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Title: Essays In Pastoral Medicine
Author: ÓMalley, Austin, Walsh, James J. (James Joseph), 1865-1942
Language: English
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Copyright Status: Not copyrighted in the United States. If you live elsewhere check the laws of your country before downloading this ebook. See comments about copyright issues at end of book.

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{iii}


ESSAYS IN PASTORAL MEDICINE


BY


AUSTIN ÓMALLEY, 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 öophorectomy
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. Küstner 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 René 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.

Génicot (_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 ÓMALLEY.


{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 ÓMALLEY.

{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 Guérard, 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, eâ omissâ, mater et infans
  perituri sint, eâ e contra admissâ, 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 ÓMALLEY.

{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 ÓMALLEY.


{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 Förster,
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 monstruosités_, 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 Duplicität 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. Müller, 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. Förster 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. Förster 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 Würtemberg 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 médicale_ 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. Förster
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 ÓMALLEY.


{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. Féré 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. Féré, 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
Bicétre, 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 _habitué_ 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 Génicot'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 Génicot 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 ÓMALLEY.


{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° 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 rôle 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 Tromsö, 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 mém. 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 ÓMALLEY.


{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 ÓMALLEY.


{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 ÓMALLEY.

{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 ÓMALLEY.


{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 rôle 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 ÓMALLEY.


{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 Wüthen wieder gelag.
  St. Vits Tanz ward genannt die Plag."

Beckmann (_Historia des Fürstenthums 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 ÓMALLEY.


{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 ÓMALLEY.


{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 rôle, 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 idée obsédante_, 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 rôle 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 _persécutés persécuteurs_, 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 ÓMALLEY.


{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, § 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 Radàma
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. Krügelstein
(_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 ÓMALLEY.


{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 médicales,_ 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 Féré. New York, 1889.)

In Ricard's _Journal de magnétisme 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 _Société 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 Féré. Op. cit., p.
199.) Charcot and his pupils at the Salpêtrière 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
Lefèvre 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 ÓMALLEY.


{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.
Génicot 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

_Idée obsédante,_ 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.
_Persécuteurs persécutés_, 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.





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