have met with
+decided opposition in every country of Europe and also here in
+America. This opposition has come especially from serious students of
+abnormal types who have devoted much time to the study of criminals
+and other supposedly degenerate individuals. Magnan, the very well and
+widely known French authority on insane peculiarities, especially the
+so-called criminal monomaniacs, and whose opportunities for careful
+investigation of such cases in the Asile St. Anne in Paris have been
+very extensive, utterly rejects the idea of a special physical
+conformation as characteristic of the criminal.
+
+He is not the only one of the distinguished authorities in mental
+diseases who is in opposition to Lombroso in this matter. Dr. Emile
+Laurent, the eminent criminologist of Paris, has shown that the same
+anomalies which are supposed to characterise criminals are to be found
+among those who have never committed any criminal act, and that these
+supposed signs of degeneracy are not sufficient to indicate even {272}
+that there are criminal tendencies. Manouvrier, the distinguished
+anthropological authority of the University of Paris, does not
+hesitate to advance the opinion that he can not find any distinctive
+difference between criminals and normal men in the extensive studies
+of the comparative anatomy of the two classes. He admits, however,
+that environment sometimes leads to the formation of habits which
+modify the anatomy in certain ways, and that of course traces of hard
+work, as well as of poor living, can be found in the anatomical
+conformation of many habitual criminals.
+
+Dr. von Holder, a distinguished German authority on the subject, says
+that it is impossible to draw any conclusion from cranial asymmetries
+as to psychical characteristics, and that physical signs of
+degeneration indicate nothing further than the possible presence of a
+tendency to psychic degeneration. Dr. Wines, quoted by Draehms in his
+book on _The Criminal, a Scientific Study_, says that in a strictly
+scientific sense, the existence of an anthropological criminal type
+has not been proved, and it is doubtful whether it ever can be proved.
+Dr. Arthur McDonald, the well known American specialist in criminology
+and degeneracy, some of whose work in connection with the National
+Bureau of Education at Washington has attracted widespread attention,
+says, in his _Abnormal Man:_ "The study of the criminal can also be
+the study of a normal man, for most criminals are so by occasion or
+accident, and differ in no essential respect from other men. Most
+human beings who are abnormal or defective in any way are much more
+like than unlike normal individuals."
+
+How much the subject of criminology has been overdone because of the
+morbid popularity of the idea that many persons are, as it were,
+forced by their natures into the commission of crime, can best be
+appreciated from some recent publications with regard to left-handed
+individuals. A number of supposed observers, much more anxious,
+evidently, to make out a case for a pet preconceived theory, than to
+make observations that would add to the present store of truth, have
+rushed into print. As a result, left-handed persons have been said to
+be criminals much more commonly than {273} those who habitually use
+their right hand, and have also been said to be defective in other
+ways. They were spoken of as weaklings, degenerates, and the like.
+Statistics even were quoted to show a much larger proportion of
+criminals than might be expected, according to the normal percentage,
+between right-handed and left-handed people, among those who use their
+left hand by preference. As a matter of fact, left-handed people are
+far from being the weaklings or degenerates they are thus proclaimed;
+but on the contrary are often magnificent athletes and excellent
+specimens of normal development. Left-handedness is due to
+right-brainedness and this is an accident dependent on a diversion of
+blood supply in an increased amount to this side of the brain in early
+embryonic life. This question of the criminal and the left-handed
+individual and their mutual relations is only a good example, then, of
+how far over zealous advocates of a theory have been led astray in
+their attempts to bolster it up.
+
+Draehms, whose opinion on the supposed born criminal is worth while
+quoting, as it is founded on his personal experiences and observations
+while a resident chaplain of the state prison at San Quentin,
+California, says:
+
+"Crime is not, as Lombroso and his coadjutors would have us believe,
+wholly either a disease or a neurosis in the sense of a direct,
+absolute, physiological, pathognomonic entity, though doubtless not
+infrequently closely associated with physical, anatomical, and nerve
+degeneration, as above conceded. To presuppose absolute and necessary
+brain lesion or diseased nerve action, or anomalous, physiognomonical,
+or anatomical diathesis, as the inevitable precursor of any form of
+mental and moral deflection, is an assumption wholly unwarranted and
+is nowhere substantiated by facts, though its advocates have sought to
+lay their foundations deep and wide in the materialistic hypothesis.
+Most criminals present unusually sound physiological conditions, and
+there is among them no unusual death rate, considering their habits
+and mode of life, as we shall hereafter see. Hence their moral
+instability can not be associated with physiological instability in
+the absolute sense. The physical defect must be either reversionary or
+incidental, rather than absolute."
+
+{274}
+
+The impetus in the study of criminals, which came as a result of the
+revolutionary teaching of the Italian school, has not been without a
+good effect. Criminals all over the world have been studied more
+closely and more sympathetically, in order to test the new ideas,
+until now it is possible to draw definite conclusions with regard to
+certain features of the problem. After a time, Lombroso came to admit
+that the so-called criminal type occurred in somewhat less than half
+the criminal cases. Criminal anthropologists, however, have shown that
+the physical conformation called by the name criminal, is really only
+the result of a defective or degenerative physical constitution. It is
+easy to understand that persons born with a defective nervous system,
+or with serious degenerative lesions in other parts of the body, which
+prevent the proper nutrition and functional development of the nervous
+system, would perform many more materially criminal acts than the rest
+of the population. The idiot and certain forms of the degenerative
+insane show this. Any defective development of the nervous system,
+moreover, may lead to instability of moral character, because the free
+action of the soul may be hampered by the physical environment with
+which it is associated.
+
+Certain of the physical peculiarities most frequently seen in
+criminals have an influence of this kind and merit discussion. A
+knowledge of them will furnish clergymen with reasons for a larger
+charity to those unfortunates, and a greater tolerance for their
+relapses, without allowing sentiment to play too important a role in
+dealing with them. There are all grades of defective human beings,
+from the idiot up to those little less than normal. Anatomical
+peculiarities prevent the proper functions of the nervous system, as
+it is not hard to understand. The will is hampered in its action by
+the defect of the instrument through which it must work.
+
+In persons properly to be considered as degenerates usually the head
+is small, though this may not be very noticeable because of
+over-development of the jaws. A heavy lower jaw particularly, because
+of the principle of bone-development that size depends on functional
+action and reaction, may lead to over-thickness of the skull at the
+point of articulation. The {275} jaw articulates with the base of the
+skull, and as a consequence the cranial capacity of these individuals
+is distinctly less than normal. Besides this, there is commonly some
+abnormality in the shape of the head, or the cranium is distinctly
+asymmetrical. It has been noted that criminals have a large orbital
+capacity, that is to say, the bony framework surrounding the eye is so
+large as to encroach much more than usual upon the space left within
+the cranium for nervous tissue. The bones of the skull are likely to
+be thicker and heavier than usual, thus also limiting the cranial
+capacity. The superciliary ridges often project and give the beetling
+brow that is sometimes so remarkable. The jaws are heavy, and
+especially the lower jaw is apt to be large and prognathic, that is,
+projecting. This may extend even to the existence of a so-called
+lemurian appendix of the jaw. The zygomatic process is apt to be
+prominent, in keeping with the heaviness of the upper jaw. The nose is
+usually somewhat flattened, and may be crooked. This peculiar
+development of the nose puts most of the internal parts of that
+important organ within the skull itself. This further encroaches upon
+the cranial capacity. The ears are asymmetrical, often unevenly placed
+at the sides of the head, sometimes adherent at the lobule, sometimes
+very prominent. The displacement of the soft tissues is due to the
+existence of asymmetry of the skull. As may be seen, all of the
+characteristics of the criminal type, pointed out by Lombroso, may
+practically be summed up in the one expression, there is diminished
+amount of intracranial space.
+
+With regard to many cranial deformities, and especially various
+thickenings of the cranial bones, it must not be forgotten that they
+are not the expression of physical heredity, but are often
+pathologically acquired. Certain diseases of children are accountable
+for many of them. Various disorders of nutrition in the early years of
+life express themselves in bony deformities, and the skull is not
+spared. Rickets, for instance, is well recognised as a cause of such
+deformities. Owing to a wrong etymology of this word, by which it is
+supposed to be derived from the Greek word [Greek text], meaning the
+spine, rickets is sometimes scientifically {276} called rachitis. The
+connection, then, between the cranial deformity and some underlying
+nervous disturbance might be assumed. It does not exist, however.
+Rickets is an English word, the derivation of which is unknown, but
+probably it is _wricken_, twisted, deformed, and its use has crept in
+because the disease was first described in England, and is indeed
+often spoken of on the continent of Europe as an English disease. Not
+that it is any more frequent in England, however, but was there first
+recognised as a distinct pathological entity. As the result of this
+affection the children, usually of poor parents, suffer from
+gastro-intestinal disorders of various kinds, and develop symptoms of
+malnutrition, affecting especially bone tissue. The ends of the long
+bones at the wrists and at the ankles, where the effects of the
+disease can be noticed particularly, become more thickened and nodular
+than usual. The ends of the ribs, where the bones join the cartilages,
+also become nodular, so that a series of beads can be seen down each
+of the child's sides, a condition described as the rickety rosary. In
+a similar way the bones of the skull become thickened, especially at
+the edges of the fontanels, that is, the openings in the child's head
+before complete ossification of the skull has taken place. As a
+consequence of this thickening these openings do not close as they
+should, and the head becomes markedly deformed in some cases.
+
+Indeed, as has been shown by experts in children's diseases, many of
+the peculiarities that have been pointed out by over enthusiastic
+craniologists as indicating criminal degeneration, are really the
+results of the rickety process on the skull. Needless to say, however,
+this does not change the character of the individual, nor is there any
+good reason why such deformities should have any special connection
+with criminality. It happens that many of the criminal classes suffer
+from malnutrition in their early childhood, and as a consequence there
+is a faulty bony development of the skull. It is observations of this
+kind, particularly, that have served to discredit craniology as an
+independent science.
+
+With regard to habitual criminals, the question of criminality must be
+discussed from the standpoint, not of those who theorise, but of those
+who know from actual {277} observation most about the criminal
+classes. In an article in _The Nineteenth Century and After_ for
+December, 1901, Sir Robert Anderson discusses how to put an end to
+professional crime. Sir Robert has been Chairman of the Criminal
+Investigation Committee of the English Parliament for many years. His
+opinion, then, is worth weighing well and is very strikingly different
+from those of the criminologists who would find a very large
+proportion of criminals among mankind. He says:
+
+"I am not turning phrases about this matter, or dealing in rhetorical
+fireworks. I am speaking seriously and deliberately, and I appeal to
+all who have any confidence in my judgment and knowledge of the
+subject, to accept my assurance that if not 70,000 but 70 known
+criminals were put out of the way, the whole organisation of crime
+against property in England would be dislocated, and we should, not
+ten years hence but immediately, enjoy an amount of immunity from
+crimes of this kind that it might to-day seem Utopian to expect. The
+criminal statistics cult blinds its votaries. It is the crime
+committed by professional criminals that keeps the community in a
+state of siege. The professional criminals are few and I may add they
+are well known to the police. The theory that these men commit crimes
+under the overpowering pressure of habit, or of impulse, is altogether
+mistaken. They pursue a career of crime because, as Sir Alfred Wills
+expresses it, they calculate and accept its risks. And just in
+proportion as you increase the risks you will diminish the number of
+those who will face them. True it is that the army of crime includes a
+certain number of wretched creatures who have not sufficient moral
+stamina to resist the criminal impulse. I believe there are fewer of
+this class in England than abroad, but I know that these are not the
+sort of criminals whose crimes perplex the police. The high-class
+criminal is a different type of person altogether."
+
+Sir Robert gives an extract from one of the morning papers of the day
+on which he wrote these lines, in order to show how different is the
+status of every ordinary habitual criminal from that which the
+enthusiastic criminologist supposes it to be:
+
+{278}
+
+"Hewson Patchett, 48, was sentenced yesterday for obtaining seven
+pounds and a gold watch by false pretenses. He urged it was his first
+offence, but a London detective informed the court that there were
+about two hundred cases against him for housebreaking."
+
+Sir Robert adds: "If Patchett is a cool-headed, deliberate criminal,
+the whole proceeding is a farce. And if he be one of those miserable,
+weak creatures who can not abstain from crime, the sentence is
+barbarous."
+
+Such experiences as Sir Robert hints at as occurring frequently in
+England, are certainly by no means uncommon in this country. Within
+the past year in at least four cases in New York City, in which a
+burglar, besides committing robbery, wounded or killed some one,
+either in the commission of the crime itself or in endeavouring to
+avoid arrest afterwards, there were more than two convictions
+registered against the criminal in his previous life. There can be no
+doubt that criminality becomes for some men a sort of mania, and that
+society must protect itself against their actions quite as it does
+against those of the insane by confining them under surveillance. It
+seems very clear that while a man may, under stress of circumstances
+or because of some specially tempting opportunity, be induced to
+commit burglary or some other crime by violence in order to obtain
+money, this will not happen a second time, except in the case of
+certain individuals whose moral tone is so perverted that reformation
+is practically hopeless. If a second conviction for burglary,
+therefore, is secured, a longer sentence than is now the custom should
+be inflicted, and the individual should not be allowed to go from
+under the surveillance of the authorities until he has demonstrated,
+for at least five years, his willingness and capacity to earn an
+honest living.
+
+This may seem a drastic method. It may also appear to some that there
+would be consequent upon this system of regulating criminals a very
+undesirable increase of our present rather extensive system for the
+care of criminals. Here is where Sir Robert Anderson's experience is
+of value. The confirmed criminals are not near so many in number as is
+usually supposed, or as is even claimed by certain heedless {279}
+statistical experts in criminology. There is no doubt, however, that
+these men succeed in drawing others around them and in organising most
+of the crimes of violence that are committed. There is a certain
+glamour about the successful burglar that allures the young man and
+starts him in the downward path of criminal tendencies from which he
+may not be able later easily to withdraw.
+
+If those who are most deeply interested in the reform of the criminal
+classes would unite in an effort to secure legislation to the effect
+that the habitual criminal should receive, not a definite sentence but
+an indeterminate sentence; that is to say, that on his second
+conviction for burglary, he should be sent to jail until such a time
+as, in the opinion of officers of the institution where he has been
+confined, he shows signs of a disposition to become a worthy member of
+society, and that then he should be allowed to be at liberty only
+under such circumstances as would permit of reports with regard to his
+conduct for a time equal at least to the years spent in prison, then
+there would be much less need of the theoretical considerations with
+regard to the heredity of criminal traits, and the supposed all
+powerful influence of environment in fostering criminal tendencies.
+There is in this matter a very worthy field for the development of
+philanthropic qualities, and the student of the abnormal man will find
+many opportunities for the exercise of a large-hearted charity, rather
+than the facile condemnation which places all violations of law under
+the head of criminality.
+
+Those who have made special studies with regard to criminals have, as
+a rule, come to the conclusion that our modern method of treating
+those convicted of crime is eminently irrational. It is a rare thing
+to pick up a newspaper without finding that a crime by violence has
+been committed by some one who has previously been in state's prison
+for a similar crime. Most of the burglars have a police record.
+Pickpockets and others continue to pursue their avocations,
+notwithstanding a series of convictions. It is clear that a sentence
+of a year or two, or even more each time that a crime is committed,
+does not act as a deterrent. Such people are differently constituted
+from those who are influenced by {280} public conviction of crime and
+restraint of liberty. There is something radically wrong with their
+moral sense. It would seem that the proper way to treat them is after
+the same fashion as the method used with those who are mentally
+impaired.
+
+After a man has shown, by a second conviction of a crime by violence,
+that he is one of those whose moral sense can not be restored by
+punishment to a realisation of his action, then an indeterminate
+sentence, somewhat as in the case of the mentally unstable, who are
+allowed to leave the asylum but are kept under observation, is the
+only proper method.
+
+Men like Sir Robert Anderson are sure that this procedure could be
+adopted with regard to quite a liberal number of leading criminals
+whose influence induces others to crime. There would be much less need
+for all machinery of the criminal law than at the present time, and
+the community would be better protected. This is certainly true as
+regards the large cities, where crimes against property are almost
+without exception committed by those who have been previously
+convicted for such crimes, or who at least have been in intimate
+association with such convicted criminals.
+
+This view of the criminal, as one against whom society must protect
+itself just as it does against the insane, is comparatively modern. It
+must be borne in mind, however, that insane asylums are by no means an
+old institution, and that the present restraint of very large numbers
+of the insane is something unknown before in history. It seems not
+unlikely that if this newer aspect of criminology could be made
+popular great benefit would follow, not only to the peace of the
+community and the freedom of its members from fear as to such crimes,
+but also a number of the weaker individuals, who are now influenced
+and led astray by clever criminals, would be saved from commission of
+crime and the necessity of punishment, with the degradation and
+lifelong stigma that this involves.
+
+This is an aspect of criminology with which the Christian clergyman
+can be in sympathy, and that does not smack of the utter materialism
+which was at the foundation of much of the discussion of the so-called
+criminal type. The {281} recognition of moral perversion as a form of
+insanity requiring treatment and then constant observation for many
+years, just as in the case of mental disequilibration would be a
+distinct advance over our present crude methods of dealing with
+criminals.
+
+JAMES J. WALSH.
+
+
+{282}
+
+XXVI
+
+PARANOIA, A STUDY IN CRANKS
+
+
+Of late years the crank, in the various forms in which he or she may
+occur, has became a subject of great popular as well as scientific
+interest. As a matter of fact, the queernesses of people are a more
+absorbing study to the neurologists and psychologists than are any
+forms of insanity. It not infrequently happens that individuals of
+peculiar tendencies are prone to have special affinity for religious
+ideas, and strange applications of Christian formulae of thought. Even
+when they do not become absolutely insane in their religiosity, they
+may often go to extremes. It must be remembered, too, that some cranks
+are mentally affected in but mild form, and it may be difficult to
+determine whether their oddity is really the result of a certain
+amount of mental torsion, or merely intellectual tension.
+
+Such persons are more likely to be brought in close contact with their
+pastors and other clergymen and with religious Superiors of various
+kinds than even normal individuals. They often put their confessors,
+particularly, in serious quandaries in the matter of spiritual advice.
+A review, then, of the accepted ideas of experts with regard to such
+people is likely to be of special service to those who would
+understand these cases as well as possible, though the present state
+of medical knowledge, here as elsewhere, leaves much to be desired.
+
+A distinguished authority in mental diseases once said, half in jest
+though he meant it to be taken at least half in earnest, that a great
+many more of us are cracked than are usually thought to be, only that
+most of us succeed in concealing the crack quite well. The frequency
+of the crank adds to the {283} interest of his study, which is by no
+means a department of medical science of recent growth. While interest
+in this class of persons has become much more intense in recent years,
+eccentric individuals have been an object of close observation and of
+serious study almost as far back as history goes. When Quintilian said
+that genius was not far separated from insanity, he meant to record
+the conclusion of his time, that men of genius are apt to seem
+inexplicable in their ways to those who come closely in contact with
+them. Eccentric persons, however, are by no means always undesirable
+members of a generation. It has been noted by historians in all ages
+that to the refusal of eccentric individuals,--often thought at the
+beginning, particularly, to be little better than insane--to accept
+the traditions of the past, we owe many of the privileges which we
+enjoy at the present time. Their refusal to think along old lines of
+thought often makes them valuable pioneers in progress.
+
+Definite knowledge with regard to the pathological basis of crankism,
+or eccentricities, has not yet been obtained. What has been learned,
+however, has enabled the neurologist to distinguish various forms of
+mental perturbation, to recognise the probable influence of certain
+conditions and environments on the future action of eccentric
+individuals, and to foretell the probable outcome of the cases. All of
+this information is of very practical importance to religious
+Superiors and others in positions of religious confidence, who are
+sure to be brought, even more than the rest of the community, in
+contact with the eccentric class. It has seemed advisable, then, to
+condense some of the recent knowledge on this subject into popular
+form for the use of confessors, spiritual directors, and those in
+religious authority.
+
+How recently medical knowledge on this important subject has developed
+along strictly scientific lines may perhaps best be appreciated from
+the fact that Professor Mendel of Berlin, to whom we owe the term
+_paranoia_, the recognised scientific designation for crankism, is yet
+alive and continuing his lectures on neurology at the great German
+university. The term, from the Greek word [Greek text], meaning
+alongside of, and {284} [Greek text], mind, expresses the fact that
+the mental faculties of individuals designated by it are beside
+themselves, that is, the mental powers are not entirely under the
+control of the individual, so that they only come near voluntary
+intellection in its highest sense. In a word, the term contains a
+series of expressive innuendos by its etymological derivation.
+
+Professor Berkley of Johns Hopkins University says that the word
+paranoia was first adapted by Mendel from the writings of Plato, to
+indicate an especial form of mental disease occurring in individuals
+capable of considerable education, at times of brilliant acquirements,
+yet possessing a mental twist that makes them a class apart from the
+great mass of humanity.
+
+Professor Peterson, the President of the New York State Commission of
+Lunacy, gives a very good definition of the condition which, though
+couched in somewhat technical terms, furnishes the most definite idea
+of the essential properties of paranoia. He says: "Paranoia may be
+defined as a progressive psychosis founded on a hereditary basis,
+characterised by an early hypochondriacal stage, followed by a stage
+of systematisation of delusions of persecution, which are later
+transformed into systematised illusions of grandeur." He continues:
+"Though hallucinations, especially of hearing, are often present, the
+cardinal symptom is the elabourate system of fixed delusion."
+
+In a word, the paranoiac is a crank usually descended from more or
+less cranky ancestors, with an overweening interest in his health to
+begin with, who later develops the idea that many people are trying to
+do him harm, or at least to prevent his rise in the world, and who
+finally becomes possessed of the notion that he is "somebody," even
+though those around him refuse to acknowledge it and pay very little
+attention to the claim. Such people not infrequently hear things that
+are not said. That is, not only do they hear the voices of the dead,
+of spirits good and evil, but also the voices of living persons, who
+are at a distance from them and sometimes even when those living
+persons are present, but have said absolutely nothing. These delusions
+of hearing, however, are not so important as the self-deception forced
+upon them by their {285} mental state with regard to their importance
+in the world and their relations to other people.
+
+The most significant consideration with regard to paranoia is the fact
+that it is practically always hereditary. Krafft-Ebing said that he
+never saw a case of true and reasonably well developed paranoia
+without hereditary taint. This does not imply, of course, that the
+same symptom of delusions exists in several generations, but some
+serious mental peculiarity is always found to exist in the preceding
+generation. Other authorities are not quite so sweeping in their
+assertion of heredity for these cases, though practically all are
+agreed that in over 80 per centum of the cases, some hereditary
+element can be traced without overstretching the details of family
+history that are given.
+
+Paranoia occurs a little more commonly in females than in males. As it
+is of hereditary origin, it is not surprising to find that the
+peculiarities are noticed very early in life, though they may not be
+sufficiently emphasised to attract the attention of any but acute
+observers, who are brought closely in contact with the patients. Even
+in childhood, patients who subsequently develop serious forms of
+paranoia, usually have been shy, backward, inclined not to play
+readily, irritable, peculiar, precocious, prone to spend much time in
+study at an age when they ought to be interested mainly in sports, and
+they are generally old beyond their years. A typical example of this
+was Friederich Nietzsche, the German philosopher, who died a few years
+ago in an insane asylum.
+
+Olla Hanssen, Nietzsche's biographer, who carefully collected the
+family accounts of the philosopher's childhood, said that he did not
+talk until much later in childhood than is usual. "As a boy he was
+retiring and solitary in his habits. During his school days he was
+always interested in books not in sports, in lonely walks not in young
+companions." A history of this kind will be found in the early career
+of many queer folk. Very often these old-fashioned traits are a source
+of pleasure to parents and sometimes even to teachers. During
+childhood, however, the sports of childhood should satisfy the child,
+and abnormalities of interest in things outside of childhood's sphere
+are always suspicious. The growing {286} organism needs, first of all,
+muscular exercise, and after that the freedom of mind that comes with
+spontaneous play. It may be said, in passing, that the walk of a city
+child with its maid, when even the child's choice in the matter of
+where it shall walk is not consulted and the maid's will is constantly
+imposed, is the worst possible training for spontaneous action or
+volition in later life.
+
+In the cases that develop early in life it will practically always be
+found that infantile cerebral disorders of some kind are a prominent
+feature of the history. The mother's delivery was difficult perhaps,
+and the child was for some time after birth unconscious, or infantile
+convulsions occurred. It may be remarked here that a history of
+convulsions in childhood is now considered by physicians as of serious
+import for the future nervous and mental life of the child. It has
+recently been announced, for instance, that so-called idiopathic
+epilepsy,--that is, epilepsy without some directly immediate
+cause,--very seldom develops later in life in persons who have not had
+in childhood convulsive seizures as the result of some extreme
+irritation. This does not imply that every child that has convulsions
+will suffer from some serious nervous or mental condition later; but
+every child whose mental and nervous equilibrium is not stable,
+because of hereditary elements of weakness, will almost certainly
+suffer. Injuries to the head in childhood are nearly of as great
+importance as the actual occurrence of convulsions.
+
+There are usually three stages of paranoia described by authorities in
+mental diseases. These have been called the prodromal or initial
+period, which is also, because of the set of symptoms usually most
+prominent in it, often called the hypochondriacal stage of the
+disease. The patient occupies himself with his feelings and his
+sensations. He is concerned very much about the state of his health
+and is prone to think himself affected by diseases that he reads about
+or hears described. This set of symptoms, by itself alone, is not an
+index of enduring mental disturbance, but may be only a manifestation
+of a passing mental perturbation in sympathy with some slight physical
+ailment. This state may indeed be nothing more than the result of too
+persistent introspection. {287} Most medical students suffer from a
+certain amount of hypochondria during their early acquisition of a
+knowledge of the symptoms of disease.
+
+In the true hypochondriac, however, every bodily sensation, or as it
+is technically called, somaesthetic sensation, is translated to mean a
+significant symptom of serious disease. A slight feeling of fatigue
+becomes to the patient's mind the "tired feeling" of a dangerous
+constitutional disorder. Any peculiar feeling, such as that of the
+hand or foot going to sleep, is set down at once as a symptom of a
+serious nervous disease, or if the patient has heard that in old
+people numbness of the extremities is a forerunner of apoplexy, he is
+sure to conclude that apoplexy is threatening in his own case.
+Subjective sensations of heat and cold set him to taking his
+temperature and his pulse, and even slight variations in these are
+magnified into important physical signs of disease.
+
+Very often such slight symptoms as passing lapses of memory are
+magnified into approaching complete failure of memory, and lassitude
+becomes a permanent loss of will power, evidently due to disease in
+the patient's mind, and there begins the persuasion that nothing can
+overcome it. Morbid introspection becomes, after a time, the favourite
+occupation, and every slightest sensation or feeling sets up trains of
+thought that lead to far-reaching conclusions with regard to physical
+weakness. The patient is apt to be greatly preoccupied with himself,
+to neglect his duty towards others, to be utterly selfish, to fail to
+realise how much sympathy is being wasted on him.
+
+Some people never pass beyond this preliminary stage of the mental
+disorder. Usually, however, after a time the patient misinterprets not
+only his own sensations, but the actions of other people in his
+regard; he becomes suspicious and distrustful of everybody around him,
+sometimes even of his best friends. He is passing on to the second
+stage of the disease, in which he is sure to feel that he is the
+object of persecution. Just as he misunderstood his physical symptoms,
+so he misconstrues the actions of his friends. He is sure that they
+look at him curiously, that they smile {288} ironically. Sometimes he
+thinks that they wink at one another with regard to him, or make signs
+behind his back that are meant to be derisive. Even harmless passing
+observations may be morbidly perverted into severe and inimical
+criticism of himself and his actions.
+
+The paranoiac is now apt to enter fully upon the second or persecutory
+stage of his mental disorder. His distress and discomfort he
+attributes to those around him and he is sure that he is the subject
+of persecution. At first his persecutors are not very definitely
+recognised. No particular person is picked out and even no particular
+set of persons. There is just a vague sense of persecution. A
+distinguished neurologist once said that no sane person in this world,
+outside of a novel or a play, has time to make it his business to
+persecute anyone else. When people come, then, with stories of
+persecution, either they themselves are not in their right mind and
+are deluded as to the source of the persecution, or else their
+persecutor is not in his right mind and the case needs seeing to from
+the other standpoint.
+
+After a time, longer or shorter in individual cases, the paranoiac
+begins to recognise definitely who his persecutors are. As a rule, it
+is not some single individual, but a combination of individuals.
+Already there is the beginning of the third state of the disease--the
+grandiose stage of the disease, in which the patient feels an extreme
+sense of his own importance. It would be derogatory to his self
+conceit to consider himself the subject of persecution by an
+individual, and so it is usually some society, or the government, or
+its officials, or some secret organisation that is persecuting him,
+and perhaps also persecuting those who are near and dear to him.
+
+Sometimes it is the Odd Fellows, or perhaps the Masons, who are the
+persecutors. If the newspapers have recently had some account of the
+disappearance of Morgan years ago, and this subject crops up
+periodically in the papers, then the Masons become a favourite subject
+for paranoiacs' delusions of persecutions. Just after the Cronin
+murder in Chicago, the Clan-na-Gael became an extremely fearsome
+spectre for paranoiacs who thought themselves persecuted. It is of
+some {289} importance to know, as a rule, what the usual reading
+matter of a patient is, and what things are likely in his past history
+to have impressed him, in order to realise what the real source of his
+delusions of persecutions are.
+
+It is curious how rational these patients may be on all other subjects
+except the special topic of their delusion. During the past year a
+paranoiac has been under observation, who is considered a reasonably
+rational individual by those who know him well, who follows his daily
+occupation, that of clerk, without intermission and with business
+ability, who is a faithful attendant at church, and who is very kind
+to his family, but who is sure that he is the subject of persecution
+by the Clan-na-Gael. He never belonged to the organisation. He is
+not able to give any good reason why he should be persecuted, except
+perhaps the fact that, though an Irishman, he never did belong to
+them. He is perfectly sure, however, that they are planning to poison
+him and his family. He finds peculiar tastes in the tea and the coffee
+at times. He throws out these materials and insists on his wife
+getting others at another grocery store. He sometimes brings groceries
+home from a distance and yet finds that if he ever buys materials a
+second time in the same place, they are sure to have been tampered
+with in the meantime by emissaries of this secret organisation. He
+feels sure that he has seen these secret agents, but he is only able
+to give vague descriptions. Not a little of the prejudice against
+these organisations is really founded on such morbid suspicions.
+
+Another form that the idea of persecution sometimes takes, in this
+second stage, is the delusion that the patient is neglected by those
+who should specially care for him or her. A woman insists that she is
+neglected by her husband. She may become intensely jealous of him and
+make life extremely miserable for him without there being any good
+reason for her jealousy. These cases are not nearly so rare as might
+be thought. On the other hand, men suspect their wives of
+unfaithfulness. This suspicion may go to very serious lengths in
+persecution at home, though the man all the time keeps his suspicions
+to himself, in order not to make a laughing stock of himself outside
+of the house. It is this curious mixture of {290} rationality and
+delusion that is the characteristic feature of the disease. It is for
+this reason that these conditions were sometimes called monomanias, as
+if patients were really disturbed only on one point. As a matter of
+fact, however, patients are mentally wrong on a number of points,
+though there is some one mental aberration so much more prominent than
+other peculiarities that it overshadows the others.
+
+It is not long after the persecutory stage sets in before patients are
+apt to become themselves persecutors of others as a result of their
+belief that they are being persecuted. The French have a suggestive
+expression for this. It is _persecutes persecuteurs_, that is to say,
+"persecuted persecutors,"--patients who are trying to repay supposed
+persecutors by persecution on their own part. Such patients, of
+course, very easily become dangerous. They need to be carefully
+watched. As a rule, the persons whom they are prone to select as the
+persecutors upon whom they must avenge themselves are absolutely
+innocent parties. At times they are even dear and well meaning
+friends.
+
+After the persecutory stage in paranoia, comes the third, or so-called
+expansive period of the disease. It has been remarked that sometimes
+this develops as a sort of logical sequence from the patient's ideas
+of persecution. If he has too many enemies and if important secret
+organisations are trying to be rid of him, he must be a person of some
+importance. As a consequence he evolves for himself a royal or
+aristocratic descent, or hints that he is the unacknowledged son of
+great personages. In a kingdom royalty is, of course, a dominant idea.
+In a republic like our own, he may consider himself to be the
+President or the politician to whom the President owes his office.
+
+_Paranoia Religiosa_.--Not infrequently the first hint of their
+supposed greatness comes to such patients suddenly in a dream or in a
+vision; when their expansiveness takes a religious turn, this is
+especially apt to be the case. They may believe themselves to be
+especially chosen by the Almighty, a new Messiah or even Christ
+Himself, come once more to earth. Such people may retain much of their
+rationality on most of the points relating to practical life, and yet
+have this {291} hallucination as to their close relationship with the
+divinity. Not only may they retain their mental equilibrium on other
+points, but they may even give decided manifestations of great genius.
+This is, I suppose, one of the most interesting features of this form
+of mental disease, but it is well illustrated in the lives of many
+modern founders of religious sects, even in our own generation.
+
+Such religious reformers as Mahomet and Swedenborg seem undoubtedly to
+have been afflicted with this third stage of expansive paranoia. In
+our own day there is no doubt that many of the founders of new
+religious sects, many of the heaven-sent apostles or reincarnations of
+patriarchs and prophets, the miraculous healers and the like, are
+afflicted in this same way. It is useless and entirely contrary to the
+known facts to put such people aside as mere imposters. Imposters they
+are, but they have imposed on themselves as well as on their
+followers. They are sincere as far as they go, and the mental twist
+that gives them their power has occurred in the midst of the
+manifestation of the intellectual faculties of a highly practical
+character and of executive ability, with wonderful capacity for the
+direction of complex affairs. A prominent neurologist said, not long
+ago, that the most interesting feature of Christian Science is to
+contemplate in the study of the movement how near people may come to
+insanity and yet retain their faculty to make and handle money and
+even accumulate fortunes.
+
+_Paranoia Erotica_.--After the _paranoia religiosa_, the most common
+form of the disease is the _paranoia erotica_. There are authorities
+in mental diseases who do not hesitate to say that an excess of
+religiosity and of erotic sentimentality are more or less
+interchangeable. This declaration represents, however, the unconscious
+exaggeration of a mind unsympathetic towards religious ideas. But it
+must not be lost sight of that the two forms of excesses, erotic and
+religious, are more nearly related than would be ordinarily supposed,
+and that erotic manifestations may be confidently looked for in
+patients who have been afflicted by a too highly wrought religious
+sentimentality. St. Theresa seems to have realised this very well and
+has touched on the subject in one of her letters.
+
+{292}
+
+Ordinarily erotic paranoia manifests itself by the patient imagining
+himself or herself to be beloved by some one of superior station. This
+love is of rather a platonic character and the "lover" cranks are
+prone to pick out as the object of their attention and annoyance some
+young woman rather prominently in the public eye, but whose reputation
+is of the very highest. Mary Anderson was the subject of a good deal
+of this sort of persecution. At the present moment the well and
+favourably known daughter of a great millionaire is the subject of
+many such attentions.
+
+These paranoiacs are apt to become dangerous if they are prevented
+from paying what they consider suitable attention to the object of
+their affection. In hospitals they have to be carefully watched, and
+more than one accident has taken place as the result of relaxation of
+vigilance on the part of their attendants. If kept from the object of
+his affection, delusions of persecution become prominent in the
+amorous paranoiac, and he may become a persecutor in turn and thus a
+dangerous lunatic. He can not be made to understand that the sending
+of flowers and photographs and letters is entirely distasteful to the
+chosen one. Fortunately, after a time, in many of these cases, a state
+of dementia sets in, and then the patients become mild-mannered
+imbeciles whom it is not at all difficult to manage.
+
+As a rule where the patient has passed through the various stages of
+paranoia, dementia, with symptoms of imbecility, closes the scene. The
+paranoia may not always follow the course mapped out for it. Stages
+may be skipped, several forms of delusions may become prominent in the
+life of the individual at about the same time. The main feature of the
+disease is its progressive character, and its diagnosis depends on the
+queerness exhibited all during the course of life, as well as on the
+presence of hereditary neurotic influences.
+
+_Special Forms of Paranoia_.--There are besides the two types
+described a number of special forms of paranoia, some of which aroused
+attention first under the form of monomanias, that seem to merit brief
+treatment by themselves. In their extreme forms they are easy of
+recognition. Milder types, however, may easily escape classification
+under the {293} head of paranoia, because they are considered to be
+individual oddities and not due to any physical or mental incapacity.
+Undoubtedly, however, the study of these peculiar "types," as the
+French call them, from the standard of the alienist or expert in
+mental diseases, will serve to make clearer the real significance of
+many otherwise almost unaccountable actions. There is no doubt, that
+the consideration of these eccentrics as paranoiacs makes the
+charitable judgment of many of their acts much easier, and at the same
+time is of service in managing them. They are likely to be of much
+less harm to the community and to their friends, when it is realised
+that they are not to be taken too seriously, but that, on the
+contrary, there is ample justification for a benevolent combination of
+interests to keep them from injuring themselves and their friends.
+
+_Paranoia Querulans_.--One of the most important and familiar forms of
+the special types of paranoia is what is known scientifically
+_paranoia querulans_, that is, the peculiarity of those who insist on
+going to law whenever there is the slightest pretext. It is pretty
+generally recognised that a goodly proportion of the civil suits that
+crowd our law courts are due to the peculiarities of these people who
+insist on having their rights, or what they think their rights,
+vindicated for them by a court of justice. There are very peculiar
+characters in this line, some of whom make themselves very much feared
+and detested by their neighbours. There are some individuals to whom
+the slightest injury or show of injury means an immediate appeal to
+the law.
+
+Not infrequently these patients, for such they are in the highest
+sense of that word, waste their own substance and even the means of
+support of wife and children, on their foolish law schemes. When their
+queerness reaches a certain excessive degree its pathological
+character is readily recognised. In a less degree _paranoia querulans_
+may be a source of very serious discomfort to friends and neighbours
+without exciting a suspicion of its basis in mental abnormality. Not
+infrequently such patients become more irrational at times when their
+physical condition is lower than normal, and a return to their
+ordinary health makes them {294} more amenable to reason and less
+prone to appeal to expensive litigation.
+
+It is evident that the irrationality of frequent appeals to expensive
+and bothersome litigation should arouse suspicion. Such patients need
+to be cared for quite as effectually as those who have tendencies to
+gamble away their substance or to waste it in the midst of inebriety.
+Unfortunately it is extremely difficult to frame laws so as to meet
+such conditions. Severer forms of the affliction are readily
+recognised and the sufferer is properly restrained. I remember once
+seeing a patient in Professor Flechsig's clinic in Leipzig, who had
+been sent to the asylum because of his tendency to go to law on the
+smallest possible pretext. This patient's incarceration in the asylum
+was due to a very striking manifestation of his _paranoia querulans_.
+He answered an advertisement for a clerk, published by one of the
+large commercial houses. He found himself one of a row of applicants
+for the position, and as the member of the firm whose duty it was to
+engage the clerk was at the moment busy, he had to wait several hours
+before his application was heard and refused. He tried to secure a
+warrant for the firm in order to have them indemnify him for the time
+he had spent while waiting for his application to be heard, at the
+rate of wages they would have been bound to pay him had he obtained
+the vacant clerkship; only as they had spoiled a day he claimed a full
+day's wages.
+
+This patient had been in the asylum several times before because of
+his tendency to go to law. He always gained in weight while in the
+asylum, became much more tractable and less querulous as his physical
+condition improved, and usually after some months could be allowed to
+leave the institution. He was, however, one of the inept. With the
+help of asylum influence he usually obtained some occupation more or
+less suitable, but was not able to retain it for long. When out of a
+situation he worried about himself, usually did not take proper food,
+and then soon his litigious peculiarities began to manifest themselves
+once more in such form that if he could get the money to retain an
+attorney, or if he could persuade one to take his case on a contingent
+fee, and he was very ingenious at this, he soon became a veritable
+nuisance to {295} those around him. When in poor health he was never
+contented unless he had at least one lawsuit on his hands, and only
+really happy when he had several.
+
+_The Gambler Paranoiac_.--A form of paranoia that inflicts almost more
+of human suffering on the friends of the patient than any other is
+that in which the sufferer is possessed of the idea that he can, by
+luck or by ingenious combinations, succeed in winning money at
+gambling. Milder forms of this paranoia are so common that it is the
+custom not to think of even the severer forms of the gambling mania as
+a manifestation of irrational mentality. When a man thinks, however,
+that he can beat a gambler at his own game, or when by long
+lucubration he comes to the conclusion that he has invented a system
+by which he can beat a roulette wheel, he is, on this subject at
+least, as little responsible as the man who thinks that he has
+discovered perpetual motion.
+
+This form of paranoia inflicts suffering mainly on the near relatives
+of the patient. There is no doubt that when extreme manifestation of
+the gambling mania becomes evident, patients should be legally
+restrained from further foolishness. One difficulty with regard to the
+proper appreciation of gambling has been an unfortunate tendency to
+class gambling among the malicious actions. There are many people for
+whom only two sins seem to have any special importance, drunkenness
+and gambling. As a rule, there is not the least spirit of malice in
+the ordinary gambler; not meaning, of course, by this the sharpers,
+who try to make money at the expense of others, but the man who
+believes that, somehow, chance and fate are going to conspire to
+enrich him at the expense of others, though it must be confessed that
+he does not usually even think of this latter part of the proposition
+which he accepts so readily.
+
+We have had in recent times so many manifestations of the practical
+universality of the gambling spirit, the belief by people that brokers
+and banking concerns are ready to make them rich quick, that we have
+in it perhaps the best illustration of the partial truth of the
+proposition that "half the world is off, and the other half not quite
+on."
+
+_The "Phobias."_--Sometimes the special form of queerness {296} takes
+on a very harmless aspect. Patients are worried because of the fact
+that they can not keep themselves clean. They want to wash their hands
+every time they touch any object that has been handled by others,
+whether that object seems to be specially dirty or not. Such patients
+may wear the skin off their hands washing them forty or fifty times a
+day. They almost absolutely refuse to touch a door-knob, because it is
+handled by so many people. They will consent to take only perfectly
+new bills. It is almost amusing to see the efforts they make to avoid
+shaking hands with people, without giving direct offense. When it
+comes to shaking hands with their physician, they are apt candidly to
+declare that he must not ask them to do so, because they can not
+overcome their feelings as to the possibility of contamination from
+hands that come in contact with so many patients. This fear of dirt
+has received the name Misophobia.
+
+There are a number of other "phobias," and the patient's fears are
+manifested at the most peculiar objects. Agoraphobia, for instance, is
+the fear of crossing an open place. These patients begin to tremble as
+soon as they get away from the line of buildings in a street, in their
+way across the square. This trembling becomes actual staggering, with
+a sense of oppression over the heart that makes locomotion almost or
+quite impossible. Claustrophobia, the opposite of Agoraphobia, is the
+fear of narrow places, and prevents some people from going through a
+narrow street with high buildings. Many of these "phobias" have a
+physical basis in some organic or nervous heart affection.
+
+_The Tramp_.--One of the striking manifestations of paranoia in our
+modern life is the tramp. Most people are inclined to consider that
+the cause for the wandering life of these unfortunates is rather what
+a distinguished physician euphemistically called by the scientific
+name, _pigritia indurata_, that is, chronic laziness, than any
+pathological condition of mind. Most tramps, however, will be found,
+on that close acquaintanceship which alone will justify judgment of
+their actions, to have many other peculiarities of mind besides the
+shiftlessness which prompts them to wander more or less aimlessly from
+place to place. After all, it will hardly be denied that the calm
+{297} acceptance of the notion that it is more satisfactory to indulge
+in laziness and wander without home or fireside, suffering the many
+privations and hardships, especially from the weather which these
+creatures do, rather than work and be respected and comfortable among
+their fellows, is of itself irrational.
+
+Many of these tramps prove on close acquaintance to be interesting
+pathological characters. Various stages of outspoken paranoia will be
+found to exist among them. It is not unusual to find that certain
+among them have acquired the idea not so uncommon now among large
+classes of humanity, that the world is so unjust in its treatment of
+the labouring man, that work seems to them almost a persecution that
+must be undergone for the sake of the pittance derived from it.
+Sometimes there is the actual extrinsic idea of personal persecution
+for some fancied wrong done to a large corporation during a strike, or
+labour troubles, which they cherish as the reason for which they have
+had to give up a fixed habitation, and resign the idea of supporting
+themselves honestly and respectably. This persecution stage of
+paranoia easily turns to the second phase of this affection as already
+described, that in which the fancied victim of persecution becomes in
+turn the persecutor. Tramps thus readily give way to even organised
+attempts at revenge upon social order, and are led to believe
+themselves justified in attempts to burn and otherwise destroy
+property because of their enmity towards property holders and
+employers generally. Not infrequently the third stage of paranoia, in
+which there are delusions of grandeur, may be observed.
+
+Personally I have known two tramps who wandered about the country with
+these grandiose ideas. One of them thought that he had in his
+possession immense wealth in the shape of large checks, signed
+supposedly by various important capitalists, and even foreign rulers.
+These checks were actually signed in the names of these personages, at
+the tramp's own request, by any chance passer-by or acquaintance. This
+patient died in a country insane asylum in the demented stage of
+paranoia, having gone through all the usual phases of the disease.
+Another tramp was confident that each recurring election he was to be
+elected to one of the highest offices in {298} the state, or even to
+be made President of the United States. Not every one was taken into
+his confidence in this matter, however. The simplest declaration after
+the election from any chance acquaintance would assure him of his
+success at the polls, and on more than one occasion he turned up at
+the Capitol to claim exalted office, but was generally inoffensive in
+his ways, and was rather readily persuaded that his term of office did
+not begin for some time. It is easy to understand that a person might
+come into the possession of the idea that the official holding office
+in his stead should be removed; the result might very well be one of
+the sad tragedies supposedly due to anarchism, but really to paranoia.
+
+Of course as with criminals, so with tramps; not a few of them take up
+this manner of life without any sufficient justification in their
+mental state to lessen our worst opinion of them. I do not think I
+should hesitate to say, however, that the majority of these
+unfortunates present distinct signs of physical and mental
+degeneration and are rather deserving of pity and care than of
+condemnation. They need, as a rule, very special environment to enable
+them to lead ordinary, respectable lives, because they were not
+originally endowed with sufficient initiative and independence of
+spirit to enable them to carry on the struggle for life in the midst
+of the hurry and bustle of our modern civilisation. As the pressure of
+the time becomes severer, more of these unfit come into evidence. They
+arc examples of the lowered mental states, unable to stand the rivalry
+with fellowmen, and ready to give up the struggle whenever the example
+of others who have already given it up is brought prominently to their
+notice.
+
+It is not a little surprising how many of these tramps belonged
+originally to excellent, respectable families. Careful investigation
+of their personal history, however, will show that they have been, as
+a rule, backward children at school, always a little awkward in the
+way they took hold of things early in life, unsuccessful in the
+rivalries of school competitions, and in their first efforts at labour
+after school days were over. They always needed the encouragement of
+those whom they loved and respected, to keep them at their
+unsatisfactorily fulfilled tasks. They were the predestined failures
+{299} in life, and have found out their uselessness early in their
+careers. This is the view of tramp life that is coming to be realised
+as true by all those who have studied the question, not from the
+standpoint of theory, but of practical experience with it.
+
+_So-called Monomania_. The old term for paranoia employed for a long
+time was monomania, a word coined by Esquirol at the beginning of the
+nineteenth century. This word has dropped out of the terminology of
+mental diseases because there is no such thing as a patient suffering
+from a single symptom of mental disturbance, that is, being mentally
+perturbed on but one line of thought. There are always others, though
+they may be hidden except from the careful investigator. When Esquirol
+introduced the term he applied it to the most prominent symptom of the
+patient's mental alienation, but did not intend it to be taken as
+excluding other symptoms by which the essential nature of the
+patient's insanity could be diagnosed. Careful study will always
+disclose the fact that other symptoms are present. The word monomania
+has been an unfortunate one for scientific psychiatry, because it has
+been abused to shield criminals. The plea is often heard that a person
+under charge of crime is really subject to some mania that brought
+about the commission of the crime.
+
+We often hear of kleptomania as a defence for persons who have failed
+to recognise the distinction between _meum_ and _tuum_, and are haled
+before the court because of the detection of infringements of this
+distinction. True kleptomaniacs there are, but there are always other
+symptoms of their mental disturbance besides the tendency to steal.
+Their queerness in other ways has usually been recognised by their
+friends and by their family physician before the incident which calls
+attention to this special form of disequilibration occurs.
+Kleptomaniacs, too, are usually prone to take things of little value,
+or not especially suited to their wants and for which they have
+practically no use.
+
+It is true collectors, that is, those who have a hobby for gathering
+curiosities of one kind or another to make a collection, may become so
+interested in additions to their collection {300} as to be tempted to
+appropriate to themselves articles of which they can not otherwise
+obtain possession. Such actions may easily go beyond the bounds of
+reason. It must be remembered however, that the collection mania
+itself is often so pronounced as to be a little beyond the bounds of
+ordinary rationality.
+
+Other so-called monomaniacs have the same characteristic and are
+associated with related symptoms of mental disturbance. Pyromania is
+sometimes pleaded as a defense for arson. It is a legitimate defense,
+however, only when the careful tracing of the patient's history
+beforehand shows the existence of other symptoms of mental unbalance.
+The homicidal mania is of the same order. There have been cases where
+men seem to have delighted in inflicting injuries or death upon fellow
+creatures from pure malice. Such cases as that of Jack the Ripper, for
+instance, are undoubtedly due to a special tendency to take life. In
+these cases, however, associated symptoms are never lacking. It is not
+improbable that in Jack the Ripper's case a sexual element was
+present, because the victims were always of one low class, and that
+the general character of the murderer would have revealed his
+irresponsibility. There are several stories of children--whose mothers
+delighted in seeing their husbands, who were butchers, slaughter
+animals--who seem to have had a veritable mania for seeing blood flow
+and to have exercised it in the murder of human beings.
+
+Only the most careful examinations of the previous life of the
+patient, the investigation of childish tendencies and habits at
+school, and the incidents of boyhood and youth will sometimes enable
+the expert to recognise the constant existence of symptoms of mental
+disequilibration, the decided manifestation of which leads to serious
+events in after life. Monomania as a defense for crime has brought
+expert evidence into great disrepute. In this matter the greatest care
+is undoubtedly needed, however, for it is easy to do great wrong and
+punish the irresponsible victim of an impulse over which he has no
+proper control. On the other hand, it must not be forgotten that no
+such thing is known to exist as the perversion of the will on a single
+point. Moral insanity with regard to one special set of actions is a
+delusion that the {301} increase of knowledge with regard to mental
+diseases has erased from the text books on this subject.
+
+_Responsibility of Paranoiacs_.--From what has been said it is easy to
+understand how difficult is the determination of the responsibility of
+paranoiacs. Many classes of persons ordinarily considered to be quite
+responsible for their actions are yet so circumstanced that they are
+led into the performance of actions usually not considered rational,
+though not tempted thereto by any benefit directly accruing to
+themselves. On the contrary, it not infrequently happens that the mode
+of life adopted by the paranoiacs is of such a kind as would of
+itself, because of the hardships involved or the mental trials, deter
+ordinary people from following it. Paranoia, at least in its severer
+forms, completely justifies the plea of irresponsibility for actions
+committed. When it is remembered, however, that paranoiacs are often
+cunning enough to take advantage of their own supposed queerness
+voluntarily to commit crimes they might otherwise be deterred from by
+fear of punishment, some idea of the difficulty of the decision in
+these cases may be appreciated.
+
+It is important, of course, that the physician should, as far as
+possible, avoid falling into the error of judging such people too
+harshly, since after all on him depends the attitude of society
+towards them. It would seem to be quite as important that the
+clergyman should occupy an advanced position in this matter. It might
+seem that charity could easily be overdone; it must never be
+forgotten, however, that it is better that ninety-nine guilty should
+escape rather than that one innocent person should be punished.
+
+As a matter of fact, prejudice is much more likely to be against the
+supposed criminal than in his favour. While it is often declared that
+too many persons, who have done at least material wrong, are allowed
+to escape deserved punishment, as our knowledge of mental diseases
+increases there is more and more of a tendency on the part of experts
+to recognise that for many apparently voluntary actions men have only
+a modicum of responsibility. Responsibility is, after all, not the
+same in all men, but modified very much by the character of the
+individual, by his environment and by the {302} motives which have
+come to be the well-springs of his actions. No two men are equal in
+their responsibility when there is question of certain temptations to
+do wrong. Some men find it perfectly easy to resist allurements to
+dishonesty which others can not resist. Some men are perfectly free as
+regards their attitude towards indulgence in spirituous liquors.
+Others find it almost impossible to resist their cravings in this
+direction. One might go through the list of passionate actions and
+find this true with regard to every one of them. If this must be
+admitted with regard to men who are considered perfectly sane and
+responsible, how much more so does it become true of those who are
+already somewhat mentally unbalanced?
+
+Unfortunately, the tendency to judge harshly, rather than mercifully,
+still continues to be one main reason for the infliction of punishment
+where often it is not deserved. Above all the clergyman must be a
+leader in this tendency to mercy, and his influence should be felt in
+popular education in this regard. It only too often happens that
+clergymen are found to be strenuous upholders of the opinion that
+right is simply right and wrong, wrong, and that a man who knows the
+difference between right and wrong must be considered as responsible
+for his actions, no matter what modifying circumstances or mental
+conditions may enter into the problem of the decision as to his
+responsibility. If the clergyman would but realise how difficult in
+any individual case must be such a decision, and how much must be
+known with regard to the previous character of the individual, then a
+great beginning for the modification of the present over-severe modes
+of thought will have been made.
+
+From a theoretic standpoint, it would not be easy to state all that
+the physician considers necessary to enable him to make his decision
+as to individual responsibility. Perhaps, however, the consideration
+of a series of cases that have attracted widespread attention, and
+which have been most carefully investigated in all their
+circumstances, may present the methods of responsible determination
+better than any set of rules. Three presidents of the United States
+have been murdered within forty years. The murderers were native-born
+{303} Americans. In none of the three cases was there any adequate
+motive for the commission of the crime. The assassin in President
+Lincoln's case might, it is true, be presumed to have a sufficient
+political motive, but no entirely sane man could have thought for a
+moment that any good would be accomplished at that time for the South
+by the removal of Lincoln. A man of known erratic tendency, with the
+craving for theatrical effects deeply ingrained in his nature, with a
+personal history not entirely free from even more serious
+manifestations of mental disequilibration, and with a family history
+of more than suspicious character as regards the mental qualities of
+his ancestors, committed the crime. He met his death at the hands of
+pursuing soldiers. Such was the temper of the time, that had he been
+captured alive he would surely have suffered the formal legal death
+penalty. Even as it was, public sentiment clamoured for legal victims
+and unfortunately they were found.
+
+It seems clear, beyond all doubt, that in this case complete
+responsibility for his action was not present in the assassin himself.
+The courts decided later that there had been a conspiracy, but there
+has always been the feeling that justice was misled by over-zeal to
+find scapegoats for injured public sentiment. There is no doubt that
+it is an extremely difficult matter to say what shall be done to the
+assassin in such a case. The unfortunate result is as much an accident
+as the fatal consequences of any other perverted natural force. An
+earthquake may kill its thousands and the inevitable must simply be
+accepted. Society may protect itself from the further manifestations
+of such perverse individuals by confining the unfortunate murderer for
+life, but capital punishment, in the sense of a sanction for broken
+law, can scarcely be considered to have a place in the given
+conditions.
+
+With regard to the murderer of our second assassinated President we
+had the farce of a long-drawn-out public trial of a man who was
+evidently not in his right senses. Once more a victim had to be found
+to satisfy injured public feeling. Guiteau was condemned to death and
+suffered the death penalty. Any one who reads the proceedings of the
+trial and who realises the significance of the motive that Guiteau
+{304} himself gave for his act, will appreciate that the court had to
+do with an irresponsible doer of a material but not a moral wrong.
+There were many signs of mental disequilibration in Guiteau's previous
+career. It is on these eventually that the expert in mental diseases
+must depend in order to enable him to obtain a proper estimate of the
+extent of the mental disturbance in any given individual. It may seem
+that many real criminals can be defended on this same principle of
+finding an inadequate motive for their crimes. There are, however,
+certain signs of irrationality not difficult to detect if the previous
+life of the individual be carefully scrutinised and these must form
+the ultimate criterion as to criminal responsibility.
+
+With regard to the third murderer of a President the case is clear. He
+was an ignorant, somewhat conceited individual, but he presented none
+of the signs of true mental disequilibration that can ordinarily be
+depended on to indicate such a disturbance of the physical basis of
+mind as impairs responsibility. He was not entirely without a motive,
+which in the mind of a brooding, conceited individual, might seem to
+be adequate for the commission of the crime. His sentence of the death
+penalty was then in accord with the judgment of the best mental
+experts. How society shall protect itself, and especially its high
+officials, against such notoriety seekers is hard to say.
+
+The consideration of these cases gives a clear idea of how a physician
+endeavours to fill up gaps in his knowledge of the character of the
+man, his heredity and environment, as well as his previous actions at
+various times in life when under the stress of emotion. It may be
+considered that such a weighing of circumstances will serve to excuse
+many genuine criminals who eminently deserve to be punished. This is,
+however, the assumption of the older generation who considered that if
+a man did a material wrong he must be punished for it. It is a
+heritage of the day, when even accidental killing was considered to
+demand some punishment. At the present time the tendency is rather to
+consider only the moral wrong, that is, to calculate responsibility
+only for such actions as are committed with due {305} deliberation,
+intention, and the knowledge of right and wrong as well as the freedom
+to perform the action. The old English legal opinion which declared a
+man responsible if he knows that what he is doing is wrong has now
+given way in most judicial proceedings to the principle that the man
+must not only know that he is doing wrong, but that he must also
+realise that he is free not to do that which he knows to be wrong.
+That is to say, if he feels himself compelled to the commission of
+crime, there is surely an impairment of responsibility. Such impulses
+to do wrong without adequate motive occur not infrequently among those
+whose mental condition is not perfectly normal, and this must always
+be taken into consideration in the ultimate decision as to their
+responsibility for their action.
+
+JAMES J. WALSH.
+
+
+{306}
+
+
+XXVII
+
+SUICIDES
+
+It is a very difficult problem at times to explain just how a suicide
+is due to mental alienation in a person whose intellectual powers
+appeared previously unimpaired, yet in most of the cases a knowledge
+of all the circumstances and of the individual himself would lead
+inevitably to this more charitable view. Most suicides are persons
+that have been recognised as paranoiacs and likely to do queer things
+for a long time beforehand. Indeed, some of the melancholic qualities
+on which the unfortunate impulse to self-murder depends are likely to
+have exhibited themselves in former generations. Not long since it was
+argued that the regular occurrence of a certain number of suicides
+every year--varying in various places, always on the increase, but
+evidently showing a definite relationship to certain local conditions
+--demonstrate that the human will is not free, since from a set of
+statistics one can foretell about how many cases of suicide would take
+place in a given city during the next year. As a matter of fact,
+suicides are not in possession of free will as a rule, but are the
+victims of circumstances and are unable to resist external influences.
+
+The most important feature of suicide in recent years is the constant
+increase in the number, the increase affecting disproportionately
+young adults. This increase in the number of suicides is no illusion;
+it is not due to more careful statistics. It is true that in recent
+years, that is to say during the last quarter of a century
+particularly, the unsparing investigation by the authorities of all
+cases of suspicious death, and their report by sensational newspapers,
+has added somewhat to the apparent number of suicides. {307} Families
+were accustomed to announce accidental death and have their story
+unquestioned, in a certain number of cases, where now there is no hope
+of concealment because of the unfortunate publicity that has crept
+into life. This increase, however, would account for only a small
+additional number of suicides, while the actual figures have more than
+trebled in the last thirty years.
+
+This increase has come especially in the large cities. According to
+the report of the New York Board of Health, there were 1,308 suicides
+in New York City during the decade from 1870 to 1880. During the
+decade from 1890 to 1900 there were 3,944 suicides. This increase is
+much more than the corresponding increase in population. During the
+first decade mentioned there were 124 suicides per million of
+population. During the last decade this had risen to 196 suicides per
+million. The increase is nearly 60 per centum. The increase is
+variously distributed over the different ages. While every five years
+from twenty upwards shows a percentage of increase in the number of
+suicides committed, somewhat less than the percentage of increase for
+all ages, the five years between fifteen and twenty shows an increase
+of 106 per centum. In a word the deaths of adolescents from suicide
+have more than doubled in the last thirty years.
+
+Towards the end of the last decade of the nineteenth century there was
+for a time a cessation of the continuous increase. This occurred
+during the years 1898 and 1899. Apparently it was due to the fact that
+the occupation of the country with other interests, the war and its
+problems, and the fact that an era of prosperity made material
+conditions better, and thus gave less occasion for depression of
+spirits. During the years since 1900, however, the increase has not
+only reasserted itself, but has more than made up for the period
+during which suicides were less frequent. The increase during the last
+four years is more than was noted during the six years from 1891 to
+1897.
+
+The same increase has been noted in European cities. The higher the
+scale of civilisation in a city, or at least the greater the material
+progress and the more strenuous the life, {308} the higher the death
+rate. In Dresden, for instance, the rate is 51 suicides per 100,000
+every year. In Paris it is 42, in Berlin it is 36; while in Lisbon and
+Madrid it is lowest, being only respectively two and three per 100,000
+per year. While suicides are more common among men than women in all
+countries, this is not true for certain ages. Between the ages of
+fifteen and twenty-five the suicides of women are more numerous than
+those of men. The suicides of women are increasing faster than those
+of men. Fifty years ago the proportion was five to one. Twenty years
+ago it had fallen from three to one. Now it is less than two and a
+half to one. The saddest feature of the suicide situation is the
+increasing number of the children who commit suicide.
+
+Almost needless to say, children's suicides are without any serious
+motives and are usually due to an attack of pique because of a slight
+from a playmate, a reprimand at home, a rebuke from a teacher, envy of
+the success of a companion, disappointment over a passing love affair,
+sometimes a peculiar attachment in the case of weak and morbid
+individuals, the manifestations of which are resented by its object,
+or are forbidden by parents and guardians. These unfortunate accidents
+have become so common now that special care must be taken with regard
+to children of neurotic heredity. When in previous generations there
+have been the manifestations of lack of mental equilibrium, then
+children's mutterings with regard to possible recourse to suicide
+should be the signal for the exercise of close surveillance. As far as
+possible such children should be kept from the strenuous competition
+at school in modern life.
+
+As has been well pointed out there is no doubt that the power of
+suggestion and example has much to do with the increase of suicide.
+Dymond, an authority in the matter, says, "The power of the example of
+the suicide is much greater than has been thought. Every act of
+suicide tacitly conveys the sanction of one more judgment in its
+favour. Frequency of repetition diminishes the sensation of abhorrence
+and makes succeeding sufferers, even of less degree, resort to it with
+less reluctance."
+
+{309}
+
+Our modern newspapers, by supplying all the details of every suicide
+that occurs, especially if it presents any criminally interesting
+features or morbidly sentimental accessories, familiarise the mind,
+particularly of the impressionable young, with the idea of suicide.
+When troubles come lack of experience in life makes the youthful mind
+forecast a future of hopeless suffering. Love episodes are responsible
+for most of the suicides in the young, while sickness and physical
+ills are the causes in the old. In a certain number of cases, however,
+domestic quarrels, and especially the infliction of punishment on the
+young at an age when they are beginning to feel their independence and
+their right to be delivered from what they are prone to consider
+restriction, are apt to be followed in the morbidly unstable by
+thoughts of suicide.
+
+The important practical question is the prevention of the fulfilment
+of the morbid impulse during these impressionable years. Many a young
+person has been saved from suicide at this time to realise the
+enormity of the act and to live without any further temptation to its
+commission for a long lifetime. As a rule the motive for the act is so
+trivial and often so insensate that it is not difficult to make
+patients (because patients they truly are) see the folly of their
+irrational impulse.
+
+In order to forestall the putting into action of their impulse it is
+important that those who are close to the patient should have some
+realisation of the possibility of its occurrence. There are usually
+some signs beforehand of the possibility of the crime. Many of these
+early suicides have distinct tendencies to and stigmata of hebephrenic
+melancholia. The best known symptoms of this condition are those
+described by Dr. Peterson, the present president of State Commission
+of Lunacy of New York in his book on mental diseases. The symptoms
+noted are extraordinarily rapid and paradoxical changes of
+disposition. Depressed ideas intrude themselves in the midst of
+boisterous gaiety, and untimely jocularity in the deepest depression,
+or at solemn moments. Then there is the paradoxical facial expression,
+the so-called paramimia, that is, a look of joy and pleasure when
+really mental depression is present, or a look of depression when
+joyful sentiments {310} are being expressed. The existence of such
+rather noticeable peculiarities may lead to the suspicion of mental
+disequilibration in young people.
+
+The most important warning may well be the occurrence of suicide in
+any other member of the family for several generations before. The
+tendency of suicide to repeat itself in families is now well known and
+recognised. During the year 1901 in New York City, in one case other
+members of the immediate family had committed suicide in six
+instances. The subject has taken on additional interest because of the
+suicide of a well-known gambler who was the fourth of his family in
+two generations to take his own life. In another case, reported within
+the last five years, the suicide was the last of a family of nine
+children, every one of whom had committed suicide. There is the record
+in the German army of four generations of a noble family, the eldest
+son of which committed suicide during the 5 years from 50 to 55.
+
+In these cases the tendency to suicide is not directly inherited, but
+there is a mental weakness that makes the individual incapable of
+withstanding the sufferings life may entail. In the later members of
+the family there is also a suggestibility that the frequent
+contemplation of the idea of suicide finally leads to the putting off
+of the natural abhorrence at the thought of its commission. In such
+families, therefore, it is particularly important to warn medical
+attendants and members of the family of the possibilities of
+unfortunate acts so as to prevent if possible the execution of any
+impulse to self-murder.
+
+JAMES J. WALSH.
+
+
+{311}
+
+XXVIII
+
+VENEREAL DISEASES AND MARRIAGE
+
+
+Syphilis is a disease that is contagious, inoculable, and
+transmissible by heredity. It may be acquired innocently, and it is so
+acquired in about 4 per centum of cases according to good authority,
+but the other 96 per centum is venereal. The disease attacks any part
+of the body within and without from the soles of the feet to the hair
+and finger-nails. The first evidence, where the case is not
+hereditary, is a hardened sore called a chancre; next the lymphatic
+glands swell, and many forms of skin-eruption occur; then follows a
+chronic inflammation of the cellulo-vascular tissues and the bones,
+and small tumours, called gummata, may develop in almost any part of
+the body. The disease may vary from a light attack to malignancy.
+There are periods in the course of the disease.
+
+1. The period of primary incubation, or the time from infection to the
+appearance of the chancre. This is commonly three weeks.
+
+2. The primary stage: the chancre forms and the neighbouring glands
+are affected. This stage lasts from three to ten days.
+
+3. The secondary incubation, or the time between the appearance of the
+chancre and the development of what are called the secondary
+symptoms,--usually about six months.
+
+4. The secondary stage. Here occur fever, anaemia, neuralgic pains,
+and the eruptions on the skin and the mucous membranes. This period
+lasts from twelve to eighteen months in the majority of cases.
+
+5. The intermediate period. During this time there may be no symptom,
+or slighter recurrence of the secondary {312} symptoms. This period
+lasts from two to four years. It may end in recovery of health or be
+followed by tertiary symptoms.
+
+6. The tertiary stage. In this period gummata form, or there may be
+diffuse infiltration of various parts of the body, chronic
+inflammation and ulceration of the bones, skin and other tissues,
+nervous diseases, and so on. The tertiary stage commonly begins from
+three to four years after the primary infection.
+
+The three chief divisions, which are apt to blend one into the other,
+are the primary, secondary, and tertiary periods.
+
+The affections of the secondary stage are often severe. There may be
+fever associated with weakness, headache, general malaise and pain,
+and this may be marked or rather light. In this stage iritis is liable
+to occur, and if it is not properly diagnosed and treated it will
+result in blindness.
+
+The lesions of the tertiary stage may cause great destruction of
+tissues and very grave consequences. Cerebral syphilis, if unchecked,
+will inevitably cause paralysis or paresis. There may be loss of
+speech, epilepsy, coma, paralyses, apoplectic hemiplegia, and so on.
+The pain is harassing and often it amounts to great anguish. Whatever
+part of the brain substance is destroyed will not be restored.
+
+In syphilitic affections of the spinal cord, if the inflammation is
+acute death ensues in a few days or weeks. _Tabes dorsalis_, or
+locomotor ataxia, is caused in about 93 per centum of cases of this
+disease by syphilis, and it is an incurable and dreadful malady.
+
+If there is neuritis from the virus it becomes intense and causes
+muscular contractions, paresis, and paralysis. The optic, auditory,
+and olfactory nerves may be attacked and destroyed. The nose also may
+be destroyed and it commonly caves in. The bones of the face are
+frequently attacked in the tertiary stage and they rot away. The tibia
+is diseased more frequently than the other long bones.
+
+The heart is rarely injured, but when it is, the prognosis usually is
+bad. In a large number of cases death is sudden and unexpected. If the
+arteries are involved the prognosis again is bad, because the symptoms
+here do not show until {313} too late for effective treatment When the
+liver is the seat of gummata these may be cured in the early stage,
+but in the later stage the prognosis is unfavourable. Some forms of
+renal syphilis are remediable, but others are not, especially the
+interstitial kind.
+
+Syphilis is transmitted to a child congenitally, not as a tendency or
+predisposition, but as an active contagion. It may come from the
+father, the mother, from both parents, or by direct infection.
+
+The transmission from the father is the most frequent. The spermatozoa
+carry the infection to the maternal ovum. Down to the end of the
+secondary stage, and half through the intermediate period between the
+secondary and tertiary stages of syphilis, a father or mother may
+beget a child that will be infected with hereditary syphilis, a
+shivering, blasted, rotten little wretch for whom a quick death is the
+greatest imaginable blessing, and it usually gets this blessing. In
+the acute stage of a virulent syphilis the disease is most likely to
+be transmitted; but sometimes, though rarely, a father that has been
+free from all symptoms of syphilis for many years may beget a child
+that is born with a virulent hereditary form of the disease.
+
+Infection by the mother is more certain and more harmful than that
+from the father, because the intrauterine life of the child is
+poisoned throughout its course. Two-thirds of the cases of hereditary
+syphilis die either by abortion, or if they live to term they die
+shortly after delivery. If the mother is infected during the first
+eight months of pregnancy the child will nearly always be syphilitic,
+but if she is infected after the eighth month the child may escape.
+
+If at the moment of conception both parents have the disease the child
+will almost certainly take it, and this infection will cause its
+death. In a series observed by Fournier, 28 per centum of the cases
+caused by paternal infections died and 37 per centum showed the luetic
+taint; in the cases caused by maternal infection 60 per centum died,
+and 84 per centum had syphilitic lesions; in the mixed heredity, that
+is when both the father and mother were luetic, 68.5 per centum died
+and 92 per centum were born syphilitic. When a child {314} is first
+infected at delivery the case is not technically classed as hereditary
+syphilis.
+
+During the first year after the father or mother has taken syphilis
+the probability of infecting the child is the greatest. In the third
+year the liability of infecting the child is lessened, but present. In
+a series of 562 cases of hereditary syphilis observed by Fournier, 60
+children, over 10 per centum, were infected more than six years after
+the primary parental infection. Carefully observed cases have been
+exceptionally found where infection of the child has occurred in the
+fifteenth and even the twentieth year after the original parental
+lesion. Fournier reports the case of one woman that had nineteen
+consecutive stillbirths from syphilis.
+
+Mild parental syphilis may transmit hereditarily the most malignant
+type of the disease, and very virulent parental infection may result
+in a comparatively mild infection of the child, if any infection by
+syphilis may be called mild. That the parent shows no symptoms from an
+old infection is no proof that he or she is cured, or that the child
+may not be infected.
+
+With proper treatment of the mother the infantile mortality in
+hereditary syphilis is reduced from 59 per centum to 3 per centum, and
+the children that are born living are not unfrequently free from
+syphilis. When a woman is infected at the conception of her child
+miscarriage takes place before the child is viable, from the first to
+the sixth month; later other miscarriages occur; later still, living
+but syphilitic children are born, of whom one-fourth die within the
+first six months; finally she may have children that are not infected.
+
+If a syphilitic man has been properly treated he may, after four
+years, beget healthy children, and he commonly does, but he may be the
+father of syphilitic children. Syphilitic women properly treated may,
+after about six years from infection, bring forth healthy children,
+and they commonly do, but not always.
+
+There is a wide diversity of opinion among the best authorities
+concerning the curability of syphilis. Gowers (_Syphilis and the
+Nervous System_. 1892) says: "There is no evidence that the disease
+ever is or ever has been cured, the {315} word 'disease' being here
+used to designate that which causes the various manifestations of the
+malady." He means there is no absolute proof that a person who has
+once been infected is ever so fully cured that he may marry without
+danger of transmitting the disease.
+
+Fournier requires, as the minimum time, four years of methodical
+treatment before he deems the patient safe, but even this arbitrary
+fixing of the number of years is not warranted by experience. Many
+physicians hold that in the tertiary stage the disease is not
+transmissible, but that statement is not true. Commonly it is,
+sometimes it is not. After all symptoms have disappeared the disease
+has been transmitted.
+
+In short, a person that wittingly marries any one who has had syphilis
+at any time is a fool; and if one of the contracting parties has had
+syphilis within the four years preceding the marriage the marriage is
+criminal, even if the syphilis has been carefully and skilfully
+treated by a physician.
+
+Gonorrhoea is always a dangerous disease. In the male, beside the
+acute lesions, it can cause chronic or fatal inflammations along the
+various parts of the genito-urinary tract or in different organs of
+the body. When the disease becomes chronic it lasts indefinitely. It
+may then cause cystitis, or so affect the kidneys as to bring about
+very grave results; it may get into the circulation and induce
+gonorrhoeal rheumatism of the joints, especially of the knee joint,
+and result in a partly or completely stiffened joint. The heart may be
+affected and endocarditis ensue; there may be meningitis or
+inflammation of the cerebral membranes; the eye may be infected, and
+unless it is skilfully treated blindness will follow. Strictures of
+the male urethra from chronic gonorrhoeal inflammation often require
+major surgical operations for relief.
+
+The disease in women has most of these complications, and other grave
+peculiar phases. All prostitutes have acute or chronic gonorrhoea, and
+12 per centum, probably more, of reputable women are infected; and the
+suffering caused is very great. The gonococcus remains virulent for
+two or three years at the least in a man's chronic gleet, and if he
+marries he infects his wife. Should her womb be infected {316} she is
+seldom completely cured. If the Fallopian tubes are involved, and this
+happens frequently, they suppurate, and often they must be removed by
+coeliotomy. The woman suffers for a long time when the tubes are
+attacked by the disease, and she becomes sterile ordinarily.
+
+When a child is born to a woman that has gonorrhoea its eyes are
+infected at delivery, and if it is not very skilfully treated it will
+surely lose its sight. Because of this danger, in maternity hospitals
+the eyes of all babies are treated at delivery as a precaution, and
+many physicians observe the same precaution in private practice.
+
+When, therefore, a man has chronic gonorrhoea he should not marry
+until about four years after the last infection, and he should be
+carefully treated in the meantime. There is a popular opinion that
+gonorrhoea is a trifling disease, but the contrary is the truth: it is
+a grave disease, especially in women; and the person that carelessly
+infects another is certainly guilty of crime for which a long term in
+jail would be a light punishment.
+
+AUSTIN OMALLEY.
+
+
+{317}
+
+XXIX
+
+SOCIAL DISEASES
+
+
+There are certain affections not at all uncommon and as a rule
+producing rather serious effects upon the social body, of which,
+though their existence is well known to all, very little is said. It
+is certain that what is considered the more severe of these venereal
+diseases may be acquired quite innocently. Indeed, many thousands of
+cases of this affection, acquired innocently, have now been reported
+by medical men in this country alone. If the statistics of all the
+world were gathered together, there would probably be a hundred
+thousand cases of this dreadful affection, which have been acquired
+without any blame on the part of the sufferer. It has become the
+custom, especially in English speaking countries, to ignore the
+presence of these diseases, and this has led to a multiplication of
+opportunities for their spread to such a degree that now the condition
+of affairs, for those who know it best, is rather alarming. It is with
+the intention that a few definite ideas, given absolutely without
+exaggeration and without any striving after effect, may enlist
+clergymen, as well as physicians, in a crusade against these diseases,
+that the present chapter is written.
+
+It has been said over and over again at medical society meetings that
+it is a very unfortunate thing that universities in these modern times
+are situated in large cities. The young man just freed from the
+restraints of home life, or of the seclusion of a college, is at once
+without any preliminary training, exposed to all the dangers, moral
+and physical, of large city life. Not only is this true, but he is
+even not properly warned of the dangers that lie so close to his path.
+Our prudery has gone so far that the very names of these {318}
+affections are tabooed and above all must not be mentioned before the
+young. As to the awful evils that such diseases may cause, as to the
+lifelong suffering, even to mental degeneration and early death, that
+they may involve, not even a hint is considered to be proper. The
+consequence is that young men expose themselves not infrequently to
+danger, absolutely unknowing the significance that such diseases have
+in recent years acquired in the minds of modern physicians, and it is
+usually not until a serious mistake has been made that the young man
+is brought in contact with the physician who may be frank in pointing
+out evils utterly unknown before.
+
+This state of affairs has come to be considered as so irrational in
+many foreign universities that now a special course of lectures is
+given every year on the significance of what may be called the social
+diseases. The students are told very frankly what the possibilities of
+danger for them in certain excesses may be, so that at least the young
+man can not say "I knew nothing about it," when the risk becomes an
+actual reality of danger. At the University of Berlin the first course
+of such lectures was established, and the interest aroused and the
+results obtained were such as to make other universities consider the
+advisability of such lectures for their students. Even here in prim
+and prude America, one or two of the great universities have come to
+the realisation that the physical well being of their students is
+committed to their care, as well as their intellectual development,
+and at least a beginning of that precious wisdom that comes from the
+fear of the physical evils of sin has been acquired because of
+opportunities provided by the faculty.
+
+It is well admitted now by all that ignorance is not innocence and
+that knowledge of the consequences of social diseases is likely to be
+a very important factor in preventing young men from taking risks that
+would otherwise be considered very slight, perhaps. As a matter of
+fact, nothing can be more helpful from the ethical standpoint than
+this knowledge of how closely may follow the wages of sin, which is
+death. It is for this reason that clergymen would seem to owe it, as a
+duty to themselves and their position in social {319} life, to acquire
+a certain knowledge of these affections. A very great change has come
+over the attitude of the medical profession towards the so-called
+venereal diseases in recent years. A quarter of a century ago they
+were considered to be not very serious after all, and indeed in some
+cases to be no more serious than a cold, a mere passing incident in
+life. Now it is well recognised that almost never do they leave their
+victim in the state of health in which he was before, and that
+unfortunately the deterioration of tissues which has taken place is
+likely to be enduring. Even many years afterwards there may be serious
+complications involving health or even life.
+
+For instance, it is now very generally conceded that paresis, or what
+is sometimes called general paralysis of the insane,--a progressive
+mental and nervous disease, which invariably ends fatally in from
+three to seven years,--is always due to one of the so-called social or
+venereal diseases. How important this affection has become in modern
+life can be best appreciated from the fact that in Europe nearly one
+in four of those who die in the insane asylums are sufferers from
+paresis. In this country the disease is not so frequent, the
+proportion being less than one in five or even one in six. The disease
+is becoming more and more common, however, as large city life becomes
+more prominent, and as the possibility of infection with social
+diseases is more widespread.
+
+Paresis is what is sometimes called softening of the brain, and it
+attacks by preference men under thirty-five. The first symptoms of it
+as a rule are not alarming. A young man's disposition changes, so that
+an individual heretofore rather stingy becomes extravagant, while
+occasionally a prodigal becomes very saving and considers that he has
+already a large sum of money to his credit. The most prominent feature
+of the early stage of the disease is the occurrence of delusions of
+grandeur, that is to say, the patients get the idea that they are
+important personages, or that they have fallen heirs to a large sum of
+money, or that they have been appointed to high salaried positions. As
+a consequence of these delusions, they may make expensive presents to
+their friends. Occasionally there are other changes in disposition. A
+young {320} man, for instance, who has been of genial character
+becomes morose and hard to live with. The opposite change to greater
+liveliness of disposition is not unknown, but is more infrequent.
+Sometimes there are marked excesses, high living, luxurious habits,
+and the like, before the existence of disease is recognised.
+
+The mental stigmata of the disease at the beginning are not alarming
+at all. There are slight lapses of memory. A man who has hitherto been
+known as an accurate mathematician, makes frequent mistakes in adding
+or multiplying. The physical signs are even slighter. In using long
+words, syllables are omitted from them. A favourite method of testing
+the speech of a person suspected of beginning paresis is to ask for
+the pronunciation of a word like Constantinople. Usually a syllable
+will be elided, and the reply will be "Constanople," or something
+similar. There is a slight tremulousness of the hands and usually a
+rather easily marked tremor of the lips, especially when the tongue is
+protruded. Often in the very earliest stage of the disease, there are
+changes in the pupils. They may be unequal, or may fail entirely to
+react to light.
+
+When these signs are positive, that is, when there is a change in
+disposition and then the physical stigmata that we have gone over
+appear, the diagnosis of the disease is almost certain. The physician
+is able to say, with considerable assurance, that the young, strong,
+healthy-looking patient, who has often had to be tempted to come to
+see the doctor by some specious reason, because he does not consider
+himself that he has anything wrong with him, will have to be confined
+in an asylum within a year, or at most, two, and will die in a state
+of dementia within five years. This, of course, is an awful picture.
+This is the course of the disease in nearly 20 per centum of the
+inmates of our asylums. Almost without exception there is a history of
+syphilis in these cases, and the medical world is now persuaded that
+this is the most important factor in the production of paresis.
+
+Another nervous disease, corresponding in some of its features to
+paresis and indeed sometimes spoken of as a spinal form of paresis, is
+locomotor ataxia. This affection {321} begins usually with loss of
+sensation in the soles of the feet so that the patient thinks that he
+is walking on carpet all the time. Before this there may have been
+some disturbance of vision. The pupils may fail to react to light.
+Occasionally the first symptoms are motor, that is, the man notices
+that he is not able to walk as readily as before. He staggers easily.
+If he tries to turn round while walking he is apt to lose his balance.
+If he tries to walk in the dark, he is almost sure to have so great a
+sense of insecurity that he dare not go far from the wall.
+Occasionally the first sign is a sinking of the limbs on the way down
+stairs. In certain very sad cases, the first and only symptom is a
+failure of sight which goes on progressively, until the optic nerve is
+completely destroyed and sight forever rendered impossible.
+
+All these symptoms are traceable directly to certain changes which
+have been noted in the spinal cord. These changes are due to
+disturbance of the blood and lymph supply of the nervous tissue. Once
+the changes have taken place, there is no hope of the patient ever
+recovering the normal use of his limbs. Not infrequently he becomes
+bedridden and can not walk at all because he is not able to steady
+himself. He may not suffer in his general health, however, to any
+serious extent, and may live on for twenty years, though usually his
+resistive vitality is lowered and he is carried off by some
+intercurrent disease.
+
+At times locomotor ataxia begins with very severe pain seizures, known
+as crises. These may occur in the legs or arms or in the stomach or
+sometimes in other organs. Occasionally they are the first symptoms of
+the disease that are noticed, and they may continue for months or even
+years before other symptoms manifest themselves. This sometimes makes
+it difficult to recognise the disease for what it really is. The pains
+are usually most excruciating, are tearing or boring in character, and
+are sometimes described by the patient as being similar to the
+sensation that would be felt if a red hot iron were forced into them,
+or if a knife were inserted and then twisted round. Hence the
+descriptive name which has been applied to them of "lightning pains"
+which describes the suddenness of their onset and the intensity of
+their character. {322} Most of the ordinary anodyne or pain-killing
+medicines fall to influence them, and the patient is one of the most
+pitiable of objects while they last.
+
+It is now conceded on all sides that at least 75 per centum of the
+cases of tabes are directly due to syphilis. Indeed this affection and
+paresis are sometimes spoken of as parasyphilitic affections.
+Unfortunately the ordinary treatment for syphilitic manifestations
+does not affect them in the least. So far as we know at the present
+time, there is nothing that will hinder the course or prevent the
+progress or alleviate the symptoms or have any curative action on
+either of these dreadful diseases. They are much more common in Europe
+than they are in this country, but have been seen here with quite
+sufficient frequency in recent years to make physicians, at least,
+realise the necessity for having young men appreciate the dangers they
+invite in thoughtlessly yielding to the temptations of great city
+life.
+
+There are other affections which can be traced directly to the social
+diseases. One of the most important of these consists of certain brain
+tumours which may even cause death if not properly treated. These
+syphilitic brain tumours frequently cause paralysis and may lead to
+permanent changes in the nervous system with consequent loss of motor
+power. Whenever the symptoms of brain tumour occur, careful inquiry is
+made as to the previous existence of syphilis in the case, in order to
+determine, if possible, if this is the morbid agent at work. If there
+is a history of syphilis it is usually said to be fortunate, for brain
+tumours due to syphilis may be made to disappear by the proper use of
+mercury and the iodides. If the treatment of the case is delayed,
+however, alterations in the nerve substance take place which can not
+be improved.
+
+This disease affects especially the blood vessels and, as a
+consequence of the thickening of the coats of the arteries, blood may
+be shut off from certain portions of the brain entirely. This will, of
+course, produce symptoms of paralysis. Indeed, whenever paralytic
+symptoms manifest themselves under forty years of age, the physician's
+first thought is sure to be that there is syphilis in the case. This
+is not always {323} true, for by heredity and very hard work
+occasionally arteries become so degenerate that they rupture before a
+patient has reached many years beyond forty, but the case is always
+suspicious. In this, as in the corresponding instance of brain tumour,
+treatment, if applied sufficiently early, may not only give relief of
+all the symptoms, but produce a complete cure. That is, at least the
+symptoms are relieved for the time, though there may be relapses.
+Usually these relapses are quite amenable to treatment, but sometimes
+they get beyond the control of the physician and death ensues. It is
+almost the rule where there have been serious nervous symptoms once,
+that recurrences of them must be feared, and they will eventually
+shorten the patient's life.
+
+Syphilitic manifestations of serious character develop, however, not
+only in the nervous system, but also in certain of the important
+internal organs. The liver may become so much affected as to refuse to
+do its work. Solid tumours may develop in the stomach, or along the
+course of the intestines, resembling cancer so much that occasionally
+operations are performed for their removal. As a rule, however, these
+yield quite promptly to proper antisyphilitic treatment. Whenever an
+obscure intraabdominal tumour is present, accordingly, it has become
+the custom among physicians and surgeons not to make an absolute
+diagnosis nor to perform any serious operation until antisyphilitic
+treatment has been tried. The surprises of such treatment constitute a
+very interesting chapter in obscure diseases in medicine.
+
+As we said at the beginning, it is perfectly possible to have
+contracted the disease innocently, and indeed, the first
+manifestations may be so mild as to fail to attract the patient's
+attention. In these cases there will be no history of syphilis, yet
+the test of antisyphilitic treatment will demonstrate that the disease
+has been present. Not a few physicians have died from these serious
+manifestations of syphilis after having contracted the disease through
+a cut on the finger or the prick of an infected needle in the ordinary
+course of their professional work. Some of these cases in young men
+prove to be especially malignant and fail to react to treatment, so
+that a fatal issue takes place within a few years.
+
+{324}
+
+On the other hand, in general it may be said that the disease is
+eminently curable, though it may require great care on the part of the
+patient and the avoidance of all excesses either of work or indulgence
+for the rest of life. It has often been noted that people who live in
+the midst of serious emotional strain are most likely to suffer from
+manifestations of syphilis in their nervous system. Hence it is that
+paresis and locomotor ataxia are comparatively quite common among
+actors, brokers, and financiers. They are also quite common among sea
+captains and military men who are exposed to severe hardships and have
+to assume weighty responsibilities. In such men the previous attack of
+syphilis has so weakened the nervous system that it degenerates under
+the strain placed upon it by the subsequent responsibilities. These
+diseases are very uncommon among clergymen and are less common in
+Ireland than in any other country in the world, which would serve to
+confirm the opinion that the venereal disease is a prominent factor in
+their causation.
+
+We would not have the idea be assumed that syphilis is an incurable
+disease and is bound to be followed in all cases by the awful
+manifestations that we have described. There are many thousands of
+cases of syphilis that never have any of these serious manifestations
+at all. It is evident that some cases are completely cured and that no
+deleterious influence remains. On the other hand, it must not be
+forgotten that the presence of this disease in the tissues of either
+parent during the first five years of its course are almost sure to
+affect offspring born at this time. The children may suffer from the
+skin lesions of syphilis in their early life, may suffer from serious
+eye diseases a little later, and then eventually succumb to nervous
+and mental diseases resembling paresis and locomotor ataxia in early
+adult life. In fact it is this transmission of the disease that
+constitutes one of its saddest pictures, and the sins of the parents
+are indeed visited on the children.
+
+Besides this severer type of social disease, there is what has been
+called sometimes a milder form. It consists only of a discharge with
+some fever, which is considered to last not more than a few weeks. As
+a matter of fact, however, the disease may continue to exist, though
+the symptoms become latent {325} and the patient may infect others
+when he least suspects it. This form of disease gives rise to many sad
+complications in family life. Practically all the severe eye diseases
+of newly born children, the ophthalmia from which so many eyes are
+lost, is due to this disease. Special medical care is now taken of
+these cases, and the serious consequences are not so often seen as
+used to be the case. Within a score of years, however, about one-half
+of the inmates of blind asylums owed their loss of sight to this
+disease. At the present time there still remains a very notable
+proportion of persons blind from early childhood whose infirmity must
+be attributed to the sad consequences of the social disease.
+
+Most of the sterility in families is due to the same cause. There is
+an unfortunate impression that usually the woman is responsible in
+these cases, and not a little sympathy is wasted on the man, because
+of the absence of children in the family. Almost invariably, however,
+the real cause of the family misfortune is to be traced to an
+infectious disease in the man contracted perhaps many years before, of
+whose presence he may be more or less unconscious, the symptoms have
+become so slight, but this has proved sufficient to infect the wife
+and bring about serious changes that preclude all possibility of the
+procreation of children.
+
+These statements may seem exaggerated. On the contrary, they are
+rather understatements of actualities. No one who knows the real state
+of the case will fail to realise this. Physicians themselves have only
+come properly to appreciate the true state of affairs in the last
+twenty years. We need a coordination of all the forces that make for
+social amelioration in modern life to correct present false
+impressions.
+
+JAMES J. WALSH.
+
+
+{326}
+
+XXX
+
+DE IMPEDIMENTO MATRIMONII DIRIMENTE IMPOTENTIA
+
+Hoc argumentum praecipue ad juris consultos ecclesiasticos et civiles
+pertinet; et quamvis differentia sit inter jurisdictionem judicis
+civilis et ecclesiastici tamen judicium utriusque quatenus necessario
+pendet ab existentia conditionum physicalium in medici consilio situm
+est. Obscuritas doctrinae et quidem gravis de hoc impedimento, libris
+moralistarum, medicorum et juris consultorum perlectis, invenitur; et
+quamvis, elapsis perpaucis annis, fere omnis liber tractans de
+scientia medicinali parva fide dignus, tamen multa ex editis
+physiologorum veterum tanquam vera a moralistis praesertim
+promulgantur. Hae difficultates per ignorantiam anatomiae et
+physiologiae genitalium non minuuntur. Ut auxilium, si quid sit, ad
+difficultates solvendas feram, species et gradus Impotentiae hie
+collegi tanquam medicus, eo modo ut conditio physica clarius
+cognoscatur.
+
+In unoquoque Statuum Foederatorum Americae Septentrionalis impotentia
+ratio sufficiens divortium obtenendi est, in plurimis autem
+matrimonium irritum ab initio non reddit. Impotentia vel temporanea
+causa divortii esse potest si impotens intra spatium temporis
+rationabile remedium medicinale recuset. Sub lege civili Americana
+contrahens qui tempore matrimonii ineundi certior erat de impotentia
+consortis jus divortii petendi propter abnormalitatem istam amittit.
+Procrastinatio longa et inexplicabilis divortii petendi, et etiam
+inscitia culpabilis impotentiae consortis divortium impossibile coram
+judice civili reddunt.
+
+Conditio haec etiam impedimentum dirimens matrimonii sub lege canonica
+Ecclesiae est. Si impotentia contractum matrimonii anteat et perpetua
+sit, matrimonii contractus {327} solvitur ipso facto, quandocumque
+detegitur. Procrastinatio aut ignorantia culpabilis non excusant.
+
+Jurgia oriuntur ex eo quod impotentia cum sterilitate saepius
+confunditur. Juris consulti civiles infrequenter hoc modo offendunt,
+medici autem et moralistae crebro in errore isto versantur. Juris
+consulti Americani et medici de impotentia doctrinam accipiunt
+librorum praesertim _On Domestic Relations_, auctore Irving Browne
+(Boston. 1890), _A System of Legal Medicine_, auctore Allen MacLean
+Hamilton (Neo-Eboraci, 1897), et _A Manual of Medical Jurisprudence_,
+auctore A. S. Taylor (Neo-Eboraci, 1897). Irving Browne (op. cit.)
+ait: "Ubi Impotentia adsit nullum habetur matrimonium validum.
+Impotentia autem incapacitatem prae se fert physiciam, non meram
+frigitatem, declinationem seu repugnantiam, neque etiam recusationem
+absolutam coitus sexualis. Neque sterilitas nec malformatio quae
+copulam non impediant, neque infirmatio quaecumque sanabilis
+incapacitatem gignunt. Impotentiam tempore ineundi matrimonii
+exstitisse necesse est." Eadem est doctrina Schouleri et Baldwinii.
+
+White et Martin, medici, (_Genito-Urinary and Venereal Diseases_.
+Philadelphiae. 1897.) impotentiam ita definiunt: "Inabilitas actus
+sexualis perficiendi. Non necessario cum sterilitate consociatur,
+neque necesse est quod sterilis impotens sit." Et ita alii omnes.
+
+Significatio vocis Impotentiae sub lege canonica deducitur, (1), ex
+dijudicationibus Pontificum Romanorum, aut (2), ex judiciis
+Congregationis Sancti Officii, tribunalis ad sententias hujus generis
+pronuntiandas instituti, aut, (3), ex legis interpretatione a
+moralistis scientia praeditis.
+
+Sixtus V, Pontifex Romanus, (Const. _Cum frequenter_, anno 1587)
+decrevit eunuchos impotentes esse sensu legis canonicae de Impotentia,
+nullum autem judicium papale totam questionem conficit. Congregatio
+etiam Sancti Officii in perpaucis casibus particularibus dijudicavit
+sed legem nullomodo distincte definiebat. Norma igitur a nobis
+sequenda ex interpretatione moralistarum est depromenda.
+
+{328}
+
+Lex non est decretum mere disciplinare: e natura ipsa contractus
+matrimonialis desumitur. Ballerini (_Theol. Mor._, vol. 6, p. 658)
+scribit matrimonium consistere "in mutua traditione potestatis ad
+copulam conjugalem." S. Thomas (_Supplem. Sum, Theol._, q. 58, a. 3)
+ait: "In matrimonio est contractus quidam, quo unus alteri obligatur
+ad debitum carnale solvendum: unde sicut in aliis contractibus non est
+conveniens obligatio si aliquis se obliget ad hoc quod non potest dare
+vel facere, ita non est conveniens matrimonii contractus, si fiat ab
+aliquo qui debitum carnale solvere non possit; et hoc impedimentum
+vocatur _impotentia coeundi._"
+
+Antequam explicationem a moralistis pleniorem vocum "Impotentia
+coeundi" dabamus, attendendum accurate est ad definitionem matrimonii
+finum a S. Alphonso Liguorio (_Theol. Mor._, lib. vi., n. 882) datam.
+"_Fines_," inquit, "intrinseci essentiales [sc. matrimonii] sunt duo:
+traditio mutua cum obligatione reddendi debitum, et vinculum
+indissolubile. _Fines intrinseci accidentales_ pariter sunt duo:
+procreatio prolis et remedium concupiscentiae. _Fines_ autem
+_accidentales extrinseci_ plurimi esse possunt, ut pax concilianda,
+voluptas captanda, etc. His positis, certum est quod si quis
+excluderet duos fines intrinsecos accidentales, non solum valide, sed
+etiam licite posset quandoque contrahere; prout si esset senex et
+nuberet sine spe procreandi prolem, nec intenderet remedium
+concupiscentiae; sufficit enim ut salventur fines substantiales, ut
+supra."
+
+Haec sententia S. Alphonsi magni momenti est, et in ea solutio
+multarum difficultatum inveniri potest. Dicit hic (1) fines
+intrinsecos essentiales matrimonii esse traditionem mutuam cum
+obligatione reddendi debitum, et vinculum indissolubile, atque illis
+demptis nullum matrimonium; (2) procreationem autem prolis et remedium
+concupiscentiae abesse posse, et tamen matrimonium esse validum si duo
+fines essentiales adsint.
+
+Sanctus hoc loco infert, ut patet e contextu alibi (_e. g._, lib. vi.,
+n. 1095, res. 2), traditionem mutuam potestatis ad copulam carnalem
+necessario potentiam coeundi supponere, potentiam autem generandi non
+esse necessariam nec remedium concupiscentiae. In libro vi., n. 1096,
+ait: "Impotentia est illa propter quam conjuges non possunt copulam
+habere per se aptam ad generationem; unde sicut validum est
+matrimonium {329} inter eos qui possunt copulari, esto per accidens
+nequeunt generare, puta quia steriles aut senes, vel quia femina semen
+non retinet, ita nullum est matrimonium inter eos qui nequeunt
+consummare eo actu, quo ex se esset possibilis generatio."
+
+Distinctio haec inter potentiam coeundi et potentiam generandi a
+moralistis omnibus datur; illa autem data, plurimi distinctionem
+obliviscuntur et sterilitatem simplicem cum impotentia confundunt.
+
+A. Konings, C.SS.R., (_Theol. Mor._, ed. 7, vol. 2, p. 276) haec
+habet: Impotentia est "incapacitas ad copulam carnalem, per se aptam
+ad generationem." In n. 1619, Sec. 5, ait: "Non est confundenda
+impotentia coeundi cum impotentia generandi. Hinc steriles et senes
+qui matrimonium consummare valent, valide contrahunt, item mulieres
+quae possunt semen excipere, etsi illud non retineant." Hanc doctrinam
+S. Alphonso refert (_Theol. Mor._, lib. 4, n. 1095, ed. Mech. 1845),
+et paragraphum hoc modo complet: "Non tamen carentes utero vel
+vagina." Hoc est, tenet mulierem utero et vagina carentem impotentem
+esse. Unusquisque carentiam vaginae impotentiam esse admittit; mulier
+autem sine utero semen excipiendi capax est, concupiscentiam quoque
+maris satiare potest. Sterilis tantum est. Potentiam etiam habet
+coeundi, semen excipere potest et retinere, concupiscentiam quoque
+satiare potest, etiamsi uterus, ovaria et tubi Fallopiani absint.
+Praeterea, _illi duo fines intrinseci essentiales matrimonii
+existunt_.
+
+Augustinus Lehmkuhl, S.J., (_Theol. Mor._), alius illustris discipulus
+S. Alphonsi est Impotentiam definit: "Defectus propter quern conjuges
+non possunt copulam habere per se aptam ad generationem." Alibi
+(_American Ecclesiastical Review_, vol. 28, n. 3), de impotentia
+excisioneque ovariorum scribens, ait: "Puto, questionem propositam,
+utrum excisio ovariorum vel uteri constituat impedimentum dirimens
+necne, _theoretice_ nondum esse plane solutam." Existimat autem
+questionem _practice_ solutam esse judiciis Congregationis S. Officii,
+d. 3 Februarii, 1887, et d. 30 Julii, 1890, editis, matrimonium
+mulieris ovariis carentis et mulieris utero et ovariis carentis,
+permittentibus. Etiamsi haec judicia non edarentur tanquam leges
+formaliter generales, Lehmkuhl opinatur in {330} casibus ejusdem
+generis aptari posse. Re quidem vera illa doctrina sequi potest
+practice et theoretice; nulla enim est quaestio seria de impotentia in
+muliere carente ovariis.
+
+Joseph Antonelli tamen (_De Conceptu Impotentiae et Sterilitatis
+relate ad Matrimonium_, Romae, 1900) tenet carentiam ovariorum esse
+impotentiam sub lege; et Casacca (_Amer. Eccl. Rev._, vol. xxvii, n.
+6, et alibi) eamdem opinionem sequitur. E contra, Marc (_Inst. Mor.
+Alphon._) docet carentiam ovariorum uterique non esse impotentiam.
+
+Joseph Hild (_Amer. Ecc. Rev._ vol. xxviii., n. 6) optime vindicat
+opinionem, nempe, carentiam ovariorum non esse impotentiam, et in
+corpore tractatus citat definitiones impotentiae a moralistis egregiis
+prolatas.
+
+Schmalzgrueber (_Theol. Mor._, lib. iv., tit 15, n. 31) dicit: "Sola
+impotentia ad copulam dirimit matrimonium, non vero impotentia ad
+generationem."
+
+Coninck (_De Sacr._, vol. ii., d. 31, dub. 7, n. 86) ita habet:
+"Steriles ... si aliter potentes sint ad usum matrimonii, valide
+contrahunt; quia nec generatio nec potestas generandi est de essentia
+matrimonii."
+
+Mastrius (_Dis. de Matr._, q. v., n. 114) ait: "Impotentia est
+inhabilitas perpetua ad consummandum matrimonium . . . non est ex eo
+praecise quod alteruter conjugum aut uterque sint steriles, quia
+impotentia ad generandum seu ad prolificandum, dummodo adsit potentia
+ad copulam carnalem et seminationem, non est impedimentum dirimens, ut
+omnes passim concedunt cum Scoto . . . et ubi est certa impossibilitas
+ad bonum prolis, tunc matrimonium est ibi in remedium, non in
+officium."
+
+Vincentius de Justis (_De Dispens. Matr._ lib. ii, c. 17, nn. 1, 2, 3)
+scribit: "Impotentia ad matrimonium est duplex. Prima, quae
+_sterilitas_ dicitur, efficit ut proles generari non possit, ex se
+tamen matrimonium nec impedit nec dirimit, ut docent Sanchez, Guttier,
+Coninck. . . . Ratio est, quia nec generatio, nec generandi potestas
+sunt de essentia matrimonii."
+
+S. Thomas (_Supplem_, q. 58, a. 1) in articulo de Impotentia, quam
+_Frigiditatem_ et _Impotentiam Coeundi_ nuncupat, nihil de sterilitate
+scribit, nec de impotentia generandi tanquam quid impotentiae coeundi
+oppositum.
+
+{331}
+
+In omnibus hisce definitionibus verba _de se, ex se, per se,_ et alia
+similia, adhibentur de copula carnali _qua copula_. Amort (_De Matr_,
+q. 101) de his verbis loquens ait: "Impotentia est inhabilitas
+corporalis ad copulam carnalem _de se_ ad generationem prolis
+idoneam.--Dicitur: _de se;_ potest enim contingere _per accidens_, v.
+g., ob debilitatem spirituum seminalium in viro aut femina, vel ob
+_indispositionem matricis_ in muliere, quod copula carnalis, etiam
+perfecta, hoc est, _per effusionem seminis in vagina_ mulieris
+completa, non sit idonea ad generationem prolis." Loquuntur
+moralistae, ut dixi, de copula carnali quatenus copula est sine
+respectu ad possibilitatem generandi.
+
+Hisce omnibus positis, rogamus:
+
+(1), Quid sit impotentia sub lege in muliere?
+
+(2), Estne mulier carens ovariis, utero vel tubis Fallopianis
+impotens?
+
+(3), Quid sit impotentia sub hac lege in viro?
+
+(4), Estne vir aspermatosus impotens, et quid de viris semen sterile
+habentibus?
+
+I. _Impotentia Mulieris._ Mulieres steriles frequentius quam viris,
+viri autem impotentes frequentius quam mulieres sunt. Impotentia
+absoluta et perpetua raro in mulieribus, in viris crebro invenitur.
+
+In fundo pelvis femineae septum est a latere in latus, rectum inter et
+vesicam urinariam, et in medio hujus partitionis uterus, qui
+piroformis est, quasi ad perpendiculum jacet et cervix sua in vaginam
+intrat.
+
+A cornibus uteri, i.e., ab angulis superioribus, tubi Fallopiani
+procedunt ad libellam, et apud terminos tuborum ovarium est in utroque
+latere. Tubi aperti sunt prope ovaria, et non substantiae ovariorum
+continui. Si unum ovarium et tubus oppositi lateris demantur, vel si
+tubus iste occludatur, ovum ex ovario manente migrare per partem
+exteriorem uteri et foecundari potest.
+
+Genitalia externa mulieris e labiis majoribus praecipue constant;
+intra et inter haec labia minora seu nymphae sunt. Intra labia minora
+ad summum versus clitoris est; infra hanc est meatus urinarius; infra
+meatum, orificium vaginae. Per imam partem orificii in virginibus
+extenditur pellicula tenuis quae hymen vocatur. Haec communiter in
+coitu primo rumpitur.
+
+{332}
+
+Tempore mensium praesertim ova egrediuntur ex ovariis in tubos
+Fallopianos et inde in uterum. Si ova non foecundentur per vaginam
+amittuntur. Foecundatio in tube Fallopiano fit.
+
+In muliere impotentia temporanea aut perpetua oriri potest e causis
+sequentibus:
+
+(1), propter hymenem imperforabilem aut cribriformem, aut septatum aut
+annularem;
+
+(2), propter vaginam duplicem;
+
+(3), propter vaginismum aut dolorem;
+
+(4), propter uterum prolapsum aut productionem cervicis uteri;
+
+(5), propter atresiam vaginae aut labia adhaerentia;
+
+(6), propter orificium vaginae in loco abnormali;
+
+(7), propter arctationem vaginae;
+
+(8), propter tumores aut incrementum morbidum intra vel circa
+genitalia;
+
+(9), propter Sadismum;
+
+(10), propter Masochismum;
+
+(11), propter Sodomiam gradus secundi seu defeminationem; Sodomiam
+gradus tertii; Sodomiam cum horrore; Urningismum; Androgyniam.
+
+1. Aliquando vice hymenis normalis invenitur membrana densa seu
+cartilaginosa, aut membrana continua, aut cribro similis, aut tanquam
+septum, aut annularis, quae impediat intromissionem. Operatione
+simplici chirurgica conditio removetur.
+
+2. Raro septum adest quod vaginam in duas partes dividit et
+impotentiae causa est. Chirurgus septum removere potest.
+
+3. Vaginismus contractio spasmodica musculorum ad orificium vaginae
+est, et haec vaginam claudit. Frequenter inter neuroses ideopathicas
+includitur, scrutinium autem diligens locum inflammationis detegit qui
+origo est spasmi reflexi. Insolenter conditio ex hyperaesthesia
+murorum vaginalium inducitur.
+
+Medicatio vaginismi examen expertum supponit et quandoque scrutinium
+endoscopicum vesicae urinariae. Fissurae in ano, endometritis
+chronica, urethritis granosa circa cervicem vesicae urinariae, causae
+principales sunt vaginismi, et istae {333} causae sanabiles sunt.
+Inflammatio acuta vulvae, vaginae, uteri, tuborum aut ovariorum,
+carunculae urethrales, urethritis, fissurae cervicis vesicae
+urinariae, haemorrhoides, fissurae recti, coccygodinia, ulcera uteri
+et amotio uteri vel ovariorum e loco debito, possunt tantum dolorem in
+coitu infligere ut mulier practice impotens fiat. Morbi autem isti
+fere omnes medicabiles sunt, sed tamen aliqui omnino pervicaces sunt.
+In vaginismo hysterico et in aliis casibus insanabilibus intromissio
+fieri potest ope chloroformi ad evitandum divortium.
+
+4. Quando uterus prolabitur vel cervix producitur ita ut copula
+impossibilis sit, chirurgus mederi potest.
+
+5. Atresia vaginae est occlusio vaginae in longum perfecta vel
+imperfecta. Nullum orificium invenitur. Congenita esse potest, et tunc
+plerumque desunt omnia organa generativa. Atresia etiam consequitur
+vulnera et inflammationes morborum, ut diphtheritis et scarlatina.
+
+Ubi atresia per totam vaginam extenditur nullum datur medicamentum, et
+impotentia absoluta et perpetua adest. Labia adhaerentia separari
+possunt.
+
+6. Aliquando sed perraro vagina in rectum aperit. Possibilitas
+removendi impotentiam e loco orificii vaginae pendet.
+
+7. Arctatio vaginae oritur ex causis atresiae, et remotio conditionis
+quum impotentia inducat impossibilis esse potest.
+
+8. Tumores pudendi, vaginae et recti, hypertrophia labiorum et
+clitoridis, et elephantiasis labiorum copulam impedire possunt. Alii
+tumores et hypertrophiae removeri possunt, alii autem insanabiles
+sunt.
+
+9. Dantur perversitates sexuales quae viros impotentes reddunt, et
+haec aliquando in mulieribus inveniuntur. Tales sunt Sadismus,
+Masochismus, et gradus Sodomiae praeter primum. Isti morbi animi
+causae sunt impotentiae in muliere propter aversionem ejus virorum
+etiamsi physice potens sit. Vix in matrimonium iniit talis mulier, et
+igitur perversitates istae parvi momenti relate ad mulieres, relate
+autem ad viros magni momenti sunt. De his quid infra dicendum erit.
+
+10. Senectus nunquam reddit mulierem impotentem, virum autem reddit.
+Etiamsi nihil ad impotentiam pertineat, hic {334} juvat dicere in
+locis temperatis terrae parturitionem maxima ex parte desinere anno a
+natu quadragesimo-quinto. Cessare potest anno vicesimo-octavo, et
+perstare post annum quinquagesimum. J. Whitridge Williams
+(_Obstetrics._ Neo-Ebor. 1903), casum citat mulieris quae anno
+sexagesimo-tertio aetatis puerum vicesimum-secundum peperit et postea
+menses aderant. Parturitio aliquando decem vel duodecim annos post
+ultimos menses evenit.
+
+Nunc, estne mulier ovariis carens impotens? Nullo modo: sterilis
+tantum est. Nam (1) Congregatio S. Officii in matrimonium duas
+mulieres ovariis orbatas inire permisit. (2) Talis mulier capax est
+copulae carnalis aeque ac mulier habens ovaria, et moralistae omnes
+concedunt nil amplius requirendum ut matrimonium validum fiat. (3) Si
+talis mulier impotens sit omnis mulier insanabiliter sterilis impotens
+esset, et discrimen a moralistis prolatum impotentiam inter et
+sterilitatem nugatorium esset et puerile. Mulier in qua tubi
+Fallopiani occludantur sterilis est perpetuo; idem dicendum de muliere
+habente uterum infantilem, vel ovaria rudimentaria, vel ovaria
+morbida, et ita porro. Nemo autem tales tanquam impotentes unquam
+tenet.
+
+Aliquando mulier ovariis orbata sensationem sexualem possidet, vulgo
+autem non possidet. In utroque casu tamen remedium idem
+concupiscentiae mari perstat, et hoc sufficit pro viro ut matrimonium
+validum sit. Huc accedit, relate tum ad mulierem tum ad virum, quod
+duo fines intrinseci essentiales matrimonii, et fines sufficientes
+juxta S. Alphonsum, adsint, scilicet, traditio mutua cum obligatione
+et possibilitate reddendi debitum, et vinculum indissolubile.
+
+Si in tali muliere existat sensatio sexualis, pro ea remedium
+concupiscentiae habetur, sin minus, dantur saltem duo fines
+essentiales intrinseci matrimonii. Re quidem vera mulier carens
+ovariis et eodem tempore expers sensationis sexualis differt a muliere
+quae parturit sed sine sensatione sexuali est; nihilominus semper
+manent illi ovariis carenti duo fines essentiales intrinseci
+matrimonii.
+
+Vetula communiter nequit parire et expers sensationis sexualis est,
+sed licite matrimonium contrahit. Conditio vetulae est eadem ac
+conditio mulieris ovariis orbatae. Lehmkuhl {335} (_Amer. Ecc. Rev._
+vol. 28, n. 3), in hanc assertionem urget excisionem ovariorum esse
+quid "positive actum contra primarium matrimonii finem," quum senectus
+conditio naturalis sit Chirurgus honestus aut inhonestus nunquam
+removet ovaria ut conceptio evitetur; operatio enim nimis periculosa
+est. Removentur ovaria primario ad morbum gravem medendum, et
+sterilitas consequens intenditur tantum per accidens. Remotio
+ovariorum igitur est quid _per accidens_ actum contra "primarium finem
+matrimonii," (et iste non est finis essentialis intrinsecus) seu
+generationem prolis; et nihil refert etiamsi positive actum esset si
+non sit in fraudem legis. In casu mulieris habentis ovaria
+rudimentaria et nullam sensationem sexualem (casus enim quandoque
+contingit) quid sit "positive actum contra primarium finem
+matrimonii"? Estne una lex pro ista a natura castrata et alia pro
+muliere a chirurgo castrata et tertia pro vetula senectute castrata?
+
+Inter ovaria et testiculos analogia est, etiamsi obstet D. Bossu,
+medicus Gallicus, a Professore Hild (_Amer. Ecc. Rev._ vol. 28, n. 1)
+et Eschbach citatus. Demptis ovariis sensatio sexualis destruitur haud
+secus ac quum testiculi removeantur, sed analogia incompleta est et
+claudit. Eunuchus insuper incapax est communiter intromissionis, et
+semper inseminationis. Moralistae vulgo docent inseminationem
+essentialem esse copulae carnali. Utcumque de inseminationis
+necessitate veritas sit (de qua infra) eunuchus nequit satisfacere
+primo matrimonii fini essentiali intrinseco, mulier expers ovariis
+satisdare potest.
+
+Carentia aut occlusio tuborum Fallopianorum sterilitatem insanabilem
+efficit, sed usque adhuc nemo tenet illam carentiam vel occlusionem
+esse impotentiam. Conditio quoad potentiam generandi eadem est ac in
+carentia ovariorum, sensationem autem sexualem proprie carentia
+tuborum non efficit. Idem omnino dicendum est de carentia uteri. Si
+vagina remaneat capax talis mulier copulae carnalis est.
+
+Mulier igitur impotens est sub lege ecclesiastica tantum in quinque
+casibus:
+
+(1), ubi atresia vaginae aut adhaesio labiorum insanabiles sunt: haec
+atresia et adhaesio raro inveniuntur;
+
+{336}
+
+(2), in casu rarissimo in quo vagina in rectum aperit insanabiliter;
+
+(3), ubi arctatio vaginae immedicabilis sit: haec rara est;
+
+(4), quando adsunt tumores maligni aut incrementa morbida quae
+nequeant removeri;
+
+(5), in casibus defeminationis aut Urningismi (de quibus infra).
+Sadismus et Masochismus et aliae perversitates sexuales ita
+infrequenter observantur, in gradu saltem in quo impotentiam creant,
+ut negligi possint.
+
+II. _Impotentia Maris._ Tractus genitalis viri, a testiculis ad meatum
+urinarium seu orificium penis, ad centimetra 81 (uncias fere 32)
+extenditur. Ex testiculis chorda spermatica per inguen infra cutem
+transit, murum abdominalem penetrat per annulum inguinalem, et sub
+vesica urinaria urethram juxta cervicem vesicae intrat. Semen non ex
+uno fonte provenit. Secretio ista fluida est et cinerea, partim ex
+testiculis qui in scroto sunt oriens et partim ex vesiculis
+seminalibus, prostate, glandulis Cowperi, et folliculis cryptisque
+urethrae, quae omnia extra scrotum sunt. Elementum essentiale in
+semine cellulae sunt quae spermatozoa vocantur, et haec ex testiculis
+proveniunt. Locomotionis potentiam habent spermatozoa et in
+foecundatione ovum penetrant. Secretio glandularum quae spermatozoa
+fert alkalina est et removet aciditatem urinae; acidus enim
+spermatozoa destruit.
+
+Erectio penis praecedit ejectionem seminis, et centra nervosa
+erectionis et ejectionis in chorda spinale apud lumbos sunt. Erectio
+effectus est dilatationis arteriarum penis et occlusionis venarum quae
+congestionem sanguinis efficiunt; postea musculi perineales aliique
+musculi erectionem perficiunt.
+
+Impotentia maris in tria genera dividi potest; videlicet: Impotentia
+Psychica, Impotentia Atonica, Impotentia Organica:
+
+I. Impotentia Psychica.
+Species:
+
+  (1), Impotentia Psychica absoluta aut relativa;
+  (2), Sadismus;
+  (3), Masochismus;
+  (4), Fetichismus;
+
+{337}
+
+  (5), Eviratio;
+  (6), Urningismus;
+  (7), Sodomia cum horrore;
+  (8), Gynandria;
+  (9), Metamorphosis Sexualis Paranoica;
+  (10), Anaesthesia Sexualis;
+
+
+II. Impotentia Atonica.
+Species:
+
+  (1), Impotentia Paralytica;
+  (2), Impotentia e venenis;
+  (3), Impotentia ex irritatione.
+
+
+III. Impotentia Organica.
+Species:
+
+  (1), absentia penis;
+  (2), penis multiplex;
+  (3), hypertrophia aut magnitudo penis vel praeputii;
+  (4), penis rudimentarius;
+  (5), adhaesio penis scroto, ingueni vel abdomini;
+  (6), hypospadias et epispadias;
+  (7), distortiones penis ex podagra, lue, rheumatismo, gonorrhoea;
+  (8), aneurysma corporum cavernosorum et varix venae dorsalis penis;
+  (9), frenum nimis curtum;
+  (10), anchylosis articulamenti coxendicis et abdomen permagnum;
+  (11), tumores et incrementa morbida circa genitalia, sicut herniae,
+  hydrocele, haematocele, elephantiasis, lipoma, carcinoma, sarcoma,
+  cystoma, enchondroma et fibroma;
+  (12), phthisis testiculorum et varicocele;
+  (13), anorchismus et castratio;
+  (14), prostratitis chronica;
+  (15), senectus;
+  (16), aspermia.
+
+I. Impotentia Psychica.
+
+1. Impotentia psychica ea est quae ex coercitatione inhibente cerebri
+in centrum genito-spinale exercitata devenit. "Impotentia ex
+maleficio" veterum moralistarum est. Timor, luctus, gaudium magnum, et
+aversio hanc impotentiam psychicam efficiunt. Quandoque {338} nuper
+maritus propter excitationem passionis ejectionem praecocem vel
+erectionem debilem vel nullam habet. In his casibus impotentia
+temporanea est si medicus peritus prudensque sit. Haec impotentia
+relativa esse potest.
+
+2. Sadismus. Haec paraesthesia sexualis et aliae perversitates ex
+excessu venereo deveniunt et impotentiam gignunt. Sadismus nomen habet
+a quodem libidinoso Gallico marchione de Sade, saeculo duodevicesimo
+vigente. Datur libido magna erga alium sexum sed cum crudelitate in
+objectum uriginis, quae crudelitas usque ad homicidium cum mutilatione
+frequenter extendit, vel saltem adesse debet humiliatio personae
+amatae.
+
+Sadistae erant Nero et Tiberius; et exemplum infame erat Giles de
+Laval, qui A.D. 1440, supplicium capitis affectus est, post
+trucidationem Sadisticam fere 200 liberorum inter octo annos.
+Occisiones apud White Chapel Londini probabiliter Sadisticae fuerunt.
+
+Sadista impotens est exceptis casibus in quibus crudelis vel saltem
+contumeliosus simul esse potest. Haec crudelitas gradus habet a
+Sadismo symbolico, in quo crudelitas simulatur, vel mere dramatica
+est, per contumeliam veram usque ad homicidium et anthropophagiam.
+Formae etiam bestiales et sodomiticae inveniuntur. Sadista nullo modo
+tanquam semper insanus considerari debet, species autem suae pessimae
+paranoicae sunt, et degeneratio neurotica frequens est in familiis
+Sadistarum.
+
+Sadismus maris frequens est, sed Kraft-Ebing (_Psycopathia Sexualis_,
+Philadelphiae, 1893) tantum duos casus inter mulieres invenit.
+Fictiones antiquae de Lamiis et Marmolycibus ex actibus mulierum
+Sadisticarum ortae sunt.
+
+Necrophilia, seu libido erga cadavera cum propensione ad mutilationem,
+species est Sadismi quae vulgo paranoica est.
+
+3. Masochismus. Haec degeneratio nomen habet a fabularum scriptore
+Sacher-Masoch. Conditio est Sadismo contraria. Masochista uriginem
+habet magnam uti Sadista, et nulla datur potentia sexualis sine
+crudelitate vel humiliatione; crudelitas autem vel humiliatio in
+Masochistam ipsum vertenda est. Hic homicidium non intrat.
+Masochismus, natura sua passiva, vitium feminarum esse debet, sed
+solummodo {339} casus unus in muliere inventus est a Kraft-Ebing.
+Valde communis est inter mares.
+
+Masochismus Larvatus est species hujus degenerationis in qua sordes
+physicae sordibus adduntur moralibus.
+
+4. Masochismus Symbolicus seu Fetichismus. Fetichista potens est
+tantum praesente parte vestium, e. g., calccus mulieris, vel aliud
+objectum seu "Fetich," quodcumque sit. Aliquando mera imaginatio
+sufficit. Tonsores furtivi capillorum puellarum quandoque Fetichistae
+sunt, et in capillis longis virorum attractio sexualis quandoque est
+mulieribus. Virtus musicorum saepe in capillis Samsoniis est plus quam
+arte. Westermarck (_History of Human Marriage._ Neo-Eboraci. 1891)
+describit seditionem gravem mulierum in Madagascar quum Rex Radama
+capillos longos militum tonderi jusserit. Relatio etiam est odores
+inter et passionem sexualem. Si nervi olfactorii catelli scindantur
+catellus nunquam canem femineam recognoscit. Meretrices gaudent
+odoramentis pungentibus, e.g., moscho.
+
+5. Eviratio. Haec degeneratio gradus est Sodomiae. In gradu primo
+Sodomiae impotentia non necesse adest, in gradu autem secundo semper
+adest. In hoc secundo gradu homo Sodomiticus meretrix masculina evadit
+cum maribus, atque transformatio profunda et stabilis animi
+supervenit, ita ut mas se feminam esse in actu sexuali sentit. Hic est
+effeminatio usque ad statum criminalem pregrediens. Gradus initialis
+hujus status est amicitia inordinata inter duos pueros aut duas
+puellas.
+
+In casibus firmatis evirationis, Sodomista agit tanquam pellex
+masculina aliis Sodomistis, aut in vestibus femineis ut uxor se gerit.
+Coloniae sunt Sodomistarum hujus generis in fere omne urbe magna; se
+invicem cognoscunt, societates, choreas publicas, et dialectum
+completam habent, praesertim Berolini, Lutetiae-Parisiorum, Neapolis
+et Washingtonii. Impotentes sunt ad copulam carnalem naturalem.
+
+Sodomia cum effeminatione seu viraginitate frequens est inter
+mulieres. Hie degenerata marem mente evenit. Impotens vix dici potest,
+nisi propter aversionem sexualem a maribus.
+
+6. Urningismus. _Urning_ est vox Germanica ab Ulrichs inventa.
+Urningismus idem est in re ac Sodomia primi et {340} secundi gradus,
+sed additur mollitia scriptionis poesis, ambulationum imminente luna,
+et aliorum hujusmodi.
+
+7. Sodomia cum horrore est similis evirationi et defeminationi, sed
+vice frigiditatis adest horror alterius sexus.
+
+8. Gynandria et Androgynia. In istis degenerationibus transformatio
+ita profunda est ut Sodomista masculinus circa pectus et in modo se
+gerendi feminae similis sit physice, et virago virum evadat aspectu.
+Exempla sunt _bote et mujerado_ inter Sioux et Pueblos Indos
+Americanos.
+
+9. Metamorphosis Sexualis Paranoica species insaniae est in qua
+patiens imaginat sexum suum mutatum esse. Insanabilis est.
+
+Degenerationes istae fere omnes cum masturbatione incipiunt. Medicatio
+moralis esse debet, sed Kraft-Ebing et von Schrenk-Notzing sanationem
+obtinuerunt ope hypnosis.
+
+10. Anaesthesia Sexualis status est in quo vir aut mulier omnino caret
+sensatione sexuali. Illi secus habent corpora normalia. Conditio valde
+infrequens est. Kraft-Ebing enumerat decem casus congenitos in
+maribus, et duos in feminis. Anaesthesia sexualis acquisita etiam
+invenitur.
+
+
+
+II. Impotentia Atonica.
+
+1. Impotentia Paralytica. Centra nervosa sexualia in chorda spinale
+apud lumbos atonica esse possunt propter morbum generalem, aut venena,
+aut paralysem. Impotentia atonica frequens est in anaemia, diabete
+mellito, uraemia, cholaemia, lepra, rheumatismo, ataxia lumbali, lue
+chordae spinalis, myelitide, parese, et haemorrhagia cerebrali.
+
+Aliqui tumores cerebrales impotentiam gignunt, paralysis diphtheritica
+causa est impotentiae temporaneae, et conditio invenitur in cachexia
+alicujus morbi tabescentis. Phthisicus autem saepe potens est usque ad
+finem vitae. Utrum impotentia perpetua sit necne ex natura morbi
+dependet.
+
+2. Impotentia ex venenis. Potentia sexualis minuitur vel destruitur
+abusu venenorum vel absorbendo eadem, uti opium, morphina, chloral,
+potassii bromidum et iodidum, cannabis Indica, carbonei sulphidum,
+arsenium, antimonium, plumbum et iodum. Fabri, ut pictores
+(house-painters) et typographi, qui plumbo utuntur hoc modo patiuntur.
+Alcohol frequenter origo est impotentiae, et quandoque tabacum eumdem
+{341} affectum habet sine alio indicio physico. Impotentia pervicax
+esse potest ex utraque causa.
+
+3. Impotentia ex irritatione. Irritatio chronica urethrae prostaticae
+e libidine, gonorrhoea, masturbatione, urina acida aut neurosibus
+genito-urinariis impotentiam inducit. Neuroses centrorum sexualium
+sensibiles aut motoriae esse possunt, et neuroses motoriae quandoque
+impotentiam creant. Prognosis hujusmodi impotentiae fausta est nisi
+adsint spermatorrhoea et genitalium atrophia. Prostatorrhoea quoque
+impotentiae causa esse potest, et hic prognosis melior quam in
+spermatorrhoea est. Athletae, ut pugil, cursor, et alii ejusdem
+classis temporaliter impotentes esse possunt
+
+III. Impotentia Organica. Mas impotens esse potest propter
+malformationes congenitas aut acquisitas, morbos et defectus
+genitalium.
+
+1. Absentia congenita aut postnatalis penis impotentiam insanabilem
+creat.
+
+2. Penis rudimentarius causa impotentiae est, sed casus
+amplificationis post matrimonium habentur.
+
+3. Penis multiplex rarissime impotentiam creat.
+
+4. Hypertrophia penis aut praeputii, et magnitudo relativa penis
+rarissime efficiunt hominem impotentem.
+
+5. Adhaesio penis scroto, ingueni vel abdomini reddit hominem
+impotentem; sanabilis autem est conditio.
+
+6. Impotentiam quandoque creat hypospadias, seu absentia partis
+inferioris urethrae, et epispadias, seu absentia partis dorsalis
+urethrae; sed conditiones a chirurgo sanari plerumque possunt,
+quandoque autem nequeunt.
+
+7. Distortiones penis e podagra, lue, rheuraatismo, et gonorrhoea
+impotentem faciunt virum quandoque immedicabiliter.
+
+8. Aneurysma corporum cavernosorum et varix venae dorsalis penis
+impotentiae a chirurgo sanabilis causae sunt.
+
+9. Frenum glandulae penis curtum nimis incurvat penem, et ita vir
+impotens est. Conditio facile a chirurgo removeri potest.
+
+10. Rarissime anchylosis articulamenti coxendicis et venter
+pinguedineus impotentem virum reddit. Anchylosis insanabilis est.
+
+11. Tumores et incrementa morbida circa genitalia, ut {342} herniae,
+hydrocele, haematocele, elephantiasis, lipoma, carcinoma, sarcoma,
+cystoma, enchondroma, et fibroma causae sunt impotentiae. Herniae,
+lipoma, hydrocele, haematocele, et quandoque elephantiasis scroti
+sanari possunt; tumores benigni et maligni aliquando removentur sed
+vulgo amputatione penis aut testiculorum.
+
+12. Testiculi marcescunt in varicocele et impotentia sequitur.
+Varicocele amoveri potest, et si mature operetur chirurgus impotentia
+evitatur. Lues testiculorum destrui potest substantiam testiculorum
+nisi morbus mature sanetur, et impotentia potest esse absoluta.
+Tuberculosis testiculorum destruit organum.
+
+13. Anorchismus seu absentia testiculorum bilateralis et congenita,
+idem efficit ac castratio. Conditio rara est Cryptorchismus, seu
+retentio testiculorum in abdomine, plerumque sterilitatem gignit non
+necessario impotentiam.
+
+Castratio completa, morbo vel secus, impotentiae causa est, sed non
+necessario statim post castrationem. Gross (_A Practical Treatise on
+Impotence_, Philadelphiae. 1890) citat quattuor casus in quibus
+erectio permanebat, in uno homine usque ad decennium. Kruegelstein
+(_Henke's Zeitschrift._ 1842. vol. I, p. 348) dicit virum quemdam post
+amissionem testiculorum uxorem foecundavit. Si casus revera
+contigerit, spermatazoa in vesciculis seminalibus permanserant.
+
+14. Prostatitis chronica causa est impotentiae et plerumque
+insanabilis est.
+
+15. Nulla regula firma dari potest de impotentia physiologica
+senectutis in maribus. Viri sexto et octogesimo anno non solum
+potentes inventi sunt sed etiam liberos generaverunt. Potentia
+generandi in maribus vulgo circa annum sexagesimum-secundum cessat,
+exceptiones autem multae inveniuntur. Potentia coeundi permanere
+potest longe post annum sexagesimum-secundum. Ecclesia igitur senes
+cujuscumque aetatis ad matrimonium admittit; et confessarius nihil
+rogat de potentia nisi ab ipso sene interrogatur. Si confessarius
+sciat senem revera impotentem esse, non permittere debet matrimonium
+ejus.
+
+16. Opinio videtur esse moralistarum ad habendam copulam carnalem
+necessariam esse non solum erectionem et {343} intromissionem sed
+ettam inseminationem plus minusve perfectam.
+
+Laymann (_De Imped. Matr.,_ cap. 11) ait: "Impotentia perpetua ad
+copulam perfectam dirimit matrimonium subsequens." Et addit: "Dixi
+_perfectam,_ id est, quae fit cum effusione veri seminis in vas
+muliebre." Mastrius (loco jam citato) tenet inseminationem esse
+necessariam.
+
+Lehmkuhl (_Theol. Mor._) in definitione impotentiae absolutae dicit
+talem esse impotentiam quae "aliquem ad quamlibet copulam consummatam
+inhabilem reddit." Hic utitur vocibtis, _copula consummata,_ in qua
+Ballerini requirit inseminationem quasi perfectam (_op, cit._, vol. 6,
+p. 178), et Sanchez (_De Matr.,_ lib. 2, disp. 21, n. 5)
+inseminationem imperfectam. Petrus de Ledesma quoque (apud Eschbach.
+_Disputationes Physico-Theologiae._ Disp. 200) de senibus loquens ait:
+"Si enim senes ita senio confecti et exhausti, quod nullo modo semine
+valeant, quamvis possint erigere membrum et penetrare vas, non possunt
+contrahere, et si contrahunt, matrimonium est invalidum."
+
+Qui steriles sunt ita sunt ex tribus causis: (1) Aspermia, seu
+absentia absoluta seminis; (2) Azoospermia, seu absentia spermatozoon
+in semine; (3) Oligospermia, seu carentia alicujus partis seminis.
+
+Aspermia vulgo efficitur occlusione urethrae vel obliteratione partis
+ejusdem. Defectus isti congeniti esse possunt vel ex morbo aut
+vulnere. Tumores tractus generativi claudere possunt aditum inter
+testiculos meatumque urinarium et ita aspermia efficitur. Spadones,
+etiamsi raro potentiam habeant intromissionis, aspermia afflictantur
+quoad partem seminis ex testiculis provenientem (in qua spermatozoa
+sunt), sed humor ex parte anteriori tractus generativi adesse aliquo
+modo potest.
+
+Azoospermia fere eodem modo oritur, obstructio autem vel destructio
+prope testiculos est, et ita secretio aliarum partium tractus
+generativi exire potest, sed sine spermatozois.
+
+In Oligospermia spermatozoa adesse possunt, sed quia aliud elementum
+seminis deest spermatozoa inertia sunt.
+
+Casus inveniuntur in quibus propter malformationem semen perfectum in
+vesicam urinariam ejactatur.
+
+{344}
+
+Omnes istae conditiones insanabiles esse possunt, raro sanari possunt.
+
+Estne vir aspermatosus, seu carens semine, impotens?
+
+(1). Affirmant multi moralistae qui inseminationem requirant talem
+impotentem.
+
+(2). Ejectio seminis confectio est actus sexualis viro, et alia in
+actu ejectioni mere conducunt.
+
+In Azoospermia copula carnalis qua copula eadem est ac in coitu
+normali: microscopium solum aut sterilitas absentiam spermatozoon
+detegunt. In Oligospermia coitus quoque normalis esse paret.
+
+Opinor virum aspermatosum impotentem sub lege esse quia nequit copulam
+sexualem perficere; e contra, virum oligo-spermatosum aut
+azoospermatosum steriles tantum esse.
+
+Impotentia igitur definiri potest, in viro: Impotens est quum (1) vel
+absolute et perpetua, vel relative et perpetua, incapax sit
+intromissionis et quasi inseminationis; aut (2) quum spado sit, et ita
+sub decreto Sixti V veniat.
+
+Impotentia in muliere definiri potest: quum nullam vaginam vel vaginam
+perpetuo impenetrabilem habeat; vel cum pathologice recuset marem.
+
+Impotentia coeundi potest esse (1) aut antecedens aut consequens;
+prout matrimonii contractum anteit aut illi supervenit; (2) perpetua
+seu insanabilis, aut temporanea; (3) absoluta aut relativa, in quantum
+"aliquem ad quemlibet copulam consummatam inhabilem reddit, aut
+tantummodo usum matrimonii inter duas certas personas impossibilem
+facit" (Lehmkuhl).
+
+Ut impotentia tanquam impedimentum matrimonii dirimens habeatur, debet
+esse: (1) impotentia coeundi; (2) insanabilis; (3) antecedens; (4) aut
+absoluta aut relativa.
+
+AUGUSTINUS OMALLEY.
+
+
+{345}
+
+APPENDIX
+
+{346}
+
+{347}
+
+APPENDIX
+
+BLOODY SWEAT
+
+
+The bloody sweat of our Lord mentioned in Saint Luke's Gospel (xxii.,
+44), has given rise to not a little discussion. The Greek text is:
+[Greek text]. The Vulgate has this text thus: "Et factus est sudor
+ejus sicut guttae sanguinis decurrentis in terram." The Douay version
+is: "And his sweat became as drops of blood trickling down upon the
+ground." The King James translation has it: "And his sweat was as it
+were great drops of blood falling down to the ground." The Greek text
+and the Vulgate and Douay versions are the same, but in the King James
+translation the words, "as it were great" differ somewhat from the
+statement in Greek.
+
+The belief in the Catholic Church is that our Lord literally sweat
+blood through His unbroken skin, and this sweat is commonly deemed
+miraculous. Those that deny the sweat was really blood have no ground
+whatever for their assertion, because apart from all miracle bloody
+sweat can be a purely natural occurrence.
+
+Dr. J. H. Pooley, in _The Popular Science Monthly_ (vol. 26, p. 357),
+has an article on this subject in which he reported 47 cases of bloody
+sweat through unbroken skin. He, however, is of the opinion that our
+Lord's sweat had no real blood in it. Whatever his reason may be for
+this assertion he carefully conceals it.
+
+Hemorrhage through the unbroken skin is a rare occurrence; but, as has
+been said, Dr. Pooley found 47 cases reported, and there are probably
+many others. The discharge may be pure blood which coagulates in
+crusts, or it may be blood mixed with sweat; it may be present over
+the whole surface of the body or only in those parts where the {348}
+skin is thin and delicate. Commonly, bloody sweat is an oozing, but
+Hebra, is his _Diseases of the Skin,_ tells of a young man that he
+himself observed, from whose legs and hand blood ran, sometimes in
+minute jets one-twelfth of an inch in height. The skin was sound, and
+the bloody sweat was not caused by any emotion.
+
+The flow may be intermittent, appearing at intervals from a few hours
+to months. Sometimes the discharge is connected with skin diseases,
+but often the skin is unaffected. Examples have been found at every
+age and in both sexes, but this sweat is commoner in women. Du Gard
+reports an instance in a child only three months old, and Spolinus
+tells of such a sweat in a child twelve years of age.
+
+Bloody sweat may occur in malaria; it may be connected with
+neurasthenic conditions, and it has been caused frequently by
+overwhelming emotion, as terror and anguish.
+
+De Thou tells of a French officer who was in command at Monte Maro in
+Piedmont in 1552, who sweated blood after he had been threatened with
+an ignominious execution if he did not surrender the town. The same
+writer mentions a young Florentine, put to death in Rome during the
+pontificate of Sixtus V, who sweated blood before execution.
+
+The Society of Arts at Haarlem reported the case of a Danish sailor
+who sweated blood through terror in a storm. This man was observed
+carefully by a physician on the ship. The physician at first thought
+the man had been wounded by a fall, but after wiping away the blood he
+discovered that the oozing came through uninjured skin. When the storm
+had ceased the sailor at once regained a healthy condition.
+
+In the _French Transactions medicales,_ for November, 1830, is
+narrated the case of a young woman who had turned from Protestantism
+to Catholicism, and after this conversion she grew hysterical because
+of persecution by her family. During the hysterical attacks she sweat
+blood from the surface of her cheeks and belly.
+
+Before the Christian era bloody sweat was observed by Aristotle,
+Galen, Diodorus Siculus, and Lucan also mention such occurrences.
+
+The stigmata of some saints are authenticated cases of bleeding
+through the sound skin of the hands, feet, and side during
+extraordinary sympathy with our Lord in His Passion, and deep mental
+concentration upon that Passion,--the stigmata of Saint Francis of
+Assisi, for example. Such bleeding is regarded in the Church as
+miraculous. Apart from any question of faith, there is no reason why
+they may not be {349} miraculous, especially if the supernatural
+quality is supported by other facts; but, again, such stigmata can be
+natural. To prove, in general, that stigmata are miraculous requires
+commonly heroic sanctity as a background, and even then in all cases
+the proof is not necessarily absolute.
+
+Focachon, a chemist at Charmes, applied postage stamps to the left
+shoulder of a hypnotised subject, and kept them in place with ordinary
+sticking plaster and a bandage. He suggested to the patient that he
+had applied a blister. The subject was watched, and after twenty-four
+hours the bandage, which had been untouched, was removed. The skin
+under the postage stamps was thickened, necrotic, of a yellowish-white
+colour, puffy with the serum of the blood and leucocytes, and
+surrounded by an intensely red zone of inflammation. Several
+physicians, including Beaunis, confirmed this observation; and Beaunis
+made photographs of the blister, which he showed to the Society of
+Physiological Psychology, June 29, 1885. (_Animal Magnetism._ Binet
+and Fere. New York, 1889.)
+
+In Ricard's _Journal de magnetisme animal,_ 2d year, 1840, pp. 18,
+151, is a similar case. Prejalmini, in November, 1840, raised a
+blister on the healthy skin of a somnambulist by a piece of ordinary
+writing paper on which he had written a prescription for a blister.
+
+At the meeting of the _Societe de biologie,_ on July 11, 1885, Bourru
+and Burot, professors of the Rochefort school, published records of
+epistaxis and of bloody sweat, produced by suggestion on a male
+hysteric. On one occasion, after the patient had been hypnotised, his
+name was traced with the end of a blunt probe on both the patient's
+forearms. There was, of course, no mark of any kind left on the arms.
+Then the patient was told: "This afternoon, at four o'clock, you will
+go to sleep, and blood will then issue from your arms on the lines
+which I have now traced." The man was paralytic and anaesthetic on the
+left side. He fell asleep at four o'clock, and while he was asleep the
+name appeared on the sound left arm, raised in a red wheal, and there
+were minute drops of complete blood (serum and corpuscles) in several
+places. There was no change on the paralysed right forearm. Later the
+patient himself commanded the arm to bleed and it did so. This second
+occurrence was observed by Mabille. (Binet and Fere. Op. cit., p.
+199.) Charcot and his pupils at the Salpetriere have often produced by
+suggestion alone the effects of burns upon the skin of hypnotised
+patients. The blisters in these cases did not appear at once {350} but
+after some hours had elapsed. The blisters, of course, contained
+blood.
+
+The weekly bleeding, through the unbroken skin, of the hands and feet
+of Louise Lateau is an example of stigmata in our own day, which may
+have been supernatural or natural. Physicians would call it natural,
+an effect of autohypnosis, but there is no reason why it may not have
+been just as miraculous as the stigmata of the saints. Professor
+Lefevre of the University of Louvain, a physician, said her stigmata
+were miraculous. Theodore Schwann, the discoverer of the cell
+doctrine, deemed her condition natural.
+
+In the Letters of the Rt. Rev. Casper Borgess, Bishop of Detroit,
+Michigan, is an account of a visit to Louise Lateau made in July,
+1877. He says, "I first seated myself on the only chair in the room,
+which I had placed at the right side, near the head of the bed.
+Louise's two hands rested on several thicknesses of folded linen,
+spread over the bed-cover, and were covered with a folded linen cloth.
+This I removed. The hands were both heavily covered with blood; in
+some places it had congealed, and looked very dark; but in the centre,
+between the fore and little fingers, on the upper part of the hand,
+the blood was quite fresh and flowed freely. Not knowing at the time
+that the wiping of the hands causes her intense pain, I proceeded to
+wipe off the hands, for a more perfect inspection of the wound on each
+hand. The wound, or stigma, on the right hand seemed more than one
+inch in length, about half an inch at its greatest width, and was of
+oval shape. Turning the hand, I saw a wound of the same form in the
+palm of the hand, and opposite the wound on the back of the same. The
+blood seemed to rise in bubbles, forming in rapid succession, flowing
+in a spread stream down to the wrist. Examining the wound itself, I
+was well convinced that the skin of the hand was not broken nor in any
+way injured; and there was no sign of a wound made by any material
+instrument, sharp or dull. And, withal, the blood oozing out of the
+wound appeared a reality, and complete in form."
+
+The bishop evidently uses the term "wound" in a figurative sense,
+because he draws attention to the fact that the skin was intact,
+continuous. She bled from the dorsal and palmar surfaces of the hands
+in areas shaped like the wounds represented by painters on the hands
+of our Lord. While the bishop was examining her hands Louise went into
+an ecstatic condition.
+
+If the Church defines that a bloody sweat or the stigmata of a saint
+are supernatural, that definition, of course, ends the matter for
+Catholics as far as the particular case is concerned; {351} but until
+such a decision has been made these conditions are all to be regarded
+as effects of natural causes working in a natural manner.
+
+In many conditions where the nervous system can have influence a
+miracle is very difficult of proof from the context. There can, of
+course, be evident miracles in the cure of some nervous disorders,
+supposing the diagnosis to be certain. The sudden cure of advanced
+paresis would be as much a miracle as the sudden replacing of a lost
+femur. Commonly, however, in neuroses if there is an apparently
+miraculous healing or similar effect, the supernatural quality can not
+be established. Suppose Bernadette reported that she had seen the
+Blessed Virgin at Lourdes: the only safe thing to do in such a case is
+to deny the apparition until it has been proved. Suppose, secondly,
+that a patient who has been confined to bed for years by an hysterical
+paralysis, believed in the reality of the vision, had himself carried
+to Lourdes, and while at prayer there he suddenly stood up cured. That
+effect would prove neither the reality of the vision nor the
+supernatural quality of the cure; nor would it disprove either. We
+simply can not judge the case, because exactly the same effect has
+happened hundreds of times from purely natural impressions. If that
+same paralytic were lying in his bed at home and you set the house
+afire he would jump up and run.
+
+If the patient, however, had been bedridden with a paralysis caused by
+certain degeneration of nervous tissue, and he were cured in the
+manner described, that effect would be supernatural, miraculous;
+always provided there is no error in the medical diagnosis.
+
+There is a genuine diabetes and a pseudodiabetes. The latter condition
+may be diagnosed as true diabetes by a number of physicians, but it is
+only a symptom of hysteria. If the pseudodiabetes is suddenly cured,
+this cure may or may not be miraculous, but no one can say which is
+the truth; the probability is a hundred to one that the cure is
+altogether natural. There was a flourishing Christian Science
+congregation established in the west recently upon "miraculous" cure
+of a case of pseudodiabetes, which some ignorant physicians had called
+true diabetes, notwithstanding the fact that Christian Science does
+not believe in either diabetes or false diabetes.
+
+We must not, then, call every strange event miraculous; nor, what is
+worse, are we rashly to make the supernatural a matter to be explained
+away loftily by the impudence of half science. A Belgian priest named
+Hahn wrote a monograph {352} to the effect that the ecstatic
+conditions observed in the life of Saint Teresa were autohypnotic, and
+he succeeded in drawing upon himself the undivided attention of the
+Congregation of the Index and a serious disturbance of his peace of
+mind. He became a martyr to science. We all like to be "liberal,"
+impartial; but from the religious Mugwump _libera nos, Domine!_
+Autohypnosis is always a mark of degeneracy in the natural order, and
+to call the ecstacy of a saint autohypnosis not only takes all worth
+from the manifestation, but the assertion is also untrue. There is a
+vast difference between the intense intellectual contemplation of a
+great saint in ecstacy, which leaves the person unconscious of the
+body and its surroundings, and the cataleptic trance of a neurotic
+patient who may mimic the saint.
+
+Hypnotic or autohypnotic stigmata, and by stigmata here is meant
+bleeding from the hands, feet, and side, would be degeneracy of the
+mind and body in the natural order. Moreover, no clearly established
+cases are known, because conditions like those of Louise Lateau are by
+no means certainly physical from all points of view, as they would be
+if they occurred in an ordinary hysteric. In hypnosis or autohypnosis
+the subject's mind and body are degenerate; in sanctity, where at
+times may be displayed certain effects that resemble autohypnosis,
+there is always a sound mind. A saint may have an unsound, neurotic
+body, but a crazy "saint" or an hysterical "saint" is no better than
+any other lunatic or hysteric, and certainly anything but a saint. If
+a saint has stigmata, these external marks might come (1)
+miraculously, as a gratuitous sign of divine favour; (2) as an effect
+of natural, intense contemplation of the Passion of our Lord,
+producing these bleedings in a sound body; or (3) as an effect of a
+rational, intense contemplation of the same Passion, acting, more
+easily, on a neurotic body.
+
+Scientific theorising on this matter is necessarily sterile, because
+such an investigation is only half material for science,--physical
+science. Science is not a bad thing in itself, especially when it
+minds its own business and keeps its place below stairs; but it never
+sympathises with sanctity, and there is no deep knowledge without
+sympathy. Fact-grinding made Darwin "nauseate Shakspere." Science can
+not see in the dark as genius and sanctity see, and if it does see in
+the dark it is no longer science but genius working on a scientific
+object. As Professor William James said: "Science taken in its essence
+should stand only for a method, and not for any special beliefs, yet,
+as habitually taken by its {353} votaries, Science has come to be
+identified with a certain fixed general belief, the belief that the
+deeper order of Nature is mechanical exclusively, and that
+non-mechanical categories are irrational ways of conceiving and
+explaining even such a thing as human life." Science should recognise
+its own limitations and not meddle in attempted explanations of the
+inexplicable. Therefore, what of the stigmata of the saints from a
+scientific point of view? There is no scientific point of view.
+
+AUSTIN OMALLEY.
+
+
+{354}
+
+{355}
+
+INDEX
+
+{356}
+
+{357}
+
+INDEX
+
+A
+
+Abdominal pregnancy, 5.
+Abortion, 22, 48;
+  causes of, 48, 49, 51, 52, 53;
+  in puerperal pneumonia, 151;
+  tubal, 6.
+
+_Abortus_, 19, 20, 49.
+Acephalus, 75.
+Actinomyces, visits in, 183.
+Acute indigestion in the aged, 154.
+Addison's disease, death in, 155;
+  symptoms of, 156.
+Adipocere, 7.
+Aertnys on ectopic gestation, 26, 27.
+Aggressor, 18, 19.
+Agoraphobia, 296.
+Air-space, 204.
+Alcohol,
+  effects on the mind, 109;
+  in proprietary medicines, 93;
+  in snake-poisoning, 118;
+  in typhoid fever, 118.
+
+Alcoholic amnesia, 110;
+  climacteric, 108;
+  delusions, 109, 110;
+  insanity, 107, 105, 109;
+  liquors, 108;
+  poisoning, 107, 109, 110;
+  pseudo-paranoia, 109.
+
+Alcoholism, 105;
+  and cirrhosis of the liver, 156;
+  and coma, 138;
+  and conjugal infidelity, 109;
+  and epilepsy, 256;
+  and idiocy, 113;
+  and imbecility, 112, 114;
+  and marriage, 111, 126;
+  and pneumonia, 151;
+  and surgical operations, 163;
+  and the will, 111;
+  causes of, 108;
+  children in, 112;
+  complicating disease, 162;
+  temperance societies, 112.
+
+Amateur medical advice, 89.
+Ambulatory epilepsy, 261.
+Amenorrhoea, 241.
+Amnesia and epilepsy, 263.
+Ampullar pregnancy, 5.
+Amputations, uterine, 65.
+Anaesthesia in mania, 227.
+_Anatomia genitalium mulieris_, 331.
+Androgynia, 340.
+Aneurism,
+  causes of, 155;
+  death in, 155.
+
+Angina pectoris, death in, 142.
+Anointing in smallpox, 177.
+Anopheles mosquito, 186.
+Anthrax, visits in, 184.
+Antitoxin, 171, 195.
+Aortic valvular disease, death in, 140.
+Apoplexy, 143;
+  and fainting, 145;
+  hard arteries and, 144;
+  short neck and, 146;
+  symptoms of, 144;
+  the third stroke in, 146;
+  treatment in, 145;
+  vertigo and, 144.
+
+Appendicitis,
+  peritonitis in, 153;
+  prognosis in, 153.
+
+Apraxia, 263.
+Aristotle, his determinants of morality, 14.
+Arteries in apoplexy, 146.
+Arteriosclerosis and apoplexy, 144.
+Aspects of intoxication, 105.
+Aspermia, 343.
+Asomata, 75.
+Assassins of presidents, 302.
+_Atresia vaginae et impotentia_, 333.
+Autohypnosis, 130.
+Autositic monsters, 75.
+Azoospermia, 343.
+
+B
+
+Bacteria, 168;
+  kinds of, 169;
+  specific causes of disease, 169.
+
+Baptism in ectopic gestation, 83;
+  of monsters, 87.
+
+Barber's itch, contagiousness, 198.
+Barkers, 237.
+Beer, percentage of alcohol in, 108.
+Beriberi, visits in, 184.
+Bibliography of hypnotism, 117.
+Bichloride of mercury, a disinfectant, 191.
+Black death, 184;
+  mortality of, 184.
+
+Black fevers, 160.
+Bleeders, 124.
+Blood brought out by suggestion, 349.
+Bloody sweat, 347;
+  and hypnosis, 349;
+  cases of, 348.
+
+Books and infection, 195;
+  disinfection of, 190.
+Borgess on the Lateau case, 350.
+Brain tumours, 148;
+  and syphilis, 322;
+  symptoms of, 148.
+
+Breeding places of mosquitoes, 186.
+Breuss' ovum, 73.
+                                                               {356}
+Brick in buildings, 203.
+Broad ligament, 3.
+Broad-ligament pregnancy, 5.
+Bromides and epilepsy, 98.
+Bubonic plague,
+  mortality in, 185;
+  transmission of, 185;
+  visits in, 184.
+
+Building materials, 203.
+Building sites, 202.
+Burns, death in, 156.
+
+C
+
+Caesarean section, 41, 42, 51, 55;
+  and sepsis, 56, 57;
+  indications for, 55;
+  statistics of, 55.
+
+Cancer complicating pregnancy, 44;
+  death in, 158.
+
+Canonical law on impotence, 326.
+Carbonic add in the air, 206.
+Cardiac massage, 165.
+_Carentia ovariorum_, 334.
+Carpets, disinfection of, 194.
+Cases of ectopic gestation, 22.
+_Castratio et impotentia,_ 342.
+Catarrh and proprietary drugs, 100
+Cathartics, 100.
+_Causae impotentiae mulieris,_ 332.
+Cats and diphtheria, 195.
+Cells, 69.
+Cellular activity and death, 164.
+Centrosome, 70.
+Cerebrospinal meningitis, 148, 182.
+Cerebral neurasthenia, 230.
+Chickenpox, 197.
+Children of drunkards, 112;
+  suicide of, 308.
+
+Chorea, 51;
+  and menstrual disorders, 243.
+
+Chromatin, 70.
+Chromosomes, 70, 71.
+Circular insanity, 228.
+Circumstances m morality, 12.
+Cirrhosis of the liver,
+  causes of, 156;
+  death in, 156.
+
+Classrooms, 204.
+Claustrophobia, 296.
+Clothes, disinfection of, 191.
+Cocaine, insanity from, 116;
+  intoxication, 115, 116, 117.
+
+Coeliotomy, 4.
+Colelithiasis, death in, 160.
+Coma and alcoholism, 138;
+  and kidney disease, 138.
+
+Composite monsters, 77.
+Compulsory vaccination, 175.
+Confluent smallpox, 172.
+Congenital syphilis, 313;
+  statistics of, 313.
+
+Conjugata vera, 55, 56, 57.
+Conjunctivitis, infectiousness of, 199.
+Coninck on impotence, 330.
+Consanguinity and monsters, 76.
+Conscience, 15.
+Constipation, 100.
+Contagion, 168.
+_Copula carnalis_, 331.
+Cornish jumpers, 237.
+Cough, physiology of, 91.
+_Convulsionnaires_, 237.
+Cranial asymmetry and crime, 272, 275.
+Craniopagus, 84.
+Craniotomy, 22, 28, 42, 55, 56, 58, 59;
+  indications for, 58;
+  mortality in, 59.
+
+Cranks, 282.
+Crile's method of resuscitation, 166.
+Crime, suppression of, 278.
+Criminal types not a scientific fact, 271.
+Criminals, indeterminate sentence for, 279.
+Criminology and the habitual criminal, 271.
+Cross immunisation, 172.
+Cyclops, 75.
+Cysts complicating pregnancy, 40, 41.
+Cytoplasm, 70.
+
+D
+
+Dancing plague, 236.
+Death
+  from alcohol, 162;
+  from varicose veins, 159;
+  in acute indigestion, 154;
+  in Addison's disease, 155;
+  in aneurism, 155;
+  in appendicitis, 153;
+  in burns, 156;
+  in cancer, 158;
+  in cirrhosis of the liver, 156;
+  in colelithiasis, 160;
+  in delirium tremens, 162;
+  in dysentery, 155;
+  in ear disease, 159;
+  in gastric ulcer, 161;
+  in hydrophobia, 161;
+  in kidney diseases, 137;
+  in the lymphatic diathesis, 157;
+  in mania, 227;
+  in pancreatitis, 160;
+  in rheumatism, 153;
+  in tetanus, 161;
+  in tuberculosis, 158;
+  moment of, 164;
+  prognosis of, 136;
+  resuscitation after apparent, 164;
+  unexpected, 135.
+
+Degeneration and criminals, 271.
+Degeneracy, symptoms of, 274.
+_De impedimento impotentia,_ 326.
+Dejecta, disinfection of, 192.
+De Lugo, on homicide, 18.
+Delirium tremens, 109;
+  death in, 162.
+
+Delusions in melancholia, 221.
+Dementia, 228.
+Dengue, visits in, 181.
+Dermoid cysts, 86.
+Desks in schools, 207.
+Desquamation after disease, 197.
+Destruction of infected articles, 194.
+Dicephali, examples of, 80, 81.
+Dicephalus, species of, 79, 80.
+                                                      {359}
+Diphtheria
+  and domestic animals, 195;
+  antitoxin, 103, 195;
+  bacillus, persistence of, 192;
+  cause of, 187;
+  communication of, 187, 190;
+  disinfection in, 190, 193;
+  error in diagnosis of, 187;
+  immunity against, 188;
+  in a school, 196;
+  precautions against, 190;
+  visits in, 181.
+
+Diprosopi, species of, 79.
+Dipsomania, 110;
+  cured by hypnotism, 117.
+
+Dipygi, 83.
+Diseases
+  caused by bacteria, 169;
+  caused by plasmodia, 169.
+
+Disinfection
+  by formalin, 193;
+  by steam, 193;
+  in diphtheria, 190;
+  of carpets, 194;
+  of clothing, 191;
+  of dejecta, 192;
+  of eating utensils, 192;
+  of money, 194;
+  of rooms, 193;
+  of the body, 193.
+
+Divorce and impotence, 326.
+Domestic animals and diphtheria, 195.
+Dormitories, 204.
+Double autositic monsters, 79.
+Draehms on the criminal, 272.
+Drainage,
+  defects of, 203;
+  of buildings, 203.
+
+Drinking cups and infection, 195.
+Drunkenness, accountability in, 106.
+Dysmenorrhoea, 242;
+  varieties of, 242.
+
+Dysentery, death in, 155.
+
+E
+
+Ear disease and death, 159.
+Eclampsia, 52.
+Ecstacy of saints and hysterics, 352.
+Ectoderm, 73.
+Ectopic gestation, 1;
+  baptism in, 11;
+  children saved in, 30;
+  difficult to diagnose, 8;
+  location of, 1;
+  medical treatment of, 10;
+  opinions of physicians, 8, 9;
+  statistics of, 33, 34;
+  surgical operation for, 23.
+
+Effect of actions, 14, 15.
+Embryo, 4;
+  development of, 73, 74.
+
+Embryotomy, 58.
+Emmet on ectopic gestation, 8.
+End in morality, 13.
+Endoderm, 73.
+Epiblast, 73.
+Epidemic hysteria, 236, 237.
+Epilepsy,
+  ambulatory form of, 261;
+  and alcoholism, 256;
+  and homicide, 253;
+  and insanity, 253;
+  and lapse of memory, 262;
+  and religiosity, 254;
+  and responsibility, 251;
+  age at development, 258;
+  examples of cases of, 259, 262;
+  idiopathic form of, 257;
+  irritability in, 253;
+  masked or psychic, 252;
+  notions of persecution in, 255;
+  prognosis in, 257;
+  symptoms of, 252;
+  treatment of, 99, 258.
+
+Epileptics and bromides, 98.
+Epileptiform convulsions, 256.
+Erlich's theory of immunity, 171.
+Erysipelas, visits in, 183.
+Eunuchs and impotence, 327.
+Eviratio, 339.
+Evisceration, 58.
+Exophthalmic goitre, 247.
+Extreme unction in smallpox, 177.
+Extrauterine pregnancy, 1, 154.
+Eye,
+  diphtheria in the, 200;
+  gonococci in the, 200;
+  infections of the, 199.
+
+Eyesight and schools, 208.
+
+F
+
+Fainting and apoplexy, 145.
+Fallopian tubes, 1, 2;
+  rupture of, 5.
+
+False angina pectoris, 142.
+Favus, contagiousness of, 198.
+Fecundation, 3.
+Fibroid tumours in pregnancy, 41.
+Fimbria ovarica, 2.
+Fission fungi, 168.
+Fission theory for composite monsters, 77, 78.
+Flat pelves, 56.
+Foetal blood, 67.
+Foetal death,
+  causes of, 8;
+  in ectopic gestation, 6.
+
+Foetus, 4;
+  anideus, 75;
+  in utero, 67;
+  when viable, 4.
+
+Food in schools, 208.
+Formalin disinfection, 190, 193.
+Fractures of the skull, 147.
+Frigidity, 330.
+Fusion theory for monsters, 77.
+
+G
+
+Gall stones, 160.
+Gambling mania, 295.
+Gambler's paranoia, 295.
+Garfield's assassination, 303.
+Gastric ulcer, death in, 161.
+Gastritis, death in, 154.
+Gastrula, 73.
+Genicot on ectopic gestation, 21.
+_Genitalia maris_, 336.
+_Genitalia mulieris_, 331.
+Germinal vesicle, 72.
+Gestation,
+  duration of, 3;
+  ectopic, 1;
+  term of, 4.
+
+Glanders, visits in, 181.
+Glottis, oedema of the, 139.
+Gonorrhoea, 324;
+  and ectopic gestation, 36;
+  effects of, 315;
+  and marriage, 315;
+  and sterility, 325.
+
+Goodell on ectopic gestation, 9.
+Grandeur, delusions of, 290.
+Granular eyelids, 200.
+Graves' disease, responsibility in, 246.
+Grief and melancholia, 215.
+Grippe, visits in, 181.
+Guiteau's insanity, 303.
+Gynandria, 340.
+
+                                                       {360}
+H
+
+Habitual criminals, 271.
+Haematocele, 6.
+Haematosalpynx, 6.
+Harelip, 123.
+
+Heart disease
+  and mania, 226;
+  death in, 140;
+  in pregnancy, 49;
+  in typhoid fever, 152;
+  pulse signification in, 141.
+
+Heating of schools, 206.
+Hebephrenic melancholia, 309.
+Hebra's case of bloody sweat, 348.
+Hecker on the plague, 185.
+Hemiterata, 74.
+Hemophilia, 123.
+Heredity, 120;
+  and acquired characteristics, 122;
+  and melancholia, 216;
+  circular insanity and, 228;
+  in insanity, 224, 225;
+  mania and, 224.
+
+Hermaphrodites, 74.
+Heterotaxic monsters, 74.
+Hirst on ectopic gestation, 8.
+Holaind
+  on ectopic gestation, 8;
+  on self-defence, 18, 19.
+
+Holy Office on abortion, 20, 49, 50, 51.
+Homesickness, melancholia and, 217.
+Homicide, 17, 18;
+  direct, 17;
+  indirect, 18, 43;
+  morality of, 17, 18.
+
+Homicidal mania, 300.
+Humoral pathology, 88.
+Huntingdon's chorea, 122.
+Hydramnios, 53.
+Hydrophobia, death in, 161.
+Hygiene in schools, 202.
+Hymen imperforabilis, 332.
+Hypnosis
+  and bloody sweat, 345;
+  and crime, 131, 132;
+  and responsibility, 131;
+  danger in, 130, 131;
+  utility of, 130.
+
+Hypnotism, 129;
+  bibliography of, 117;
+  in dipsomania, 117;
+  in morphinism, 117.
+
+Hypoblast, 73.
+Hypochondriacs, 287.
+Hysterectomy, 42.
+Hysteria, 235;
+  and marriage, 239;
+  causes of, 235;
+  imitative form of, 236;
+  in males, 235;
+  major form of, 237;
+  manifestations of, 235;
+  minor forms of, 238;
+  symptoms of, 238;
+  treatment of, 239.
+
+I
+
+_Idee obsedante,_ 266.
+Idiocy
+  and alcoholism, 113;
+  and maternal impressions, 64.
+
+Idiopathic insanity, 212
+Imbecility
+  and alcoholism, 112, 114;
+  grades of, 114.
+
+Imitative hysteria, 236, 237.
+Immunity to disease, 170, 171.
+Impetigo, contagiousness, 199.
+Impotence,
+  American authorities on, 327;
+  and American law, 326;
+  canon law on, 326;
+  definition, 327;
+  definition by moralists, 329, 330;
+  St. Alphonsus's definition, 328.
+
+_Impotentia_
+  _atonica_, 340;
+  _e morbis penis_, 341;
+  _e vaginismo_, 332;
+  _e venenis_, 340;
+  _et aspermia_, 344;
+  _et castratio_, 342;
+  _et inseminatio_, 343;
+  _et prolapsus_, 333;
+  _et senectus_, 333;
+  _et varicocele_, 342;
+  _ex irritatione_, 341;
+  _ex maleficio_, 337;
+  _maris_, 336;
+  _mulieris_, 331;
+  _organica_, 341;
+  _paralytica_, 340;
+  _propter atresiam_, 333;
+  _pychica_, 336, 337;
+  _impotentiae definitio_, 344;
+  _multeris causae_, 332.
+
+Impregnation, 240.
+Impulse and responsibility, 266.
+Indeterminate sentence tor criminals, 279, 280.
+Infected patient, release of, 192.
+Infection, 168.
+Infectious diseases, 168;
+  and mania, 226;
+  in schools, 187.
+
+Influenza, visits in, 181.
+Insanity, 212;
+  alcoholic, 107;
+  and crime, 274;
+  and epilepsy, 253;
+  and heredity, 224;
+  and menstrual diseases, 243, 244;
+  and religious vocations, 226;
+  and sexuality, 226;
+  diagnosis of, 106;
+  from cocaine, 116;
+  marriage and, 225;
+  recurrence of, 213.
+
+_Inseminatio_, 341.
+Interstitial tubal pregnancy, 5.
+Intoxicants, 105.
+Intrauterine hemorrhage, 53.
+Iodide of potassium and sarsaparilla, 96.
+Ischiopagi, 82.
+Isthmic ectopic pregnancy, 5.
+Italian school of criminology, 271.
+Itch, 198.
+
+J
+
+Jacksonian epilepsy, 257.
+Jews and the plague, 185.
+
+K
+
+Kelly on ectopic gestation, 5, 8.
+Kidney diseases
+  and oedema, 139;
+  coma in, 138;
+  effect of heat and cold in, 138;
+  fatality of, 137.
+
+Kleptomania, 299.
+Konings on impotence, 329.
+
+L
+
+Laurent on criminals, 271.
+Law, St. Thomas's definition of, 16.
+Left-handedness and crime, 272.
+Lehmkuhl
+  on abortion, 19;
+  on ectopic gestation, 25;
+  on impotence, 329.
+
+Leprosy,
+  contagiousness of, 183;
+  visits in, 182.
+
+Lice, 198.
+Lighting of schools, 205.
+Lincoln's assassination, 303.
+Life, beginning of, 3.
+
+                                                      {361}
+
+Lithopoedion, 7.
+Lockjaw, 161.
+Locomotor ataxia, 312, 320;
+  symptoms of, 321.
+
+Lombroso's theory on criminals, 271.
+Louise Lateau, 350.
+Lungs, oedema of, 139.
+Lusk on ectopic gestation, 9.
+Lymphatic diathesis, 157.
+
+M
+
+MacDonald on criminals, 272.
+McKinley's assassination, 304.
+Magnan on criminal monomanias, 271.
+Mahomet a paranoiac, 291.
+Major hysteria, 237.
+Malaria, 186.
+Malta fever, 185.
+_Malum comitiale_, 251.
+Mammalian ovum, 69.
+Mania, 222;
+  anaesthesia in, 227;
+  after infectious diseases, 226;
+  a potu, 109;
+  causes of, 224;
+  death in, 227;
+  prognosis in, 227;
+  symptoms of, 223.
+
+Manouvrier on criminals, 272.
+Marriage,
+  ends of, 328;
+  and hysteria, 239;
+  and insanity, 225;
+  and venereal diseases, 311;
+  Liguorian definition, 328.
+
+_Maris impotentia_, 336.
+Masked epilepsy, 252.
+Massachusetts report on alcoholic tonics, 93.
+Mastrius on impotence, 330.
+_Masochismus_, 338;
+  _symbolicus_, 339.
+
+Maternal impressions, 60;
+  and idiocy, 64.
+
+Materially unjust aggressor, 19, 26.
+Means in morality, 14.
+Measles, disinfection after, 197.
+Mediaeval plagues, 185
+Melancholia, 214;
+  and grief, 215;
+  autointoxication in, 217;
+  causes of, 215;
+  childbearing and, 217;
+  delusions in, 221;
+  heredity and, 216;
+  in women, 217;
+  predisposition to, 216;
+  prognosis m, 220;
+  recurrence of, 214;
+  starving in, 222;
+  suicide in, 218, 219;
+  symptoms of, 218.
+
+Membranous croup, 187.
+Memory and alcoholism, 110.
+Memory in epilepsy, 263.
+Mendel and heredity, 120, 128.
+Meningitis, 148.
+Menopause, 240, 242;
+  and responsibility, 249.
+
+Menorrhagia, 241.
+Menstrual diseases, 240;
+  and insanity, 243.
+
+Menstruation, 3, 240;
+  beginning of, 240;
+  derangements of, 241;
+  process of, 240.
+
+Mental defects and pregnancy, 63.
+Mental diseases and spiritual direction, 211.
+Mesoblast, 73.
+Mesoderm, 73.
+Metamorphosis sexualis, 340.
+Metrorrhagia, 241.
+Middle ear disease, 159.
+Minor hysteria, 238.
+Miracles and the nervous diseases, 351.
+Miracles, physical proof of, 351.
+Miscarriage, 48.
+Misophobia, 296.
+Mitotic division of cells, 70.
+Moment of death, 164.
+Money, disinfection of, 194.
+Monomanias, 292, 299.
+Monsters, 69;
+  aetiology of, 76;
+  composite, 77;
+  double autositic, 79;
+  produced artificially, 76.
+
+Morality,
+  circumstances in, 12;
+  determinants of, 12, 13, 105;
+  end in, 13, 15;
+  general laws in, 15;
+  means in, 14;
+  object in, 12, 15;
+  will in, 13.
+
+Morphinism, 115;
+  causes of, 115;
+  effects of, 115.
+
+Morula, 73.
+Mosquitoes as disease-carriers, 186.
+_Mulieris impotentia_, 331.
+Mumps, 199.
+
+N
+
+Narrow pelves, 55.
+Nephritis, responsibility in, 246.
+Nervous school-children, 208.
+Nervous strain and syphilis, 324.
+Neuralgic dysmenorrhoea, 242.
+Neurasthenia, 230;
+  causes of, 233;
+  and responsibility, 248;
+  sexual form of, 232;
+  spinal form of, 232;
+  symptoms of, 230;
+  traumatic form of, 233;
+  treatment of, 233;
+  types of, 231.
+
+Neurotic dysmenorrhoea, 242.
+Neurotic superiors, 248.
+Newspapers and suicide, 132, 133.
+Nietzsche, 285.
+
+O
+
+Object in morality, 12.
+Obsession, 266.
+Obstructive dysmenorrhoea, 242.
+Oedema
+  in kidney diseases, 139;
+  of the glottis, 139.
+
+Oil-stocks in smallpox visits, 177.
+Oligospermia, 343.
+Omphalopagus, 84.
+Omphalositic monsters, 75.
+Omphalosites, origin of, 76.
+Operation in ectopic gestation, 23.
+Ophthalmia, 200;
+  neonatorum, 200.
+
+Opisthotonos, 237.
+Ovarian pregnancy, 5.
+_Ovariorum carentia_, 334.
+
+                                                 {362}
+
+Ovary, anatomy of, 2.
+Ovulation, 3, 240.
+Ovum, 2, 3, 69, 72;
+  arrest of, in tube, 4;
+  segmentation-nucleus of, 3.
+
+P
+
+Pancreatitis, death in, 160.
+Paracephalus, 75.
+Paralysis from syphilis, 322.
+Paramimia, 309.
+Paranoia, 220, 282;
+  and suicide, 306;
+  erotica, 291;
+  occurrence of, 285;
+  of tramps, 297;
+  persecution and, 288;
+  querulans, 293;
+  religiosa, 290;
+  responsibility in, 301;
+  signification of, 283, 284;
+  special forms of, 292;
+  stages of, 286;
+  symptoms of, 284, 285, 286.
+
+Parasitic monsters, 85.
+Paresis and syphilis, 319;
+  symptoms of, 319.
+
+Pathological micro-organisms, 168.
+Pelvic tumours in pregnancy, 40.
+Perforation of the intestines, 152.
+Peritonitis in typhoid fever, 152.
+Pernicious vomiting, 53.
+_Persecuteurs persecutes_, 290.
+Persecution and paranoia, 288.
+Peterson on paranoia, 284.
+Peters' ovum, 73.
+Phobias, 295.
+Physical exercise in schools, 209.
+_Pigritia indurata_, 296.
+Placenta, 6, 23, 24, 67;
+  praevia, 53.
+
+Plague, 185.
+Pneumococcic meningitis, 148.
+Pneumonia,
+  alcoholism and, 151;
+  in pregnancy, 150;
+  prognosis in, 150;
+  visits in, 182;
+  walking cases of, 151.
+
+Pooley on bloody sweat, 347.
+Porrigo, 199.
+Porro operation, 50.
+Pregnancy,
+  ampullar, 5;
+  extrauterine, 1;
+  in broad ligament, 5;
+  interstitial, 5;
+  isthmic, 5;
+  pneumonia in, 150;
+  term of, 3;
+  tubo-abdominal,5;
+  tubo-ovarian, 5.
+
+Premature labour, 48.
+Prepotency, 71.
+Price on ectopic gestation, 9.
+Priest in infectious diseases, 168.
+Primitive trace, 74.
+Probabilism, 15;
+  and law, 16;
+  constituents of, 16.
+
+Professional criminals, suppression of, 277.
+Promulgation of law, 16.
+Proprietary drugs
+  and alcohol, 93;
+  evils of, 91.
+
+Prosopothoracopagus, 84.
+Protozoa, 165.
+Pseudo-angina pectoris, 142.
+Psychic epilepsy, 259;
+  and secondary personality, 259.
+
+Pyelonephritis, 51.
+Pygopagi, 83.
+Pyromania, 300.
+
+Q
+
+Quarantine, needless of, 188.
+
+R
+
+Rabies, 161, 180;
+  symptoms of, 162.
+Rachipagus, 84.
+Relapsing fever, 179.
+Religious perversions in epilepsy, 254.
+Responsibility
+  and epilepsy, 252;
+  and impulse, 266;
+  Graves' disease and, 246;
+  in paranoia, 301;
+  judgment of, 268;
+  nephritis and, 246.
+
+Resuscitation, cases of, 165.
+Rheumatism
+  and proprietary drugs, 101,
+  fatal cases of, 153.
+
+Rickets
+  and cranial deformity, 275;
+  and degeneration, 276.
+
+Ringworm, contagiousness of, 198.
+Rituale Romanum on monsters, 87.
+Rupture in ectopic gestation, 29.
+
+S
+
+Sabetti on ectopic gestation, 24.
+Sacraments
+ in apoplexy, 147;
+ in apparent death, 167;
+  in smallpox, 176;
+  in typhus, 179.
+
+Sadismus, 338.
+Scabies, 198.
+Scarlet fever,
+  disinfection after, 197;
+  visits in, 170.
+
+Schmaltzgreuber on impotence, 330.
+School desks, rules for, 207.
+Schools,
+  disinfection of, 196;
+  food in, 208;
+  heating of, 206;
+  hygiene, 202;
+  infection in, 187;
+  lighting of, 205;
+  sites for, 202;
+  stairways, 200;
+  ventilation of, 206;
+  water-closets in, 207;
+  windows in, 205.
+
+Scrupulosity, 208, 231.
+Secondary personality, 259.
+Self-defence, 18.
+_Senectus et impotentia_, 333.
+Serum therapy, 172.
+Sexuality and insanity, 226.
+Sexual perverts, 233.
+Sewer gas, 203.
+Skull-formation of criminals, 275.
+Skull, fractures of, 147.
+Siamese twins, 84.
+Single monsters, 75.
+Siren, 75.
+Sir Robert Anderson on criminals, 277.
+Sites for schools, 202.
+Sixtus V, decree on eunuchs, 327.
+Smallpox, 172;
+  contagiousness, 170, 172;
+  mortality in, 174;
+  precautions in visiting, 176;
+  sacraments in, 176.
+
+                                                  {363}
+
+Snake-bite and alcohol, 118.
+Social diseases, 317;
+  and youth, 318.
+
+Social medicine, 88.
+Softening of the brain, 319.
+Soil under school buildings, 202.
+Soothing syrups, evils of, 99.
+Soul,
+  entrance of, 3;
+  when it leaves the body, 164.
+
+_Spaltungstheorie_, 77.
+Spermatozoon, 3, 70, 72, 73.
+_Spes phthisica_, 158.
+Spiritual direction and mental disease, 211.
+Sports in plants, 127.
+Stairways in schools, 206.
+Stegomyia mosquito, 186.
+Stigmata, 348;
+  and science, 352.
+
+Stole in smallpox visits, 177.
+Suicide, 306;
+  and newspapers, 132, 309;
+  and paranoia, 306;
+  European statistics of, 308;
+  heredity in, 132;
+  increase of, 306;
+  in families, 310;
+  melancholia and, 218;
+  of children, 308;
+  statistics of, 307.
+
+Sulphur as a disinfectant, 190, 196.
+Superfoetation, 82.
+Superimpregnation, 82.
+Superiors, chronic disease in, 245, 249.
+Surgery and alcoholism, 163.
+Susceptibility to disease, 170.
+Symphyseotomy, 56, 57;
+  mortality in, 57.
+
+Syncephalus, 84.
+Syphilis, 311;
+  accidental infection with, 323;
+  and marriage, 315;
+  and nervous strain, 324;
+  cause of paresis, 319;
+  cause of tabes, 312, 322;
+  classes affected, 324;
+  congenital form of, 313;
+  maternal form of, 313;
+  prognosis in, 314, 324;
+  stages in, 311;
+  statistics of congenital form of, 314;
+  symptoms of, 311 312, 313;
+  transmission of, 313.
+
+Syphilitic affection
+  of the trunk organs, 323;
+  arterial disease, 323;
+  brain tumours, 322;
+  paralysis, 322.
+
+T
+
+Tabes dorsalis, 312, 320.
+Tait on tubal pregnancy, 5, 6.
+Tarantism, 236.
+Terata, 69;
+  anadidyma, 79, 83;
+  anakatadidyma, 79, 84;
+  classification of, 74;
+  katadidyma, 70.
+
+Tetanus,
+  death in, 161;
+  visits in, 183.
+
+Thomas on ectopic gestation, 9.
+Thoracopagus, 84.
+Tinea favosa, 197.
+Tobacco,
+  not a disinfectant, 173;
+  use of by boys, 209.
+
+Trachoma, 200.
+Tramps, 296.
+Triple monsters, 86.
+Tubal
+  abortion, 6;
+  pregnancy, 5.
+
+Tuberculosis, 89, 90;
+  and proprietary drugs, 91;
+  curability of, 90;
+  death in, 158;
+  in schools, 198;
+  prophylaxis, 90;
+  visits in, 182.
+
+Tubo-abdominal pregnancy, 5.
+Tubo-ovarian pregnancy, 5.
+Tumours of the brain, 148
+Typhoid fever, 152;
+  peritonitis in, 152;
+  prognosis of, 152;
+  walking cases of, 152.
+
+Typhus, 179.
+Twins, 78.
+
+U
+
+Unexpected death, 135, 150.
+Unjust aggressor, 18.
+Urningismus, 339.
+Uterine amputations, 65.
+Uterus,
+  abnormal, 7;
+  anatomy of, 1.
+
+V
+
+Vaccination, 173;
+  compulsory, 175;
+  symptoms of, 176.
+
+_Vaginismus et impotentia_, 332.
+_Varicocele et impotentia_, 342.
+Varicose veins, 159.
+Venereal diseases and marriage, 311.
+Ventilation, 206.
+Vertigo and apoplexy, 144.
+_Verwachsungstheorie_, 77
+Viaticum in smallpox, 178.
+Vincentius de Justis on impotence, 330.
+Vital tripod, 136.
+Vitelline membrane, 72.
+Vitellus, 72.
+Von Holder on criminals, 272.
+
+W
+
+Wall-paper, disinfection of, 194.
+Walls of buildings, 203.
+Water-closets in schools, 207.
+Whiskey, percentage of alcohol in, 108.
+Whooping cough, danger in, 199.
+Will in morality, 13.
+Windows in schools, 205.
+Wines, percentage of alcohol in, 108.
+_Witzelsucht_, 224.
+Working hours for children, 204.
+
+Y
+
+Yellow fever, aetiology of, 185.
+Youth and social diseases, 318.
+
+Z
+
+Zona pellucida, 72.
+
+
+
+
+
+
+End of the Project Gutenberg EBook of Essays In Pastoral Medicine, by
+Austin OMalley and James J. Walsh
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